Elastoma of the Orbit: A Case Report.

A 78-year-old man presenting for revision ptosis surgery was found to have an asymptomatic left inferomedial orbital mass visible below the left lower eyelid on external inspection, and subconjunctivally on examination. This was subsequently diagnosed as an isolated elastoma. A mass in a similar location was excised 60 years previously. His other ophthalmological history included stable diplopia corrected with prism, left-sided ectropion, bilateral sequential phacoemulsification, and past bilateral ptosis which has been persistent on the left side despite surgical repair and revision. His examination revealed left hypertropia but was otherwise largely unremarkable. However, imaging demonstrated the soft tissue lesion abutting the left globe. An anterior orbitotomy was performed, and the lesion was biopsied and specimens sent for histopathological examination and immunohistochemistry. This is the first case of an elastoma of the orbit reported in the literature to the best of the authors' knowledge.

Bisphosphonate-Induced Orbital Inflammation: A Case Series and Review.

INTRODUCTION: To present a series of patients with bisphosphonate induced orbital inflammation, and to review the clinical presentation, radiological features, treatment options and outcomes. METHODS: We present a multicentre, retrospective case series review of patients with a clinico-radiological diagnosis of bisphosphonate induced orbital inflammation and review all the reported cases of this complication in the literature. RESULTS: Four new patients with bisphosphonate induced orbital inflammation were added to the 25 cases in the literature. Intravenous zoledronate was the commonest precipitant (22/29, 75.9%) and inflammation occurred 1-28 (mean 3) days post-infusion. Orbital imaging identified orbital inflammation in 22/29 cases and extra-ocular muscle enlargement in 8/29. Five patients presented with reduced vision of which one - with anterior ischaemic optic neuropathy - did not resolve. The vision resolved in all except one patient, with most requiring steroid treatment. CONCLUSIONS: Bisphosphonates have a pro-inflammatory effect, which can precipitate orbital inflammation. This rare, but potentially serious complication of bisphosphonate treatment should be considered by clinicians using bisphosphonate treatment and by ophthalmologists seeing patients with orbital inflammatory disease.

Acute suppurative bacterial dacryoadenitis: a case series.

BACKGROUND: We present a series of patients with acute suppurative bacterial dacryoadenitis and review the clinical presentation, microbiology, treatment options and outcome. METHODS: A multicentre, retrospective, case series review of patients with a clinical diagnosis of acute bacterial suppurative dacryoadenitis (ASBD). Records were examined to obtain information regarding patient demographics, presenting symptoms and signs, radiology, microbiology, management, outcomes and follow-up. RESULTS: 11 patients (9 men, 2 women; mean age 43.9 years, range: 6-82 years) were included. Average time to presentation was 2.8 days, and predisposing conditions were found in 45% of cases. Common presenting symptoms were eyelid swelling, pain, redness and diplopia, and common signs were ptosis, discharge and restriction of eye movements. The most common causative bacteria were Staphylococcus aureus and skin flora. Lacrimal gland swelling was universally seen on CT, with globe indentation of displacement in 27% of cases. Intravenous antibiotics were used in 91% of cases, which subsequently resolved over an average period of 9.7 days. Those with abscess formation (n=2) required incision and drainage. CONCLUSIONS: ASBD is a rare condition that resolves quickly if managed appropriately. Underlying anatomical, infectious or inflammatory conditions should be investigated, and skin commensals should be covered with the instigation of antibiotic therapy.

Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature.

BACKGROUND: Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment. DESIGN: Retrospective case series of 14 consecutive patients with biopsy-proven invasive fungal sinusitis from four tertiary hospitals. PARTICIPANTS: Fourteen patients (10 men and 4 women; age range 46-82 years). METHODS: Retrospective chart review of all patients presenting with invasive fungal sinusitis between 1994 and 2010 at each hospital, with a close analysis of the tempo of the disease to identify any potential window of opportunity for treatment. MAIN OUTCOME MEASURES: Demographic data, background medical history (including predisposing factors), symptoms, signs, radiological findings, histopathological findings, treatment approach and subsequent clinical course were recorded and analysed. RESULTS: Only one patient was correctly diagnosed at presentation. Only two patients were not diabetic or immunocompromised. The tempo was acute in two patients, subacute in nine patients and chronic in three patients. In the subacute and chronic cases, there was about 1 week of opportunity for treatment, from the time there was a complete orbital apex syndrome, and still a chance for saving the patient, to the time there was central nervous system invasion, which was invariably fatal. Only two patients survived - both had orbital exenteration, as well as antifungal drug treatment. CONCLUSIONS: Invasive fungal sinusitis can, rarely, occur in healthy individuals and should be suspected as a possible cause of a progressive orbital apex syndrome.

