Orbital invasion of a conjunctival atypical fibroxanthoma in a patient with systemic diffuse large B-cell lymphoma.

An 88-year-old male patient presented with a large mass on the left lateral bulbar conjunctiva. The tumor appeared two months after the resection of a conjunctival atypical fibroxanthoma (AFX) performed by a cornea specialist. Magnetic resonance imaging of the orbits showed deep orbital invasion along the lateral rectus muscle. The mass and the entire conjunctival sac were totally excised with lid-sparing orbital exenteration. Histopathological analysis confirmed that the mass was an extension of the AFX. Two weeks after surgery, large B-cell lymphoma was diagnosed in the oropharynx. Chemotherapy was initiated, and after seven months of follow-up, there was no recurrence of the AFX. The authors believe that this is the first report of orbital invasion by AFX.

Orbital Bone Decompression for Non-Thyroid Eye Disease Proptosis.

PURPOSE: To report a multicenter large case series of orbital decompression for non-thyroid eye disease proptosis. METHODS: Retrospective chart review of cases of orbital decompression performed by 9 experienced orbital surgeons from different countries from 2014 to 2017 for non-thyroid eye disease proptosis. Patients were divided into 3 groups: 1) negative vector (high axial length or shallow orbit), 2) inflammatory, and 3) tumor. Types of orbital decompression and Hertel exophthalmometry (preoperative and minimum 6 months postoperative) were recorded. Charts were also assessed for serious complications. The amount of exophthalmometry improvement was recorded according to the above groups. RESULTS: The analysis included 41 orbits of 29 patients (14 women and 15 men) with a mean age of 38.9 years (ranging from 9 to 74; standard deviation (SD) 15.66). There were 17 orbits of 11 patients in the negative vector group, 16 orbits of 10 patients in the inflammatory group, and 8 orbits of 8 patients in the tumor group. The mean reduction of proptosis was 2.95 mm in the negative vector group, 2.54 mm in the inflammatory group, and 5.75 mm in the tumor group. There were no serious complications. CONCLUSIONS: Orbital decompression was safe and effective in reducing proptosis for non-thyroid eye disease indications in this series. The amount of exophthalmometry improvement was less in the inflammatory orbitopathy group compared with other proptosis etiology groups.Orbital decompression may have a role in improving proptosis in non-thyroid eye disease entities.

Transvenous embolization of dural carotid cavernous fistulas: the role of liquid embolic agents in association with coils on patient outcomes.

INTRODUCTION: Transvenous embolization is the standard treatment for dural carotid cavernous fistulas (DCCF). Although various embolic materials have been used, the best embolic material for the treatment of DCCF is still unknown. OBJECTIVE: To assess the safety and efficacy of different embolic materials used for the endovascular treatment of DCCF. METHODS: A retrospective data analysis of a consecutive series of 62 patients presenting DCCF was performed. Clinical and radiological data from patients were assessed, and the embolic material used-coils or liquids-were compared between two groups of patients. RESULTS: Complete angiographic occlusion of DCCF after treatment was achieved in 83.9% of the patients (52/62). We found a higher rate of complete occlusion of DCCF when liquids were associated with coils than with coils alone (96.5% vs 71.8%, p=0.01), and no differences in complication rates or clinical outcomes were seen between the two groups. At the 6-month follow-up, we found a higher rate of improvement in ocular symptoms compared with cranial nerve palsy improvement (94.7% vs 77.7%, p=0.02). Two patients (3.2%) had treatment-related complications without clinical symptoms. CONCLUSION: In this study, in comparison with the use of coils alone, the association of transvenous embolization with liquid embolic agents for DCCF treatment resulted in higher rates of complete occlusion without increasing complication rates. The clinical outcome at the 6-month follow-up showed significant improvement in ocular symptoms over cranial nerve palsy regression, which was independent of the embolic agent chosen for treatment.

Complications and Management of Polymethylmethacrylate (PMMA) Injections to the Midface.

