Superior oblique tuck-effectiveness in reducing vertical deviations when performed as a primary versus secondary procedure in superior oblique paresis.

PURPOSE: To quantify the effectiveness of superior oblique tuck (SOT) surgery in patients with a hyperdeviation secondary to superior oblique paresis (SOP). Surgical outcomes were compared in patients undergoing SOT surgery as a primary procedure with those who had previously undergone ipsilateral inferior oblique weakening surgery. METHODS: This retrospective study assessed surgical outcomes from all patients undergoing SOT surgery for SOP between 2012 and 2021 across 2 hospitals. The effectiveness of SOT surgery in reducing the hyperdeviation was assessed in the primary position (PP) and in contralateral elevation and depression. Results were compared between those undergoing primary SOT surgery with those who had previously undergone ipsilateral inferior oblique weakening surgery. RESULTS: A total of 60 SOT procedures were performed between 2012 and 2021. 7 were removed due to incomplete data. The remaining 53 cases experienced a mean reduction in hyperdeviation of 6.5 prism dioptres (PD), 6.7PD and 12.0PD in the PP, contralateral elevation and contralateral depression respectively. In eyes with previous IO weakening, the reduction of hyperdeviation was larger than in those eyes with no previous IO weakening surgery, with mean reductions of 8.0PD vs 5.2PD, 7.4PD vs 6.2PD and 12.4PD vs 11.6PD in the PP, contralateral elevation and contralateral depression respectively. CONCLUSION: SOT surgery is a safe and effective procedure with high patient satisfaction and resolution of symptoms in those patients with troublesome diplopia in downgaze secondary to SOP. This is true in both unoperated eyes and in those who have previously undergone inferior oblique weakening surgery.

Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery.

BACKGROUND: Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation. METHODS: The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures. RESULTS: One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02). CONCLUSIONS: The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Monocular elevation deficit after scleral perforation repair.

Monocular elevation deficit can result from either inferior rectus restriction, superior rectus palsy or from supranuclear causes. We report a case of monocular elevation deficit after scleral perforation repair which was managed by surgery on contra lateral eye. This improved elevation of the affected eye with no diplopia in the postoperative period.

Bagolini filter bars: an analysis of light transmittance and their use in a pediatric population.

Purpose: The purpose of this study is to determine whether the Sbisa bar (Sbisa Ophthalmic Instruments) (referred to in this article as the BF(Sbisa) bar) and Bagolini Filter bar (C.O.I. Vision) (referred to in this article as the BF(new) bar) are repeatable and comparable, for measuring density of suppression or strength of abnormal binocular single vision (BSV), in a pediatric population. Methods: Using a spot photometer, percentage light transmittance of filters on two BF(Sbisa) bars and two BF(new) bars was measured. Thirty-three participants aged 5-12 years with unilateral strabismus were recruited. Density of suppression or strength of abnormal BSV was measured with two of each bar, in addition to a repeated measure with one of each bar. Results: Light transmittance did not reduce consistently with increasing filter number (the number assigned to each filter by the manufacturer). Using data as filter numbers, a BF(Sbisa) bar was not comparable to a BF(new) bar (ᵶ = -3.936, p < 0.001, r = -0.28); different BF(Sbisa) bars were not comparable (ᵶ = -3.103, p = 0.005, r = -0.22) but different BF(new) bars were comparable (ᵶ = -1.165, p = 1.285, r = -0.08). Using light transmittance values, a BF(Sbisa) bar was comparable to a BF(new) bar (ᵶ = -0.385, p = 3.535, r = -0.03); different BF(Sbisa) bars were comparable (ᵶ = -1.476, p = 0.720, r = -0.10) but different BF(new) bars were not comparable (ᵶ = -3.354, p < 0.001, r = -0.24). The BF(Sbisa) and BF(new) bars were not repeatable using filter numbers (ᵶ = -3.648, p < 0.001, r = -0.26 and ᵶ = -3.099, p = 0.005, r = -0.22, respectively) or light transmittance values (ᵶ = -3.743, p < 0.001, r = -0.27 and ᵶ = -2.727, p = 0.025, r = -0.19, respectively). An order effect existed using filter numbers (ᵶ = -4.473, p < 0.001, r = -0.32) and light transmittance values (ᵶ = -4.525, p < 0.001, r = -0.32). Conclusion: There is a need for the production of bars with consistently reducing and comparable light transmittance of filters if measurement of density of suppression or strength of abnormal BSV with filter bars is to continue, because the current bars show inconsistencies, particularly at lower filter numbers. In the meantime, the bars are limited by their lack of comparability or repeatability. Using only BF(new) bars is preferable to using BF(Sbisa) bars or a mixture of the two types of bar because two different BF(new) bars may be comparable using filter number readings, but filter number readings from different BF(Sbisa) bars or from a BF(Sbisa) and BF(new) bar are not comparable. As the BF(Sbisa) and BF(new) bars are currently labeled, a second measure of density of suppression or strength of abnormal BSV is not recommended within 2 min of an initial measurement, because the measurement procedure seems to cause a reduction in suppression or abnormal BSV that does not recover with repeated measurements 2 min apart.

