Glucocorticoids in the treatment of non-infectious superior ophthalmic vein thrombosis - Three cases and a review of the literature.

Purpose: Superior ophthalmic vein thrombosis (SOVT) is a rare clinical entity, which can have a septic and an aseptic cause. Aseptic SOVT is typically treated with anticoagulation. Glucocorticoids are reserved for cases with concurrent orbital inflammation.We present three cases of SOVT due to carotid cavernous fistula not responding to standard treatment, subsequently successfully treated with glucocorticoids. Observations: Three patients with various degrees of proptosis, ophthalmoplegia, orbital stasis and reduced vision are presented. One patient was confirmed to have isolated SOVT, while the other two had associated cavernous sinus thrombosis. All patients had underlying carotid-cavernous fistula without signs of infection. All patients were initially treated with parenteral anticoagulation. Two patients were treated with intraocular pressure-reducing medication. One of whom underwent canthotomy-cantholysis. Two patients experienced a gradual worsening of symptoms during treatment with anticoagulation, while one patient improved before deteriorating. All patients received additional treatment with glucocorticoids consisting of a three-day treatment with intravenous methylprednisolone 500 mg, followed by oral glucocorticoids resulting in total regression of symptoms. Two patients regained 20/20 vision, with some vision field defects, while the third patient regained 20/25 vision. Conclusion and importance: The addition of glucocorticoids in the treatment of aseptic SOVT can lead to improvement of symptoms and a potentially better prognosis. However, the risk of complications of glucocorticoid treatment must be carefully considered on a case-by-case basis.

Ectropion. / Ektropion.

In ectropion, the eyelid margin - typically the lower eyelid - is turned outward. This condition is becoming increasingly common due to the ageing population. Ectropion is classified as either acquired or congenital, with the former being the most prevalent. Acquired ectropion is further divided into involutional, paralytic, mechanical and cicatricial subtypes. Involutional ectropion is the most common where there is no patient population bias. This clinical review provides an overview of ectropion.

Conservative or surgical management of orbital schwannomas: a population-based case series.

INTRODUCTION: Orbital schwannomas (OS) are rare occurrences with no more than 500 cases reported in the literature. The tumor's potential to compromise the delicate neuro-ophthalmic structures within the orbit prompts surgical removal. Tumor removal is performed by ophthalmologists, often requiring a multidisciplinary surgical approach. The literature contains a very limited number of cases managed non-surgically. However, the inherent risks of orbital surgery warrant a comparison of the outcomes of conservative and surgical management strategies. AIMS: To review the national Swedish experience with the management of orbital schwannomas. METHODS: The study center is the primary Swedish referral center for the multidisciplinary management of orbital tumors, including schwannomas. During the period of 2005 to 2021, 16 patients with an OS diagnosis were managed at the center. RESULTS: Four patients initially underwent surgery where gross total resection (GTR) was achieved in three (75%) and subtotal resection (STR) in one (25%) case. The remaining 12 patients, who had a low risk of neuro-ophthalmic impairment, were managed conservatively with radiological and clinical examinations at regular intervals. After an average follow-up of 17 months, surgery was performed in three of these cases (25%). No recurrences or tumor growths were detected on radiological follow-ups (mean 50 months), and all patients experienced postoperative improvement at clinical follow-up (mean 65 months). The remainder of the conservatively treated patients (n=9) experienced no clinical progression (mean 30 months). A slight radiological tumor progression was detected in one patient after 17 months. CONCLUSION: There were no differences in long-term outcome between patients who had been managed with early surgery and those operated later after an initially conservative management. Conservatively treated patients had minimal to no symptoms and remained clinically stable throughout the follow-up period. Based on these findings, conservative management may successfully be adopted in cases with mild symptoms, no signs of compressive optic neuropathy and low risk of neuro-ophthalmic impairment. Conversion to surgical management is indicated upon clinical deterioration or tumor growth. Based on the findings of this study a decision tree for the management of orbital schwannomas is suggested.

Fine-Needle Aspiration Biopsy as a Diagnostic Modality for Orbital Adnexal Lymphoma.