BACKGROUND: Polymethylmethacrylate (PMMA) has been used as an injectable filler to treat hollows and reduce rhytids. PMMA injections have been associated with several side effects, however, the literature is scarce on periorbital complications and their treatments. OBJECTIVES: The purpose of this study is to report a series of complications after periorbital PMMA injections to the midface and to describe their management. METHODS: Retrospective chart review, including photography and histopathology when available. RESULTS: The authors identified 11 cases of complications of PMMA injections to the midface. Patient ages ranged from 36 to 62 years (mean, 47 years; median, 44 years). Two (18%) were males and 9 (82%) were females. Adverse effects began between 2 to 24 months after injection (mean, 7.2 months; median, 6 months). All patients had edema, erythema, and contour irregularity. Seven (64%) patients had nodules, 4 (36%) had yellow, xanthomatous skin changes, and 2 (18%) had eyelid malposition. Histopathology demonstrated a giant cell inflammation in 5 of 6 cases. Corticosteroid injection was tried in 6 cases but was associated with minimal clinical improvement. Surgical debulking of the implanted material was performed in 9 (82%) cases and was effective in improving edema, erythema, and nodularity. CONCLUSIONS: PMMA injection to the midface may be associated with chronic inflammation, fibrotic nodules, yellowing of the skin, and eyelid malposition. Intralesional corticosteroid injections yielded minimal or no improvement; surgical debulking achieved favorable results. LEVEL OF EVIDENCE 4: Therapeutic.

Radiation-induced dedifferentiated chondrosarcoma with orbital invasion.

PURPOSE: To report 2 interventional cases of dedifferentiated chondrosarcoma with orbital involvement after radiotherapy performed in childhood and to review the literature on chondrosarcoma in the orbit following radiation treatment. METHODS: Retrospective analysis of medical records of 2 patients with chondrosarcoma of the orbits with review of the literature. RESULTS: The first patient developed chondrosarcoma of the orbital and maxillary sinus 36 years after external beam radiation therapy to the OS to treat retinoblastoma. The second patient developed a large orbital chondrosarcoma 35 years after external beam radiation therapy in the treatment of craniofacial fibrous dysplasia. CONCLUSIONS: These cases highlight the risk of secondary chondrosarcoma in patients following radiotherapy and the importance of lifetime monitoring.

Graded müllerectomy for correction of graves upper eyelid retraction: effect on eyelid movements.

PURPOSE: To measure the effect of müllerectomy from posterior approach on the amplitudes of spontaneous blinking and downward eyelid saccades. METHODS: Spontaneous blinks and downward upper eyelid saccadic movements of 16 patients (23 eyelids) with Graves orbitopathy were measured before and after müllerectomy from posterior approach. A new video system was used to continuously register the blinking activity while subjects viewed a commercial movie for 5 minutes. Downward eyelid saccades (30° of downgaze) were also measured with the video system. RESULTS: Müllerectomy had no effect on the amplitude of the blink. However, as the eyelid margins were significantly lowered by the surgery, the amplitude of the blink movements relative to the pupil center increased substantially. The number of movements occluding the pupil center increased from 0% to 13%. Due to the increased efficiency of blinking, the blink rate decreased. Surgery induced a mean increase of 1.1 mm of downward saccades. CONCLUSIONS: The effects of müllerectomy on the blinks are indirect and related to correction of eyelid retraction. The relative amplitude of blink movements increases and blink rate decreases. Müllerectomy does affect the downward eyelid saccades increasing the ability of the upper eyelid to relax on downgaze.

Tissue ingrowth into perforated polymethylmethacrylate orbital implants: an experimental study.

PURPOSE: To evaluate the clinical response and fibrovascular ingrowth into perforated acrylic orbital implants in a rabbit model. METHODS: Perforated implants were manufactured by drilling channels interconnected at the center in conventional 12- to 13-mm acrylic spheres. The implants were placed in 16 eviscerated eyes with posterior sclerotomy of 16 New Zealand white rabbits. Clinical evaluation was performed daily for the first 14 days after surgery and at 7-day intervals until the end of the study (180 days). Histopathologic analysis was performed at 14, 45, 90, and 180 days after implantation. Hematoxylin-eosin and picrosirius red staining was used to assess the inflammatory reaction and collagen formation. RESULTS: There were no signs of infection, implant exposure, or extrusion in any animal during the study. Tissue ingrowth in the implant center was already detected by 14 days. At the end of the study, there was a dense collagen ingrowth with just a few inflammatory cells inside the implant. No multinucleated giant cells were found in any implant. CONCLUSIONS: Similar to porous implants, perforated acrylic implants permit fibrovascular ingrowth from surrounding orbital tissues.

Cosmetic orbital inferomedial decompression: quantifying the risk of diplopia associated with extraocular muscle dimensions.

