Orbital histiocytosis; From A to Z.

PURPOSE: Histiocytosis is one of the most challenging diseases in medical practice. Because of the broad spectrum of clinical manifestations, systemic involvements, unknown etiology, and complex management, different types of histiocytosis are still a big question mark for us. Orbital histiocytosis is characterized by the abnormal proliferation of histiocytes in orbital tissues. It could affect the orbit, eyelid, conjunctiva, and uveal tract. Orbital histiocytosis can cause limited eye movement, proptosis, decreased visual acuity, and epiphora. In this study, we review the novel findings regarding the pathophysiology, diagnosis, and treatment of different types of histiocytosis, focusing on their orbital manifestations. METHOD: This review was performed based on a search of the PubMed, Scopus, and Embase databases or relevant published papers regarding orbital histiocytosis on October 9th, 2023. No time restriction was proposed, and articles were excluded if they were not referenced in English. RESULTS: 391 articles were screened, most of them being case reports. The pathophysiology of histiocytosis is still unclear. However, different mutations are found to be prevalent in most of the patients. The diagnostic path can be different based on various factors such as age, lesion site, type of histiocytosis, and the stage of the disease. Some modalities, such as corticosteroids and surgery, are used widely for treatment. On the other hand, based on some specific etiological factors for each type, alternative treatments have been proposed. CONCLUSION: Significant progress has been made in the detection of somatic molecular changes. Many case studies describe various disease patterns influencing the biological perspectives on different types of histiocytosis. It is necessary to continue investigating and clustering data from a broad range of patients with histiocytosis in children and adults to define the best ways to diagnose and treat these patients.

Unusual orbital mucormycosis due to pecking injury: clinical characteristics and outcomes of four immunocompetent pediatric patients.

Mucormycosis is a serious fungal infection caused by fungi in the order of Mucorales. Orbital mucormycosis occurs more frequently in rhino-orbital, sino-orbital, and rhino-orbito-cerebral forms of the disease, while isolated orbital mucormycosis is much less common. Herein, we present four cases of immunocompetent children who developed primary cutaneous mucormycosis, which subsequently invaded and progressed to orbital mucormycosis following direct traumatic injury caused by pecking from Acridotheres tristis (Common Myna). Given the low prevalence of orbital mucormycosis in healthy children, an unknown source of infection and delayed diagnosis followed by late therapeutic interventions could result in life-threatening conditions and serious sequelae.

COVID-19 associated rhino-orbito-cerebral mucormycosis, risk factors and outcome predictors; a multicentric study.

BACKGROUND: Since the onset of the Covid-19 pandemic, an increase in mucormycosis cases has been observed in many countries, including Iran. However, the role of covid-19 and associated risk factors have not been thoroughly investigated. OBJECTIVE: This study is designed to identify epidemiologic characteristics, risk factors, and outcome predictors of Covid-19-Associated Rhino-Orbito-Cerebral Mucormycosis (C-ROCM). METHODS: Data of pathology proven Covid Associated ROCM cases were retrospectively obtained from 7 tertiary care centers throughout Iran from February 20, 2021, to July 22, 2021. Univariate and multivariate analyses were performed using binary logistic regression to assess the effects of various factors on the outcome. RESULTS: A total of 132 patients with C-ROCM were included in the study. The mean age of patients was 61.6 ± 13.9 (60.6% male). In 12 patients (9.1%), both eyes were involved. Diabetes was the most common comorbidity (94.7%). The mortality rate was 9.1%, higher in males (12.5%) than females (3.8%). Severe vision impairment was seen in 58 patients (43.9%). Main factors that had a negative impact on the outcome in the univariate analysis include older age (P < 0.001), higher steroid dosage (P < 0.001), higher HbA1c level (P < 0.001), Covid-19 severity (P < 0.001), and brain involvement (P < 0.001). However, in the multivariate analysis, the effects of age (P = 0.062), steroid dosage (P = 0.226), and Covid-19 intensity (P = 0.084) decreased, and the difference was no longer statistically significant. CRAO was a predictor of mortality in the univariate analysis (P = 0.008, OR = 4.50), but in the multivariate analysis, this effect decreased and was no longer significant (P = 0.125). CONCLUSION: The risk of C-ROCM and its complications may increase in patients with more severe Covid-19, steroid over-prescription, ICU admission due to Covid-19, and poor glycemic control during and after Covid-19 treatment.

