Ptosis and Miosis Associated with Fibrosing Mediastinitis.

BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation of fibrosing mediastinitis that, to our knowledge, has never been seen before. CASE REPORT A 30-year-old female Colombian flight attendant presented with a right eyelid droop. Examination revealed partial right-sided ptosis and miosis but no anhidrosis. An ill-defined firm swelling was palpable at the root of the neck. Chest radiography revealed a widened mediastinum, and computerized tomography (CT) showed a right paratracheal mass without calcification extending to the thoracic inlet, encasing multiple blood vessels. All basic blood tests, magnetic resonance imaging of the head, and ultrasound Doppler of the neck vessels were normal. History and work up for infections including fungal diseases, granulomatous diseases, vasculitis, and autoimmune diseases were negative. Positron emission tomography (PET) showed significant FDG uptake in the mediastinum. Mediastinal biopsy was histologically consistent with fibrosing mediastinitis. All relevant immunohistochemistry and microbiological studies were negative. Subsequently, the patient developed signs of superior vena cava compression; this was managed by balloon angioplasty, which resulted in improvement of symptoms. However, over time, her symptoms worsened progressively, resulting in a left-sided ptosis and radiological progression of the mass on CT. She received treatment with rituximab and concomitant steroids, which yielded excellent results: the treatment led to both resolution of her symptoms and regression of the mass and its metabolic activity on PET scan. CONCLUSIONS Fibrosing mediastinitis can present with an incomplete Horner's syndrome. Treatment with rituximab and steroids shows promising results in select cases of metabolically active idiopathic fibrosing mediastinitis.

Efficacy of preoperative nonsteroidal anti-inflammatory drug and the re-dilation technique in minimizing miosis after femtosecond laser in cataract surgery / Eficácia do AINE pré-operatório e da técnica de re-dilatação em minimizar a miose na cirurgia de catarata com laser de femtosegundo

ABSTRACT Purpose: To assess the efficacy of using a nonste­roidal anti-inflammatory drug preoperatively and of applying the re-dilation technique when necessary to minimize pupil size variation when comparing the degree of mydriasis before femtosecond laser pretreatment with that at the beginning of phacoemulsification. Methods: This retrospective study included patients who underwent cataract surgery using the LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Our routine dilating regimen with flurbiprofen, tropicamide, and phenylephrine was used. The re-dilation technique was applied on eyes that manifested with a pupillary diameter that was smaller than the programmed capsulotomy diameter after laser pretreatment. The technique consists of overcoming pupillary contraction by instilling tropicamide and phenylephrine before phacoemulsification. Pupil size was assessed before femtosecond laser application and at the beginning of phacoemulsification. Results: Seventy-five eyes (70 patients) were included. Nine (12%) eyes underwent the re-dilation technique. There was no significant difference in mean pupillary diameter and mean pupillary area between the two studied surgical time points (p=0.412 and 0.437, respectively). The overall pupillary area constriction was 2.4 mm2. Immediately before opening the wounds for phacoemulsification, none of the eyes presented with a pupillary diameter <5 mm, and 61 (85.3%) eyes had a pupillary diameter >6 mm. Conclusion: Preoperative administration of nonsteroidal anti-inflammatory drug and the re-dilation technique resulted in no significant pupil size variation in eyes that were pretreated with the femtosecond laser, when comparing the measurements made before the laser application and at the beginning of phacoemulsification. This approach can avoid the need to proceed with cataract extraction with a constricted pupil.

RESUMO Objetivo: Avaliar a eficácia do uso de anti-inflamatório não-esteróide no pré-operatório e aplicação da técnica de re-dilatação quando necessária para minimizar a variação do tamanho pupilar ao comparar o grau de midríase antes do tra­tamento com laser de femtosegundo no início da facoemulsificação. Métodos: Esse estudo retrospectivo incluiu pacientes que foram submetidos à cirurgia de catarata usando o LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Nosso regime de di­latação de rotina com flurbiprofeno, tropicamida e fenilefrina foi usado. A técnica de re-dilatação doi aplicada em olhos que se manifestaram com um diâmetro pupilar menor do que o diâmetro da capsulotomia programado após o pré-tratamento a laser. A técnica consiste em superar a contração pupilar pela instilação de tropicamida e fenilefrina antes da facoemulsificação. O tamanho pupilar foi avaliado antes da aplicação do laser de femtosegundo e no inicio da facoemulsificação. Resultados: Setenta e cinco olhos (70 pacientes) foram incluídos. Nove (12%) olhos foram submetidos à técnica de re-dilatação. Não houve diferença significativa no diâmetro pupilar médio e na área pupilar média entre os dois tempos cirúrgicos estudados (p=0,412 e 0,437, respectivamente). A constrição global da área pupilar foi de 2,4 mm2. Imediatamente antes de abrir as incisões para a facoemulsificação, nenhum dos olhos apresentava diâmetro pupilar <5 mm e 61 (85,3%) olhos apresentavam um diâmetro pupilar >6 mm. Conclusões: O administração pré-operatória de anti-inflamatório não-esteróide e da técnica de re-dilatação resultaram em uma variação significativa do tamanho pupilar em olhos que foram pré-tratados com laser de femtosegundo, comparando as medidas realizadas antes da aplicação do laser e no inicio da facoemulsificação. Essa abordagem pode evitar a necessidade de prosseguir com a extração da catarata com uma pupila contraída.

