Early Intervention in Orbital Floor Fractures: Postoperative Ocular Motility and Diplopia Outcomes.

Purpose: Orbital floor fractures commonly occur during orbital trauma. Currently, the indications for orbital fracture repair and the appropriate duration between trauma and surgical intervention remain controversial. Methods: Eyes diagnosed with orbital floor fractures that underwent reconstruction surgery were retrospectively reviewed. Demographic data were analyzed. Patients were classified based on the timing of the surgical intervention after injury. Ocular limitation and diplopia were evaluated preoperatively and postoperatively at one week, one month, and three months. Results: Two hundred seventy eyes of 270 patients (174 males and 96 females, mean age: 40.9 ± 16.3 years) were identified. The mean duration from injury to surgical intervention was 18.0 ± 21.2 days (range: 0−117 days). In the subgroup analysis, compared to delayed treatment, the early repair of floor fractures, i.e., within 7 days, was associated with significant motility and diplopia resolution at one week (p = 0.001, p < 0.001), one month (p < 0.001, p < 0.001), and three months (p < 0.001, p < 0.001). Sex and the duration from injury to repair were significantly associated with postoperative ocular motility (p = 0.001; p = 0.024) and diplopia (p < 0.001; p = 0.008) at three months. Multivariate analysis revealed that preoperative limitation and diplopia were correlated with postoperative limitation (p = 0.007) and diplopia (p = 0.001), respectively. Conclusions: The duration between orbital floor fracture and surgical treatment was associated with postoperative limitation and diplopia. Our results suggest that earlier intervention in symptomatic patients with orbital trauma may improve postoperative visual function.

A Novel Method Ensuring an Immediate Target Angle After Horizontal Strabismus Surgery in Children.

Purpose: Pediatric strabismus surgery has low success rates and high reoperation rates because of difficult alignment measurements and the nature of different strabismus types. Furthermore, adjustable sutures are not easily employed in children on an OPD basis. Methods: This was a retrospective comparative case study of children less than 12 years old who underwent strabismus surgery and were followed up at least 6 months postoperatively. We proposed a novel method that combines adjustable sutures and corneal light reflexes in regular strabismus surgery to improve surgical results. Efficacy and safety were evaluated and compared with those in a regular fixed-suture group. Results: In total, 128 children (88: exotropia and 41: esotropia) in the novel method group (Group 1) and 109 (71: exotropia and 38: esotropia) in the regular fixed-suture group (Group 2) were enrolled. The primary outcome was the immediate target angle (for esotropia within 4 PD of orthotropia and exotropia within 8 PD of esotropia within the first week postoperatively); the secondary outcome was success at the 6-month visit (angle of deviation < 10 PD). Consequently, there was a significantly higher proportion of achieving the immediate target range and success rate in both exotropic and esotropic patients in Group 1 than in Group 2. A significantly lower reoperation rate was also demonstrated in Group 1. No complications were noted in either group.Conclusions: The novel method enabled a higher proportion of subjects to achieve an immediate target range and success rate and a lower chance of reoperation among both esotropic and exotropic patients.

Successful Resection of Retrobulbar Carcinosarcoma without Recurrence: A Case Report.

Carcinosarcomas are biphasic tumors comprising carcinoma and sarcoma components that occur in many tissues but are rarely found in the orbit. A 70-year-old male presented to the ophthalmic clinic with progressive proptosis, having decreased vision in the left eye for 8 months. On examination, severe exophthalmos and lagophthalmos with limited extraocular movement were noted. Orbital computed tomography scans revealed a large, well-defined, heterogeneously enhanced mass in the left retrobulbar orbital cavity. The tumor was completely resected, and the pathological examination revealed a carcinosarcoma. The prognosis was excellent without local recurrence at 48 months postoperatively. Thus, when considering treatment for effective management of such tumors, tumor resection followed by radiotherapy or chemotherapy is highly recommended.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post-Caldwell-Luc Surgery: A Case Report.

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

A simple marking system for accurate intraoperative monitoring and adjustment of cyclotorsion strabismus surgery.

