Large extraocular extension of a choroidal melanoma with orbital inflammation.

Purpose: To describe an atypical case of a choroidal melanoma presenting with eyelid edema, chemosis, pain and diplopia and demonstrating significant extraocular extension on ultrasonography and neuroimaging. Observations: A 69-year-old woman presented with a headache, eyelid edema, chemosis and pain in the right eye. Upon subsequent onset of diplopia, MRI of the orbits was performed and demonstrated a predominantly extraocular, intraconal mass with a small intraocular component. She was started on corticosteroids and referred to the ocular oncology service for evaluation. On fundus examination, she was noted to have a pigmented choroidal lesion consistent with melanoma, and ultrasound showed a large area of extraocular extension. Enucleation, enucleation with subsequent radiation and exenteration were discussed, and the patient requested an opinion from radiation oncology. A repeat MRI obtained by radiation oncology demonstrated a decrease in the extraocular component after corticosteroid treatment. The improvement was interpreted as suggestive of lymphoma by the radiation oncologist who recommended external beam radiation (EBRT). Fine needle aspiration biopsy was insufficient for cytopathologic diagnosis, and the patient elected to proceed with EBRT in the absence of a definitive diagnosis. Next generation sequencing revealed GNA11 and SF3B1 mutations, which supported the diagnosis of uveal melanoma and led to enucleation. Conclusion and Importance: Choroidal melanoma may present with pain and orbital inflammation secondary to tumor necrosis, which may delay diagnosis and decrease the diagnostic yield of fine-needle aspiration biopsy. Next generation sequencing may aid the diagnosis of choroidal melanoma when there is clinical uncertainty and cytopathology is unavailable.

Blue Rubber Bleb Nevus Syndrome Manifesting as an Isolated Congenital Orbital Mass in a Neonate.

A male neonate presented with an isolated congenital right orbital vascular malformation without other mucocutaneous lesions or signs/symptoms of systemic disease. The orbital mass was progressive, causing amblyogenic ptosis by 6 months of age. Over 11 years, the patient underwent 4 orbital mass resections, 3 embolizations, and even a craniotomy with mass resection for an intraorbital meningoencephalocele secondary to orbital bony erosion. A diagnosis of blue rubber bleb nevus syndrome was made at age 7 when the patient developed a tender vascular lesion on his foot and was found to have other mucocutaneous lesions of the extremities and gastrointestinal tract. This is the first pediatric case of such an aggressive orbital vascular malformation from blue rubber bleb nevus syndrome causing neonatal amblyogenic ptosis and intraorbital meningoencephalocele in childhood. It is the second report of a patient presenting with an isolated orbital vascular malformation without other manifestations of blue rubber bleb nevus syndrome, leading to his delayed diagnosis.

Primary ductal adenocarcinoma of the lacrimal gland: A review and report of five cases.

Primary ductal adenocarcinoma (PDA) is a rare epithelial tumor of the lacrimal gland. Herein we report 5 cases and review 29 published cases of PDA of the lacrimal gland. Among these 5 cases, the most common clinical presentation was painless swelling and/or proptosis of their eye. The size of the lesions ranged from 1.6 to 2.5 cm. Histopathologic examination revealed proliferations of ductal or gland-like cells with vesiculated pleomorphic nuclei and prominent nucleoli. Tumor cells stained positive for epithelial and apocrine differentiation markers. Immunohistochemistry for human epidermal growth factor 2 was positive in 2 of the 4 cases. Four of the five patients were alive at the last follow-up visit. One died with bone metastases, which were diagnosed 25 months after exenteration and then survived an additional 51 months. On reviewing of twenty-nine previously published cases of PDA, the mean age of diagnosis was 58 years, with a male predominance (75%). Fifteen patients (54%) had distant metastases, 1 (4%) had local recurrence, and 10 (37%) suffered from a PDA-related death. PDA is a high-grade aggressive epithelial tumor of the lacrimal gland. Although rare, awareness and recognition of this malignancy are important to help determine prognosis and treatment options.

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

PURPOSE: To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. METHODS: A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. RESULTS: In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. CONCLUSIONS: Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.

