Correlation of retrobulbar perfusion deficits with glaucomatous visual field defects.

PURPOSE: This study is to evaluate the correlation between retrobulbar perfusion deficits and glaucomatous visual field defects. METHODS: Eighty-four patients with glaucoma and 17 normal subjects serving as controls were selected. Color Doppler imaging (CDI) was used to measure the changes in blood flow parameters in the retrobulbar ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (SPCAs). Visual field testing was performed using a Humphrey perimeter, categorizing the visual field deficits into four stages according to the Advanced Glaucoma Intervention Study (AGIS) scoring method. Subsequently, the correlation of retrobulbar hemodynamic parameter alterations among glaucomatous patients with varying visual field defects was examined. RESULTS: The higher the visual field stage, the lower the peak systolic velocity (PSV) of the OA, CRA, and SPCAs in glaucomatous patients. The CRA had the highest sensitivity to changes in its PSV. The PSV of the temporal SPCA (TSPCA-PSV) was lower in advanced glaucoma than in early-stage glaucoma. The PSVs of the OA, CRA, and TSPCA, as well as the resistance index of the CRA (CRA-RI), were positively correlated with the visual field index and the mean deviation. Except for that of OA, the PSV of the retrobulbar vessels was negatively correlated with the pattern standard deviation (PSD). The OA-PSV and end-diastolic velocity (EDV) of the CRA and TSPCA were lower in patients with superior visual field defects than in those with inferior visual field defects. CONCLUSIONS: Greater severity of visual field defects corresponded to poorer retrobulbar blood flow in glaucomatous patients. Patients suffered significant perfusion impairments in the CRA at the early stage, accompanied by SPCA perfusion disorder at the advanced stage. The presence of a bow-shaped defect in the superior or inferior region of the visual field in moderate-stage glaucoma was closely correlated with retrobulbar vascular EDV. TRIAL REGISTRATION: ChiCTR2200059048 (2022-04-23).

Percentage of Myeloid Dendritic Cells in Peripheral Venous Blood Is Negatively Related to Incidence of Graves' Orbitopathy.

The aim of the study was to evaluate the distribution of blood dendritic cells (DCs) in patients with Graves' orbitopathy (GO) and to assess the influence of methylprednisolone therapy on subsets of peripheral blood mononuclear cells (PBMCs). Peripheral blood DC subsets were analyzed by flow cytometry in patients with active GO (n = 17), inactive GO (n = 8), and Graves' disease (GD) without GO (n = 8) and controls (n = 15); additionally, in patients with active GO (n = 17), analyses were done at three time points, i.e., before methylprednisolone treatment and after 6 weeks and after 12 weeks of the treatment. Percentage of myeloid DCs (mDCs) in PBMC fraction was significantly lower in patients with both active and inactive GO, compared to patients with GD without GO and controls (p < 0.05). In addition, mDCs were also documented to be an independent factor negatively associated with GO, however without essential differences between active and inactive phases. On the other hand, we did not observe any changes in the percentage of DCs after methylprednisolone therapy (p > 0.05). In the present study, we have succeeded to firstly demonstrate-according to our knowledge-that blood mDCs are negatively related to GO incidence.

Ophthalmic and orbital considerations in the evaluation of skull base malignancies.

INTRODUCTION: The orbital contents, afferent and efferent visual pathways, and the cranial nerves involved in eye movement, corneal sensation and eyelid closure traverse the skull base, a region bounded by the intracranial cavity, the paranasal sinuses, and the deep spaces of the face and head. As such, tumors from above or below have potential to affect some aspect of the visual system. METHODS: We discuss here the clinical ophthalmologic and orbital considerations in the evaluation of patients with these tumors, as well as the ophthalmic sequelae of treatment with radiation or surgery (or both). And for the surgeon, we discuss the ophthalmic and orbital considerations in surgical planning, the role of the orbital surgeon in skull base surgery, and briefly discuss transorbital approaches to the skull base. RESULTS AND CONCLUSION: Ophthalmic and orbital dysfunction may be the main source of disability in patients with skull base malignancy; it is thus incumbent on those who manage patients with tumors of this region to be aware of the ophthalmic, neuro-ophthalmic and orbital manifestations, so as to best tailor therapy and monitor treatment outcomes.