Ocular cyclotorsion is treatable only with surgery. The surgical procedure must be tailored individually to the specific etiologies causing the horizontal and vertical strabismus and its torsional components. An adjustable surgical approach is often used for postoperative or intraoperative adjustments. However, the methods currently used have some limitations. In this study, we propose a simple intraoperative marking system for all cyclotorsion correction surgery. The proposed marking system used three sets of surface markers: external horizontal markings, ocular horizontal markings, and surgical torsion markings, drawn in sequence. We retrospectively analyzed the surgical results using this novel marking system in this single-center, single-surgeon study. Fifteen patients with cyclotorsion who underwent treatment using the proposed marking system as an intraoperative aid between August 2019 and August 2021 were included. The medical charts were thoroughly reviewed, and the pre-and postoperative subjective and objective cyclotorsion were analyzed. Among the study subjects (10 males, 5 females; age range: 6-89 years), 13 had excyclotorsion and 2 incyclotorsion. Preoperative mean net subjective cyclotorsion measured by the double Maddox rod (DMR) test was 6.0° (standard deviation: 10.8°) and mean net disc-to-fovea angle (DFA) was 20.23° (13.21°). The postoperative net DMR and DFA were 0.2° (2.1°) and 14.09° (5.97°), respectively. The mean absolute net DMR and DFA being treated were 9.8° (4.8°) and 9.76° (4.61°). Overall, the proposed intraoperative marking system is a simple and quantitative method to assess, monitor, and adjust the torsional aspect for all strabismus surgeries.

"Pulsating proptosis and heavy eye syndrome precipitated by neurofibromatosis type 1: A case report".

RATIONALE: Neurofibromatosis type 1 (NF1) is a hereditary disease characterized by café-au-lait spots, peripheral neurofibromas, Lisch nodules, optic nerve glioma, and sphenoid wing dysplasia. Pulsating proptosis is associated with a sphenoid bony defect. Heavy eye syndrome is characterized by acquired esohypotropia in patients with high myopia. This study aimed to describe the presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1 and its management. PATIENT CONCERNS: A 41-year-old woman presented with progressive pulsating proptosis and hypodeviation of the right eye over the past 2 years. The axial length of the right eye was 36.81 mm. The right eye presented with esohypotropia and hypoglobus. The ocular motility examination showed limitations in all directions, especially in supraduction. Brain computed tomography revealed sphenoid wing dysplasia of the right orbit. The meningocele protruded through the orbital defect, lifting the globe. Brain magnetic resonance imaging demonstrated superior rectus muscle (SR) medial displacement and lateral rectus muscle inferior displacement. Physical examination revealed café-au-lait macules and neurofibromas on the trunk. DIAGNOSIS: NF1 with pulsating proptosis and heavy eye syndrome. INTERVENTIONS: The patient declined neurosurgery due to risk and economic reasons. To manage her main concern regarding cosmetics, we performed orbital floor decompression, SR resection with advancement, maximal hang-back recession of the inferior rectus muscle, and a partial Jensen's procedure. OUTCOMES: Proptosis was reduced. The eye position became more symmetrical. The range of eye movements was also increased. LESSONS: This case describes a rare synchronous presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1. Adult-onset presentation implied a progressive process in NF1. The case also showed a different etiology from that of typical heavy eye syndrome. It reminds ophthalmologists that orbital imaging should be performed in high myopia patients with strabismus to evaluate the extraocular muscle pathway. Furthermore, the case demonstrated a management that avoided the risk and expensive cost of neurosurgery, which has not been reported.

A Novel Procedure for the Management of Severe Hyphema after Glaucoma Filtering Surgery: Air-Blood Exchange under a Slit-Lamp Biomicroscopy.

