Periorbital necrotizing fasciitis -- a review

Necrotizing fasciitis (NF) is a severe infection characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin. Periorbital NF is uncommon because of the excellent blood supply to that area; nevertheless, it can sometimes result in death. The aim of this study is to present a systematic review and analyse the factors associated with death. We carried out a systematic literature review of all cases of periorbital NF published in the English language over the past 20 years and present the predisposing conditions, triggering factors, organisms causing NF, presence or absence of toxic shock and the prognosis. The significance of various risk factors leading to death was analysed. We traced a total of 94 patients with periorbital NF from 61 reports. There were no triggering incidents in 25 cases (26.6%). In 48 cases (51.1%), the organism responsible for NF was Group A beta haemolytic Streptococcus. Toxic shock occurred in 29 (30.9%) cases, and loss of vision in 13 (13.8%). Surgical debridement was carried out in 80 (85.1%) cases. There were eight cases (8.5%) of death. This seems to be less than previously reported figures. Toxic shock syndrome (p < 0.001), type 1 infections (p = 0.018), facial involvement (p = 0.032) and blindness because of periorbital NF (p = 0.035) were significantly associated with mortality. Mortality caused by NF arising from the periorbital area seems to be on the decline. However, it is important to recognize it early and institute treatment to avoid toxic shock that leads to death. Type 1 infections, although rare in periorbital area, are not associated with immunocompromised status and nevertheless carry a significant risk of mortality. Major morbidity is loss of vision followed by soft-tissue defects affecting function and cosmesis.

Ophthalmic involvement in cranio-facial trauma

OBJECTIVES

This is a retrospective descriptive case study which will look into the spectrum of ophthalmic involvement in cases with orbital and eye injuries after cranio-facial trauma and to analyse the visual and motility outcome.

MATERIAL

One hundred and four cases with ophthalmic involvement after cranio-facial trauma that were referred to and seen in the eye department of a tertiary teaching hospital in Singapore between 1991-97 were included in the study.

METHODS

The case records of 104 such patients were traced. The demographic data, the mode of injury, the type of fracture sustained and presence of serious eye injury were noted. The details about visual acuity, significant diplopia and enophthalmos at the first and last visits were charted. Presence of traumatic optic neuropathy including the type of treatment given was recorded.

RESULTS

There was a male preponderance (82%). The industrial accidents were 21%, only next to road traffic accidents, which constituted approximately 36.5%. The predominant types of fractures seen were blow-out orbital fractures, complex fractures comprising of Le-Fort II, III, panfacial and fronto-basilar skull fractures. Diplopia was the most common presenting feature (40%) with visual acuity disturbance (23% having <6/60) as the next most common finding. Traumatic optic neuropathy was seen in 20% of patients and serious eye injury was present in 9% of patients. The incidence of traumatic optic neuropathy was significantly higher (p<0.001) in patients with complex fractures and fronto-basilar fractures, as compared to the blow-out and zygomatico-maxillary fractures. Analysis of final results indicated 15% as having significant diplopia in one or more gazes and 12.5% as having a vision of <6/60.

CONCLUSION

Diplopia and visual acuity disturbances seem to be the most common ophthalmic presentations in cranio-facial trauma. A significant number of patients suffer from poor vision and significant diplopia despite treatment.

Thyroid eye disease: a Southeast Asian experience

AIM

To study the demographics, comorbidities, clinical manifestations and treatment methods of thyroid eye disease (TED) in Singapore.

METHODS

In this retrospective case series, we analysed the case records of all patients with TED who presented at our multidisciplinary Thyroid Eye Clinic from November 2002 to October 2012.