Purpose To evaluate fine-needle aspiration biopsy (FNAB) as a diagnostic tool for lymphoproliferative orbital lesions in light of recent improvements in cytomorphological and immunologic analyses. Method Retrospective case series including all orbital FNABs with a lymphoproliferative outcome at Karolinska University Hospital, Stockholm, Sweden during the period 2005-2015. Results Of the 38 patients included, 31 (82%) were conclusively diagnosed as having lymphoma according to the first FNAB. Disease in 20 patients (65%) could be sub-classified. The diagnosis in seven patients (18%) was either inconclusive, suggestive of lymphoma, or reactive lymphatic infiltrate. These seven patients were re-investigated, and the initial suspected diagnosis of malignant lymphoma was confirmed in four. Two of the remaining three patients were initially diagnosed as having non-lymphoproliferative disease, however, this was later changed to a lympho¬proliferative diagnosis following re-investigation, while the results of both reFNAB and incisional biopsy were inconclusive in the third. Conclusion In the majority of the 38 patients, a definitive diagnosis of lymphoma could be made based on FNAB alone, using cytomorphological and immunological workup, and sub-classification was possible in 20 patients (65%). Primary low-grade malignant orbital lymphomas are traditionally treated with low-dose radiotherapy regardless of subtype, and incisional biopsy was not needed to initiate treatment. Our findings suggest that FNAB is a valid first option for the diagnosis of suspected orbital lymphomas due to the minimal risk of complications compared to incisional biopsy, and the fact that it can be performed as an outpatient procedure with no anesthesia.

Mapping of Perfusion During Full-Thickness Blepharotomy Using Laser Speckle Contrast Imaging.

PURPOSE: The aim of this study was to monitor how the blood perfusion in human upper eyelids is affected during full-thickness blepharotomy. METHODS: Seven eyelids in 5 patients with upper eyelid retraction due to Graves' disease underwent full-thickness blepharotomy. Perfusion was measured using laser speckle contrast imaging in the eyelid margin and in the conjunctival pedicle. RESULTS: Immediately following the procedure, a nonsignificant reduction in perfusion was observed in the skin of the pretarsal eyelid margin, being 66% of the initial value ( p = n.s.). However, a statistically significant decrease in perfusion, to 53% of the initial value ( p < 0.01), was seen in the central pedicle of the conjunctiva. There were no surgical complications such as infection, signs of ischemia, or bleeding. CONCLUSIONS: In this study, eyelid perfusion was mapped during full-thickness blepharotomy for the first time using laser speckle contrast imaging. The results showed that perfusion is sufficiently preserved during surgery, probably due to the rich vascular supply in the periocular region, which may explain the low risk of postoperative complications such as ischemia and infection.

[Acute orbital trauma - risk of permanent impaired vision and double vision]. / Viktigt att agera snabbt vid traumatiska orbitala tillstånd.

The purpose of this article is to highlight the importance of appropriate management of acute orbital trauma, in order to prevent permanent impaired vision and double vision. Orbital blowout fractures with entrapment, so-called trapdoor fractures, occur more often in children than in adults, and require immediate surgical intervention. A blowout fracture with impingement, so-called open door fracture, does not require immediate intervention. However, if the motility does not improve within 1-2 weeks surgery may be required. The symptomatology in children with orbital fractures may differ significantly from that in adults, and vasovagal symptoms such as bradycardia and nausea are common.  Orbital compartment syndrome is characterized by an acute increase in orbital pressure, and may result in irreversible blindness if not promptly treated with lateral canthotomy and cantholysis.

Successful Free Bilamellar Eyelid Grafts for the Repair of Upper and Lower Eyelid Defects in Patients and Laser Speckle Contrast Imaging of Revascularization.