Ocular Compartment Syndrome and Lateral Canthotomy Procedure.

BACKGROUND: Ocular compartment syndrome (OCS) is a serious ophthalmological emergency that should be diagnosed and treated immediately to prevent permanent loss of vision. It is usually caused by a retro-orbital bleed that will subsequently increase intra-orbital pressure and threaten the patient's vision. Lateral canthotomy and cantholysis is a minor bedside procedure using simple equipment that is readily available in emergency departments, and the aim of such a procedure is to free the eye globe from its lateral attachment to the bony orbital wall and allow more eye protrusion and hence reduce intra-orbital pressure and save the patient's sight. The case we present describes a 42-year-old man who presented with facial injuries following an alleged assault and in whom a computed tomography scan of the head showed a retro-orbital hemorrhage. The patient had subtle signs of increased intra-orbital pressure for which lateral canthotomy and cantholysis was indicated. DISCUSSION: OCS is an ophthalmological emergency that can present with subtle signs of increased intraocular pressure that can lead to irreversible loss of vision if not treated with a simple bedside operation called lateral canthotomy and cantholysis within a specific time frame. We explore the pathophysiology and presentation of OCS and how to perform the lateral canthotomy with cantholysis procedure. CONCLUSIONS: The aim of this case presentation is to highlight the importance of diagnosing OCS as an ophthalmological emergency and discuss how to perform the sight-saving procedure.

Cerebral Venous Thrombosis: An Uncommon Cause of Papilledema on Bedside Ocular Ultrasound.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare, difficult-to-diagnose form of venous thromboembolic disease and is considered a type of stroke. Its presentation is highly variable and may be easily confused for more common and less debilitating or life-threatening diagnoses such as migraine, seizure, or idiopathic intracranial hypertension. CASE REPORT: A 25-year-old woman presented with a complaint of bifrontal throbbing headache and blurry vision. A bedside ultrasound of the orbit suggested increased intracranial pressure. A subsequent computed tomography venogram demonstrated a left transverse sinus thrombosis. The patient was started on enoxaparin and admitted for bridging to warfarin and evaluation for hypercoagulable state. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CVT is a rare form of stroke that carries a high rate of mortality and morbidity and masquerades as more common and benign diagnoses. Emergency department bedside ultrasound of the orbit may make the diagnosis of CVT more attainable by identifying patients with increased intracranial pressure.

Orbital Fat Injection: Technique and 5-Year Follow-Up.

BACKGROUND: Orbital volume loss, early or late, is common after placement of an orbital implant or dermis fat graft, and there is currently no satisfactory long-lasting solution. Hyaluronic fillers are relatively easy to administer but are prone to migration and are temporary. Cannula-based orbital fat grafting has not gained the status of standard of care because of perceived low likelihood of success in the near term. This paper describes a technique for fat volume augmentation, its rationale, long-term follow-up, and a description of a complication unique to fat grafting in the orbit. METHODS: Ten consecutive subjects with acquired anophthalmic enophthalmos were enrolled in two IRB (institutional review board)-approved protocols (10.27 and 12.01) undergoing a single session of autologous fat grafting to the orbit using a closed blunt cannula technique. Preoperative photography and non-contrast MRIs (magnetic resonance imaging) were obtained prior, immediately after, and at 1 year after injection. Yearly postoperative photography was performed on subjects with successful results. RESULTS: Three of five subjects in IRB 10.27 clearly showed a clinically apparent increase in orbital volume at 1 year. One subject who failed to show improvement also sustained inadvertent injection into three extraocular muscles; she subsequently volunteered to enter IRB 12.01. Three of five subjects in IRB 12.01 did benefit, showing volume increase at 1 year, including the subject who had experienced intramuscular injection in 10.27. One subject in IRB 12.01 was lost to follow-up. Of the total of ten subjects enrolled, three showed no improvement and one was lost to follow-up; six subjects showed volume improvement at 1 year with two retaining the correction at 5 years and four showing variable diminution over 2-5 years. With the exception of the subject who sustained injection into extraocular muscles, none experienced complications. CONCLUSION: A modified technique is recommended for orbital fat injection distinct from methods used elsewhere in the body. Theoretical limits of volumetric enhancement temper expectations in orbital fat grafting and should inform surgical planning. Cannula-based orbital fat grafting can be done safely and result in a gain of orbital fat volume at 1 year and in some cases up to 5 years. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Conservatively Treated Orbital Blowout Fractures: Spontaneous Radiologic Improvement.

