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BACKGROUND: To assess topical dorzolamide as medical therapy for idiopathic full-thickness macular holes (FTMHs). METHODS: Randomised, double-blinded, placebo-controlled, single-centre clinical trial involving 32 patients with idiopathic small FTMHs (<400 µm $$ \upmu \mathrm{m} $$ ). Participants in both arms used topical dorzolamide 2% or saline thrice daily for 8 weeks with monthly OCT. Those with persisting FTMH underwent vitrectomy with ILM peel and gas tamponade. The primary outcome was the rate of FTMH closure at the end of treatment. RESULTS: Between 6 March 2020 and 16 June 2023, 32 eligible patients were enrolled: 16 participants in each arm. All participants in both groups were included in the final analysis. At the final visit, 3 of 16 (18.8%) patients in both the topical dorzolamide and placebo group demonstrated closure. There was no statistically significant difference in the proportion of FTMH closure between the control and treatment group (p = 1.00), nor statistically significant difference in the mean change in best corrected visual acuity (BCVA; p = 0.909). There was no difference in the change in FTMH diameter between groups (p = 0.225). No serious adverse events were reported in either group. CONCLUSION: Topical dorzolamide was safe but not superior to placebo in the functional and anatomical outcomes of FTMH.
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BACKGROUND: Endophthalmitis following intravitreal injection is a potentially devastating complication of anti-VEGF injections. Post-injection endophthalmitis due to Enterococcus faecalis is rare, and no previous case of Morganella morganii endophthalmitis after intravitreal injection has been reported. CASE PRESENTATION: We present the first reported case of Morganella morganii and Enterococcus faecalis endophthalmitis after intravitreal injection in an immunocompetent patient in the absence of recent ocular surgery. Our patient presented with hand movement visual acuity one day after anti-VEGF injection and demonstrated no clinical improvement despite repeated intravitreal ceftazidime and vancomycin injections. A decision was made to proceed with early vitrectomy given failure of intravitreal antibiotics. Visual acuity improved to 6/90 at 12 weeks after vitrectomy without any evidence of disease recurrence. CONCLUSIONS: Post-injection endophthalmitis due to concurrent Morganella morganii and Enterococcus faecalis infections can have visually devastating consequences despite repeated empirical and targeted intravitreal antibiotics. Lack of clinical improvement following intravitreal antibiotics should warrant consideration of early vitrectomy. Our experience is a pertinent reminder of the ever-growing threat of uncommon and multi-resistant bacteria that must be considered when treating infections such as post-injection endophthalmitis.
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Endoftalmitis , Infecciones Bacterianas del Ojo , Morganella morganii , Humanos , Enterococcus faecalis , Inyecciones Intravítreas , Infecciones Bacterianas del Ojo/diagnóstico , Infecciones Bacterianas del Ojo/tratamiento farmacológico , Infecciones Bacterianas del Ojo/microbiología , Endoftalmitis/diagnóstico , Endoftalmitis/tratamiento farmacológico , Endoftalmitis/microbiología , Antibacterianos/uso terapéutico , Vitrectomía/efectos adversos , Bacterias , Estudios RetrospectivosRESUMEN
BACKGROUND: The accurate encoding of operation notes is essential for activity-based funding and workforce planning. The aim of this project was to evaluate the procedural coding accuracy of vitrectomy and to develop machine learning, natural language processing (NLP) models that may assist with this task. METHODS: This retrospective cohort study involved vitrectomy operation notes between a 21-month period at the Royal Adelaide Hospital. Coding of procedures were based on the Medicare Benefits Schedule (MBS)-the Australian equivalent to the Current Procedural Terminology (CPT®) codes used in the United States. Manual encoding was conducted for all procedures and reviewed by two vitreoretinal consultants. XGBoost, random forest and logistic regression models were developed for classification experiments. A cost-based analysis was subsequently conducted. RESULTS: There were a total of 1724 procedures with individual codes performed within 617 vitrectomy operation notes totalling $1 528 086.60 after manual review. A total of 1147 (66.5%) codes were missed in the original coding that amounted to $736 539.20 (48.2%). Our XGBoost model had the highest classification accuracy (94.6%) in the multi-label classification for the five most common procedures. The XGBoost model was the most successful model in identifying operation notes with two or more missing codes with an AUC of 0.87 (95% CI 0.80-0.92). CONCLUSIONS: Machine learning has been successful in the classification of vitrectomy operation note encoding. We recommend a combined human and machine learning approach to clinical coding as automation may facilitate more accurate reimbursement and enable surgeons to prioritise higher quality clinical care.
