Orbital complication of acute ethmoiditis: A Tunisian paediatric cross sectional study.

OBJECTIVE: The anatomical and developmental particularities of sinus cavities in paediatric population lead acute ethmoiditis to be the earliest form of sinusitis in children. Orbital complications are frequent and could lead to visual and neurological impairment. This study investigated the clinical, biological and radiological features of orbital complications. We identified the predictive factors of severe ophthalmological lesions and/or associated cerebral complications of acute ethmoiditis. DESIGN AND METHODS: This cross sectional study included all patients identified as having orbital extension of acute ethmoiditis in the database of a single academic paediatric care centre over a period of 14 years. All orbital and cerebral Scans of the included patients were reviewed and the cohort was classified using Chandler's classification as having less severe lesions (Chandler's 1 and 2) or more serious lesions (Chandler's 3, 4 and 5). RESULTS: In total, 16 patients (12 girls and 4 boys) were included among 39 consecutives cases of ethmoiditis recessed with a complication rate of 41%. Average consultation delay was 4.88 days. The mean age was 4.37 years. Fever was objectified in 13 cases (81%). Six patients (37.5%) had exophthalmos. Orbital extension spectrum was: stage I (n = 4, 25%), stage II (n = 4, 25%), stage III (n = 6, 37.5%), stage IV (n = 1, 6.5%), stage V (n = 1, 6.5%) and intra cranial extension was associated in two cases. Univariate analysis showed that fever, exophthalmos, ophthalmoplegia, positive CRP, age and white blood cells count were not associated with more severe lesions in the CT scan. Initially, all children received intravenous antibiotic treatment. Association of multiple antibiotics was prescribed in 75% of the cases. With 21.07 days ±â€¯5.51 days as a total treatment duration. Only Four patients underwent surgical treatment. CONCLUSION: Orbital complications of ethmoiditis are frequent. No clinical or biological criteria seem to predict the severity of orbital lesions. Both orbital and brain CT scan could help detect eventual complications on time to adapt antibiotic treatment and eventually bring forward surgical intervention.

Prosthetic guidelines for ocular rehabilitation in patients with phthisis bulbi: a treatment-based classification system.

Prosthetic rehabilitation of phthisis bulbi defects is the only treatment option for cosmetic rehabilitation of patients with such defects. Currently, there is no treatment-based classification for prosthetic rehabilitation of patients with phthisis bulbi. Phthisical ocular defects and/or prosthetic rehabilitation were evaluated in an attempt to establish prosthetic guidelines that could be organized into a classification system. Fifty patients who received rehabilitation for phthisis bulbi were reviewed. Phthisis bulbi defects were divided into 4 classes. All the patients had rehabilitation, depending upon the class to which they were assigned. The aim of this treatment-oriented classification system was to organize and define the complex nature of the restorative decision-making process for patients with phthisis bulbi.

Correlation between volume of herniated orbital contents and the amount of enophthalmos in orbital floor and wall fractures.

PURPOSE: To analyze the correlation between the volume of herniated orbital contents and the amount of enophthalmos in orbital floor and wall fractures. MATERIALS AND METHODS: Patients with secondary enophthalmos due to unilateral orbital floor and wall fractures were recruited. Computed tomography-assisted measurements of both orbits as well as of the amount of enophthalmos were performed. The following volumes were calculated: 1) the overall volume of both the healthy and fractured orbit, 2) the volume of herniated orbital contents at the orbital walls, 3) the volume of herniated orbital contents anterior and posterior to the vertical eyeball equator. The amount of enophthalmos was also measured by computed tomography. Multifactor linear regression analysis was performed to obtain correlations between the amount of enophthalmos and the measured volumes. RESULTS: Twenty-three patients were included. The average enophthalmos was 4.0 mm (SD = 1.49). Although correlation between volume differences of healthy and fractured sides was not statistically significant, the overall volume of the herniated orbital contents was significantly correlated (P < .05) with the amount of enophthalmos. Regarding the specific orbital sites of herniation, the orbital floor was detected to be most significantly correlated to the amount of enophthalmos (P < .05), although only the herniation posterior to the vertical eyeball equator. CONCLUSION: The overall volume of herniated orbital contents correlated significantly with the amount of enophthalmos. The orbital floor was detected to be the site most significantly correlated with the amount of enophthalmos (although only if herniation occurred posterior to the vertical eyeball equator). Only the volume of herniated soft tissues posterior to the eyeball equator showed correlation with the amount of enophthalmos.

