Evan Kalin-Hajdu

Visual acuity of children treated with chemotherapy for optic pathway gliomas

Chemotherapy is the most common primary treatment modality for pediatric optic pathway gliomas (OPGs). Due to the risk of severe visual impairment, visual acuity (VA) has become a clinical parameter of fundamental importance for children with OPGs. Despite this reality, most studies omit crucial information necessary for analysis of the effect of chemotherapy on VA in patients with cerebral gliomas. The principal goal of this study was to determine the immediate and long‐term visual outcome of children treated first with chemotherapy for OPGs.

Controversies of the lacrimal system

Numerous long-standing controversies influence the management of lacrimal sac abscesses, canalicular lacerations, and obstruction of the nasolacrimal duct. We examined the debatable beliefs that underline these controversies and concluded the following: drainage of a pointing lacrimal sac abscess can be well tolerated under local anesthesia, is associated with few adverse events, and should be performed regardless of whether systemic antibiotics have been administered. Reconstruction of monocanalicular lacerations should be considered in all cases, without distinction to whether the injury involves the upper or lower canaliculus. Finally, no firm evidence currently exists supporting intubation with routine dacryocystorhinostomy.

Outcome of viscodilation and tensioning of Schlemm’s canal for uveitic glaucoma

OBJECTIVE To evaluate the safety and efficacy of circumferential viscodilation and tensioning of Schlemms canal (canaloplasty) in the treatment of uveitic glaucoma (UG). DESIGN Pilot, retrospective, noncomparative case series. PARTICIPANTS Nineteen uveitic eyes of 15 patients with UG. METHODS The main outcome measure was surgical success. Secondary outcome measures included intraocular pressure, usage of ocular hypotensive medication, visual acuity, and sight-threatening complications. Patients were included when UG could not be controlled despite maximum tolerated medical therapy. Exclusion criteria were peripheral anterior synechiae and previous glaucoma surgery. RESULTS Mean follow-up time from canaloplasty was 2.6 ± 1.1 years. Mean intraocular pressure decreased from 30.4 ± 8.4 mm Hg preoperatively to 13.8 ± 5.0 mm Hg at last follow-up (p < 0.001). The mean number of ocular hypotensive medications decreased from 3.7 ± 0.8 preoperatively to 0.4 ± 1.0 at last follow-up (p < 0.001). At last follow-up, the complete success, qualified success, and failure rates were 73.7%, 10.5%, and 15.8%, respectively. No canaloplasty-related permanent sight-reducing complications occurred. Preoperative best corrected visual acuity decreased more than 1 Snellen line in 1 eye due to exacerbation of uveitis 18 months postoperatively. CONCLUSIONS Canaloplasty appears to be a relatively safe and effective initial surgical intervention in UG.

Invasive fungal sinusitis: treatment of the orbit

Purpose of review To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit. Recent findings Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options. Summary Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.

Comparison of Two Polypropylene Frontalis Suspension Techniques in 92 Patients with Oculopharyngeal Muscular Dystrophy.

PURPOSE To compare the functional outcome of the polypropylene trapezoid frontalis suspension with the polypropylene modified Crawford frontalis suspension in a large cohort of patients with oculopharyngeal muscular dystrophy. METHODS Retrospective, nonrandomized comparative case series. Patients with oculopharyngeal muscular dystrophy who underwent bilateral polypropylene frontalis suspension were selected for chart review. Main outcome measures were margin reflex distance, duration of surgery, and ptosis recurrence. RESULTS Ninety-two patients qualified for chart review; 39 patients underwent the trapezoid sling and 53 patients the modified Crawford sling. There was no difference in preoperative margin reflex distance or levator function between the 2 surgical groups. Postoperative improvement in margin reflex distance was 2.95 ± 1.56 mm in the trapezoid group compared with 2.85 ± 1.65 mm in the modified Crawford group (p = 0.67). Duration of surgery was 40.49 ± 13.33 minutes in the trapezoid group compared with 53.77 ± 16.04 minutes in the modified Crawford group (p < 0.001). Five percent of eyes in the trapezoid group had ptosis recurrence compared with 13% of eyes in the modified Crawford group (p = 0.07). CONCLUSION Both polypropylene frontalis suspension techniques generated an equivalent increase in margin reflex distance. However, the trapezoid frontalis suspension required less operative time and trended toward a lower rate of ptosis recurrence.

Ocular Penetration Secondary to Cocaine-Induced Midline Destructive Lesion.

Herein, the authors present a retrospective case report of a patient with ocular penetration due to cocaine-induced midline destructive lesion. To their knowledge, this is the first documented case of ocular penetration secondary to cocaine insufflation.

