Dacryocystocele and Subsequent Dacryocystectomy in a Patient With Bosma Arhinia Microphthalmia Syndrome (BAMS): A Case Report and Review of Literature

Bosma arhinia microphthalmia syndrome (BAMS) is a rare syndrome consisting of several craniofacial abnormalities, including congenital arhinia. In this case report, the authors present the first case of a patient with BAMS and dacryocystocele who successfully underwent dacryocystectomy. Dacryocystectomy may serve as a viable surgical approach for dacryocystocele in patients with abnormal nasal anatomy. [J Pediatr Ophthalmol Strabismus. 2024;61(3):e16-e18.].

Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature to determine the efficacy and safety of thermal pulsation technologies in improving signs or symptoms of meibomian gland dysfunction (MGD) and dry eye compared with no therapy or with conventional warm compress therapy or eyelid hygiene.

METHODS

A literature search was conducted in the PubMed database in June 2022 and again in March 2023 to identify all studies in the English language on the use of thermal pulsation to treat MGD or dry eye. The search yielded 59 citations, and 11 articles met all of the inclusion criteria. The panel methodologist then assigned a level of evidence rating for each study; 8 studies were rated level I evidence and 3 studies were rated level II evidence.

RESULTS

All included studies evaluated a single 12-minute session using the LipiFlow automated thermal pulsation system (TearScience, Inc, or Johnson & Johnson). Improvements were detected in subjective and objective metrics of MGD or dry eye in patients within 1 to 12 months of thermal pulsation treatment compared with nontreatment. Most of the studies (9/11) reported greater efficacy with thermal pulsation than with standard warm compress therapy and eyelid hygiene. Four of these studies showed relevant industry conflicts of interest. Two of the 4 level I studies without direct industry participation concluded that thermal pulsation treatment was not significantly different from conventional hygiene or warm compress therapy control treatments (in symptoms in one of the studies and in objective findings in the second study). No serious adverse events were reported in any of the 11 studies.

CONCLUSIONS

According to the current literature, a single thermal pulsation session may improve subjective or objective parameters of MGD and dry eye safely. However, industry support and participation were present in 4 of the 8 level I studies. The durability beyond several months and cost efficacy remain uncertain. Because the inclusion parameters of this assessment captured only the LipiFlow system, the conclusions are limited to that product. High-quality independent studies are needed to assess the long-term benefits of this intervention.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Use of Mitomycin C in Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature on the adjuvant use of mitomycin C (MMC) during dacryocystorhinostomy (DCR) in adults with primary nasolacrimal duct obstructions (NLDOs) to determine the efficacy in improving functional and anatomic outcomes with an acceptable level of risk.

METHODS

A literature search conducted in November 2020 and updated in November 2022 yielded 137 articles. Twenty-four articles met the inclusion criteria and were rated for level of evidence by the panel methodologist. Inclusion criteria required controlled studies on the effect of MMC on outcomes of external, endoscopic endonasal, or diode laser-assisted transcanalicular DCR in adults with primary acquired nasolacrimal obstruction with 6 months minimum follow-up and at least 10 participants.

RESULTS

Six of the 24 articles were rated level I evidence, 15 level II , and 3 level III. In primary external DCR, MMC significantly improved functional outcomes in 3 of 9 series. In primary endoscopic endonasal DCR, MMC significantly improved functional outcomes in 1 of 9 series. In revision endoscopic endonasal DCR, MMC significantly improved functional success in 1 of 3 series. The use of MMC did not improve outcomes statistically in any diode laser-assisted transcanalicular DCR studies. Concentrations of MMC ranged from 0.05 to 1 mg/ml, with 0.2 mg/ml used most frequently in 12 series, with duration of application ranging from 2 to 30 minutes. Ostium size was significantly larger in MMC groups than in control groups at 6 months after surgery in 4 of 5 reporting studies. However, these larger ostia did not confer higher functional success rates. Reporting of adverse events related to MMC were rare, with delayed cutaneous wound healing reported in 1 of 750 patients.