Periorbital hyperpigmentation in Asians: an epidemiologic study and a proposed classification.

BACKGROUND: Periorbital hyperpigmentation (POH) presents with a dark area surrounding the eyelids. It is an ill-defined condition, and the pathogenesis can be multifactorial. OBJECTIVE: This epidemiologic study was conducted to assess the prevalence of periorbital hyperpigmentation in Singapore in an attempt to propose a classification. MATERIALS AND METHODS: One thousand consecutive patients attending the general dermatology clinic at the National Skin Center were enrolled in the study to assess for POH, of whom 200 with POH were examined and investigated to define the cause of POH. The possible causes were determined according to a detailed history, clinical examination, and assessment by three dermatologists. The extent of the POH was measured using a mexameter. RESULTS: The commonest form of POH was the vascular type (41.8%), followed by constitutional (38.6%), postinflammatory hyperpigmentation (12%), and shadow effects (11.4%). The vascular type was seen predominantly in Chinese, whereas as the constitutional type was most common in Indians and Malays. CONCLUSION: The vascular form of POH was the predominant type. We propose a comprehensive classification for POH that we hope will influence the choice of treatment modalities used in managing POH in the future.

Do subtypes of graves' orbitopathy exist?

PURPOSE: To describe the prevalence of fat and muscle volume (MV) increase in Graves' orbitopathy (GO) patients, calculated from computed tomography scans, and the associated ophthalmic and endocrine characteristics. DESIGN: Consecutive, observational case series. PARTICIPANTS: Ninety-five consecutive Caucasian GO patients attending the thyroid eye clinic. METHODS: Volumetry using age-specific reference values in untreated GO patients who had been rendered euthyroid. MAIN OUTCOME MEASURES: Subgroups in GO and main characteristics. RESULTS: Four subgroups could be distinguished: Group 1, no fat volume (FV) or MV increase (n = 24); group 2, only FV increase (n = 5); group 3, only MV increase (n = 58); and group 4, both FV and MV increase (n = 8). Patients with an increase of MV were older and had higher thyroid-stimulating hormone-binding inhibitory immunoglobulin TBII, more proptosis, and more impaired ductions than those without MV increase. Patients with an increase of FV differed from those without FV increase only in having more proptosis. The clinical activity score did not differ between the 4 groups. CONCLUSIONS: Of these GO patients, 25% have orbital fat and MVs within an age-specific reference range. An increase of the FV is seen in only 14% of GO patients and characterized by proptosis. Muscle enlargement occurs in 70% of patients and is associated with older age, higher TBII values, more proptosis, and impaired motility.

Spectrum of orbital disease in South India: an aravind study of 6328 consecutive patients.

AIM: To review the incidence of orbital diseases in South India and to compare with other case series published. METHODS: Retrospective review of 6328 consecutive patients with orbital disease evaluated at Aravind Eye Hospital between January 1997 and December 2008. The main outcome measure was incidence of orbital disease in South Indian population, as determined by clinical and histopathologic criteria. A literature review was conducted to compare the results of this study with those of previously published reports. RESULTS: Of the 6328 patients, 2161 (34.1%) had inflammatory orbital disease, 1965 (31.0%) had systemic conditions involving the orbit, 1277 (20.1%) had neoplasm, 600 (9.4%) had congenital lesions, 308 (4.8%) had trauma, and 17 (0.2%) had vascular disease. Of the 2161 patients presenting with inflammatory disease, 1473 (68.1%) had idiopathic orbital inflammation, 270 (12.5%) had infection, 126 (5.8%) had dacryoadenitis, and 292 (13.5%) had other etiologies. Among the 1965 patients presenting with systemic disease involving the orbit, 1938 (98.6%) were diagnosed with thyroid orbitopathy, 22 (1.1%) with amyloidosis, and 5 (0.2%) with sarcoidosis. Of the 1277 patients with neoplasm, the tumor was vascular in 369 (28.8%), neural in 336 (26.3%), lymphoid or leukemic in 131 (10.2%), secondary neoplasm in 82 (6.4%), epithelial in 68 (5.3%), adipose in 53 (4.1%), metastatic in 39 (3.0%), and fibrous, fibro-osseous, striated muscle, histiocytic, and other cellular origin in 40 (3.1%), 37 (2.8%), 23 (1.8%), 21 (1.6%), and 78 (6.1%), respectively. Of the 600 patients with congenital lesions, 427 (71.1%) had dermoid and 170 (28.3%) had dermolipoma, followed by meningoencephalocele. CONCLUSIONS: The most common causes of orbital disease in South India are inflammatory (34.1%) and systemic conditions (31.0%). With the exception of higher incidence of inflammatory etiologies, these data are largely consistent with prior published reports.