PURPOSE: To determine if conservatively treated blowout fractures of the orbit undergo spontaneous improvement based on radiologic findings. DESIGN: Prospective, noncomparative series. PARTICIPANTS: Patients with conservatively treated orbital blowout fractures in a single tertiary institution from 2012 through 2016 with initial and follow-up computed tomography (CT) scans. METHODS: Comparison of initial and follow-up CT to assess for smoothening of bony contour, joining of bony edges, reduction in herniation of orbital contents, and new bone formation. Orbital and fracture volumes were calculated using a 3-dimensional reconstruction software program (3D Workstation; TeraRecon, Foster City, CA). MAIN OUTCOME MEASURES: Change in bony contour, new bone formation, and decrease in orbital and fracture volumes. RESULTS: Our study comprised 41 patients and 44 orbits, with 38 unilateral and 3 bilateral cases. Most were men (65.9%; n = 27), and the mean age was 34.3±13.5 years. The mean time from injury to follow-up scan was 4.6 months (range, 1-15 months). All orbits showed changes in bony contour from initial to follow up CT, including smoothening of the orbital contour (88.6%), joining of bony edges (90.9%), and reduction in herniation of orbital contents (65.9%). Most of the orbits (n = 41; 93.2%) showed features of neobone formation. Of the 44 orbits, 91.4% showed a decrease in orbital volume, whereas 94.3% showed a decrease in fracture volume. The reduction in volume was statistically significant for both orbital (from 23.7±4.0 to 21.8±3.9 ml) as well as fracture (from 1.2±0.8 to 0.7±0.6 ml) volumes from initial to follow-up scans, respectively (P < 0.001). CONCLUSIONS: A large proportion of patients showed improvement in radiologic findings despite being treated conservatively. This highlights the spontaneous improvement that can occur in untreated blowout fractures not just clinically, but radiologically, in terms of soft tissue and bony findings.

Bilateral Subperiosteal Hematoma and Orbital Compression Syndrome in Sickle Cell Disease.

A 14-year-old boy with sickle cell disease presented with preseptal cellulitis findings as proptosis, eyelid edema, and hyperemia. His best corrected visual acuity in the right eye was 20/20 and 16/20 in the left eye. He had limited ductions in vertical and lateral gazes in both eyes. Bilateral venous tortuosity was observed in posterior segment examination. Orbital bone infarction and subperiosteal hematoma were seen in magnetic resonance imaging. He was diagnosed as having orbital compression syndrome secondary to vaso-occlusive crisis of sickle cell disease and was treated with intravenous ampicilin-sulbactam and methylprednisolone.

Ophthalmic Changes Associated with Long-Term Exposure to Microgravity.

This review discusses recent publications on the problem of ophthalmic changes associated with long-term effects of microgravity during space flights. Described changes include hyperopic shift of refraction, change in intraocular pressure, increased intracranial pressure, changes in the choroid and retina tissues, and swelling of the optic nerve. These effects are caused by redistribution of blood and fluid to the upper half of the body, increased intracranial pressure and congestion of venous blood and lymph in the upper half of the body and head. The reviewed also discusses other factors that may triggervision impairment caused by microgravity. Photographic illustrations of changes are also provided.

