Exploring the globe salvaging treatment options in patients of COVID-19-associated mucormycosis with orbital involvement

Purpose: To explore the various globe salvaging treatment strategies for patients with coronavirus disease 2019?associated mucormycosis (CAM). Methods: This was a prospective interventional analytical study conducted at a Medical College in rural India. A total of 84 patients of CAM admitted between May 2021 and August 2021 were enrolled for the study. Patients with histologically proven CAM with clinical and/or radiological evidence of orbital involvement were divided into three treatment categories based on the site and extent of the lesion. Re?assessment was performed after 7 days. For patients who worsened with the primary approach, orbital exenteration was considered based on a Sion Hospital Scoring System. A novel approach to intra?orbital anti?fungal therapy, site?centered peri?bulbar injection of amphotericin B (SCPeriAmB), was also explored. All the patients were followed up for at least 3 months. Convenience sampling with descriptive statistics was used. Results: Six patients had to finally undergo exenteration by the end of the study period. The rest of the patients were reported to be stable or improved. No mortalities were reported on delaying the exenteration. No adverse events were noted in patients who were given SCPeriAmB. Conclusion: Globe salvaging treatment options should be advocated as a primary approach in patients with CAM. Site?centered peri?bulbar injections can be considered as an approach for delivering intra?orbital anti?fungal therapy in selected patients

Hematoma orbitario secundario a cirugía endoscópica nasosinusal / Orbital hematoma secondary to endoscopic sinus surgery

Resumen Durante la cirugía endoscópica nasosinusal, la sección inadvertida y retracción hacia la órbita de la arteria etmoidal anterior (AEA) es el mecanismo habitual del hematoma orbitario (HO); éste se manifiesta con proptosis, dolor y déficit visual potencialmente irreversible. El déficit visual es secundario a isquemia del nervio óptico por aumento de la presión intraocular, siendo suficientes treinta minutos para que ocurra daño visual permanente. Por sus secuelas el tratamiento del HO debe ser rápido y agresivo. Presentamos el caso de un varón de 72 años con diagnóstico de rinosinusitis crónica con pólipos nasales refractaria a tratamiento médico que se sometió a cirugía endoscópica nasal y que desarrolló en el posoperatorio inmediato con un HO. Se manejó precozmente con cantotomía-cantolisis, descompresión orbitaria medial endoscópica y control vascular de la AEA. El paciente evoluciona favorablemente, sin déficit visual. En este artículo se discutirán el diagnóstico y manejo oportunos del hematoma orbitario iatrogénico.

Abstract During endoscopic sinonasal surgery, inadvertent section of the anterior ethmoidal artery (AEA) with retraction into the orbit is the usual mechanism of orbital hematoma (OH), leading to proptosis, pain, and potentially irreversible visual loss. Thirty minutes is sufficient for retinal ischemia and permanent visual loss. The explanation for blindness is due to increased intraorbital pressure. The treatment of iatrogenic HO must be quick and aggressive, because if it is not managed in time, it can cause a permanent visual deficit. We present the case of a 72-year-old man with a diagnosis of chronic rhinosinusitis with nasal polyps refractory to medical treatment who underwent nasal endoscopic surgery, evolving in the immediate postoperative period with an HO, requiring canthotomy - cantolysis and early surgical reintervention for endoscopic medial orbital decompression and vascular control of AEA. The patient evolves favorably, without visual deficit. This article will discuss the timely diagnosis and management of iatrogenic orbital hematoma.

Analysis of COVID-19-associated rhino-orbital-cerebral mucormycosis patients in a tertiary care center in Northern India

Purpose: An unprecedented surge has been noted in rhino?orbital?Cerebral mucormycosis (ROCM) in times of current COVID?19 pandemic. The present prospective study aims to evaluate clinico?epidemiological profile, risk factors, management, and outcome of the cases of ROCM that presented to our tertiary care center during the study period from April to June 2021. Methods: All patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were staged and were treated with intravenous liposomal amphotericin B (AMB) and sino?nasal debridement of local necrotic tissue. Transcutaneous retrobulbar AMB (TRAMB), orbital decompression, and exenteration were instituted as indicated. All patients were followed up for a minimum of 6 months before arriving at the final outcome. Statistical analysis was performed. Results: A total of 49 patients presented during the study period, with a mean age of 42.2 years. The major risk factors included uncontrolled diabetes (89.8%), COVID?19 positivity (51.02%), and concurrent steroid use (38.77%). The most common presenting symptom was facial pain/swelling (43.65%), while the most common presenting sign was deterioration in vision (75.51%). Intravenous liposomal AMB was given to all patients along with sino?nasal debridement (85.71%), TRAMB (57.14%), orbital decompression (14.28%), and exenteration (12.24%). Overall, mortality at 6 months was 22.45% (11 patients). Age more than 60 years, intracranial extension, and HbA1c of more than 8.0% were observed to be statistically significant indicators of mortality. Conclusion: Early suspicion and timely diagnosis of mucormycosis at rhino?orbital stage is warranted in order to salvage life as well as visual function. TRAMB may prove as potentially favorable treatment modality in cases with limited orbital involvement.