PURPOSE: To quantify the risk of new diplopia in inferomedial orbital decompression performed for cosmetic reasons. METHODS: Retrospective analysis of 114 patients with Graves orbitopathy who underwent an inferomedial orbital decompression. No patient had diplopia in any of the gaze positions or optic neuropathy. A single coronal slice 9 mm posterior to the lateral orbital rim was employed to quantify the muscular index of the extraocular recti and of the superior complex. A control group of 56 patients imaged for other reasons were also measured. After surgery the oculomotor status of all patients who complained of diplopia and of 51 patients free of diplopia was measured with the prism and cover test in the primary and secondary gaze positions. RESULTS: The rate of new-onset diplopia was 14.0% (16 patients). Eye deviations were confirmed in 14 patients. Of these, 10 had significant strabismus that warranted surgical or prism treatment. Most patients had esotropia associated with small vertical deviations. The size of the medial and inferior recti was significantly associated with the development of diplopia. The estimated odds for the appearance of diplopia in patients with muscle enlargement was 12.76 (medial rectus) and 5.21 (inferior rectus). Small-angle deviations were also detected in 27.4% of patients who did not experience diplopia. CONCLUSIONS: Medial and inferior recti enlargement is a strong predictor of new-onset diplopia. A large number of patients who do not report diplopia also present with small-angle deviations.

Orbital invasion by squamous cell carcinoma arising in multiple epidermoid cysts.

Epidermal or epidermoid cysts usually are benign, solitary-growing masses located in the mid- or lower dermis. They are believed to derive from pilosebaceous units and are lined with an epidermis-like epithelium including a granular cell layer. The occurrence of multiple epidermal cysts on the scalp of nonsyndromic patients is extremely rare. Although the presence of squamous cell carcinoma in the wall of an isolated epidermoid cysts is well documented in the dermatological literature,, the authors are not aware of any article in the English literature describing orbital invasion by a carcinoma developed in isolated or multiple epidermoid cysts.

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.

Management of globe luxation followed by traumatic liquoric fistula: case report.

This report describes the only case in the literature of globe luxation due to traumatic cerebrospinal fluid fistula to the orbit caused by fire gun with ocular globe maintenance. E.N., female, white, 7 months, admitted with left orbitocranial injury by fire gun. Ocular globe luxation was detected with complete ocular motility restriction and absence of pupillary reflex in the left orbit. Computed tomography showed fracture of the medial orbital wall; bone fragments near the apex of the orbit and a stretched optic nerve. Surgical exploration was performed, showing liquor fistula through the ethmoid-sphenoid wall that was blocked with sponge (Gelfoam®) plus organic glue in the left orbit posterior wall, with immediate resolution of the proptosis and ocular integrity maintenance. Although controversial, maintenance of the ocular globe instead of enucleation was performed due to the integrity of the globe in this case. Despite the blindness, we considered the result to the proposed treatment excellent, once the maintenance of the ocular globe provides a good appearance and will contribute to an adequate facial bone development.

[Epidemiology of trachoma in the village of Araripe plateau--Ceará State]. / Epidemiologia do tracoma em povoado da chapada do Araripe--CE.

PURPOSE: To evaluate the epidemiological factors of trachoma in the Simão village. METHODS: Through a field research, 412 individuals (178 men and 234 women) were examined in a village of the Araripe plateau in Ceará State. The median age was 34 years for both genders. Traditional data from trachoma epidemiology were collected and diagnosis of trachoma was performed using binocular loupes of x 2.5. RESULTS: 304 (73.8%) individuals were normal and 108 (26.2%) were trachomatous (5 TF, 98 TS, 3 TT and 2 CO). Regarding socio-economic factors relating to individuals, the illiterate were 1.9 times more likely to have trachoma (p<0.0001), but the more affluent were more affected (p<0.0001). As for the face appearance, the disease was more prevalent in patients with dirty faces (p=0.432). A difference was noted in multivariate analysis of socio-economic factors relating to housing; only the variable number of people per room, which was higher in the normal group (p=0.010). CONCLUSIONS: The good infrastructure found in the Simão village, especially the amount of houses with piped water and the good personal hygiene habits, favored the low findings of infectious forms.

[Biodegradable systems containing prednisolone acetate for orbital administration]. / Sistemas biodegradáveis contendo acetato de prednisolona para administração orbitária.