Slowly progressive Lemierre's syndrome with orbital pain and exophthalmos.

Lemierre's syndrome is an oropharyngeal bacterial infection characterized by rapidly progressive septic thrombophlebitis of the internal jugular vein. A lack of appropriate antibiotic therapy can be life-threatening. We describe the case of a 39-year-old man with Lemierre's syndrome who presented with long-lasting orbital pain and acute exophthalmos 6 weeks after initial infection. This report is to help clinicians consider the diagnosis of Lemierre's syndrome when encountering a patient with long-lasting orbital pain and acute exophthalmos. Neck ultrasonography is useful for detecting thrombophlebitis of the internal jugular vein in Lemierre's syndrome patients.

[Diagnosis and treatment of orbit solitary fibrous tumor: a report of 4 cases].

OBJECTIVE: To investigate the diagnosis, treatment and prognosis of orbital solitary fibrous tumor. METHODS: Clinical data of 4 cases with orbital solitary fibrous tumor from January 2001 to June 2014 in the Second Affiliated Hospital of Xi'an Jiaotong University was retrospectively analyzed and the image, pathologic and immunohistochemical findings were reviewed. RESULTS: In the 4 cases, 3 were males and 1 was female, aged from 48 to 67 years. The main symptoms were unilateral progressive proptosis, orbital tumor and decreased vision. Two cases involved the left orbit and 2 in right. The locations of the tumor were in the lateral (2 cases) or inferior orbit (2 cases). Encapsulated smooth round shadow was shown in imaging examination and a homogeneous enhancement strengthening was seen by CT scanning. All cases underwent surgical resection and the removed tumors, appeared as round or irregular oval with fibrous capsule, were 1.5-5.0 cm in size. Three cases were pathological benign and 1 was malignant. Microscopically, the tumors were composed of a large number of spindle tumor cells and varying amounts of interstitial collagen deposition and angiogenesis. There was no atypia in benign tumor, while there was atypia in malignant tumor. Moreover, the tumor was invasive, capsuleless and shown hyperplasia area by light microscope in the case with malignant disease. CD34 and Vimentin were positive in 4 cases and Bcl-2 positive in 2 cases by immunohistochemistry staining. One patient with malignant pathology showed strong positive staining of Ki-67 (>70%) and died of tumor recurrence 10 months after he received the second operation. No metastasis or recurrence occurred by a follow-up of 2 months to 5 years in other 3 cases. CONCLUSIONS: Orbital SFT is characteristic of unilateral progressive proptosis in symptom. Imaging examination is an important diagnostic tool and a complete surgical resection of the tumor is the primary treatment method. Diagnosis depends on pathological and immunohistochemical staining. Malignant transformation may be occurred from benign lesion, hence postoperative follow-up is essential for confirmed patients.(Chin J Ophthalmol, 2016, 52: 268-272).

Clinical features and long-term prognosis of trochlear headaches.

BACKGROUND AND PURPOSE: Trochlear headaches are a recently recognized cause of headache, of which both primary and inflammatory subtypes are recognized. The clinical features, long-term prognosis and optimal treatment strategy have not been well defined. METHODS: A cohort of 25 patients with trochlear headache seen at the Mayo Clinic between 10 July 2007 and 28 June 2012 were identified. RESULTS: The diagnosis of trochlear headache was not recognized by the referring neurologist or ophthalmologist in any case. Patients most often presented with a new daily from onset headache (n = 22, 88%). The most characteristic headache syndrome was reported as continuous, achy, periorbital pain associated with photophobia and aggravation by eye movement, especially reading. Individuals with a prior history of migraine were likely to have associated nausea and experience trochlear migraine. Amongst individuals with trochleitis, 5/12 (41.6%) had an identified secondary mechanism. Treatment responses were generally, but not invariably, favorable to dexamethasone/lidocaine injections near the trochlea. At a median follow-up of 34 months (range 0-68), 10/25 (40%) of the cohort had experienced complete remission. CONCLUSIONS: Trochlear headaches are poorly recognized, have characteristic clinical features, and often require serial injections to optimize the treatment outcome. The identification of trochleitis should prompt neuroimaging to look for a secondary cause.