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Registros Electrónicos de Salud , Vitrectomía , Anciano , Humanos , Estudios Retrospectivos , Australia , Programas Nacionales de Salud , Aprendizaje AutomáticoRESUMEN
Background Lumbar spine MRI studies are widely used for back pain assessment. Interpretation involves grading lumbar spinal stenosis, which is repetitive and time consuming. Deep learning (DL) could provide faster and more consistent interpretation. Purpose To assess the speed and interobserver agreement of radiologists for reporting lumbar spinal stenosis with and without DL assistance. Materials and Methods In this retrospective study, a DL model designed to assist radiologists in the interpretation of spinal canal, lateral recess, and neural foraminal stenoses on lumbar spine MRI scans was used. Randomly selected lumbar spine MRI studies obtained in patients with back pain who were 18 years and older over a 3-year period, from September 2015 to September 2018, were included in an internal test data set. Studies with instrumentation and scoliosis were excluded. Eight radiologists, each with 2-13 years of experience in spine MRI interpretation, reviewed studies with and without DL model assistance with a 1-month washout period. Time to diagnosis (in seconds) and interobserver agreement (using Gwet κ) were assessed for stenosis grading for each radiologist with and without the DL model and compared with test data set labels provided by an external musculoskeletal radiologist (with 32 years of experience) as the reference standard. Results Overall, 444 images in 25 patients (mean age, 51 years ± 20 [SD]; 14 women) were evaluated in a test data set. DL-assisted radiologists had a reduced interpretation time per spine MRI study, from a mean of 124-274 seconds (SD, 25-88 seconds) to 47-71 seconds (SD, 24-29 seconds) (P < .001). DL-assisted radiologists had either superior or equivalent interobserver agreement for all stenosis gradings compared with unassisted radiologists. DL-assisted general and in-training radiologists improved their interobserver agreement for four-class neural foraminal stenosis, with κ values of 0.71 and 0.70 (with DL) versus 0.39 and 0.39 (without DL), respectively (both P < .001). Conclusion Radiologists who were assisted by deep learning for interpretation of lumbar spinal stenosis on MRI scans showed a marked reduction in reporting time and superior or equivalent interobserver agreement for all stenosis gradings compared with radiologists who were unassisted by deep learning. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Hayashi in this issue.
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Aprendizaje Profundo , Estenosis Espinal , Constricción Patológica , Femenino , Humanos , Vértebras Lumbares/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Canal Medular , Estenosis Espinal/diagnóstico por imagenRESUMEN
PURPOSE: To analyze the single surgery success rate and anterior segment complications related to phacoemulsification and intraocular lens implantation in a series of patients undergoing phacovitrectomy for all types of primary rhegmatogenous retinal detachment. METHODS: We performed a retrospective interventional case series on 302 eyes undergoing phacovitrectomy for primary rhegmatogenous retinal detachment repair between November 1, 2016, and February 2, 2019, in Edmonton, Canada. Primary outcomes included single surgery retinal reattachment rate and anterior segment complications. Secondary outcomes included the effects of proliferative vitreoretinopathy and macula and/or peripheral internal limiting membrane peeling on the rate of surgical success. RESULTS: The single surgery success rate of phacovitrectomy for all types of primary rhegmatogenous retinal detachment was 85.1%. The presence of proliferative vitreoretinopathy was associated with lower surgical success (odds ratio, 0.33; P = 0.01). Macular internal limiting membrane peeling was associated with higher surgical success (odds ratio, 2.4; P = 0.05). Anterior segment complications included posterior capsular opacification (28.8%), posterior synechiae (10.9%), and posterior capsular rupture (2.3%). CONCLUSION: Phacovitrectomy is a safe and effective treatment option for the primary repair of rhegmatogenous retinal detachments. This study provides evidence to support the safe incorporation of phacoemulsification and intraocular lens implantation with retinal surgery.