Orbital histiocytosis and fibrohistiocytosis: the clinicopathological characteristics of 117 patients, over a decade of experience.

PURPOSE: To describe the clinicopathological features of a large cohort of patients with orbital histiocytoses and fibrohistiocytosis, such as Langerhans cell histiocytosis (LCH) and non-LCH disorders, and correlate patients' clinical characteristics with their pathological diagnosis. METHODS: In this retrospective study, medical records of patients presenting to Farabi Eye Hospital, a tertiary eye care center in Tehran, Iran, from 2010 until 2022, were reviewed. Patients' demographics, chief complaint, location and laterality of the tumor, best-corrected visual acuity, presence of bone erosion on imaging, and their pathological diagnosis were retrieved. Excisional biopsy was performed and evaluated through light microscopy and immunohistochemistry study for their respective markers, including CD1a, CD68, CD207, and S100. RESULTS: A total of 117 patients with 11 pathological subtypes of histiocytoses and fibrohistiocyosis were identified, with 56.4% male and 43.6% female patients. The mean age at presentation was 23.4 years (range 1.5 months-73 years). Swelling and palpable mass were the most common chief complaints. LCH was the most common pathology (32.5%), followed by juvenile xanthogranuloma (26.5%) and adult xanthogranuloma (21.4%). Age, lesion location, and bone erosion had a statistically significant difference among the various diagnosed subtypes. CONCLUSIONS: Histiocytoses and fibrohistiocytosis are diverse and rare disorders potentially involving multiple organ systems. Ophthalmic manifestations of these diseases are even more uncommon. We reviewed their orbital presentation along with their respective histopathological findings. Our results also suggested that an orbital CT scan can be of diagnostic value to discriminate LCH from other histiocytic pathologies.

"The influence of orbital vector on involutional entropion and ectropion".

PURPOSE: This study aimed to evaluate the effect of orbital vector and other biometric parameters (i.e. axial globe length, axial globe projection) on the development of involutional entropion or ectropion. METHODS: In this cross-sectional study, 167 eyes from 132 patients were included. Of these eyes, 128 had involutional entropion and 39 had involutional ectropion, all of lower lids. The axial globe projection was measured using Hertel exophthalmometry; axial globe length was assessed by A-mode ultrasound; and orbital vector was determined clinically. Patient-specific categorical variables and continuous variables were compared using the chi-square test and the two-sided t test, respectively. Correlations were derived using the Pearson correlation. RESULTS: The percentage of females was 59% and 33.3% in the entropion group and in the ectropion group, respectively. A significant association was found between the gender and type of eyelid malposition (p = 0.015). Exophthalmometry reading was greater in the ectropion group than in the entropion group (17.7 ± 2.5 versus 10.8 ± 3.7 mm, respectively; p < 0.001). There was no significant correlation between axial globe length and exophthalmometry reading. Positive orbital vectors were observed in 87.5% of eyelids with involutional entropion. Negative orbital vectors were observed in 92.3% of eyelids with involutional ectropion (p < 0.001). Patients with negative orbital vectors showed greater axial globe projection than patients with positive orbital vectors (18.0 ± 2.1 versus 10.6 ± 3.5 mm, respectively; p < 0.001). CONCLUSIONS: There is an association between orbital vector measurement and involutional entropion and ectropion. Measuring the orbital vector may help predict the development of these lid malpositions.

Bupivacaine Injection for Management of Lagophthalmos Due to Long-Standing Idiopathic Facial Nerve Palsy.

PURPOSE: To report the results of bupivacaine injection into the orbicularis oculi muscle to treat lagophthalmos in patients with long-standing Bell palsy. METHODS: In this prospective interventional case series, bupivacaine, 5 ml of a 0.750% solution, was injected into the preseptal and pretarsal area of the orbicularis oculi in each of 10 patients with idiopathic peripheral facial nerve palsy. The measures of vertical eyelid apertures during open and closed eyes were made before the procedure and 1, 3, and 6 months after injection. RESULTS: A total of 10 eyes including 2 men and 8 women with an average age of 43 years (26-64 years) were studied. The mean amount of lagophthalmos before injection and after 6 months of follow up were 3.9 mm and 2.3 mm, respectively (p = 0.01)). The mean amount of corneal exposure before injection and after 6 months of follow up was 1.05 mm and 0.25 mm, respectively (p < 0.01). The mean scleral show in open eyes before injection and after 6 months of follow up were 1.20 mm and 0.75 mm, respectively (p = 0.08). The mean scleral show in closed eyes before injection and after 6 months of follow up were 1.95 mm and 1.15 mm, respectively (p = 0.01). All the patients reported significant decrease in epiphora. CONCLUSION: Bupivacaine injection in the paretic orbicularis oculi muscle improves eyelid closure and lagophthalmos and epiphora.

