Análisis médico legal de la fractura de órbita por "blow out" o estallido: reporte de caso / Medical-legal analysis of blow out fracture of the orbit: case report

La fractura orbitaria por estallido o fractura en "blow out" es una de las fracturas más comunes a nivel facial por lo que su importancia reside en saber identificarlas por el enmascaramiento clínico que podría o no, estar presente. Es de vital importancia complementar la valoración clínica con estudios de imagenología que confirmen las sospechas clínicas. De no hacerlo si el paciente no consulta a un servicio médico quirúrgico la pérdida de la capacidad funcional o la debilitación persistente en la salud ocasionada por la fractura no podrá ser validada en un Dictamen Médico Legal de Secuelas.

The orbital blow out fracture is one of the most common fractures at facial level, so its importance lies in knowing how to identify them due to the clinical masking that may or may not be present. It is of vital importance to complement the clinical evaluation with imaging studies to confirm the clinical suspicions. Otherwise, if the patient does not consult a surgical medical service, the loss of functional capacity or the persistent debilitation in health caused by the fracture cannot be validated in a Forensic Medical Report of Sequelae.

Síndrome de Tolosa-Hunt una extraña causa de oftalmoplejía dolorosa: reporte de caso / Tolosa-Hunt syndrome a strange cause of painful ophthalmoplegia: case report

RESUMEN INTRODUCCIÓN: El síndrome de Tolosa-Hunt (STH) se caracteriza por una oftalmoplejía dolorosa, de etiología desconocida. De acuerdo con los hallazgos histopatológicos, se ha descrito la formación de un tejido granulomatoso en los senos cavernosos. PRESENTACIÓN DEL CASO: Una mujer de 22 años con cuadro clínico de 3 semanas de evolución caracterizado por cefalea hemicránea derecha, dolor ocular derecho y diplopía. Su examen físico evidenció la existencia de una oftalmoplejía derecha; la resonancia magnética (RM) de silla turca demostró engrosamiento y realce en la región del seno cavernoso derecho. Se presenta el caso clínico de una causa inusual de oftalmoplejía dolorosa. DISCUSIÓN: La oftalmoplejía dolorosa tiene múltiples diagnósticos diferenciales que incluyen causas neoplá-sicas, vasculares, inflamatorias e infecciosas que pueden afectar el seno cavernoso o la fisura orbitaria superior. El STH, que es una causa rara de oftalmoplejía dolorosa, sigue siendo un diagnóstico de exclusión. Por otra parte, se caracteriza por tener una adecuada respuesta al tratamiento con glucocorticoides. CONCLUSIÓN: La negatividad en las investigaciones de las etiologías de oftalmoplejía, los hallazgos imagenológicos en la RM y la adecuada respuesta cínica con el uso de los corticoides permiten confirmar el diagnóstico. No debería ser necesaria la biopsia del seno cavernoso ante la sospecha de STH con adecuada respuesta al manejo corticoide.

ABSTRACT INTRODUCTION: Tolosa-Hunt syndrome (THS) is characterized by painful ophthalmoplegia of unknown etiology, the formation of a granulomatous tissue in the cavernous sinuses has been described in histopatho-logical findings. CASE PRESENTATION: A 22-year-old woman presenting with 3 weeks of right sided headache, right eye pain and diplopia. Physical examination revealed the existence of a right ophthalmoplegia; magnetic resonance imaging (MRI) of the sella turcica showed thickening and enhancement of the right cavernous sinus. A clinical case of an unusual cause of painful ophthalmoplegia is presented. DISCUSSION: Painful ophthalmoplegia has multiple differential diagnoses that include neoplastic, vascular, inflammatory and infectious causes that can affect the cavernous sinus or the superior orbital fissure. STH is a rare case of painful ophthalmoplegia that continues to be a diagnosis of exclusion characterized by an adequate response to treatment with glucocorticoids. CONCLUSION: The negativity of the investigations for the causes of ophthalmoplegia, the imaging findings in the MRI and the adequate response to corticosteroids allows the diagnosis to be made. Biopsy should not be necessary when THS is suspected and there is an adequate response to corticosteroid management.

Mucocele fronto-etmoidal gigante / Giant frontoethmoidal mucocele

Se presenta el caso de un paciente varón de 18 años, con un gran mucocele frontoetmoidal derecho, postoperado en dos oportunidades anteriores, que acudió a nuestro servicio por un empeoramiento de la diplopía. Al examen físico se visualizaba un desplazamiento del globo ocular hacia abajo y afuera. Se le realizó estudios de imágenes, una tomografía computarizada y una resonancia magnética nuclear que sugerían un mucocele frontoetmoidal derecho. Se le realizó una sinusotomía tipo Draf III para drenaje de la lesión, con mejoría de los síntomas.

We present the case of an 18-year-old male patient with a large right frontoethmoidal mucocele, postoperatively on two previous occasions, who came to our department due to worsening diplopia. Physical examination revealed a downward and outward displacement of the eyeball. Imaging studies, computed tomography, and magnetic resonance imaging were performed that suggested a right frontoethmoidal mucocele. A type Draf III sinusotomy was performed to drain the lesion, with improvement of the symptoms.

