[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 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

Pediatric Vogt-Koyanagi-Harada [VKH]-Associated Panuveitis: Clinical Course and Management

To assess the clinical course, determine the efficacy and safety of oral methotrexate in the control of intraocular inflammation and evaluate the outcomes of lensectomy-vitrectomy and goniosynechiolysis in pediatric VKH-associated panuveitis. In this retrospective non-comparative interventional case series, 10 patients [20 eyes] with pediatric VKH-associated panuveitis [onset of disease at age 14 years or younger] were studied. All patients underwent stepwise medical treatment consisting of oral prednisolone [0.5-1 mg/kg], supplemented by oral methotrexate [5-7.5 mg/wk] in refractory cases. Surgical intervention was performed for complications such as visually significant cataracts and secondary glaucoma and included pars plana lensectomy-vitrectomy and peripheral anterior synechiolysis in a one-stage procedure. Control of inflammation, corticosteroid requirement, visual acuity, and intraocular pressure [IOP] were the main outcome measures. Ten consecutive patients with minimum follow up of six months were analyzed. All patients were initially treated with oral corticosteroids; methotrexate was additionally required in six subjects. In all eyes, inflammation decreased and vision was preserved or improved. Side effects of methotrexate were mild and transient. Nine eyes of five patients underwent combined lensectomy and vitrectomy. The procedure was successful in all eyes without any exacerbation of inflammation. Eight eyes had elevated IOP, six of which underwent peripheral anterior synechiolysis at the time of lensectomy-vitrectomy. IOP was controlled after the procedure in all eyes with timolol only. Overall, final visual acuity was

Traumatic dislocation of the globe into the Maxillary Sinus

To report a case of enophthalmos secondary to complete globe dislocation into the maxillary sinus due to orbital fracture. An 18-year-old man was referred to Labafinejad hospital, one week after a car accident. At initial examination, the globe was not seen within the right orbit. A large floor fracture and globe luxation into the right maxillary sinus were confirmed on CT scan. Repair of fracture using Medpore implant and globe repositioning were performed. Visual acuity following' surgery was no light perception without improvement during follow-up. Visual impairment in this case was most probably due to traumatic optic neuropathy and delayed surgical intervention and medical therapy with systemic corticosteroid

[Lacrimal drainage obstruction as an early presentation of lacrimal sac lymphoma]

To report a case of lacrimal sac lymphoma presenting with nasolacrimal obstruction. A 35-year-old women presented with epiphora and swelling of the left lacrimal sac area and cervical lymphadenopathy. She had undergone dacryocystorhinostomy [DCR] 6 months before. Computed tomography demonstrated a lacrimal sac mass involving the nasal cavity. Histopathologic examination revealed diffuse large cell lymphoma. According to immunohistologic staining, the tumor was B-cell type. The patient was treated with irradiation and chemotherapy. Lacrimal sac tumors may present with epiphora and dacryocystits masquerading as nasolacrimal canal obstruction

[Amniotic membrane transplantation for congenital distichiasis]

To evaluate the use of amniotic membrane transplantation [AMT] for management of congenital distichiasis. This interventional case series was performed on 16 eyelids of 5 patients with congenital distichiasis treated with posterior lamella resection and AMT. All patients were men aged 2 to 42 years. Mean follow up was 17 months [6-29months]. Post-operative symptoms of dry eye were controlled by medical treatment in all patients. Misdirected eyelashes recurred in 3 eyelids [18.8%] outside the AMT area and in 2 eyelids within the AMT area which were treated by gentle laser epilation. AMT is a useful option in management of distichiasis with a low rate of complications and acceptable eyelid contour

[Comparing two methods of fascia lata use for frontalis suspension]

To compare the results of two different methods of frontalis suspension using fascia lata in congenital ptosis. In randomized clinical trial, double triangle sling was compared with single triangle sling using fascia lata. Eight patients with unilateral and 11 patients with bilateral congenital ptosis were randomly assigned for each procedure. There was no statistically significant difference between the two groups in terms of age and sex. Mean increase in interpalpebral fissure was 4.35 +/- 2.32 mm in the double triangle group and 4.36 +/- 1.89 mm in the single triangle group. Increase in palpebral fissure was statistically significant in both groups [P=0.00] but there was no difference between the two groups regarding functions during [lid fissure height] and cosmetic [lid margin contour] results and early or late complications during follow up. Single triangle sling method using fascia lata is safe, easy, and fast with acceptable results and can be used instead of conventional double triangle fascia lata sling for treatment of low function ptosis

[Prevalence of different types of orbital tumors at Labafinejad Hospital]

Purpose: to determine the relative prevalence of different types of orbital tumors at labafinejad hospital, Tehran-Iran

Methods: we reviewed the hospital records of 267 patients with orbital tumors who were operated during 1981-2001. Age, sex, and pathologic reports of orbital tumors were evaluated

Results: cystic lesions accounted for 61 cases [23%], inflammatory masses for 19 cases [7%], lacrimal fossa lesions for 33 [12%], secondary orbital tumors for 73 cases [27%], lymphoid tumors and leukemic infiltrates for 21 [8%], vasogenic lesions for 15 [5.5%], peripheral nerve tumors for 7 [3%], optic nerve and meningeal tumors for 2 [1%], rhabdomyosarcoma for 9 [3%], myxomatous and adipose lesions for 4 [1.5%], metastatic tumors for 4 [1.5%], and histiocytic and related lesion for 1 [0.5%]

Conclusion: secondary and metastatic tumors were the most prevalent tumors in this study and there was no report of melanocytic, osseous, or cartilaginous tumors