The effect of local anesthetic solution volume applied in retrobulbar block in cataract surgery on the duration of anesthesia and patient comfort / Efeito do volume da solução anestésica local aplicada no bloqueio retrobulbar na cirurgia de catarata na duração da anestesia e no conforto do paciente

Abstract Objective: To compare the use of 2 different local anesthetic solution (LAS) volumes of 1.5 mL and 3 mL in retrobulbar block in patients undergoing cataract surgery in terms of anesthesia, akinesia, and pain levels. Methods: 80 patients between 18-90 years old, ASA I-II-III, were included in the study. For retrobulbar anesthesia, 1.5 mL LAS was applied to one group (Group LV), and 3 mL LAS to the other group (Group HV). The patients' ocular and eyelid motion scores were evaluated and recorded in the first, third, fifth, and tenth minutes after the block, and at 30-minute intervals for 4 hours post-operatively. One day later, the first hour of analgesic need and the number of times they took analgesic agents were asked and recorded. In addition, side effects were questioned and recorded. Results: The 39 (48.75%) patients were male and 41 (51.25%) patients were female. The criteria determined in terms of ocular motor score after the retrobulbar block (ocular motor score≤4) were met in 92.5% of patients in Group LV in all patients in Group HV, and the time to fulfill the determined criteria in Group HV was found to be significantly lower compared to Group LV (p=0.004). The movements of the eye in all direction except the inward movement recovered in Group LV in a significantly shorter time than Group HV (p=0.004). There was no significant difference in pain levels and side effects between the groups (p=0.34). Conclusions: After 1.5 mL LAS administration in retrobulbar block, adequate akinesia was not achieved in about one tenth of patients, but no significant difference was found between 1.5 mL and 3 mL LAS volumes in analgesic efficacy and side effects.

Resumo Objetivo: Comparar o uso de 2 volumes diferentes de solução anestésica local (LAS) de 1,5 mL e 3 mL no bloqueio retrobulbar em pacientes submetidos à cirurgia de catarata em termos de anestesia, acinesia e níveis de dor. Métodos: 80 pacientes entre 18 e 90 anos, ASA I-II-III, foram incluídos no estudo. Para anestesia retrobulbar, 1,5 mL de LAS foi aplicado em um grupo (Grupo LV) e 3 mL de LAS no outro grupo (Grupo HV). Os escores de movimento ocular e palpebral dos pacientes foram avaliados e registrados no primeiro, terceiro, quinto e décimo minutos após o bloqueio e em intervalos de 30 minutos por 4 horas no pós-operatório. Um dia depois, a primeira hora de necessidade de analgésico e o número de vezes que eles tomaram analgésicos foram solicitados e registrados. Além disso, os efeitos colaterais foram questionados e registrados. Resultados: 39 (48,75%) pacientes eram do sexo masculino e 41 (51,25%) do sexo feminino. Os critérios determinados em termos de escore motor ocular após o bloqueio retrobulbar (escore motor ocular≤4) foram atendidos em 92,5% dos pacientes do Grupo LV em todos os pacientes do Grupo HV, e foi encontrado o tempo para atender aos critérios determinados no Grupo HV ser significativamente menor em comparação ao grupo LV (p = 0,004). Os movimentos do olho em todas as direções, exceto o movimento interior, se recuperaram no Grupo LV em um tempo significativamente menor que o Grupo HV (p = 0,004). Não houve diferença significativa nos níveis de dor e efeitos colaterais entre os grupos (p = 0,34). Conclusões: Após administração de 1,5 mL de LAS no bloqueio retrobulbar, não foi alcançada acinesia adequada em cerca de um décimo dos pacientes, mas não foi encontrada diferença significativa entre os volumes de 1,5 mL e 3 mL de LAS na eficácia analgésica e efeitos colaterais.