Tiempo de evolución y eliminación de la diplopía binocular en pacientes con paresia o parálisis oculomotoras / Evolution Time and Elimination of Binocular Diplopia in Patients with Oculomotor Paresis or Paralysis

Objetivo: Determinar la relación existente entre tiempo de evolución y eliminación de la diplopía binocular en pacientes con paresia o parálisis oculomotoras. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de casos que acudieron a la consulta del Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer y que cumplían con los criterios de inclusión en el periodo comprendido entre mayo del 2018 a junio del 2019. Se evaluaron las variables: sexo, tiempo de evolución, opciones de tratamiento, eliminación de diplopía, fusión y estereopsis. Resultados: El mayor número de casos acudieron a consulta entre una semana y menos de un mes de evolución de la enfermedad y más de seis meses. No resultó significativo la relación sexo, etiología y tiempo de evolución en acudir los pacientes a consulta externa. El 66,7 por ciento de la muestra estudiada resolvió solo con tratamiento médico, incluidos el 100 por ciento de los pacientes con menos de una semana de evolución. Todos los pacientes con tiempo de evolución menor de seis meses eliminaron la diplopía y se encontró diferencia estadística (p = 0,04) entre estas variables. El 76,7 por ciento logró fusión y el 56,7 por ciento estereopsis. Conclusiones: La mayor parte de los pacientes con tiempo de evolución menor de seis meses eliminaron la diplopía solo con tratamiento médico, incluidos el 100 por ciento de los pacientes con menos de una semana de evolución, observándose una relación entre la recuperación y la cronicidad de la diplopía(AU)

Objective: To determine the relationship between time of evolution and elimination of binocular diplopia in patients with oculomotor paresis or paralysis. Methods: A descriptive, longitudinal and prospective study was carried out, from May 2018 to June 2019, of a series of cases that were assisted in consultation of the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology and that met the inclusion criteria. The variables evaluated were sex, evolution time, treatment options, elimination of diplopia, fusion and stereopsis. Results: The largest number of cases were assisted in consultation between one week and less than one month of evolution of the disease and more than six months. The relationship between sex, etiology and time of evolution in attending the outpatient clinic was not significant. 66.7 percent of the studied sample solved only with medical treatment, including 100 percent of patients with less than one week of evolution. All patients with evolution time of lesser than six months eliminated diplopia and a statistical difference was found (p = 0.04) between these variables. 76.7 percent achieved fusion and 56.7 percent stereopsis. Conclusions: Most of the patients with evolution time of lesser than six months eliminated diplopia only with medical treatment, including 100 percent of patients with less than one week of evolution, observing a relationship between recovery and chronicity of diplopia. Diplopia(AU)

Etiología y evolución de la diplopía binocular en pacientes con paresia o parálisis oculomotoras / Etiology and Course of Binocular Diplopia in Patients with Oculomotor Paresis or Paralysis

Objetivo: Determinar la etiología y evolución de la diplopía binocular en pacientes con paresia o parálisis oculomotoras. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de casos que acudieron a la consulta del Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer y cumplían con los criterios de inclusión en el periodo comprendido entre mayo del 2018 a junio del 2019. Se evaluaron las variables: edad, sexo, factores de riesgo, etiología, opciones de tratamiento y eliminación de diplopía. Resultados: La edad media de la muestra estudiada fue de 56,8 años y predominó el sexo masculino (56,7 por ciento versus 43,3 por ciento). El factor de riesgo más frecuente fue el microvascular (86,7 por ciento), 14 pacientes con hipertensión arterial y 12 con diabetes mellitus. Predominó también la etiología microvascular en 18 pacientes de 30. El 66,7 por ciento de la muestra estudiada resolvió solo con tratamiento médico y el 86,7 por ciento de los casos eliminaron la diplopía en todas las posiciones diagnósticas de la mirada. Conclusiones: El nervio craneal más frecuente afectado es el sexto y prevaleció la etiología microvascular en el sexto y tercer nervio craneal, sin embargo, para el cuarto es la traumática la única causa encontrada, lo cual concuerdan con la literatura revisada(AU)

Objective: To determine the etiology and evolution of binocular diplopia in patients with oculomotor paresis or paralysis. Methods: A descriptive, longitudinal and prospective study was carried out, from May 2018 to June 2019, of a series of cases that were assisted in the consultation of the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology and met the inclusion criteria. The variables evaluated were age, sex, risk factors, etiology, treatment options and elimination of diplopia. Results: The mean age of the studied sample was 56.8 years and the male sex predominated (56.7 percent versus 43.3 percent). The most frequent risk factor was microvascular (86.7 percent), fourteen patients with arterial hypertension and 12 with diabetes mellitus. Microvascular etiology also predominated in 18 patients out of 30. The medical treatment only solved 66.7 percent of the studied sample and 86.7 percent of cases eliminated diplopia in all diagnostic gaze positions. Conclusions: The most frequently affected cranial nerve is the sixth and microvascular etiology prevailed in the sixth and third cranial nerves, however, for the fourth traumatic is the only cause found, which is consistent with the literature reviewed(AU)

