[Management of a complex strabismus secondary to complicated endoscopic dacryocystorhinostomy]

To report a patient with exotropia due to medial rectus muscle entrapment as a complication of endoscopic dacryocystorhinostomy [EDCR]. A 34-year-old female was referred with left exotropia 18 days after EDCR for treatment of primary nasolacrimal duct obstruction. She had a large angle left exotropia in primary position as well as complete limitation of adduction and partial limitation of abduction in the left eye. Forced duction test was positive in adduction and abduction, and force generation test revealed total paralysis of the left medial rectus. CT scan showed a large fracture of the medial orbital wall in which the medial rectus muscle was entrapped. She underwent the first operation through a medial canthal incision for releasing the entrapped muscle as well as repair of the medial orbital wall defect. After two additional surgeries including medial transposition of vertical rectus muscles and left lateral rectus muscle disinsertion she had 10 PD exotropia and her diplopia disappeared in primary position. In addition the patient had developed optic atrophy and superior arcuate visual field defect in her left eye probably because of intraoperative trauma to the optic nerve after EDCR. To the best of our knowledge, this is the first report of medial rectus entrapment following EDCR. This complication should be kept in mind in the approach to a patient with strabismus following endoscopic sinus and nasal surgeries in order to select appropriate diagnostic and therapeutic measures

[Pyogenic granuloma of the lacrimal sac]

To report a case of free floating pyogenic granuloma within the lacrimal sac. A 13 month old infant with unresolving dacryocystitis and history of two times failed probing and once failed turbinate fracture was scheduled for dacryocystorhinostomy [DCR]. A free floating red mass was removed from the sac. Histopathologic examination confirmed a diagnosis of pyogenic granuloma. Eight months after the operation the patient was asymptomatic. When probing of the lacrimal duct fails to improve its obstruction, in addition to nasal lesions, lacrimal sac masses including pyogenic granuloma must be considered

[ case of traumatic carotid cavernous fistula]

To describe a complicated case of traumatic carotid-cavernous fistula [CCF] and our management strategy. A 13-year-old patient was referred one month following a car accident and facial trauma with severe proptosis, chemosis and limitation of ocular movement. Presence of murmur and an enlarged superior ophthalmic vein on orbital imaging suggested an arteriovenous fistula. The patient underwent transarterial fistula ballooning which resulted in alleviation of the fistula and improvement of signs and symptoms. Orbital signs and symptoms following trauma may indicate an arteriovenous fistula

[Outcomes of treatment for sixth nerve palsy]

To report the outcomes of surgical and non-surgical treatment for sixth nerve palsy and paresis in our center. Hospital records of 33 patients [35 eyes] with sixth nerve dysfunction who were referred to Labbafinejad Medical Center from September 1996 to September 2006 and underwent surgical procedures or botulinum toxin injection were reviewed. Patients were divided into three groups: Group A had muscle surgery without transposition; group B had transposition procedures and group C had botulinum toxin injection. The deviation improved from 50.3 +/- 16.8 to 6 +/- 9.8 prism diopter [PD] after the first operation and to 2.5 +/- 5 PD after the second operation in group A; from 56.9 +/- 24.3 to 5.5 +/- 16 PD after the first operation and to almost zero following the second operation in group B; and from 44.3 +/- 10.5 to 15 +/- 20 PD 6 months following botulinum toxin injection. Head posture and limitations of motility also improved significantly in all three groups. The overall reoperation rate was 18.2%. Various procedures are effective for sixth nerve dysfunction; all improve ocular deviation, head turn and abductive capacity of the eye. The rate of reoperation is not high if treatment is selected appropriately according to the patient's condition

[Outcomes of levator resection at labbafinejad medical center during 1995-2005]

To describe the etiology, outcomes and complications of levator resection procedure for correction of congenital and acquired blepharoptosis. In a retrospective nonrandomized study, medical records of 136 patients with blepharoptosis who underwent levator resection at Labbafinejad Medical Center from 1995 to 2005 were evaluated. Of 136 patients undergoing levator resection [including 44.1% men and 55.9% women with mean age of 20 +/- 13.8 [range 2-80] years], 120 cases had congenital ptosis [88.2%] while others had acquired ptosis. Success rate was 83.1% which was more frequent in acquired ptosis than congenital ptosis [93.8% vs. 81.7%, P=0.30]. Second and third surgeries for residual ptosis were performed in 19.1% and 2.2% of patients, respectively. The most common complication was under-correction [13.9%]. Levator resection an effective method for correction of upper eyelid ptosis with low complication rates and seems to be more effective in acquired ptosis

[Intelligene quotient in patients with congenital strabismus]

To evaluate intelligene quotient [IQ] in patients with congenital strabismus scheduled for surgery at Labbafinejad Medical Center. All patients with congenital strabismus scheduled for surgery were enrolled consequtively over a one year period in a cross sectional study and were evaluated for verbal, performance and total IQ, and compared with normal population whose mean IQ is 100 +/- 15. During the study period, 109 patients with a mean age of 18.4 +/- 10.5 years [range: 4-63 years] were included. Educational status in most patients [%80] was less than high-school diploma. Most patients [%79.8] lived in urban areas, 46 patients [%42.2] had some degrees of unilateral or bilateral amblyopia. Mean verbal IQ was 87.2 +/- 19.6 [range 45-127], performance IQ was 81 +/- 15.5 [range 44-111] and total IQ was 83.5 +/- 18.3 [range 40-120].Total IQ was lower in comparison with normal population [P<0.01] and was significantly higher in urban residents as compared to rural residents [85.1 +/- 19.5 versus 77.3 +/- 10.8, P=0.016]. Patients with non educated parents and with coexisting amblyopia had lower IQ levels. Total IQ was higher in myopes than emmetropes and both had better IQ levels than hyperopes. IQ was betters with vertical deviations and was higher in ETs than XTs, however, these comparisons were not statistically significant [All Ps> 0.05]. Patients with congenital strabisumus assessed in this study had lower mean IQ than normal. The reason may be genetic background or acquired causes secondary to strabismus