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Implantación de Lentes Intraoculares , Facoemulsificación , Desprendimiento de Retina/cirugía , Vitrectomía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Seudofaquia/fisiopatología , Desprendimiento de Retina/fisiopatología , Estudios Retrospectivos , Resultado del Tratamiento , Agudeza Visual , Vitreorretinopatía Proliferativa/complicaciones , Vitreorretinopatía Proliferativa/fisiopatología , Adulto JovenRESUMEN
Luxatio erecta humeri (LEH), also known as inferior shoulder dislocation, is uncommon, comprising about 0.5% of all cases of shoulder dislocation. Synchronous bilateral LEH is exceedingly rare and, to our knowledge, there are no descriptions of axillary nerve injury on magnetic resonance imaging (MRI) following LEH. We present a case of traumatic bilateral LEH in a 59-year-old woman who fell from a fast-moving mobility scooter and sustained direct axial loading forces on the fully abducted shoulders. Both shoulders were successfully reduced using the traction-countertraction technique in the emergency department. In this article, we describe the characteristic features of LEH on plain radiography and the pattern of acute soft-tissue injuries on MRI. We emphasize the importance of reviewing the axillary neurovascular bundle, which by virtue of its location beneath the shoulder joint, is prone to injury in inferior shoulder dislocation and thus has a substantial impact on functional recovery. This important complication is unfortunately not routinely examined by radiologists, partly because of the paucity of literature highlighting its clinical significance.
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Luxaciones Articulares/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Luxación del Hombro/diagnóstico por imagen , Accidentes por Caídas , Femenino , Humanos , Luxaciones Articulares/etiología , Luxaciones Articulares/terapia , Persona de Mediana Edad , Luxación del Hombro/etiología , Luxación del Hombro/terapiaRESUMEN
BACKGROUND: Surgeon-performed periarticular injections and anesthesiologist-performed femoral nerve or adductor canal blocks with local anesthetic are in common use as part of multimodal pain management regimens for patients undergoing TKA. However, femoral nerve blocks risk causing quadriceps weakness and falls, and anesthesiologist-performed adductor canal blocks are costly in time and resources and may be unreliable. We investigated the feasibility of a surgeon-performed saphenous nerve ("adductor canal") block from within the knee at the time of TKA. QUESTIONS/PURPOSES: (1) Can the saphenous nerve consistently be identified distally on MRI studies, and is there a consistent relationship between the width of the femoral transepicondylar axis (TEA) and the proximal (cephalad) location where the saphenous nerve emerges from the adductor canal? With these MRI data, we asked the second question: (2) Can we utilize this anatomic relationship to simulate a surgeon-performed intraoperative block of the distal saphenous nerve from within the knee with injections of dyes after implantation of trial TKA components in cadaveric lower extremity specimens? METHODS: A retrospective analysis of 94 thigh-knee MRI studies was performed to determine the relationship between the width of the distal femur at the epicondylar axis and the proximal location of the saphenous nerve after its exit from the adductor canal and separation from the superficial femoral artery. These studies, obtained from one hospital's MRI library, had to depict the saphenous nerve in the distal thigh and the femoral epicondyles and excluded patients younger than 18 years of age or with metal implants. These studies were performed to evaluate thigh and knee trauma or unexplained pain, and 55 had some degree of osteoarthritis. After obtaining these data, TKA resections and trial component implantation were performed, using a medial parapatellar approach, in 11 fresh cadaveric lower extremity specimens. There were six male and five female limbs from cadavers with a mean age of 70 years (range, 57-80 years) and mean body mass index of 20 kg/m (range, 15-26 kg/m) without known knee arthritis. Using a blunt-tipped 1.5-cm needle, we injected 10 mL each of two different colored solutions from inside the knee at two different locations and, after 30 minutes, dissected the femoral and saphenous nerves and femoral artery from the hip to the knee. Our endpoints were whether the saphenous nerve was bathed in dye and if the dye or needle was located in the femoral artery or vein. RESULTS: Based on the MRI analysis, the mean ± SD TEA was 75 ± 4 mm in females and 87 ± 4 mm in males. The saphenous nerve exited the adductor canal and was located at a mean of 1.5 ± 0.16 times the TEA width in females and a mean of 1.3 ± 0.13 times the TEA width in males proximal to the medial epicondyle. After placement of TKA trial components and injection, the proximal injection site solution bathed the saphenous nerve in eight of 11 specimens. In two cachectic female cadaver limbs, the dye was located posteriorly to the nerve in hamstring muscle. The proximal blunt needle and colored solution were directly adjacent to but did not penetrate the femoral artery in only one specimen. CONCLUSIONS: This study indicates, based on MRI measurements, cadaveric injections, and dissections, that a surgeon-performed injection of the saphenous nerve from within the knee after it exits from the adductor canal seems to be a feasible procedure. CLINICAL RELEVANCE: This technique may be a useful alternative to an ultrasound-guided block. A trial comparing surgeon- and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure.