Diplopía binocular por paresia o parálisis oculomotoras: resultados de las opciones de tratamiento / Binocular Diplopia due to Oculomotor Paresis or Palsies: Outcomes of Treatment Options

Objetivo: Determinar resultados de las opciones de tratamiento para la diplopía binocular en pacientes con paresia o parálisis oculomotoras. Método: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de casos que acudieron a la consulta del Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer. Se evaluaron las variables: edad, sexo, etiología, opciones de tratamiento, limitación de los movimientos oculares, eliminación de diplopía, fusión y estereopsis. Resultados: La etiología más frecuente fue la microvascular. El 66,7 por ciento de la muestra estudiada se resolvió solo con tratamiento médico, de ellos el 100,0 por ciento con diagnóstico de paresias o parálisis del tercer nervio craneal, seguido por el sexto y cuarto con 63,6 por ciento y 33,3 por ciento, respectivamente. Necesitaron tratamiento médico, quirúrgico y aplicación de toxina botulínica seis pacientes, el 33,3 por ciento del cuarto y el 22,7 por ciento del sexto nervio craneal. El resto de las opciones de tratamiento solo con un paciente. No se halló asociación significativa entre opciones de tratamiento y nervio craneal afectado. El 86,6 por ciento finalizó sin limitación de los movimientos oculares. El 86,7 por ciento de los casos eliminaron la diplopía en todas las posiciones diagnósticas de la mirada. El 76,7 por ciento logró fusión y el 56,7 por ciento estereopsis. Conclusiones: El tratamiento médico y el combinado de médico más inyección de toxina botulínica y cirugía de músculos extraoculares fueron las opciones más utilizadas y permitieron alineamiento ocular y eliminación de la diplopía binocular(AU)

Objective: To determine outcomes of treatment options for binocular diplopia in patients with oculomotor paresis or paralysis. Method: A descriptive, longitudinal and prospective study was carried out of a series of cases that were assisted at the consultation of the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology. The variables evaluated were age, sex, etiology, treatment options, limitation of ocular movements, elimination of diplopia, fusion and stereopsis. Results: The microvascular etiology was the most frequent. 66.7 percent of the studied sample was resolved only with medical treatment, 100.0 percent of them had a diagnosis of paresis or paralysis of the third cranial nerve, followed by the sixth and fourth with 63.6 percent and 33.3 percent, respectively. Six patients required medical and surgical treatment and application of botulinum toxin, 33.3 percent of the fourth and 22.7 percent of the sixth cranial nerve. The rest of the treatment options with only one patient. No significant association was found between treatment options and affected cranial nerve. 86.6 percent finished without limitation of eye movements. 86.7 percent of cases eliminated diplopia in all diagnostic gaze positions. 76.7 percent achieved fusion and 56.7 percent stereopsis. Conclusions: Medical treatment and combined medical treatment plus botulinum toxin injection and extraocular muscle surgery were the most used options and allowed ocular alignment and elimination of binocular diplopia(AU)

Astenopia em docentes universitários durante a pandemia da COVID-19 / Asthenopia in college lecturers during the COVID-19 pandemic

RESUMO Objetivo: Avaliar sintomas astenópicos e fatores sociodemográficos, hábitos comportamentais e clínicos nos docentes universitários durante a pandemia da COVID-19. Métodos: Trata-se de estudo transversal que avaliou a ocorrência de astenopia em 104 docentes. Questionários de sintomatologia visual validados foram adaptados para a coleta de dados. Houve comparação dos docentes quanto à ocorrência ou não de sintomas astenópicos, bem como foi aplicada regressão logística binária, para aferir a associação com variáveis independentes (p<0,05). Resultados: Houve maior aparecimento de sintomas astenópicos durante o período pandêmico, em que o tempo de exposição a telas parece ter sido o fator mais determinante. Além disso, os indivíduos com tempo de tela superior a 5 horas diárias, que faziam uso de telas para o lazer e usavam colírio/lubrificantes apresentaram significativamente maior chance de estar no grupo com sintomas astenópicos. Conclusão: Foi identificada associação significativa entre a ocorrência de sintomas astenópicos e o uso de telas durante o período pandêmico, principalmente nos grupos com maior duração do tempo de tela. O estudo chama atenção para a saúde ocular de docentes universitários em ensino remoto, além de suscitar novos estudos para investigação desse quadro em distintos ambientes escolares.

ABSTRACT Objective: To assess asthenopic symptoms and sociodemographic factors, behavioral and clinical aspects in college lecturers during the COVID-19 pandemic. Methods: This is a cross-sectional study evaluating asthenopia in 104 lecturers. Some validated visual symptom questionnaires were adapted for data collection. Lecturers were compared regarding the occurrence or not of asthenopic symptoms, and binary logistic regression was applied to measure the association with independent variables (p<0.05). Results: Asthenopic symptoms occurred more often during the pandemic, when exposure to screens was a determinant factor. The individuals with screen time longer than five hours a day, who used screens for leisure, and who used eye drops/lubricants were significantly more likely to be in the group with asthenopic symptoms. Conclusion: A significant association was identified in occurrence of asthenopic symptoms and screen use during the pandemic period, especially in groups with longer screen time. The study draws attention to the eye health of college lecturers in distance learning, and the need for further research on this situation in different school environments.

