Orbital supratrochlear fistula secondary to anaesthetic block in cataract surgery. / Fístula orbitaria supratroclear secundaria a la realización de un bloqueo para anestesia en una cirugía de catarata.

A case is described of a woman with history of right peribulbar nerve block prior to cataract surgery that, within a few days, presented with a trochlear intraorbital arteriovenous fistula. This was resolved without sequelae after three months by performing intermittent homolateral carotid massages. This is the first case of supratrochlear intraorbital arteriovenous fistula. There are only 8 cases reported of traumatic intraorbital arteriovenous fistula, and only one was with post-peribulbar anaesthesia.

Periorbital emphysema after dive barotrauma without radiological evidence of paranasal sinus injury.

BACKGROUND: Scuba diving has increased in popularity since its invention in 1943, with over 21 million PADI registered members worldwide. Injuries to the paranasal sinuses caused by barotrauma are the second most common after injury to the middle ear. CASE REPORT: In this paper we present a case of unilateral periorbital surgical emphysema in a 23-yr-old male commercial scuba diver with minimal symptoms following an uneventful 13-ft (4-m) dive. The only symptoms experienced were pain and pressure over the right maxillary sinus and retrorbitally. Imaging with computed tomography showed no fracture of his paranasal sinuses. DISCUSSION: The authors recommend that a high index of suspicion for paranasal sinus barotrauma should be maintained in all patients reporting minor symptoms after diving (even to shallow depths) to facilitate rapid clinical diagnosis and prompt medical management.

[Orbital abscess after peribulbar anesthesia in a frontoethmoidal mucocele]. / Absceso orbitario tras anestesia peribulbar en mucocele frontoetmoidal.

CLINIC CASE: Peribulbar anesthesia is used in daily practice during cataract surgery. It is a safe technique, but not without complications. We present the case of a man who had an orbital abscess secondary to peribulbar anesthesia that led to the perforation of an unknown frontoethmoidal mucocele. DISCUSSION: Orbital abscess secondary to an iatrogenic mucocele perforation after anesthesia is a periorbital complication not described. The detection of the orbital process, intensive medical treatment and monitoring for signs of deterioration are vital in preventing serious complications.

A new approach to aesthetic maxillofacial surgery: surgical treatment of unilateral exophthalmos due to maxillary sinus mucocele.

Maxillary sinus mucocele, known as a rare condition, can cause major therapeutic difficulties, especially when it invades the orbit leading to exophthalmia. Treatment is very difficult because the eye globe has to be repositioned, and the facial symmetry needs to be reconstructed as a result of malar bone invasion. This article reports the case of a 54-year-old patient with unilateral exophthalmia caused by the evolution of a maxillary mucocele that extended toward the orbit after destroying the malar bone and the orbital floor. The treatment consisted of a 1-step restoration of both the orbit floor and the malar bone using a temporomandibular flap composed of 2 bone fragments. Lipostructure and a titanium mesh to reconstruct the calvarial defect were necessary to restore facial aesthetics after placing back the eye globe in its initial site. After surgery, the patient followed a complex rehabilitation program including massage kinesiotherapy and psychological consultation and support. These had an essential contribution to the successful final outcome in terms of psychological impact, functionality, and aesthetics.

Elephantoid eyelid edema associated with continuous positive airway pressure treatment.

A man with rosacea developed bilateral eyelid edema from wearing a continuous positive airway pressure nasal mask daily. The edema was refractory to steroid, diuretics, and lymphatic drainage massage. The effect may be related to cumulative venous congestion and lymphostasis due to the continuous positive airway pressure treatment.

Teaching corner: Regional anaesthesia for ophthalmic surgery.

Performing safe and effective regional anaesthesia for ophthalmic surgery is an important skill for anaesthetic and ophthalmologic practitioners. Akinetic sharp-needle blocks are generally safe but rare, sight and life threatening complications occur. Sub-Tenon's block using a blunt canula provides akinesa and is a safer alternative but serious complications have been reported. This review provides an introduction to the relevant anatomy, local anaesthetic drugs and commonly used techniques and a practical guide to their safe performance.

[The atypical course of subperiosteal abscess of the orbital wall].