CONCLUSIONS

Intraoperative use of MMC in external and endoscopic endonasal DCR has been shown to improve functional and anatomic outcomes compared with controls in some series, but there is no agreement on the recommended concentration or application time for MMC in DCR. The data support that MMC use can result in a larger ostium size, decreased granulation tissue formation, and a decreased number of postoperative nasal debridements compared with controls, but this does not translate into improved functional success.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

An orbital calcific cyst following exenteration

A 77-year-old Asian female with a history of left orbit exenteration and lid-sparing reconstruction for recurrent sebaceous carcinoma presented with fluid-like sensation of the left orbit. Magnetic resonance imaging (MRI) demonstrated bright T2 signal and a cyst-like cavity within the exenterated orbit. Decision was made to proceed with surgical exploration and excision. A calcified, bone-like cavity was encountered intraoperatively and removed. Histopathology revealed dense fibrous connective tissue with areas of calcification without osseous metaplasia, suggestive of retained blood in the orbit that underwent dystrophic calcification. This case report illustrates a rare occurrence of a bone-like calcific cyst following exenteration.

Orbital Radiation for Thyroid Eye Disease: A Report by the American Academy of Ophthalmology

PURPOSE

To review the current literature on the safety and efficacy of orbital radiation for the management of thyroid eye disease (TED).

METHODS

A literature search was conducted last in February 2021 of the PubMed database to identify all articles published in the English language on original research that assessed the effect of orbital radiation on TED. The search identified 55 articles, and 18 met the inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study, and all of them were rated level III.

RESULTS

Two large retrospective studies demonstrated the efficacy of radiation treatment, with or without corticosteroid use, in preventing or treating compressive optic neuropathy (CON). Three studies highlighted the role of orbital radiation therapy (RT) to facilitate the tapering of corticosteroids. Several other studies showed a possible role for RT to improve diplopia and soft tissue signs.

CONCLUSIONS

Although no level I or level II evidence exists, the best available evidence suggests that orbital radiation, used with or without corticosteroids, is efficacious in preventing CON, improving motility restriction, and decreasing clinical activity in TED. Orbital radiation also may facilitate a corticosteroid taper. Together, these studies show that RT seems to modify the active phase of TED. Short-term risks of orbital radiation are minor, but long-term outcome data are lacking.

Transcriptomic Profiling of Control and Thyroid-Associated Orbitopathy (TAO) Orbital Fat and TAO Orbital Fibroblasts Undergoing Adipogenesis

Purpose

Orbital fat hyperplasia commonly occurs in thyroid-associated orbitopathy (TAO). To understand molecular mechanisms underlying orbital adipogenesis, we used transcriptomics to compare gene expression in controls and patients with TAO, as well as in orbital fibroblasts (OFs) undergoing adipogenic differentiation.

Methods

We performed bulk RNA sequencing (RNA-Seq) on intraconal orbital fat from controls and patients with TAO. We treated cultured OFs derived from patients with TAO with adipogenic media to induce adipogenesis. We used single nucleus RNA-Seq (snRNA-Seq) to profile treated and control OFs, identifying genes that are dynamically expressed during orbital adipogenesis in vitro, and compared these results to data from control and TAO orbital fat.

Results

Gene expression profiles in control and TAO orbital fat are distinct. Signaling pathways including PI3K-Akt signaling, cAMP signaling, AGE-RAGE signaling, regulation of lipolysis, and thyroid hormone signaling are enriched in orbital fat isolated from patients with TAO. SnRNA-Seq of orbital fibroblasts undergoing adipogenesis reveals differential expression of the adipocyte-specific genes FABP4/5, APOE, PPARG, and ADIPOQ during adipogenic differentiation. The insulin-like growth factor-1 receptor and Wnt signaling pathways appear to be enriched early in adipogenesis. Gene modules that are enriched in TAO orbital fat are upregulated in orbital adipocytes during differentiation in vitro, whereas genes that are enriched in control orbital fat are enriched in undifferentiated OFs.

Conclusions

We identified pathways enriched in TAO orbital fat, and dynamic changes in gene expression that occur during adipogenic differentiation of orbital fibroblasts. These findings may help guide functional studies of genes and pathways critical for orbital adipogenesis.

Homeopathic Agents or Vitamins in Reducing Ecchymosis after Oculofacial Surgery: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature to determine the efficacy and safety of homeopathic agents or vitamins in reducing ecchymosis after oculofacial surgery or laser surgery.

METHODS

A literature search was conducted in the PubMed database initially in December 2019 and updated in March 2020 to identify all studies in the English language literature on the use of homeopathic agents or vitamins in oculofacial procedures, including laser surgery. The search yielded 124 citations, and 11 articles met all inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study. Eleven studies met inclusion criteria; 9 were rated level I, and 2 were rated level III.

