Richard L. Anderson

Optic Nerve Blindness Following Blunt Forehead Trauma

Abstract Seven cases of sudden monocular blindness following frontal head trauma are presented. The average age of these patients was 18 years. Four of the seven patients underwent transethmoid-sphenoid nerve decompression with only one of the four achieving a minor return of vision. None of the three out of six patients who failed to respond to megadose steroids regained vision with optic nerve decompression. Three out of six patients had return of good vision with megadose steroids without optic nerve decompression. Two of these three patients had a delayed loss of vision. One of the three patients with visual return developed visual loss again following a facial fracture reduction, which again responded to megadose steroids without optic nerve decompression. Another patient had visual return on steroids but also required removal of a subperiosteal hematoma to obtain near normal vision. This case differs from our other cases in that subperiosteal hematoma is an unusual complication of these injuries and caused the optic nerve compression in the orbital apex in this case. Review of the literature and our clinical and experimental findings suggest that the etiology of the indirect optic nerve injury is secondary to a stretching, tearing, torsion, or contusion of the nerve caused not only from the momentum of the eyeball and orbital contents being absorbed by the fixed canalicular portion of the optic nerve but also by skeletal distortion caused by forces remote from the initial impact. This is well illustrated by the holographic findings. These injuries cause direct injury to the nerve or vascular compromise from tearing, thrombosis, hematoma, or compression of the small nutrient vessels supplying the optic nerve. Megadose steroids appear to be useful in some cases of traumatic monocular blindness secondary to blunt facial trauma and as an adjunct to or an indication for surgery in others. The authors recommended indications for optic nerve decompression (transethmoid-sphenoidotomy with removal of the medial wall of the optic canal) following blunt trauma are (1) delayed visual loss following frontal head trauma unresponsive to 12 hours of megadose steroid therapy and (2) initial return of vision with megadose steroids followed by visual decrease while on steroids or with the tapering of steroids.

The Aponeurotic Approach to Eyelid Retraction

A technique for the upper lid retraction that involves an anterior approach similar to aponeurotic ptosis surgery is presented. Instead of advancing the aponeurosis, it is recessed and Müllers muscle is completely extirpated. The lateral horn of the levator must be cut to relieve the marked temporal elevation of the eyelid. Lid height and contour are adjusted intraoperatively with patient cooperation. In the lower lid, the retractors are recessed via a conjunctival approach unless simultaneously performed with orbital decompression. Any amount of lid retraction may be corrected by this technique in the upper lid and up to 3 mm of lower lid retraction can be corrected. Lid height in both the upper and lower lid is lasting and predictable. Thirty-one patients (63 eyelids) have been operated on using this technique with good results. Results in 17 patients (35 eyelids) with follow-up ranging from 8 to 42 months are presented.

Orbital Malignant Melanoma and Oculodermal Melanocytosis: Report of Two Cases and Review of the Literature

Oculodermal melanocytosis is a congenital melanoblastic hamartoma affecting ocular tissues and facial skin. It is seen more commonly in oriental and black patients. Malignant degeneration, once believed to be rare in this syndrome, occurs in 4.6% of all reported cases, and is more frequent in whites. The actual incidence of malignant melanoma in this syndrome is difficult to determine as many uncomplicated cases go unreported. The most common site of malignant melanoma associated with this entity is in the choroid. Four previously described orbital tumors represent the second most frequent area of presentation. A review of the literature in this disease is discussed as well as a new case of orbital malignant melanoma associated with it. A second case of presumed orbital melanoma associated with oculodermal melanocytosis is also discussed.