RESULTS

There were a total of 174 patients-111 female patients (63.8%) and 63 male patients (36.2%). The majority of the patients were ethnically Chinese (80.5%), followed by Malay (10.3%) and Indian (6.3%). The mean age was 40.2 years (SD±15.5, range 0.3-87.0). The commonest sign on ophthalmic examination was eyelid retraction (62.1%), followed by proptosis (61.0%) and lid lag (57.5). Acquired epiblepharon and corneal erosions were noted in 11.5% and 29.3% respectively. Eight patients (4.6%) had dysthyroid optic neuropathy. The mean exophthalmometry reading was 18.8 mm (SD±3.32, range 10.0-28.0). Mild, moderate and severe disease was noted in 71.3%, 20.7% and 8.0% respectively. Thyroid dysfunction was managed with anti-thyroid medication only (40.2%), β blockers (19.5%), thyroxine replacement (14.4%), radioactive iodine (14.4%) and block-replace regime (9.8%). Clinically significant active orbitopathy was managed with intravenous corticosteroids (12.1%). Surgical procedures consisted of thyroidectomy (10.3%), eyelid surgery (8.6%), orbital decompression (7.5%), epiblepharon correction (2.3%) and strabismus surgery (0.6%).

CONCLUSIONS

Corneal erosion secondary to acquired epiblepharon is a common sign in East Asian patients with TED, thus increased awareness among physicians should be encouraged. Mean exophthalmometry values and frequencies of upper eyelid retraction and oedema are lower in East Asian patients compared with Caucasian patients. Among Singapore's multi-ethnic population, Malay patients with TED had the highest exophthalmometry reading.

Epiblepharon in East asian patients: the singapore experience

PURPOSE

To describe the demographics, presenting symptoms, indications for surgery, and surgical outcomes of epiblepharon correction in a tertiary care hospital in Singapore.

DESIGN

Retrospective review of patients who underwent surgery by 2 surgeons in a referral oculoplastic practice at the National University Health System, Singapore, from 2001 to 2007.

PARTICIPANTS

A total of 108 patients who underwent surgery for clinically significant epiblepharon.

INTERVENTION

Modified Hotz procedure or suture correction for patients in whom conservative treatment failed.

MAIN OUTCOME MEASURES

Comparison of symptoms, keratopathy, and recurrence on follow-up between the 2 procedures.

RESULTS

The mean age of the patients was 9.0 years, with an age range of 0.5 to 68 years. Of the patients, 51.9% were male. The majority were Chinese (n = 102). Seventy-four (68.5%) patients were symptomatic. Eighty-nine patients (82.4%) had keratopathy. In 98 patients (90.7%) both eyes were affected, and the majority of patients (75.0%) had epiblepharon of the lower lids. Initial treatment for the majority was lubricants (n = 71, 65.7%). The main indications for surgery were symptoms and keratopathy, with 37.9% of patients having both, and 44.4% and 15.7% of patients having either keratopathy or symptoms alone, respectively. Surgical correction consisted mostly of a modified Hotz procedure (n = 88, 81.5%), lid-everting sutures (n = 9, 8.3%), and others, including upper lid blepharoplasty with lid crease formation (n = 11, 10.2%). Outcomes were good, with the majority (n = 88, 81.5%) of lids being well corrected. Complications included undercorrection, overcorrection, wound dehiscence, and wound infections.

CONCLUSIONS

Symptomatic epiblepharon, usually associated with keratopathy and commonly seen in children of East Asian descent, often requires surgical intervention with good surgical outcome. Increased awareness among ophthalmologists and pediatricians dealing with this ethnic group and age is emphasized. Contrary to the current practice of expectant observation, definitive surgical management should be considered when symptoms or keratopathy is present.

FINANCIAL DISCLOSURE(S)

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

Refractive changes in epiblepharon

PURPOSE

To study the prevalence of astigmatism in patients with epiblepharon and keratopathy and to determine if astigmatism was influenced by surgical correction.

DESIGN

This is a retrospective review of 182 eyes of 91 patients who were diagnosed with significant epiblepharon at the National University Hospital, Singapore.

METHODS

Demographic data, best-corrected visual acuity, refractive error at presentation and annually thereafter, presence of amblyopia, severity of keratopathy, and nature of surgical intervention if any were recorded.

