Isolated oculomotor nerve palsy related to sinusitis?

The association of sinusitis with ocular motility disorders is a seductive theory due to their close anatomical vicinity. Typically, sinusitis can influence ocular motility by affecting single muscles or a combination of muscles and/or cranial nerves due to a local inflammatory tissue reaction. Although rare, sinusitis has been suggested at least as a cause for superior-branch oculomotor palsy. We report a case of progressive, isolated, third-cranial-nerve palsy caused by an aneurysm of the posterior-communicating artery that initially was thought to be related to pansinusitis

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

IgG4-assoziierte orbitale Entzündungen

INTRODUCTION: Serum immunoglobulin G4 (IgG4)-related systemic disease is a newly found entity and should be considered as a further differential diagnosis to the big pool of unspecific orbital inflammation. We describe clinical appearance and treatment options. PATIENTS AND METHODS: We retrospectively analyzed all patients with the diagnosis IgG4-related orbital inflammation who were examined in our outpatient clinic. We compared symptoms, clinical and histological findings and therapy. RESULTS: In the last 17 months five patients were diagnosed with IgG4-related orbital disease. Biopsies were performed of most affected areas as seen in the computerised tomography scan. Histology revealed marked infiltration with IgG4-positive plasma cells. Serum IgG4-levels were partly significantly elevated. Based on these findings diagnosis of an IgG4-related disease was agreed and treatment with oral prednisone installed. In one patient a therapy with Rituximab was successfully started. CONCLUSION: Extended unspecific orbital inflammation, especially when bilateral and associated with systemic disease should be considered to be IgG4-related. Histological proof of IgG4-positive plasma cells and elevated IgG4 serum levels do confirm this diagnosis. Strict follow-up and interdisciplinary work-up is recommended

Bisphosphonate-associated orbital inflammatory disease and uveitis anterior - a case report and review

BACKGROUND: Drug-induced cases of orbital inflammation and uveitis are rare.We present a bisphosphonate-induced case of unilateral orbital inflammation and bilateral anterior uveitis. PATIENTS AND METHODS: A 75-year-old female presents because of pain and swelling around her left eye with an onset 2 days after an intravenous zoledronic acid therapy for osteoporosis. Examination reveals reduced visual acuity of 0.2, proptosis of 4 mm, marked conjunctival chemosis and hyperemia, ophthalmoplegia and choroidal folds in the left eye and a bilateral anterior uveitis. CT and MRI scans show signs of diffuse pre- and postseptal inflammation in the left orbit. RESULTS: Initiation of intravenous methylprednisolon leads to a complete regression of the inflammatory process within days. This causality between the therapy with bisphosphonates and an orbital inflammation as well as an anterior uveitis corresponds to the literature. Drug-induced cases of orbital inflammation and uveitis have also been reported following use of antiinfectious drugs, biologica and vaccines. CONCLUSIONS: Iatrogenic causes should be considered in the differential diagnosis of orbital inflammations, scleritis and uveitis. Findings are mostly reversible after discontinuation of the drug and therapy of inflammation