Efficacy of preoperative nonsteroidal anti-inflammatory drug and the re-dilation technique in minimizing miosis after femtosecond laser in cataract surgery.

PURPOSE: To assess the efficacy of using a nonste-roidal anti-inflammatory drug preoperatively and of applying the re-dilation technique when necessary to minimize pupil size variation when comparing the degree of mydriasis before femtosecond laser pretreatment with that at the beginning of phacoemulsification. METHODS: This retrospective study included patients who underwent cataract surgery using the LenSx (Alcon Laboratories, Inc., Fort Worth, TX). Our routine dilating regimen with flurbiprofen, tropicamide, and phenylephrine was used. The re-dilation technique was applied on eyes that manifested with a pupillary diameter that was smaller than the programmed capsulotomy diameter after laser pretreatment. The technique consists of overcoming pupillary contraction by instilling tropicamide and phenylephrine before phacoemulsification. Pupil size was assessed before femtosecond laser application and at the beginning of phacoemulsification. RESULTS: Seventy-five eyes (70 patients) were included. Nine (12%) eyes underwent the re-dilation technique. There was no significant difference in mean pupillary diameter and mean pupillary area between the two studied surgical time points (p=0.412 and 0.437, respectively). The overall pupillary area constriction was 2.4 mm2. Immediately before opening the wounds for phacoemulsification, none of the eyes presented with a pupillary diameter <5 mm, and 61 (85.3%) eyes had a pupillary diameter >6 mm. CONCLUSION: Preoperative administration of nonsteroidal anti-inflammatory drug and the re-dilation technique resulted in no significant pupil size variation in eyes that were pretreated with the femtosecond laser, when comparing the measurements made before the laser application and at the beginning of phacoemulsification. This approach can avoid the need to proceed with cataract extraction with a constricted pupil.

Factors influencing pupil behaviour during femtosecond laser assisted cataract surgery.

AIM: Femtosecond laser assisted cataract surgery is associated with pupillary constriction. This study aims to look at patient and surgical factors predisposing to abnormal pupil behaviour during FLACS. METHODS: This prospective observational study included all patients undergoing FLACS in the Princess of Wales Hospital, Bridgend, UK between February and June 2017. Pupils were measured at three time points; immediately before and after laser pre-treatment, and at the start of surgery. Pupil behaviour during surgery was noted in descriptive terms, patient demographic, co-morbidities, eye measurements, suction on time, shifting time and laser energy levels were recorded. RESULTS: Seventy-three eyes were included. Average patient age was 74.84 ±â€¯9.1 years. Mean horizontal pupil sizes immediately before and after femto pre-treatment were 7.87 ±â€¯0.87 mm and 7.7 ±â€¯0.89 mm respectively (P < 0.0005). Mean horizontal pupil size at the start of surgery was 6.83 ±â€¯1.43 mm (P < 0.0005). Short capsulotomy-pupil distance (P = 0.01), shallower anterior chamber (P = 0.0012), smaller pre-operative pupil size (P = 0.045) and longer suction on time (P = 0.0019) were significantly associated with intra-operative miosis during FLACS. Sustained mydriasis was observed in eyes in whom topical diclofenac was used within 2 h of surgery. CONCLUSIONS: FLACS can result in significant pupil miosis. Eyes particularly at risk are ones with smaller pre-operative pupils and shallower anterior chambers and those subjected to longer suction on time. Well-timed NSAIDs application could be protective against this phenomenon.

Efficacy of 0.015% intracameral epinephrine for significant miosis induced by photodisruption during femtosecond laser-assisted cataract surgery.