RESULTS

Mean age of the patients was 7.23 +/- 6.43 years. 52.2% of patients had astigmatism of 1 diopter (D) or more (range, -0.5 to -4.0 D), and the astigmatism was largely with-the-rule. There was no significant association between severity of keratopathy and astigmatism. Nine percent of patients had amblyopia after spectacle correction and all had significant astigmatism. A total of 70.3% of patients underwent surgery and mean time to surgery was 12.2 +/- 13.1 months after diagnosis. Mean age to surgery was 7.5 +/- 7.12 years. Comparison of pre- and postoperative astigmatism in patients younger than age 5 at the time of surgery showed no significant changes in astigmatism at one to two years of follow-up.

CONCLUSIONS

There was high prevalence of astigmatism in patients with epiblepharon (52.2% had 1 D or more of astigmatism). A total of 9% of patients had amblyopia from astigmatism. Surgery did not seem to affect astigmatism especially in young children. Possibility of amblyopia from astigmatism must be borne in mind while treating children with epiblepharon.

Use of bioresorbable implants for orbital fracture reconstruction

PURPOSE

Bioresorbable implants offer several advantages over permanent implants and serve as a useful alternative in the reconstruction of orbital fractures. Our aim of the study was to evaluate the clinical effectiveness and safety of various bioresorbable implants in the repair of orbital fractures.

METHODS

A retrospective review of all patients who had undergone orbital fracture repair with bioresorbable implants in a single tertiary trauma centre from January 2005 to December 2014 was performed. Main outcome measures included improvement in ocular motility, diplopia, enophthalmos and infraorbital hypoaesthesia, as well as complication rates.

RESULTS

Our study comprised 94 patients and 98 orbits. The types of fractures included orbital floor blow-out fractures (56.1%), zygomaticomaxillary complex fractures (20.4%), combined orbital floor and medial wall fractures (15.3%) and medial wall blow-out fractures (5.1%). The implants evaluated included poly-L/DL-lactide implants (P[L/DL]LA) 85/15 (Rapidsorb), (P[L/DL]LA) 70/30 (PolyMax), polycaprolactone (Osteomesh) and (P[L/DL]LA) 70/30 (MacroPore). There was significant improvement in ocular motility, diplopia, enophthalmos and infraorbital hypoaesthesia postoperatively at week 1, 1 month and 6 months (p<0.001). Comparison of results between the various implants and types of fractures showed no significant difference in postoperative outcome and complications. Late postoperative imaging at 15-24 months showed complete resorption of implants and features of neobone formation in all patients.

CONCLUSION

Our experience with bioresorbable implants shows them to be safe and clinically effective in the reconstruction of orbital fractures.

Ocular prosthetics: use of a tissue conditioner material to modify a stock ocular prosthesis

The custom-made ocular prosthesis contributes to enhanced tissue health of the anophthalmic socket. For this purpose, an acrylic resin ocular prosthesis may be modified, by using an appropriate dental impression material and being adapted closely to the anophthalmic socket. The modeling impression material is subsequently replaced by acrylic resin. This article describes the application of a viscoelastic tissue conditioner material, as an impression medium for prosthetic modification of an ocular prosthesis. The tissue conditioner material exhibits favorable tissue compatibility, adhesion to acrylic resin, and detailed surface registration. These advantages facilitate the clinical procedure and evaluation of modifications made to the ocular prosthesis.

Tear flow dynamics in the human nasolacrimal ducts--a pilot study using dynamic magnetic resonance imaging

BACKGROUND

Jones's theory of tear drainage suggests that the lacrimal sac fills when the eyelids are closed and empties into the nasolacrimal duct when the eyelids are open. This is aided by the contraction of the orbicularis muscle during each blink. This study was undertaken to ascertain the possibility of seeing the dynamic movement of tears in the nasolacrimal system during blinks using magnetic resonance dacryocystography (MR-DCG).

METHODS

The sac was initially localized with a three-plane gradient echo sequence using a 1.5-T MRI platform. Fast, dynamic MR-DCG was carried out after we had instilled topically balanced salt solution (BSS) in five subjects and 0.5% gadolinium in seven subjects. The volunteers were asked to close and open their eyes during the fast imaging. The images were digitized to enable us to see the actual movement of fluid in the system.

