A Case of Bilateral Septic Cavernous Sinus Thrombosis after Facial Trauma

PURPOSE: We report a case of a patient with ptosis, lid swelling, limitation of ocular movement, and visual disturbance after a trauma. The patient was diagnosed with unilateral orbital cellulitis, ophthalmic vein thrombosis and bilateral septic cavernous thrombosis and treated. CASE SUMMARY: After head and facial area trauma that occurred 1 month earlier, a 56-year-old man suffered from ongoing visual loss, limitation of ocular movement in all directions, proptosis in the left eye and abduction limitation of the right eye. A week before admission, mild fever and chills were also present. At admission, visual acuity of the left eye was no light perception and pupil reflex was lost. Brain MRA and MRI indicated dilation and thrombosis of the left superior ophthalmic vein, left orbital cellulitis and inflammation in bilateral cavernous sinuses. The patient was immediately treated with systemic antibiotics and steroid injection. Coagulase negative staphylococci were detected in blood culture. CONCLUSIONS: Infection caused by facial trauma spread through the facial area's venous plexus and caused orbital cellulitis. As a result, septic cavernous sinus thrombosis and ophthalmic vein thrombophlebitis occurred. Serious complications can occur after facial trauma, thus rapid differential diagnosis and appropriate treatment are important in determining prognosis.

The Effect of Bilateral Slanted Lateral Rectus Recession in Exotropia with Near-Far Disparity

PURPOSE: To evaluate the efficacy of slanted recession of the lateral rectus (LR) muscle for exodeviation with larger deviation angle at near than far fixation. METHODS: A retrospective chart review was conducted of 31 patients. Seventeen patients underwent slanted LR recession, the upper fiber of the LR was recessed according to the distance deviation angle and the lower fiber was recessed according to the near deviation. Fourteen patients underwent classic recession. To evaluate the effect of slant LR recession, postoperative ocular alignment between them was checked at 1 week, 1 month, 3 months and 6 months after operation. RESULTS: At the postoperative 6 months, bilateral slanted LR recession reduced the mean exodeviation at near from 33.82 PD to 7.29 PD, and same amount recession group reduced 33.67 PD to 11.13 PD. The far deviation change was from 25.59 PD to 2.59 PD, 23.67 PD to 4.00 PD in each group. The change of near-distance difference was from 10.29 PD to 4.71 PD in slanted recession group, and 9.67 PD to 7.93 PD in same amount recession group, showed that slanted recession group reduced angle more significantly (p = 0.002). Success rate was 35% in bilateral slanted LR recession group, 7% in classic recession group, showed that slanted recession group had significantly high success rate (p < 0.05). CONCLUSIONS: Bilateral slanted LR recession effectively reduces near and distance exodeviation angle, and reduces near-distance incomitance more superior to classic bilateral LR recession technique.

Clinical Features Associated with the Direction of Deviation in Sensory Strabismus

PURPOSE: To assess the clinical features associated with the direction of deviation in sensory strabismus and postoperative stability of strabismus angles. METHODS: The authors retrospectively reviewed the medical records of 98 patients diagnosed with sensory strabismus who were treated surgically. Among the factors analyzed were sex, age, direction of strabismus, preoperative visual acuity, age at onset of visual loss, cause of primary sensory deficit, refractive error, age at operation, deviation angle at 1 and 6 months postoperatively and after at least 5 years. RESULTS: At baseline, 20 patients (20.4%) had esotropia and 78 (79.6%) had exotropia. Common causes of primary sensory deficit were corneal opacity (25.5%), vitreoretinal disorder (23.5%), and congenital cataracts (16.3%). The proportion of esotropia increased significantly as the refractive error of the sound eye became more hyperopic. The older the patients were when they lost their vision, the higher the proportion of exotropia. Patients with longer duration of vision loss were more likely to have a larger deviation angle with exotropia, but the association was not significant with esotropia. CONCLUSIONS: Patients with sensory strabismus tend to develop exotropia. Refractive error of the sound eye and age at onset of vision loss were associated with the direction of strabismus. Despite poor sensory fusion even after surgery, more than 50% of patients maintained a stable eye position.