Despite the various advantages of femtosecond laser-assisted cataract surgery (FLACS), pupillary constriction during laser photodisruption is considered one of the most unfavorable events. This study aimed to investigate the efficacy of intracameral 0.015% epinephrine injection for miosis after laser pretreatment during FLACS.A total of 82 patients who underwent FLACS for age-related cataracts were investigated in this retrospective study. The epinephrine group included patients who received intracameral epinephrine injection for miosis after femtosecond laser pretreatment, while the no-epinephrine group included the patients who underwent FLACS without intracameral epinephrine due to minimal miosis. Quantitative pupil area measurements were performed through the analysis of captured images extracted from surgical videos of both femtosecond laser pretreatment and phacoemulsification.Laser photodisruption induced miosis in both groups, although the degree of miosis was greater in the epinephrine group (4.65 ±â€Š0.87 mm) than in the no-epinephrine group (6.30 ±â€Š0.65 mm; P < .001). The intracameral epinephrine injection significantly increased the pupil diameter from 4.65 ±â€Š0.87 to 5.49 ±â€Š0.76 mm (21.61 ±â€Š22.68%; P < .001) and the pupil area from 70.28 ±â€Š24.46 to 96.49 ±â€Š25.24 mm (52.89 ±â€Š63.54%; P < .001). After additional viscomydriasis, there was no difference between groups in pupil diameter (epinephrine vs no-epinephrine group; 6.10 ±â€Š0.77 vs 6.39 ±â€Š0.65 mm; P = .073).A single intracameral injection of 0.015% epinephrine provided immediate and appropriate redilation of pupil in patients with significant miosis after femtosecond laser photodisruption. Intracameral epinephrine is a simple and practical option for pupil redilation in case of miosis during FLACS.

Ptosis, miosis and cats.

Horner's syndrome (HS) is caused by a disruption in the oculosympathetic pathway. Both congenital and acquired HS are unusual in children. Acquired HS can be caused by trauma, surgical intervention, tumours, vascular malformations or infection.We describe the case of a 6-year-old boy who was brought to our emergency department with ptosis, miosis, painful cervical lymphadenopathy and a cat scratch on a hand. The diagnosis of a cat scratch disease was confirmed by serology. A full recovery was observed on antibiotic treatment and cervical lymphadenomegaly reduction 3 weeks later.

A rare presentation of myxofibrosarcoma as a Pancoast tumor: a case report.

BACKGROUND: Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor. CASE PRESENTATION: A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable. Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma. CONCLUSIONS: Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner's syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature.

Effects of Femtosecond Laser-Assisted Cataract Pretreatment on Pupil Diameter: A Comparison Between Three Laser Platforms.

PURPOSE: To assess pupil diameter before and after femtosecond laser-assisted cataract surgery (FLACS) pretreatment and compare the outcomes of three laser platforms. METHODS: This prospective observational case series included consecutive patients scheduled to undergo cataract extraction using FLACS between August 2013 and February 2015. All eyes received FLACS pretreatment using three laser platforms: LenSx (Alcon Laboratories, Inc., Fort Worth, TX), Catalys (Abbott Medical Optics Inc., Santa Ana, CA), and Victus (Bausch & Lomb, Inc., Rochester, NY). The same protocol for preoperative medical mydriasis was used for all patients, and pupil diameter was assessed immediately before and 3 minutes after FLACS using a surgical ruler. RESULTS: A total of 198 eyes of 161 patients were included in the study. Mean pupillary miosis was 1.42 ± 1.26 mm for the LenSx, 0.66 ± 0.89 mm for the Catalys, and 0.14 ± 0.34 mm for the Victus groups. Furthermore, 8 of the 198 eyes (4.0%) demonstrated a pupil diameter of less than 5 mm after FLACS and 48 eyes (24.24%) demonstrated a pupil diameter of 6 mm or less. There was a statistically significant decrease in pupil diameter for all groups individually (P < .05). There was also a statistically significant difference among the three groups (P < .05), with LenSx inducing the highest degree of miosis, followed by Catalys, and finally Victus. A correlation between the pupil diameter before FLACS and degree of FLACS-induced miosis was demonstrated (P < .05), with larger pupil diameter before FLACS associated with greater miosis. CONCLUSIONS: FLACS pretreatment seems to induce significant pupillary miosis with all laser platforms assessed in this study. The decrease in pupil diameter after FLACS reached clinical significance for cataract extraction (< 5 mm) in 4.0% of cases, whereas 20.2% of eyes demonstrated small pupil diameter (≤ 6 mm) after FLACS pretreatment.

Phaco-nucleotomy techniques in management of pseudoexfoliation syndrome.