Langzeitergebnisse nach chirurgischer Korrektur von Exodeviationen

DEUTSCH: HINTERGRUND: In der Strabologie stellt die präoperative Festlegung und laufende Kontrolle der Operationsdosierung eine besondere Herausforderung dar. Der Langzeitverlauf nach Augenmuskelchirurgie bei Exodeviationen wurde untersucht und die erzielte Wirkung durch den bestehenden Dosierungsansatz überprüft. PATIENTEN UND METHODEN: Bei 53 konsekutiven Patienten mit divergenten Schielformen wurden die Operationsresultate nach einem Jahr nach streng definierten Kriterien analysiert. Bei 18 der 53 Patienten konnten Langzeitverläufe von durchschnittlich 13 Jahren verfolgt werden. Die Subgruppe der 41 einseitig operierten Patienten (Rücklagerung M. Rectus lateralis, Resektion M. rectus medialis) wurde gesondert ausgewertet. Von dieser Subgruppe konnte bei 13 Patienten ein Langzeitverlauf erhoben werden. Für Patienten mit intermittierendem Strabismus divergens und dekompensierender Exophorie galten folgende Kriterien für die Operationsresultate nach einem Jahr und im Langzeitverlauf: sehr gut: Orthophorie oder Orthotropie mit Exo- oder Esophorie bis 5 Prismendioptrien (PD); gut: Orthotropie mit Exo- oder Esophorie bis 10 PD; zufriedenstellend: Orthotropie mit Exo- oder Esophorie > 10 PD, 10 PD oder Exo- oder Esotropie > 10 PD, < präoperativem Wert; schlecht: Winkel wie präoperativ oder größer. Eine subjektive Beurteilung erfolgte mittels Patienten-Fragebogen. ERGEBNISSE: Ein Jahr postoperativ waren die Resultate wie folgt: 6 sehr gut, 14 gut, 31 zufriedenstellend und 2 schlecht. Dreizehn Jahre postoperativ waren die Resultate wie folgt: 0 sehr gut, 4 gut, 12 zufriedenstellend und 2 schlecht. Die subjektive Beurteilung durch die Patienten fiel zu beiden Zeitpunkten deutlich besser aus. Der mittlere Exoshift im ersten postoperativen Jahr betrug 3,5°, in den darauffolgenden 12 Jahren nahm der mittlere divergente Winkel um 2,9° weiter zu. SCHLUSSFOLGERUNGEN: Die postoperativen Langzeitresultate zeigen eine erstaunliche Stabilität nach dem ersten postoperativen Jahr. Bei einer aggressiveren Dosierung wären mehr orthophore Ergebnisse zu erwarten gewesen, doch müsste man mit deutlich mehr unerwünschten Überkorrekturen rechnen. ENGLISH: BACKGROUND: In strabismus surgery the challenge is the preoperative determination of the surgical dosage. We assessed the long-term follow-up after strabismus surgery for exodeviations and evaluated the employed dosage. PATIENTS AND METHODS: We present a study of 53 consecutive patients who underwent surgery for exodeviations. One year postoperative results were analysed based on strict criteria. Out of the original group of 53 patients we could evaluate the long-term follow-up in 18 patients, after an average period of 13 years. The criteria for patients with intermittent exotropia and decompensating exophoria after one year and in the long-term follow-up were determined as follows: very good: orthophoria or orthotropia with exo- or esophoria less than 5 PD; good: orthotropia with exo- or esotropia less than 10 PD; satisfactory: orthotropia with exo- or esophoria > 10PD but less than the preoperative angle; bad: constant eso- or exotropia or > preoperative angle. For patients with a constant divergent strabismus the following criteria were determined: very good: orthophoria or orthotropia with exo- or esophoria less than 5 PD; good: exo- or esophoria less than 10 PD or tropia of 5° (microstrabismus); satisfactory: exo- or esophoria > 10 PD or exo- or esotropia > 10 PD but < preoperative angle; bad: same as preoperative or more. A subgroup analysis of 41 patients who underwent monolateral combined rectus muscle surgery was performed regarding their long-term follow-up (average: 13 years) as well. Concurrently the patients completed a questionnaire. RESULTS: One year postoperatively 6 outcomes were very good, 14 good, 31 satisfactory and 2 were poor. On average 13 years postoperatively the same patients were evaluated based on the same strict criteria. No outcome was very good, 4 good, 12 satisfactory and 2 were poor. The judgement of the patients in the questionnaire was at both times clearly better. The exo-shift in the first postoperative year was 3.5°, in the next on average 12 years the mean divergent strabismus angle increased by another 2.9°. CONCLUSIONS: The outcome evaluation after a long-term follow-up showed amazingly stable results compared to the follow-up after one year. With a more aggressive dosage we could have achieved more orthophoric results, but also more undesirable overcorrections

Hypoglobus – Schein oder Sein? Ätiologien vertikaler Bulbusdislokationen in einem tertiären Zentrumsspital