Síndrome de tolosa hunt: presentación de caso clínico / Tolosa Hunt syndrome: case report

El síndrome de Tolosa-Hunt es una entidad poco frecuente cuya etiopatogenia y mecanismos fi- siopatológicos son controversiales, se caracteri- za por cefalea asociada a parálisis de uno o más nervios craneales, diplopía, estrabismo y ptosis palpebral, ocasionados por el compromiso del seno cavernoso o la fisura orbitaria superior. Su diagnóstico es un reto y se aborda dentro de los diagnósticos diferenciales de las oftalmoplejías dolorosas. Con el objetivo de describir y actua- lizar el conocimiento sobre esta enfermedad se presenta el caso de una paciente de 14 años que acudió a consulta por cefalea intensa, dolor ocu- lar y afección de nervios craneales. Los hallazgos clínicos y la resonancia magnética confirmaron el diagnóstico del síndrome de Tolosa Hunt...(AU)

Oftalmoplejía internuclear bilateral (WEBINO) en un paciente pediátrico con Lupus Eritematoso Sistémico / Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) in a pediatric patient with Systemic Lupus Erythematosus

Resumen El síndrome de WEBINO (wall-eyed bilateral internuclear ophthalmoplegia), se presenta por una lesión del tegmento pontino (incluye área pontina paramediana, fascículo longitudinal medial y núcleo del abducens). Presenta limitación bilateral en la aducción y exotropía en la posición de la mirada primaria, nistagmo del ojo que abduce e incapacidad para la convergencia. Reporte de caso: Presentamos el caso de una paciente de 14 años con antecedente de Lupus Eritematoso Sistémico que debutó con diplopía horizontal de inicio súbito. El diagnóstico de WEBINO fue clínico y asociado con hallazgos de lesión isquémico pontomesencefálica en Resonancia Nuclear Magnética y angioresonancia cerebral. Se administró tratamiento con Metilprednisolona y presentó resolución gradual de los síntomas, sin embargo una semana después falleció por criptococosis sistémica. Conclusiones: Hacer el diagnostico de WEBINO se hace desafiante por su rareza y por la precisión de su localización neuroanatómica. Se debe realizar una exploración detallada para definir la causa probable y establecer el tratamiento oportuno que favorezca el pronóstico neurológico.

Background: Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is presented by a lesion of the pontine tegment (includes paramedian pontine area, medial longitudinal fascicle and nuclei of the abducens). It presents bilateral limitation in adduction and exotropia in the position of the primary gaze, abducting eye nystagmus and inability to converge. Case report: We present the case of a 14-year-old patient with a history of Systemic Lupus Erythematosus who debuted with sudden onset horizontal diplopia. WEBINO's diagnosis was clinical and associated with findings of ponto-mesencephalic ischemic injury in magnetic resonance imaging and magnetic resonance angiography. Treatment with Methylprednisolone was administered and she presented gradual resolution of the symptoms, however, one week later she died of systemic cryptococcosis. Conclusions: Making the WEBINO diagnosis is challenging due to its rarity and the precision of its neuroanatomical location. A detailed examination should be performed to define the probable cause and establish the appropriate treatment that favors the neurological prognosis.

Síndrome de pseudo-Duane secundario a Schwannoma de nervio abducens: Reporte de caso y revisión / Pseudo-Duane syndrome secondary to abducens nerve schwannoma: Case report and review

Reporte de caso de síndrome de pseudo-Duane asociado a schwannoma de nervio abducens y neurofibromatosis tipo 2 (NF2). Este síndrome es raro, caracterizado por limitación en abducción, retracción ocular, disminución de hendidura palpebral en abducción y restricción del recto medial ipsilateral en test de ducción forzada. La NF2 es también una enfermedad infrecuente caracterizada por tumores de sistema nervioso central y periférico. Los schwannomas de nervio abducens son también poco frecuentes, y se presentan comúnmente con diplopia. Se revisan brevemente estas enfermedades. Es el primer caso reportado de pseudo-Duane secundario a schwannoma de nervio abducens y NF2 según nuestro conocimiento.

A pseudo-Duane syndrome case associated with abducens nerve schwannoma and neurofibromatosis type 2 (NF2) is presented. This syndrome is a rare disease characterised by abduction limitation, ocular retraction, narrowing of the palpebral fissure in abduction, and ipsilateral medial rectus restriction on forced duction test. NF2 is also an uncommon disease which is characterised by peripheral and central nervous system tumours. Abducens nerve schwannomas are also uncommon and presents usually as diplopia. A short review of these diseases is given. This is the first case of pseudo-Duane secondary to abducens nerve schwannoma, to our knowledge.

