Herpes zoster ophthalmicus and the orbital apex syndrome

Herpes zoster ophthalmicus (HZO) commonly causes isolated ophthalmoplegic syndromes. Visual loss caused by optic neuritis secondary to HZO can be reversible or irreversible. HZO rarely presents as an orbital apex syndrome, when an association with meningo-encephalitis has been reported. We report a case of orbital apex syndrome secondary to HZO treated with systemic steroids and acyclovir. Our patient suffered no systemic complications and displayed a rapid resolution of optic neuropathy. We discuss this case in the light of previous reports and explore the possible pathogenic mechanisms involved.

An unusual orbital lesion: hepatoma metastatic to the orbit

The authors describe a case of histologically proven orbital metastasis from a hepatic carcinoma in an 85-year-old patient with rapid onset of proptosis and visual loss. The clinical diagnosis of orbital metastatic lesion was established by standardized echography and CT scan. To the best of our knowledge, this is only the third histologically proven case of hepatoma metastatic to the orbit.

Spontaneous thrombosis of a traumatic cavernous sinus fistula

Post-traumatic thrombosis of cavernous sinus and orbital veins has been reported in conjunction with carotid-cavernous sinus fistula (CCSF). CCSF are abnormal communications between the carotid artery and the cavernous sinus. Spontaneous thrombosis of a CCSF is a rare event mainly seen in the indirect (dural) type of fistula. We report on a patient with a possible post-traumatic CSSF which underwent partial spontaneous thrombosis and presented with an extreme degree of proptosis.

Upper eyelid retraction after retinal detachment repair

Two patients with high myopia developed unilateral upper eyelid retraction after retinal detachment surgery with superiorly placed scleral buckles and 360-degree encircling elements. The isolated upper eyelid retraction was stable for 16 and 23 years, respectively. Other common causes of eyelid retraction, including cicatricial processes such as thyroid-related orbitopathy, neurogenic disease, and pseudoretraction of the eyelid, were excluded in both patients. The first patient had no evidence of proptosis or lid lag on downgaze but had exposure keratitis that required recession of Müller's muscle and conjunctiva. The second patient had lid lag on downgaze, and orbital computed tomography demonstrated an enlarged eye with an encircling element that caused mild pseudoproptosis. This patient required no treatment. The unilateral upper eyelid retraction did not progress in either patient. Although the exact mechanism of the upper eyelid retraction in these two cases is unclear, previous retinal surgery that involves superiorly placed implants must be considered in the differential diagnosis of unilateral upper eyelid retraction, especially when the patient has a history of pathologic myopia.

Ocular pulsation in neurofibromatosis. A clinical/neuroradiologic correlation

A 61-year-old woman presented with early cataract formation in an eye which had been pulsating synchronously with her heart beat all of her life. This report presents the first, to our knowledge, three dimensional reconstruction CT images of this form of neurofibromatosis 1. It also documents by MRI and MRA the association of an asymptomatic carotid-ophthalmic junction aneurysm ipsilateral to the sphenoid dysplasia.

A wooden orbital foreign body

A case is reported in which a patient presented, 18 months after initial injury, with a progressive proptosis of the left eye. X-rays did not reveal a foreign body but a fracture of the lateral orbital wall and an area of soft tissue density were seen on the CT scan. Exploration of the orbit revealed a 2 cm wooden fragment in the floor of the orbit.

Bilateral proptosis after post-traumatic hydrocephalus: a case report

Hydrocephalus can cause several neuro-ophthalmological complications but only rarely has it been reported to cause proptosis. A 23-year-old woman developed post-traumatic hydrocephalus after a road traffic accident. She was found to have deteriorating visual acuity bilaterally and bilateral proptosis. Both these complications resolved after a ventriculo-peritoneal shunt was inserted.

[Unilateral exophthalmos during the course of epidural hematoma]

Based on 10 cases in the literature and one of our own a review is made on the occurrence of an association of an intracranial epidural haematoma with unilateral exophthalmos. The possible pathogenesis of this infrequent phenomenon is discussed.