The application of volumometry as an indication criterion in blow-out fractures.

Backgroung and Aim. This work builds on our publication on the subject of creating a mathematical model for calculating the volume of proplaped soft tissue of the orbit in blow-out fractures, which aids us greatly in our choice of the most effective treatment immediately post-accident. PATIENTS AND METHODS: In this prospective study (2014 - 2016) we treated 29 patients with blow-out fractures. 18 (62%) were treated conservatively and in 11 (38%) we proceeded surgically. We decided whether surgical or non-surgical therapy was appropriate on the basis of clinical ENT, eye examination and the total volume of prolapsed orbital soft tissue. All procedures were perfomed by the same operating team with a uniform subciliary approach and using PMR splints adapted to the correct size and shape. RESULTS: On the basis of the mathematical model we reassessed findings in 2 patients: in one we decided against a surgical solution and in the other a surgical approach was indicated. All 18 patients treated conservatively, fully recovered and are free of diplopia. The 11 operated patients are also free of diplopia, only 1 patient (3%) displays clinically insignificant postoperative diplopia in extreme posisitons when looking upwards. CONCLUSION: With proper selection of the optimal treatment, the rate of complete disappearance of diplopia and fully preserved motility of the eyeball ranges from 91 to 97%. Surgical treatment of orbital floor fractures is important, mainly to minimise persistent post-traumatic diplopia which significantly reduces a patient's quality of life.

[The complications of transethmoidal decompressive orbitotomy associated with endocrine ophthalmopathy]. / Oslozhneniia transétmoidal'noi dekompressionnoi orbitotomii pri éndokrinnoi oftal'mopatii.

The objective of the present study was the analysis of the results of transethmoidal decompressive orbitotomy (TEDO) with the resection of the bone matrix of the medial and inferior orbital walls in the patients presenting with endocrine ophthalmopathy (EOP) with the purpose of reduction of the risk of development of this pathological conditions. A total of 51 patient with EOP at the stage of complete remission or pharmacotherapeutic compensation underwent transethmoidal decompressive medial orbitotomy in the ENT Clinic of 1 I.M. Sechenov First Moscow State Medical University during the period from 2006 to 2016. Twenty two of these patients presented with the unilateral process and 29 ones with bilateral exophthalmos. The surgical intervention was performed on the total of 80 eye orbits. The main complaints of the treated patients during the post-operative period included difficulties in nasal breathing (33%), dryness of the nose and crust formation (43%), discharge from the nose and along the posterior pharyngeal wall (15%), nasal bleeding (2%), pain in the forehead and maxillary region (8%), headache (2%). As far as the state of eyes and sight is concerned, 14 (27%) patients reported double vision at the primary gaze position while 6 others (12%) complained of the appearance of diplopia upon a change in the gaze position during the post-operative period. The post-operative endoscopic study revealed synechiae of different localization in the nasal cavity (47%), discharge from the maxillary sinuses (16%) and from the frontal sinus (2%). Eight (16%) patients were found to suffer from maxillary sinusitis, one had acute frontitis, and one sphenoidal sinus mucocelle. These complications were eliminated by pharmacotherapy and additional surgical interventions (2%). Analysis of the results of the study has demonstrated that the above complications were associated with the inadequate post-operative care for the nasal cavity, the excessively large size of the bone window formed during transethmoidal decompressive orbitotomy, resection of the inferior orbital wall, intrusion of the medial rectus muscle of the eye into the wide bone window. We evaluated the possible influence of the orbital soft tissues on the physiological parameters of the functioning of the paranasal sinuses in the post-operative period including blockade of the paranasal drainage pathways by the prolapsed orbital tissues. A few possible approaches to the reduction of the risk of post-operative complications are proposed. The authors emphasize the importance of the further improvement of the surgical treatment of endocrine ophthalmopathy.