Paquimeningitis hipertrófica idiopática en un anciano. Signo de Eiffel de noche / Idiopathic hypertrophic pachymeningitis in an elderly man. Eiffel-by-night sign

Masculino de 71 años, hipertenso, con tabaquismo activo (IPA 51); ingresó a urgencias por disminución progresiva de la agudeza visual bilateral hasta llegar a amaurosis bilateral, no dolor ocular. Asociado a cefalea crónica frontal bilateral, pulsátil. RNM cerebral mostró engrosamiento difuso de la meninge en relación con paquimeningitis. Biopsia de meninge mostró paquimeninge. Se descartaron casusas neoplásicas, infecciosas, autoinmunes, por lo cual se consideró una paquimeningitis hipertrófica idiopática (PHI). La paquimeningitis hipertrófica es una entidad clínica rara caracterizada por engrosamiento localizado o difuso de la duramadre, con o sin una inflamación asociada, produce déficit neurológico progresivo por compresión de las estructuras adyacentes (1). El dolor de cabeza es el síntoma inicial más común, seguido de síntomas oftalmológicos, como pérdida visual y diplopía (2). Su etiología es multifactorial, en estudios de imagen se encuentra engrosamiento dural en la fosa craneal posterior (2), imitando la torre Eiffel iluminada en noche (signo de Eiffel de noche) (3).

A 71-year-old hypertensive male who was an active smoker (IPA 51) was admitted to the emergency room due to progressively decreasing bilateral eyesight to the point of bilateral amaurosis, without ocular pain. This was associated with a chronic bilateral pulsatile frontal headache. A brain NMR showed diffuse meningeal thickening related to pachymeningitis. A meningeal biopsy showed pachymeninge. Neoplastic, infectious and autoimmune causes were ruled out; therefore, it was considered to be idiopathic hypertrophic pachymeningitis (IHP). Hypertrophic pachymeningitis is a rare clinical entity characterized by localized or diffuse thickening of the dura mater, with or without associated inflammation. It causes progressive neurological deficit due to compression of the adjacent structures (1). Headache is the most common initial symptom, followed by ophthalmological symp-toms such as vision loss and diplopia (2). Its etiology is multifactorial. Dural thickening in the posterior cranial fossa, mimicking the Eiffel Tower illuminated at night (Eiffel-by-night sign), is found on imaging studies. References 1. Uchida H, Ogawa Y, Tominaga T. Marked effectiveness of low-dose oral methotrexate for steroid-resistant idiopathic hypertrophic pachymeningitis: Case report. Clin Neurol Neurosurg. 2018 May;168:30­3. 2. Hahn LD, Fulbright R, Baehring JM. Hypertrophic pachymeningitis. J Neurol Sci. 2016 Aug;367:278­83. 3. Dash GK, Thomas B, Nair M, Radhakrishnan A. Clinico-radiological spectrum and outcome in idiopathic hypertrophic pachymeningitis. J Neurol Sci. 2015 Mar;350(1­2):51­60. Figure 1. A: Brain NRM with gadolinium, coronal view. Diffuse meningeal thickening, mainly on the right, with significant enhancement on diffuse gadolinium application, compatible with pachymeningitis. B: Orbital NRM with gadolinium. Diffuse pachymeningitis changes which reach the left and right orbital fissures. Figure 2. Meningeal biopsy (H&E 40X). Fibroconnective tissue can be seen, with fibroblast proliferation, increased collagen, cal-cifications and mononuclear inflammatory infiltrate throughout its thickness, compatible with pachymeninge.

Hematoma subperiosteal orbitário secundário a barotrauma em aviação civil / Orbital subperiosteal hematoma secondary to barotrauma in civil aviation

RESUMO Os diagnósticos diferenciais que compõem as proptoses agudas são, muitas vezes, desafiadores. A anamnese e o exame clínico exigem do oftalmologista atenção especial aos detalhes que permitem diferenciar quadros relativamente benignos e autolimitados de quadros que evoluirão com incapacidades permanentes. Relatamos o caso de uma paciente de 49 anos que, durante viagem de avião, apresentou dor ocular, hematoma periorbitário e proptose do olho esquerdo súbitos. Referia diplopia aguda incapacitante. Exames de tomografia e angiorressonância magnética confirmaram diagnóstico de sinusopatia do seio etmoidal esquerdo e hematoma subperiosteal da órbita esquerda, associado ao barotrauma. Apesar de raro, o diagnóstico de hematoma subperiosteal não traumático deve ser considerado diferencial em relação a proptoses agudas, sendo a anamnese fundamental para essa elucidação diagnóstica.

ABSTRACT Differential diagnoses of acute proptosis are often challenging. History and clinical examination require from ophthalmologists special attention to details, which make it possible to differentiate relatively benign and self-limited conditions from those that will progress to permanent disabilities. We report a 49-year-old female patient who had sudden eye pain, periorbital hematoma and proptosis of the left eye during a commercial flight. She also complained of disabling acute diplopia. Computed tomography and magnetic resonance angiography imaging confirmed the diagnosis of subperiosteal hematoma of the left orbit, associated with left ethmoid sinus disease. Although rare, non-traumatic subperiosteal hematoma should be considered in differential diagnoses of acute proptosis, and history taking is fundamental to elucidate the picture.

