A Rare Case of Cyclotorsion Due to Medial Rectus Displacement Following Orbital Trauma.

We describe a rare case of cyclotorsion likely secondary to medial rectus and inferior rectus pathology in a patient with orbital trauma. Sequential orthoptic measurements including Hess charts are presented alongside relevant sections of the orbital CT scans over the course of the patient's treatment. Following the insertion of a plate to repair an orbital floor fracture, the patient developed cyclotorsion. A combined approach of sequential orthoptic assessment and imaging revealed the likely underlying mechanism. Inferior rectus mechanical restriction combined with displacement of the medial rectus pulley appear to be the likely culprits. Once the orbital plate was exchanged for a smaller sized plate the patient's symptoms and clinical features resolved. Although orbital plate malpositioning is not an uncommon event, medial rectus deviation as a cause of cyclotorsion has not previously been described. We discuss the alternative differentials for patients with similar orthoptic findings and how they were excluded.

Inferior Oblique Botulinum Toxin Injection: A Postoperative Diplopia Test for Secondary Inferior Oblique Muscle Overaction.

PURPOSE: To evaluate the utility of botulinum toxin injection into the inferior oblique muscle for secondary inferior oblique muscle overaction. METHODS: A retrospective review of 18 patients and 23 injections performed over a 9-year period. Indications and deviations in primary position and contralateral gaze before and after injection were recorded. Functional outcomes and further management (conservative vs surgical) were observed. RESULTS: In 14 patients, chemodenervation resulted in a temporary improvement in symptoms. Eleven of these patients went on to have inferior oblique myectomy with resolution of their diplopia. Two patients preferred to receive regular injections of botulinum toxin as a treatment. CONCLUSIONS: Botulinum toxin chemodenervation of the inferior oblique muscle in cases of secondary inferior oblique muscle overaction is useful where one needs to establish a risk of overcorrection following planned inferior oblique muscle weakening. This is particularly true in cases where the primary position deviation may be small but symptoms of diplopia exist on contralateral side gaze, giving rise to a narrowed field of binocular single vision.

Unaugmented Muscle Union Surgery for Heavy Eye Syndrome Without Combined Medial Rectus Recession.

PURPOSE: Simple loop myopexy or retro-equitorial muscle union surgery has been shown to effectively treat the strabismus seen in heavy eye syndrome. In most cases, this has been described with combined recession of the medial rectus muscle, particularly where medial rectus contracture was demonstrated on forced duction testing intraoperatively. The authors report the outcomes of muscle union surgery alone without combined medial rectus recession in 29 eyes with heavy eye syndrome. METHODS: A retrospective review was conducted of 26 patients and 29 eyes with heavy eye syndrome treated with a simple loop myopexy procedure. The preoperative and postoperative deviations in primary position were measured along with restriction in ocular motility in abduction and elevation. Patients with residual esotropia and/or persistence of symptoms were offered a second-stage medial rectus recession procedure. RESULTS: In 21 patients, muscle union was sufficient in improving the diplopia or cosmetic appearance of the eyes. In these cases, the average preoperative deviation improved from 21.2 ± 16.3 to 5.5 ± 9.1 prism diopters (PD). Eight eyes went on to have a second-stage medial rectus recession with excellent outcomes. CONCLUSIONS: The authors found that muscle union surgery alone is an effective and successful procedure in restoring the ocular motility disturbance and also in treating heavy eye syndrome. There was a much lower incidence (up to 70% lower) of medial rectus recession than other similar case series. There were no cases of overcorrection and no complications.

Hypotension-induced blindness in haemodialysis patients.

Hypotension is a commonly encountered complication in haemodialysis patients and is a significant cause of morbidity and mortality. Bilateral visual loss in dialysis induced hypotension remains poorly recognized as a complication by both renal physicians and ophthalmologists. We report 2 cases of patients on renal dialysis who suffered severe longstanding hypotension with bilateral non-arteritic anterior ischaemic optic neuropathy. Both patients experienced bilateral loss of vision over a short time period. We feel that physicians must be aware of patients complaining of painless visual loss in this high risk group, as control of blood pressure may be the most important factor in prevention of this visually devastating condition.

Isolated Pupil-Involving Third Nerve Palsy as the First Presentation of Sarcoidosis.

Neurosarcoidosis is seen in 5-15% of patients with systemic sarcoidosis. The most common cranial nerve presentations are optic neuropathy and facial nerve palsy. The authors present a case of sarcoidosis presenting with a pupil-involving third nerve palsy. The patient responded to corticosteroid therapy with resolution of investigations her cranial nerve palsy but progressed to develop cerebellar signs. This is the first documented case of a pupil-involving third nerve palsy occurring as the first presentation of neurosarcoidosis. Although typically a pupil-involving third nerve palsy necessitates urgent neuroimaging to rule out a posterior communicating artery aneurysm, it is important to recognise inflammatory causes in the differential diagnosis.