The conversion of bulbar redness grades using psychophysical scaling.

PURPOSE: To use psychophysical scaling to investigate if the inclusion of reference anchors affected the perceived redness of the reference images of four bulbar redness grading scales and to convert grades between scales. METHODS: Ten participants were asked to arrange printed copies of the McMonnies/Chapman-Davies (6), IER (4), and Efron (5) grading scale images relative to each other, using the stationary but unlabeled 10, 30, 50, 70, and 90 reference images of the validated bulbar redness scale as additional anchors within a given 0 (minimum) to 100 (maximum) redness range (anchored scaling). The position of each image was averaged across observers to represent its perceived redness within this range. Anchored scaling data were then compared with data from a previous study, where the images of all four grading scales had been scaled for the same experimental setup, but with no reference anchors provided (non-anchored scaling). Averaged perceived redness as determined with anchored scaling was used to cross-calibrate grades between scales. RESULTS: Overall, perceived redness of the reference images was significantly different within each scale (repeated measures analysis of variance, all scales p < 0.001). There were differences in perceived redness range and when comparing reference levels between scales. Anchored scaling resulted in an apparent shift to lower perceived redness for all but one reference image compared with non-anchored scaling, with the rank order of the 20 images for both procedures remaining fairly constant (Spearman's ρ = 0.99). CONCLUSIONS: The re-scaling of the reference images in the anchored scaling experiment suggests that redness was assessed based on within-scale characteristics and not using absolute redness scores, a mechanism that can be referred to as clinical scale constancy. The perceived redness data allow practitioners to modify the grades of the scale they commonly use for comparison of their grading estimates with grades obtained with another calibrated scale.

Mucormicosis en una paciente diabética: caso clínico y revisión de la literatura / Mucormycosis in a diabetic patient: case report and literature review

Presentamos un caso de Mucormicosis Rinoorbitaria en una mujer de 48 años, diabética, en cetoacidosis, a quien se hizo el diagnóstico por histopatología. Tratada con anfotericina B intravenosa y un agresivo debridamiento quirúrgico para eliminar tejidos infartados y necróticos de gran parte de la hemicara y ojo derecho, logra sobrevivir a esta catastrófica infección. La mucormicosis es una infección aguda y extremadamente grave causada por hongos oportunistas y ubicuos del orden Mucoroles pertenecientes a la clase Phycomycetes, que afecta principalmente a un grupo de pacientes cuyas condiciones inmunológicas y metabólicas favorecen el desarrollo del hongo. Hacemos una definición del grupo de "pacientes en riesgo", lo que es extremadamente importante, ya que de la sospecha clínica se puede abordar un diagnóstico precoz para evitar la alta mortalidad y morbilidad que esta enfermedad provoca. Analizamos la patogenia de la enfermedad, así como una revisión de la literatura sobre modalidades de diagnóstico y terapéutica. El diagnóstico de urgencia sigue siendo de responsabilidad del patólogo, y el tratamiento de mayor éxito es la anfotericina B.