Monitorização de células-tronco mesenquimais injetadas via retrobulbar próximas ao nervo óptico lesados de coelhos / Monitoring of stem cells from adipose tissue injected via retrobulbar next to previously injured optic nerve of rabbits

Resumo Objetivo: Verificar a presença das células-tronco mesenquimais (MSC) na área próxima ao nervo óptico de coelhos previamente lesado com álcool absoluto. Métodos: Os 12 coelhos da raça Nova Zelândia foram distribuídos em 2 lotes. Após sedação, cada olho do animal recebeu uma injeção retrobulbar de 1 ml de álcool absoluto em um dos olhos e de 1 ml de solução fisiológica 0,9% (SF) no olho contralateral. Após 15 dias deste procedimento inicial todos os olhos dos animais pertencentes ao lote A, receberam via retrobulbar, uma solução contendo MSC de tecido adiposo humano e previamente marcadas com Qdots,. Todos os olhos dos animais do lote B receberam solução PBS. Resultados: Após 15 dias desta última aplicação os animais foram sacrificados e as lâminas foram analisadas. A presença das MSC foi observada em 100% dos olhos dos animais do lote A. Conclusão: Os resultados sugerem que a marcação prévia das MSC com Qdots permitiu o acompanhamento das mesmas na região aplicada e em áreas mais internas do nervo óptico. A permanência de MSC após 15 dias de aplicação ao redor do nervo óptico sugere a viabilidade e possível participação das mesmas no processo de regeneração do tecido lesado. Nas condições deste estudo, a via de aplicação retrobulbar permitiu a mobilização das células tronco do local de aplicação até áreas centrais dos nervos ópticos nos animais do lote A, sugerindo que esta poderá ser uma via de acesso eficaz para as MSC no processo de regeneração de neuropatias ópticas.

Abstract Obtective: To verify the presence of mesenchymal stem cells (MSC) in the area close to the optic nerve of previously injured with absolute alcohol. Methods: Twelve New Zealand breed rabbits were divided into two groups, and after sedation, each eye of the animal received a retrobulbar injection of 1 ml of absolute ethanol in one eye, and 1 ml of physiological solution 0.9 % (PS) in the contralateral eye. After 15 days all eyes of animals belonging to group A, received via retrobulbar a solution containing MSCs from human adipose tissue (AT) and previously marked with Qdots, while all eyes of animals from group B received solution containing PBS. Results: The presence of MSC was observed in 100% of the eyes of the animals of group A and the more central areas near and into the optic nerve. Conclusion: The results suggest that the appointment of MSC with Qdots allowed their follow-up applied in the region and in the inner areas of the optic nerve. The MSC permanence after 15 days of application around the optic nerve suggests the feasibility and possible involvement of the same during the damaged tissue regeneration process. Under the conditions of this study, the route of retrobulbar application and the presence of the stem cells to the central areas of the optic nerves in animals of group A, suggests that this might be an effective approach for MSCs in regeneration process of optic neuropathies.

Retrobulbar dexmedetomidine in pediatric vitreoretinal surgery eliminates the need for intraoperative fentanyl and postoperative analgesia: A randomized controlled study

Purpose: This study evaluated the efficacy of retrobulbar ropivacaine plus dexmedetomidine compared with systemic fentanyl in pediatric vitreoretinal (VR) surgery. Methods: This prospective double-blind, randomized controlled study was performed in 60 children undergoing VR surgery, age from 2 to 7 years. After general anesthesia, the following procedure was administrated: (1) retrobulbar block with 0.5% ropivacaine plus dexmedetomidine 1 ?g/kg (group RD, n = 20), (2) retrobulbar block with 0.5% ropivacaine (group RB, n = 20), and (3) control group with general anesthesia only (group F, n = 20). Hemodynamics, postoperative pain scores, anesthetics consumption (remifentanil, propofol, fentanyl), and emergence agitation were recorded. Results: Respiratory depression was observed in 7 of the 20 patients in group F after the laryngeal mask airway was removed in the operating room, compared with none in groups RD and RB. All patients in group F required intraoperative rescue fentanyl (average intraoperative fentanyl consumption, 26.6 ± 12.6 ?g per patient). Some rescue fentanyl was required in group RB (three patients required one dose of rescue fentanyl). Patients in group RD required none. Groups RD and RB reported lower pain scores than group F at 4 h postoperatively (RD group: P < 0.001; RB group: P =0.002); pain scores in group RD were lower than that in group F at 6 h postoperatively (P < 0.001). Conclusion: Retrobulbar dexmedetomidine as an adjuvant to ropivacaine is a safe and effective alternative to systemic fentanyl. This regimen provides better pain management, hemodynamic stability, and stress response suppression in pediatric VR surgery.

Unilateral blindness due to retrobulbar hematoma after lower blepharoplasty

Blepharoplasty is one of the most popular cosmetic surgical procedures for people who are concerned with minimizing the effects of aging and maintaining an aesthetically attractive appearance. If periorbital surgery is not performed by an expert, the risk of complications increases. In particular, retrobulbar hematoma, which is the most serious complication after blepharoplasty, can lead to permanent blindness. We report a rare case of unilateral permanent blindness due to careless and unprofessional treatment following a retrobulbar hematoma after lower blepharoplasty. In conclusion, it is necessary to check for symptoms and signs including pain, proptosis, visual acuity, and light reflex after the operation. Careful instructions should then be given to patients and their caregivers to avoid actions that may cause postoperative bleeding. We emphasize that if a patient complains of symptoms, painkillers should not be used and computed tomography should be performed for an accurate and rapid diagnosis. Appropriate procedures must then be taken to prevent permanent vision loss.