RESULTS

The agents studied in the articles identified included oral or topical Arnica montana (AM), oral Melilotus extract, topical vitamin K oxide, and topical AM combined with Rhododendron tomentosum. Metrics to describe ecchymosis varied. In 7 controlled studies, perioperative AM provided no or negligible benefit versus placebo. In 2 studies, vitamin K cream was equivalent to placebo. One study of oral Melilotus extract had less ecchymosis compared with controls in paranasal and eyelid ecchymosis at postoperative day (POD) 7, but not at PODs 1 and 4. A lone cohort study of combined topical AM and R. tomentosum lacked objective metrics and adequate controls. No serious side effects from administration of homeopathic agents or vitamins were identified.

CONCLUSIONS

The current literature does not support the use of AM, vitamin K oxide, R. tomentosum, or Melilotus extract for reducing ecchymosis after oculofacial surgery or pulsed dye laser surgery.

Segmental Imaging of the Trochlear Nerve: Anatomic and Pathologic Considerations

BACKGROUND

The trochlear nerve (the fourth cranial nerve) is the only cranial nerve that arises from the dorsal aspect of the midbrain. The nerve has a lengthy course making it highly susceptible to injury. It is also the smallest cranial nerve and is often difficult to identify on neuroimaging.

EVIDENCE ACQUISITION

High-resolution 3-dimensional skull base MRI allows for submillimeter isotropic acquisition and is optimal for cranial nerve evaluation. In this text, the detailed anatomy of the fourth cranial nerve applicable to imaging will be reviewed.

RESULTS

Detailed anatomic knowledge of each segment of the trochlear nerve is necessary in patients with trochlear nerve palsy. A systematic approach to identification and assessment of each trochlear nerve segment is essential. Pathologic cases are provided for each segment.

CONCLUSIONS

A segmental approach to high-resolution 3-dimensional MRI for the study of the trochlear nerve is suggested.

Interventions for Indirect Traumatic Optic Neuropathy: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head.

METHODS

A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis.

RESULTS

No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.

CONCLUSIONS

Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.

Thyroid Eye Disease-Related Epiblepharon: A Comparative Case Study

PURPOSE

This study describes the clinical features and management of epiblepharon as a manifestation of thyroid eye disease (TED). In addition, we compare the frequency and age in Asian and non-Asian patients, and discuss pathophysiologic implications.

DESIGN

Retrospective case-control study.

METHODS

This is a single-center retrospective review that identified 172 adult patients (age 19 to 83) with TED that were consecutively evaluated by 1 author (T.J.M.) between December 2015 and July 2018. Diagnosis of TED and epiblepharon was based upon clinical assessment as documented in the medical record.

RESULTS

In a cohort of 172 patients (mean age 52; 138 female), 3 patients with acquired epiblepharon were identified, all of whom were Asian. The proportion of affected Asian patients (3/of 17, 17.6%) was significantly higher than that of non-Asian patients (0/155, P < 0.001). Patients with epiblepharon were also significantly younger than those without epiblepharon, 29.7 ± 2.1 versus 48.7 ± 13 years of age (P = 0.026). All 3 patients underwent surgical correction with lateral canthoplasty and anterior lamellar pretarsal fixation with successful outcomes.

CONCLUSIONS

Lower eyelid epiblepharon may occur in TED. In our clinic-based population, this finding was significantly more frequent in Asian patients and in younger patients. Relieving horizontal tension in conjunction with anterior lamella pretarsal fixation is an effective method of correcting TED-associated epiblepharon.

Association of Giant Cell Arteritis With Race

Importance

Giant cell arteritis (GCA) is the most common vasculitis in adults and is associated with significant morbidity and mortality. Its incidence has been carefully studied in white populations, yet its relevance among other racial and ethnic groups is less well known.

Objective

To examine the incidence of biopsy-proven GCA (BP-GCA) in a tertiary care center-based population with a sizeable proportion of black patients.

Design, Setting, and Participants

This retrospective cohort study identified all patients who underwent temporal artery biopsy (TAB) from July 1, 2007, through September 30, 2017, using the electronic medical record system at the Johns Hopkins Wilmer Eye Institute. Associations between self-reported race, sex, and age were explored and compared with all other patients attending the hospital over the same period. Data were analyzed from November 1, 2017, through July 31, 2018.

Main Outcomes and Measures

Estimated incidence rates of BP-GCA in black and white patients.

