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.

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.

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.

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.

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.

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.

Eccentric fixation in Stargardt's disease assessed by Tübingen perimetry.

PURPOSE: To measure eccentric fixation characteristics in visual fields of patients with Stargardt's disease. METHODS: The positions of fixation loci (FL) in the visual field were determined by Tübingen perimetry (TP), using the position of the blind spots in 173 patients. Altogether, 669 visual fields were measured at baseline and during follow-up. Twenty patients were also examined by scanning laser ophthalmoscope (SLO). RESULTS: Ninety-five of 173 patients showed a ring scotoma with central fixation in at least one test, which could persist for up to 18.8 years. The median age for a 50% chance of the development of eccentric fixation was 23.6 years. One hundred four patients (203 eyes) used eccentric fixation in at least one eye; in 154 eyes, the FL was placed below the scotoma and in 33 eyes to the left of it, in 11 to the right of it, and in 5 above it. Once the FL was chosen, it remained within the same visual field area at subsequent tests, varying on average by 1.76 degrees. Compared with SLO results, the mean distance between FL and PRL was 1.90 degrees. CONCLUSIONS: It is possible to determine the position of the FL by perimetry with sufficient accuracy if the blind spot is well delimited. Stargardt patients can keep central fixation for different time intervals before changing to an eccentric FL. Most of them show an FL below the central scotoma, which is considered favorable for horizontal reading.

[McCune Albright syndrome - diffuse orbital involvement due to fibrous dysplasia: a case report]. / Envolvimento orbitário difuso por displasia fibrosa na síndrome de McCune Albright: relato de caso.

Fibrous dysplasia is a benign, slowly progressive bone disorder, in which normal bone is replaced by fibrous tissue. It is called McCune Albright syndrome when associated with skin hyperpigmentation and endocrinological disorders. We report a rare case of McCune Albright syndrome in a boy, who presented bilateral and diffuse involvement of orbits but few external craniofacial distortions.

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.

Computed tomographic patterns of orbital cellulitis due to sinusitis.

PURPOSE: To describe the CT findings of orbital cellulitis due to sinusitis. METHODS: The records and CT scans of 45 consecutive patients with orbital cellulitis due to sinusitis treated at the Hospital of the Medical School of Ribeirão Preto were analyzed by a radiologist and two orbital surgeons. RESULTS: Three major types of CT changes were observed: diffuse fat infiltration, subperiosteal abscess and orbital abscess. Diffuse fat infiltration (characterized by an increased density of the extra- or intraconal fat) was seen in 11 patients (24.44%). A subperiosteal abscess was diagnosed in 28 patients (62.23%). A surgically proved orbital abscess was detected in 6 patients (13.33%). CONCLUSIONS: In all cases of orbital cellulitis due to sinusitis intraorbital changes can be detected by CT scans either as a diffuse infiltration of the orbital fat or as a detachment of the periorbita (subperiosteal abscess) or a true orbital abscess. Category I of Chandler orbital cellulitis classification (inflammatory edema) must be understood as a stage of a process that is already happening within the orbit and, as the term "preseptal cellulitis" means a palpebral infection, this designation should not be used to stage orbital cellulitis.

Pain induced by phacoemulsification without sedation using topical or peribulbar anesthesia.

PURPOSE: To evaluate patient-reported pain induced by phacoemulsification without sedation using topical or peribulbar anesthesia. SETTING: Department of Ophthalmology, School of Medicine of Ribeirão Preto, São Paulo, Brazil. METHODS: This study assessed patient-perceived pain during phacoemulsification cataract surgery with peribulbar anesthesia (lidocaine 2%-bupivacaine 0.5% mixture) or with topical anesthesia (tetracaine drops); no patient received sedation. The same surgeon performed all surgeries using a clear corneal approach and in-the-bag intraocular lens implantation. Approximately 15 minutes after surgery, patients in the topical anesthesia group (n = 20) were asked to rate their pain during the procedure and patients in the peribulbar anesthesia group (n = 21), during infiltration of the anesthetic solution. Patients graded their pain using a 0- to 10-point visual analog scale (0 = no pain; 10 = unbearable pain). The results in the 2 groups were compared using the nonparametric Mann-Whitney U test. RESULTS: The median pain score in the topical anesthesia group was 2 (range 0 to 5) and in the peribulbar anesthesia group, 3 (range 0 to 7). The mean rank in the topical anesthesia group (15.78) was significantly lower than the mean rank in the peribulbar anesthesia group (25.98) (P = .0057, Mann-Whitney U test). CONCLUSION: In patients having phacoemulsification without sedation, those receiving peribulbar anesthesia reported more pain than those receiving topical anesthesia during anesthetic solution infiltration and during the procedure, respectively.

[Comparison between the pain induced by phacoemulsification with topical anesthesia and by peribulbar anesthesia without sedation]. / Comparação entre a dor provocada pela facoemulsificação com anestesia tópica e a pela infiltração peribulbar sem sedação.

PURPOSE: To compare pain sensation induced by phacoemulsification with topical anesthesia with that by peribulbar anesthesia, without sedation. METHODS: Using a 10-level visual pain analogue scale, the pain induced by phacoemulsification with topical anesthesia (2% tetracaine drops) was measured in 20 patients. The same scale was used to measure the pain induced by peribulbar anesthesia (2% lidocaine and 0.5% bupivacaine) in 21 patients. The same surgeon performed peribulbar infiltrations and surgeries. The phacoemulsifications were done using clear corneal approach followed by in-the-bag intraocular lens implantation. Pain comparison between the two groups was performed by the non-parametrical U Mann-Whitney test. RESULTS: The distribution of the pain scores of the patients who underwent cataract extraction with topical anesthesia ranged from 0 to 5 (median value = 2). The scores of the patients who underwent peribulbar infiltration ranged from 0 to 7 (median value = 3). The mean rank of the group of patients who had surgery with topical anesthesia (15.78) was significantly different from the mean rank of the patients who received peribulbar anesthesia (25.98) (p = 0.0057). CONCLUSION: Without sedation, the pain induced by phacoemulsification with topical anesthesia was milder than the pain induced by peribulbar infiltration.

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.

[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.