Transcaruncular Medial Wall Orbital Decompression: An Effective Approach for Patients with Unilateral Graves Ophthalmopathy

Purpose. To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. Methods. Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. Results. The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). Conclusions. Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results

Intraorbital foreign body projectile as a consideration for unilateral pupillary defect

Intraorbital foreign bodies are frequently the result of high-velocity injuries with varying clinical presentations. The resultant diagnosis, management, and outcome depend on the type of foreign body present, anatomical location, tissue disruption, and symptomatology. A patient who presented to the Emergency Department with a large intraorbital foreign body projectile that was not evident clinically, but found incidentally on computed tomography and subsequent plain films is reported. The emergency room physician needs to be aware of the differential diagnosis of a unilateral irregular pupil with or without visual acuity changes. The differential diagnosis for any trauma patient with an irregular pupil with significant visual loss must include intraorbital foreign body and associated injury to the optic nerve directly or via orbital compartment syndrome secondary to hemorrhage and/or edema. Patients with significantly decreased visual acuity may benefit from emergent surgical intervention. In patients with intact visual acuity, the patient must be monitored closely for any visual changes as this may require emergent surgical intervention

IgG4 Immunostaining and Its Implications in Orbital Inflammatory Disease

Objective IgG4-related disease is an emerging clinical entity which frequently involves tissue within the orbit. In order to appreciate the implications of IgG4 immunostaining, we analyzed gene expression and the prevalence of IgG4- immunostaining among subjects with orbital inflammatory diseases. Methods We organized an international consortium to collect orbital biopsies from 108 subjects including 22 with no known orbital disease, 42 with nonspecific orbital inflammatory disease (NSOI), 26 with thyroid eye disease (TED), 12 with sarcoidosis, and 6 with granulomatosis with polyangiitis (GPA). Lacrimal gland and orbital adipose tissue biopsies were immunostained for IgG4 or IgG secreting plasma cells. RNA transcripts were quantified by Affymetrix arrays. Results None of the healthy controls or subjects with TED had substantial IgG4 staining. Among the 63 others, the prevalence of significant IgG4-immunostaining ranged from 11 to 39% depending on the definition for significant. IgG4 staining was detectable in the majority of tissues from subjects with GPA and less commonly in tissue from subjects with sarcoidosis or NSOI. The detection of IgG4+ cells correlated with inflammation in the lacrimal gland based on histology. IgG4 staining tissue expressed an increase in transcripts associated with inflammation, especially B cell-related genes. Functional annotation analysis confirmed this. Conclusion IgG4+ plasma cells are common in orbital tissue from patients with sarcoidosis, GPA, or NSOI. Even using the low threshold of 10 IgG4+ cells/high powered field, IgG4 staining correlates with increased inflammation in the lacrimal gland based on histology and gene expression

Central retinal vein occlusion

Retinal vein occlusion (RVO) is the second most common retinal vascular disease and is a common loss of vision in older patients. There are two types of RVO: Branch retinal vein occlusion (BRVO) and Central retinal vein occlusion (CRVO). Central retinal vein occlusion is an occlusion of the main retinal vein posterior to the lamina cribrosa of the optic nerve and is typically caused by thrombosis. Central retinal vein occlusion is further divided into two categories: non-ischemic (perfused) and ischemic (nonperfused). Branch retinal vein occlusion is a blockage of one of the tributaries of the central retinal vein. Non-ischemic CRVO is the most common, accounting for about 70% of cases. Best-corrected visual acuity (BCVA) is often better than 20/200. The characteristics of non-ischemic central retinal vein occlusion include good visual acuity, a mild or no pupillary defect, and mild visual changes. Non-ischemic central retinal vein occlusion can also be referred to as partial, perfused, or venous stasis retinopathy. Ischemic CRVO can be the primary or progression of a non-ischemic CRVO, although progression is not common. Approximately half resolve without treatment or intervention. Ischemic central retinal vein occlusion has a much lower visual prognosis and accounts for about 30% of cases. Around 90% of patients with visual acuities worse than 20/200 have ischemic central retinal vein occlusion. Ischemic central retinal vein occlusion carries a poorer prognosis and is defined as having at least 10 areas of retinal capillary nonperfusion. Other names for ischemic central retinal vein occlusion include complete, nonperfused, or hemorrhagic retinopathy

Retinal detachment

The retina is the innermost layer of tissue of the posterior portion of the eye. It is composed of multiple cellular layers. The outermost layer abuts the vitreal cavity and the innermost layer, the choroid. Retinal detachment is when the neurosensory retina loses adherence to the underlying retinal pigment epithelium (RPE). The outer portion of the neurosensory retina is where the photoreceptors lie. The choroid supplies the oxygen and nutrition for the photoreceptors. Within the fovea, there are no retinal blood vessels, and retinal tissue within this area depends entirely on the choroid for its oxygen requirements. A detachment of the macula can lead to permanent damage to the photoreceptors in this location. Vision is potentially retainable if the macula remains attached, and the retina gets appropriately reattached. However, if the macula comes off, vision may remain poor despite surgical intervention. There are three categories of retinal detachment: rhegmatogenous, tractional, and exudative. Rhegmatogenous retinal detachments are the most common and are caused by fluid passing from the vitreous cavity via a retinal tear or break into the potential space between the sensory retina and the RPE. Tractional detachments occur when proliferative membranes contract and elevate the retina. Components of rhegmatogenous and tractional etiologies may also lead to retinal detachment. Exudative detachments result from fluid accumulation beneath the sensory retina caused by retinal or choroidal diseases