Results

Among 586 patients who underwent TAB (mean [SD] age, 70.5 [11.1] years; age range, 32-103 years; 423 [72.2%] women), 167 (28.5%) were black, 382 (65.2%) were white, and 37 (6.3%) were other or unknown. Of 573 individuals 50 years and older, 92 (16.1%) had BP-GCA; 14 were black (8.4% of all black patients undergoing testing) and 75 were white (19.6% of all white patients undergoing testing). Crude annual incidence rates for BP-GCA were 2.9 (95% CI, 1.3-5.5) per 100 000 for black and 4.2 (95% CI, 3.0-5.6) per 100 000 for white patients within the study population. Population-adjusted age- and sex-standardized incidence rates were 3.1 (95% CI, 1.0-5.2) and 3.6 (95% CI, 2.5-4.7) per 100 000 for black and white patients, respectively (difference, 0.5; 95% CI, -1.7 to 2.7; P = .70). The incidence rate ratio was 1.9 in women compared with men (95% CI, 1.1-3.4; P = .03) but was not significant in white compared with black patients (1.2; 95% CI, 0.6-2.4; P = .66).

Conclusions and Relevance

In our cohort, BP-GCA occurred more commonly in women, but rates were similar between races. These findings do not appear to support the conclusion that GCA occurs more frequently in white compared with black patients.

Delayed Orbital Emphysema Mimicking Orbital Cellulitis: An Uncommon Complication of Dental Surgery

A 79-year-old man presented to the ophthalmology clinic with acute-onset left orbital and periorbital swelling, 6 days following surgery to revise a zygomatic implant to anchor his dentures. On evaluation, there was left eye proptosis with ipsilateral facial crepitus. Emphysema was confirmed on computed tomography. With visual function and motility remaining intact, he was observed without intervention. Within 2 weeks, his evaluation returned to baseline. Periorbital emphysema is a rare complication of dental procedures. Awareness of this potential complication enables timely diagnosis and avoidance of unnecessary therapy.

Temperature changes associated with bone drilling in an orbital model: comparison of ultrasonic bone curette and conventional high-speed rotational drill

Purpose: Thermal injury to the optic nerve is a potential complication of bony decompression of the orbital apex. An animal model was used to compare and contrast temperature change while removing orbital bone with ultrasonic and conventional drills. Methods: Two devices, Sonopet ultrasonic bone curette and TPS CORE Micro drill, were used to remove bone from six unpreserved exenterated porcine orbits at fixed distances from the optic canal while temperature was recorded. Increasing irrigation flow rate and decreasing saline temperature with the ultrasonic bone curette were also investigated. Results: The mean change in temperature at the optic canal using the ultrasonic bone curette with 18 ml/min 24°C irrigation was +7.2 ± 3.3°C (range 3.3-12.7°C) at 60 s, and using the rotational drill was +1.7 ± 1.3°C (range 0.1-3.3°C), representing a statistically significant increase above baseline for both drills (p < 0.01 for each). The difference in temperature change between drills was statistically significant (p < 0.01). When irrigation fluid was changed from room temperature saline (24°C), rate 18 ml/min to chilled (10°C) irrigation saline, rate 40 ml/min, the magnitude of the mean temperature increase was reduced by 3.1°C, p < 0.05. Conclusions: In this orbital decompression model, both ultrasonic and rotational drills induced a rise in temperature. This increase was significantly greater with the ultrasonic bone curette, measuring up to 13.7°C. Clinicians should be aware of the potential for temperature spikes when decompressing the orbital apex. Increasing irrigation flow rate and using chilled saline may mitigate increases in temperature.

Intravitreal Triamcinolone Acetonide Injection in a Rodent Model of Anterior Ischemic Optic Neuropathy

INTRODUCTION

The management of nonarteritic anterior ischemic optic neuropathy centers around prevention of second eye involvement, without a uniformly accepted therapy for the involved eye. Several researchers have assessed the benefit of steroids with conflicting results. This experimental study was designed to evaluate the efficacy of a single intravitreal triamcinolone acetonide injection (IVTA) in preserving retinal ganglion cells (RGCs) in a rodent model of anterior ischemic optic neuropathy (rAION).

METHODS

The rAION was induced in female Wistar rats. Animals were randomized into 3 groups: 1) untreated, 2) treated with 56 μg IVTA, and 3) intravitreal saline (placebo). Procedures were performed in the left eye, with the right eye serving as control. After 30 days, animals were sacrificed and eyes were assessed histologically for RGC number.

RESULTS

The average number of RGC was significantly lower in rAION subgroups when compared with the control group (P < 0.001). No significant difference was seen between rAION eyes treated with IVTA, placebo, and untreated eyes (P > 0.05%).

