A case of permanent vision loss due to a carotidcavernous fistula: importance of early diagnosis / Relato de caso de perda visual secundária a fístuda carótido-cavernosa: a importância de um diagnóstico adequado

ABSTRACT A 97-year-old female presented with spontaneous acute-onset palpebral hyperemia and edema of the right eye that had progressively worsen over the previous three days. These signs did not suggest possible carotid-cavernous fistula until a second examination 72 h later, during which the patient exhibited significant progression. Despite embolization, the patient exhibited sustained corneal edema, clots, and turbidity in the aqueous humor, which resulted in permanent visual loss. A greater level of clinical suspicion for possible carotid-cavernous fistula is warranted on initial presentation of palpebral hyperemia and edema to prevent possible irreversible vision loss.

RESUMO O objetivo deste relato é apresentar o caso de uma paciente de 97 anos com início agudo e espontâneo de hiperemia e edema palpebral. Estes sinais não levaram a uma suspeita diagnóstica de fístula carótido-cavernosa até um segundo momento, quando a paciente apresentou progressão importante do quadro clínico. Apesar da realização de tratamento efetivo com embolização da fístula, a paciente manteve alterações oculares como edema de córnea, coágulos e turvação no humor aquoso, e manteve perda visual definitiva.

A case of permanent vision loss due to a carotidcavernous fistula: importance of early diagnosis.

A 97-year-old female presented with spontaneous acute-onset palpebral hyperemia and edema of the right eye that had progressively worsen over the previous three days. These signs did not suggest possible carotid-cavernous fistula until a second examination 72 h later, during which the patient exhibited significant progression. Despite embolization, the patient exhibited sustained corneal edema, clots, and turbidity in the aqueous humor, which resulted in permanent visual loss. A greater level of clinical suspicion for possible carotid-cavernous fistula is warranted on initial presentation of palpebral hyperemia and edema to prevent possible irreversible vision loss.

Topical mitomycin in endoscopic-assisted probing for the treatment of congenital nasolacrimal duct obstruction in older children.

PURPOSE: Mitomycin C has been used in ophthalmic surgery to mitigate postoperative scarring. However, the outcomes of endoscopic-assisted probing for the treatment of congenital nasolacrimal duct obstruction with adjunctive mitomycin C in children remain unknown. Our study was aimed to evaluate the efficacy and safety of adjunctive application of mitomycin C after endoscopic-assisted probing for the treatment of congenital nasolacrimal duct obstruction in children. METHODS: This is a retrospective chart review performed in a tertiary eye care hospital involving children with congenital nasolacrimal duct obstruction, who underwent endoscopic-assisted probing from October 2013 to August 2015. We compared children who underwent endoscopic-assisted probing with mitomycin C (mitomycin C group) versus others who underwent endoscopic-assisted probing without mitomycin C (endoscopic-assisted probing group). The mitomycin C group received 0.2 mg/ml within 4 min to the nasolacrimal duct ostium using a cotton tip applicator immediately after probing. Probing was considered successful when patient complaints of tearing were reduced or the results of the dye disappearance test were normal. Demographic data, clinical features, and intraoperative and postoperative variables were correlated to the success rate. RESULTS: The study sample comprised 68 lacrimal vies. The majority of children had bilateral obstruction and no previous history of probing. The mean age of the patients was approximately 4 years. Most obstructions were considered complex. The success rates were high in both groups (p>0.05). There were no adverse events related to the use of mitomycin C (p>0.05). CONCLUSIONS: Although mitomycin C has no adverse effects when applied to the opening of the nasolacrimal duct, its use after lacrimal probing for the treatment of congenital nasolacrimal duct obstruction does not improve the chance of success.

Success Rates of Endoscopic-Assisted Probing Compared to Conventional Probing in Children 48 Months or Older.

BACKGROUND: To evaluate the success rates of endoscopic-assisted probing compared to conventional probing in children 48 months or older. METHODS: This retrospective study included children 48 months and older with CNLDO who underwent endoscopic-assisted probing or conventional probing between January 2011 to August 2015 at a tertiary eye care hospital in central Saudi Arabia. Probing was considered successful when signals of tearing or discharge disappeared and fluorescein dye disappearance test (FDDT) was normal. Demographic data, clinical features, intraoperative and postoperative variables were correlated to the success rate. RESULTS: One hundred and twelve children with CNLDO undergoing endoscopic-assisted (37 patients) or conventional (75 patients) probing were included. The success rates of endoscopic-assisted and conventional probing were 94.6% [95% confidence interval (CI): 89.5-99.7] and 58.7% [95% (CI): 47.6-69.8], respectively. The success rate was higher with endoscopic probing, especially in older children. CONCLUSIONS: Endoscopic-assisted probing can achieve better outcomes to treat CNLDO, even in older children. The significantly higher success rates with endoscopic probing are likely due to the ability to observe and treat associated problems.

