Blink Lagophthalmos in Graves Orbitopathy.

PURPOSE: To investigate the relationship between the kinematics of spontaneous blinks and the anterior area of the levator palpebrae superioris muscle in patients with Graves orbitopathy (GO). METHODS: This is a case-control study. The authors measured the margin reflex distance of the upper eyelid (margin reflex distance 1), the kinematics of spontaneous blinks, and the anterior area of levator palpebrae superioris muscle in CT coronal scans of patients with Graves upper eyelid retraction (GO) and a control group. The eye with the greatest margin reflex distance 1 was selected for analysis in each group. RESULTS: A total of 68 participants were included, with 36 in the GO group and 32 in the control group. In the GO group, the mean margin reflex distance 1 measured 6.5 mm, while in the control group, it was 3.9 mm. Almost all parameters related to the closing phase of spontaneous blinking activity, including amplitude, velocity, blinking rate, and interblink time, did not differ between the two groups. However, the effectiveness of the blink's amplitude (ratio of blink amplitude to margin reflex distance 1) and the main sequence (relationship between amplitude and velocity) were significantly reduced in the GO group compared with the control group. The area of the levator palpebrae superioris muscle was significantly larger in GO than in controls, with 71.4% of patients' muscles outside of the maximum range of the controls. CONCLUSIONS: In patients with GO, there is a reduction in blinking effectiveness, also known as blink lagophthalmos, which is a factor in the common occurrence of ocular surface symptoms. The increase in velocity with amplitude is also reduced in GO.

Apical bleeding: a rare cause of blindness after orbital decompression / Sangramento apical: uma causa rara de cegueira pós descompressão orbitária

ABSTRACT Orbital decompression is widely performed for the management of proptosis for cosmetic and functional cases of Graves orbitopathy. The main side effects include dry eye, diplopia, and numbness. Blindness after orbital decompression is extremely rare. The mechanisms of vision loss after decompression are not well described in the literature. Considering the devastating effect and rarity of this complication, this study presented two cases of blindness after orbital decompression. In both cases, vision loss was provoked by slight bleeding in the orbital apex.

RESUMO A descompressão orbitária é uma cirurgia amplamente empregada para correção da proptose em casos cosméticos e funcionais da orbitopatia de Graves. Os principais efeitos colaterais induzidos pela descompressão são olho seco, diplopia e parestesias. Amaurose pós descompressão é uma complicação extremamente rara e cujos mecanismos são pouco discutidos na literatura. Considerando o efeito devastador representado pela perda visual e a escassez de relatos dessa complicação, os autores apresentam dois relatos de amaurose após descompressão orbitária. Nos dois casos a perda visual ocorreu devido a sangramento de pequena monta no ápice orbitário.

Apical bleeding: a rare cause of blindness after orbital decompression.

Orbital decompression is widely performed for the management of proptosis for cosmetic and functional cases of Graves orbitopathy. The main side effects include dry eye, diplopia, and numbness. Blindness after orbital decompression is extremely rare. The mechanisms of vision loss after decompression are not well described in the literature. Considering the devastating effect and rarity of this complication, this study presented two cases of blindness after orbital decompression. In both cases, vision loss was provoked by slight bleeding in the orbital apex.

Computed tomography and magnetic resonance imaging of an unusual intraconal orbital osteoma.

We report the case of a 64-year-old male patient with a 5 month history of proptosis, motility limitation and vision loss in OD. Visual acuity (VA) was 20/200 in OD and 20/20 in OS. CT showed a large, round, intraconal lesion, with bony density and no apparent connection to adjacent orbital walls. MRI showed a T1-weighted hypointense lesion surrounded by a contrast enhancing capsule. The orbital tumor was excised through a lateral orbitotomy revealing a nodular, round, osseous structure. Histological examination disclosed well-formed lamellar bone trabeculae, with no necrosis or mitosis figures. Immunohistochemical staining was negative for MDM2 and CDK4. After 3 years, there was no evidence of tumor recurrence and VA had improved to 20/30. Intraconal osteomas with no clear attachment to orbital walls are extremely rare. We are aware of a few reported cases in the lid, hand, thigh, tongue, pterygopalatine fossa and brain. To the authors' knowledge, this is the first report in English literature of an orbital intraconal osteoma without any visible relation to the orbital walls.

Effect of Rim-Off Deep Lateral Orbital Decompression on Interpalpebral Fissure Shape.