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Anestésicos Locales/administración & dosificación , Cuidados Intraoperatorios/métodos , Rodilla/inervación , Rodilla/cirugía , Imagen por Resonancia Magnética Intervencional , Bloqueo Nervioso/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Puntos Anatómicos de Referencia , Anestésicos Locales/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Cadáver , Estudios de Factibilidad , Femenino , Humanos , Inyecciones Intraarticulares , Cuidados Intraoperatorios/efectos adversos , Rodilla/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/efectos adversos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Thiamine deficiency classically manifests as the triad of Wernicke encephalopathy: acute confusional state, ataxic gait, and ocular motor dysfunction. However, most patients do no present with this classic triad. Optic neuropathy in thiamine deficiency is a rare manifestation and is usually associated with fundus appearances of optic disc swelling or optic disc pallor. We present 2 unique cases of thiamine deficiency where the fundus demonstrated peripapillary retinal nerve fiber layer thickening without florid disc swelling or pallor.
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Fibras Nerviosas/patología , Enfermedades del Nervio Óptico/etiología , Enfermedades del Nervio Óptico/patología , Retina/patología , Deficiencia de Tiamina/complicaciones , Alcoholismo/complicaciones , Femenino , Humanos , Persona de Mediana Edad , Deficiencia de Tiamina/etiología , Tomografía de Coherencia Óptica , Adulto JovenAsunto(s)
Absorciometría de Fotón/métodos , Gota , Procesamiento de Imagen Asistido por Computador/métodos , Dolor de la Región Lumbar , Vértebras Lumbares , Columna Vertebral/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Articulación Cigapofisaria , Adulto , Diagnóstico Diferencial , Gota/diagnóstico , Gota/fisiopatología , Humanos , Imagenología Tridimensional , Artropatías/diagnóstico , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/etiología , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/patología , Imagen por Resonancia Magnética/métodos , Masculino , Articulación Cigapofisaria/diagnóstico por imagen , Articulación Cigapofisaria/patologíaRESUMEN
Superior ophthalmic vein (SOV) thrombosis is a rare complication of carotid-cavernous fistula (CCF) embolization and is usually associated with a paradoxical worsening of signs followed by subsequent spontaneous resolution. We report a case in a 69-year-old female who developed orbital compartment syndrome due to SOV thrombosis following transvenous embolization of an indirect CCF. The patient was treated with an urgent lateral canthotomy and cantholysis and had good recovery. This report demonstrates that the paradoxical worsening due to SOV thrombosis in CCF may result in orbital compartment syndrome and require early recognition and prompt decompressive measures to avoid permanent visual sequelae.
