Bisphosphonate-associated orbital inflammatory disease and uveitis anterior--a case report and review.

BACKGROUND: Drug-induced cases of orbital inflammation and uveitis are rare.We present a bisphosphonate-induced case of unilateral orbital inflammation and bilateral anterior uveitis. PATIENTS AND METHODS: A 75-year-old female presents because of pain and swelling around her left eye with an onset 2 days after an intravenous zoledronic acid therapy for osteoporosis. Examination reveals reduced visual acuity of 0.2, proptosis of 4 mm, marked conjunctival chemosis and hyperemia, ophthalmoplegia and choroidal folds in the left eye and a bilateral anterior uveitis. CT and MRI scans show signs of diffuse pre- and postseptal inflammation in the left orbit. RESULTS: Initiation of intravenous methylprednisolon leads to a complete regression of the inflammatory process within days. This causality between the therapy with bisphosphonates and an orbital inflammation as well as an anterior uveitis corresponds to the literature. Drug-induced cases of orbital inflammation and uveitis have also been reported following use of antiinfectious drugs, biologica and vaccines. CONCLUSIONS: Iatrogenic causes should be considered in the differential diagnosis of orbital inflammations, scleritis and uveitis. Findings are mostly reversible after discontinuation of the drug and therapy of inflammation.

[IgG4-related orbital inflammation]. / IgG4-assoziierte orbitale Entzündungen.

INTRODUCTION: Serum immunoglobulin G4 (IgG4)-related systemic disease is a newly found entity and should be considered as a further differential diagnosis to the big pool of unspecific orbital inflammation. We describe clinical appearance and treatment options. PATIENTS AND METHODS: We retrospectively analyzed all patients with the diagnosis IgG4-related orbital inflammation who were examined in our outpatient clinic. We compared symptoms, clinical and histological findings and therapy. RESULTS: In the last 17 months five patients were diagnosed with IgG4-related orbital disease. Biopsies were performed of most affected areas as seen in the computerised tomography scan. Histology revealed marked infiltration with IgG4-positive plasma cells. Serum IgG4-levels were partly significantly elevated. Based on these findings diagnosis of an IgG4-related disease was agreed and treatment with oral prednisone installed. In one patient a therapy with Rituximab was successfully started. CONCLUSION: Extended unspecific orbital inflammation, especially when bilateral and associated with systemic disease should be considered to be IgG4-related. Histological proof of IgG4-positive plasma cells and elevated IgG4 serum levels do confirm this diagnosis. Strict follow-up and interdisciplinary work-up is recommended.

[Hypoglobus--illusive or real? Etiologies of vertical globe displacement in a tertiary referral centre]. / Hypoglobus--Schein oder Sein? Ätiologien vertikaler Bulbusdislokationen in einem tertiären Zentrumsspital.

BACKGROUND: While exophthalmus is quantifiable with readily available measurement tools, there is no such tool for hypoglobus/hyperglobus. Despite its possible life-threatening causes only few articles address the etiologies of vertical globe displacement in the current literature. The aim of our study was to describe etiologies of hypoglobus and to analyze the ratio of malignant diseases. PATIENTS AND METHODS: 3000 portrait photographs taken in our ophthalmology department between 2005 and 2009 were retrospectively screened for patients with vertical globe displacement. Pictures were assessed by three independent ophthalmology-trained observers and matched to the diagnosis based on patient records. RESULTS: 95 patients with supposed vertical globe displacement were identified. Vertical globe displacement was due to an intracranial or orbital disease in 45 patients including 6 patients with a malignant disease. Additional 10 patients had thyroid associated orbitopathy. 11 patients turned out to have mere facial asymmetry, 26 patients had strabism and four patients had an ocular prosthesis. CONCLUSIONS: The etiologies of hypoglobus ranges from orbital fractures to life-threatening malignant tumors. Distinction between apparent and true hypoglobus can be challenging.

[Solitary fibrous tumour of the orbit: clinical, radiological, histological findings and differential diagnosis of an uncommon tumour]. / Solitärer fibröser Tumor der Orbita: klinische, radiologische, histologische Merkmale und Differenzialdiagnose eines ungewöhnlichen Tumors.

BACKGROUND: Solitary fibrous tumours (SFT) are mesenchymal neoplasias rarely found in the orbit. Due to their sharp delineation they are frequently mistaken for various benign neoplasma, such as cavernous hemangiomas, neurinomas and pleomorphic adenomas. We present two cases of SFT in the orbit and one in the lacrimal sac and discuss the radiological and histological differential diagnosis. PATIENTS AND METHODS: Among 9 patients diagnosed and operated in our department between 2008 and 2010 with an orbital tumour, three had the histological diagnosis of a solitary fibrous tumour. In 5 cases an MRI scan was performed preoperatively, in 4 cases a CT scan. RESULTS: Histology showed 2 pleomorphic adenomas, 2 cavernous hemangiomas, 2 neurinomas and 3 SFT. All SFT were intraoperatively well circumscribed and enucleated, showing histologically incomplete resection. No further treatment was given. There is no recurrence in any of the patients in the follow up of an average of 10 months (range 1 - 30 months). CONCLUSIONS: SFT are rare mesenchymal tumours of the orbit. The radiological differential diagnosis is difficult and they can be mistaken for more common tumours. The SFT has a wide range of histological appearances. Long term clinical follow-up is mandatory in all cases of SFT.