PURPOSE: The purpose of this study is to compare the palpebral fissure shape after rim-off deep lateral decompression with and without restoration of the lateral orbital rim. METHODS: Retrospective cross-sectional quantitative analysis of the palpebral fissure images of 17 patients (25 eyes) who underwent rim-off deep lateral orbital decompression without repositioning of the rim (G1) and of 20 patients (34 eyes) operated with rim restoration. Quantification of palpebral fissure images included MRD 1 and MRD 2 , two lateral mid-pupil lid margin (MPD) distances, the width of the palpebral fissure, and the height and shape of the lateral canthus. RESULTS: Proptosis reduction did not differ significantly between G1 and G2. In both groups, decompression reduced the mean values of the MRD 1 and MRD 2 , the lateral height of the upper eyelid, and the height and angle of the lateral canthus. The palpebral fissure width and lateral height of the lateral lower eyelid were not affected. There was no significant difference between the mean changes of G1 and G2. Multivariate analysis showed that the lateral canthus decrease was correlated with changes in MRD 1 and MRD 2 . CONCLUSIONS: Small changes in palpebral fissure shape after deep lateral decompression are not dependent on the presence or absence of the lateral rim.

Bilateral Dacryoadenitis and Central Nervous System Involvement in a Child With Kimura Disease.

Kimura's disease (KD) is a systemic inflammatory condition characterized by lymphadenopathy and subcutaneous nodules in the head and neck region. The lesions have a distinctive histopathological pattern formed by follicular hyperplasia, eosinophilic infiltrates, fibrosis, and vessel proliferation. The disease may occur at all ages but predominates among young males with autoimmune dysfunctions. Visceral and orbital involvement is uncommon. We report a girl with KD who developed bilateral enlargement of the lacrimal glands and a lesion in the left lateral ventricle of the brain indistinguishable from a central nervous system neoplasia. A biopsy of both the lacrimal gland and the lateral ventricle was consistent with KD.

Progressive chronic calvarial osteomyelitis in rhino-orbital mucormycosis associated with COVID-19.

We describe two cases of extensive indolent calvarial osteomyelitis after rhino-orbital-mucormycosis in diabetic patients previously diagnosed with COVID-19. Both patients presented with acute rhino-orbital symptoms about one month after being diagnosed with COVID-19. Treatment with intravenous liposomal Amphotericin B and prompt radical surgical debridement was instituted, but calvarial osteomyelitis ensued and persisted chronically despite maintenance of antifungal therapy and partial debridement of necrotic calvarial bone. The patients were discharged to continue antifungal therapy on a day-hospital regime. After more than 8 months of treatment, they remain with radiological signs of osteomyelitis but with no symptoms or intracranial extension of the infection. Calvarial indolent osteomyelitis secondary to mucormycosis is extremely rare, and little is known regarding its treatment. We believe it can be controlled with medical treatment and partial bony debridement although more studies are necessary to better define therapy.

Massive Orbital Infiltration and Trigeminal Enlargement in Churg-Strauss Syndrome Associated With IgG4 Plasma Cell Positivity.

The association of C-antineutrophil cytoplasmic antibody (ANCA) vasculitis and IgG4 positivity is a new condition not well described in clinical terms. The authors examined a 28-year-old man with a previous diagnosis of eosinophilic granulomatosis with polyangiitis, formerly known as Churg-Strauss disease, who presented with bilateral orbital inflammation. Magnetic resonance imaging revealed diffuse orbital infiltration and enlargement of the major divisions of the trigeminal nerve. Biopsy of the orbital contents showed necrotizing granulomatous vasculitis and a high number of IgG4-positive plasma cells (IgG4/IgG = 60%).

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.

Upper eyelid contour symmetry measurement with Bézier curves / Medida da simetria do contorno da pálpebra superior com curvas de Bézier

ABSTRACT Purpose: The purpose of the present work is to measure the interocular upper lid contour symmetry using a new method of lid contour quantification. Methods: The Bézier curve tool of the Image J software was used to extract the right and left upper eyelid contours of 75 normal subjects. Inter-observer variability of 29 right lid contours obtained by two independent observers was estimated using the coefficient of overlap of two curves and an analysis of the differences of the contour peak location. A two-way analysis of variance was used to test the mean value of the coefficient of overlap of the right and left contours in males and females and lid segments. The same analysis was performed to compare the location of the contour peak of the right and left contours. Results: The coefficient of contour overlap obtained by independent observers ranged from 93.5% to 98.8%, with a mean of 96.1% ± 1.6 SD. There was a mean difference of 0.02 mm in the location of the contour peak. Right and left contour symmetry did not differ between females and males and was within the range of the method variability for contour overlap and location of the contour peak. Conclusions: The upper eyelid contour is highly symmetrical. Bézier lines allow a quick and fast quantification of the lid contour, with a mean inter-observer variability of 3.9%.