CFH, VEGF and HTRA1 promoter genotype may influence the response to intravitreal ranibizumab therapy for neovascular age-related macular degeneration.

AIMS: To investigate an association between genotype for three single nucleotide polymorphisms strongly associated with the development of age-related macular degeneration (AMD) and the early response to treatment with intravitreal ranibizumab for neovascular AMD. METHODS: Best corrected visual acuity letter score was recorded at baseline and each subsequent visit. Age, sex, smoking history, lesion type and the number of injections were also recorded. Genotypes were obtained for rs11200638 in HTRA1, rs1061170 in CFH and rs1413711 in VEGF. Data were analysed with treatment response at month 6 as both a binary (>5 letter improvement vs ≤5 letter gain) and a linear trait. RESULTS: This initial study cohort consisted of 104 Caucasian neovascular AMD patients treated with intravitreal ranibizumab. Trends towards a more favourable outcome were seen with the higher AMD risk genotypes in CFH and VEGF in both the linear and binary models and in HTRA1 in the linear model alone. For CFH, mean letter score change after 6 months was +1.6, +5.9 and +7.2 letters for the TT, TC and CC genotypes and a >5 letter gain was seen in 34.6%, 56.6% and 56%, respectively. For VEGF, mean letter score change after 6 months was +1.3, +5.8 and +7.4 letters for the TT, TC and CC genotypes and a >5 letter gain was seen in 40%, 55.8% and 51.9%, respectively. For HTRA1, mean letter score change was +2.2, +7.5 and +2.9 letters for the GG, GA and AA genotypes. CONCLUSIONS: This study reports preliminary evidence suggesting that the higher AMD risk genotypes in CFH, VEGF and HTRA1 may influence the short-term response to treatment with ranibizumab for neovascular AMD.

The management of "coats' response" in a patient with x-linked retinitis pigmentosa-a case report.

The management of exudative retinal detachment in Coats disease can be very difficult with variable results. A case is presented of a 12 year old boy who was diagnosed with X-linked retinitis pigmentosa with an associated "Coat's Response". The patient had a marked reduction in his left visual acuity due to intragel and subhyaloid haemorrhage as well as exudative retinal detachment. This was managed successfully with vitrectomy and endolaser, resulting in clearance of the haemorrhage and flattening of the retina. In our experience endolaser should be considered as viable therapeutic option in the management of this condition.

Spontaneous anterior dislocation of a mature cataract following old trauma.

We report a case of a patient who incurred spontaneous anterior dislocation of a mature cataract which required prompt surgical removal. Some years previous to this, he had sustained blunt trauma to the eye.

Cystoid macular oedema in Cogans syndrome-a case report.

INTRODUCTION: Cogan's Syndrome is typically characterised by a non syphilitic interstitial keratitis (IK), with or without conjunctivitis, iritis or subconjunctival bleeding and progressive sensorineural hearing loss within two years of ocular signs. Atypical ocular manifestations include episcleritis, scleritis, posterior scleritis, retinal artery occlusion, choroiditis, retinal vasculitis, and optic disc oedema. We report a case of Cogan's syndrome in with recurrent cystoid macular oedema was the main feature. CASE PRESENTATION: A patient was diagnosed with Cogan's syndrome nearly 2 years after first presentation. He had cystoid macular edema which failed to respond initially to steroid, methotrexate and azothiaprine however resolved after treatment with mycophenolate mofetil. CONCLUSION: Cogan's syndrome is rare and presents a challenge in terms of diagnosis and treatment. Recurrent cystoid macular oedema is a unique finding in this condition and can be difficult to control. Multidisciplinary management of this multisystem disorder is vital.

The role of botulinum toxin in decompensated strabismus.

BACKGROUND: The surgical management of decompensated strabismus is well described. Conservative treatment may employ the use of lenses and prisms. However, the use of botulinum toxin in decompensated squint is poorly documented. In these patients, with the potential for fusion, botulinum toxin may serve to stabilize the ocular alignment by bringing the images within the fusion range. PURPOSE: The aim of this study was to assess the role of botulinum toxin in the treatment of decompensated squints. METHODS: A retrospective case series involving 92 patients with decompensated squints between December 1990 and July 2005. Botulinum toxin was injected into the lateral rectus in 45 cases and into the medial rectus in 47. This was performed under local anesthesia in 74 cases, the remainder with ketamine anesthesia. Patients were assessed preoperatively at 2 weeks, 4 months, and a minimum of 12 months postoperatively. We defined successful treatment where the resultant stabilized deviation was less than or equal to 10 prism diopters with resolution of diplopia. RESULTS: In this study, 47 patients had a decompensated microesotropia and 45 had a decompensated exophoria. We found that 27 (29.3%) patients were asymptomatic following injection of botulinum toxin. Fourteen (15.2%) patients were better controlled and did not require further intervention. Subsequent surgery was performed in 45 patients (48.9%). CONCLUSION: Our results suggest almost half of those patients requiring treatment for decompensated squint benefit from botulinum toxin, without requiring surgical intervention. This approach is less invasive and allows potential for recovery of binocular function.

