Management of traumatic luxation of the globe. A case report

PURPOSE

To report the management of a patient who had LeFort type III fractures and traumatic luxation of the globe with avulsion of the optic nerve and all extraocular muscles except for the medial rectus.

METHODS

Eight hours after the trauma, the detached and retracted superior and lateral recti muscles could be found and sutured to their original insertions. The inferior rectus could not be retrieved.

RESULTS

Although the left eye had no light perception, most of its motility was restored resulting in an unblemished cosmesis.

CONCLUSION

Avoiding primary enucleation helped to alleviate the psychological burden of the trauma on the patient. In case of the eventual development of phthisis bulbi, the patient will have a chance to be fitted with a prosthesis over his own eye with a resulting better motility.

Clinical findings in a patient with spontaneous arteriovenous fistulas of the orbit

PURPOSE

To report clinical and radiologic findings of a patient with spontaneous arteriovenous fistulas of the orbit.

METHOD

Case report.

RESULTS

A 73-year-old woman was initially examined with a 1-year history of mild proptosis of the right eye. She had no history of trauma. Neuro-ophthalmologic examination disclosed dilatation of conjunctival vessels, increased intraocular pressure, mild proptosis and bruit in the right eye, and ocular signs suggestive of carotid-cavernous sinus fistulas or orbital arteriovenous malformations. The patient exhibited dilation of the superior ophthalmic vein in enhanced computed tomography of the orbit. Selective cerebral angiography disclosed communications between branches of both ophthalmic and facial arteries and the superior ophthalmic vein in the orbit.

CONCLUSION

Arteriovenous fistulas of the orbit must be considered in the differential diagnosis of carotid-cavernous sinus fistulas and arteriovenous malformations, although they are quite rare.

[Digital subtraction angiography of cerebrum for diagnosis of cavernous sinus fistula and its intravascular treatment]

OBJECTIVE

To evaluate the diagnosis of digital subtraction angiography (DSA) of cerebral arteries and the intravascular treatment for carotid artery-cavernous sinus fistula (CCF) mainly manifesting as pulsating exophthalmos.

METHODS

Digital subtraction angiography (DSA) of cerebral arteries was carried out for 15 patients with pulsating exophthalmos. Of them, detectable balloon and tungsten filament microcoil were used for intravascular embolism treatment in 12 cases, and the 3 cases with CCF of the branch of external carotid artery were not treated.

RESULTS

Of the 15 cases, 12 were fallen in the CCF of high flow type of unilateral internal carotid artery, and 3 in the CCF of low flow type of unilateral external carotid artery. The symptoms and signs of intravascular embolism disappeared after treatment in 11 cases.

CONCLUSION

Cerebral artery DSA and intravascular therapy are the ideal methods for the diagnosis and treatment of CCF mainly manifesting as pulsating exophthalmos.

Unilateral exophthalmos caused by traumatic vertebral artery to vertebral and jugular vein fistula: problems in diagnosis and management

Skull base venous fistulas are rare. A 15-year-old boy was stabbed in the left side of his neck, just below the mastoid process. Two years later, he presented with a protruded and pulsating left eye with red sclera. A soft murmur was audible all over his head and neck. Angiography revealed an arteriovenous fistula between the third portion of the vertebral artery (V3) and the vertebral venous plexus, as well as the ipsilateral jugular vein (VVJF). The fistula recruited several arterial feeders and rising the venous pressure along the outflow system of the skull base had led to unilateral exophthalmos.

Ophthalmic manifestations of allergic fungal sinusitis

PURPOSE

To highlight allergic fungal sinusitis as a cause of ophthalmic and sinus problems by identifying the profile of the patient with allergic fungal sinusitis and presenting a successful treatment approach.

METHODS

Six consecutive cases of patients with ophthalmic manifestations of allergic fungal sinusitis were reviewed. Ophthalmic findings, sinus involvement, mycology, immune response, imaging studies, and treatment were examined. The characteristics of this patient group with ophthalmic manifestations of allergic fungal sinusitis were compared with those of the general group of patients with allergic fungal sinusitis.