Surgical Outcomes of Large-Angle Exotropia

PURPOSE: To examine the surgical results of large-angle exodeviations over 30 prism diopters (PD) and correlation factors influencing surgical outcomes. METHODS: The authors retrospectively examined 63 patients with an exodeviation greater than 30 PD. All patients were examined for at least six months after the operation. Near and far deviation angles, age at operation, operation method, and alignment at postoperative one week, one month, three months and six months were analyzed as factors influencing the surgical outcome. RESULTS: The preoperative deviation was 35 to 40 PD (38.1%) in most cases. Forty-five patients underwent bilateral lateral rectus recession, 16 patients underwent unilateral medial rectus resection and lateral rectus recession, and two patients underwent surgery on three different muscles. Success was defined as sustained alignment from esotropia 10 PD to exotropia 10 PD. The success rate was 79.4% at the first week, 77.8% at one month, 73.0% at three months, and 68.3% at six months postoperatively. In particular, the success rate was significantly lower at six months postoperatively in the group with exotropia greater than 45 PD (36.4%). The patients with esotropia on the first postoperative week showed a significantly high success rate (86.6%); however, neither the age at operation nor the operation method affected the surgical results. CONCLUSIONS: Large-angle exodeviations can be successfully approached with a single operation, with a success rate of 68.3% at six months postoperatively. Esotropia of less than 10 PD at the first postoperative week shows the most ideal surgical results. For patients having exodeviations greater than 45 PD, the success rate will decrease over time. Therefore, surgeons should carefully plan for large-angle exodeviation surgery.

Comparison of Inferior Oblique Myectomy, Recession, and Anterior Transposition in Unilateral Congenital Superior Oblique Palsy

PURPOSE: To compare the clinical outcomes of myectomy, recession, and anterior transposition (AT) of the inferior oblique muscle in congenital unilateral superior oblique palsy. METHODS: A total of 40 patients who were followed for longer than three months postoperatively and, who underwent inferior oblique myectomy, recession, or AT were evaluated retrospectively. RESULTS: We compared the result of inferior oblique myectomy, recession, and AT in congenital unilateral superior oblique palsy. The decreased amounts of inferior oblique overaction (IOOA) were 2.24+/-0.67, 2.00+/-0.76, 3.00+/-1.15 for myectomy, recession, and AT, respectively. Improvement of superior oblique underaction was 0.80+/-0.66, 0.86+/-0.83, 1.00+/-0.58, and the changes in hyperdeviation were 10.96PD, 8.25PD, 14.86PD for myectomy, recession, and AT, respectively. There were no significant differences among the surgical methods. The proportion of patients who showed IOOA in the contralateral eye after operation were 20.0% in myectomy, 25.0% in recession, and 57.1% in AT. CONCLUSIONS: The efficacies of myectomy, recession, and AT of inferior oblique muscle in the congenital unilateral superior oblique palsies showed no significant differences among methods. The AT group tended to show a larger effect than did the other methods, along with a high development percentage of contralateral eye IOOA. Based on these results, AT of the IO shoud be selectively chosen in more severe cases.

Clinical Observations on Tolosa-Hunt Syndrome

PURPOSE: The authors reviewed clinical features, response to treatment and recurrence rate of Tolosa-Hunt syndrome. METHODS: A retrospective chart review was performed on 6 patients, who fulfilled the diagnosis for Tolosa-Hunt syndrome according to the International Headache Society (IHS) classification of 2004. RESULTS: Every patient had orbital pain as a first symptom, followed by cranial nerve paresis. The third cranial nerve was most commonly involved (83.3%), followed by the sixth nerve (50%), the forth nerve (16.7%), and the first branch of the fifth cranial nerve (16.7%). Two of the patients showed multiple cranial nerve paresis (33.3%, 2 out of 6). All patients received high-dose steroid therapy for more than 5 days, and all patients had resolution of orbital pain within 72 hours of treatment. Full recovery of cranial nerve paresis occurred on average in 2.3 months (3 days to 12 months). During the 29 months of follow-up, 2 patients (33.3%) had a recurrence episode. CONCLUSIONS: Tolosa-Hunt syndrome responds well to steroid therapy, and full recovery is possible with proper treatment. The exact diagnosis and treatment of Tolosa-Hunt syndrome is important. Because Tolosa-Hunt syndrome often recurs after full recovery, the authors suggest a minimum follow-up period of 2 years.

A Case of Bilateral Marcus-Gunn Syndrome

PURPOSE: To report a case of bilateral Marcus Gunn syndrome, which can be easily overlooked. CASE SUMMARY: A 6-year-old boy visited our clinic complaining of right ptosis. On ocular examination, the palpebral fissure width was 4 mm in the right lid and 7 mm in the left lid. Marginal reflex distance 1 (MRD 1) was -1 mm in the right lid and 2 mm in the left lid. Bilateral levator muscle function was good. When the patient moved the jaw to the right side, the left eyelid was retracted by 2 mm, and when the jaw was moved to the left side, the right upper eyelid retracted by 4 mm, which showed a moderate bilateral jaw-winking phenomenon. There was no change in bilateral palpebral fissure width when only opening the mouth without jaw movement. CONCLUSIONS: Asymmetrical bilateral ptosis can be easily misdiagnosed for unilateral ptosis, and concurrent Marcus Gunn phenomenon can exist. Therefore, a thorough examination is necessary when examining a ptosis patient.

