ABSTRACT
Carotid-cavernous fistulas, characterized by abnormal arteriovenous communication within the cavernous sinus (CS), can be classified as direct or indirect. Direct fistulas are defined as a direct connection between the internal carotid artery (ICA) and CS, whereas indirect fistulas result from an abnormal connection between the CS and dural arterial branches. The first-line treatment for both types of fistulas is endovascular intervention, most commonly accomplished through the transarterial and transvenous approaches of the conventional pathway, including the ICA, inferior and superior petrosal sinuses, or basilar plexus. Nonetheless, a retrograde approach through the superior ophthalmic vein may be necessary for individuals in whom conventional endovascular treatment fails. Herein, the current principles of surgical indication and technique are presented, along with case studies.
ABSTRACT
Purpose@#To report a case of traumatic optic neuropathy aggravated by orbital emphysema after an orbital fracture.Case summary: A 19-year-old man with no specific medical history was referred for a right orbital fracture caused by blunt trauma to the supraorbital rim of the right eye. Computed tomography (CT) showed a right orbital fracture involving the inferomedial wall and inferomedial strut. The corrected visual acuity was 0.4 in the right eye (RE) and 1.0 in the left and the intraocular pressure was 15 and 18 mmHg, respectively. Restriction on downgaze, abduction, and an indefinite relative afferent pupillary defect (RAPD) were observed in the RE. Fundus exam was non-specific other than commotio retinae on the temporal side of the macula in the RE. After 12 hours post trauma, the visual acuity of the RE had decreased to light perception. Definite RAPD was observed with optic disc swelling on the fundus photo and optical coherence tomography. Orbital CT showed air shadows, which were not seen on the initial evaluation, adjacent to the optic disc. We diagnosed traumatic optic neuropathy aggravated by orbital emphysema. High-dose intravenous steroid was given for 3 days. Despite a lateral canthotomy and cantholysis to decompress the right orbit, visual acuity did not improve above counting fingers. @*Conclusions@#Increased intraorbital pressure and congestion caused by orbital emphysema may exacerbate traumatic optic neuropathy. Therefore, close observation is required.
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Purpose@#Chondroid syringoma of the skin is a rare subcutaneous tumor and localization in the eyelid and orbital region that has rarely been described. We report a case of chondroid syringoma that involved the sub-brow region and was accompanied by hair loss. Case summary: A 57-year-old women presented with a mass on the lateral side of the left sub-brow region which was observed 25 years earlier. The mass, which recurred 2 months after surgery at another hospital through a skin incision was accompanied by an itching sensation. The mass was not tender or ulcerated but was reddish with superficial blood vessels and had a smooth surface with hair loss at the site of the mass. The mass showed high signal intensity on a T2-weighted magnetic resonance image and a round echogenic nodule with an irregular hypoechoic portion was observed on ultrasonography. A full-thickness excision including the adjacent normal tissue of the sub-brow mass and direct closure were subsequently performed. The pathological diagnosis was chondroid syringoma which was revealed as numerous tubular structures with various lumens in a collagenous stroma. Mucinous and fibrous findings were also observed. No recurrence was detected during the first 2 years after surgery. @*Conclusions@#Chondroid syringoma in the eyelid and sub-brow region is uncommon. Complete resection is required to differentiate it from a malignancy and reduce the possibility of recurrence. Incomplete resection or capsular rupture during removal of the tumor could induce recurrence or a malignant change in the tumor.