Divergence Palsy due to Divalproex and Oxcarbazepine.

OBJECTIVE: This case series is the first to describe divergence palsy as an adverse effect of antiepileptic drug use. Diplopia is a common adverse effect of antiepileptic drugs, but no explanatory motility deficit has ever been reported. METHODS: We present 2 patients, 1 on oxcarbazepine and 1 on divalproex, each with a normal examination result between spells and divergency palsy when symptomatic. RESULTS: Discontinuation of the antiepileptic medication led to resolution of the episodes in both cases. Rechallenge with the offending agent after washout in one patient resulted in recurrence of diplopia and divergence palsy, both resolving after subsequent withdrawal of the antiepileptic. CONCLUSIONS: Antiepileptic drugs may cause divergence palsy.

Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management.

OBJECTIVE: The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos. METHODS: In this retrospective institutional review board-approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair. RESULTS: Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93. CONCLUSION: Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

Real Time Navigation-Assisted Orbital Wall Reconstruction in Blowout Fractures.

BACKGROUND: Limitation in performing restoration of orbital structures is the narrow, deep, and dark surgical field, which makes it difficult to view the operative site directly. To avoid perioperative complications from this limitation, the authors have evaluated the usefulness of computer-assisted navigation techniques in surgical treatment of blowout fracture. METHODS: Total 37 patients (14 medial orbital wall fractures and 23 inferior orbital wall fractures) with facial deformities had surgical treatment under the guide of navigation system between September 2012 and January 2015. RESULTS: All 37 patients were treated successfully and safely with navigation-assisted surgery without any complications, including diplopia, retrobulbar hematoma, globe injury, implant migration, and blindness. CONCLUSIONS: Blowout fracture can be treated safely under guidance of a surgical navigation system. In orbital surgery, navigation-assisted technology could give rise to improvements in the functional and aesthetic outcome and checking the position of the instruments on the surgical site in real time, without injuring important anatomic structures.

[Intracranial hypertension and jugular vein thrombosis]. / Intrakranielle Hypertension und Jugularvenenthrombose.

BACKGROUND: Pseudotumor cerebri is an idiopathic increase in intracranial pressure, which commonly affects obese women of fertile age. The diagnostic criteria according to the guidelines of the German Society for Neurology are increased cerebrospinal fluid (CSF) pressure, symptoms of increased CSF pressure, normal results of CSF examination, no relevant medication and a lack of structural and vascular lesions in magnetic resonance imaging (MRI). CASE REPORT: This article presents the case of a 39-year-old male patient who presented at hospital with visual obscuration and recently occurred double vision. Except for a recently diagnosed thrombosis of the left jugular vein of unknown origin, there was nothing else of note in the medical history. Biomicroscopic examination showed papilledema with hemorrhages and cotton wool spots. The CSF opening pressure was initially > 50 cmH2O. During therapy by lumbar puncture (three times), oral carbonic anhydrase inhibitors and loop diuretics, the abducens nerve palsy and papilledema receded. Anticoagulation therapy (initially with coumarin derivatives, then with low molecular weight heparins) was unsuccessful in eliminating the thrombosis of the jugular vein. Surgical intervention was not recommended by the vascular surgeons. CONCLUSION: This case report demonstrates the unusual combination of (idiopathic) intracranial hypertension and thrombosis of the jugular vein, which occurred spontaneously and without any detectable coagulation disorders.

A report on 15 years of clinical negligence claims in rhinology.

