Alan Lessner

Fixation Duress in the Pathogenesis of Upper Eyelid Retraction in Thyroid Orbitopathy: A Prospective Study

BACKGROUND Upper eyelid retraction in thyroid eye disease may be caused by proptosis, levator and Müllers muscle infiltration with fibrosis or individual fiber enlargement, excessive sympathetic innervation, abnormal adhesions between levator palpebrae muscle and surrounding tissues, or fixation duress. Fixation duress refers to upper eyelid retraction while fixating with an eye with inferior rectus muscle restriction due to excessive simultaneous firing of the ipsilateral superior rectus and levator palpebrae muscles. METHODS The authors prospectively examined six patients with strabismus and thyroid eye disease associated with inferior rectus restriction and upper eyelid retraction in whom the eyelid retraction was suspected clinically to be a result of fixation duress. All six patients underwent recession of both inferior recti ranging from 3 to 6.5 mm (mean, 4.5 mm) to improve the ocular motility and alignment, reduce the diplopia, and mitigate the upper eyelid retraction. RESULTS Reduction of upper eyelid retraction measured as the preoperative versus postoperative difference in corneal light reflex-upper eyelid margin measurements was achieved in all patients postoperatively, ranging from 1.5 to 5.5 mm (mean, 3.2 mm). Only one patient showed significant residual retraction to warrant consideration of upper eyelid surgery. CONCLUSION Fixation duress plays a significant role in upper eyelid retraction of thyroid eye disease in a subset of patients with restriction of the inferior rectus muscle. In this selected group of patients, the upper eyelid retraction may be reduced or eliminated upon proper recession of the tight inferior rectus muscle(s).

Management of Traumatic Eyelid Lacerations

(1994). Management of Traumatic Eyelid Lacerations. Seminars in Ophthalmology: Vol. 9, No. 3, pp. 145-151.

Breaking the Mold of Orbital Cellulitis

A 52-year-old, immune-suppressed man presented with painful proptosis. Orbital imaging revealed enhancement of his right inferior rectus muscle and mild ethmoidal sinus disease. Sinus washings and turbinectomy demonstrated Curvularia. Despite aggressive intravenous antimicrobials, the patient remained febrile. Repeat imaging demonstrated a well-defined intramuscular abscess without contiguous orbital or paranasal involvement. Following surgical drainage, the patient improved. Cultures of the material expressed from the abscess confirmed a co-infection with Fusarium. Although rare, fungal abscess of the extraocular muscle should be considered in patients (particularly if immunosuppressed) with extraocular muscle enlargement resistant to conventional antimicrobial therapy. Prompt diagnosis and treatment could potentially prevent further serious morbidity or mortality.