Paresia unilateral do terceiro nervo após uso de Metronidazol oral / Unilateral third nerve palsy after use of oral Metronidazole

Resumo Paciente do sexo feminino, 19 anos, com queixa de diplopia, náusea e vômito de início súbito. Ao exame físico, a paciente apresentava rotação da cabeça para a esquerda e limitação da adução do olho direito, sugerindo paresia do músculo reto medial. Ausência de ptose palpebral ou paresia de outra musculatura ocular extrínseca e sem outras alterações na avaliação oftalmológica. Foi relatado pelo paciente o uso de Metronidazol, duas doses de 500 mg, no mesmo dia em que os sintomas começaram. A ressonância magnética do crânio foi solicitada. O resultado mostrou um cisto da glândula pineal, estando os outros aspectos dentro da normalidade. A paresia do músculo reto medial e diplopia persistiram por 14 dias, mesmo após a suspensão do antibiótico, optando, assim, por iniciar a corticoterapia oral, evoluindo com boa resposta clínica, melhora dos sintomas e regressão da paresia muscular.

Abstract Female patient, 19 years old, with a complaint of diplopia, nausea and vomiting of sudden onset. Upon physical examination, the patient presented herself with the head position rotated to the left and limitation of adduction of the right eye, suggesting paresis of the medial rectus muscle. Absence of palpebral ptosis or paresis of other extrinsic musculature of the eye, and without other alterations in the ophthalmological evaluation. It was reported by the patient the use of Metronidazole, two doses of 500 mg, the same day the symptoms started. The magnetic resonance imaging of the skull was requested. The result showed a cyst of the pineal gland, the other aspects being within normality. The paresis of the medial rectus muscle and diplopia persisted for 14 days, even after the antibiotic was discontinued, thus opting to initiate oral corticosteroid therapy, evolving with good clinical response, improvement of symptoms and regression of muscular paresis.

Síndrome anti-GQ1b en un niño con síndrome de Miller-Fisher-Bickerstaff / Anti-GQ1b syndrome. A child with Miller-Fisher-Bickerstaff syndrome

El síndrome anti-GQ1b reúne el síndrome de Miller-Fisher y la encefalitis del tronco cerebral de Bickerstaff, entre otras entidades. Tienen etiopatogenia común, constituida por la presencia de anticuerpos anti-GQ1b que reaccionan contra los sitios GQ1b del sistema nervioso según sea su accesibilidad. La prevalencia anual del síndrome de Miller-Fisher es de 0,09 casos por 100 000 habitantes por año y no existen estudios epidemiológicos sobre la encefalitis del tronco cerebral de Bickerstaff, que sería menos frecuente. De evolución natural hacia la mejoría, se beneficia del tratamiento con gammaglobulina endovenosa.Se presenta a un paciente de 12 años con síndrome de Miller-Fisher­Bickerstaff tras un episodio de diarrea aguda por Campylobacter jejuni en el que los anticuerpos anti-GQ1b resultaron positivos. Es nuestro objetivo comunicar sobre un síndrome de presentación poco habitual en pediatría a fin de advertir acerca de la necesidad de su sospecha precoz y solicitud de estudios de laboratorio específico

Miller-Fisher syndrome and Bickerstaff brainstem encephalitis, among others, constitute the anti-GQ1b syndrome, with a common immune pathophysiologic pathway characterized by the presence of anti-GQ1b antibodies, which react against the different nervous system GQ1b sites according to their different accessibility. The Miller-Fisher syndrome has a prevalence of 0.09 cases per 100 000 people-year but there are not epidemiological studies about Bickerstaff brainstem encephalitis, that it seems to be less frequent. In spite of having a good natural outcome, the immunoglobulin administration has been established as efficacious at improving it. A twelve-year-old boy suffering from Miller-Fisher-Bickerstaff syndrome after an acute Campylobacter jejuni diarrhea with positive titers of anti-GQ1b and anti-QGT1a antibodies is presented. We communicate a very uncommon pediatric disease with the aim of warning about the importance of its early suspicion and the need of specific laboratory determination

Parálisis del nervio motor ocular externo luego de anestesia neuroaxial combinada epidural-espinal / Paralysis of the external oculomotor nerve after combined epidural-spinal neuroaxial anesthesia

Introducción: El abordaje del espacio subaracnoideo fue descrito por Quincke en el 1891. En la actualidad es práctica común para la realización de la anestesia neuroaxial subaracnoidea en las pacientes obstétricas. Las complicaciones descritas, asociadas a esto, son varias. Dentro de estas, la parálisis del nervio abducens o VI par no es frecuente y en ocasiones, no está relacionada a la punción ya que se produce días después del evento. Objetivo: Revisar la información relacionada con la complicación de parálisis del VI par. Presentación del caso: Paciente de 33 años de edad, femenina, de profesión médico, con antecedentes personales de migraña, historia de anestesia neuroaxial epidural sin complicaciones, que para la realización de una cesárea de segmento arciforme y salpinguectomia parcial bilateral, recibió una anestesia combinada peridural-espinal. El transoperatorio transcurre con estabilidad hemodinámica, hizo cefalea al tercer día del posoperatorio, que la atribuyó al antecedente de migraña y fue tratada sin evaluación por anestesiología con dipirona. A los 10 días de operada hace desviación de la mirada y diplopia, se diagnostica parálisis del VI par. Fue tratada por Neurología y se plantean varios diagnósticos diferenciales. Los estudios imagenológicos resultan negativos, se trató con vitaminas y se produjo remisión a las 6 semanas. Conclusiones: El diagnóstico de esta complicación es necesario ya que puede pasar inadvertida la relación con la anestesia y, por tanto, ser mal conducido su tratamiento(AU)