BACKGROUND: This study was designed to determine the characteristics of medical negligence claims in rhinology. In 2010-2011 the National Health Service (NHS) litigation bill surpassed 1 billion Great British Pounds (GBP; 1.52 billion U.S. dollars [US$]). Systematic analysis of malpractice complaints allows for the identification of errors and can thereby improve patient safety and reduce the burden of litigation claims on health services. METHODS: Claims relating to ear, nose, and throat between 1995 and 2010 were obtained from the NHS Litigation Authority and were analyzed. RESULTS: The series contains 65 closed claims that resulted in payment totaling 3.1 million GBP (US$4.7 million). Fifty claims were related to surgical complications. Functional endoscopic sinus surgery and septoplasty were the procedures most commonly associated with successful claims. There were 11 cases of orbital injury including 6 cases of visual loss and 5 cases of diplopia. The most common cause of a claim was failure to recognize the complication or manage it appropriately. Lack of informed consent was claimed in eight cases. Other claims arose because of errors in outpatient procedures (two), diagnosis (six), delayed surgery (one), and errors in medical management (three). CONCLUSION: This is the first study to report the outcomes of negligence claims in rhinology in the United Kingdom. Claims in rhinology are associated with a high success rate. Steps that can be taken to reduce litigation include careful patient workup and ensuring adequate informed consent. Where there is a suspicion of orbital damage early recognition and intervention is needed to reduce long-term injury to the patient.

Post-cataract surgery diplopia: aetiology, management and prevention.

Diplopia is an infrequent but distressing adverse outcome after uncomplicated cataract surgery. Many factors may contribute to the occurrence of this problem, including prolonged sensory deprivation resulting in disruption of sensory fusion, paresis of one or more extraocular muscles, myotoxic effects of local anaesthesia, optical aberrations (for example, aniseikonia) and pre-existing disorders (for example, thyroid orbitopathy). The purpose of this review is to present the aetiology and clinical features of diplopia after cataract surgery and to discuss the possible modalities for the prevention and treatment of this frustrating complication.

[Treatment of severe recurrent symblepharopterygium: combined ipsilateral autologous limbus and homologous amniotic membrane transplantation]. / Behandlung des schweren rezidivierenden Pterygiums mit Symblepharonbildung: Kombinierte ipsilaterale autologe Limbus- und homologe Amnionmembrantransplantation.

BACKGROUND: This retrospective study reports on four patients with severe recurrent symblepharopterygium formation and extensive subconjunctival scarring who were treated with a novel surgical technique combining free limbal autografting and amniotic membrane transplantation. PATIENTS AND METHODS: The surgical technique included symblepharolysis, meticulous removal of subconjunctival scar tissue, ipsilateral free limbal autograft and homologous amniotic membrane transplantation. RESULTS: There were no intraoperative or postoperative adverse events and three patients had no manifestation of recurrence of pterygium, symblepharon or diplopia during a mean follow-up period of 172 ± 18 weeks (39 ± 4 months) postoperatively. Only one patient had persistent symblepharon and experienced a recurrence of pterygium approximately 40 weeks (9 months) after surgery. CONCLUSION: The results suggest that ipsilateral autologous limbal and homologous amniotic membrane transplantation can be an effective therapeutic approach in the treatment of recurrent pterygium with symblepharon formation.

[Granular cell tumors of the orbit: diagnostics and therapeutic aspects exemplified by a case report]. / Granularzelltumor der Orbita: Diagnostische und therapeutische Aspekte anhand eines Fallberichtes.