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Fístula del Seno Cavernoso de la Carótida/terapia , Síndromes Compartimentales/etiología , Embolización Terapéutica/efectos adversos , Enfermedades Orbitales/etiología , Anciano , Blefaroptosis/diagnóstico por imagen , Blefaroptosis/etiología , Blefaroptosis/cirugía , Fístula del Seno Cavernoso de la Carótida/diagnóstico por imagen , Síndromes Compartimentales/diagnóstico por imagen , Síndromes Compartimentales/cirugía , Exoftalmia/diagnóstico por imagen , Exoftalmia/etiología , Exoftalmia/cirugía , Femenino , Humanos , Presión Intraocular , Enfermedades Orbitales/diagnóstico por imagen , Enfermedades Orbitales/cirugía , Trastornos de la Pupila/diagnóstico por imagen , Trastornos de la Pupila/etiología , Trastornos de la Pupila/cirugía , Tomografía Computarizada por Rayos X , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/cirugíaRESUMEN
Orbital surgery is often conducted in areas with limited exposure where vital structures are tightly crowded together. A bloodless field is paramount in orbital surgery for the proper identification of normal and pathologic tissue and even minimal bleeding can obscure the surgical field, making surgery more difficult and increasing the risk of complications. Surgery for highly vascular orbital lesions is an additional situation where maintaining an adequate surgical field is often challenging but paramount. The role of the anaesthetist in controlling surgical blood loss has been increasingly recognized in the last few decades. Various techniques including hypotensive anaesthesia have been described, but the control of intraoperative bleeding does not rely on a single particular technique, but a series of well-designed interventions that result in optimal conditions. An understanding of the anaesthetic considerations pertinent to haemostasis is invaluable for oculoplastic surgeons. Additionally, with the growing use of endonasal approaches to medial wall decompression and accessing the medial orbit, it has become increasingly important that orbital surgeons understand the anaesthetic requirements of their colleagues in other disciplines.
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Anestésicos Generales/administración & dosificación , Hemostasis Quirúrgica/métodos , Enfermedades Orbitales/cirugía , Pérdida de Sangre Quirúrgica/prevención & control , Humanos , Procedimientos Quirúrgicos OftalmológicosRESUMEN
OBJECTIVE: To describe the development of a web-based data collection tool to track the management and outcomes of uveal melanoma patients. DESIGN: Description of a clinical registry. PARTICIPANTS: Patients with uveal melanoma. METHODS: A panel of expert ocular oncologists, with input from other relevant specialties and individuals with expertise in registry development, collaborated to formulate a minimum data set to be collected to track patient centred, real-world outcomes in uveal melanoma. This data set was used to create the Fight Tumour Blindness! (FTB!) registry within Save Sight Registries. RESULTS: The data set to be collected includes patient demographics and medical history, baseline visit, follow-up visit including tumour treatment, metastatic staging and surveillance, pathology, and patient-reported questionnaires. The inbuilt mechanisms to ensure efficient and complete data collection are described. CONCLUSIONS: The FTB! registry can be used to monitor outcomes for patients with uveal melanoma. It allows benchmarking of outcomes and comparisons between different clinics and countries.
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Melanoma , Sistema de Registros , Neoplasias de la Úvea , Humanos , Neoplasias de la Úvea/epidemiología , Ceguera/epidemiología , Ceguera/prevención & control , Ceguera/etiología , Femenino , Masculino , Encuestas y CuestionariosRESUMEN
There are over 300 million people living in the world today who are visually impaired and a further 45 million who are blind. The large majority (90%) of these people live in developing countries, and up to 75% of blindness are avoidable. With cataracts being the major cause of blindness and visual impairment, many ophthalmic aid programmes are aimed at alleviating the enormous burden caused by this readily treatable disease. Having said that, caution should be exercised that short surgical visits to remote rural areas that are not coordinated with local national eye care managers should be discouraged because they do little for the development of sustainable eye care programmes. With this in view, it has become imperative to design blindness prevention and ophthalmic support programmes that are workable, comprehensive, economical and sustainable.
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Ceguera/prevención & control , Países en Desarrollo , Programas Nacionales de Salud/organización & administración , Oftalmología/organización & administración , Baja Visión/prevención & control , Personas con Daño Visual/estadística & datos numéricos , Ceguera/epidemiología , Ceguera/etiología , Salud Global , Promoción de la Salud , Humanos , Baja Visión/epidemiología , Baja Visión/etiologíaRESUMEN
We present an unusual case of polypoidal choroidal vasculopathy (PCV) lying above the retinal pigment epithelium (RPE) in a 60-year-old Caucasian female. PCV lesions are typically located beneath the RPE layer. However, they may rarely lie above the level of the RPE due to a discontinuity in the RPE and Bruch's membrane.