We present a case of rhinoorbital mucormycosis in a diabetic, developing ketoacidose, 48-year old woman. Diagnosis was established through histopathology. The patient was successfully treated and survives with a combination of anphotericin B and an aggressive surgery in order to eliminate all the ischemic and necrotic tissues affecting almost the entire right side of the face and intraorbital structures surviving to this catastrophic infection. Mucormycosis is an acute and often fatal infection caused by opportunistic fungus of the class Zygomycetes, order Mucoroles that affects a select group of patients associated with underlying metabolic and immunological disorders. A definition of "risk-group" is proposed. This definition is of extreme importance for a prompt diagnosis avoiding the high rate of morbidity and mortality associated with this condition. We review both pathogenic mechanism and literature related to diagnostic modalities and new therapeutical approaches. Emergency diagnosis is still in hands of pathologists and the most successful treatment is with anphotericin B.

Color Doppler imaging of the superior ophthalmic vein in different clinical forms of Graves' orbitopathy.

PURPOSE: To compare color Doppler imaging (CDI) parameters of the superior ophthalmic vein (SOV) in patients with Graves' orbitopathy (GO) and in normal controls. METHODS: Forty-three GO patients and 14 normal controls underwent CDI of the SOV. Patients had either fibrotic (lipogenic or myogenic) or congestive orbitopathy. The findings for each group were compared. RESULTS: Fifty-eight orbits with fibrotic orbitopathy, 28 with congestive orbitopathy, and 28 from controls, were studied. In the congestive group, SOV flow was detected in 13, undetectable in 11, and reversed in four orbits; in the fibrotic group, it was present in 41 and undetectable in 17 orbits. In normal controls, SOV flow was detected in 25 and undetectable in three orbits. The differences among the three groups were significant. There was also a significant difference between controls and the congestive GO orbits but not between the fibrotic group and the other two groups. Fibrotic myogenic orbitopathy patients displayed a significantly smaller SOV flow than patients with lipogenic orbitopathy. CONCLUSIONS: SOV was significantly reduced in orbits with congestive GO or with myogenic fibrotic GO, but not in orbits with fibrotic lipogenic orbitopathy. SOV congestion may be a contributing pathogenic factor in both congestive and fibrotic myogenic Graves' orbitopathy.

Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases.

OBJECTIVE: Peri-orbital infections can be classified as pre-septal or post-septal depending upon the location of the focus of infection. The ability to differentiate between these two is frequently difficult at the initial presentation, with marked orbital edema and pain limiting the ophthalmic examination. Hence, it is important to identify all the features at presentation that will lead to an accurate and rapid diagnosis and treatment. Our retrospective review of peri-orbital infections identifies contrasting features between these two groups that will aid the clinician in the subsequent management of these infections. DESIGN AND SETTING: A retrospective review over an 11-year period of children admitted to a tertiary children's hospital for the treatment of peri-orbital cellulitis was undertaken. The two subgroups were identified, those suffering from a pre-septal infection and those with a post-septal infection. The groups were compared with respect to their presentation, clinical findings, findings on CT and surgical intervention. RESULTS: Two hundred and sixty-two children were identified with peri-orbital infections, 227 pre-septal, and 35 post-septal. There were statistically significant differences between the pre- and post-septal groups with regards to the following: age (3.9 vs. 7.5 years, p<0.001), medical co-morbidities (19% vs. 0%, p<0.01), a history of trauma (40% vs. 11% of cases, p<0.003), clinical diagnosis of acute sinusitis (9% vs. 91% of cases, p<0.001), and fever (47% vs. 94%, p<0.001). Ophthalmologic examination identified diplopia (p<0.001), opthalmoplegia (p<0.001) and proptosis (p<0.001) as significant features of a post-septal infection. Intravenous antibiotics were successful in treating the majority of cases, with 5% of pre-septal, and 25% of post-septal infections requiring surgery. CONCLUSION: When considering the management of a child with a peri-orbital infection, features from the history and examination such as trauma, medical co-morbidities and ophthalmic signs will guide management and delineate the indications for early CT imaging. In the absence of acute visual compromise or other signs of disease progression, initial management with intravenous antibiotics for 48 h to cover Staphylococcal aureus and Streptococcal pyogenes with nasal decongestant should be considered before surgical intervention is contemplated. A multi team approach is essential in obtaining the best outcome for the child.

Orbital complications of acute rhinosinusitis: a new classification.