Scleral Contact Lenses in an Academic Oculoplastics Clinic: Epidemiology and Emerging Considerations.

PURPOSE: To describe the role and efficacy of scleral contact lenses (SCLs) in the treatment of progressive keratopathy in patients who have undergone periocular surgical procedures, to investigate the financial impact of these surgical interventions, and to demonstrate the role of oculoplastic surgery in improving scleral contact lens fit. METHODS: A retrospective medical record review was performed to identify patients who both received SCLs and were examined by the oculoplastics service at the University of Iowa between January 1990 and December 2015. Inclusion criteria also required a minimum of 12 months of patient follow up after being fit with a SCL. The indication for SCL use, as well as clinical outcomes and cumulative relative value units (RVUs) of prior oculoplastic treatments and SCL therapy were recorded for each patient. RESULTS: Six hundred and fifty-nine patients were fitted with SCLs at the authors' institution during the 25-year study period, 43 of whom were examined by the oculoplastics service for reasons related to their SCL. Patients who were fitted for SCLs before (27 patients) or after (16 patients) evaluation in the oculoplastics clinic presented with a variety of corneal and periocular pathology. Corneal indications for SCLs in patients seen secondarily in the oculoplastics clinic included decreased corneal sensation (from CN V palsy or neurotrophic keratopathy), decreased corneal healing from limbal stem cell deficiency, exposure keratopathy, and keratoconjunctivitis sicca secondary to Sjogren's syndrome or orbital radiation. Indications for oculoplastic clinic evaluation in current scleral lens patients included lagophthalmos, trichiasis, epiphora, cicatricial changes in the eyelids or fornices, and eyelid or eyebrow malposition affecting SCL centration. In all 27 patients, surgical intervention resulted in improved SCL centration. Sixteen patients (5 with CN VII palsy, 4 with CN V and CN VII palsy, 4 with neurotrophic keratitis, and 3 with cicatricial entropion) had progressive corneal decompensation despite primary oculoplastics procedures to protect the cornea and ultimately benefitted from SCL treatment secondarily. Fourteen of these 16 patients demonstrated an improved visual acuity of 1 line or more using SCLs. Procedures performed before referral for SCLs included tarsorrhaphies, gold weights, ectropion repair with lateral tarsal strip, retraction repair with spacer grafts, full-thickness skin grafts, cheek lifts, and punctal occlusion. The total RVUs of these procedures performed per patient were tabulated. The RVU range was 10.47-33.96 with an average of 19.5 RVUs (standard deviation = 9.4 RVUs) per patient. CONCLUSIONS: Scleral contact lenses may offer a useful alternative to stabilize the ocular surface, improve vision, and minimize the financial impact and morbidity of multiple periocular procedures in select patients with progressive keratopathy of varying etiologies. The therapeutic indications and utilization of SCLs are likely to increase in oculoplastic practices with optometric support, particularly in academic settings. Surgical correction of eyelid and eyebrow malposition, as well as epiphora, may also be useful adjunctive procedures to optimize SCL fit.

Rethinking Our Definition of Postoperative Success: A Comparative Analysis of Three Upper Eyelid Retraction Repair Techniques Using Novel Metrics to Capture Functional and Aesthetic Outcomes.