PURPOSE: It is generally believed that large eyelid defects must be repaired using a vascularized flap for 1 lamella, while the other can be a free graft. Recent studies indicate that the pedicle of a tarsoconjunctival flap does not contribute to blood perfusion. The purpose of this study was to explore whether large eyelid defects can be repaired using a free bilamellar eyelid autograft alone. METHODS: Ten large upper and lower eyelid defects resulting from tumor excision were reconstructed using bilamellar grafts harvested from the contralateral or opposing eyelid. Revascularization of the flap was monitored during healing using laser speckle contrast imaging, and the surgical outcome was assessed. RESULTS: The functional and cosmetic results were excellent. All grafts survived and there was no tissue necrosis. Only 1 patient underwent revision after 4 days as the sutures came loose. Two patients developed minimal ectropion but needed no reoperation. All patients were satisfied with the surgical results. Perfusion monitoring showed that the grafts were gradually revascularized, exhibiting 50% perfusion after 4 weeks and 90% perfusion after 8 weeks. CONCLUSIONS: A free bilamellar eyelid graft appears to be an excellent alternative to the tarsoconjunctival flap procedure in the reconstruction of both upper and lower eyelid defects, especially in patients who cannot tolerate visual axis occlusion or the 2-stage procedure of the conventional staged flap procedure.

Novel Evidence Concerning Lacrimal Sac Movement Using Ultra-High-Frequency Ultrasound Examinations of Lacrimal Drainage Systems.

PURPOSE: Current hypothesis regarding the mechanism of active tear drainage is based on studies performed ex vivo or under nonphysiological conditions. Novel ultra-high-frequency ultrasound has the advantage of generating images with superior resolution, enabling measurements of low flow in small vessels, and the tracking of tissue motion in real time. The purpose of this study was to investigate the lacrimal drainage system and active drainage using this modality. METHODS: The upper lacrimal drainage system was investigated with 40-70 MHz ultrasound in 22 eyes in 13 patients. Irrigation confirmed a lacrimal obstruction in 10 eyes. Motion tracking was used to map movement of the lateral lacrimal sac wall and to measure flow when possible. RESULTS: The anatomy of the upper lacrimal drainage system was mapped in vivo, including the proximal canaliculi, which have not previously been imaged. The lacrimal sac lumen is slit shaped in its resting state but is distended when irrigated or if a nasolacrimal duct obstruction is present. Thus, the healthy lacrimal sac is not a cavity, and the medial retinaculum does not act against a stretched structure. Motion tracking visualized the "lacrimal pump," showing that the direction of motion of the lateral lacrimal sac wall is mainly in the sagittal plane during blinking. CONCLUSIONS: Ultra-high-frequency ultrasound allows detailed physiological monitoring of the upper lacrimal drainage system in vivo. Our findings suggest that current theories of active tear drainage need to be reappraised.

Long-term outcome of lacrimal stent intubation for complete acquired lacrimal drainage obstructions.

PURPOSE: To investigate long-term outcome and report reoperation rate of non-infected, complete acquired lacrimal drainage obstruction (ALDO) treated with canaliculodacryocystoplasty (CDCP) depending on site of stenosis. METHOD: Consecutive adult patients with non-infected, complete ALDO treated with CDCP were followed for 76 months. Location of stenosis at preoperative visit and intraoperative probing was recorded, and during follow-up, recurrence of stenosis prompting additional surgery and complications were noted. Survival analysis was applied to compare reoperation rate depending on site of stenosis. A follow-up questionnaire was sent to patients not requiring reoperation asking to grade current epiphora problems. RESULTS: Among 85 included cases (71 patients), 57 were classified as canalicular stenosis and 28 as nasolacrimal duct obstruction (NLDO) preoperatively. At the end of follow-up, 39% (33/85) of cases had required additional surgery due to persistent/recurrent symptoms. No statistical difference was found between these groups. During CDCP, 25 of the 57 preoperatively classified canalicular stenosis were found to have an additional obstruction below the sac. The group with only canalicular stenosis had a statistically significant higher survival compared with cases with NLDO or multiple obstructions (p = 0.03). Of patients responding to the follow-up questionnaire, 11/37 cases experienced epiphora often or constant. CONCLUSION: Treating complete NLDO with CDCP results in a high reoperation rate and seems an insufficient alternative. Canaliculodacryocystoplasty (CDCP) may be discussed if preoperative examination indicates canalicular stenosis and dacryocystorhinostomy is not desirable. However, the patient needs to be aware of the higher risk for additional surgery, especially if a second stenosis is found during probing.