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Enfermedades de la Coroides/diagnóstico , Coroides/patología , Pólipos/diagnóstico , Diagnóstico Diferencial , Femenino , Angiografía con Fluoresceína , Fondo de Ojo , Humanos , Persona de Mediana Edad , Tomografía de Coherencia ÓpticaRESUMEN
PURPOSE: We present two atypical cases of calciphylaxis presenting with ocular ischemic pathology - both without the hallmark cutaneous manifestations - to raise awareness of this rare yet highly disabling condition. OBSERVATIONS: We report two cases of ophthalmic calciphylaxis presenting as (1) anterior ischemic optic neuropathy (AION) and cilioretinal artery occlusion in a 76-year-old woman with pre-dialysis kidney failure, and (2) AION with contralateral central retinal artery occlusion (CRAO) in a 44-year-old man on hemodialysis. CONCLUSION AND IMPORTANCE: These cases highlight the need for judicious clinical suspicion of calciphylaxis in patients with kidney failure, presenting with microvascular ischemic ophthalmic pathology such as AION or CRAO. Confirmation with temporal artery biopsy is essential to direct targeted individualized multi-disciplinary treatment of calciphylaxis and avoid unnecessary steroid exposure in cases masquerading as giant cell arteritis (GCA).
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Orbitofrontal cholesterol granuloma is a rare entity that has a predilection for men in their fourth or fifth decade and occurs almost exclusively within the frontal bone overlying the lacrimal fossa. Surgery by drainage and curettage is virtually curative in all cases and recurrence is very rare. We describe the case of a 77-year-old man with recurrent orbitofrontal cholesterol granuloma 11 years after surgery, presumably due to subtotal curettage. The potential use of an endoscope to aid complete removal of lesion is discussed.
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Colesterol , Granuloma de Cuerpo Extraño/diagnóstico , Enfermedades Orbitales/diagnóstico , Anciano , Endoscopía/métodos , Hueso Frontal/patología , Granuloma de Cuerpo Extraño/cirugía , Humanos , Masculino , Enfermedades Orbitales/cirugía , Recurrencia , Tomografía Computarizada por Rayos XRESUMEN
The use of endoscopic orbital and optic nerve decompression for traumatic optic neuropathy and dysthyroid orbitopathy have been well documented; however, reports on endoscopic decompression for benign orbital apex lesions are scarce. The records of two patients who underwent endoscopic decompression of the bony orbit for progressive visual loss were reviewed. Patient 1 had fibrous dysplasia and presented with headache and visual field defects. Patient 2 had sphenoid wing meningioma and multiple previous attempts of transcranial tumor resection and orbital decompression. Both had progressive visual deterioration and ultimately underwent transnasal endoscopic orbital decompression. Post-operatively, both patients had subjective and objective improvement in visual function and compressive symptoms. No complications from the endoscopic decompression were observed in both patients. Transnasal endoscopic approach may be a viable option for decompression of benign orbital apex lesions.
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Endoscopía/métodos , Enfermedades del Nervio Óptico/cirugía , Enfermedades Orbitales/cirugía , Adulto , Descompresión Quirúrgica , Diagnóstico Diferencial , Femenino , Displasia Fibrosa Ósea/complicaciones , Displasia Fibrosa Ósea/cirugía , Humanos , Meningioma/complicaciones , Meningioma/cirugía , Persona de Mediana Edad , Enfermedades del Nervio Óptico/diagnóstico , Enfermedades del Nervio Óptico/etiología , Enfermedades Orbitales/diagnóstico , Enfermedades Orbitales/etiología , Tomografía Computarizada por Rayos X , Agudeza VisualRESUMEN
We describe two patients with late-onset capsular block syndrome who presented 6 years and 4 years, respectively, after cataract surgery and were successfully treated with Nd:YAG capsulotomy.