PURPOSE: To compare 3 upper eyelid retraction repair techniques and introduce novel metrics, which enhance the analysis of postoperative aesthetic outcomes. METHODS: Retrospective review with Image J 1.48 digital analysis of patients who underwent repair of thyroid-related upper eyelid retraction at the University of Iowa from 1996 to 2014 via 1 of 3 surgical techniques, septum-opening levator recession with Muellerectomy, modified septum-preserving levator recession with Muellerectomy, and modified septum-preserving full-thickness blepharotomy, was conducted. Photographs were obtained preoperatively, 3 to 6 months postoperatively, and at last follow up (>6 months) and evaluated by digital image analysis (denoted by "i"). Outcome measures assessed were marginal reflex distance (iMRD1), temporal-to-nasal ratio, tarsal platform show (iTPS), pupil to visible eyelid crease, brow fat span (iBFS), tarsal platform show to brow fat span ratio (iTPS:iBFS), and tarsal platform show minimizing power (iTPS-minimizing power). RESULTS: A total of 121 eyelids (28 septum-opening levator recession with Muellerectomy, 66 septum-preserving levator recession with Muellerectomy, and 27 septum-preserving full-thickness blepharotomy) from 74 patients were evaluated with a mean follow up of 24.2 months. There were no statistically significant differences between techniques in terms of iMRD1 or temporal-to-nasal ratio reduction at either time point (intertechnique p values of 0.17 to >0.99). The percentage of eyelids from subjects undergoing bilateral intervention that achieved a final iMRD1 between 2.50 mm and 4.50 mm was similar (intertechnique p value of 0.23), with no difference regarding the number of subjects demonstrating iMRD1 symmetry within 1 mm (intertechnique p value of 0.15). Though iTPS elongation was greater at 3 to 6 months with septum-opening compared with the combined septum-preserving techniques (p value of 0.04), this difference was not maintained at final follow up (p value of >0.99). There was no difference in terms of iTPS symmetry at time of final follow up (intertechnique p value of 0.69). The pupil to visible eyelid crease was unchanged in all techniques (p values >0.99). Mean changes in iBFS at final follow up were -1.27 mm, -0.44 mm, and +0.55 mm for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy (p values of 0.01, 0.49, and >0.99, respectively). Mean iTPS:iBFS ratios at final follow up were not statistically different between techniques (intertechnique p value of 0.10) and no difference in symmetry was demonstrated (intertechnique p value of 0.47). Median values for iTPS-minimizing power were: -0.83, -0.93, and -1.01 for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy, respectively (intertechnique p value of 0.54). CONCLUSIONS: Each technique appropriately lowered the eyelid and improved contour without intertechnique variability. Septum-preserving techniques demonstrated less iTPS elongation initially, but this difference was not maintained. The visible eyelid crease height (pupil to visible eyelid crease) remained stable in all techniques, indicating that the iTPS elongation seen with each technique was secondary to reduction in iMRD1 and the iBFS reduction seen with septum-opening levator recession with Muellerectomy was due to brow descent. No intertechnique differences in the amount of iTPS elongation relative to iMRD1 reduction (i.e., the novel iTPS-minimizing power) were seen. Given that each procedure evaluated yielded similar results, technique selection may be guided by surgeon experience and preference.

Upper Eyelid Splitting to Facilitate the Insertion of Glaucoma Drainage Devices.

PURPOSE: To describe a new application for vertical splitting of the upper eyelid, a technique traditionally used for orbital access, to facilitate glaucoma drainage device (GDD) implantation in patients with poor surgical exposure. METHODS: Case series. CASES: We present a case of Möbius syndrome with complete restriction of the extraocular muscles, followed by a case of cicatricial narrowing of the palpebral fissures due to chronic allergic dermatitis. Both patients had severe, medically uncontrolled glaucoma, but poor surgical exposure precluded implantation of a GDD. Both cases underwent vertical splitting of the upper eyelid, which allowed for adequate exposure of the superior globe quadrants and successful implantation of a GDD. CONCLUSIONS: A variety of congenital or acquired conditions result in narrowing of the palpebral fissure or restriction of extraocular motility. When these patients have concurrent advanced glaucoma, inadequate surgical exposure can impede necessary surgical intervention. Use of a vertical upper eyelid split technique allows for access to the superior globe and facilitates implantation of a GDD.

Donor-Derived Conjunctival-Limbal Melanoma After a Keratolimbal Allograft.