Accessory lacrimal gland duct cyst: 23 years of experience in the Saudi population.

BACKGROUND AND OBJECTIVES: Accessory lacrimal gland ductal cyst is a rare clinical entity that has been reported after trauma, infection, or conjunctival inflammation. Trachoma has been postulated as an etiologic factor for this dacryops in Saudis. We studied the prevalence, demographics, clinicopathological features and surgical approach for these lesions. DESIGN AND SETTING: Retrospective study of 23 consecutive ductal cysts diagnosed clinically and proved histopathologically at King Khaled Eye Specialist Hospital (KKESH) over 23 years (1991-2014). PATIENTS AND METHODS: Data on patient demographics, clinical features, surgery, and outcome were collected by chart review. The histopathologic slides were reviewed by a single pathologist. RESULTS: Of 23 cases of accessory lacrimal gland ductal cysts confirmed histopathologically, 14 were males and 9 females with a median age of 38.8 years. Cysts were located in the upper eyelid in 73.9%. The commonest presentation was a painless eyelid mass in 91.3%. Excision by conjunctival incision was performed in 14 and intra-operative perforation occurred in 9. Trachomatous scarring was evident in 39.1% but did not have significance in relation to this rupture. No recurrences have been observed with a mean follow up of 34.6 months. CONCLUSION: The approximate prevalence of accessory lacrimal gland dacryops in the Saudi population is 1/6800. Trachoma does not seem to be a major predisposing factor. They are more frequent in males. Their histopathological appearance is identical regardless of origin. The presence of conjunctival scarring, dacryops size, and the surgical incision type did not seem to have significant correlation with the iatrogenic rupture of the cyst. We recommend careful dissection for complete cyst excision through conjunctival approach with no expected recurrence.

Globe Protrusion and Interorbital Divergence in Syndromic Faciocraniosynostoses.

PURPOSE: The aim of this study was to quantify the relationship between globe protrusion (GP), length of medial and lateral walls, interzygomatic distance, and interorbital angle in syndromic faciocraniosynostoses. METHODS: The axial slices of computed tomography of the orbits of 43 patients with faciocraniosynostosis (31 with Crouzon syndrome and 12 with Apert syndrome) and 23 control subjects were measured with the Image J software. The following 5 variables were quantified: the degree of GP, the length of the medial and lateral walls, the interzygomatic distance, and the interorbital angle. RESULTS: Independent t-tests revealed significant differences between the patients and the controls regarding the mean values of all variables measured. The degree of GP was better correlated with the interorbital angle (r = 0.81) than with the medial wall length (r = 0.73). No correlation was found between GP and lateral orbital wall length. CONCLUSIONS: In syndromic faciocraniosynostoses, GP is highly correlated with the interorbital angle. The increment in the interorbital angle is a natural geometric consequence of the fact that a decrease in the orbital depth is not adequately compensated by an increase in the distance between the lateral orbit rims.

Graves upper eyelid retraction.

Graves upper eyelid retraction (GUER) is the most common and characteristic sign of Graves orbitopathy. Despite being well recognized since the 19th century, GUER is still a subject of controversy. We review GUER, including historical aspects, diagnosis, methods of measurements, ocular surface abnormalities, etiology, and medical and surgical treatments. There is no consensus about the mechanisms of its etiology or the best surgical correction. There is a need for quantitative studies on the effects of GUER on lid movements.