RESULTS

The tear movement was clearly seen as a bolus in the volunteers where BSS was used. The fluid passed into the nasolacrimal duct after several blinks when patent. The sac was never seen to empty completely. Though differential filling was seen between the upper and lower part of the sac, it was difficult to see the actual fluid movement in the volunteers when topical gadolinium was used.

CONCLUSION

The findings of the study are supportive of the notion of fluid travel in the form of a bolus through the sac. Once a threshold volume is reached in the lower end of the sac, the fluid is seen to pass through the nasolacrimal duct. This happens after several blinks.

Review of orbital imaging

CT and MRI are commonly used in the evaluation of patients with suspected orbital disease. Many different diseases may present within this small anatomical space. The purpose of this article is to present a diagnostic strategy based on a compartment model. Localizing pathology to sinus, bone, extraconal space, muscle cone, intraconal space, optic nerve, globe or lacrimal fossa allows significant reduction in the number of differential diagnoses as these compartments contain different tissues which disease may involve or arise from. Certain diseases may also present in multiple compartments. Common diseases which might present in one or multiple compartments will be discussed.

Epidemiology of oculoplastic conditions: the Singapore experience

PURPOSE

To study the prevalence of eyelid, lacrimal, orbital conditions in an outpatient and surgical environment in a tertiary care hospital in Singapore.

METHODS

An 8-month study was conducted in the Oculoplastics Department at the National University Health System (NUHS). Demographic data, diagnosis details and surgical records were compared.

RESULTS

Of 623 patients seen over 906 visits, prevalence was as follows: eyelid (60.3%), orbital (20.6%), lacrimal (16.3%), dysthyroid exophthalmos (6.0%). Sixty-two (10.0%) patients had more than one condition. The most common conditions encountered included blepharoptosis, lacrimal obstruction, and orbital deformities (including fractures). During the same period, distribution of surgical procedures was as follows: eyelid (77.4%), lacrimal (13.1%) and orbit (9.5%). Interestingly, epiblepharon correction comprised 9.5% of the clinical/surgical cases.

CONCLUSIONS

Although eyelid related conditions are most common, lacrimal and orbital pathologies cause significant morbidity. Oculoplastics specialists and ophthalmologists should consider placing more emphasis on surgical training specific to such conditions. We also propose separate classifications for epiblepharon and thyroid eye disease in the International Classification of Diseases (ICD) as they are unique clinical problems in their own right. A postoperative status will also help efficiently classify patients as such patients are at risk for related complications subsequently. An examination of healthcare budget allocation for such conditions is also suggested.

Outcomes of levator advancement and Müller muscle-conjunctiva resection for the repair of upper eyelid ptosis

Both the Müller muscle-conjunctiva resection (MMCR) and levator advancement (LA) procedures can be used to manage ptosis in patients with good levator function. The aim of this article is to evaluate the efficacy and cosmetic outcomes of the two procedures. The clinical records of 29 consecutive eyelids of 26 patients undergoing MMCR and 30 eyelids of 23 patients undergoing LA were analysed. Eleven (42%) in the LA group and 9 (39%) in the MMCR group were male. The preoperative eyelid measurements were significantly different in the LA compared to the MMCR groups, in terms of palpebral aperture (PA) (6.3 vs 7.4, p = 0.01), marginal reflex distance 1 (MRD1) (-0.1 vs 1.5, p < 0.001) and levator function (LF) (12.1 vs 13.4, p = 0.03). The MRD1 1 month post-surgery was slightly less in the LA group compared to the MMCR group (2.6 vs 3.18 mm, p = 0.047) but not significantly different at months 3 and 6. The final change in MRD1 was significantly higher in the LA group (2.93 vs 1.76, p = 0.004). The MMCR group had a lower incidence of lid contour abnormalities (0% vs 20%, p = 0.01) and overcorrection (0% vs 13%, p = 0.04). There was no statistically significant difference in the rates of undercorrection in either group. Both the MMCR as well as LA procedures are effective for mild to moderate ptosis in patients with good levator function. Patients undergoing MMCR had higher success rates, better preservation of the natural lid contour, and a lower incidence of overcorrection than patients undergoing LA.