Two Case Reports of a Purtscher-like Retinopathy Occurring after Retrobulbar Anesthesia

PURPOSE: Although there are significant risks, retrobulbar anesthesia is commonly used for eye surgery. We report two cases of Purtscher-like retinopathy, a rare complication. CASE SUMMARY: (Case 1) A 76-year-old female visited our hospital because of decreased vision. She underwent right cataract surgery with retrobulbar anesthesia. After 7 days, she had decreased visual acuity (VA) and a constricted visual field. Multiple white spots and cotton wool spots around the optic nerve and post pole, macular edema (ME), and subretinal fluid (SRF) were found using a fundus examination. A non-perfusion area and staining of the vascular wall were seen using fluorescence angiography. Although carotid arterial angiography, thrombolysis, and intravenous injection of high-dose steroids were performed, the ME and SRF persisted. After intravitreal aflibercept was injected twice (2-month interval), the ME and SRF decreased and remained stable. (Case 2) A 61-year-old male underwent left cataract surgery with retrobulbar anesthesia. After anesthesia, the VA of the left eye was 10 cm finger count. The fundus examination showed multiple hemorrhage blots and retinal hemorrhages, and hyperfluorescence around the optic nerve and post pole; vascular wall staining revealed a Purtscher-like retinopathy. Left carotid arterial angiography, thrombolysis, and intravenous injection of high-dose steroids were then performed. After treatment, the VA of the left eye, ME, and SRF were improved at the 4-month follow-up. CONCLUSIONS: We report rare complications of retrobulbar anesthesia, with active and timely treatment having a positive impact on the visual prognosis.

Application of retrobulbar nerve block combined with general anesthesia in corneal transplantation / 器官移植

Objective To explore the application value of retrobulbar nerve block combined with general anesthesia in the penetrating keratoplasty (PKP). Methods A total of 100 recipients undergoing PKP from January 2017 to January 2019 were recruited in this study. All recipients were divided into the observation group (n=50) and control group (n=50) by random number table method. In the control group, patients received laryngeal mask airway under general anesthesia, and in the observation group, patients received laryngeal mask airway under general anesthesia combined with retrobulbar nerve block. Hemodynamic changes of the PKP recipients before and after operation were observed in two groups. The dosage of analgesic drugs and the incidence of complications were observed in two groups. The degree of pain at postoperative 2-, 6- and 24-h was evaluated by visual analogue scale (VAS) in two groups. The awakening situation of the recipients in two groups was observed. The levels of inflammatory cytokines at 1 d before and after operation were statistically compared in two groups. Results The average arterial pressure and heart rate at intraoperative 15 min and after the surgery in the observation group were significantly higher than those in the control group (both P < 0.05). In the observation group, the dosage of remifentanil and propofol were (1.0±0.4) mg and (299±40) mg, significantly lower than (1.3±0.6) mg and (365±42) mg in the control group (both P < 0.05). The incidence of complications did not significantly differ between two groups (P > 0.05). In the observation group, the VAS scores at 2-, 6- and 12-h after operation were remarkably lower than those in the control group (all P < 0.01). The respiratory recovery time, eye opening time, directional force recovery time and extubation time of the recipients in the observation group were significantly shorter than those in the control group (all P < 0.05). The expression levels of including interleukin (IL)-1, IL-6 and tumor necrosis factor-α (TNF-α) at postoperative 1 d in the observation group were considerably lower than those in the control group (all P < 0.05). Conclusions Retrobulbar nerve block combined with general anesthesia can maintain hemodynamic stability during PKP, reduce the dosage of remifentanil and propofol and alleviate the degree of postoperative pain and inflammatory responses of the recipients.

Amaurosis and contralateral cranial nerve pairs III and VI paralysis after peribulbar block - Case report / Amaurose e paralisia do III e do VI pares cranianos contralaterais após bloqueio peribulbar - relato de caso

Abstract Background and objectives: Peribulbar anesthesia has emerged as a safer option compared with intraconal retrobulbar block. Still, peribulbar anesthesia may not be considered without risk. Numerous complications have been described when performing this technique. This report aims to describe a rare case of amaurosis and contralateral paralysis while attempting to perform a peribulbar anesthesia. Case report: Male patient, 75-year old, physical status ASA II, undergoing cataract surgery by phacoemulsification with intraocular lens implantation. Sedated with fentanyl and midazolam and subjected to peribulbar anesthesia. There were no complications during surgery. After finishing the procedure, the patient reported lack of vision in the contralateral eye. Akinesia of the muscles innervated by the cranial nerve pairs III and VI, ptosis, and medium-sized pupils unresponsive to light stimulus were observed. Four hours after anesthesia, complete recovery of vision and eyelid and eyeball movements was seen in the non-operated eye. Conclusions: During peribulbar anesthesia, structures located in the intraconal space can be accidentally hit leading to complications such as described in the above report. Following the technical guidelines and using appropriate size needles may reduce the risk of such complication, but not completely.