The normal and variant clinical anatomy of the sensory supply of the orbit.

Orbital and retro-orbital pain are relatively common clinical conditions that are associated with such disorders as trigeminal, lacrimal, and ciliary neuralgia, cluster headaches, paroxysmal hemicrania, inflammatory orbital pseudotumor, trochleitis, and herpetic neuralgia ophthalmicus, thus making the nerves supplying the orbit of great clinical importance. Surprisingly, how pain from this region reaches conscious levels is enigmatic. Classically, it has been assumed that pain reaches the ophthalmic division of the trigeminal nerve (V1 ) and travels to the descending spinal trigeminal nucleus. However, exactly where the receptors for orbital pain are located and how impulses reach V1 is speculative. In this project, we reviewed all of the reported connections between the orbital nerves and V1 in order to understand how pain from this region is transmitted to the brain. We found reported neural connections to exist between cranial nerve (CN) V1 and CNs III, IV, and VI within the orbit, as well as direct neural branches to extra-ocular muscles from the nasociliary, frontal, and supraorbital nerves. We also found reported neural connections to exist between the presumed carotid plexus and CN VI and CN V1 , CN VI and CN V1 and V2 , and between CN V1 and CN III, all within the cavernous sinus. Whether or not these connections are sympathetic or sensory or some combination of both connections remains unclear. An understanding of the variability and frequency of these neural connections could lead to safer surgical procedures of the orbit and effective treatments for patients with orbital pain.

A case of odontogenic orbital cellulitis causing blindness by severe tension orbit.

We report a very rare case of odontogenic orbital cellulitis causing blindness by severe tension orbit. A 41-yr old male patient had visited the hospital due to severe periorbital swelling and nasal stuffiness while he was treated for a periodontal abscess. He was diagnosed with odontogenic sinusitis and orbital cellulitis, and treated with antibiotics. The symptoms were aggravated and emergency sinus drainage was performed. On the next day, a sudden decrease in vision occurred with findings of ischemic optic neuropathy and central retinal artery occlusion. Deformation of the eyeball posterior pole into a cone shape was found from the orbital CT. A high-dose steroid was administered immediately resulting in improvements of periorbital swelling, but the patient's vision had not recovered. Odontogenic orbital cellulitis is relatively rare, but can cause blindness via rapidly progressing tension orbit. Therefore even the simplest of dental problems requires careful attention.

Complication following reconstruction of orbital floor with temporalis-coronoid flap after subtotal maxillectomy.

A 33-year-old lady was referred to the Department of Oral and Maxillofacial Surgery of Taleghani hospital in 2008. She complained of firm swelling on the left side of her face with toothache, lacrimation, and nasal stiffness. There was a large mass in the left maxillary sinus with extension to the orbital floor, nasal bone, ethmoid sinus, and infratemporal fossa. The incisional biopsy revealed a neurofibroma of the maxilla. She underwent hemimaxillectomy and simultaneous reconstruction with temporalis-coronoid flap for orbital floor reconstruction. After 2 months' follow-up with no complication, she complained of left globe upward movement during gum chewing. The orbital and visual examinations were otherwise normal. This unusual complication has continued for 4 years with no resolution, although the patient does not worry about it any more.

Orbital stress analysis, Part IV: Use of a "stiffness-graded" biodegradable implants to repair orbital blow-out fracture.