Endoscopic Marsupialization of Postoperative Cheek Cyst with Orbital Floor Defect

BACKGROUND AND OBJECTIVES: The postoperative cheek cyst with orbital involvement is a rare condition and the treatment of eroded orbital floor is controversial. This study evaluated the efficacy of endoscopic marsupialization for treating postoperative cheek cyst with orbital floor defect and assessed the requirements of a direct orbital approach for orbital reconstruction. MATERIALS AND METHODS: The study involved a retrospective review of twelve patients with postoperative cheek cyst and orbital floor defect. Medical records were reviewed for details of previous surgery, presenting symptoms, surgical approach and the results of the operation. The maximum diameter of the involved orbital floor was calculated using the coronal imaging of paranasal sinus computed tomography (PNS CT). RESULTS: All patients had previously undergone Caldwell-Luc procedures. The most common symptom was pressure on the cheek. According to PNS CT, the maximum diameter of the involved orbital floor ranged from 0.7 to 3.1 cm (mean 1.46 cm) and the involved orbital area ranged from 0.35 to 4.23 cm2 (mean 1.87 cm2). All patients underwent only endoscopic marsupialization without orbital reconstruction. Postoperatively, all patients showed no recurrence of symptoms or required revision surgery. CONCLUSION: Endoscopic marsupialization without reconstruction of the orbital floor could be considered as a first treatment option for postoperative cheek cyst combined with orbital floor defect.

Ophthalmic Artery Occlusion With Third Cranial Nerve Paresis Associated With Acute Internal Carotid Artery Occlusion

PURPOSE: We report a case of ophthalmic artery occlusion with third nerve paresis in the left eye due to acute occlusion of the left ICA. CASE SUMMARY: A 37-year-old man visited our emergency room with "black out" in the left eye, headache, and nausea. The corrected visual acuity was 20/25 in the right eye, and hand motion in the left eye. In the left eye, a relative afferent papillary defect was noted, with an intraocular pressure of six mmHg. Twenty prisms of exotropia in the primary position was observed, and ocular motor examination revealed limitations of supraduction, infraduction, and adduction in the left eye, suggesting third nerve palsy of the left eye. Fundus examination revealed a pale retina in the macula of the left eye. Brain MRI demonstrated multifocal faint low densities in the left caudate nucleus as well as the frontal and parietal lobes. CT angiography and four-vessel angiography demonstrated complete occlusion in the proximal part of the left internal carotid artery ICA.

A Case of Anti-GQ1b-Positive Atypical Miller Fisher Syndrome With Pupil Involvement

PURPOSE: To report a case of atypical Miller Fisher syndrome with pupil involvement. CASE SUMMARY: An 18-year-old woman visited our clinic with a headache and blurred vision. Ophthalmic examination revealed a corrected visual acuity of 20/20 in both eyes, with both pupils dilated to 7.5 mm. There was a loss of light reflex and near reflex in both eyes. Ocular motor examination revealed bilateral abduction, and supraduction limitation, and mild adduction limitation. Neurological examination demonstrated hyporeflexia without ataxia. Brain CT, brain MRI, nerve conduction test, CSF study, and thyroid function tests were normal. The serologic anti-GQ1b IgG test was positive. CONCLUSIONS: We confirmed a case of atypical Miller Fisher syndrome with an anti-GQ1 antibody test that had pupil involvement, areflexia, and acute ophthlamoparesis.

Ophthalmologic Findings of Boucher-Neuhauser Syndrome

To report a case of Boucher-Neuhauser syndrome, which is an autosomal recessive disorder characterized by the triad of spinocerebellar ataxia, chorioretinal dystrophy, and hypogonadotropic hypogonadism. An 18-year-old man was seen for visual problems, which had been diagnosed as retinitis pigmentosa at the age of 12 years. His puberty was delayed. At 16 years of age, the patient experienced progressive deterioration of his balance and gait disturbance. Then he was referred to our clinic because Boucher-Neuhauser syndrome was suspected. He had no specific family history; his visual acuity was 0.04 in both eyes. We observed broad retinal pigment epithelium atrophy and degeneration in both fundi. Both fluorescein and indocyanine green angiography showed choriocapillaris atrophy in the posterior pole area and midperiphery. Macular optical coherence tomography showed thinning of the neurosensory retina. An electroretinographic examination showed no photopic or scotopic responses. The Boucher-Neuhauser syndrome should be included in the differential diagnosis of patients with retinitis pigment epithelium atrophy and degeneration.