Trochleitis with Superior Oblique Myositis

Thirteen patients complained of recent fluctuating aching of one orbit, punctuated by stabbing pains. All had exquisite point tenderness over the trochlea and in half of the patients the pain was aggravated by eye movement. Standardized A-scan echography demonstrated swelling of the peritrochlear tissue and thickening of the superior oblique muscle with low internal acoustic reflectivity, typical of myositis. CT scan showed a soft tissue density in the region of the trochlea. Biopsy, performed on two patients, revealed peri-trochlear inflammation. In all patients the symptoms resolved within a period of weeks or months: indomethacin or naproxen were not effective, but oral or locally injected corticosteroids shortened the course compared to no treatment. None of the patients had ptosis, proptosis, Browns syndrome, or a click, nor did they have echographic or radiographic signs of sinusitis or inflammation away from the trochlea. This probably represents a highly localized subtype of idiopathic orbital inflammation (pseudotumor).

Petriellidium (Allescheria) Boydii Orbital and Brain Abscess Treated with Intravenous Miconazole

A previously healthy 4-year-old boy suffered a penetrating injury to his left orbit and left frontal lobe, which resulted in an infection by Petriellidium boydii. The patient was successfully treated with intravenous miconazole and multiple debridements.

Tarsal Strip Procedure for Correction of Eyelid Laxity and Canthal Malposition in the Anophthalmic Socket

Surgically anophthalmic sockets commonly have laxity of the lower eyelid, inferior displacement of the lower eyelid and lateral canthus, shallowing of the inferior fornix, and a deep superior sulcus. These deformities result in difficulty in prosthesis retention, pooling of tears and mucus, epiphora and lower eyelid irritation, and poor cosmesis with an appearance of facial asymmetry. The causes of these problems are numerous, but the main anatomic deformity is a marked laxity and elongation of the lateral canthal tendon. The tarsal strip procedure is ideal for correcting or improving these deformities simultaneously with one simple procedure. We are very pleased with our results in 26 patients with surgically anophthalmic sockets in which this procedure was utilized. We highly recommend the tarsal strip procedure not only to correct these conditions in anophthalmic sockets but in almost any condition where laxity of the eyelids or canthal malposition requires surgical correction.

Iris melanoma. Nevus or malignancy

Although iris melanomas have an excellent prognosis when diagnosed and treated early, they should not be considered benign lesions. The authors report the orbital recurrence of a melanoma in a patient whose eye had been enucleated 30 years earlier because of an iris melanoma. The clinical, epidemiological and pathological characteristics of iris melanomas are summarized and compared to those of other uveal melanomas. The similarities suggest that iris melanomas are not by nature more benign than other uveal melanomas and that their better prognosis is due to the earlier detection allowed by their more obvious location.

Sudden Blindness following Facial Trauma

Blindness following facial trauma may occur with what appears to be a minor insult to the periorbital area. This report deals with our experience in treating five patients who had sudden blindness following frontal head trauma. Unselected optic nerve decompression was in general unrewarding in reversing blindness. However, the early administration of pharmacologic doses of corticosteroids does appear effective in reversing blindness in this select patient population and may indicate which patient is a good candidate for decompression. Examination of holographic experiments performed on dried skulls, in addition to clinical findings, appears to suggest that the cause of blindness associated with frontal head trauma may be related to stretching of the optic nerve and not necessarily to compression.

Giant Cell (Reparative) Granuloma of the Orbit

Clinically and histologically, there exists considerable controversy as to what constitutes a giant cell tumor. There is an increasing awareness that the term giant cell tumors should not be used indiscriminately in describing lesions of the mandible, maxilla, and facial bones which contain multinucleated giant cells. This paper reports a rare case of giant cell reparative granuloma of the orbit. The differentiation between giant cell reparative granuloma and the true giant cell tumor is discussed and a description of the visual symptomatology associated with these lesions of th sphenoid bone is presented. These tumors must be removed completely to prevent recurrence.

Metastatic Carcinoid Unresponsive to Radiation Therapy Presenting as a Lacrimal Fossa Mass

A case of metastatic carcinoid tumor presenting as a lacrimal fossa mass is described. This appears to be only the fourth case report of metastatic carcinoid to the orbit and the first to include ultrasound evaluation. the tumor mass did not regress despite radiation therapy as documented on serial ultrasound examinations. Therapeutic implications of this finding are discussed. Metastatic carcinoid tumors are reviewed.