CONCLUSIONS

In this rodent model for AION, no therapeutic benefit of intravitreal steroid injection was identified.

Brown Syndrome Following Upper Eyelid Ptosis Repair

Brown syndrome is characterised by impaired supraduction worse in adduction due to a restricted superior oblique tendon passing through the trochlea. A few reports have previously described Brown syndrome after upper eyelid surgery, including blepharoplasty and ptosis repair. The authors describe two additional cases of Brown syndrome following ptosis repair. The first case is a 65-year-old woman with new-onset vertical binocular diplopia following bilateral levator advancement surgery. Ocular motility examination demonstrated moderate impairment of elevation in adduction. The second case is a 35-year-old woman who presented with new-onset intermittent binocular diplopia following right upper lid ptosis repair. Examination revealed large vertical fusional amplitudes and a large left intermittent hyperphoria in an alignment pattern consistent with Brown syndrome. Despite presenting after surgery, these cases differ in mechanism. The first case likely occurred due to intraoperative impairment of the superior oblique tendon sheath or trochlea, whereas the second case represented an unmasking of a long-standing, previous vertical strabismus that was consistent with a Brown syndrome pattern.

Medial Rectus Muscle Incarceration in Pediatric Medial Orbital Wall Trapdoor Fractures

PURPOSE

We describe two cases of orbital trapdoor fractures with medial rectus muscle incarceration.

METHODS

Small interventional case series.

RESULTS

This is a retrospective university based report of two healthy males (11 and 14 years old) who developed diplopia following blunt orbital trauma. Both patients had decreased horizontal ocular motility of the involved eye with minimal additional evidence of trauma. Computed tomography (CT) demonstrated no significant bony displacement; however, the left medial rectus muscle was located within the ethmoid sinus in the first and had an abnormal size and shape in the second case. In both cases, during urgent surgical repair, the incarcerated medial rectus muscle was gently released from linear non-displaced medial wall fractures and ocular motility normalized postoperatively.

CONCLUSIONS

In pediatric patients sustaining blunt orbital trauma, medial rectus incarceration should be considered and managed accordingly.

Orbital Disease in Neuro-Ophthalmology

Many abnormalities of the orbit present with neuro-ophthalmic findings, such as impaired ocular motility or alignment, and sensory changes, including optic neuropathy. Comprehensive coverage of all orbital diseases is beyond the scope of this article. This review focuses on diagnosis and management of the most common and the most vision- or life-threatening orbital conditions as well as more recently discovered entities and points of active controversy. These conditions include orbital trauma, vascular disease, inflammatory and infectious diseases, and neoplasms. Common presenting symptoms and associated neuro-orbital diseases also are summarized.

Intracranial pressure and skull remodeling

In this article we review bony changes resulting from alterations in intracranial pressure (ICP) and the implications for ophthalmologists and the patients for whom we care. Before addressing ophthalmic implications, we will begin with a brief overview of bone remodeling. Bony changes seen with chronic intracranial hypotension and hypertension will be discussed. The primary objective of this review was to bring attention to bony changes seen with chronic intracranial hypotension. Intracranial hypotension skull remodeling can result in enophthalmos. In advanced disease enophthalmos develops to a degree that is truly disfiguring. The most common finding for which subjects are referred is ocular surface disease, related to loss of contact between the eyelids and the cornea. Other abnormalities seen include abnormal ocular motility and optic atrophy. Recognition of such changes is important to allow for diagnosis and treatment prior to advanced clinical deterioration. Routine radiographic assessment of bony changes may allow for the identification of patient with abnormal ICP prior to the development of clinically significant disease.

Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was "rounded" relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically.

Spontaneous subperiosteal orbital hemorrhage

Subperiosteal orbital hemorrhage typically results from trauma. Spontaneous subperiosteal orbital hemorrhage (SSOH) is rare and has been reported with sudden elevation of cranial venous pressure, bleeding diathesis, and sinusitis. This article presents a series of 9 patients (11 orbits) with SSOH and review the associated systemic conditions. 10 out of 11 orbits (91%) underwent surgical intervention due to advanced orbital signs or poor vision.

Sphenoid sinus expansion: a radiographic sign of intracranial hypotension and the sunken eyes, sagging brain syndrome (an American Ophthalmological Society thesis)

PURPOSE

To test the hypothesis that in patient with sunken eyes, sagging brain syndrome, bone remodeling is not limited to the orbits. Volumetric analysis of the sphenoid sinus is performed in this study.