Anatomical Evaluation of Extraocular Muscles and Relationships Among Macula and Optic Nerve in Enucleated Eye

PURPOSE: To make an anatomical evaluation of extraocular muscles, macular and optic nerve in enucleated eyes of live subjects and to compare the results with a previous autopsy study. METHODS: Twenty-four surgically enucleated eyes were studied. The distance from the limbus to the muscle insertion site, muscle width, and the distance between muscle insertion sites were measured and compared with an Apt study. After an incision through the eyeball, a 26-gauge needle was passed perpendicularly through the macula to the sclera. We measured the distances between the oblique muscles and the macula and optic nerves from an external site of the eyeball. RESULTS: The distance from the limbus to the muscle insertion site showed a significant difference in the superior and inferior rectus muscle. All measurements of muscle widths were significantly narrower than those of autopsy studies. The distances between the muscles were significantly closer between the lateral and superior muscles and between the superior and medial rectus muscles. From the optic nerve to the muscle was 3.99+/-0.62 mm, to the superior oblique muscle was 7.89+/-0.88 mm, to the inferior oblique muscle was 5.95+/-0.83 mm, and the macula to the inferior oblique muscle was 1.35+/-0.42 mm. CONCLUSIONS: Since most of the measurements were different from those of autopsy studies, we should consider the effects of preservation and fixation solution on autopsy eyes, race, and the differences among measurement instruments.

A Case of Intraorbital Foreign Body Removed Using A Magnet Under C-arm Fluoroscopy

PURPOSE: We report a case of an intraorbital foreign body removed in a walk-in patient using a magnet under fluoroscopy. METHODS: A patient walked into the eye clinic complaining of ocular pain caused by foreign body that pernetrated into his right lower eyelid while mowing the lawn one day before he came to the hospital. Since an orbital foreign body was observed when the patient entered the hospital, and a high-density metallic response was diagnosed within the orbit from a computerized tomogram, we performed an emergency operation to take out the foreign body within the orbit. RESULTS: We removed the metallic foreign body, which was 5 mm in size and buried in the orbital fat, in an operation using a magnet under fluoroscopy. CONCLUSIONS: This study shows that fluoroscopy and magnets are an efficient operative means of removing foreign bodies that are found within the orbital fat layer and are difficult to access.

Effect of Lacrimal Sac Incision Using Keratome in Endonasal Dacryocystorhinostomy

PURPOSE: To evaluate the effectiveness of using Keratome in endonasal Dacryocystorhinostomy (DCR). METHODS: The authors used 3.0mm keratome, designed for cataract surgery, to incise medial wall of the lacrimal sac during endoscopic endonasal DCR in 11 patients with nasolacrimal duct obstruction. RESULTS: Surgical success rate was 90% with fast recovery time of nasal mucosa without specific complication. CONCLUSIONS: Lacrimal sac incision using keratome was more effective and non-invasive than using nasal forceps, with advantages such as shorter operation time and less nasal mucosa injury with rapid recovery time.

Clinical Analysis of Rhegmatougenous Retinal Detachment after Laser Refractive Surgery

PURPOSE: To evaluate the clinical presentation, surgical outcome of rhegmatogenous retinal detachment(RRD) after laser refractive surgery and the relationship between RRD and laser refractive surgery. METHODS: We examined age distribution, refractive error, time interval of RRD onset after refractive surgery, shape and location of retinal break, extent of RD, refractive change and postoperative complications in fifteen patients who experienced RRD after LASIK(9 eyes), or PRK(6 eyes) from March 1993 to August 2001. RESULTS: 66% of patents were in twenties, 47% of patients developed RD within 1 year after refractive surgery, 80% of patients had horse shoe type retinal tear and refractive changes after RD surgery were within 2 diopters. Patients who had undergone LASIK had shorter time interval in developing RRD, more refractive change, and more complications than those with PRK. CONCLUSIONS: These results suggest that laser refractive surgery can be one of the cause of RD. LASIK had more association with RD than PRK. Thorough retinal exam will be needed in patients undergoing LASIK.

Reproducibility Among Residents in Evaluating Cup-disc Ratio Using Computer-aided Planimetry

PURPOSE: To investigate the intra-observer agreement and inter-observer agreement among observers assessing optic disc cup-disc ratio of glaucoma patients. METHODS: Fifty stereoscopic optic disc photographs of patients with glaucoma were digitized and five ophthalmology residents drew optic disc and cup margin in a masked random fashion. It was performed twice on same photographs weekly under monoscopic and stereoscopic conditions. The agreement was estimated by Pearson correlation coefficient r. RESULTS: Intra-observer agreement for estimating linear cup-disc ratio (LCDR) under monoscopic (0.84) and stereoscopic conditions (0.86) were high and inter-observer agreement was also high under monoscopic (0.81) and stereoscopic conditions (0.83) showing more perfect agreement under stereoscopic condition. The observers estimated smaller cup-disc ratio when evaluating under stereoscopic condition than under monoscopic condition. CONCLUSIONS: Evaluating optic disc stereoscopically with computer-aided planimetry can be clinically useful when managing patients with glaucoma since it has a high reproducibility.