RESULTS

All six patients had proptosis. One had symptomatic diplopia and one had visual loss. Imaging studies, fungal characterization, and immune profiles were similar to the reported allergic fungal sinusitis population. After treatment there was no recurrence of ophthalmic or sinus symptoms at a mean follow-up of 34 months (range, 8 to 48 months). There were no complications of treatment.

CONCLUSIONS

Initial diagnosis of allergic fungal sinusitis requires suspicion on the part of the ophthalmologist. Proptosis is the most common ophthalmic sign. Differentiation from invasive forms of fungal sinus disease is crucial, because systemic antifungal medication and extensive surgical tissue debridement are not required in allergic fungal sinusitis. Treatment consists of extirpation of the allergic mucin and fungus, sinus aeration, and systemic and topical corticosteroids.

Orbital computed tomographic characteristics of globe subluxation in thyroid orbitopathy

OBJECTIVE

Axial globe subluxation may complicate thyroid orbitopathy. This acute event is defined by anterior displacement of the globe equator beyond the orbital rim, lid retraction behind the equator, and tethering of the optic nerve. The authors explored the factors leading to spontaneous globe subluxation in patients with thyroid orbitopathy.

DESIGN

A clinical review.

MAIN OUTCOME MEASURES

The medical charts and axial and coronal orbital computed tomographic (CT) scans of all the patients with spontaneous globe subluxation were reviewed. The patients were categorized according to their CT scans into type I ("lipogenic" variant) or type II ("myogenic" variant).

RESULTS

Four (0.1 %) of approximately 4000 patients with thyroid orbitopathy presented with spontaneous globe subluxation. All of these patients had increased orbital fat without significant enlargement of the extraocular muscles. Thus, they represent type-I thyroid orbitopathy.

CONCLUSIONS

Globe subluxation in thyroid orbitopathy requires compliance of the orbital soft tissues and extensibility of the extraocular muscles. These are characteristics of type-I orbitopathy. The increased fat content results in more compliance of the soft tissues, and the normal caliber of the muscles allows them to become more extensible. This permits the acute contraction of the eyelids posterior to the equator of the globe. Patients with type-I orbitopathy and extensive proptosis may be at relatively greater risk of having globe subluxation develop.

Transcranial correction of orbital neurofibromatosis

Neurofibromatosis is a systemic disease that often produces striking disfigurement. Orbital manifestations are common and include sphenoid dysplasia with or without infiltration of the periorbital soft tissues. The resultant deficiency of the posterolateral orbital wall may lead to protrusion of the temporal lobe into the orbit, displacement of the globe, and pulsatile exophthalmos. Treatment at our unit has consisted of transcranial orbital reconstruction with bone grafts and periorbital soft-tissue correction. Observation of complete bone graft resorption in one patient prompted an assessment of the Australian Craniofacial Unit's experience with particular attention paid to the stability of operative correction. Of 36 patients with head and neck neurofibromatosis treated during the period from 1981 to 1995, 14 patients underwent transcranial correction of orbital deformities secondary to sphenoid dysplasia. The treatment and outcomes of this transcranial group are reviewed. The most notable finding was that of recurrent globe pulsation in four patients following initial resolution. Computed tomography scans have documented partial to complete bone graft resorption in three of these patients. Titanium mesh is now being utilized to provide a more durable reconstruction.

Orbital CT. Current use in the MR era

The additional advantages of spiral CT have further cemented CTs role as the screening examination of choice for the orbit. The shorter scan times permit ideal enhancement yet reduce the contrast load, providing the optimal postcontrast studies that routine imaging of the orbit requires. This article is not a comprehensive study of orbital CT, but a general review emphasizing CTs strengths, especially the evaluation of childhood leukocoria (calcification), proptosis screening, and trauma.