METHODS

In this university-based retrospective case-control study, the dimensions of the sphenoid sinus were measured in four patients (2 males, 2 females; mean age 26.3 years, range 16-38 years) out of five individuals identified with sunken eyes, sagging brain syndrome. Three measurements were taken: the distance between the orbital apices, the posterior extension of the sphenoid sinus posterior to the orbital apices, and the maximal horizontal width. The mean of each was determined and compared to that of the control group (5 males, 5 females; mean age 35.6 years, range 23-45 years).

RESULTS

Posterior extension and width of the sphenoid sinus were markedly larger in the enophthalmic patients than in the control group: posterior extension (26.3 ± 4.1 mm vs 13.4 ± 6.3 mm, P=.0015, Student's t test), width (39.2 ± 8.7 mm vs 25.1 ± 6.9 mm, P=.0035, Student's t test). Mean distance between the orbital apices was slightly greater (36.3 ± 1.7 mm vs 34.1 ± 2.1 mm, P=.047, Student's t test).

CONCLUSIONS

Skull remodeling occurring in association with intracranial hypotension after ventriculoperitoneal shunting is not limited to the orbits. In this study we have demonstrated expansion of the sphenoid sinus. This finding adds to our knowledge and understanding of the scope of the sunken eyes, sagging brain syndrome and elucidates a clinically useful radiographic sign.

Long-term management of orbital and systemic reactive lymphoid hyperplasia with rituximab

Rituximab, a monoclonal antibody to the B cell marker CD20, is becoming increasingly popular in the treatment of various orbital disorders. In this university-based interventional case series, we describe two patients with bilateral orbital and extra-orbital reactive lymphoid hyperplasia (RLH) treated with rituximab. Initially both had favorable responses; but roughly a year later recurrent disease necessitated maintenance therapy in both cases. Both again responded to additional courses of rituximab. Although recalcitrant disease may persist after treatment, rituxmab may play a role in the management of RLH with widespread involvement.

Comparison of Humphrey Matrix frequency doubling technology to standard automated perimetry in neuro-ophthalmic disease

Purpose:

We compared Humphrey Matrix FDT 30-2 (FDT) and Humphrey Visual Field Analyzer 30-2 SITA standard (SAP) in the assessment of anterior (optic nerve or chiasm) and posterior (retro-chiasmal) afferent visual pathway defects.

Materials and Methods:

In this retrospective comparative study, the charts of 37 patients (16 males, range 13-84 years, mean 72.1), with neuro-ophthalmic visual field defects who were tested with both FDT and SAP, were reviewed. Two masked graders assessed the concordance and extent of field defects between the perimeters. The mean concordance between anterior and posterior disease was compared using the Wilcoxon rank sum test. The mean deviation (MD) and pattern standard deviation (PSD) of each perimeter were correlated with the Spearman coefficient.

Results:

Twenty-eight patients had anterior and nine had posterior disease. Most had a fair or good concordance (89.3% anterior, 88.9% posterior). When comparing anterior to posterior disease, the mean concordance of the defects of the two parameters was not statistically different (P = 0.94 and P = 0.61 for total deviation and pattern deviation, respectively). The MD and PSD between perimeters had a significant correlation.

Conclusions:

Our series, using 30-2 field analysis, demonstrates fair to good correlation between FDT and SAP in the majority of patients. In roughly 10% findings between FDT and SAP were discordant. This difference was similar for anterior and posterior disease.

Evisceration in the modern age

Evisceration is an ophthalmic surgery that removes the internal contents of the eye followed usually by placement of an orbital implant to replace the lost ocular volume. Unlike enucleation, which involves removal of the entire eye, evisceration potentially causes exposure of uveal antigens; therefore, historically there has been a concern about sympathetic ophthalmic (SO) associated with evisceration. However, critical review of the literature shows that SO occurs very rarely, if ever, as a consequence of evisceration. Its clinical applications overlap with those of enucleation in cases of penetrating ocular trauma and blind painful eyes, but it is absolutely contraindicated in the setting of suspected intraocular malignancy and may be preferred for treatment of end-stage endophthalmitis. From a technical standpoint, traditional evisceration has a limitation in the orbital implant size. Innovations with scleral modification have overcome this limitation, and accordingly, due to its simplicity, efficiency, and good cosmetic results, evisceration has once again been gaining popularity.