Resumo Justificativa e objetivos: A anestesia peribulbar surgiu como uma opção mais segura quando comparada com o bloqueio retrobulbar intraconal. Ainda assim, a anestesia peribulbar não pode ser considerada isenta de riscos. Inúmeras complicações foram descritas quando da aplicação dessa técnica. O presente relato tem como objetivo descrever um caso raro caracterizado por amaurose e paralisia contralaterais quando da tentativa de se fazer a anestesia peribulbar. Relato de caso: Paciente masculino, 75 anos, estado físico ASA II, submetido à facectomia por facoemulsificação com implante de lente intraocular. Sedado com fentanil e midazolam e submetido a APB. Não houve intercorrências durante a cirurgia. Após o término do procedimento o paciente relatou ausência de visão no olho contralateral. Foram observadas acinesia da musculatura inervada pelo III e VI pares cranianos, ptose palpebral e pupilas de tamanho médio, não responsivas ao estímulo luminoso. Após quatro horas da anestesia, houve recuperação completa da visão, da movimentação das pálpebras e do globo ocular não operado. Conclusões: Durante a APB, estruturas localizadas no espaço intraconal podem ser atingidas acidentalmente levando a complicações como a descrita no relato acima. O respeito às diretrizes técnicas e o uso de agulhas com o tamanho adequado podem reduzir o risco de tal complicação, mas não de forma completa.

Effects of retrobulbar or intravitreal injection of triamcinolone acetonide combined with laser photocoagulation for diabetic macular edema / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To investigate the clinical efficacy of retrobulbar or intravitreal injection of triamcinolone acetonide combined with 532nm laser photocoagulation in the treatment of diabetic macular edema(DME). <p>METHODS: Sixty-two eyes in 40 DME patients were divided into two groups(Group A and Group B)randomly. Thirty-one eyes in Group A were treated with retrobulbar injection of triamcinolone acetonide(RBTA)and 31 eyes in Group B were treated with intravitreous injection of triamcinolone acetonide(IVTA). Eyes with limited macular edema were treated by local direct retinal laser, those with diffuse and cystic macular edema were treated by grid retinal laser using Vitra 532nm fundus lasers at 1mo after injection. Visual acuity, intraocular pressure, fundus, macular edema and complications were recorded after 1wk, 1, 3 and 6mo in the follow-up study. <p>RESULTS: The mean best corrected visual acuity was improved and macular edema subsided after treatment in the two groups in the follow-up study at 1wk, 1, 3 and 6mo(<i>P</i><0.05), while there had no significant difference between groups(<i>P</i>>0.05). In Group A, significant efficiency rate was 39%(12/31), total effective rate was 90%(28/31). In Group B, significant efficiency rate was 39%(12/31), total effective rate was 94%(29/31). The follow-up study showed no retinal detachment, endophthalmitis, intraocular hemorrhage and other complications. <p>CONCLUSION: Triamcinolone acetonide injection combined with laser photocoagulation is an effective method for treatment of DME with significant effect, less adverse reactions, patient's vision improved effectively and macular edema reduced. No significant difference was noted in the treatment of DME between RBTA and IVTA.

Influence of retrobulbar anesthesia or atropine pretreatment before strabismus surgery for oculocardiac reflex in children / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To assess the effect of applying retrobulbar anesthesia or atropine pretreatment as an available method to prevent oculocardiac reflex(OCR). <p>METHODS:A total of 92 pediatric patients(166 eyes)aged 5-13 years old who underwent elective strabismus surgery from March 2015 to March 2016 were enrolled and randomly assigned into three groups. Traditional anesthesia(TA)group was intravenously injected with propofol 2 mg/kg, fentanyl 1 mg/kg and atracurium 0.5mg/kg. Retrobulbar anesthesia(RA)group received both traditional anesthesia and retrobulbar injection of 2% lidocaine 2mL. Atropine pretreatment(AP)group received both traditional anesthesia and intravenous injection of atropine 0.15 mg/kg before surgery. The heart rate decreased by over 10% from the baseline value was considered as OCR positive. The anesthesia time, operation time, the baseline value of heart rate and the muscles induced OCR were recorded and analyzed. <p>RESULTS:The incidence of intraoperative OCR was 20% in RA group, 22% in AP group and 58% in TA group. There was no significant difference in anesthesia time, operation time, the baseline value of heart rate and corrective rate of postoperative eye position among three groups(<i>P></i>0.05). <p>CONCLUSION: Retrobulbar anesthesia and atropine pretreatment both effectively reduced the incidence of OCR in children's strabismus surgery, which could be potentially effective methods to prevent OCR and further provide more operation security for children with strabismus.