A comparison between patients with epiphora and cataract of the activity limitations they experience in daily life due to their visual disability.

PURPOSE: The objective of this study was to compare patients with epiphora and cataract in terms of the activity limitations they experience in daily life due to their visual disability and to validate the use of the Catquest-9SF questionnaire for epiphora patients. METHODS: Seventy-two consecutively encountered adult patients with confirmed lacrimal obstruction and listed for dacryocystorhinostomy (DCR) or lacrimal intubation at the St. Erik Eye Hospital, Stockholm, Sweden, completed the Catquest-9SF questionnaire, which measures activity limitations in daily life due to visual disability. The psychometric qualities of the Catquest-9SF results obtained from this group of patients were evaluated by Rasch analysis. Rasch analysis was further employed to convert the ordinal raw data to a Rasch score for comparison with the preoperative scores of patients registered in the Swedish National Cataract Register (NCR) during March 2013. RESULTS: The Catquest-9SF exhibited good psychometric qualities when investigating epiphora patients, with the exception of a misfit for Item 4, the item regarding facial recognition. On the Rasch scale (-5.43 = no activity limitations to +5.01 = severe activity limitations), the mean score for epiphora patients was -0.82 while for patients listed for 1st eye and 2nd eye cataract surgery it was -0.17 and -0.76, respectively. An equivalence test confirmed that the reported visual disability of epiphora patients was not significantly different from visual disability reported by patients waiting for 2nd eye cataract surgery. CONCLUSION: The Catquest-9SF is a valid measure of visual disability in patients with epiphora. Epiphora patients experience visual disability to the same degree as patients awaiting 2nd eye cataract surgery.

Chronic anophthalmic socket pain treated by implant removal and dermis fat graft.

AIMS: To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patients with chronic anophthalmic socket pain (ASP), in whom all detectable causes of pain had been ruled out and medical management had failed. METHODS: Retrospective, multicentre case series. A review of all cases undergoing orbital implant replacement with DFG between 2007 and 2013 was conducted at the University of Iowa Hospitals and Clinics (UIHC), USA, and St. Erik Eye Hospital, Sweden. Inclusion criteria included (1) chronic ASP >2 years and unresponsive to treatment, (2) absence of pathological or structural cause for pain established by socket examination and orbital imaging, and (3) minimum 12-month post-surgical follow-up. RESULTS: Six cases with chronic ASP were identified, four were post-enucleation and two were eviscerated at an average age of 45 years. The incidence of chronic ASP among enucleations at UIHC over a 6-year period was 0.7%. Indications for enucleation and evisceration included tumours and glaucoma. Intractable ASP had been present for an average of 11 years and persisted despite medical management. All patients were free of pain within 3 months of implant removal and DFG placement and remained pain free at an average 24 months following surgery. CONCLUSIONS: Orbital implant replacement with DFG was effective at relieving chronic ASP, and pain resolution was sustained in all cases. This surgical intervention may be a useful management option for patients in whom all detectable causes of chronic pain have been excluded and have failed medical pain management.

Pain and discomfort in the anophthalmic socket.

PURPOSE OF REVIEW: The aim of this review is to summarize causes of pain and discomfort in the anophthalmic socket and to aid the clinician in evaluating anophthalmic patients. RECENT FINDINGS: Causes of pain and discomfort can be categorized into dysfunctional orbit/anophthalmic socket, phantom eye pain, and psychological/psychiatric factors. Recent research has brought attention to the role of prosthesis deposits in mucous formation, meibomian gland dysfunction causing dry socket, and the anophthalmic patients' experience of phantom eye pain. SUMMARY: Anophthalmic patients may experience pain and discomfort for a variety of reasons. The treating physician needs to recognize this as treatment options are distinctly different.