Malignant peripheral nerve sheath tumor of lacrimal nerve: a case report.

BACKGROUND: Orbital and periorbital presentation is rare for malignant peripheral nerve sheath tumors. These tumors are poorly defined spindle cell neoplasms of peripheral nerves and have not been reported to develop in the lacrimal gland to date. AIM: To report a rare presentation of malignant peripheral nerve sheath tumor in the orbital cavity. CASE REPORT: A 65-year-old man was admitted with the chief complaint of prominent right eye. His symptoms began 16 months prior to his admission. He had obvious limited ocular motion in upgaze and lateral gaze directions, as well as diplopia in all directions. He underwent imaging studies, and an iso-dense mass lesion in the lacrimal gland was revealed in orbital CT scan. In the MRI, there was a well-defined iso-intense mass lesion in T1-weighted images that was hyperintense in T2-weighted images and was enhanced with Gadolinium. Excisional biopsy revealed epithelioid and spindle cells with hyperchromatic rather than pleomorphic nuclei. Immunohistochemistry confirmed the presence of positive markers consistent with malignant peripheral nerve sheath tumor. CONCLUSION: Malignant peripheral nerve sheath tumor should be considered in the differential diagnosis of lacrimal gland tumors. Imaging studies may be helpful but tissue biopsy should be performed for accurate diagnosis. Complete excision of the mass lesion and adjunctive chemotherapy and radiotherapy should be considered in these cases.

Lower lid retraction in thyroid orbitopathy: lamellar shortening or proptosis?

To investigate any correlation between lower lid retraction and proptosis and also between lower lid retraction and lamellar length, as measured by fornix depth, in patients with thyroid eye disease (TED). One hundred and sixty-six eyes of 83 patients with TED were enrolled. The inferior fornix depth, Hertel exophthalmometry measurement, clinical activity score, and lower lid position were the main outcome variables. The correlation between lower lid position measurement and Hertel measurements and also between the lower lid position measurement and inferior fornix depth were evaluated using ANOVA and Pearson's tests. The mean age of subjects in patients with and without lid retraction was 42.8 ± 1.5 and 47.7 ± 1.6 years, respectively (P = 0.4). The inferior fornix depth in patients with and without lower lid retraction was 11.8 ± 1.5 and 11.8 ± 1.3 mm, respectively (P = 0.960). Pearson's analysis showed a significant correlation between the degree of proptosis and lower lid retraction in TED patients (P = 0.01). However, no significant correlation was found between the level of lower lid retraction and the fornix depth (P = 0.87). The main cause of lower lid retraction in TED is proptosis. The beneficial effect of orbital decompression on improvement of lower lid retraction must be considered during a stepwise surgical approach in TED patients.

Videographic analysis of blink dynamics in patients with chronic progressive external ophthalmoplegia, myogenic ptosis, and facial nerve palsy using smartphone camera: A comparative analysis.

Background and Aims: Congenital myogenic ptosis (CMP), chronic progressive external ophthalmoplegia (CPEO), and facial nerve palsy (FNP) are among the disorders which can seriously affect the blink dynamics of patients. Smartphone videography is a simple, convenient, and inexpensive way to capture eyelid movement. This study has measured and compared a variety of blink dynamics in these patients compared to healthy controls using 2-dimensional smartphone videography to enhance the utility of this method in both clinical and research settings. Methods: A total of 30 adult participants with a complaint of impaired eyelid movements including 10 with CMP, 10 with CPEO, and 10 with unilateral FNP, as well as 10 healthy controls were recruited. Using a smartphone camera with a resolution of 240 frames per second in 720 p, various blink dynamics were measured. Results: All case groups had significantly lower values of peak and average closing velocities, average opening velocity, and palpebral aperture and significantly higher values of eyelid closing duration, compared to controls. FNP participants also had significantly lower values in the full blink rate and peak opening velocity (POV) measures, and CPEO patients showed significantly lower values in the POV. Other measures were not statistically significantly different compared to healthy controls. Conclusion: Our results indicated that all patients with CMP, FNP, and CPEO had different blinking dynamics compared to healthy controls, which is consistent with previous studies. Smartphone videography has achieved sufficient resolution and frame-rate to provide valuable information and anatomic details for clinical and research purposes. Further studies could utilize smartphone videography for further investigation and confirmation of the methodology in various conditions.