[Long-term follow-up after surgery for exodeviation]. / Langzeitergebnisse nach chirurgischer Korrektur von Exodeviationen.

BACKGROUND: In strabismus surgery the challenge is the preoperative determination of the surgical dosage. We assessed the long-term follow-up after strabismus surgery for exodeviations and evaluated the employed dosage. PATIENTS AND METHODS: We present a study of 53 consecutive patients who underwent surgery for exodeviations. One year postoperative results were analysed based on strict criteria. Out of the original group of 53 patients we could evaluate the long-term follow-up in 18 patients, after an average period of 13 years. The criteria for patients with intermittent exotropia and decompensating exophoria after one year and in the long-term follow-up were determined as follows: very good: orthophoria or orthotropia with exo- or esophoria less than 5 PD; good: orthotropia with exo- or esotropia less than 10 PD; satisfactory: orthotropia with exo- or esophoria > 10 PD but less than the preoperative angle; bad: constant eso- or exotropia or > preoperative angle. For patients with a constant divergent strabismus the following criteria were determined: very good: orthophoria or orthotropia with exo- or esophoria less than 5 PD; good: exo- or esophoria less than 10 PD or tropia of 5 degrees (microstrabismus); satisfactory: exo- or esophoria > 10 PD or exo- or esotropia > 10 PD but < preoperative angle; bad: same as preoperative or more. A subgroup analysis of 41 patients who underwent monolateral combined rectus muscle surgery was performed regarding their long-term follow-up (average: 13 years) as well. Concurrently the patients completed a questionnaire. RESULTS: One year postoperatively 6 outcomes were very good, 14 good, 31 satisfactory and 2 were poor. On average 13 years postoperatively the same patients were evaluated based on the same strict criteria. No outcome was very good, 4 good, 12 satisfactory and 2 were poor. The judgement of the patients in the questionnaire was at both times clearly better. The exo-shift in the first postoperative year was 3.5 degrees , in the next on average 12 years the mean divergent strabismus angle increased by another 2.9 degrees. CONCLUSIONS: The outcome evaluation after a long-term follow-up showed amazingly stable results compared to the follow-up after one year. With a more aggressive dosage we could have achieved more orthophoric results, but also more undesirable overcorrections.

[Sinusitis and ocular motility disorders]. / Sinusitis und okuläre Motilitätseinschränkungen.

BACKGROUND: Secondary inflammatory orbital involvement due to acute or chronic sinusitis is common. The pneumatized system of the paranasal sinuses is abut to the bones of the orbit in up to 80 percent, therefore the association is a seductive theory due to their anatomic closeness. Typically, sinusitis can influence ocular motility by affecting single muscles or a combination of muscles/cranial nerves due to a local inflammatory tissue reaction. The expected picture would be a more or less complex restriction of eye movements. PATIENTS AND METHODS: In this case study nine consecutive patients were prospectively included between January 2006 and August 2007. RESULTS: Five of the patients did not experience any motility disorder, the other four had a restricted motility. Case reports of the four patients are presented to demonstrate the range of ocular motility disorders related to sinusitis. CONCLUSIONS: Orbital complications due to sinusitis include motility disorders among others. They can even cause orbital sepsis and cavernous sinus thrombosis. On the one hand sinusitis can affect almost the whole spectrum of ocular motility disorders, on the other hand it may mask a dangerous cerebral aneurysm. The "close-lying" connections, as seductive they are, should not divert from the rule: infrequent causes are infrequent and frequent causes are frequent!

Perioperative posterior ischemic optic neuropathy as a rare complication of blepharoplasty.

PURPOSE: To report a case of visual loss to light perception in the right eye after upper and lower eyelid blepharoplasty. DESIGN: Case report. METHOD: A 46-year-old man was referred 3 days after combined bilateral upper and lower lid blepharoplasty with visual acuity of light perception in the right eye. The fundus examination, fluorescein angiography and magnetic resonance imaging of the orbit were normal. Ocular motility was full in all directions of gaze. RESULT: The diagnosis of optic nerve damage was initially based on the relative afferent pupillary defect. The diagnosis of a perioperative posterior ischemic optic neuropathy was based on the Goldmann visual field examination and the subsequent optic atrophy. Central visual acuity, color vision as well as the visual field improved markedly within 3 months. CONCLUSION: Blindness is a rare but feared complication of blepharoplasty and is reported to occur in about 0.04% of cases. Although intraorbital hemorrhage is thought to be the leading cause for optic nerve damage in most of the patients with this devastating condition, we present a case with perioperative posterior ischemic optic neuropathy leading to visual loss after blepharoplasty. The mechanism leading to optic nerve damage in this patient may include compromised small arteries perfusing the optic disk due to direct mechanical compression and a probable vasoconstrictive activity of the anesthetic agent.