The authors describe a clinical case of malformation of intranasal structures of the lateral wall and the middle turbinated bone of the nose (bullous middle turbinated bone, lateral position of the middle turbinated bone, hypertrophy of ethmoidal bulla and uncinate process) in combination with expressed deformation of the nasal septum. These malformations were responsible for the development of acute hemisinusitis complicated by subperiosteal abscess of the superomedial orbital wall. Conjunctival chemosis was impossible to remove by traditional medicamental therapy and surgical intervention. Hirudotherapy produced the well-apparent anti-odematous, anti-inflammatory, anti-coagulative, and thrombolytic effects that resulted in reduced conjunctival oedema and marked positive dynamics of the state of the eyeball. Subcutaneous administration of anticoagulants was used to prevent thrombosis of orbital veins and cerebral venous sinuses.

Orbital involvement in craniofacial brown tumors.

PURPOSE: To describe the clinical and radiologic features of orbital involvement in craniofacial brown tumors and to compare the rate of brown tumors in primary and secondary hyperparathyroidism. METHODS: A retrospective hospital-based study of 115 patients with chronic kidney disease and secondary hyperparathyroidism and 34 with primary hyperparathyroidism was conducted. Laboratory results such as serum levels of alkaline phosphatase, calcium, phosphorus, and parathyroid hormone were recorded. Demographic data (age, sex, duration of disease) and image findings (bone scan scintigraphy, skull and long bone x-rays, CT) were also obtained. The main outcome measures were analysis of clinical, biochemical, and radiologic findings of all patients. RESULTS: Of the 115 patients with chronic kidney disease, 10 (8.7%) had brown tumors in different bones of the skeleton. Five patients had lesions in the craniofacial bones. The maxilla, mandible, maxillary sinus, and nasal cavity were the most affected sites. The orbit was involved in 2 patients with lesions arising in the maxillary and ethmoid sinuses. One patient had facial leontiasis. All patients with brown tumors had extremely high levels of parathyroid hormone (>1,000 pg/ml, normal values 10-69 pg/ml) and alkaline phosphatase (>400 U/l, normal values 65-300 U/l). The mean serum levels of phosphorus and calcium were not abnormal among the patients with brown tumors. Age and time of renal failure were similar for patients with and without brown tumors. Among the patients with primary hyperparathyroidism, only 2 (5.8%) had brown tumors, and in just 1, the lesion was localized in the craniofacial skeleton. A 2-tailed Z test applied to compare the proportion of occurrence of brown tumors in the 2 groups revealed that the difference at the 90% of confidence level was not significant. CONCLUSIONS: Brown tumors are equally found in secondary and primary hyperparathyroidism. Craniofacial brown tumors involve the orbit, usually because of the osteodystrophy process that involves the maxilla and paranasal sinuses. The lesions do not necessarily need to be excised and may regress spontaneously after the control of hyperparathyroidism.

Orbital infarction syndrome in nephrotic syndrome patient with extensive carotid arteries occlusion.

Orbital infarction syndrome is defined as ischemia of global intraorbital structures such as extraocular muscles, optic nerves, and retina. The most common cause of this syndrome is carotid arterial occlusion. Other causes include vasculitis, vasospasm, and compression of intraorbital circulation. There has never been reported a case of orbital infarction syndrome in nephrotic syndrome patient. We present a case of 42-year-old Thai man with underlying disease nephrotic syndrome presented with abrupt onset of headache at left temporal area, horizontal diplopia, limitation of eye movement in all directions, ptosis, and blurred vision on the left eye. He was treated with pulse methylprednisolone intravenously for 3 days. Leg edema was improved however, the eye symptoms persisted. There was no evidence of hypercoagulable state. Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA) revealed loss of signal intensity at left internal carotid artery from base of skull to intracavernous part. Cerebral angiography demonstrated complete occlusion of left common carotid artery. After the anticoagulant treatment, his symptoms were gradually improved. The cause of extensive carotid arterial occlusion in this patient is most likely from hypercoagulable state. Although it was negative for hypercoagulable state evidence, the authors assume that the high dose steroid treatment could lead to remission of nephrotic syndrome and resulting in the resolution of hypercoagulable state.

Orbital cellulitis as a postoperative complication of sub-Tenon anaesthesia in cataract surgery.

Orbital cellulitis is a rarely reported sight-threatening complication of sub-Tenon anaesthesia. We report a case of orbital cellulitis in a patient who had received sub-Tenon anaesthesia for routine cataract surgery. We discuss the potential under-reporting of complications of sub-Tenon anaesthesia that had a delayed presentation, and the possible association between the use of hyaluronidase in the anaesthetic mixture and orbital cellulitis following sub-Tenon anaesthesia.