Echographic measurement of extraocular muscle thickness in proptosis

Echographic extraocular muscle thickness was measured in 102 eyes of 51 patients with proptosis of varied etiology. That of vascular origin was associated with extraocular muscle enlargement in all cases. Enlargement of the medial rectus was found to be statistically significant in thyroid orbitopathy. Sixty percent of cases with nonspecific orbital inflammatory disease had enlarged extraocular muscles. We discuss the supportive role of determining echographic measurements of extraocular muscle thickness in proptosis and highlight the uniform extraocular muscle enlargement found in proptosis of vascular origin.

[Possibilities of computerized tomography in destructive bone changes in patients with polypous rhinosinusopathy]

The authors made a CT investigation of 15 patients (11 men and 4 women) suffering from polypous rhinosinusopathy. Thirteen patients prior to it underwent polypectomy of the nose. Ophthalmocele was observed in 7 patients. The results of CT investigation made it possible to define the spreading of the destructive process in the accessory nasal sinuses in its polypous lesion and reject a tumor process.

Mechanisms of visual loss in severe proptosis

Vision loss in orbital hypertension secondary to sudden space-occupying lesions is usually attributed to one of three causes: central retinal artery occlusion, direct compressive optic neuropathy, or compression of optic nerve vasculature. Accepted modes of decompressive therapy include lateral canthotomy and cantholysis; drainage of localized orbital air, hematoma, or abscess; and bony wall decompression. Five cases are presented in which orbital hypertension caused severe proptosis with traction on the optic nerve and tenting of the posterior globe. Another mechanism contributing to visual loss is proposed in these cases: ischemic optic neuropathy due to stretching of nutrient vessels. In these cases, rapid posterior decompression should theoretically be favored to reduce orbital pressure and relieve traction on the optic nerve vasculature.

Proptosis from a cephalhematoma in a twelve-year-old girl--a case report

We report a unique case of a 12-year-old girl with unilateral proptosis form orbital extension of an extensive bilateral cephalhematoma. Loss of vision in the left eye due to severe proptosis was reversed by prompt aspiration and tarsorrhaphy.

[Orbital myositis]

Four patients with unspecific myositis of the extraocular muscles were treated in the Ophthalmological Department Medical School in Białystok in the period 1983-1988. The authors discuss the problems connected with the diagnosis and treatment of this pathological condition. Special attention is called to the new diagnostic methods.

Surgical correction of exophthalmos secondary to Graves' disease

Graves' disease has been recorded in the medical literature for more than 150 years. Despite introduction of iodine into the diet, Graves' disease still remains the most important disorder of the thyroid gland. Clinically, Graves' disease is a multisystem disorder of unknown etiology characterized by the clinical triad of infiltrative pretibial dermopathy, thyroid glandular hyperplasia, and ophthalmopathy. Expansion of the bony orbital volume is an effective method of treating moderate to severe exophthalmos. Our experience with a simplified version of a three-wall orbital decompression to correct exophthalmos secondary to Graves' disease is presented.

Endoscopic transnasal orbital decompression

Orbital decompression for dysthyroid orbitopathy has traditionally been performed through either an external or a transantral approach. The advent of intranasal endoscopes allowed for the development of a transnasal approach for medial and inferior orbital wall decompression. Using this approach, orbital decompressions were performed on 13 orbits in eight patients with severe complicated dysthyroid orbitopathy. Simultaneous bilateral lateral orbitotomies were performed on five patients. Walsh-Ogura decompressions and lateral orbitotomies were performed on two orbits. When combined with lateral orbitotomy, Hertel measurements improved an average of 5.7 mm in orbits decompressed transnasally and 4.5 mm in orbits decompressed with a Walsh-Ogura approach. Transnasal decompression alone improved Hertel measurements an average of 4.7 mm. Visual acuity improved in three of four patients with optic neuropathy, and in all patients with exposure keratopathy. We conclude that the endoscopic transnasal approach provides comparable decompression to traditional methods while avoiding the morbidity of an external ethmoidectomy or Caldwell-Luc antrotomy.