PURPOSE: The present study aimed to evaluate an injectable extended-release formulation of prednisolone acetate (PA) for orbital administration. METHODS: Microspheres (MEs) of poly-e-caprolactone (PCL) containing PA were developed by the method of solvent evaporation. The MEs obtained were characterized by scanning electron microscopy (SEM), differential scanning calorimetry (DSC), encapsulation efficiency and in vitro release profile. The in vivo release profile was evaluated in rabbits after periocular injection of an aqueous suspension of MEs. The local biocompatibility of the system was verified by histopathologic analysis of the deployment region. RESULTS: After MEs preparation, morphological analysis by SEM showed the feasibility of the employed method. The content of PA encapsulated was 43+/-7% and can be considered as satisfactory. The system characterization by DSC technique, in addition to confirm the system stability, did not indicate the existence of interaction between the drug and the polymer. The in vitro release study showed the prolonged-release features of the developed system. Preliminary in vivo study showed the absence of local toxicity and confirmed the prolonged release profile of PA from MEs, suggesting the viability of the developed system for the treatment of orbital inflammatory diseases. CONCLUSION: The results obtained in this work are relevant and accredit the system developed as a possible alternative to the treatment of inflammatory orbitopathy.

Refractive error changes in children with intermittent exotropia under overminus lens therapy.

PURPOSE: Intermittent exotropia may be decreased by stimulation of accommodative convergence. Once excessive accommodation has been related to myopia, our objective was to evaluate refractive errors changes in children under overcorrecting minus lens therapy. METHODS: A retrospective chart review of 21 children with intermittent exotropia was performed. All patients were treated with occlusion, and a 13-patient subset of them received overminus lens therapy (group A). Eight children received spectacles as necessary (group B). Initial age, age interval, initial spherical equivalent (SE), and magnitude of overcorrection were considered as co-variables of the mean variation in refractive error (SE of each eye) between groups, through a multivariate analysis. RESULTS: Overcorrection used in group A ranged from 0.5 D to 3.5 D (2.46 +/- 0.87 D). Although initial SE of each eye was significant different between group A and B (OD - p=0.02; OS - p=0.01), initial age (p=0.69), age interval (p=0.90), and mean variation in refractive errors (p=0.36) did not differ between groups. Multivariate analysis with linear regression showed no significantly difference regarding all co-variables enrolled. CONCLUSIONS: Treatment of intermittent exotropia with overcorrecting minus lens did not induce refractive errors changes, even considering age, treatment period, initial spherical equivalent and overcorrection magnitude used.

[Upper and lower eyelid position in different degrees of downgaze and upgaze]. / Posicionamento palpebral superior e inferior em diferentes graus de rotação ocular ao longo do meridiano vertical.

PURPOSE: To quantify the relation between eye and eyelids placement in different positions during downgaze and upgaze in healthy subjects. METHODS: The position of the eye and eyelids of 10 healthy individuals was quantified by palpebral fissure image processing with NIH Image software. Upper and lower mid-pupil margin distance was measured in 7 positions: -30, -20, -10, 0, +10, +20 and +30 degrees (positive signs correspond to upgaze and negative signs to downgaze) along vertical meridian. RESULTS: The upper mid-pupil margin distance decreases in upgaze and even more in downgaze. The lower mid-pupil margin distance increases in upgaze and decreases in downgaze. About the palpebral fissure height, it gets larger in upgaze until 20 degrees and smaller in downgaze. CONCLUSION: Our data showed that the interpalpebral fissure height varies with vertical meridian gaze amplitude and that considerations about mid-pupil margin distance must consider the amount of upgaze or downgaze.

[New standardized texts in Brazilian Portuguese to assess reading speed--comparison with four European languages]. / Textos padronizados em português (BR) para medida da velocidade de leitura--comparação com quatro idiomas europeus.

PURPOSE: To develop standardized texts in Brazilian Portuguese to assess reading speed and compare performances among four European languages. METHODS: 10 texts were designed by a linguistic expert at the level of a sixth grade reading material (reading ages 10-12 years) and were matched for length and syntactic complexity, according to the syntactic prediction locality theory of Gibson. Normally sighted native speaking volunteers aged 18-35 years read each text aloud at random. RESULTS: The reading speed was on average 1100 +/- 167 (standard deviation) characters per minute. Only small differences were found between the measured reading speeds of the 10 texts, and these differences were not statistically significant in groups of at least 6 texts. The mean reading speed in age-matched volunteers in Finnish was: 1263 +/- 142; French: 1214 +/- 152; English: 1234 +/- 147; and German: 1126 +/- 105. CONCLUSIONS: The authors developed a set of standardized, homogeneous, and comparable texts in Brazilian Portuguese. These texts will be a valuable tool to measure reading speed for repeated measurements and in international studies in the field of reading and low vision research.

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.