RESUMO Objetivo: O objetivo do presente estudo é mensurar a simetria interocular do contorno da pálpebra superior por meio de um novo método de quantificação de contorno palpebral com curvas de Bézier. Métodos: A ferramenta de curva de Bézier do software ImageJ foi utilizada para extrair os contornos palpebrais direito e esquerdo de 75 sujeitos normais. A variabilidade interobservador de 29 contornos palpebrais do olho direito obtidos por dois observadores diferentes foi estimada pelo coeficiente de superposição de duas curvas e pela análise das diferenças das posições do pico do contorno. Análise de variância de dois fatores foi empregada para testar a média do coeficiente de superposição entre os contornos direito e esquerdo quanto ao sexo e segmento palpebral. A mesma análise foi utilizada para comparar a localização do pico do contorno dos olhos direito e esquerdo. Resultados: O coeficiente de superposição obtidos por observadores independentes variou ente 93,5% e 98,8% com média de 96,1% ± 1,6 DP. A diferença das médias da localização do pico do contorno palpebral foi de 0,02 mm. A simetria entre os contornos dos olhos direito e esquerdo não diferiu entre o sexo feminino e masculino e esteve na faixa de variabilidade do método para o coeficiente de superposição e localização do pico do contorno. Conclusões: O contorno da pálpebra superior é altamente simétrico. As linhas Bézier permitem uma rápida e prática quantificação do contorno palpebral com uma média de variabilidade interobservador de 3,9%.

Upper eyelid contour symmetry measurement with Bézier curves.

PURPOSE: The purpose of the present work is to measure the interocular upper lid contour symmetry using a new method of lid contour quantification. METHODS: The Bézier curve tool of the Image J software was used to extract the right and left upper eyelid contours of 75 normal subjects. Inter-observer variability of 29 right lid contours obtained by two independent observers was estimated using the coefficient of overlap of two curves and an analysis of the differences of the contour peak location. A two-way analysis of variance was used to test the mean value of the coefficient of overlap of the right and left contours in males and females and lid segments. The same analysis was performed to compare the location of the contour peak of the right and left contours. RESULTS: The coefficient of contour overlap obtained by independent observers ranged from 93.5% to 98.8%, with a mean of 96.1% ± 1.6 SD. There was a mean difference of 0.02 mm in the location of the contour peak. Right and left contour symmetry did not differ between females and males and was within the range of the method variability for contour overlap and location of the contour peak. CONCLUSIONS: The upper eyelid contour is highly symmetrical. Bézier lines allow a quick and fast quantification of the lid contour, with a mean inter-observer variability of 3.9%.

Lower Eyelid Contour in Graves Orbitopathy.

Purpose: The aim of the present study was to analyze quantitively the lower lid contour of patients with Graves orbitopathy.Methods: Bézier curves were manually adjusted to the ciliated and nasal (or lacrimal) portions of the lower lid contour of 41 patients with Graves orbitopathy and 43 normal subjects using National Institute of Health (NIH) ImageJ software. Considering the main coordinates of the Bézier functions, the Matlab software was employed to express the lid contours with 1000 points. The first order numerical derivative of the curves was calculated in order to compare the curvature of the whole lid contour of patients and controls. The same comparison was made for the temporal and nasal contour segments. Other parameters measured included the location of the lowest point on the contours (contour peak); the position of the lateral and medial canthi, as well as the angle formed by the lower lacrimal punctum and the vertex of the inner canthus.Results: The curvature of the temporal portion of the lid contours of patients and controls correlated with both the height of the lateral canthus and the magnitude of the MRD2. Graves retraction affects the medial and lateral portion of the lid. Both segments were more curved in patients than in controls. The lower punctum was significantly lowered, increasing the angle between the lower punctum and the medial canthus.Conclusions: The increased lateral curvature of the lower lid seen in patients with Graves disease is a natural geometric effect of the increment of MRD2. The nasal portion of the lid is also significantly lowered by retraction.

Intraconal gauze mass: An unusual complication of orbital fracture repair - a case report.

Gossypiboma and textiloma are terms used to describe tumor-like masses caused by retained gauze or surgical sponges after any operation. It is a rare surgical complication, usually difficult to diagnose due to its variable clinical presentation and nonstandard radiological appearance. We describe here a rare case of orbital gossypiboma in a child after surgical correction of an orbital blowout fracture.

Intraocular Plasmablastic Lymphoma in a HIV Patient.

Plasmablastic lymphoma (PBL) is a rare B-cell lymphoma occurring mainly in HIV patients. The tumor frequently involves extranodal sites such as the oral cavity, nasal cavity, gastrointestinal tract, skin, and lungs. The neoplastic cells are characterized by a plasmablastic appearance and typical immunophenotype that indicates plasma cell differentiation. Herein, we report a case of intraocular involvement by plasmablastic lymphoma in a HIV patient with a long history of cytomegalovirus retinitis and loss of vision. After an evisceration performed to control the blind, painful eye a diagnosis of PBL was made by examining the eye contents. Two months later, a biopsy of cervical lymph node revealed nodal lymphoma of the same type. To the best of our knowledge, this is the second case of intraocular PBL reported in English literature.