BACKGROUND: Granular cell tumors (Abrikossoff's tumor) are very rare, mostly benign tumors of neurogenic origin which preferentially occur in the upper aerodigestive tract. Granular cell tumors rarely originate in the orbit and are therefore a diagnostic and therapeutic challenge. METHOD AND PATIENTS: A 42-year-old male patient presented to the Orthoptic Department of the University Eye Clinic in Salzburg with motility disturbances and diplopia in the right eye. The clinical examination revealed right-sided exophthalmos and shrinking of the choroid and retina due to a retrobulbar mass. The radiological examination showed an infiltrative tumor 1.7 × 1.3 cm in size in the lower temporal quarter of the orbit. Due to the localization a sonographically controlled fine needle puncture was carried out for preoperative diagnostics by a specialist in clinical cytology. The cytological examination confirmed the presence of a granular cell tumor. The tumor was excised via a conjunctival access route. RESULTS: Motility testing in the postoperative course control showed an improvement in the findings and the exophthalmos was clearly regressive. Vision improved from 0.5 preoperatively to 1.0 postoperatively. During the postoperative observational period of 12 months no recurrences occurred. Clinical control examinations are planned every 3 months and imaging controls every 6 months. CONCLUSION: Granular cell tumors of the orbit should be included in the differential diagnostics of orbital tumors despite the low incidence. A sonographically controlled fine needle puncture is an adequate procedure with respect to the diagnostics and further therapy for poorly differentiated tumors of the orbit with a suspicion of infiltrative growth and for which in toto resection is questionably possible. A complete surgical excision should be the aim of treatment of granular cell tumors. Continuous clinical and imaging control is necessary to enable early recognition of recurrences.

Endoscopic orbital floor decompression with preservation of the inferomedial strut.

BACKGROUND: Medial and inferior orbital decompression is most commonly performed in the setting of dysthyroid orbitopathy. Diplopia represents the most common complication and may be minimized through the preservation of a bony inferomedial strut (IMS). Historically, this has required a transconjunctival approach due to the technical demands of performing an isolated orbital floor decompression using endoscopic instrumentation. Here we describe a novel technique of a purely endoscopic orbital floor decompression with reliable preservation of the IMS. METHODS: Description of a novel surgical technique for endoscopic orbital floor decompression with IMS preservation using frontal sinus instrumentation visualized by a 70-degree endoscope. RESULTS: We have successfully used this technique in 12 orbits with 100% preservation of the bony inferomedial strut and no complications. The extent of decompression and width of the residual strut may be fine tuned as needed to optimize results. CONCLUSION: Orbital floor decompression with IMS preservation may be reliably performed using purely endoscopic techniques. Successful completion of this procedure requires the adaptation of standard frontal sinus instrumentation to the maxillary sinus roof and thus may be readily mastered by any endoscopic surgeon comfortable with frontal sinus techniques.

The therapeutic outcome to intravenous steroid therapy for active Graves' orbitopathy is influenced by the time of response but not polymorphisms of the glucocorticoid receptor.

BACKGROUND: Glucocorticoids are the mainstay of immunosuppression for active moderate-severe Graves' orbitopathy (GO). AIM: To analyze the response to therapy and the contribution of glucocorticoid receptor (GR) gene polymorphisms to the therapeutic outcome of intravenous glucocorticoids (IVGC) in active moderate-severe GO. METHODS: we have studied 58 patients treated with 7.5 g i.v. methylprednisolone (cumulative dose). ophthalmological assessment was performed at baseline and at 6-8, 12-16, and 24-30 weeks after the first infusion. Three GR gene polymorphisms, ER22/23EK, N363S, and BCL1, which have been associated to variable sensitivity to steroids, were studied in 43/58 patients. The therapeutic outcomes defined as: i) reduction of the clinical activity score (CAS) ≥2 points or ii) reduction of proptosis ≥2 mm or iii) improvement of diplopia according to the Gorman score were also studied in relation to treatment schedule, age, gender, duration of thyroid or GO, smoking habits, and serum TSH-receptor autoantibodies levels. RESULTS: In total, 70% of patients responded and had GO inactivation (CAS <4) as early as 6-8 weeks. At 12-16 weeks, the proportion of patients who became inactive increased by another 10% up to a total of 80%. ER22/23EK and N363S polymorphisms were present only in about 7%, while the Bcl1 variant was present in 30% of patients; no significant association of any of the GR polymorphisms with either the therapeutic response or the occurrence of side effects was observed. CONCLUSIONS: Most patients with active GO respond to IVGC as early as 6-8 weeks of therapy and the analyzed GR polymorphisms do not influence the therapeutic effect of steroids. Questions arise about the need of continuing therapy up to 12 weeks in nonresponders. We suggest that these patients may be switched to other treatments alone or in combination with steroids.