PURPOSE: The purpose of this study was to develop a finite element model (FEM) of a human orbit, of 1 patient, who had an orbital blow-out fracture, to study the effect of using a "stiffness-graded" (SG) biodegradable implant on the biomechanics of bone-fracture repair. METHODS: An FEM of the orbit and the globe, of 1 patient who had an orbital blow-out fracture and was treated with biodegradable poly-L/DL-lactide [P(L/DL)LA 70/30], was generated based on computed tomography scan images. Simulations were performed with a computer using a commercially available finite element software. The FEM was then used to study the effect of using an SG biodegradable implant on the stress distribution in the fractured bone. This was compared with the stress distribution at the fracture interface and at the bone-implant interface, when using P(L/DL)LA implant with a uniform stiffness. RESULTS: The use of SG implants caused less stress shielding to the fractured bone. At 50% of the bone healing stage, stress at the fracture interface was compressive in nature, that is, 0.2 MPa for the uniform implant, whereas SG implants resulted in tensile stress of 0.2 MPa. The result was that SG implants allowed the 50% healed bone to participate in loadings. Stiffness-graded implants are more flexible and hence permit more bending of the fractured bone. This results in higher compressive stresses, induced at the fractured faces, to accelerate bone healing. However, away from the fracture interface, the reduced stiffness and elastic modulus of the implant cause the neutral axis of the composite structure to be lowered into the bone, resulting in the higher tensile stress in the bone layer underneath the implant. CONCLUSIONS: The use of SG implants induced significant changes in the stress patterns at the fracture interface and at the bone-implant interface. Stiffness-graded biodegradable implants offered less stress shielding to the bone, providing higher compressive stress at the fractured surface, to induce accelerated bone healing, as well as higher tensile stress in the intact portion of the bone. It seems that this is the first reported study, in the literature, on the use of SG biodegradable implants to repair and promote bone healing at the fracture site of the inferior orbital wall bone defect.

[Enophtalmos of the anophtalmic socket: incidence of the orbital morphology and therapeutic implications. Clinical study of 86 cases]. / Énophtalmie de la cavité anophtalme : incidence de la morphologie orbitaire et implications thérapeutiques. Étude clinique de 86 cas.

AIM OF THE STUDY: From a light asymmetry to a sunken eye aspect, a great disparity between the results after anophtalmic socket rehabilitation is noticeable: what are the factors involved in the degree of residual enophtalmos following excision of the eye? The litterature's response is based on physiopathological considerations around intraorbital architectural disturbance. We propose a geometrical approach related to the existence of different morphological types of orbit. PATIENTS AND METHOD: Eighty-six records of eviscerated and enucleated patients have been studied and submitted to a statistical analysis. A preliminary study has defined four types of orbit depending on the shape and operture of the orbital "window": two opposite types IA and III, a type II intermediate and a particular one, the type IB. A classification of enophtalmos' degree allows to analyze the parameters chosen and to identify the predictive factors. RESULTS: The statistical analysis confirms the incidence of the orbital morphology on the degree of enophtalmos but do not support the theories based on the intraorbital septal architecture changes. Depending on the orbital shape and the container-content relation, the volume loss is more visible on the whole orbitopalpebral surface of opened and high orbit but remains centered on the anteroposterior position of the implant of a closed and lengthened orbit. At the contrary to the type III, the type IA is not favorable for the anophtalmic patient and predispose to a higher degree of enophtalmos. This new approach has therapeutic implications on primary and secondary surgery for volume loss replacement. CONCLUSION: The success of anophtalmic socket rehabilitation is influenced by the orbital morphological type that has to be considered in the therapeutic strategy.

[Specific damage of ocular and orbital structures in sarcoidosis].

Complex damage of ocular and orbital structures is an important manifestation of sarcoidosis. Incidence of ocular sarcoidosis varies among the different groups of patients. Nevertheless all patients should undergo specific examination of eye and orbit. Delayed diagnosis of ocular sarcoidosis and improper treatment may result in severe complications. Orbital changes should be also revealed in time and properly evaluated. These are the reasons for searching of new methods of eye and orbit examination in patients with sarcoidosis.