Thomas A. Bersani

Medial rectus muscle injuries associated with functional endoscopic sinus surgery: Characterization and management

Objective To characterize and evaluate treatment options for medial rectus muscle (MR) injury associated with functional endoscopic sinus surgery (FESS). Design Retrospective interventional case series Participants A total of 30 cases were gathered from 10 centers. Methods Cases of orbital MR injury associated with FESS surgery were solicited from members of the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) through an e-mail discussion group. Main Outcome Measures Variables assessed included patient demographics, computerized tomography and operative findings, extent of MR injury and entrapment, secondary orbital/ocular injuries, initial and final ocular alignment and ductions, and interventions. Results A spectrum of MR injury ranging from simple contusion to complete MR transection, with and without entrapment, was observed. Four general patterns of presentation and corresponding injury were categorized. Conclusions Medial rectus muscle injury as a complication of FESS can vary markedly. Proper characterization and treatment are important, particularly with reference to the degree of direct MR injury (muscle tissue loss) and entrapment. Patients with severe MR disruption can benefit from intervention but continue to show persistent limitation of ocular motility and functional impairment. Prevention and early recognition and treatment of these injuries are emphasized.

Increased patient comfort utilizing botulinum toxin type a reconstituted with preserved versus nonpreserved saline.

Purpose: To demonstrate that injection of botulinum toxin type A is less painful when mixed with preserved saline compared with the suggested preservative-free saline reconstitution. Methods: Two different injections were compared on 20 patients who had prior botulinum toxin type A treatments. Each side was injected with toxin reconstituted with either preserved or nonpreserved (0.9%) saline. The investigators and patients were blinded, and outcome was assessed with a verbal scale. Clinical outcome was subjectively and informally assessed by patient questioning and physician observation. Results: Injection of botulinum toxin type A was noted to be less painful with the use of the preserved compared with the nonpreserved preparation (P<0.0001). The preserved reconstitution appeared to have no effect on clinical outcome. Conclusions: Injection of botulinum toxin reconstituted with preserved saline is less painful than nonpreserved saline preparations.

Multiple bilateral extraocular muscle metastases as the initial manifestation of breast cancer.

A 75-year-old woman had gradually progressive binocular diplopia and 2 months later had breast cancer diagnosed. Examination showed bilateral external ophthalmoplegia with lid retraction and lag and no pupillary abnormalities. Orbital magnetic resonance imaging showed enlargement and enhancement of all extraocular muscles bilaterally. A right orbital biopsy was consistent with metastatic breast carcinoma. Positron emission tomography, bone scan, and computed tomography of the chest, abdomen, and pelvis failed to disclose other evidence of breast cancer metastases. It is unusual to encounter metastatic breast cancer affecting every extraocular muscle before the diagnosis of the primary carcinoma.

Benign approach to a malignant orbital tumor: metastatic renal cell carcinoma

A well-circumscribed, pseudoencapsulated benign-appearing lesion in the retrobulbar orbit of a 50-year-old man was found to be a metastatic renal cell carcinoma. The patient had a nephrectomy for renal cell carcinoma 15 years before, and had developed four other isolated metastases over the preceding 8 years. He had a further distant metastasis 1 year later, but is living and well 4 years after excision of the orbital tumor. Metastatic renal cell carcinoma of the orbit may have very benign characteristics, both clinically and radiographically, and can often be managed effectively by local excision with prolonged survival.

Prevalence of canaliculitis requiring removal of SmartPlugs.

Purpose: To report the first accurate prevalence of canaliculitis associated with the use of the SmartPlug. Methods: All patients from a single private ophthalmology practice who received SmartPlugs from 2002 to 2007 were identified. All patients from the private ophthalmology practice that developed canaliculitis secondary to SmartPlug insertion were referred to a single private ophthalmic plastic and reconstructive surgery office. A retrospective review of those 17 patients was performed. Results: From 2002 to 2007, a total of 235 patients were identified from a single private ophthalmology practice with a total of 402 SmartPlugs inserted. Of those 235 patients, 17 developed canaliculitis and were referred to a single private ophthalmic plastic and reconstructive surgery office. The prevalence of canaliculitis per patient was 7.23%. The prevalence of canaliculitis per SmartPlug inserted was 4.73%. The average time from SmartPlugs insertion to onset of symptoms was 3 years. All affected patients required canaliculotomy and plug removal. Conclusions: This is the first study reporting the prevalence of canaliculitis associated with the use of the SmartPlug. All affected patients required surgical intervention, after which many continued to have dry eye and one required bilateral Jones tubes. Ophthalmologists using the SmartPlug for the treatment of dry eye syndrome should carefully weigh the risks and benefits of their use.