Regulation of connexin43 gap junction protein triggers vascular recovery and healing in human ocular persistent epithelial defect wounds.

Transiently blocking the expression of the gap junction protein connexin43 using antisense oligodeoxynucleotides or blocking hemichannels with connexin mimetic peptides has been shown to significantly improve outcomes in a range of acute wound models. Less is known about their likely effects in nonhealing wounds. In the eye, prolonged inflammation and lack of epithelial recovery in nonhealing corneal epithelial wounds may lead to corneal opacity, blindness or enucleation. We report here the first human applications of antisense oligodeoxynucleotides that transiently block translation of connexin43 in a prospective study of five eyes with severe ocular surface burns (persistent epithelial defects), which were unresponsive to established therapy for 7 days to 8 weeks prior to treatment. Connexin43-specific antisense oligodeoxynucleotide was delivered in cold, thermoreversible Poloxamer407 gel under either an amniotic membrane graft or a bandage contact lens. The connexin43-specific antisense application reduced inflammation within 1-2 days, and in all five eyes complete and stable corneal reepithelialization was obtained. Recovery of the vascular bed and limbal reperfusion appeared to precede corneal epithelial recovery. We conclude that connexin modulation provides a number of benefits for nonhealing ocular burn wounds, one of which is to promote vascular recovery.

Herpes simplex encephalitis presenting after steroid treatment of panuveitis.

A 62-year-old woman with an autoimmune disease presented with panuveitis and was treated with immune suppression. She subsequently developed herpetic acute retinal necrosis and later died of herpes simplex encephalitis. Acute retinal necrosis usually occurs months to years after herpes simplex encephalitis. In our case, the ocular findings were present for 5 weeks before the encephalitis presented. To our knowledge, this is the first Australian case of acute retinal necrosis preceding herpes simplex encephalitis.

Aldose reductase gene polymorphisms and diabetic retinopathy susceptibility.

OBJECTIVE: Aldose reductase (ALR) is involved in diabetic microvascular damage via the polyol pathway. A recent meta-analysis found genetic variation in the ALR gene (AKR1B1) to be significantly associated with diabetic retinopathy (DR). We investigated the genetic association of AKR1B1 with DR. RESEARCH DESIGN AND METHODS: The study enrolled 909 individuals with diabetes. Participants were genotyped for an AKR1B1 (CA)n microsatellite and 14 tag single nucleotide polymorphisms, and ophthalmological assessment was performed. RESULTS: A total of 514 individuals were found to have DR. rs9640883 was significantly associated with DR (P = 0.0005). However, AKR1B1 variation was not independently associated with DR development after adjusting for relevant clinical parameters. rs9640883 was associated with duration of diabetes (P = 0.002). CONCLUSION: Many previous reports have failed to account for known risk factors for DR. The commonly reported association of AKR1B1 with DR may be due to an association of the gene with younger age at onset of diabetes.

Sudden loss of vision--history and examination.

BACKGROUND: Sudden loss of vision requires careful history and examination to identify the underlying cause. OBJECTIVE: This article discusses the various causes of sudden loss of vision and provides the general practitioner with a guide to examination. DISCUSSION: Rapidity of onset, duration and associated symptoms provide vital clues to the nature of the disease process. Simple examination techniques such as visual acuity measurement, confrontational visual field testing, pupil assessment and fundoscopy are integral to the appropriate assessment, treatment and referral of patients presenting with sudden loss of vision.

Sudden loss of vision--investigation and management.

BACKGROUND: Sudden vision loss usually requires urgent ophthalmic assessment. Diagnosis and management requires the judicious use of a wide range of serological and imaging investigations to guide appropriate treatment and referral. OBJECTIVE: This article follows on from the previous discussion of the role of history and examination to discuss the appropriate investigation and management of common causes of sudden visual loss. DISCUSSION: The key historical and examination findings have now been extracted and synthesised and these inform the next step. The general practitioner must now decide upon the most appropriate and timely investigation pathway or the need for, and urgency of, referral.

Absence of lateral palpebral raphe in Caucasians.

Classical anatomical teaching reports the presence of the lateral palpebral raphe formed at the union in the preseptal and orbital parts of the orbicularis oculi muscle, or by the tendon adhering these to the underlying zygomatic bone. The lateral palpebral raphe has been shown to be absent in Asian cadavers. The current study uses both evidence from the anatomical dissection of five eyelids from three Caucasian cadavers, and histological assessment of the lateral canthus of 13 eyelids from seven Caucasian cadavers to illustrate the absence of the lateral palpebral raphe in Caucasian population.