Intracranial pressure and skull remodeling

In this article we review bony changes resulting from alterations in intracranial pressure [ICP] and the implications for ophthalmologists and the patients for whom we care. Before addressing ophthalmic implications, we will begin with a brief overview of bone remodeling. Bony changes seen with chronic intracranial hypotension and hypertension will be discussed. The primary objective of this review was to bring attention to bony changes seen with chronic intracranial hypotension. Intracranial hypotension skull remodeling can result in enophthalmos. In advanced disease enophthalmos develops to a degree that is truly disfiguring. The most common finding for which subjects are referred is ocular surface disease, related to loss of contact between the eyelids and the cornea. Other abnormalities seen include abnormal ocular motility and optic atrophy. Recognition of such changes is important to allow for diagnosis and treatment prior to advanced clinical deterioration. Routine radiographic assessment of bony changes may allow for the identification of patient with abnormal ICP prior to the development of clinically significant disease

Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was "rounded" relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically

Long-term management of orbital and systemic reactive lymphoid hyperplasia with rituximab

Rituximab, a monoclonal antibody to the B cell marker CD20, is becoming increasingly popular in the treatment of various orbital disorders. In this university-based interventional case series, we describe two patients with bilateral orbital and extra-orbital reactive lymphoid hyperplasia [RLH] treated with rituximab. Initially both had favorable responses; but roughly a year later recurrent disease necessitated maintenance therapy in both cases. Both again responded to additional courses of rituximab. Although recalcitrant disease may persist after treatment, rituxmab may play a role in the management of RLH with widespread involvement

Orbital trapdoor fractures

Orbital trapdoor fractures are commonly encountered in children. Awareness of trapdoor fractures is of particular importance. This is because early recognition and treatment are necessary to prevent permanent motility abnormities. In this article, we will provide a brief overview of orbital fractures. The clinical and radiographic features of trapdoor fractures will then be reviewed, followed by a discussion on their proper management

Evisceration in the modern age

Evisceration is an ophthalmic surgery that removes the internal contents of the eye followed usually by placement of an orbital implant to replace the lost ocular volume. Unlike enucleation, which involves removal of the entire eye, evisceration potentially causes exposure of uveal antigens; therefore, historically there has been a concern about sympathetic ophthalmic [SO] associated with evisceration. However, critical review of the literature shows that SO occurs very rarely, if ever, as a consequence of evisceration. Its clinical applications overlap with those of enucleation in cases of penetrating ocular trauma and blind painful eyes, but it is absolutely contraindicated in the setting of suspected intraocular malignancy and may be preferred for treatment of end-stage endophthalmitis. From a technical standpoint, traditional evisceration has a limitation in the orbital implant size. Innovations with scleral modification have overcome this limitation, and accordingly, due to its simplicity, efficiency, and good cosmetic results, evisceration has once again been gaining popularity

Comparison of humphrey matrix frequency doubling technology to standard automated perimetry in neuro-ophthalmic disease

We compared Humphrey Matrix FDT 30-2 [FDT] and Humphrey Visual Field Analyzer 30-2 SITA standard [SAP] in the assessment of anterior [optic nerve or chiasm] and posterior [retro-chiasmal] afferent visual pathway defects. In this retrospective comparative study, the charts of 37 patients [16 males, range 13-84 years, mean 72.1], with neuro-ophthalmic visual field defects who were tested with both FDT and SAP, were reviewed. Two masked graders assessed the concordance and extent of field defects between the perimeters. The mean concordance between anterior and posterior disease was compared using the Wilcoxon rank sum test. The mean deviation [MD] and pattern standard deviation [PSD] of each perimeter were correlated with the Spearman coefficient. Twenty-eight patients had anterior and nine had posterior disease. Most had a fair or good concordance [89.3% anterior, 88.9% posterior]. When comparing anterior to posterior disease, the mean concordance of the defects of the two parameters was not statistically different [P=0.94 and P=0.61 for total deviation and pattern deviation, respectively]. The MD and PSD between perimeters had a significant correlation. Conclusions: Our series, using 30-2 field analysis, demonstrates fair to good correlation between FDT and SAP in the majority of patients. In roughly 10% findings between FDT and SAP were discordant. This difference was similar for anterior and posterior disease