Globe rupture

Globe rupture, globe laceration, globe perforation, or open globe injuries are forms of ocular trauma that require urgent diagnosis and treatment. Globe rupture is the common term used to describe all potential types of open globe injuries. Two primary mechanisms can disrupt the integrity of the globe - penetration/perforation/laceration and rupture due to blunt force. A penetrating injury is when an object penetrates the eye, but the object does not go all the way through the eye. In these cases, there can be an intraocular foreign body that remains in the eye. If there is an entrance and an exit wound, then this is considered a perforating injury. In the United States, estimated cases of globe rupture are approximately 3 per 100000. Diagnosis of globe rupture is based on history and clinical ophthalmologic examination, typically consisting of the slit lamp and fundoscopic evaluation. Imaging may not be reliable to diagnose a globe rupture but should be obtained as a supplement to the workup. When there is a high index of suspicion, an immediate consultation with an ophthalmologist for evaluation is the recommended course of treatment

Quantification of the Aesthetically Desirable Female Midface Position

© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Background: The purpose of this study was to attempt to determine a reliable method of evaluating midface position. We assessed a novel parameter called WIZDOM (Width of the Interzygomatic Distance of the Midface) and its relationship to other facial metrics. Objectives: The goal was to evaluate midfacial position quantitatively in women by examining 2-dimensional photographs of a subset of women with idealized facial proportions. Methods: Three examiners analyzed stock photographs of nonsmiling female model faces. Numerous parameters were analyzed for each photograph, including: interpupillary distance, medial canthus (MC) to lip, brow length, WIZDOM, WIZDOM to MC, WIZDOM to hairline, WIZDOM to chin vertical, and lateral brow to WIZDOM. Meaningful relationships between various parameters were statistically analyzed. Examiner measurements were assessed for interobserver reliability. Results: Fifty-five female model photographs were included in the analysis. The average interpupillary distance was 59.2 mm ± 3.54 (range, 50.5- 67.3 mm). The WIZDOM average was 108 mm ± 5.81 (range, 93-127 mm) and brow length was 107 mm ± 5.87 (range, 96.7-124 mm). The difference between brow length and WIZDOM was not statistically different (P = 0.834). The interobserver reliability between the 3 examiners was excellent for all parameters (P \u3c 0.01), ranging from 0.718 (WIZDOM-MC) to 0.993 (interpupillary distance). The WIZDOM measurement was reproducible with an interobserver coefficient of 0.939. Conclusions: WIZDOM can be used to quantify aesthetically desirable midfacial position in patients and can be used as a measurement to aid in assessment and as an ideal to achieve balanced aesthetic results in midface restorative procedures-lifting or volumization-in females

Canthal cutdown for emergent treatment of orbital compartment syndrome

<p>This article evaluates the use of a “canthal cutdown” technique in orbital compartment syndrome in a cadaveric model. Twelve cadaver orbits were used to simulate orbital compartment syndrome using a blood analog solution. Two pressure probes, in different orbital locations, were used to monitor orbital pressure. Pressure was monitored during successive procedures: canthotomy, cantholysis, and canthal cutdown. Orbits were then re-injected with solution, simulating an active orbital hemorrhage, and pressure measurements were recorded over a 10-minute duration. No statistically significant difference was found between the two orbital pressure monitoring devices at each measurement point (<i>p</i> = 0.99). Significant pressure reductions, for both probes, were observed after canthal cutdown compared to initial measurement after injection of 20 mL blood analog (<i>p</i> < 0.001 and <i>p</i> = 0.005). When comparing the orbital pressure following canthotomy and inferior cantholysis versus canthal cutdown, the cutdown procedure provided an additional 74% in orbital pressure reduction (p =0.01). After re-injection of 10 mL of solution and 10 minutes of egress, pressure returned to baseline (probe 1: baseline 7 mm Hg vs. post-cutdown at 10 minutes 7 mm Hg; <i>p</i> = 0.83; and probe 2: 5 mm Hg vs. 5 mm Hg; <i>p</i> = 0.83). The canthal cutdown technique provides further reduction in orbital pressure versus canthotomy and cantholysis alone. The technique may be effective for treatment of static orbital compartment syndrome and temporizing treatment of compartment syndrome from active orbital hemorrhages.</p

Antibody Development in Patients Treated Long-Term With OnabotulinumtoxinA for Benign Essential Blepharospasm and Hemifacial Spasm

Report the development of onabotulinumtoxin-A neutralizing antibodies in patients treated consecutively for 20 years or longer for benign essential blepharospasm (BEB), hemifacial spasm (HFS), and Meige Syndrome