PURPOSE: To report a single case of donor-derived conjunctival-limbal melanoma that occurred after a keratolimbal allograft (KLAL). METHODS: Case report and literature review. RESULTS: A 56-year-old white woman with a history of bilateral limbal stem cell deficiency developed a donor-related melanoma after a KLAL. Three months after undergoing an uncomplicated KLAL, the patient presented with hemorrhagic nodules within her conjunctiva and transplanted tissue. Excisional biopsy was performed, and the pathology results revealed melanoma cells. Although the donor of the KLAL had a history of metastatic melanoma, the ocular tissue was in compliance with all eye bank requirements for donation. After discovery of the tumor, the patient's systemic immunosuppression was stopped. Within 1 week, the patient demonstrated a dramatic improvement in the size of the lesion. One month after the initial biopsy, the KLAL tissue was excised, and a pathology report revealed that there were no viable tumor cells on the ocular surface. As the limbal stem cell deficiency recurred, the eye underwent placement of a Boston type 1 keratoprosthesis. CONCLUSIONS: We present a case of conjunctival-limbal melanoma after a KLAL from a donor who had a history of metastatic melanoma. In response to this case, the US eye banking guidelines were amended to include stricter parameters for vascularized ocular tissue transplantation.

Orbital Volume Augmentation for Enophthalmos Following Ventriculoperitoneal Shunting: A Case Study in "Silent Brain Syndrome".

A 21-year-old female with a history of infantile hydrocephalus and ventriculoperitoneal shunting presented with bilateral persistent tearing. Examination revealed marked bilateral enophthalmos, poor lower eyelid apposition to the ocular surface, and patent nasolacrimal systems. Radiographic imaging demonstrated expanded orbital volumes with high arching orbital roofs, sequestered air under the eyelids, short, straight optic nerves, and expanded paranasal sinuses. Surgical intervention included insertion of mesh and block implants within the subperiosteal space of the orbital roof, resulting in correction of enophthalmos, improved lower eyelid apposition and resolution of tearing. However, new onset myopic astigmatism and bilateral ptosis were noted postoperatively and treated successfully with corrective spectacles and ptosis repair. Current literature has demonstrated the benefit of orbital roof implants through a upper eyelid crease incision. The authors present a case that supports the utility of this approach and addresses its potential complications, including postoperative-induced astigmatism/myopia and ptosis.

Disaster in Cosmetic Surgery: Inadvertent Formalin Injection During Blepharoplasty.

The authors report a case where formalin was accidentally injected into the eyelids of a 71-year-old woman undergoing blepharoplasty, causing full thickness necrosis of both upper eyelids and ocular complications that required multiple reconstructive surgical procedures.

Physical and chemical injuries to eyes and eyelids.

Ocular and periocular injuries are common reasons for emergency department visits. In fact, an estimated 2 million Americans suffer ocular injuries each year. Evaluation and treatment of physical and chemical injuries to the eyes and eyelids begin with a systematic examination. Visual acuity and pupillary reaction should be assessed first. Evaluation of the eye should precede examination of the periocular structures due to the potential for causing further damage to a full-thickness ocular injury with manipulation of the eyelids. Physical injuries to the eyes and periocular structures include lacerations, abrasions, foreign bodies, and open globe injuries and can range from minor irritation to visual devastation. Chemical injuries can be divided into alkali and acid injuries. Alkali burns are more common, due to the prevalent use of alkali substances in industrial and home cleaning applications, and usually result in more serious injuries. Definitive care of chemical injuries ranges from topical antibiotics to full-thickness skin grafts with the goal of preventing cicatricial scarring and exposure of the ocular surface. Familiarity with the various types of ocular and periocular injuries is important for all medical professionals and is critical to providing the most appropriate management.

Factors affecting eyelid crease formation before and after silicone frontalis suspension for adult-onset myogenic ptosis.