Correlative imaging of sphenoid dysplasia accompanying neurofibromatosis

Experience with five cases of sphenoid dysplasia is collected and illustrated by plain film, computed tomography, and magnetic resonance imaging. Ancillary changes in the maxilla and mandible are shown. Paramount to the presentation are changes induced in the orbit resulting in a large superior orbital fissure with or without a meningeal cyst projecting through the fissure. Serial studies of one patient from birth through 5 years of age present the progressive nature of this abnormality.

Complex neuroradiologic diagnosis in unilateral exophthalmos

This is a comparative study concerning diagnosis in unilateral exophthalmos. It was carried out in 40 patients admitted to the Neurosurgery Clinic of the "Gh. Marinescu" Hospital in Bucharest during 1986-1987. The patients were submitted to CT scan and other radiologic examinations with and without contrast media in order to improve reference to the neuroradiologic laboratory and increase the accuracy of the etiopathogenic diagnosis.

Recurrent acute proptosis in atypical systemic lupus erythematosus

A patient is described who developed acute proptosis, a rare complication of systemic lupus erythematosus, 16 years after the onset of the disease. Treatment with intravenous methylprednisolone produced rapid improvement, but swelling recurred a few days later. Intravenous corticosteroid was again effective and was continued orally without further episodes of proptosis. This patient is unusual in the long period of mild disease before the development of systemic complications, and in having antibodies to nuclear ribonucleoprotein but persistently normal titres of DNA-binding antibodies in her serum.

Corticosteroid-induced exophthalmos

We describe twenty-one patients on sustained corticosteroid therapy who presented with exophthalmos. Each patient received a complete ophthalmologic examination and further tests were conducted to rule out other causes of exophthalmos. Our data suggest that corticosteroid-induced exophthalmos is an entity more common than has been previously recognized.

[New quantitative parameters for CT evaluation of orbitopathy in dysthyroid ophthalmopathy]

The new index (c/o ratio) is defined as the content of the orbit divided by the capacity of the bony orbit on the mid-orbital axial CT slice showing the medial and the lateral rectus muscles and optic nerve. Other quantitative parameters such as for exophthalmos and the capacity of bony orbit were also obtained on CT films. These parameters were measured in 474 eyes of patients with dysthyroid ophthalmopathy. The capacity of bony orbit showed large variations among all patients. The average for males was 17.8cm3 and that for females was 16.1cm3. Exophthalmos measurement on CT is more reliable than that by the Hertel exophthalmometer. The new index (c/o ratio) is a very reliable parameter for evaluating orbitopathy in dysthyroid ophthalmopathy. A large c/o ratio (greater than 1.6) was of clinical significance, because approximately 70% of the enlargement of the extraocular muscle observed in older patients (greater than 40 yrs old) was associated with a large c/o ratio (greater than 1.6).

Globe tenting: a sign of increased orbital tension

Globe tenting is a change in the posterior globe configuration that results in a tented or conical appearance and is objectively defined as a posterior globe angle of less than 130 degrees. Globe tenting is caused by an acute/subacute intraorbital mass effect producing significant proptosis with tethering of the globe by the stretched optic nerve. In this series of 10 patients, globe tenting was produced by subperiosteal abscess (five cases), hemorrhage into a lymphangioma (two cases), a varix (one case), traumatic carotid hemorrhage into a lymphangioma (two cases), a varix (one case), traumatic carotid cavernous fistula (one case), and multiple epithelial implantation cysts (one case). Progressive narrowing of the posterior globe angle correlated with an increase in proptosis and in optic nerve length, as well as with more severe visual impairment. Tenting with a posterior globe angle of 120-130 degrees correlated with mild visual symptoms and a good recovery. A posterior globe angle of less than 120 degrees with acute proptosis constitutes a surgical emergency; a delay in surgical decompression in these patients may prevent complete recovery of visual function. CT is useful in providing good characterization of globe tenting and, thus, in helping to determine the clinical significance of this abnormality.