Regression of a Paraganglioma Tumor of the Orbit

Abstract Purpose: To describe a clinical case of an orbital paraganglioma that displayed regression after biopsy alone. Methods: Case report. Results: A 75-year-old female was examined for a right orbital tumor suspected to be metastatic breast carcinoma. An orbital biopsy was performed with significant hemorrhage encountered requiring extensive cautery. There was apparent clinical regression of the tumor with no signs of proptosis or eye movement restriction two years after this patient’s biopsy. Histology was consistent with paraganglioma (glomus tumor). Conclusion: Although we cannot rule out spontaneous regression of this unique tumor, we postulate that tissue necrosis caused by the use of cautery induced regression. Unless encapsulated and easily accessible, we suggest that the best management of this rare tumor is that of observation after being found negative for malignancy by biopsy given their propensity for slow progression and in rare cases, regression.

Transcaruncular Medial Wall Orbital Decompression: An Effective Approach for Patients with Unilateral Graves Ophthalmopathy

Purpose. To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. Methods. Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. Results. The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). Conclusions. Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results.

Visual improvement after optic nerve sheath decompression in a case of congenital hydrocephalus and persistent visual loss despite intracranial pressure correction via shunting.

Among the sequelae of persistent raised intracranial pressure (ICP) are ophthalmologic signs and symptoms, including cranial nerve palsies, visual field deficits, papilledema, and vision loss. Elevated pressure within the optic nerve sheath may not be relieved by shunt procedures, which can decrease generalized ICP. The authors present a case of acute visual loss in the setting of chronic hydrocephalus and multiple shunt revisions. Despite shunt correction resolving systemic symptoms of raised ICP, this child had persistent visual loss. Bilateral optic nerve sheath decompression was performed, and the visual acuity improved over the next 3 days. This case highlights the importance of routine ophthalmologic examination in patients with hydrocephalus and shunts and demonstrates the utility of optic nerve sheath decompression as a surgical intervention when shunting alone does not resolve visual loss.

Orbital volume expansion of dysthyroid ophthalmopathy by surgical placement of lateral rim implants: a case study.

PURPOSE To measure the increase in orbital volume expansion effected by surgical placement of a lateral rim implant. METHODS Computed tomography was used to obtain 1-mm axial sections of a normal human cadaver skull. A computer program was used to measure the orbital area of each section and integrate the sum of the areas to obtain the total orbital volume. Following placement of a lateral orbital rim implant, this procedure was repeated to obtain the new orbital volume. RESULTS The orbital volume increased from 22.2 cm3 to 23.6 cm3 (an increase of 6%) following placement of the lateral orbital rim implant. CONCLUSION Surgical placement of a lateral orbital rim implant can be an effective method of orbital volume expansion in dysthyroid ophthalmopathy.

Pediatric and adult vision restoration after optic nerve sheath decompression for idiopathic intracranial hypertension

ABSTRACT To compare presentations of idiopathic intracranial hypertension and efficacy of optic nerve sheath decompression between adult and pediatric patients, a retrospective cohort study was completed All idiopathic intracranial hypertension patients undergoing optic nerve sheath decompression by one surgeon between 1991 and 2012 were included. Pre-operative and post-operative visual fields, visual acuity, color vision, and optic nerve appearance were compared between adult and pediatric (<18 years) populations. Outcome measures included percentage of patients with complications or requiring subsequent interventions. Thirty-one adults (46 eyes) and eleven pediatric patients (18 eyes) underwent optic nerve sheath decompression for vision loss from idiopathic intracranial hypertension. Mean deviation on visual field, visual acuity, color vision, and optic nerve appearance significantly improved across all subjects. Pre-operative mean deviation was significantly worse in children compared to adults (p=0.043); there was no difference in mean deviation post-operatively (p=0.838). Significantly more pediatric eyes (6) presented with light perception only or no light perception than adult eyes (0) (p=0.001). Pre-operative color vision performance in children (19%) was significantly worse than in adults (46%) (p=0.026). Percentage of patients with complications or requiring subsequent interventions did not differ between groups. The consistent improvement after surgery and low rate of complications suggest optic nerve sheath decompression is safe and effective in managing vision loss due to adult and pediatric idiopathic intracranial hypertension. Given the advanced pre-operative visual deficits seen in children, one might consider a higher index of suspicion in diagnosing, and earlier surgical intervention in treating pediatric idiopathic intracranial hypertension.