PURPOSE: To evaluate factors that affect eyelid crease formation before and after frontalis suspension. DESIGN: Nonrandomized, comparative, interventional case series. METHODS: Sixty-three patients (125 eyes) with myogenic ptosis were included. Data collected included age, gender, previous surgeries, follow up, as well as pre- and postoperative margin reflex distance, palpebral fissure height, and levator function. Intraoperative maneuvers of incorporation of the levator aponeurosis into the skin closure, conservative fat excision, and conservative skin excision were recorded. Pre- and postoperative eyelid creases were graded by 2 masked, independent observers as "good," "fair," or "poor." RESULTS: The weighted κ coefficient between the graders was 0.68 (95% CI, 0.58-0.79) preoperatively and 0.70 (95% CI, 0.61-0.79) postoperatively. Evaluating preoperative eyelid crease grades, there was no significant difference with regard to age or gender (p = 0.83 or 0.69, respectively). Eyelid crease grade correlated with margin reflex distance (p = 0.0004) and palpebral fissure height (p = 0.002). There was no significant correlation of eyelid crease with levator function (p = 0.104). After frontalis sling, intraoperative maneuvers of incorporation of the levator aponeurosis into the incision, skin preservation, and fat preservation correlated with postoperative eyelid crease (p = 0.0004, 0.059, and 0.033, respectively). CONCLUSIONS: Preoperative levator function in patients with adult onset myogenic ptosis may be an inaccurate measure of true levator palpebrae strength. Reliance on levator function alone in decision making for surgical intervention in these patients may be misguided. The inclusion of the intraoperative maneuvers of incorporation of the levator aponeurosis into the skin incision and preservation of fat and skin results in a stronger eyelid crease after frontalis sling surgery.

The clinical characterization and surgical correction of blepharoptosis associated with congenital aniridia.

PURPOSE: To document the clinical characteristics and describe our management of patients with blepharoptosis associated with congenital aniridia. METHODS: Consecutive retrospective case series of patients with congenital aniridia seen at a single institution (Cincinnati Eye Institute) from 1963 to 2010. Surgical correction was performed by 2 surgeons (J.A.N. and R.C.K.). RESULTS: Ptosis associated with congenital aniridia is marked with decreased levator function. Significant comorbid ophthalmologic disease was invariably present, particularly aniridia-associated keratopathy. Complications, most often keratopathy, were common, even following conservative correction. CONCLUSIONS: The degree of ptosis is significant, and levator function is typically reduced. Ocular surface viability appears to play a key role in preoperative, intraoperative, and postoperative management. While we are aware that congenital aniridia is rather rare, we believe these recommendations are generalizable to patients with severe ocular surface disease.

Intimate partner violence: an underappreciated etiology of orbital floor fractures.

PURPOSE: To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. METHODS: Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. RESULTS: A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence-associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non-IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. CONCLUSIONS: Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.

Ocular adnexal lymphoma of the extraocular muscles: case series from the University of Iowa and review of the literature.

PURPOSE: To review and statistically analyze the data of patients with discrete involvement of the extraocular muscles with ocular adnexal lymphoma from the tumor registry at the University of Iowa and to compile with current cases in the literature. METHODS: The records of patients with biopsy-proven orbital lymphoma at the University of Iowa Hospitals and Clinics Department of Ophthalmology and the Tumor Registry of the University of Iowa were reviewed. A review of the literature and meta-analysis were conducted. RESULTS: Eleven patients were identified with biopsy-proven ocular adnexal lymphoma with discrete involvement of the extraocular muscles at the University of Iowa. Additionally, 46 patients were identified in the literature with clinical and radiographic involvement of the extraocular muscles, 31 (67%) with biopsy-proven involvement. In the combined group of 57 patients, 16 (35%) of 45 patients with histopathologic documentation had lymphomas classified as extranodal marginal zone lymphomas. Twenty-five (67%) of the 37 patients with tumor-staging documentation had no extraorbital involvement. CONCLUSIONS: Ocular adnexal lymphoma with discrete extraocular muscle involvement is rare. Most lymphomas found in this area of the orbit are subtypes of B-cell lymphoma. This disease should be included in the differential diagnosis of enlarged extraocular muscles.

The current state of ptosis repair: a comparison of internal and external approaches.