Randomized trial of pterygium surgery with mitomycin C application using conjunctival autograft versus conjunctival-limbal autograft.

PURPOSE: To compare the outcomes of free conjunctival autograft (CAU) versus conjunctival-limbal autograft (CLAU) in the prevention of recurrence after pterygium surgery with adjunctive mitomycin C application in patients with primary or recurrent pterygia. DESIGN: Prospective, randomized study. PARTICIPANTS AND CONTROLS: Eighty-seven eyes of 86 patients with primary or recurrent nasal pterygia were included. METHODS: All eyes underwent pterygium excision followed by removal of subconjunctival fibrovascular tissue and application of 0.02% mitomycin C for 3 minutes. The eyes then were assigned randomly to receive either CAU (44 eyes) or CLAU (43 eyes). MAIN OUTCOME MEASURES: Rate of conjunctival or corneal recurrence of pterygium after surgery. RESULTS: A follow-up of at least 12 months (mean, 14 ± 2.2 months) was achieved in 78 eyes of 78 patients, including 39 eyes in the CAU group (31 primary and 8 recurrent pterygia) and 39 eyes in the CLAU group (33 primary and 6 recurrent pterygia). After surgery, no eye in the CLAU group developed pterygium recurrence; however, recurrence was seen in 2 eyes (5.1%) in the CAU group, including 1 of 31 patients (3.2%) with primary pterygia and 1 of 8 patients (12.5%) with recurrent pterygia. There was no statistically significant difference in recurrence rates between the 2 groups or in the primary and recurrent subgroups. In the CLAU group, a localized pannus formation at the donor site of the limbal graft was noted in 5 eyes (12.8%), with the appearance of pseudopterygium in 1 eye. CONCLUSIONS: There was no significant difference in recurrence rates of pterygium after surgery with mitomycin C application between the CAU and CLAU groups, more remarkably in primary cases. Limbal damage was seen in some eyes with CLAU.

Mycophenolate Mofetil (CellCept®) in Combination With Low Dose Prednisolone in Moderate to Severe Graves' Orbitopathy.

Although corticosteroids are currently the first-choice drug for thyroid eye disease (TED), in 20-30% of cases, patients show poor or non-existent responses, and when the drug is withdrawn, 10-20% of patients relapse. Thus, in this study, we aimed to investigate the efficacy of the combined use of mycophenolate mofetil (CellCept®) and low dose oral prednisolone in patients with moderate to severe Graves' orbitopathy (GO). For the first time, we investigated the relationship between TED-related parameters and proptosis reduction. In a prospective, non-randomized, interventional case series, 242 patients with moderate-to-severe GO were, assigned to receive oral prednisolone (5 mg/ d) and mycophenolate mofetil (CellCept®) (one 500 mg tablet twice per day according to the therapeutic response). The patients were monitored regularly during the 3rd, 6th, 12th, and 18th month of treatment. The main outcome measures were the clinical activity score (CAS), intraocular pressure (IOP), diplopia, proptosis and visual acuity. We also assessed the relationship between the main outcomes with proptosis changes and time to improvement (months). Adverse effects were recorded during each visit. The clinical response rate increased from 67.7% on the third month to 89.2% on the sixth month, and 94.2% on the 12th month. This therapeutic response continued until the 18th month of follow-up. The CAS responses [disease inactivation (CAS <3)] improved during our study: 70.6% on the third month, 90.0% on the sixth month, and 92.5% at 12th month. These conditions continued until the 18th month of follow-up. Proptosis improvement was 52% on the third month, 71% on the sixth month, 83% on the 12th month, and 87.1% on the 18th month. Changes in IOP and visual acuity were not significant (P = 0.568 and 0.668, respectively). The patient showed significant improvement in the Gorman score. A Shorter duration of treatment was seen in patients with earlier onset of intervention, younger age, and lack of all extraocular muscle (EOM) enlargement on computed tomography (CT) scan (p < 0.05). In addition, a better response (more reduction) in proptosis was related to: younger age at disease, earlier treatment intervention (less interval from the time the diagnosis of moderate-to-severe GO was made until medication initiation), shorter treatment time (less time to improvement), less IOP, lack of EOM enlargement on CT scan, and lack of diplopia (P < 0.05). Adverse events occurred in six patients. Findings show that mycophenolate mofetil (CellCept®) plus low-dose prednisolone can be introduced as a new optimal dosing regimen in GO due to its better effect on chronic complications such as proptosis and diplopia.