Maxillary distraction osteogenesis in Pfeiffer's syndrome: urgent ocular protection by gradual midfacial skeletal advancement

Distraction osteogenesis is increasingly recognised as a potentially useful technique to achieve the co-ordinated augmentation of craniofacial skeletal and soft tissue. A case is presented where bilateral maxillary distraction was successfully used to advance the midface in the treatment of recurrent ocular dislocation, in a 10-month-old boy with Pfeiffer's syndrome.

Unilateral proptosis and chemosis caused by dural arteriovenous malformation of the superior sagittal sinus

We describe a patient with unilateral proptosis and chemosis resulting from a dural arteriovenous malformation (AVM) of the superior sagittal sinus (SSS) fed mainly by branches of both external carotid arteries. The symptoms may have been caused by increased SSS pressure and disturbance of venous flow by the dural AVM.

Prenatal diagnosis of trisomy 18 at the 10-14-week ultrasound scan

A beneficial consequence of screening for trisomy 21 by a combination of maternal age and fetal nuchal translucency thickness (NT) at 10-14 weeks is the early diagnosis of trisomy 18. In a multicenter study of 91,091 singleton pregnancies there were 106 fetuses with trisomy 18 and 83% were identified by NT screening. Trisomy 18 was also associated with early onset intrauterine growth retardation, decreased fetal heart rate and the presence of exomphalos.

Computed tomography and magnetic resonance imaging of cavernous sinus enlargement in a dog with unilateral exophthalmos

Computed tomography (CT), magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were performed on a dog with a two year history of unilateral exophthalmos occurring two years following head trauma. On CT images, an expansile enhancing mass was present along the right intracranial cavernous sinus and extended through the orbital fissure into the retrobulbar space. With MRI, the structure appeared as a signal void due to the presence of rapidly flowing blood. Gadolinium enhancement of the adjacent brain was not present. A vascular origin of the lesion was confirmed with MRA. Based on the CT and MRI findings, the enlarged cavernous sinus and associated ophthalmic plexus were believed to represent an arterialized aneurysm, most likely the result of traumatic arteriovenous fistulization. Treatment consisted of surgical enucleation. At the time of this report, 29 months later, the dog remains free of clinical signs.

Proptosis as the manifesting sign of Weber-Christian disease

PURPOSE

To identify proptosis as a manifesting sign of Weber-Christian disease (recurrent febrile nodular panniculitis).

METHOD

Case report. A 61-year-old man had signs of right proptosis and orbital inflammation that resolved with oral corticosteroid therapy. Orbital inflammation later recurred with associated cutaneous nodules, myalgia, nausea, and malaise.

RESULTS

Rheumatologic evaluation and subcutaneous nodule biopsy led to the diagnosis of Weber-Christian disease. The patient required systemic immunosuppressive agents to control the disease.

CONCLUSION

This case shows the rare finding of proptosis as the manifesting sign of Weber-Christian disease.

Late migration of an orbital implant causing orbital hemorrhage with sudden proptosis and diplopia

A 31-year-old woman complained of sudden diplopia and proptosis associated with a headache. Approximately 10 years earlier, she had sustained a right orbital blowout fracture during a snow machine accident that was repaired using a Supramid implant. She presented with 4 mm of right-sided proptosis by Hertel exophthalmometry, with limitation of up and down gaze. She manifested a right gaze preference with a left head turn to achieve fusion. Visual acuity was 20/20 on both sides; however, there was 20% red desaturation and a subtle afferent pupillary defect on the right side. Goldmann visual fields were full and the retinal examination was normal. A computed tomography (CT) scan of the orbits with and without contrast demonstrated a large right posterior inferior orbital mass. Once the periorbita was breached during orbitotomy, a burgundy serosanguinous material emerged. Gram staining revealed red cells without organisms. The implant had not been fixed by wires or screws. Upon removal, the implant appeared oversized, encompassing the orbital floor, medial and lateral walls. Postoperatively, the proptosis, gaze preference with face turn, afferent pupillary defect, desaturation abnormality, and diplopia resolved.

[Diagnostic significance of CT in the orbital inflammatory lesions]

OBJECTIVE

To analyze and summarize the CT signs of orbital inflammatory lesions.