Orbital Implants in Orbital Fracture Reconstruction: A Ten-Year Series

Study Design

Retrospective comparative interventional series of all patients who had undergone orbital fracture repair by 2 senior orbital surgeons in a single tertiary trauma center from January 2005 to December 2014.

Objective

To compare the outcomes of different implants used for various types of orbital fractures.

Methods

Patients were evaluated by age, gender, etiology of fracture, clinical findings, type of fractures, and implant used. Main outcome measures included restoration of premorbid state without morbidity and complications including enophthalmos, diplopia, infraorbital hypoesthesia, and ocular motility restriction 1 year after fracture repair. Implant-related complications were collected for analysis.

Results

There were a total of 274 patients with 307 orbits reconstructed. Thirty-three (12.0%) patients sustained bilateral injuries; 58.0% (n = 178) of orbits had simple fractures (isolated orbital floor, medial wall, or combined floor and medial wall). The distribution of implants used were bioresorbable (n = 117, 38.1%) and prefabricated titanium plates (n = 98, 31.9%) depending upon the nature of fracture. Bioresorbables, titanium plate, and porous polyethylene were used significantly more than titanium mesh for simple fractures, and prefabricated anatomic titanium implants were used significantly more than the other implants for complex fractures. There was a statistically significant improvement in diplopia, enophthalmos, ocular motility, and infraorbital hypoesthesia (p-value < 0.001) 1 year following orbital fracture reconstruction.

Conclusions

When used appropriately, diverse alloplastic materials used in orbital fracture repair tailored to the indication aid orbital reconstruction outcomes with each material having its own unique characteristics.

Spontaneous hematic cysts of the orbit presenting with acute proptosis. A report of three cases

Three cases of spontaneous hematic cyst of the orbit are described. All cases presented with acute onset of proptosis, conjunctival chemosis, choroidal folds, restricted ocular movement, and optic nerve compression syndrome with very poor vision. A computed tomography scan demonstrated a cystic lesion situated in the upper part of the orbit. Exploration revealed a cyst containing chocolate-colored fluid. Visual recovery was complete in two of three cases. There was no definite history of trauma in all three cases. Chronic hematic cysts have been described recently, but cases with acute onset such as ours have not to our knowledge been described clearly.

Orbital metastasis of renal cell carcinoma masquerading as cysticercosis

Metastasis to the orbital soft tissues is relatively uncommon. We report a rare case of renal cell carcinoma with orbital metastasis as the first clinical manifestation. A 48-year-old-man presented with left proptosis and complete ptosis of three weeks duration. Radiological examination revealed a left intraconal heterogeneous cyst-like lesion with rim enhancement immediately deep to the left superior rectus muscle. Diagnosed as having orbital cysticercosis, he was prescribed oral albendazole and prednisolone. But there was no clinical improvement. An incisional biopsy performed showed metastatic poorly differentiated carcinoma. The patient complained of backache and weight loss in the interim. Magnetic resonance imaging (MRI) of the spine showed extensive vertebral metastasis to the thoracic and lumbosacral spine and the iliac bone, with an incidental detection of a large mass from the right kidney. Further MRI of abdomen and chest showed a large right renal mass presumed to be a renal cell carcinoma with extension into the right renal vein, intra-abdominal lymph nodes, and peritoneum. There were small nodules in the lung suggesting the possibility of pulmonary metastatic deposits. Renal cell carcinoma does not respond to chemotherapy, immunotherapy, or radiation; because of the disease's advanced stage, the patient received palliative treatment. There have been only two other reports in the literature of metastatic renal cell carcinoma in the orbit where the proptosis was the initial presenting feature similar to our case.

Pediatric thyroid eye disease--the Singapore experience

PURPOSE

To identify the demographics, risk factors, clinical manifestations and treatment methods of pediatric thyroid eye disease (TED) in a South-East Asian tertiary referral practice.