Vertical rectus muscle transposition for correcting abduction deficiency in Duane's syndrome type 1 and sixth nerve palsy.

PURPOSE: To report the clinical outcome and complications of the Scott Foster procedure for treating abduction deficiency in patients with Duane's syndrome type 1 and sixth nerve palsy. METHODS: A retrospective, interventional case series included 62 consecutive patients (62 eyes: 38 eyes with Duane's syndrome and 24 eyes with sixth nerve palsy) who underwent the Scott Foster procedure for treatment of abduction deficiency. The main outcome measures were deviation, face turn, and abduction deficiency. RESULTS: In patients with sixth nerve palsy, mean distance deviation improved from 44.7+/-7.2 prism diopters (PD) before surgery to 12.5+/-4.0 PD after surgery (P<.05), and in patients with Duane's syndrome type 1, mean distance deviation improved from 31.5+/-4.3 PD preoperatively to 9.2+/-3.1 PD. Mean near deviation improved from 27.1+/-4.5 PD to 6.2+/-2.5 PD in patients with Duane's syndrome and from 40.3+/-6.2 PD to 13.7+/-3.4 PD in patients with sixth nerve palsy. Mean abduction deficiency improved from -4 to -2 (P<.05) in both groups. Face turn improved significantly after surgery. No patient had an overcorrection. No recurrence was detected. CONCLUSION: The Scott Foster procedure is effective for improving deviation, abduction deficiency, and face turn in patients with Duane's syndrome type 1 and especially in those with sixth nerve palsy.

Ocular movement disorders and extraocular muscle involvement in Iranian Graves' ophthalmopathy patients.

PURPOSE: The aim of this study was to evaluate movement disorder patterns and extraocular muscle involvement in Iranian Graves' Ophthalmopathy (GO) patients. METHODS: We examined 75 patients (37 women and 38 men) with GO. Female to male ratio was 0.97 among all patients and 0.72 among restrictive myopathic cases (male 18(58.1%), female 13 (41.9%), P=0.2). Their age ranged from 16 to 66 years; mean age was 35.42+/-11.63 and 33.55+/-10,.31 among patients affected by restrictive enlargement and who did not, respectively. RESULTS: Orbital CT assessment showed EOM enlargement in 124 out of 150 orbits (82.6%). clinical restriction was evident in 31 (41.3%) out of 75 patients. Bilateral restriction was observed in 14 out of 31 (45.1%). The most frequent type of movement limitation was supraduction limitation followed by abduction, inferaduction, and adduction limitations (59%, 40%, 31.1% and 13.3% respectively). This was compatible with Hess screen results and orbital CT reports in regard of IR, MR, SR and LR involvement. Sixteen out of 75 patients reported diplopia. Mean Hertel exophthalmometry readings were higher in eyes with restrictive myopathy. CONCLUSION: This study showed more restrictive myopathy in cases with more extraocular enlargement and positive correlation between severity of inferior rectus enlargement and Hertel reading. A higher rate of male patients in our study may be due to ethnic differences in GO in Iranian patients or due to severity of involvement in this group.

A Comparison of Lower Eyelid Retraction in Normal Individuals with Positive versus Negative Orbital Vector.

PURPOSE: The present study aimed to compare lower eyelid retraction (LER) in individuals with a positive orbital vector with that of individuals with a negative orbital vector. MATERIALS AND METHODS: This cross-sectional study was conducted on 123 normal individuals including 64 men and 59 women aged 20-80 years. After the individuals underwent Hertel exophthalmometry, two side-view and front-view photos were taken using a camera. The orbital vector angle and the extent of scleral show were then measured in millimeter, using the Photoshop software. Eventually, the recorded data were analyzed through statistical software. RESULTS: The findings of this study showed that LER has a significant correlation with orbital vector angle and the extent of proptosis (P < 0.05). The mean value of orbital vector angle in individuals without LER was 9.76°, while this figure was calculated to be - 13.65° in individuals with LER. The mean protrusion value based on Hertel exophthalmometry was 14.08 mm in individuals without LER and 16.27 mm in individuals with LER. The extent of scleral show had a significant correlation with proptosis and orbital vector angle (P = 0.01), with a mean value of - 0.41 mm in individuals without LER and 0.94 mm in participants with LER. CONCLUSIONS: The prevalence of LER and scleral show is positively correlated with the extent of proptosis and negatively correlated with orbital vector angle.