A Case of Mucosa-associated Lymphoid Tissue Lymphoma Discovered by Repetitive Intraocular Lens Dislocation

PURPOSE: To report a case where bilateral malignant retrobulbar lymphoma was diagnosed after repetitive intraocular lens dislocation to the anterior chamber. CASE SUMMARY: An 85-year-old male with a history of stroke who had undergone cataract surgery 10 years ago at another hospital presented with repeated intraocular lens (IOL) dislocations of both eyes into the anterior chamber. He had previously undergone IOL scleral fixation once in his left eye and twice in his right eye, but IOL dislocation was still repeatedly occurring. The best-corrected visual acuity was 0.4 in both eyes. Hertel exophthalmetry was 20 mm in his right eye and 18 mm in his left eye. Painless limitation of motion at supraduction was observed in the right eye. Funduscopy showed newly appeared choroidal folding in the right eye, so orbital computed tomography (CT) with contrast was performed. The CT scans showed bilateral homogenously enhancing retrobulbar masses. Biopsy of the masses showed a MALToma. After radiation therapy, the choroidal folds resolved and exophthalmetry improved to 10 mm in both eyes. No additional IOL dislocation occurred. During 2.5 years of follow-up, there was no evidence of recurrence or distant metastasis of the MALToma. CONCLUSIONS: Orbital lymphomas can cause lid edema, exophthalmos, strabismus, and diplopia, and can be diagnosed with imaging modalities such as CT. Final diagnosis involves biopsy and radiation therapy or chemotherapy. If IOL dislocation occurs repeatedly, it may result from an increase in retrobulbar pressure, and concurrent choroidal folding using funduscopy is strongly recommended for imaging to check for the presence of retrobulbar masses.

Orbital multilobular osteochondrosarcoma in a dog / Osteocondrossarcoma multilobular em órbita de cão

Retrobulbar tumors may arise from any orbital tissue. Some are primary and others may extend from adjacent structures or derived from metastases. Multilobular osteochondrosarcomas are regarded as slowly growing and potentially malignant neoplasms in dogs. This tumor is of rare occurrence on retrobulbar region. This paper aims to report a rare case of female dog, Shih Tzu, spayed, five-year-old, that was referred to the Hospital of Veterinary Medicine, Federal University of Bahia, Brazil, with an increased volume in the orbital space, after enucleation for exophthalmia of unknown etiology. This animal was evaluated clinic and the diagnosis image (radiography and computed tomography) demonstrated a large formation of bone predominantly in the region of the right orbit and zygomatic arch, with invasion and destruction of adjacent bones. Due to her poor quality of life, the dog was submitted to euthanasia and after necropsy. On gross examination, an encapsulated nodular mass with an irregular surface, measuring 5.6 x 4.6 x 3.9 cm, was located in the right lateral skull, occupying the orbit with displacement of the zygomatic arch. The tumor was identified by histopathology as a malignant mesenchymal neoplasm, multilobular osteochondrosarcoma. Thus, differential diagnoses for exophthalmos should include cancers, including the multilobular osteocondrossarcoma.

Tumores retrobulbares podem originar-se de qualquer tecido orbital. Alguns são primários e outros podem estender-se a partir de estruturas adjacentes ou derivados de metástases. O osteocondrosarcoma multilobular é um tumor considerado de crescimento lento, potencialmente maligno e sua ocorrência é considerada rara em região orbital. Este trabalho objetiva descrever um caso de uma cadela, Shih Tzu, castrada, com cinco anos, atendida no Hospital de Medicina Veterinária da Universidade Federal da Bahia, Brasil, com apresentação de aumento de volume no espaço orbital, após enucleação devido a exoftalmia de etiologia desconhecida. O animal foi avaliado clinicamente e por exames de imagem (radiografia e tomografia computadorizada), os quais demonstraram uma grande formação óssea predominantemente na região da órbita direita e arco zigomático, com invasão e destruição dos ossos adjacentes. Devido às más condições de sobrevida apresentada pelo animal, foi indicado o procedimento de eutanásia e por fim, submetido à necropsia. No exame macroscópico, uma massa nodular encapsulada de superfície irregular, medindo 5,6 x 4,6 x 3,9 centímetros, foi localizada no crânio lateral direito, ocupando a órbita com deslocamento do arco zigomático. O tumor foi identificado por exame histopatológico como neoplasia mesenquimal maligna, osteocondrossarcoma multilobular. Desta forma, diagnósticos diferenciais para exoftalmia devem incluir neoplasias, dentre elas o osteocondrossarcoma multilobular.

Large exotropia after retrobulbar anesthesia.