ABSTRACT
Purpose@#Chondroid syringoma of the skin is a rare subcutaneous tumor and localization in the eyelid and orbital region that has rarely been described. We report a case of chondroid syringoma that involved the sub-brow region and was accompanied by hair loss. Case summary: A 57-year-old women presented with a mass on the lateral side of the left sub-brow region which was observed 25 years earlier. The mass, which recurred 2 months after surgery at another hospital through a skin incision was accompanied by an itching sensation. The mass was not tender or ulcerated but was reddish with superficial blood vessels and had a smooth surface with hair loss at the site of the mass. The mass showed high signal intensity on a T2-weighted magnetic resonance image and a round echogenic nodule with an irregular hypoechoic portion was observed on ultrasonography. A full-thickness excision including the adjacent normal tissue of the sub-brow mass and direct closure were subsequently performed. The pathological diagnosis was chondroid syringoma which was revealed as numerous tubular structures with various lumens in a collagenous stroma. Mucinous and fibrous findings were also observed. No recurrence was detected during the first 2 years after surgery. @*Conclusions@#Chondroid syringoma in the eyelid and sub-brow region is uncommon. Complete resection is required to differentiate it from a malignancy and reduce the possibility of recurrence. Incomplete resection or capsular rupture during removal of the tumor could induce recurrence or a malignant change in the tumor.
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Purpose@#To demonstrate the efficacy of subcutaneous tocilizumab (TCZ-SC) treatment for recalcitrant thyroid eye disease (TED) refractory to intravenous methylprednisolone (MP) and oral methotrexate (MTX).Case summary: (Case 1) A 52-year-old man, smoker, with hyperthyroidism presented with a 3-months history of TED. The initial clinical activity score (CAS) was 5 (total score of 7). High-dose intravenous MP and oral MTX failed to improve the symptoms. He was treated with four doses of 162 mg TCZ-SC at an interval of 2 weeks. Pre-treatment laboratory test results were within normal limits. CAS was reduced to 2 weeks after the final injection, and there were no recurrences during the 6-month follow-up. (Case 2) A 37-year-old woman, non-smoker, with a 3-months history of hyperthyroidism presented with conjunctival injection and upper eyelid erythema. The initial CAS was 4, and thyroid-stimulating immunoglobulin level was raised (475% of normal). The symptoms did not improve with 7.5 g intravenous MP and oral MTX. The patient was treated with 162 mg TCZ-SC. Pre-treatment laboratory test results were within normal limits. CAS was reduced to 1 after the final injection, and there were no recurrences during the 6-months follow-up. @*Conclusions@#TCZ-SC improves symptoms of corticosteroid-resistant TED, and may be a reasonable option in recalcitrant TED cases. However, further studies are required to justify the use of TCZ-SC for TED.
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Background@#To evaluate the patterns of distribution and clinical manifestations of ocular injuries referred to the level 1 trauma center of Pusan National University Hospital (PNUH) in Korea. @*Methods@#We analyzed 254 of 4,287 patients who were referred to the Department of Ophthalmology at the level 1 trauma center of the PNUH, from January 2016 through December 2018. Data on the incidence of ocular injuries, sex, age, monthly and seasonal distribution, day and time of injury, side of injury, cause, residence of patients, referral time to an ophthalmologist and subsequent examination time, final visual acuity (VA), and complications were obtained from medical records and retrospectively reviewed. The patients were grouped according to their main diagnosis using the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). @*Results@#The incidence of ocular injuries with major trauma was higher in men (n = 207, 81.5%), the median age at time of injury was 54 years, and Pusan recorded the most cases.The incidences of ocular injury were 1.47/100,000, 1.57/100,000, 1.48/100,000 in 2016, 2017 and 2018, respectively. The most common cause was by a motorbike accident, followed by a pedestrian traffic accident and falls. According to the BETTS classification, open-globe injuries represented 4% of cases, closed-globe injuries represented 12.6%, and other injuries represented 83.1%. Open-globe injuries were significantly associated with low final VA (P = 0.01). In the OTS, 79.4% of patients received 4 or 5 points and 13.7% of patients received 1 or 2 points. The patients who received 1 or 2 points in the OTS score showed final VA below hand movement (P < 0.001), except for two patients. Lid laceration and low initial VA were highly correlated with poor final VA (P < 0.001). @*Conclusion@#This is the first study on the epidemiology and clinical manifestations in trauma patients with ocular injuries at a level 1 trauma center. The incidences of ocular injuries with major trauma were about 1.47–1.57/100,000. BETTS, OTS, lid laceration and initial VA were associated with final VA. We expect our study to provide a basis of data for the evaluation, prevention, and management of ocular injuries in patients with systemic trauma.