Blink Lagophthalmos in Graves Orbitopathy.

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

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

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

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

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

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

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

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

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

Globe Protrusion and Interorbital Divergence in Syndromic Faciocraniosynostoses.

PURPOSE: The aim of this study was to quantify the relationship between globe protrusion (GP), length of medial and lateral walls, interzygomatic distance, and interorbital angle in syndromic faciocraniosynostoses. METHODS: The axial slices of computed tomography of the orbits of 43 patients with faciocraniosynostosis (31 with Crouzon syndrome and 12 with Apert syndrome) and 23 control subjects were measured with the Image J software. The following 5 variables were quantified: the degree of GP, the length of the medial and lateral walls, the interzygomatic distance, and the interorbital angle. RESULTS: Independent t-tests revealed significant differences between the patients and the controls regarding the mean values of all variables measured. The degree of GP was better correlated with the interorbital angle (r = 0.81) than with the medial wall length (r = 0.73). No correlation was found between GP and lateral orbital wall length. CONCLUSIONS: In syndromic faciocraniosynostoses, GP is highly correlated with the interorbital angle. The increment in the interorbital angle is a natural geometric consequence of the fact that a decrease in the orbital depth is not adequately compensated by an increase in the distance between the lateral orbit rims.

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

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

Upper eyelid contour symmetry measurement with Bézier curves.

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

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

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

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

Subperiosteal hematoma and orbital compression syndrome following minor frontal trauma in sickle cell anemia: case report.

We report the case of an 11-year-old girl with sickle cell disease who presented to the emergency room after being hit by a mud pie in the left frontal region. Examination evidenced left eye proptosis, eyelid swelling, reduced visual acuity and afferent pupillary defect, without any inflammatory signs such as fever, hyperemia or tenderness. Computed tomography of the orbits showed a large superomedial subperiosteal hematoma in the left orbit. The patient was treated with canthotomy, cantholysis and surgical draining of the hematoma. Two days after drainage she persisted with a subperiosteal hematoma and low visual acuity. A wide exploration of the orbital roof through a lid crease approach disclosed a thickened superior orbital rim with multiple bone defects along the roof and with continuous bleeding. Hemostasis was accomplished with bone wax. Orbital compression was resolved and the patient recovered her previous normal visual acuity.

Isolated low grade pilocytic astrocytoma of the optic nerve in the elderly: case report.

A 68-year-old man presented with a history of a right optic glioma. Eighteen months ago he underwent a lateral orbitotomy at another institution for removal of an optic nerve mass. At that time histology revealed that the tumor was an optic nerve glioma with a pilocytic pattern. No further treatment was instituted and one year after surgery he noticed that his right eye was proptotic again. Magnetic resonance imaging of the orbit showed that his right orbit was almost completely filled with a mass which extended through the optic canal to the chiasma. The tumor was excised by a combined neurosurgical and orbital approach. Histology proved that the neoplasm was a low grade pilocytic astrocytoma of the optic nerve.

Biomechanical and histological evaluation of glycerol-preserved human sclerae.

PURPOSE: To determine the histological and biomechanical characteristics of glycerol-preserved human sclera. METHODS: A total of 114 paired human sclerae were cleaned and preserved with 98% glycerol under refrigeration at 4 to 8 degrees C. The samples were divided into a control group with no preservation and 5 groups of 19 sclerae in 7, 15, 30, 90 and 180 days of preservation. Each specimen was submitted to histological examination and tested for traction distensibility functions. RESULTS: Preservation in glycerol did not cause alterations in the histological architecture of the scleral tissue. The mean load required to break the scleral tissue increased according to preservation time as a sigmoid function. A significant increase in mechanical resistance and decrease in distension of scleral tissue occurred after 90 days of preservation. CONCLUSIONS: Scleral preservation in glycerol keeps tissue integrity. The preserved material is less distensible after 90 days. Surgeons who use sclera in ophthalmic procedures should be aware of the mechanical characteristics of glycerol-preserved sclera and take into account tissue preservation time.

[Congenital ectropion: three case reports and literature review]. / Ectrópio congênito: relato de três casos e revisão de literatura.

To report 3 cases of congenital ectropion because of their rarity and confusing classification. Case 1: JPT, 2 days old, male, negro. Left upper eyelid eversion with chemosis was present, passive to mechanic reduction. Compressive occlusion was done with ectropion regression in 48 hours. Case 2: AJL, 6 years old, female, Caucasian, with Down syndrome. The left eye had hyperemia, lagophthalmos and inferior leucoma. She received horizontal shortening (superior and inferior tarsal strip) and skin grafts, and after 2 months the patient did not return. Case 3: GSD, 4 years old, male, Caucasian, with Down syndrome. His signs and treatment were the same as in case 2. According to Picó's classification the first case is classified as grade II due to eyelid eversion during the passage through the birth canal, more frequent in black people. Cases 2 and 3 represent grade III that is due to eyelid skin alteration, and the association with Down syndrome is observed. Treatment for ectropion grade III is always surgical, as it was done in these cases. We do not agree with Picó's classification, the only one found in medline, because there are no articles confirming the existence of grade I (absent tarsus), grade II should be called congenital upper eyelid eversion, grade IV (microphthalmos and orbital cyst) is a disease of the orbit. Grade III refers to true ectropion, because horizontal enlargement of superior and inferior eyelids (megaloblepharon).

Intraocular Plasmablastic Lymphoma in a HIV Patient.

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

[Chromatic sense: types of defects and clinical evaluation tests]. / Sentido cromático: tipos de defeitos e testes de avaliação clínica.

Evaluation of the chromatic sense has a great value in ophthalmic practice, both for diagnosis of the congenital defects (daltonism), as well as for diagnosis and follow-up of acquired defects. Many clinical tests are available to be used for this purpose. However it is necessary to know the details and sensitivity of each test, since there are many variations in the results, depending on the searched condition, if congenital or acquired pathologies. Our goal is to review the types of defects of the chromatic sense and provide information about the main current available tests and their best purpose. We further emphasize the importance of standard illumination procedure in the application of the tests.