A 67‑year‑old woman complained of horizontal diplopia shortly following bilateral cataract surgery with intraocular lens implantation performed under retrobulbar anesthesia. Retrobulbar anesthesia was administered at an inferotemporal injection site using 1 cc lidocaine hydrochloride 2% mixed with bupivacaine hydrochloride 0.5%. The initial ophthalmologic evaluation showed a 12‑prism diopter (PD) exotropia, and ocular motility evaluation revealed marked limitation of adduction without vertical limitation. One year after cataract surgery, the exodeviation increased up to 60 PD. The patient underwent an 8.0‑mm recession of the right lateral rectus and a 6.0‑mm recession of the left lateral rectus. Both lateral rectus muscles were biopsied, and biopsy revealed dense fibrous connective tissue without viable muscular cells. The lateral rectus muscle might be injured by retrobulbar anesthesia, and it could induce large exotropia.

A Case of Posterior Ischemic Optic Neuropathy Accompanied by Carotid Artery Plaque

PURPOSE: To report a case of posterior ischemic optic neuropathy accompanied by carotid artery plaque in a patient with retrobulbar optic neuritis. CASE SUMMARY: A 48-year-old man visited our clinic complaining of headache, decreasing visual acuity and defect of inferior visual field in his left eye for 3 days. The best corrected visual acuity was 1.0 in the right eye and 0.1 in the left eye. The anterior segment state, intraocular pressure, fundus examination and optical coherence tomography were normal in both eyes. Relative afferent pupillary defect, color vision deficiency and total scotoma were observed in his left eye. The results of the laboratory test and brain magnetic resonance imaging were normal. He was discharged from the hospital after 3 days of systemic steroid treatment on the basis of retrobulbar optic neuritis. A week later, fluorescent angiography and carotid ultrasonography were performed because of his history memory loss and left upper limb weakness before admission. A focal filling defect of the peripapillary area was found on fluorescent angiography. A plaque with a thickness of 1.9 mm and a length of 1.4 cm was found on carotid ultrasonography. After 6 months, the best corrected visual acuity was 0.4 in the left eye and the visual field showed a partially improved defect. CONCLUSIONS: Fluorescent angiography is recommended for potential posterior ischemic optic neuropathy in patients with retrobulbar optic neuritis, even though it is rare. Carotid ultrasonography is useful in finding atherosclerosis to prevent stroke or cardiovascular disease if ischemic cause is suspected on fluorescent angiography.

Effects of dexmedetomidine for retrobulbar anesthesia in orbital ball implants after enucleation surgery.

Background: Dexmedetomidine (DEX) can prolong the duration of local anesthetics, but the use of retrobulbar DEX has not been fully elucidated. This study was designed to determine the effects of adding DEX to lidocaine‑bupivacaine for retrobulbar block in orbital ball implants after enucleation surgery. Materials and Methods: A total of 200 patients of both sexes aged 30–60 years of American Society of Anesthesiologists I and II, scheduled for orbital ball implants after enucleation surgery, were enrolled for the study. Patients were randomly assigned into one of the two groups: Control (n = 100) received lidocaine‑bupivacaine retrobulbar block, DEX (n = 100) received lidocaine‑bupivacaine plus 1 ug/kg DEX retrobulbar block. Hemodynamic data, duration of motor and sensory blocks, pain by visual analog scale, bispectral index (BIS), side effects, consumption of dezocine as a rescue analgesic, patient and surgeon satisfaction were recorded. Results: Duration of analgesia was prolonged in the DEX, compared with the control group ([258.35 ± 66.82 min] as [130.75 ± 29.52 min], [P < 0.05]). The median number of postoperative analgesic requests per patient during the first 24 h was decreased in the DEX group (P < 0.05). In the first 24 postoperative hours, DEX group consumed significantly less dezocine (P < 0.05). BIS values and mean arterial pressure remained lower in the DEX group, but within the safe range (P < 0.05). The side effect profile was similar between the two groups. Patients and surgeon satisfaction were higher in the DEX group (P < 0.05). Demographic characteristics were comparable in both groups (P > 0.05). Conclusion: Retrobulbar DEX reduces consumption of rescue analgesic, prolonged the duration of retrobulbar block, improved postoperative pain, provided better sedation effects, and increased patient and surgeon satisfaction after orbital ball implants after enucleation surgery.

Change of retrobulbar artery hemodynamics and bulbar conjunctival microcirculation indexes of patients with optic atrophy / 国际眼科杂志(Guoji Yanke Zazhi)

AlM:To study and observe the change of retrobulbar artery hemodynamics and bulbar conjunctival microcirculation indexes of patients with optic atrophy.METHODS: Seventy patients with optic atrophy in our hospital from April 2013 to October 2014 were selected as observation group, 70 healthy persons with the same age at the same time were the control group. Retrobulbar artery hemodynamics and bulbar conjunctival microcirculation indexes of two groups were compared, those detection indexes of observation group with different types and severity degree were compared too.RESULTS: The retrobulbar artery hemodynamics and bulbar conjunctival microcirculation indexes of observation group were all worse than those of control group, and the detection results of observation group with severe optic atrophy were worse than those of patients with mild and moderate optic atrophy, and the detection results of patients with moderate optic atrophy were all worse than those of patients with mild optic atrophy ( all P 0. 05). CONCLUSlON: The change of retrobulbar artery hemodynamics and bulbar conjunctival microcirculation indexes of patients with optic atrophy are great, and the influence of the disease severity degree for the detection results are great.