Orbital trapdoor fractures

Orbital trapdoor fractures are commonly encountered in children. Awareness of trapdoor fractures is of particular importance. This is because early recognition and treatment are necessary to prevent permanent motility abnormities. In this article, we will provide a brief overview of orbital fractures. The clinical and radiographic features of trapdoor fractures will then be reviewed, followed by a discussion on their proper management.

Facial nerve injury: a complication of superficial temporal artery biopsy

PURPOSE

To describe 4 patients who sustained facial nerve injury during temporal artery biopsy.

DESIGN

Retrospective, observational case series.

METHODS

The medical records were reviewed of 4 patients (2 men, 2 women; mean age 72.8 years, range 60 to 87), referred for evaluation of palsy of the frontal branch of the facial nerve following temporal artery biopsy. Main outcomes measured were site of incision, length of follow-up, and degree of recovery.

RESULTS

In all cases, incisions were made in the preauricular region or on the pretrichial temple within 3 cm of the lateral canthal angle. Follow-up ranged from 1 month to over 5 years. No patient recovered completely; 2 had partial return of function, and 2 reported no improvement.

CONCLUSIONS

Branch facial nerve palsy can occur with temporal artery biopsy and is likely to result in permanent disability. In all cases the incision was placed within the known course of the frontal branch of the facial nerve. To prevent this rare complication, we advocate biopsy of the parietal, rather than the frontal, branch of the superficial temporal artery.

Acquired pediatric blepharoptosis related to linear scleroderma

Periocular linear scleroderma coup de sabre has been seen in association with blepharoptosis. The authors describe a 4-year-old girl who developed left blepharoptosis simultaneously with a remote scalp lesion consistent with linear scleroderma coup de sabre. This case is unique in that the scalp lesion was distant from the affected eye.

Giant cell arteritis in Asians: a comparative study

BACKGROUND

Giant cell arteritis (GCA) is a common systemic vasculitis, with a presumed Caucasian predominance. The occurrence of GCA in Asians has rarely been addressed. This study aims to assess the incidence of giant cell arteritis in Asians.

METHODS

In this retrospective review, the self-reported ethnicities of patients with biopsy-proven GCA at the University of California-San Francisco (UCSF) were recorded. Ethnic distribution of the patient population served by UCSF was estimated from an age- and sex-matched control group. The odds ratio for each ethnicity (Asian and Caucasian) was determined and compared using Fisher's exact test and logistic regression analysis.

RESULTS

The ethnic distribution of the 38 patients with positive temporal artery biopsies were as follows: Caucasian n=31 (81.6%), Asian n=1 (2.6%) and other n=6 (15.8%). The ethnic distribution of the patient population served by UCSF was as follows: Caucasian 42%, Asian 28% and other 30%. The difference in the proportion of GCA in Asians and Caucasians was statistically significant (OR 0.049 (95% CI 0.0065 to 0.374), p=0.0036).

CONCLUSIONS

In our patient population, GCA was seen 20 times less frequently in Asian than Caucasian patients. Although this difference is significantly different (p=0.036), given the small sample size and wide CI this should be viewed as a rough estimate.

Marsupialization of orbital conjunctival inclusion cysts related to strabismus surgery

A 52-year-old woman presented with a giant conjunctival cyst related to strabismus surgery that was adjacent to the medial rectus muscle. Management consisted of excision of the anterior cyst wall with suturing of the remaining cyst lining to overlying conjunctiva. Following marsupialization, the cyst did not recur with persistence of the conjunctival drainage site.

Blindness from orbital varices: case report

A 41-year-old woman presented with a 21-year history of a left orbital mass. She reported 3 distinct episodes of sudden proptosis, periorbital bruising, pain, nausea and vomiting with resulting stepwise deterioration in her vision. Her symptoms resolved spontaneously over several days, with the exception of loss in vision, which persisted. Examination was notable for ipsilateral enophthalmos in primary gaze. With Valsalva she developed proptosis. Magnetic resonance imaging (MRI) demonstrated a left orbital apex malformation consistent with a varix. She had no light perception on the left with end-stage optic atrophy. This case illustrates the severity of visual loss that can occur with orbital varices.

No correlation between intraocular pressure and intracranial pressure

A recent study has reported an excellent correlation between intraocular pressure (IOP) and intracranial pressure (ICP), suggesting that measurement of IOP may serve as a noninvasive means to determine ICP. To reexamine the relation between IOP and ICP, we reviewed the medical records of all patients who underwent lumbar puncture between 1991 and 2007 in the neuro-ophthalmology clinic at the University of California San Francisco. Data for IOP and ICP were available for 55 patients. There was no correlation between IOP and ICP (Pearson correlation coefficient, r = 0.07; p = 0.59). IOP measurement is not a useful substitute for ICP measurement.