INTRODUCTION: Pseudoexfoliation syndrome is a common clinically important systemic condition characterized by the pathological production and accumulation of an abnormal fibrillar extracellular material in many intraocular and extra ocular tissues. Many studies have shown that pseudoexfoliation syndrome patients have higher rates of intraoperative complications during cataract surgery compared to the patients without it. OBJECTIVES: To compare Phaco-chop and Divide and Conquer techniques of phacoemulsification, in the management of pseudoexfoliation syndrome in terms of intraoperative complications. MATERIALS AND METHODS: It is a hospital based prospective study of 90 patients with cataract and pseudoexfoliation syndrome attending ophthalmology outpatient department in our hospital. RESULTS: The mean age of patients in the study was 61.7 years with equal number of unilateral and bilateral cases. Intra operative complications noted in vertical chopping technique was only pupil constriction in 6.7%, no other complications were seen in this technique, whereas in horizontal chopping, 13.3% had pupil constriction, 6.7% had difficulty in chopping, 3.3% had zonular dehiscence and 3.3% had posterior capsular rent . In divide and conquer technique 16.7% had pupil constriction, 10% had difficulty in trenching, 3.3% had posterior capsular rent. Almost all the patients (97.8%) were implanted with intraocular lens after employment of various surgical modifications. CONCLUSION: Vertical chopping techniques scores over horizontal chopping and divide and conquer technique of phacoemulsification with good surgical outcome because of less complications.

[Malyugin ring for intraoperative miosis in femtosecond laser phacovitrectomy]. / Anillo de Malyugin para miosis intraoperatoria en femtofacovitrectomía.

OBJECTIVE: To evaluate the usefulness of the Malyugin ring in poor pupil dilation during phacoemulsification assisted with femtosecond laser with 23 gauge pars plana vitrectomy. METHOD: A 57-year-old female with cataract and vitreous hemorrhage, and poor pupil dilation (5.5mm). The phacoemulsification assisted with femtosecond laser, using Malyugin ring after capsulorrhexis, followed by pars plana vitrectomy, and removing at the end without complications. RESULTS: A successfull intraoperative pupil dilation was achieved without complications, with a final BCVA of 20/40. CONCLUSIONS: The Malyugin ring is an effective alternative in cases with poor pupil dilation in femtophacovitrectomy, preserving the anatomical and functional integrity.

[Spasm of the near reflex. Treatment with botulinum toxin]. / Espasmo del reflejo de cerca. Tratamiento con toxina botulínica.

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Conjunctival flap in manual sutureless small-incision cataract surgery: a necessity or dogmatic.

To compare the surgical outcomes of manual sutureless small-incision extracapsular cataract surgery (MSICS) with versus without a conjunctival flap for the treatment of cataracts. Prospective, randomized comparison of 220 consecutive patients with visually significant cataracts. Tertiary level eye clinic. 220 consecutive patients with cataracts. Patients assigned randomly to receive either SICS with a conjunctival flap or without one. Operative time, surgical complications, surgically induced astigmatism. Both surgical techniques achieved comparable surgical outcomes with comparable complication rates. The operative time was markedly less in group without flap (mean duration of 7.67 ± 1.45 min) than in group with flap (mean duration of 11.46 ± 1.69 min) (p value <0.001). In the group without a flap intraoperative pupillary miosis was significantly greater (p value 0.039) and on postoperative day 1, there were greater patients with a subconjunctival bleed involving greater than one quadrant of the bulbar conjunctiva (p value <0.0001). Also, post operative conjunctival retraction and consequent wound exposure was also significantly higher in this group (p value 0.026). However, the rate of other serious complications like any postop hyphaema, conjunctival bleb formation, iris prolapse, tunnel stability, shallow anterior chamber, post operative uveitis, malpositioned IOL, retinal detachment, cystoid macular edema, endophthalmitis were comparable in both. Both MSICS with and without a conjunctival flap achieved good surgical outcomes with comparable complication rates. But flapless MSICS is significantly faster. However it may be associated with higher intraoperative miosis and greater postoperative wound exposure.

Stellate ganglion injury after percutaneous radiofrequency ablation of a lung tumor.

The purpose of this case report is to describe the potential damage to the stellate ganglion during percutaneous lung radiofrequency ablation, to analyze the consequences of these complications, and to review the location of the stellate ganglion, which is usually not visible on imaging.

Reversible chest tube horner syndrome.

A 54-year-old woman who underwent chest tube placement after a lung biopsy was found on the first postoperative day to have ipsilateral ptosis and miosis, suggesting a Horner syndrome. A chest CT scan showed that the tip of the chest tube was apposed to the stellate ganglion. Repositioning of the chest tube later on the first postoperative day led to complete reversal of the Horner syndrome within 24 hours. We propose that the Horner syndrome arose as a result of pressure on the stellate ganglion, which interrupted neural conduction but did not sever the sympathetic pathway ("neurapraxia"). Whether prompt repositioning of the chest tube was critical in reversing the Horner syndrome is uncertain.