Cavernous sinus/orbital apex syndrome associated with indwelling orbital catheter use.

A 46-year-old man with a history of right orbital fractures and blindness underwent simultaneous fracture repair and enucleation with orbital implantation. During surgery, an orbital catheter was placed for administering local anesthesia to control postoperative pain. After administration of local anesthesia through the catheter on postoperative day 1, the patient had development of a complete ptosis, total ophthalmoplegia, mydriasis, vision loss from 20/20 to NLP, and hypesthesia of the V1 and V2 trigeminal nerve distribution. Intraocular pressures and dilated funduscopic examination were normal. There was no evidence of central nervous system effects or respiratory depression. After 4 hours of observation, the vision, sensation, motility, ptosis, and pupil response all returned to normal. Although rare, contralateral cavernous sinus/orbital apex syndrome may occur with indwelling orbital catheter administration of local anesthetic in an orbit with fractures.

Abscess of the orbit arising 48 h after root canal treatment of a maxillary first molar.

AIM: To discuss a rare, but severe complication arising following routine root canal treatment. SUMMARY: An orbital abscess is reported that occurred following routine root canal treatment. A young, healthy female patient, with no history of chronic paranasal infection had undergone root canal treatment of the right maxillary first molar. On hospital admission, she presented with extensive periorbital swelling and discreet diplopia. Computed tomography imaging identified massive purulent sinusitis and subsequent involvement of the orbit via the inferior and medial orbital wall within 48 h after completion of root canal treatment. Immediate surgical drainage of the maxillary sinus and the orbit was established and a high dose of perioperative antibiotics (Amoxicillin/Clavulanic acid, Gentamycin, Metronidazole) were administered. Vision remained undisturbed and mobility of the globe recovered within 10 days. KEY LEARNING POINTS: Rapid exacerbation of a periapical inflammation may occur following root canal treatment and may even involve the orbit. A typical speed of disease progression or ophthalmic symptoms should alert the clinician to at least consider unusual early orbital spread of odontogenic infection. When extra-alveolar spread and especially orbital spread is suspected, immediate referral to a maxillofacial or other specialized unit is mandatory.

Orbital head pain elicited by neuroendoscopy of the third ventricle performed under local anesthesia.

Endoscopic third ventriculostomy (ETVS) is considered a minimally invasive procedure for blocked hydrocephalus. In 24 cases, this procedure was carried out in awake patients under local anesthesia. All patients reported abrupt orbital pain when the third ventricle floor was manipulated. Although recent advancements in knowledge of some forms of migraine and cluster headache could be regarded as a good basis for interpreting the pain triggered by ETVS, other hypotheses should also be taken into consideration.

Cases from the aerospace medicine residents' teaching file. Decompression sickness.

Decompression sickness is an uncommon but serious risk associated with flying and SCUBA diving with potential for significant morbidity and mortality. It can occur in both novice and experienced individuals. This case illustrates an atypical presentation of decompression sickness in an experienced amateur SCUBA diver. Clinical suspicion must be high, since the presenting symptoms can be nonspecific as in this case. Early recognition and treatment are important for maximum recovery.

Medial canthus (caruncle) single injection periocular anesthesia.

We studied 151 consecutive patients scheduled for elective short-duration ophthalmic procedures to assess the efficacy of an alternative approach to periocular anesthesia. Single injection at the medial canthus was performed with a 25-gauge needle. The studied variables were: injected volume, onset time of the block, akinesia (scored on a 12-point scale), adequate surgical anesthesia (scored on a 5-point scale), and need for reinjection. The injected volume of local anesthetic solution was 8.6 +/- 1.7 mL. The onset time of anesthesia was 6.9 +/- 3.0 min, with an akinesia score of 11.6 +/- 1.1 (maximum 12). Additional reinjections were necessary in 14 cases (9.2%). There was a learning curve for the technique, with 8 of the additional injections being performed in the first 30 patients (26.6%), and 6 in the last 121 (4.9%). The surgical score recorded after surgery was 4.8 +/- 0.6 (maximum 5). There were no complications, including injury to the globe, optic nerve, or retina or orbital hematoma. Medial canthus single injection periocular anesthesia appears to be a promising alternative to the usual double injection peribulbar block.