Levator superioris muscle function in involutional blepharoptosis

PURPOSE

To assess the role of muscular degeneration, we evaluated the correlation between ptosis severity and levator muscle function.

DESIGN

Retrospective cohort study.

METHODS

The medical records of 136 patients (53 men and 83 women; mean age, 67 years) with acquired blepharoptosis were reviewed for levator function (LF), margin reflex distance (MRD), age, and gender. Multivariate linear regression was performed for statistical analysis.

RESULTS

A significant correlation (P < .001) was seen between MRD (mean, 1.0 + 1.0 mm; range, -3.0 to 3.0 mm) and LF (mean, 15.0 + 1.0 mm; range, 11.0 to 20.0 mm). On average, a 0.5-mm reduction in LF was observed for each 1.0-mm decrease in MRD. This was independent to other variables assessed.

CONCLUSIONS

In patients with involutional blepharoptosis, a directly proportional decrease in levator function and eyelid height was observed. This may implicate an abnormality of the levator muscle itself as a contributing factor in the development of involutional blepharoptosis.

Suprasellar germinoma and late perioptic seeding

PURPOSE

To report an unusual case of optic nerve seeding 12 years following treatment of a suprasellar germinoma.

METHODS

Observational case report.

RESULTS

A 34-year-old woman presented with a 3-week history of subjective right eye visual loss. She had been diagnosed with a suprasellar germinoma at 22 years of age, which had been partially excised and radiated (5400 cGy). The tumor had shown complete radiographic regression without neurologic sequelae. Pertinent findings on current examination included right eye visual acuity of 20/150, right relative afferent papillary defect, and optic nerve pallor in the right eye. In addition, partial left facial paralysis was noted. Examination was otherwise unremarkable including 20/20 acuity in the left eye. Magnetic resonance imaging demonstrated abnormal enhancement and thickening of both optic nerves and along the course of the left V and VII cranial nerves. Serum levels of alpha-fetoprotein and beta-HCG were abnormal, consistent with metastatic germinoma. Following two cycles of chemotherapy (VIP-etoposide, ifosfamide, and cisplatin), visual acuity returned to 20/20 bilaterally, with corresponding radiographic improvement and normal cerebrospinal fluid cytology.

CONCLUSIONS

Perioptic subarachnoid seeding may occur over a decade after presumed successful treatment of germinomas, suggesting the importance of lifelong observation.

Isolated sixth cranial nerve aplasia visualized with Fast Imaging Employing Steady-State Acquisition (FIESTA) MRI

An otherwise healthy 12-month-old girl presented for evaluation of reduced abduction of the left eye detected at 6 months of age. The remainder of the examination was unremarkable. A special MRI sequence-fast imaging employing steady-state acquisition (FIESTA)-visualized the right but not the left sixth nerve cisternal segment. This is the first reported use of the MRI FIESTA sequence to diagnose aplasia of the sixth cranial nerve.

Risk of non-arteritic anterior ischaemic optic neuropathy (NAION) after cataract extraction in the fellow eye of patients with prior unilateral NAION

AIM

To determine the risk of non-arteritic anterior ischaemic optic neuropathy (NAION) after cataract extraction (CE) in the fellow eye of patients with prior unilateral NAION.

DESIGN

Retrospective, cohort study.

METHODS

Medical records of patients with NAION evaluated in our institution between 1 January 1986 and 31 December 2001 were reviewed to determine the onset of NAION and the time of CE. Patients were excluded if the date of NAION and CE was unreliable, or if CE in the fellow eye was performed before the unilateral NAION. Statistical analysis was performed by including fellow eye CE as a time-dependent covariate in a Cox proportional hazards regression model of NAION incidence in the fellow eye.

RESULTS

Of the 325 eligible patients, 9 (53%) of 17 patients with NAION who underwent CE in the fellow eye developed fellow eye NAION, and 59 (19%) of 308 patients with NAION who did not undergo CE in the fellow eye developed fellow eye NAION. Cataract extraction in the fellow eye increased the risk of NAION occurrence in the fellow eye by 3.6-fold (Cox regression, p=0.001).

CONCLUSIONS

Patients with unilateral NAION are at a significantly higher risk of developing NAION in the fellow eye after CE.