METHODS

Retrospective case series of all pediatric patients (aged 18 years and under) who presented to our TED clinic between Jan 2006 and Dec 2012.

RESULTS

Thirteen patients (26 eyes) were identified - 8 females (61.5%) and 5 males (38.5%), accounting for 6.2% of all TED patients in our practice. Median age was 10.0 years (range, 0.3-18.0). Positive family history was noted in 9 patients (69.2%) and there were no active/passive smokers. Mean follow-up duration was 1.81 years (range, 0-5.2). Common presenting signs included proptosis (92.3%), eyelid retraction (84.6%), acquired epiblepharon (69.2%), corneal erosion (53.8%), and lagophthalmos (53.8%). None had optic neuropathy or strabismus. Mean exophthalmometry was 17.8 mm (SD ± 3.6 mm, range 13.0-27.0). Ten patients (76.9%) had mild disease, 3 patients (23.1%) had moderate disease and none had severe disease. Clinically significant Active disease as defined in adults (VISA Inflammatory Score >4/10), was not observed in any patient. The majority of the patients were treated conservatively. One patient underwent bilateral orbital decompression for severe proptosis, while two patients underwent bilateral lower epiblepharon correction with good outcomes. None required corticosteroids (oral/pulsed).

CONCLUSION

Clinical manifestations in pediatric TED are relatively mild and respond well to conservative therapy. Orbital decompression is rarely required but may be considered in children with severe proptosis. Mean exophthalmometry values are lower in East-Asian pediatric TED as compared to Caucasians. Symptomatic acquired epiblepharon, usually associated with keratopathy, is commonly seen in East-Asian pediatric TED; thus, increased awareness among ophthalmologists and pediatricians should be emphasized.

Blowout fractures: surgical outcome in relation to age, time of intervention, and other preoperative risk factors

We sought to describe outcome of surgical repair in patients presenting with orbital blowout fractures. This noncomparative, retrospective, consecutive case series reviewed the case notes of 63 consecutive patients who underwent surgery for a blowout fracture between November 1992 and March 2005. Risk factors for motility outcome as well as presence of enophthalmos after surgery were analyzed. Children had earlier surgery than adults (p < 001) and tended to have better motility outcome than adults. Surgery performed within the first week showed a trend for better outcome, but this was not statistically significant (p = 0.231). Assault had the best motility outcome, compared with other modes of trauma. Patients with worse preoperative motility had better outcome (p < 0.001). Enophthalmos improved significantly after surgery (p < 001). Children as compared with adults and surgery performed within the first week tended to have better motility outcome, but this was not statistically significant.

Comparison of incidence of ptosis after combined phacotrabeculectomy with mitomycin C and phacoemulsification

OBJECTIVE

To compare the incidence of upper eyelid blepharoptosis after combined phacotrabeculectomy with mitomycin C and phacoemulsification surgeries and the relationship of bleb morphology to the incidence of ptosis.

DESIGN

Retrospective observation study.

PARTICIPANTS

We included 46 patients after combined phacotrabeculectomy and 44 patients with phacoemulsification in the former group, and all eyes underwent a standardized two-site surgery with intra-operative mitomycin C.

MATERIALS AND METHODS

Postoperative ptosis was defined as a reduction of upper marginal reflex distance 2 mm in the operated eye compared to the fellow eye. Trabeculectomy bleb measurements were carried out using anterior segment optical coherence tomography (Visante™, Carl Zeiss Meditec, Dublin, CA, USA) which included bleb height and total area of the bleb.

RESULTS

There were 8 eyes (17.4%) and 5 eyes (11.4%) with postoperative ptosis in the phacotrabeculectomy and phacoemulsification groups, respectively (P = 0.342). In multivariate regression analysis, reduced total bleb area was significantly associated with upper eyelid ptosis after adjusting for age, gender, and type of anesthesia. The trend seemed to show that increased bleb height was also associated with ptosis, but this did not reach statistical significance.

