Bilateral proptosis from a subgaleal hematoma. Case report

A case of bilateral proptosis due to orbital extension of a subgaleal hematoma is reported. It was produced by a compressive dressing applied for treatment of the hematoma. Orbital entry seemed to be via the lateral canthal region.

Optic nerve dysfunction in thyroid eye disease: CT

Optic nerve dysfunction in thyroid eye disease is thought to be due to compression of the optic nerve by enlarged extraocular muscles near the orbital apex. High-resolution computed tomography (CT) scans of 78 orbits of 31 patients with thyroid eye disease were reviewed. Axial scans alone were inadequate for demonstrating compression of the optic nerve. With a coronal reformatted scan from the axial scans, a muscular index was devised and measured to reflect extraocular muscle impingement on the optic nerve. Orbits with optic nerve dysfunction had significantly higher muscular indices than those without optic nerve dysfunction, supporting the hypothesis that optic nerve dysfunction is usually secondary to compression by enlarged extraocular muscles. Muscular indices of 67% or greater in patients with optic nerve dysfunction were diagnostic of compressive optic neuropathy, while muscular indices of less than 50% appeared to exclude optic nerve compression. A single case of optic nerve dysfunction without muscular compression is also discussed.

[Gas gangrene of the orbit]

This case report describes a penetrating injury of the orbit damaging the inferior division of the oculomotor nerve and causing a Clostridium perfringens inflammation of the orbit within 24 hours.

Proptosis, skull infarction, and retro-orbital and epidural hematomas in a child with sickle cell disease

A Saudi child with homozygous sickle cell disease (SS) presented with bilateral periorbital swelling, right-sided proptosis, skull bone infarcts, and retro-orbital and epidural hematomas. The findings of skull bone infarcts, retro-orbital and epidural hematomas are rare in patients with sickle cell disease.

Orbital rhabdomyosarcoma in childhood

Rhabdomyosarcoma is a diagnostic and therapeutic problem in the management of pediatric tumors, representing the most common malignant orbital tumor of childhood. In this discussion of the diagnosis of rhabdomyosarcoma, the role of CT is detailed through the case reports and the radiographs presented. CT can accurately define the anatomic location of the orbital mass, the involvement of various intraorbital structures, and the extension of the pathologic process into the periorbital regions such as sinuses, nasal cavity, and intracranial compartment. Thin-needle aspiration biopsies can be done under CT guidance without complications as well as follow-up monitoring of tumor regression following therapy.

CT values in orbital hydatid cyst

The CT values of 15 cases of orbital hydatid cyst operated upon by the author were reviewed. It was found that hydatid cyst of the orbit has high CT value, contrary to the low CT value of nonorbital hydatid. This discrepancy was confirmed by an experiment using human skull and two balls simulating hydatid cyst. One ball was put in the orbit and the other in the cranial cavity. When the skull was CT scanned it was found that the orbital ball CT value was about five times higher than the cranial ball, in spite of the fact that both balls had the same content. It was concluded that the orbital bony pyramid is the cause of this high CT value in orbital hydatid. Hence it is recommended that an orbital lesion with a high CT value can be a hydatid cyst.

Orbital decompression for severe dysthyroid eye disease

Current methods of medical treatment of this difficult condition are briefly reviewed, with comments on the generally unsatisfactory response. Attention is therefore directed to surgical methods and a short history given of the various routes used for orbital decompression. The author's own results of transantral, and more recently ethmoidal, decompression are given, with a detailed description of the technique for the latter approach. An interesting frequent consequence of postoperative A pattern to the ocular movements is discussed in the light of Koornneef's concept of orbital fascial anatomy, and suggestions are made for its avoidance.

Exophthalmos induced by exogenous steroids

Two cases of bilateral exophthalmos secondary to chronic steroid therapy are presented. Exophthalmos has been reported in Cushing's disease, in which endogenous steroid production is elevated. Exophthalmos associated with chronic exogenous steroid administration is an unusual although benign form of ocular proptosis.

Exophthalmos caused by excessive fat: CT volumetric analysis and differential diagnosis

CT has proven to be excellent in identifying orbital pathology responsible for proptosis. Occasionally, no discrete mass or extraocular muscle enlargement to explain the exophthalmos is found, only an appearance suggestive of an abnormal increase in orbital fat volume. Fifteen patients were studied with proptosis apparently resulting from increased orbital fat. Clinical follow-up revealed that four of them had Graves orbitopathy, unilateral in one; two had Cushing disease/syndrome; and nine were obese without endocrinopathy. The orbital volume and percentage orbital fat volume were measured by CT software analysis in these patients and in a control group of 16 patients without proptosis. Measurements of proptosis and thickness of the scalp fat pad at the inion level were also performed. Significantly greater values for orbital fat volume, percentage fat volume, and proptosis were found in the proptosis group compared with the control group. There was excellent correlation between proptosis and percentage fat volume, supporting the contention that increased orbital fat is responsible for the proptosis. The thickness of the scalp fat pad at the inion level was significantly greater in obese and Cushing patients than in control subjects, but the thickness was not significantly greater in Graves patients than in controls. Proptosis and inion fat were well correlated (r = 0.74) in the control and obese patients, which suggests a relation between general body fat and orbital fat volume.

Computerized tomography in conditions concomitantly involving the orbits and the paranasal sinuses

Forty-three patients with computerized tomographic (CT) findings demonstrating concomitant orbital and paranasal sinus involvement are presented. Exophthalmos was the most common presenting symptom. Ethmoid and maxillary sinuses were most commonly affected. CT findings were of help in evaluating the extent of the various disease processes and are mandatory for treatment planning. Attention is drawn to the common association of paranasal lesion and ophthalmic manifestations. The combination of clinical presentation and radiological findings might indicate certain etiologies.

Extraocular muscle size comparison using standardized A-scan echography and computerized tomography scan measurements

In many clinical situations, the standard for evaluating extraocular muscle (EOM) size, particularly in thyroid ophthalmopathy, has been use of the computerized tomography (CT) scanner. The impression is generally reported as "enlarged or normal EOMs." If the report of "normal EOM" on CT scan weighs heavily against the diagnosis of thyroid eye disease, how does this qualitative assessment compare with the diagnostic modality of ultrasound? The technique of standardized A-scan measurement of extraocular muscles has been extremely accurate. In this paper, standardized A-scan measurements and CT scan estimates of EOMs are compared in a series of ten patients with a clinical diagnosis of Graves' disease. Three of ten patients displayed enlarged EOMs by CT interpretations; seven of ten patients were categorized as consistent with Graves' disease by correlation with current ultrasonographic criteria for muscle enlargement, asymmetry, and high irregularity of tissue reflectivity.

Malar fractures associated with exophthalmos

Although fracture of the malar bone is often associated with enlargement of the orbit and subsequent development of enophthalmos, occasionally, a blowin type of orbital floor fracture and exophthalmos occurs. The causes of the injury and the differential diagnosis of the blowin fracture are reviewed. An explanation is offered for the development of the symptoms. Early recognition, open reduction and fixation of the malar bone, and repair of the floor of the orbit defect are important for successful management of the injury.

Orbital hemorrhage with proptosis following a dacryocystorhinostomy

A 65-year-old patient with chronic leukemia underwent an uncomplicated dacryocystorhinostomy. On the first postoperative day, the eye was proptotic and chemotic with restricted movements. A CT scan revealed a medial juxtabulbar hemorrhage that blocked the surgical osteotomy. A clot was locally suctioned through the nose, and the symptoms resolved over the following weeks.