UNLABELLED: Rhinosinusitis is a severe sickness and may have serious complications. Orbital complications happen more often, due to anatomical particularities and are lethal in 5% of patients. They vary from inflammatory signs to proptosis, loss of ocular motility and blindness. AIM: We propose a new classification of acute rhinosinusitis complications. METHODS: A review of 83 patients with CT scan and clinical reports. Patients were evaluated at HCFMRP-USP between 1995 and 2005 and were diagnosed with complicated rhinosinusitis. RESULTS: In sixty-six patients, were identified three types of orbital complications: orbital cellulitis (46.9%), subperiosteal abscess (40.9%) and orbital abscess (12.1%). Seventeen were considered as eyelid infections and excluded from this new classification system. CONCLUSIONS: The existing classifications of orbital complications, as Chandlers, do not consider the orbits anatomical characteristics and became obsolete after the development of the CT scan. This study proposes a new, more objective classification to guide the physician in establishing lines of conduct for each case.

Complicações orbitárias da rinossinusite aguda: uma nova classificação / Orbital complications of acute rhinosinusitis: a new classification

A rinossinusite é uma doença potencialmente grave, e pode apresentar sérias complicações. As orbitárias são as mais freqüentes, graças às peculiaridades anatômicas desta região, podendo levar à morte em 5 por cento dos casos. Os sintomas variam desde sinais flogísticos periorbitários até proptose do globo ocular, oftalmoplegia e amaurose. OBJETIVOS: Proposição de uma nova classificação para as complicações orbitárias das rinossinusites agudas. MATERIAL E MÉTODO: Revisão de TC e prontuários de 83 pacientes atendidos no Hospital das Clínicas da FMRP-USP, entre os anos de 1995 a 2005, com rinossinusites agudas complicadas. RESULTADOS: Após a revisão das TC e história clínica, foram identificadas em sessenta e seis pacientes, três tipos de complicações orbitárias: celulite orbitária (46,9 por cento), abscesso subperiosteal (40,9 por cento) e abscesso orbitário (12,1 por cento). Dezessete foram considerados como infecções palpebrais, ficando excluídos da nova classificação. CONCLUSÃO: As classificações das complicações orbitárias existentes na atualidade, como a de Chandler, não levam em conta os parâmetros anatômicos da órbita e tornaram-se obsoletas com o advento da TC. Este estudo propõe uma classificação mais concisa e objetiva que ajude a guiar a conduta terapêutica de forma mais linear.

Rhinosinusitis is a severe sickness and may have serious complications. Orbital complications happen more often, due to anatomical particularities and are lethal in 5 percent of patients. They vary from inflammatory signs to proptosis, loss of ocular motility and blindness. AIM: We propose a new classification of acute rhinosinusitis complications. METHODS: A review of 83 patients with CT scan and clinical reports. Patients were evaluated at HCFMRP-USP between 1995 and 2005 and were diagnosed with complicated rhinosinusitis. RESULTS: In sixty-six patients, were identified three types of orbital complications: orbital cellulitis (46. 9 percent), subperiosteal abscess (40. 9 percent) and orbital abscess (12.1 percent). Seventeen were considered as eyelid infections and excluded from this new classification system. CONCLUSIONS: The existing classifications of orbital complications, as Chandler’s, do not consider the orbit’s anatomical characteristics and became obsolete after the development of the CT scan. This study proposes a new, more objective classification to guide the physician in establishing lines of conduct for each case.

Preseptal and orbital cellulitis in a developing country.