CONCLUSIONS

Incidence of persistent ptosis after phacoemulsification combined with trabeculectomy and mitomycin C is similar compared to stand alone phacoemulsification surgery in a multiethnic Asian population. Bleb morphology may play an important role in postoperative ptosis development and should be considered in the evaluation of upper eyelid blepharoptosis.

Radiological signs of periorbital trauma - the Singapore experience

PURPOSE

To describe the radiological signs and demographic characteristics of patients who suffered facial trauma in South-East Asia.

MATERIALS AND METHODS

This is a retrospective cross-sectional study of a 399 patients who presented with facial trauma over a 2-year period in a tertiary referral centre in South-East Asia. Patients with available CT scan films were included. Demographics, bony and soft tissue radiology characteristics were analyzed.

RESULTS

Male to female ratio was 320 (80%):79 (20%). Most of the facial trauma was due to Road Traffic Accident. Of 399 patients, 273 (68%) showed radiological signs of bone or soft tissue trauma. Of these 273 patients, left to right side involvement was 114 (41.7%) / 82 (30.03%), and 77 (28.2%) had bilateral involvement. Floor was the most involved wall (229[83.8%]) and the most involved rim was the inferior rim (164[60.07%]). There were 39 (14.2%) patients with blowout fracture. Bony nasolacrimal duct was broken in 56 (20.5%) patients. Optic canal fracture was found in 7 (2.5%) patients and it was associated with roof and superior rim fracture (P-values were 0.016, 0.046, respectively). Thirty-three (12.08%) patients had radiological signs of extraocular muscle involvement. Traumatic intracranial signs were associated with roof and superior rim fractures (P < 0.001 for both).

CONCLUSION

Floor and inferior rim were the most affected orbital structures in facial trauma. We described radiological risk factors association with optic canal, NLD fracture and intracranial involvement. We described extraocular muscle morphological signs, which could alert to the possibility of orbital floor fracture in equivocal cases.

Ophthalmic involvement in nasopharyngeal carcinoma

This article desribes the ophthalmic involvement in patients with nasopharyngeal carcinoma (NPC) pre- and post-treatment. We retrospectively reviewed data for 354 consecutive patients diagnosed with or treated for NPC at a single tertiary centre between April 2007 and July 2015. We identified 27 (7.6%) patients with ophthalmic involvement due to NPC or its treatment. Symptomatic orbital invasion by tumor occurred in 13 of 27 patients (48.1%). The mean age of diagnosis in these patients was 54 years, and 8 (61.5%) had no prior diagnosis of NPC. Ocular signs, but no orbital invasion, was present in 8 patients (29.6%). Incidental orbital involvement was detected on imaging in 2 patients (7.4%). Radiotherapy-related ocular complications affected 4 patients (14.8%). Ophthalmic symptoms from orbital invasion can be the initial presentation of NPC. This disease tends to affect a younger group of patients and early recognition is important to minimize morbidity and mortality.

Erdheim-Chester disease: a bilateral orbital mass as an indication of systemic disease

A case of bilateral orbital mass and xanthelasma of the eyelids is presented. Histology confirmed it to be a form of histiocytosis, possibly an Erdheim-Chester disease. This was further confirmed by the presence of a retroperitoneal mass and hydronephrosis, which resolved with treatment. A review of the literature on and pathological features of this rare fatal disease is presented.

Browlift--a South East Asian experience

BACKGROUND

To describe the indications, techniques and outcomes of various browlift procedures in a predominantly East-Asian community.

PATIENTS AND METHODS

Retrospective review of patients who underwent browlift procedures performed by 2 oculoplastic surgeons or under their direct supervision, in a tertiary referral hospital in South East Asia from 2002 to 2007.

RESULTS

Forty-six patients (30 female, 16 male) had browlift surgery for 89 sides from 2002 to 2007. Mean follow-up period was 10 months (6 to 44 months). 43 patients had bilateral browlift, 3 patients had unilateral browlift, 2 of whom had underlying facial nerve palsy and one had involutional brow ptosis.

INDICATIONS

involutional brow ptosis (42), mitochondrial myopathy (2), and facial palsy (2). Ethnicity of patients: Chinese (40), Indian (4) and Malay (2).