PURPOSE OF REVIEW: Posterior approach ptosis repair has made a resurgence over the last decade. The purpose of this review is to examine the history of posterior approach ptosis repair and the events that have led to its current favorable status. RECENT FINDINGS: The evolution of the posterior and anterior approach ptosis surgeries has resulted in two favored techniques for involutional ptosis repair: the Müller muscle-conjunctiva resection (MMCR) and the external levator advancement. Each procedure has strong and prominent proponents in the oculoplastic surgery community. Recently, the MMCR has converted surgeons who have previously favored the external levator advancement. A number of factors have influenced this recent elevation of the MMCR including differing opinions on the cause of involutional ptosis, the mechanism by which the MMCR works, the predictability and speed of the MMCR, and the current reimbursements for ptosis repair by insurance companies. SUMMARY: The recent preference for posterior approach ptosis surgery, in particular the MMCR, is multifactorial. In order to understand the evolution of opinions about the procedure, a historical knowledge of involutional ptosis and ptosis repair is necessary.

Effect of orbital bony decompression for Graves' orbitopathy on the volume of extraocular muscles.

AIM: To evaluate the change in the rectus muscle volume following orbital bony wall decompression for Graves' orbitopathy. METHODS: We used a computer program (syngo Volume Evaluation) to measure the rectus muscles from the digital preoperative and postoperative orbital CT. RESULTS: Of the 25 patients (20 women and five men; mean age 46 (range 18-64) years) enrolled in the study. A significant increase (mean 0.23 ml (16.5%) of preoperative volume; p=0.005) in the volume of the medial rectus muscle (MRM) was detected postoperatively, whereas no significant changes were found in the volume of the other rectus muscles and between eyes that underwent surgery in the active and inactive phases of the disease. A significant negative association was observed between the time of postoperative CT scans and the change in the MRM volume (p=0.0004) (a mean increase of 68% of preoperative MRM volume for those measured between 3 and 9 months, and a mean decrease in the volume of 50% for those measured between 41 and 50 months). CONCLUSION: The change in the volume of the MRM may partly explain the variability in the proptosis reduction following orbital decompression.

Orbital roof encephalocele mimicking a destructive neoplasm.

The purpose of this case report is to report an orbital roof encephalocele mimicking a destructive orbital neoplasm. Orbital roof encephalocele is uncommon but can mimic neoplasm. One potential mechanism for the orbital roof destruction is a post-traumatic "growing orbital roof fracture." The growing fracture has been reported mostly in children but can occur in adults. Alternative potential etiologies for the encephalocele are discussed, including Gorham syndrome. Orbital roof encephalocele is uncommon in adults, and the findings can superficially resemble an orbital neoplasm. Radiographic and clinical features that might suggest the correct diagnosis include a prior history of trauma, overlying frontal lobe encephalomalacia without significant mass effect or edema, and an orbital roof defect. The "growing fracture" mechanism may be a potential explanation for the orbital roof destruction in some cases.

Orbital volume and eye position changes after balanced orbital decompression.

PURPOSE: To evaluate the changes in eye position and orbital content expansion following medial and lateral orbital wall decompression for thyroid-associated orbitopathy. METHODS: The authors used a computer software program (syngo InSpace4D, syngo 3D, syngo fusion, and syngo Volume Evaluation; Siemens AG, Forchheim, Germany) to measure the orbital expansion gained by medial and lateral orbital wall decompression and the change in eye position between the digitized preoperative and postoperative orbital CT scans. RESULTS: Twenty patients (16 women and 4 men) with a mean age of 45 years (range, 18-64 years) were enrolled in this study. Of the 20 patients who underwent balanced decompression for thyroid-associated orbitopathy, 18 patients had bilateral medial and lateral orbital wall decompression, and 2 patients had unilateral medial and lateral decompression. The average orbital volume expansion was 3.21 mL (13.51%) of the preoperative orbital volume (2.1 mL [8.98%] gained by medial wall decompression and 1.03 mL [4.53%] by lateral wall decompression). Postoperatively, proptosis decreased by 2.53 mm on average (p < 0.0001). The eyes became closer to each other postoperatively in the horizontal plane by 2.6 mm on average (p < 0.0001). No change in the vertical eye position was detected postoperatively. CONCLUSIONS: A significant nasal shift in the eye position was noticed following balanced orbital decompression. Computerized assessment of preoperative and postoperative digitized orbital CT scans helps evaluate the orbital changes in response to different orbital decompression techniques and improve the surgical outcomes in thyroid-associated orbitopathy.