METHOD

HITACH-W, or EXEL 2400 pattern of CT was applied for the orbital scanning of 52 cases with orbital inflammatory lesions proved by clinicopathology.

RESULTS

The CT signs of orbital inflammatory lesions in our series included exophthalmos, orbital mass, ill-marginated mass, multiple space involvement, extraocular muscle enlargement, scleral thickening, eyelid thickening, optic nerve thickening, orbital fat density increasing, lacrimal gland enlargement, sinusitis, subperiosteal abscess, ring-enhancement in masses, etc.

CONCLUSION

All these findings on CT are of important significance for the diagnosis of orbital inflammatory lesions.

Indium-111 octreotide in Graves' disease and in the evaluation of active exophthalmos

Thyroid Associated Ophthalmopathy (TAO) is an autoimmune disorder generally associated with Graves' disease (GD). The aim of our study was to evaluate the uptake of indium-111 Octreotide (111In-OCT), a somatostatin (SS) analogue able to bind specific SS receptors, at the level of the thyroid and orbits in patients with TAO. Seven patients with exophthalmos were investigated: six had GD while one was affected with a non small cell lung cancer (NSCLC). One patient with GD had undergone total thyroidectomy (TT) for a thyroid cancer. At the time of the study two patients were hyperthyroid, four were euthyroid and one was hypothyroid. 111 MBq of 111In-OCT were i.v. injected and two 30-minute scans were performed at 4 and 24 hours; 5 minute planar images were also obtained at 25, 60 and 120 minutes. A 180 degrees SPECT was carried out 5 hours after the injection in one patient. A qualitative analysis was performed, comparing these images with those obtained in 7 control patients without thyroid illness or exophthalmos. Moreover, in the TAO patients thyroid, orbit and brain counts were evaluated in comparison with background (BK) and blood activity (BA), measured at the level of the venous longitudinal sinus. In GD intense thyroid uptake was demonstrated independently of the functional state, with highest ratio compared to BK seen at 24 hours. Low uptake in the patient with NSCLC, no activity in the patient with GD that underwent TT, and slight or absent thyroid uptake in the controls were observed. Intense uptake was seen in the orbits of the patient who clinically had the most severe ophthalmopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Orbital histiocytosis X

In three patients with histiocytosis X of bone with orbital involvement, CT scans were reviewed. Consistent findings included a destructive lesion of the lateral wall of the orbit with a large soft-tissue component that extended into the extraconal space, the ocular adnexa, and the infratemporal fossa. The greater wing of the sphenoid was eroded in all cases, with epidural extension into the middle cranial fossa. Cavernous sinus involvement and a second bone lesion were seen in two patients.

Exophthalmos and iatrogenic Cushing's syndrome

A 38-year-old physician presented with a 9-month history of progressive self-administration of oral prednisone < or = 160 mg per day for Addison's disease. Examination demonstrated typical Cushingoid features and bilateral proptosis with elevated intraocular pressure. Computed tomography disclosed increased intraorbital adipose tissue. We hypothesize that the increased intraorbital adipose deposition was due to the differential binding of glucocorticoids to adipose tissue receptors and an enhancement of lipoprotein lipase activity. We conclude that the findings in this case may be related to glucocorticoid-induced changes in the ocular and periorbital structures. Cushing's syndrome should be considered in the differential diagnosis of acquired exophthalmos and elevated intraocular pressure and findings of increased orbital fat on orbital imaging.

Imaging and differential diagnosis of the large eye

The initial step in the differential diagnosis of an enlarged eye is to determine whether an intraocular mass is present. The globe may be expanded by a mass, seen mainly in children with retinoblastoma. Buphthalmos with or without neurofibromatosis also enlarges the eye. Diffuse enlargement may be associated with a connective tissue disorder or be related to axial myopia. Focal enlargement represents staphyloma, which can be unilateral or bilateral. In the presence of one small eye, the normal-sized eye may be incorrectly diagnosed as large.