Orbital radiologic parameters of non-syndromic exorbitism patients in comparison with normal population.

PURPOSE: To measure orbital dimension of patients with exorbitism and defining criteria for its diagnosis. METHODS: Twelve patients with non-syndromic exorbitism (NSE) were compared with 24 control samples by means of computed tomography scan (CT-scan) findings. The proptosis severity, lateral wall length, medial wall length, optic nerve straight length, lateral wall angle, ethmoidal sinus surface area, mid-interorbital distance, anterior interorbital distance, external orbital distance, inter-pupillary distance, and lateral wall curve cord were evaluated in order to define a criterion for NSE. RESULTS: Among eleven compared radiological parameters between the study and control groups, five parameters including lateral orbital wall angle (P = 0.02), mid-interorbital distance (P = 0.007), anterior inter-orbital distance (P < 0.001), inter-pupillary distance (P = 0.01), and proptosis severity (P < 0.001) were found to be significantly different between the study groups. Therefore, NSE could be diagnosed with lateral wall angle greater than 41.74°, mid-interorbital distance more than 31.84 mm, and anterior interorbital distance more than 25.90 mm, with a sensitivity of 91% and specificity of 71%. CONCLUSIONS: Using lateral wall angle, mid-interorbital distance, and anterior interorbital distance, we defined the criterion for diagnosis of NSE. Moreover, by focusing on parameters which play a role in developing exorbitism, we can determine the best approach for improvement of aesthetic and functional features of this condition.

Correlation of peripapillary nerve fiber layer thickness with visual outcomes after decompression surgery in subclinical and clinical thyroid-related compressive optic neuropathy.

PURPOSE: To assess the correlation of peripapillary retinal nerve fiber layer (PRNFL) thickness with visual recovery in compressive optic neuropathy (CON) in patients with thyroid eye disease (TED). METHODS: Twenty-three eyes of 13 consecutive patients with TED-related CON were prospectively recruited. Assessment of PRNFL by means of spectral domain optical coherence tomography (SD-OCT), visual field (VF) parameters, color vision, and visual acuity in logMAR were compared before and 6 months after decompression surgery in the operated eye for each patient, which in ten cases included both eyes. Decompression surgery was performed as medial and inferior wall decompression sparing the orbital strut by the same surgeon. RESULTS: There was a significant correlation between the preoperative PRNFL average thickness and postoperative improvement in visual acuity among all patients (P = 0.048). This correlation was found to be significant in clinically non-edematous optic neuropathy cases (P = 0.023) but not in edematous optic neuropathy (P = 0.23). There was significant correlation between PRNFL thickness and improvement of postoperative mean deviation (MD) and pattern standard deviation (PSD) parameters in VF studies and in color vision scores (P = 0.005, P = 0.02, P = 0.01, respectively). Average PRNFL thickness and quadrantal PRNFL were all significantly reduced after decompression surgery in all of the cases (P = 0.024). CONCLUSIONS: PRNFL thickness measured by SD-OCT is correlated with visual recovery after decompression surgery in TED-related CON. In eyes with severe VF defect (MD worse than -10 dB), the ones with higher preoperative PRNFL thicknesses (>65 µm) had more improvement in MD compared with those with thin PRNFL measures (<60 µm).

Orbital alveolar echinococcosis: A case report.

PURPOSE: To report a rare case of orbital alveolar echinococcosis in Iran. METHODS: A 23-year-old woman with multi-lobular mass lesion in the right orbit underwent excisional biopsy via a deep lateral orbitotomy approach. The pathologic investigation of the lesion was a multilobulated cystic lesion shown where the cyst wall structure was compatible with alveolar Hydatid cyst in histopathology. Clinical course, surgical, and medical management of the disease is noted briefly in the case of orbital involvement of the alveolar echinococcosis. RESULTS: Patient was treated with anti-fungal medication, and the cysts were successfully removed by a surgical excision. CONCLUSION: Although orbital alveolar echinococcosis is extremely rare, it is noteworthy to study its clinical manifestations and radiological examinations to be able to make a true diagnosis.