Introduction: The approach to the subarachnoid space was described by Quincke in 1891. It is now a common practice to perform subarachnoid neuroaxial anesthesia in obstetric patients. The complications described, associated with this, are several. Within these, the paralysis of the abducens nerve or sixth pair is not frequent and sometimes is not related to the puncture, since it occurs days after the event. Objective: To review the information related to the complication of paralysis of the sixth pair. Case presentation: A 33-year-old female patient, a physician, with a personal history of migraine, a history of epidural neuroaxial anesthesia without complications, who underwent combined epidural-spinal anesthesia for performing a cranial segment cesarean section and bilateral partial salpingectomy. The transoperative period runs with hemodynamic stability. There was headache three days after surgery, which was attributed to the migraine history and the patient was treated, without evaluation by anesthesiology, with dipyrone. At 10 days after surgery, the eyes are diverted and diplopia is manifested, paralysis of the sixth pair is diagnosed. She was treated by neurology and several differential diagnoses were proposed. Imaging studies are negative. She was treated with vitamins and remission occurred at six weeks. Conclusions: The diagnosis of this complication is necessary, since the relationship with anesthesia may go unnoticed and, therefore, its treatment may be poorly conducted(AU)

Clinical Manifestations and Computed Tomography Findings of Trapdoor Type Medial Orbital Wall Blowout Fracture

PURPOSE: To report the clinical manifestations and computed tomography (CT) findings of patients with a trapdoor type medial orbital wall blowout fracture.METHODS: From March 2009 to October 2016, the clinical records and computed tomography findings of patients who underwent surgical treatment for a trapdoor type medial orbital wall blowout fracture were retrospectively analyzed.RESULTS: A total of eight patients (six males and two females) were enrolled with a combined mean age of 14.4 years. Clinical manifestations were eyeball movement limitation (abduction and adduction) and ocular motility pain (eight patients, 100%), diplopia (seven patients, 87.5%), and nausea and vomiting (four patients, 50%). On CT, the distance from the orbital apex to the fracture site was an average of 22.0 mm and occurred in the middle position of the entire wall. Two patients had missed rectus completely dislocated into the ethmoid sinus through the fracture gap and six patients had definite involvement in the fracture gap and edema of the medial rectus muscle. The medial rectus muscle cross-sectional area was 47.7 mm² which was edematous compared to the contralateral eye (40.1 mm²). Orbital wall reconstruction was performed an average of 4.1 days after the injury. In all patients with oculocardiac reflex-like nausea and vomiting immediately improved after surgery. Six out of eight patients who had eyeball movement limitations (abduction and adduction) preoperatively showed adduction limitation after surgery. The eyeball movement limitation and diplopia disappeared 11.7 days and 46.7 days after surgery, respectively.CONCLUSIONS: Patients with trapdoor type medial wall blowout fracture showed characteristic computed tomographic findings and clinical manifestations such as eyeball movement limitation, ocular motility pain, diplopia, and oculocardiac reflex. An understanding of clinical findings and quick surgical treatment are therefore required. The type of eyeball movement limitation was abduction and adduction limitation preoperatively and adduction limitation postoperatively.

Treatment of Blowout fracture with video-assisted surgery / Tratamento de fratura Blowout com auxílio de vídeo-cirurgia

ABSTRACT Posterior fractures of the orbital floor are challenging, since an incomplete visualization of the defect through conventional surgical accesses may compromise the surgical outcome. The use of the endoscope as an auxiliary method during orbital reconstructions may be considered as a tool of considerable importance, mainly due to the visualization of the whole extension of fracture and adaptation of meshes or bone grafts. This study aims to report a clinical case of a patient diagnosed with extensive blowout fracture showing diplopy, enophthalmos, and ophthalmoplegia in supraversion, who underwent a subciliary approach combined with transantral video assisted surgery. There were no intercurrences on the procedure. Currently, patient has 1 year of follow up, with reestablished orbital function and architecture.

RESUMO As fraturas posteriores do assoalho orbital são desafiadoras, visto que a incompleta visualização do defeito por meio dos acessos cirúrgicos convencionais poderá comprometer o resultado cirúrgico. O uso do endoscópio como método auxiliar durante as reconstruções orbitais pode ser considerado uma ferramenta de grande importância principalmente para visualização de toda a extensão da fratura e adaptação das malhas ou enxertos ósseos. Este trabalho tem como objetivo relatar um caso clínico de um paciente diagnosticado com uma extensa fratura blowout apresentando clinicamente diplopia, enoftalmo e oftalmoplegia em supraversão, o qual foi submetido a tratamento através da abordagem subciliar combinada com a cirurgia vídeo-assistida transantral. O procedimento foi realizado sem intercorrências, estando o paciente com 1 ano de acompanhamento, com função e arquitetura orbital restabelecidos.