Background and Objectives: This study introduces a novel office-based procedure involving air-blood exchange under a slit-lamp microscope for treatment of severe hyphema after filtering surgery. Materials and Methods: This retrospective study enrolled 17 patients (17 eyes) with a diagnosis of primary open-angle glaucoma with severe hyphema (≥4-mm height) after filtering surgery. All patients were treated with air-blood exchange under a slit-lamp using room air (12 patients) or 12% perfluoropropane (C3F8; five patients). Results: The procedures were successful in all 17 patients; they exhibited clear visual axes without complications during follow-up. In the room air group, the mean visual acuity (VA) and hyphema height significantly improved from 1.70 ± 1.07 LogMAR and 5.75 ± 1.14 mm before the procedure to 0.67 ± 0.18 LogMAR and 2.83 ± 0.54 mm after the procedure (p = 0.004; p < 0.001). In the C3F8 group, the mean VA showed a trend, though not significant, for improvement from 1.70 ± 1.10 LogMAR to 0.70 ± 0.19 LogMAR (p = 0.08); the mean hyphema height showed a trend for improvement from 5.40 ± 0.96 mm to 3.30 ± 0.45 mm. Compared with the C3F8 group, the room air group showed the same efficacy with a shorter VA recovery time. Conclusions: "Air-blood exchange under a slit-lamp using room air" is a convenient, rapid, inexpensive, and effective treatment option for severe hyphema after filtering surgery, and may reduce the risk of failure of filtering surgery.

Application of lateral tarsoconjunctival flap to correct ocular complications of Madelung's disease: A case report and literature review.

RATIONALE: Madelung's disease is a specific type of benign symmetric lipomatosis, which is characterized by overgrowing fat distributed at the neck and shoulder. This excessive fat accumulation may occur in different regions, including vital organs, such as the larynx, trachea, or the orbits. Surgery is usually performed to correct the esthetic or functional concern of the affected area. There are only few case reports mentioned about the orbital involvement of this disease. This study aimed to describe a case of Madelung's disease with ocular complications and the successful treatment using tarsoconjunctival flap. PATIENT CONCERNS: A 90-year-old obese male presented with decreased visual acuity accompanied with severe band form punctate epithelial erosions and ciliary injections in both eyes. Exophthalmos and ectropion of the lower eyelids were observed. DIAGNOSES: Orbital computed tomography revealed a rare entity of Madelung's disease with significant massive deposits of lipomas located symmetrically around the orbit and neck region. INTERVENTIONS: Bilateral lateral tarsoconjunctival flaps with lateral tarsal strip procedures were performed to correct the lower eyelid ectropion-related exposure keratopathy. OUTCOMES: The patient obtained improved visual acuity, intact and clear corneal surfaces, and perfect lower eyelid positions over both eyes. LESSONS: Madelung's disease is a rare condition. There are few reports to describe its ocular complications, due to lipoma overgrowing in the orbit. We shared our successful experience to correct ocular complications using tarsoconjunctival flap technique.

Positron emission tomography/computed tomography scan of Vogt-Koyanagi-Harada syndrome with associated autoimmune thyroid disease: A case report and literature review.

RATIONALE: Vogt-Koyanagi-Harada (VKH) syndrome is a rare disease and could be associated with autoimmune thyroid disease (AITD). This report was aimed to investigate the utility of F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) for the diagnosis of VKH syndrome with AITD and to perform a literature review on the association between the 2 diseases. PATIENT CONCERNS: A 55-year-old woman without the history of ocular trauma suffered from chronic headache. She was presented with painful blurred vision of both eyes with headache for 2 weeks. Ophthalmic evaluations revealed panuveitis, exudative retinal detachment, and papilloedema in both eyes. The clinical symptoms and presentations are compatible with the diagnosis of VKH syndrome. Other examinations for intraocular infection, malignancy, and lupus choroidopathy were of negative results. The result of contrast-enhanced computed tomography (CT) of the brain was normal. Due to the history of cancer in the patient's families, a F-FDG PET/CT whole-body scan was performed. The result indicated a focal of 2-fluoro-2-deoxy-D-glucose (FDG) uptake at the right upper lobe of the thyroid. Therefore, the patient's thyroid function was examined and the result indicated euthyroidism with detectable thyroid peroxidase/thyroglobulin antibodies. DIAGNOSES: VKH syndrome with associated AITD. INTERVENTIONS: Treatment with intravenous pulse systemic methylprednisolone (1000 mg daily) was prescribed for 3 days and then shifted gradually to tapered oral steroid medication. OUTCOMES: Symptoms of papillitis and serous retinal detachment of VKH syndrome was relieved after steroid treatment LESSONS:: F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) can be used for the effective diagnosis of VKH syndrome with AITD.