Upper eyelid entropion and dry eye in cicatricial trachoma without trichiasis / Entrópio de pálpebra superior e olho seco no tracoma cicatricial sem triquíase

PURPOSE: to evaluate the position of the upper eyelid margin and eye surface status in cicatricial trachoma without trichiasis (TS). METHODS: Slit-lamp biomicroscopy was employed to evaluate the location of the upper lid mucocutaneous transition of 156 eyes of 78 patients with trichiasis and of 130 eyes of 65 control subjects. For each eye the position of the upper lid mucocutaneous junction was graded with respect to the line of meibomian gland orifices into 3 categories: a) anterior, b) at the line, and c) posterior to the line. Ocular surface dye staining with lissamine green was performed in all eyes. All participants answered a questionnaire with queries on the presence and intensity of dry eye symptoms. RESULTS: In the eyes with trichiasis the location of the mucocutaneous transition was posterior to the meibomian gland line in 55 (35.3%), at the line in 77 (49.4%) and anterior to the line in only 24 (15.4%). In the control group these figures were: 5 (3.8%); 42 (42%) and 83 (63.8%). Lissamine staining and dry eye symptoms were also associated with trichiasis. CONCLUSION: Different degrees of upper lid entropion are already present in cicatricial trachoma even in the absence of trichiasis. Trichiasis is associated with lissamine green staining and dry eye symptoms. Conjunctivalization of the upper lid margin may play a role in the development of trachomatous dry eye.

OBJETIVOS: Avaliar a posição da margem palpebral superior e a superfície ocular no tracoma cicatricial sem triquíase (TS). MÉTODOS: A localização da transição mucocutânea da pálpebra superior foi avaliada com lâmpada de fenda em 156 olhos de 78 pacientes com triquíase e de 130 olhos de 65 controles. A posição da transição mucocutânea foi classificada em relação à linha das glândulas de Meibômio em três categorias: a) anterior, b) sobre a linha e c) posterior a linha. A superfície ocular de todos os olhos foi avaliada com verde de lissamina. Todos os participantes responderam ao questionário sobre a presença e intensidade dos sintomas relacionados ao olho seco. RESULTADOS: Nos olhos com triquíase a localização da transição mucocutânea foi posterior à linha das glândulas de Meibômio em 55 (35,3%), sobre a linha em 77 (49,4%) e anterior à linha em somente 24 (15,4%). No grupo controle essa distribuição foi 5 (3,8%); 42 (42%) e 83 (63,8%). A positividade ao corante de lissamina e sintomas de olho seco também foram associados à triquíase. CONCLUSÃO: Diferentes graus de entrópio de pálpebra superior estão presentes no tracoma cicatricial mesmo na ausência de triquíase. Triquíase está associada à positividade ao corante verde lissamine e sintomas de olho seco. A conjuntivalização da margem palpebral pode ser um fator no desenvolvimento do olho seco tracomatoso.

Upper eyelid entropion and dry eye in cicatricial trachoma without trichiasis.

PURPOSE: to evaluate the position of the upper eyelid margin and eye surface status in cicatricial trachoma without trichiasis (TS). METHODS: Slit-lamp biomicroscopy was employed to evaluate the location of the upper lid mucocutaneous transition of 156 eyes of 78 patients with trichiasis and of 130 eyes of 65 control subjects. For each eye the position of the upper lid mucocutaneous junction was graded with respect to the line of meibomian gland orifices into 3 categories: a) anterior, b) at the line, and c) posterior to the line. Ocular surface dye staining with lissamine green was performed in all eyes. All participants answered a questionnaire with queries on the presence and intensity of dry eye symptoms. RESULTS: In the eyes with trichiasis the location of the mucocutaneous transition was posterior to the meibomian gland line in 55 (35.3%), at the line in 77 (49.4%) and anterior to the line in only 24 (15.4%). In the control group these figures were: 5 (3.8%); 42 (42%) and 83 (63.8%). Lissamine staining and dry eye symptoms were also associated with trichiasis. CONCLUSION: Different degrees of upper lid entropion are already present in cicatricial trachoma even in the absence of trichiasis. Trichiasis is associated with lissamine green staining and dry eye symptoms. Conjunctivalization of the upper lid margin may play a role in the development of trachomatous dry eye.

Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy.

PURPOSE: External dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. The lower eyelid crease approach has been seldom reported. The purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. METHODS: Prospective, interventional case series. Twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± SD= 44.84 ± 23.67) were included in the study. All patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. The inner canthus was photographed with a Nikon D70S digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. The resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). RESULTS: The surgery was easily performed in all patients with a 90.48% success. Three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. One patient had a hypometric blink which spontaneously recovered within one month. The mean score for scar visibility was 2.19 (1(st) mo), 1.65 (3(th) mo) and 1.44 (6(th) mo). CONCLUSIONS: The eyelid crease approach is an excellent option for external dacryocystorhinostomy. It leaves an unapparent scar since the first month after surgery, even in younger patients. The functional results are excellent and comparable to other techniques. Care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.

Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy / Resultados cosméticos e funcionais na dacriocistorrinostomia com incisão transpalpebral

PURPOSE: External dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. The lower eyelid crease approach has been seldom reported. The purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. METHODS: Prospective, interventional case series. Twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± SD= 44.84 ± 23.67) were included in the study. All patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. The inner canthus was photographed with a Nikon D70S digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. The resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). RESULTS: The surgery was easily performed in all patients with a 90.48 percent success. Three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. One patient had a hypometric blink which spontaneously recovered within one month. The mean score for scar visibility was 2.19 (1st mo), 1.65 (3th mo) and 1.44 (6th mo). CONCLUSIONS: The eyelid crease approach is an excellent option for external dacryocystorhinostomy. It leaves an unapparent scar since the first month after surgery, even in younger patients. The functional results are excellent and comparable to other techniques. Care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.

OBJETIVOS: A dacriocistorrinostomia externa é classicamente realizada por meio de incisão cutânea nasal. Há poucos relatos sobre a incisão transpalpebral, posicionada no sulco infraciliar da pálpebra inferior. O presente estudo tem por objetivo relatar os aspectos cosméticos e funcionais utilizando a técnica transpalpebral. MÉTODOS: Série de casos, intervencional e prospectivo. Foram incluídos 25 pacientes consecutivos (17 mulheres) com idades variando de 3 a 85 anos (média ± dp= 44,84 ± 23,67), que apresentavam dacriocistite crônica. A dacriocistorrinostomia foi unilateral em 24 casos e bilateral em 1 caso. A incisão transpalpebral foi posicionada no sulco infraciliar medial, com extensão de 10 a 15 mm. Foram realizadas fotografias digitais do canto interno (Nikon D70S, lente macro, resolução de 3008 x 2000 pixels) nos tempos pós-operatórios 1, 3 e 6 meses. A visibilidade da cicatriz foi avaliada por 3 observadores (oftalmologista, cirurgião plástico e cirurgião de cabeça e pescoço) utilizando a seguinte escala: 1= imperceptível, 2= minimamente visível, 3= moderadamente visível, 4= muito visível. RESULTADOS: A DCR foi realizada sem dificuldades e com sucesso funcional em 90,48 por cento dos casos. A pontuação média para visibilidade da cicatriz foi de 2,19 (1º mês), 1,65 (3º mês) e 1,44 (6º mês). Houve 3 casos de ectrópio leve do ponto lacrimal que foram tratados conservadoramente. Um paciente apresentou piscar espontâneo incompleto, com resolução no primeiro mês de pós-operatório. CONCLUSÃO: A incisão transpalpebral é uma excelente via de acesso para realização da dacriocistorrinostomia. A cicatriz é pouco visível desde o primeiro mês após a cirurgia, mesmo em pacientes mais jovens. Os resultados funcionais são semelhantes ao das outras técnicas. Em pacientes mais idosos é necessário avaliação cuidadosa da frouxidão palpebral a fim de evitar a indução de ectrópio lacrimal.

Posterior scleral tuberculoma: case report.

Posterior scleral tuberculoma formation is an extremely rare condition. The few reports on scleral involvement in tuberculosis refer to cases of anterior scleritis. In the present manuscript we describe a patient who had rheumatoid arthritis and developed a large posterior scleral tuberculoma. The lesion provoked retinal detachment and visual loss and was diagnosed only after enucleation due to a misdiagnosis of choroidal melanoma.

Posterior scleral tuberculoma: case report / Tuberculoma escleral posterior: relato de caso

Posterior scleral tuberculoma formation is an extremely rare condition. The few reports on scleral involvement in tuberculosis refer to cases of anterior scleritis. In the present manuscript we describe a patient who had rheumatoid arthritis and developed a large posterior scleral tuberculoma. The lesion provoked retinal detachment and visual loss and was diagnosed only after enucleation due to a misdiagnosis of choroidal melanoma.

A formação de granuloma tuberculoso na esclera posterior é um evento extremamente raro. Os poucos relatos de acometimento escleral na tuberculose referem-se a casos de esclerite anterior. No presente trabalho é descrito um caso de granuloma escleral posterior em um paciente portador de artrite reumatóide. A lesão provocou descolamento da retina e perda visual e só foi diagnosticada após enucleação por suspeita de melanoma de coróide.