A survey of incidental ocular trauma by pencil and pen.

AIM: To determine characteristic features of ocular trauma resulted from self-trauma by writing instruments among pediatric population. METHODS: Thirty-six children who suffered from self-inflicted ocular trauma with a writing instrument were included in this prospective cross-sectional study. RESULTS: The mean age was 5.6±2.7y with male: female ratio of 1.77. The right eye was involved two times more than the left eye. The superomedial (55.5%) and inferomedial (30.6%) quadrants were the most common sites of injury. The leading culprit was colored pencils (44.4%). During surgical exploration, no foreign body (FB) was found in 25 (69.4%) patients while an FB was found in 11 (30.5%) patients. Brain injury was present in two patients (5.6%) and only in superomedial quadrant injuries. Zone 1 was the most common site for ocular trauma associated with penetrating injury. The mean ocular trauma score (OTS) in penetrating injuries was 3.8±1.2. The best corrected visual acuity (BCVA) was 0.3±0.6 upon admittance and 0.08±0.21 after one year. The final BCVA was significantly correlated with the entrance site, better final BCVA was found in nasal entrance site (P<0.05). CONCLUSION: The ophthalmologists should keep a high index of suspicion to rule out penetrating eye injuries related to writing instruments in a young uncooperative child. Brain injury is a life-threatening event that should be ruled out by appropriate imaging. Medial canthal area as the most common site needs an especial attention in writing instrument injuries.

Pellet gun injury as a source of ocular trauma; a retrospective review of one hundred and eleven cases.

PURPOSE: To report the demographic data, treatment methods, and outcomes among patients with pellet gun eye injuries. METHODS: This study was a retrospective review of all pellet gun eye injuries coming to Farabi Eye Hospital, a referral ocular trauma center in Iran, from February 2009 to November 2013. Patients' demographics, type of injury, choice of management, complications, and post-treatment visual acuity were recorded. RESULTS: One hundred eleven patients with a mean age of 25.7 ± 15.6 years entered the study. The most common age group was younger adults (16-45 years old) (61.3%). The mean uncorrected visual acuity after treatment was 2.05 (20/2240) ±1.5 logMAR. The most prevalent ocular zone was zone III (38.7%), and an intraocular foreign body was present in 97 patients (87.4%). Lid laceration and periocular tissue damage were present in 27 patients (24.3%). Lensectomy and vitrectomy were the most common treatment (31.5%). In most patients (87.4%), the injury was non-deliberate, and the most common time of hospitalization was the same day (45.0%). The only statistically significant indicator of post-treatment visual acuity was ocular trauma score (OTS) at admission (P < 0.001). At the end of follow-up, enucleation was performed for 20 patients (18%), and thirty-six patients (32%) had no light perception (NLP) in vision. CONCLUSION: Pellet gun injuries were more common among young male patients, and the only statistically significant indicator of post-treatment visual acuity was OTS at admission.

Determinative factors in surgical planning of eyebrow cosmetic and reconstructive surgery.

PURPOSE: The purpose of this study was to identify the different factors that an oculoplastic surgeon should consider while practicing cosmetic or reconstructive eyebrow surgery in order to have the final patient's satisfaction. SUBJECTS AND METHODS: In an observational case series study, five photographs were taken from each of 60 females to show ideal eyebrow positioning with fingers. Eyebrow landmarks, including tarsal plate show (TPS) and eyebrow height, were measured in the ideal position. Brow apex position and brow apex angle were evaluated in the desired position of eyebrow. RESULTS: The mean desired apex angle of eyebrow was measured as 135±9 mm. In all, 48.33% of our subjects preferred a wider brow angle, 28.33% a narrower one, and 23.33% a brow angle without any change. The location of brow peak was transferred to the lateral canthus in the desired position. The ideal brow peak in the lateral canthus and between lateral canthus and lateral limbus was assigned to 33.3% and 66.6% of cases, respectively. The desired eyebrow apex angle in two age groups of our subjects (>40 years and ≤40 years) was not statistically different. CONCLUSION: Landmarks of the eyebrow and its desired position are somehow different between different studies, which may be explained by the variation in race, gender, culture, and age. As there is not any uniform rule in planning of cosmetic surgeries of eyebrow, oculoplastic surgeons should consider the difference in culture, race, age, and desire of the patients and have their surgical plans for every individual patient distinctively.