[Causes and outcomes of treatment for superior oblique palsy during a decade at labbafinejad medical center]

Superior oblique palsy is a common cause of paralytic strabismus. This disorder causes diplopia, head posture and facial asymmetry. This retrospective study reviews patient with superior oblique [SO] palsy operated at Labbafinejad Medical Center from 1997 to 2007. In this descriptive study, records of patients with SO palsy scheduled for surgery were reviewed. Forced duction test [FDT] and tendon laxity was checked in each patient. Patients were divided into congenital and acquired subgroups. During the study period, 83 patients were referred for surgery. Of these 73 patients with complete records [45 males, 28 females] were enrolled into our study, with age ranging from 1.5 to 62 [mean 19.7 +/- 11.7] years. SO palsy was congenital in 56 patients [76%] and acquired in 17 patients [24%]. Most patients [47.9%] had left side and 13.7% had both eyes involvement. The most common chief complaint was ocular deviation [52.1%]. The following abnormalities were noted: positive FDT 7 patients [9.7%], tendon laxity 2 patients [2.7%], amblyopia 14 patients [19.2%], facial asymmetry 5 patients [6.8%], head tilt 10 patients [13.7%], and chin down position 3 patients [4.1%]. Mean preoperative vertical deviation was 16.2 +/- 8.3 which was reduced to 1.9 +/- 4 prism diopters after surgical intervention [P<0.05]. Mean exotropia and esotropia were 15 +/- 9.5 and 13.9 +/- 11.5 prism diopters before operation, respectively and both were reduced to mean horizontal deviation of 1.5 +/- 4.8 prism diopters after operation [P<0.05]. The most common Knapp classification of disease was type 3 [42.5%]. The most common muscle operated was the inferior oblique [83.6%] and the most common type of operation was the inferior oblique myectomy. The most common form of superior oblique palsy leading to operation is the congenital form which occurs most commonly in young men. The most popular surgical intervention at this center was inferior oblique myectomy

[Recurrent cavernous hemangioma of the orbit secondary to tumor remnants]

To report the clinical, radiological, pathological and therapeutic features of a case of recurrent cavernous hemangioma. A 32 year old lady with progressive decrease of vision in her right eye associated with blepharoptosis was diagnosed to have orbital cavernous hemangioma which was excised. 10 years later she presented with recurrent proptosis and progressive eye deviation. Imaging showed the same pathology in the same orbit and repeat excision confirmed a cavernous hemangioma. Evaluation of old CT scans showed that the recurrent lesion was a twin tumor and we had only excised one of them in the first operation. Recurrent cavernous hemangioma may be the result of a small residual tumor which grows gradually and becomes clinically evident after some years. When the mass is large or seems multilobulated, after excision of the main mass a thorough search to find small residual masses seems mandatory

[Adie's tonic pupil following chicken pox]

To report a case of Adie's tonic pupil following chicken pox. A 7-year-old girl with history of chicken pox manifesting one week ago presented with loss of near and far vision in her right eye. The right pupil was larger than the left in room light and abnormal iris configuration was seen with pen light illumination. After instillation of diluted pilocarpine [0.1%] in both eyes, miosis occurred only in the right pupil and a diagnosis of tonic pupil was established. The patient was treated with bifocal glasses which resulted in relief of the visual symptoms. We recommend pupil and refractive evaluation in children with chicken pox. Bifocal glasses can help reduce symptoms of tonic pupil until recovery of the disease

[Benign reactive lymphoid hyperplasia of caruncle and plica: report of five cases]

To report five cases of benign reactive lymphoid hyperplasia of the caruncle and plica and describe their clinical course and pathology. Five patients with fish flesh pinkish masses in the caruncle and plica were referred to Labbafinejad Hospital from 1997 to 2006. The masses were excised. Clinical appearance and course as well as pathology and immunohistochemistry confirmed benign reactive lymphoid hyperplasia. They followed for 2-108 months. No complications were detected during the follow up period. In masses of caruncle and plica with above-mentioned appearance, benign reactive lymphoid hyperplasia must be considered in the differential diagnosis. Pathologic and immunohistochemical evaluation should be performed to rule out lymphoma. Removal of these lesions incurs no complications in short-term period

[Comparison of mersilene mesh and autogenous fascia lata in ptosis correction]

To compare Mersilene mesh and autogenous fascia lata in the management of lowfunction ptosis. A randomized clinical trial was performed on 31 eyelids with poor levator function. Patients were randomly assigned to two groups: 16 eyelids in the Mersilene mesh group and 15 eyelids in the autogenous fascia lata group. Nine patients with congenital unilateral and 11 patients with bilateral ptosis underwent sling procedure. There was no difference between the two groups in terms of functional [lid fissure height stability] and cosmetic [lid margin contour] results. Dermatochalasis was seen more in the fascia lata group [10 cases] compared to the Mersilene mesh group [2 cases]. Extrusion of Mersilene mesh occurred in 2 eyelids. Mersilene mesh has favorable long-term functional results and a low rate of complication. This material may be an alternative to autogenous fascia lata as a suspensory material in ptosis surgery