Some Orbital Confusion

A 64 year old gentleman was referred for progressive horizontal diplopia.In September 2006 he had been referred for a second opinion regarding a 5 year history of intermittent swelling around the right orbit, worsening over 7 months associated with double vision, and proptosis (C,D).Acuity was 20/25. 24-2 demonstrated moderate diffuse depression OD > OS, and some arcuate VF changes OS. Palpebral fissures were 13 and 10 with an upper lid range of 15 and 12. Hertels 28/19 with some resistance to retropulsion. There was no APD, but definite limitation in elevation > abduction, adduction, and depression OD with 100 seconds stereopsis. Applanation tensions were 16 and 12. OCT demonstrated minimal thinning of NFL superiorly and nasally, but symmetric OU. CT scan (A,B) demonstrated R orbital pathology.Flow CytometryReview of the original orbital pathology failed to confirm malignancy and a repeat orbital biopsy was planned.Chlorambuci

Blood Less than Whole

Diplopia; ProptosisA 76-year old female with left eyelid difficulties. Previous history significant for diabetes and basal cell carcinoma.VA: Best-corrected, 20/25 OD, 20/40 OSN/ANeoplastic plasma cells at the skull baseXRTAttache

The Gift that Keeps Giving

Diplopia; Reduced acuityA 55-year old male with a 6-month history of double vision, reduced acuity and gradual loss of vision ODVA: 20/30 OD, 20/20 OSCT; MRIMucorAnti-bacterial agents; Steroids; Surgery1. Anderson JR, Treip CS. Radiation-induced intracranial neoplasms: A report of three possible cases. Cancer 53: 426-9, 1984. 2. Anonymous. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 3-2001. A 59-year-old diabetic man with unilateral visual loss and oculomotor-nerve palsy. N Engl J Med 344:286-93, 2001. 3. Ducatman BS, Scheithauer BW. Postirradiation neurofibrosarcoma. Cancer 51:1028-33, 1983. 4. Hussain S, Salahuddin N, Ahmad I, et al. Rhinocerebral invasive mycosis: occurrence in immunocompetent individuals. European J Radiol. 20:151-5, 1995. 5. Ron E, Modan B, Boice JD Jr, et al. Tumors of the brain and nervous system after radiotherapy in childhood. N Engl J Med 319:1033-9, 1988. 6. Yousem DM, Galetta SL, Gusnard DA, Goldberg HI. MR findings in rhinocerebral mucormycosis. J Comput Assist Tomog. 13:878-82, 1989

Now You See It, Now You Don't (Audio)

Pulsatile exopthalmosA 57-year old female with ocular pulsations. Previous history significant for refractive error, cataracts, s/p cataract surgery and map dot dystrophy.VA: 20/20 OD, 20/25 OS; Hertel exophthalmometry: 15 OU; Applanation tension: 24 OUCT; MRIMeningothelial proliferation with associated vascular ectasiaSurgery1. Druch-Gerharz D, Gerharz CD, Stegeh et al: Cutaneous lymphatic malformation in disappearing bone (Gorham-Stout Disease): A novel clue to the pathogenesis of a rare syndrome. J Am Acad Dermatol. 56:S21 -5, 2007. 2. Gorham LW, Wright AW, Schultz HH, Maxon FC: Disappearing bones: a rare form of massive osteolysis. Am J Med. 17:674-82, 1954. 3. Klein M, Metelmann HR; Gross U: Massive osteolysis (Gorham-Stout syndrome) in the maxillofacial region: an unusual manifestation. Int J Oral and Maxillofacial Surg. 25:3768, 1996. 4. Krohel GB, Freedman K; Peters GB III, Popp AJ: Gorham disease of the orbit. Am J Ophthalmol. 133:729-30, 2002. 5. Radhakrishnan K, Rockson SG: Gorham's disease: An osseous disease of lymphangiogenesis? Annal NY Acad Sci. 1131: 203-5, 2008.CLorbitalbiops

Something Out of the Sellar

MigraineA 37-year old female with a several-year history of bi-frontal migraine headache that were occasionally accompanied by nausea and vomiting.VA: 20/25 OD, 20/400 OS; Right ptosisCT; MRIInfiltrating sellar neoplasm consisting of small, round cells positive for immune markers consistent with rhabdomyosarcoma.Surgery; GlucocorticosteroidsAttache

Reconstruction Surgery of the Orbit

The knowledge of the skeletal anatomy precedes recorded medical history, but the ability to intervene is a product of modern surgical advances. Harold Gillies, while a major in the British army, established not only the foundation for modern plastic surgery, but also describes some of the earliest reconstructive procedures of the face and orbit in his 1920 volume on plastic surgery of the face. While isolated pioneering work was reported in the United States, including orbital translocation surgery by Edgerton at Johns Hopkins, the popularization of craniofacial surgery for congenital defects has been largely the work of Tessler in Paris. Over the last two decades there has been a marked interest in craniofacial reconstructive surgery, often with multidisciplinary teams consisting of ophthalmologists, head and neck, plastic, and neurosurgeons. Craniofacial reconstructive surgery requires a detailed knowledge of the anatomy of the head and neck as well as access to the appropriate diagnostic facilities