PURPOSE: To report the clinical features, etiology, management practices, and outcomes of preseptal (PC) and orbital cellulitis (OC) in a developing country. METHODS: The charts of all patients with PC and OC at the Philippine General Hospital from 1990 to 1995 were reviewed and the following data retrieved: age, gender, manner of presentation, causative agent, treatment, and outcomes. RESULTS: Of 91 patients, 56 (62%) were diagnosed with PC and 35 (38%) with OC. The mean age at presentation was 12.6 +/- 17.0 years and 17.1 +/- 18.6 years, respectively. No sex predilection was observed. Ophthalmoplegia, chemosis, pain, proptosis, and blurred vision were associated with OC. Eyelid infection was the most common antecedent factor and was present in 15 (27%) PC patients and 13 (37%) OC patients. Staphylococcus was the most frequent causative organism. Intravenous antibiotics were administered to 35 (62%) PC patients and all patients with OC. Surgical intervention was performed in 15 (27%) PC patients and 22 (63%) OC patients. None of the PC patients developed permanent sequelae. Seventeen (49%) OC patients developed serious complications such as: visual loss (29%), neurological deficits (17%), and mortality (3%). CONCLUSIONS: In developing countries, eyelid infection may be the most important predisposing factor for periocular infection. Staphylococcus is the predominant causative agent. OC can be associated with serious complications. Aggressive management of OC may improve patient outcomes.

[The clinical significance of calcification in orbital computed tomography].

OBJECTIVE: To study clinic significance of ocular and orbital diseases with computed tomographic (CT) scans. METHODS: 2181 ocular and orbital photos of computed tomographic scans were reviewed. The relevance with pathogenesis, diagnosis criteria and differential diagnosis of calcification was analyzed. RESULTS: Of 2181 CT scans, 129 showed calcified densities. 40 cases (31%) with retinoblastoma, and 3 cases (1%) with chorodal osteoma were revealed intraocular lesions containing calcium. The massive calcification was demonstrated in orbital diseases including 58 cases (45%) with vascular lesions, 19 (15%) cases with other orbital benign tumors and 9 cases (8%) with orbital malignant tumors. CONCLUSION: The calcification number, location and shape within lesions are of great value in the diagnosis of ocular and orbital diseases.

Orbital cysts of childhood--classification, clinical features, and management.

There is little in the literature about the clinical spectrum of orbital cysts of childhood and no comprehensive classification has been proposed. The authors propose a classification of orbital cysts of childhood and review their clinical features, pathology, and management. The major categories in the classification include cysts of surface epithelium, teratomatous cysts, neural cysts, secondary cysts, inflammatory cysts, and noncystic lesions with cystic component. Cysts of the surface epithelium are further divided into simple epithelial cyst (epidermal, conjunctival, respiratory, and apocrine gland), and dermoid cyst (epidermal and conjunctival). Epidermal dermoid cyst (dermoid) is by far the most common orbital cystic lesion in children, accounting for over 40% of all orbital lesions of childhood and for 89% of all orbital cystic lesions of childhood that come to biopsy or surgical removal. Neural cysts include those associated with ocular maldevelopment (congenital cystic eye and colobomatous cyst) and those associated with brain and meningeal tissue (cephalocele and optic nerve meningocele). The most important secondary cyst is mucocele that can occur in children with cystic fibrosis. Inflammatory cysts are generally due to parasitic infestations and are more common in tropical areas of the world. Noncystic lesions that can have a cystic component include adenoid cystic carcinoma, rhabdomyosarcoma, lymphangioma, and others. Each type of cyst has rather characteristic, but not pathognomonic, clinical features. Computed tomography and magnetic resonance imaging can help differentiate a cystic lesion from a solid tumor, suggest the type of cyst, and help in planning management. The pathology varies with the cells that line the cyst and with the inflammatory agent. Management varies from local excision to observation, depending on the location and type of cyst. Orbital cysts of childhood can be classified into categories, based mainly on their histopathology. The clinical, radiologic, and histopathologic features can be correlated with the classification in order to better evaluate a child with a cystic lesion in the orbit.

Classificaçäo das complicaçöes orbitais das rinossinusites / Classification of rhinosinusitis orbital complications

As rinussinusites etmoidais e esfenoidais são as que apresentam maior risco de complicações orbitais. As complicações orbitais dividem-se em pré e pós-septais, de acordo com sua localização em relação ao septo orbital, que constitui importante barreira à propagação da infecção na órbita. A complicação orbital mais comum é a celulite palpebral. Cerca de 15 por cento das complicações pós-septais evoluem para amaurose definitiva mesmo com tratamento. Com o advento da tomografia computadorizada de alta resolução dos seios paranasais, a classificação de Mortimore para as complicações orbitais das rinossinusites parece-nos a mais adequada e completa