Levator Aponeurosis Dehiscence: External Levator Advancement

Dehiscence of levator aponeurosis was historically viewed as the exclusive cause of acquired blepharoptosis with normal levator function. In reality, acquired blepharoptosis with normal levator function is likely triggered by many factors including levator aponeurosis dehiscence from the anterior face of tarsus, stretching of the aponeurosis, and/or fatty infiltration of levator muscle. Irrespective of the underlining pathophysiology, external advancement of levator aponeurosis can effectively treat acquired blepharoptosis with normal levator function. Even in experienced hands, especially when an eyelid has been previously operated or there is significant fatty infiltration of levator muscle, external levator advancement can be a challenging operation. The main steps of this surgery are as follows: identification of the anterior face of levator aponeurosis, complete disinsertion of levator aponeurosis from its insertion on tarsus, advancement of the free edge of aponeurosis, and reattachment of this edge onto tarsus.

Zoledronic acid-induced orbital inflammation in a patient with multiple myeloma

Multiple myeloma is a cancer of malignant plasma cells which stimulates osteoclasts and is associated with increased bone turnover and osteolysis. Bisphosphonates including zolendronic acid are used to prevent skeletal complications in patients with multiple myeloma. Orbital inflammation is a rare but serious complication following use of bisphosphonates. The diagnosis is made by excluding other possible causes in patients with myeloma and rapid initiation of therapy is required. Corticosteroids are the mainstay of therapy but the ideal treatment course has not been delineated. This report describes a case of this rare complication and provides a review of the literature.

Acute Vision Loss From Dacryocystitis

Report of a Case | A 59-year-old woman presented with 2 days of left orbital pain. Medical history was significant for hypertension controlled with lisinopril and several months of epiphora without prior dacryocystitis. Examination revealed acuity of 20/25 OD and 20/400 OS, edematous, hyperemic left eyelids, diffuse limitation in extraocular movements in the left eye, normal intraocular pressure, and normal fundi on both sides. Computed tomography with contrast revealed a left-sided lacrimal sac abscess with postseptal fat stranding largely limited to the extraconal space, minimal sinus mucosal thickening, and opacification of both nasolacrimal ducts (Figure 1A). Urgent, bedside transcutaneous incision and drainage yielded copious pus. No packing was placed, and intravenous ampicillin-sulbactam and vancomycin were started. Next-day cultures isolated grampositive cocci in chains, visual acuity in the left eye improved to 20/70, and intraocular pressure was 17 mm Hg in each eye. Two days after drainage, visual acuity remained 20/70, but with worsening eyelid edema and no improvement in extraocular movements. Repeated contrast-enhanced computed tomography revealed increased abscess size with globe compression (Figure 1B). There was minimal intraconal fat stranding, and the optic nerve was unremarkable in appearance. Intraocular pressure remained normal in each eye. The next day, the patient had intraoperative repeated incision and drainage, bacitracin washout, and surgical drain placement. On postoperative day 1, edema and pain were improved, but visual acuity in the left eye was no light perception, with a 4+ relative afferent pupillary defect and new disc edema. Intraocular pressure was within normal limits. Same-day magnetic resonance angiography demonstrated a patent ophthalmic artery; however, diffusionweighted imaging showed acute injury to the entire orbital segment of the left optic nerve (Figure 2). Cultures from the initial drainage grew pan-susceptible Streptococcus pyogenes. Antibiotics were narrowed 5 days after original incision and drainage to complete 2 weeks of ceftriaxone. She underwent an external dacryocystorhinostomy 1 month later. At 6 months, visual acuity in the left eye remained no light perception.

Normalization of Congenital Venous Stasis Retinopathy Following Sclerotherapy of a Macrocystic Lymphatic Malformation

The authors describe, for the first time to their knowledge, a case of a congenital macrocystic lymphatic malformation of the orbit with associated venous stasis retinopathy that acutely normalized after drainage and sclerotherapy of the lesion. Prenatal ultrasound revealed prominence of the left orbital soft tissue, and at birth, the patient was noted to have unilateral proptosis, tortuous retinal vessels, and intraretinal hemorrhages in all 4 quadrants in the left eye. MRI demonstrated a primarily intraconal, multiloculated, T2-hyperintense mass consistent with a lymphatic malformation. Ultrasound-guided cyst aspiration and sclerotherapy was performed, with subsequent improvement of the proptosis and resolution of the vessel tortuosity and intraretinal hemorrhages. Although venous stasis retinopathy is usually related to central retinal vein occlusion or carotid artery occlusive disease, any entity that increases orbital venous resistance can generate retinal venous dilation and intraretinal hemorrhages, including an orbital lymphatic malformation.