Iatrogenic Central Retinal Artery Occlusion Following Retrobulbar Anesthesia for Intraocular Surgery

PURPOSE: To present clinical features of central retinal artery occlusion (CRAO) following retrobulbar anesthesia for intraocular surgery. METHODS: This observational case series describes 5 consecutive patients with acute CRAO following retrobulbar anesthesia for intraocular surgery. Data collected for this study included subject characteristics, retrobulbar anesthesia technique, treatment type, initial and final best-corrected visual acuity, and other ophthalmologic examinations. RESULTS: Mean subject age was 67.0 +/- 8.2 years (range, 53 to 72 years). All patients had one or more vascular risk factors (e.g., hypertension, cerebral infarction, carotid artery stenosis) and presented with acute vision loss 1 day after uneventful intraocular surgery (cataract surgery in 2 eyes and vitrectomy in 3 eyes). All 5 patients received retrobulbar anesthesia during surgery, 4 of which involved the use of a sharp needle. No immediate complications were noted during intraocular surgery. Final visual prognosis was poor (from finger count to no light perception) although intraocular thrombolysis was attempted in 3 patients. CONCLUSIONS: Iatrogenic CRAO is a potential complication of retrobulbar anesthesia for intraocular surgery in elderly patients with vascular risk factors. Unfortunately, this complication can lead to severe vision loss. We conclude that retrobulbar anesthesia for intraocular surgery should be performed with great care and special consideration for elderly patients with vascular risk factors.

Sildenafil citrate on retrobulbar and retinal circulation of rabbits / Citrato de sildenafil sobre a circulação retrobulbar e retiniana de coelhos

The effects of sildenafil on retrobulbar and retinal circulation were studied in 18 adult male, albino, homozygous rabbits, of the New Zealand White breed, randomly divided into 3 groups of 6 animals, for drug treatment at a dose of 3.5mg kg-1 every 24 hours, for 7, 15 and 30 days. Nine animals used for control were treated with saline solution at 0.9%. It was evaluated intraocular pressure (IOP), mean arterial pressure (MAP), ocular perfusion pressure (PPO), B-mode ultrasonography and fluorescein angiography before and at the end of treatments. A slight decrease in results of IOP, MAP and PPO after treatment with sildenafil was evident, however, there was no statistical significance. It was observed significant increased diameter of the ophthalmic artery after 7 and 30 days of treatment and decreased mean arterial pressure after 7, 15 and 30 days of treatment, with no statistical difference. On fluorescein angiography, it was observed that the arterial, arteriovenous and venous stages initiated more rapidly in animals after treatment, with significant difference on the arteriovenous stage at the 7th and 15th days. It was possible to admit that the sildenafil citrate improves blood circulation in the retina of rabbits, by increasing the speed of blood flow and decreasing the perfusion pressure.

Os efeitos do sildenafil sobre a circulação retrobulbar e a retiniana foram estudados em 18 coelhos machos adultos, albinos, homozigotos, da raça Nova Zelândia Branco, distribuídos aleatoriamente em 3 grupos de 6 animais, para tratamento com o fármaco na dose de 3,5mg kg-1 a cada 24 horas, por 7, 15 e 30 dias. Nove animais foram utilizados para controle, tratados com solução fisiológica a 0.9%. Foram avaliadas a pressão intraocular (PIO), a pressão arterial média (PAM) e a pressão de perfusão ocular (PPO), ultrassonografia em modo-B e a angiografia fluoresceínica, antes e ao término dos tratamentos. Evidenciou-se discreta diminuição nos resultados da PIO, da PAM e da PPO após tratamento com sildenafil, entretanto não houve significância estatística. Observou-se aumento significativo do diâmetro da artéria oftálmica após 7 e 30 dias de tratamento e diminuição da pressão arterial média após 7, 15 e 30 dias de tratamento, sem diferença estatística. À angiografia fluoresceínica, observou-se que as fases arterial, artério-venosa e venosa iniciaram-se mais rapidamente nos animais após o tratamento, com diferença significativa na fase artério-venosa ao 7o e 15o dias. Foi possível admitir que o citrato de sildenafil melhora a circulação de sangue na retina de coelhos, através do aumento da velocidade do fluxo de sangue e diminuição da pressão de perfusão.