BACKGROUND: While exophthalmus is quantifiable with readily available measurement tools, there is no such tool for hypoglobus/hyperglobus. Despite its possible life-threatening causes only few articles address the etiologies of vertical globe displacement in the current literature. The aim of our study was to describe etiologies of hypoglobus and to analyze the ratio of malignant diseases. PATIENTS AND METHODS: 3000 portrait photographs taken in our ophthalmology department between 2005 and 2009 were retrospectively screened for patients with vertical globe displacement. Pictures were assessed by three independent ophthalmology-trained observers and matched to the diagnosis based on patient records. RESULTS: 95 patients with supposed vertical globe displacement were identified. Vertical globe displacement was due to an intracranial or orbital disease in 45 patients including 6 patients with a malignant disease. Additional 10 patients had thyroid associated orbitopathy. 11 patients turned out to have mere facial asymmetry, 26 patients had strabism and four patients had an ocular prosthesis. CONCLUSIONS: The etiologies of hypoglobus ranges from orbital fractures to life-threatening malignant tumors. Distinction between apparent and true hypoglobus can be challenging

Solitärer fibröser Tumor der Orbita: klinische, radiologische, histologische Merkmale und Differenzialdiagnose eines ungewöhnlichen Tumors

BACKGROUND: Solitary fibrous tumours (SFT) are mesenchymal neoplasias rarely found in the orbit. Due to their sharp delineation they are frequently mistaken for various benign neoplasma, such as cavernous hemangiomas, neurinomas and pleomorphic adenomas. We present two cases of SFT in the orbit and one in the lacrimal sac and discuss the radiological and histological differential diagnosis. PATIENTS AND METHODS: Among 9 patients diagnosed and operated in our department between 2008 and 2010 with an orbital tumour, three had the histological diagnosis of a solitary fibrous tumour. In 5 cases an MRI scan was performed preoperatively, in 4 cases a CT scan. RESULTS: Histology showed 2 pleomorphic adenomas, 2 cavernous hemangiomas, 2 neurinomas and 3 SFT. All SFT were intraoperatively well circumscribed and enucleated, showing histologically incomplete resection. No further treatment was given. There is no recurrence in any of the patients in the follow up of an average of 10 months (range 1 - 30 months). CONCLUSIONS: SFT are rare mesenchymal tumours of the orbit. The radiological differential diagnosis is difficult and they can be mistaken for more common tumours. The SFT has a wide range of histological appearances. Long term clinical follow-up is mandatory in all cases of SFT

Sinusitis und okuläre Motilitätseinschränkungen

Hintergrund: Die sekundäre entzündliche Mitbeteiligung orbitaler Strukturen im Verlauf einer akuten oder chronischen Sinusitis ist häufig. Die Assoziation ist allein schon angesichts der anatomischen Nachbarschaft verführerisch, das pneumatisierte System der Nasennebenhöhlen grenzt zu 60 - 80 % an die knöcherne Orbita. Typische sinugene Motilitätseinschränkungen resultieren aus der Affektion einzelner Muskeln oder Beteiligung mehrerer Muskeln und/oder Hirnnerven infolge lokaler Entzündungsprozesse und Bindegewebsmitreaktionen. Die Folge ist zumeist eine mehr oder minder komplexe Restriktion der Bulbusbeweglichkeit. Patienten und Methoden: In diese Fallserie wurden zwischen Januar 2006 und August 2007 neun konsekutive Patienten mit einer sekundären Orbitabeteiligung sinugenen Ursprungs prospektiv eingeschlossen. Ergebnisse: Bei fünf der Patienten trat keine Motilitätseinschränkung auf; die übrigen vier jedoch zeigten eine Beeinträchtigung der Motilität. Die Kasuistiken dieser vier Patienten werden präsentiert, um die Bandbreite möglicher Motilitätsstörungen im Zusammenhang mit Sinusitiden aufzuzeigen. Schlussfolgerungen: Okuläre Motilitätsstörungen sinugenen Ursprungs reihen sich ein in die orbitalen Komplikationen, die bis zur orbitalen Sepsis und zur Sinus-cavernosus-Thrombose führen können. Einerseits kann eine Sinusitis nahezu das gesamte Spektrum okulärer Motilitätseinschränkungen verursachen, andererseits gefährliche zerebrale Aneurysmen maskieren. Die „naheliegenden”, daher auch verlockenden Zusammenhänge dürfen nicht von dem Grundsatz - Häufiges ist häufig und Seltenes ist selten - ablenken