Orbital abscess secondary to acute dacryocystitis: case report.

Acute dacryocystitis usually induces preseptal infection. In rare instances the infection that is confined to the lacrimal sac can extend to the orbital contents resulting in orbital cellulitis. We present a case of intraconal abscess secondary to acute dacryocystitis and review the literature of orbital cellulitis resulting from acute lacrimal sac infection.

Acute hypocomplementemic post-infectious glomerulonephritis as a complication of sinus-related orbital cellulitis: case report.

Group A beta-hemolytic streptococcus is the most common agent implicated in post-infectious acute glomerulonephritis. We report a case of acute poststreptococcal glomerulonephritis associated with sinus-related orbital abscess in an 11-year-old boy treated with surgical drainage and intravenous ceftriaxone and clindamycin. Twelve days after supportive measures, renal function was normalized. We also discuss this potentially severe nonsuppurative complication of orbital cellulitis caused by group A beta-hemolytic streptococcus.

Orbital abscess secondary to acute dacryocystitis: case report / Abscesso orbitário secundário à dacriocistite aguda: relato de caso

Acute dacryocystitis usually induces preseptal infection. In rare instances the infection that is confined to the lacrimal sac can extend to the orbital contents resulting in orbital cellulitis. We present a case of intraconal abscess secondary to acute dacryocystitis and review the literature of orbital cellulitis resulting from acute lacrimal sac infection.

A dacriocistite aguda comumente evolui para infecção pré-septal. Raramente a infecção localizada no saco lacrimal pode estender-se ao conteúdo orbitário resultando em celulite orbitária. Apresentamos um caso de abscesso orbitário intraconal secundário à dacriocistite aguda e uma revisão de literatura de celulite orbitária causada por infecção aguda do saco lacrimal.

Acute hypocomplementemic post-infectious glomerulonephritis as a complication of sinus-related orbital cellulitis: case report / Glomerulonefrite pós-infecciosa hipocomplementêmica aguda como complicação de celulite orbitária relacionada aos seios paranasais: relato de caso

Group A beta-hemolytic streptococcus is the most common agent implicated in post-infectious acute glomerulonephritis. We report a case of acute poststreptococcal glomerulonephritis associated with sinus-related orbital abscess in an 11-year-old boy treated with surgical drainage and intravenous ceftriaxone and clindamycin. Twelve days after supportive measures, renal function was normalized. We also discuss this potentially severe nonsuppurative complication of orbital cellulitis caused by group A beta-hemolytic streptococcus.

Os estreptococos beta-hemolíticos do grupo A são os agentes mais comumente envolvidos na glomerulonefrite aguda pós-infecciosa. Relatamos um caso de glomerulonefrite pós-estreptocócica aguda associada a um abscesso orbitário secundário à sinusite, em menino de 11 anos de idade, o qual foi tratado com ceftriaxona e clindamicina endovenosas e drenagem cirúrgica. Doze dias após tratamento de suporte, a função renal se normalizou. Também discutimos a importância desta grave e potencial complicação não supurativa das celulites orbitárias causadas pelos estreptococos beta-hemolíticos do grupo A.

The role of major histocompatibility complex alleles in the susceptibility of Brazilian patients to develop the myogenic type of Graves' orbitopathy.

OBJECTIVE: To assess the frequency of the genetic markers HLA-DRB1 and DQB1 in patients with Graves' orbitopathy (GO) with and without extraocular muscle involvement. DESIGN: The frequencies of class II HLA-DRB1 and DQB1 allele groups were determined for 81 Brazilian patients with GO and 161 normal subjects. The patients were divided into myogenic and nonmyogenic groups based on the clinical characteristics of the orbitopathy and quantitative computed tomography analysis of the extraocular muscle (EOM) dimensions. MAIN OUTCOME: Compared to the frequency obtained for samples of normal subjects of the Brazilian population, HLA-DRB1 16 ( pc=0.008) was overrepresented in myogenic and HLA-DRB1 03 ( pc=0.02) in nonmyogenic patients. CONCLUSIONS: The association between the HLA-DRB1 16 and the myogenic subtype of GO suggests that EOM involvement in GO may be genetically predisposed.