Manifestações neuroftalmológicas associadas a doença de Lyme / Neuro-ophthalmological manifestations associated with Lyme disease

Resumo A doença de Lyme é uma infecção sistêmica causada pela espiroqueta Borrelia burgdorferi e transmitida pelo carrapato do gênero Ixodes sp. e espécie Amblyomma cajennense. A doença costuma se manifestar em três estágios clínicos distintos, que podem variar de acordo com as características de cada hospedeiro. O objetivo deste trabalho é relatar o caso de uma paciente de 33 anos com doença de Lyme que apresentou como manifestações neuroftalmológicas diplopia, lagoftalmo paralítico e ceratite punctata, com exames laboratoriais negativos. Embora a espiroqueta Borrelia burgdorferi tenha maior tropismo pelos tecidos da pele, sistema nervoso e articulações, o acometimento ocular não deve ter sua importância diminuída, sendo descrito neste relato de caso, que abordou os aspectos mais pertinentes à doença para auxiliar seu diagnóstico e tratamento.

Abstract Lyme disease is a systemic infection caused by the spirochete Borrelia burgdorferi and transmitted by the tick of the genus Ixodes sp. and species Amblyomma cajennense. The disease usually manifests itself in three distinct clinical stages, which may vary according to the characteristics of each host. The objective of this paper is to report the case of a 33-year-old patient with Lyme disease who presented as neuro-ophthalmological manifestations diplopia, paralytic lagophthalmos and punctate keratitis, with negative laboratory tests. Although the spirochete Borrelia burgdorferi has a greater tropism in the tissues of the skin, nervous system and joints, the ocular involvement should not be diminished, being described in this case report, which approached the most pertinent aspects to the disease to aid its diagnosis and treatment.

Correção de estrabismo incomitante por cirurgia de recuo-ressecção combinadas do mesmo músculo reto / Incomitant strabismus correction through combined resection and recession of the same rectus muscle

Resumo O presente trabalho relata o caso de um paciente, masculino, 38 anos, com estrabismo incomitante e consequente diplopia, submetido à cirurgia debilitadora com recuo e fortalecimento com ressecção do músculo reto inferior direito. O objetivo desta técnica cirúrgica é a correção do desvio em sua posição de maior incomitância, sem prejudicar o alinhamento ocular na posição primária do olhar (PPO). O resultado satisfatório, em concordância com os dados da literatura atual, contribui para fazer desta técnica uma opção no tratamento de estrabismos incomitantes de difícil manejo.

Abstract The present study reports a case of a patient, 38-year-old man, with incomitant strabismus and consequent diplopia, submitted to debilitating surgery with recession and strengthening resection of the right inferior rectus muscle. This surgical technique aims to correct the deviation in its greater incomitence position, without impairing the ocular alignment in the primary position of the eye (PPO). The satisfactory result, in agreement with data of current literature, contributes to make this technique an option in the treatment of challenging incomitant strabismus.

Regeneración aberrante del III nervio craneal por aneurisma cerebral bilateral. Reporte de caso / Aberrant regeneration of the III cranial nerve due to bilateral cerebral aneurism

RESUMEN Los trastornos de la motilidad ocular constituyen motivo de consulta periódica en Oftalmología. La regeneración aberrante, trastorno muy poco reportado, es considerada la sincinesia oculomotora de mayor invalidez y complejidad. Diversas condiciones neuroftalmológicas están implicadas en la etiopatogenia de la enfermedad, la mayoría de las cuales puede ocasionar la muerte. El manejo de los síntomas y signos provocados por paradójicos movimientos oculares conjugados es difícil. Se reportó un caso con remisión tardía a neuroftalmología por diagnóstico inicial y evolución desfavorable. La historia psicofísica arrojó diagnóstico definitivo de regeneración aberrante del III nervio craneal secundario, a aneurisma cerebral de la carótida interna bilateral, agravado por reanastomosis quirúrgica. Una rigurosa, obligatoria e impostergable historia neuroftalmológica, se impone ante toda parálisis del III nervio craneal para brindar un diagnóstico etiológico preciso y de esta forma proteger la vida.

ABSTRACT The disturbances in ocular motility are the cause of periodical consultation in Ophthalmology. The aberrant regeneration, a scarcely reported disturbance, is considered the oculomotor synkinesis of highest disability and complexness. Several neuro-ophthalmologic conditions are implicated in the disease ethiopathogeny, and most of them could lead to death. The management of the symptoms and signs caused by paradoxical conjugated ocular movements is difficult. A case is reported of late remission to Neuro-ophthalmology due to unfavorable diagnosis and evolution. The psycho-physical history led to a definitive diagnosis of aberrant regeneration of the III secondary cranial nerve, to cerebral aneurism of the bilateral internal carotid, worsened by surgical re-anastomosis. In front of any paralysis of the III cranial nerve, it is necessary a rigorous, obligatory and immediate neuro-ophthalmological history to arrive to a precise etiological diagnosis, protecting life in that way.