TECHNIQUES

direct browlift (18), transblepharoplasty browpexy (6), midforehead lift (3), coronal browlift (2) and pretrichial browlift (4), endoscopic browlift (7), limited incision nonendoscopic browlift (5) and temporal browlift (3). Adjuvant procedures included upper blepharoplasty (26), blepharoptosis correction (4), midface lift (2), upper eyelid entropion correction (1), lacrimal gland fixation (1), and upper lid gold implant (1). Encountered complications included: undercorrection 6 (12%), segmental facial nerve palsy 1(2%), visible scar 2 (5%), paraesthesia 2 (5%), suture granuloma 1 (2%). Overall 94% of our patients were satisfied.

CONCLUSION

Browlift provides satisfactory results for both patient and surgeon. A comprehensive knowledge and proper surgical technique, along with a thorough discussion with patients about the pros and cons of each procedure are essential to obtain optimal outcomes.

A study of sports-related orbital fractures in Singapore

With an increased popularity of sport and active living worldwide, our study aims to explore the incidence and features of sports-related orbital fractures in Singapore. 1421 computer tomography (CT) imaging scans of the face and orbits done at the National University Hospital over a 24-month period from January 2013 and December 2014 were reviewed retrospectively for orbital fractures. We identified 483 orbital fractures of which sports injury was the fourth most common etiology (n = 65; 13.5%) after road traffic accident (n = 131; 27.1%), geriatric fall (n = 81; 16.8%) and workplace injury (n = 67; 13.9%). The three most common sport in orbital fractures were soccer (n = 20; 30.8%), bicycling (n = 11; 16.9%) and jogging (n = 8; 12.3%). The three most common fracture patterns were zygomatico-maxillary complex fractures (n = 24; 36.9%), isolated one wall blowout fractures (n = 19; 29.2%) and naso-orbito-ethmoid fractures (n = 7; 10.8%). Sports-related orbital fractures were associated with a low mean age of patients (45.9 years, range, 14-79 years), a higher proportion of males (n = 58; 89.2%) than that from geriatric falls (n = 37, 45.6%) (P < 0.01), a higher likelihood of unilaterality (n = 62; 95.4%) than that from traffic accidents (n = 99; 75.6%) (P < 0.01) and a lower likelihood of pan-facial involvement (n = 4; 6.15%) than that from traffic accident (n = 60; 45.8%) (P < 0.01). Sports-related orbital fractures are the fourth most common cause of orbital fractures. Though commonly seen in young male adults, in view of the aging population and people exercising more regularly, education of safety measures among sports users is paramount to preventing sports-related orbital fractures.

Congenital orbito-palpebral cyst in a case of Fraser syndrome

A seven-year-old girl was referred to our clinic with absent eyelids and a mass which was gradually increasing in size from the right orbit. The child was diagnosed to have Fraser syndrome (cryptophthalmos, abnormal genitalia, mental deficiency, renal agenesis and abnormal ears). On examination, there was cryptophthalmos and a cystic swelling arising from the right orbit. The cyst was removed. On gross examination, there was a posterior eyeball with normal optic nerve. Placed in the anterior part of the eyeball was a cyst measuring about 2 cm in diameter filled with a yellow-coloured fluid. The cavity of the eyeball was communicating with the cyst. The cyst wall was lined by a single layer of epithelium. The posterior eyeball had well developed sclera, choroid, retina and optic nerve. There have been many reports of cryptophthalmos in Fraser syndrome. The most common eye deformity described with cryptophthalmos is microphthalmia or anophthalmia. To the author's knowledge, there is one other report of cystic eyeball with cryptophthalmos in the literature. The cyst seems to be due to a surface ectodermal anomaly, rather than a neuro-ectodermal anomaly where there is failure of invagination of the primary optic cup during development. The cyst wall in those cases has inverted retinal elements. In our case, differentiation of retinal elements was present in the posterior eyeball. The abnormality seemed to lie in the derivatives of surface ectoderm, namely the eyelids and the anterior segment structures.