Spontaneous resolution of congenital Brown's Syndrome - a case report.

INTRODUCTION: The natural history of congenital Brown Syndrome is poorly understood and documented. In our experience, few adult cases are encountered in clinical practice. CASE PRESENTATION: A case of bilateral congenital Brown syndrome is described, showing spontaneous resolution of clinical signs. Evidence of almost complete resolution over the years is also shown on serial Lees charts. CONCLUSION: To our knowledge, an objective record of such progressive improvement has not been previously reported. Knowledge of the natural history of Congenital Browns syndrome is useful in understanding the mechanism and also in the decision to delay surgery until full orbital growth has occurred.

Lacrimal sac mucus-secreting adenocarcinoma.

A forty year old female presented with a swelling above the medial canthal tendon, later diagnosed as a mucus secreting adenocarcinoma. This rare carcinoma arose within an inverted papilloma lined by ciliated respiratory type columnar epithelium incorporating numerous goblet cells. We were only able to find two such cases reported in the literature. The history, clinical features, histological characteristics and management are discussed. The case highlights the importance of early recognition of these tumours along with need for aggressive management.

Biometric calculation of intraocular lens power for cataract surgery following pupil dilatation.

BACKGROUND: The ability to perform biometry accurately on a dilated pupil can greatly facilitate the efficiency of a cataract service as it can be done on the day of surgery. The purpose of this study was to assess the repeatability of axial length (AL) calculations in undilated pupils and measure the difference in predicted and actual refractive outcomes in dilated pupils compared with undilated pupils. METHODS: First, intraobserver repeatability was assessed by taking two consecutive recordings of AL using applanation A-scan ultrasonography in undilated pupils in 21 eyes. The mean AL for each eye was compared with a measurement made following pupil dilatation. Second, we audited the mean spherical equivalent refractive errors following routine cataract surgery in 38 patients with undilated pupils and 36 patients with dilated pupils. RESULTS: The mean difference in intraobserver measurements was -0.05 mm (standard deviation [SD] 0.15) with pupils undilated. Following pupil dilatation, the mean dilated AL differed from the mean undilated AL reading by only 0.03 mm (P > 0.05). The mean differences between planned and actual refractive error were 0.71D (SD 0.54) and 0.55D (SD 0.41) in dilated and undilated patients, respectively. This was not statistically significant (P > 0.05). The range of differences between target and actual refraction was -1.45D to 2.70D for undilated patients and -1.88D to 1.18D in dilated patients. CONCLUSION: Although there was a greater spread of postoperative refractive errors in the dilated group, there were no statistically or clinically significant differences in postoperative refractive errors between the two categories of patients. Our study shows that applanation biometry may be safely performed for the purpose of cataract surgery after pupil dilatation.

Pseudo-Foster Kennedy Syndrome due to unilateral optic nerve hypoplasia: a case report.

INTRODUCTION: Pseudo-Foster Kennedy Syndrome is described as unilateral optic disc swelling with contralateral optic atrophy in the absence of an intracranial mass causing compression of the optic nerve. This occurs typically due to bilateral sequential optic neuritis or ischaemic optic neuropathy. CASE PRESENTATION: We describe a case of pseudo-Foster Kennedy Syndrome in a two year old boy with unilateral papilloedema due to a congenital optic disc anomaly in one eye preventing transmission of raised intracranial pressure to the optic nerve. CONCLUSION: From our findings we conclude that congenital optic nerve hypoplasia is a cause of pseudo-Foster Kennedy Syndrome.

Painful vertical diplopia as a presentation of a pituitary mass.

BACKGROUND: Pituitary tumours may present with a variety of neurological and endocrinological signs and symptoms. It is very rare however for them to present with sudden onset painful diplopia. The current literature and possible mechanisms for this are discussed. CASE PRESENTATION: We describe a case of a pituitary mass which presented with sudden onset painful diplopia with an associated restricted pattern on Lees Chart testing. This led to an initial working diagnosis of orbital myositis. CONCLUSION: Awareness of different modes of presentation of pituitary lesions is important so that appropriate imaging may be requested and delay in diagnosis prevented.

Unaugmented vertical muscle transposition surgery for chronic sixth nerve paralysis.

INTRODUCTION: Chronic sixth nerve palsy can cause incapacitating diplopia requiring vertical muscle transposition surgery. Augmentation of surgery, with lateral fixation sutures, medial rectus recession or botulinum toxin injection, is associated with an increased risk of complications. PURPOSE: Our aim was to evaluate the efficacy and safety of unaugmented full-tendon vertical rectus transposition in chronic sixth nerve paralysis. METHODS: Longitudinal study of 21 patients with chronic sixth nerve paralysis of longer than 6 months duration, who underwent superior and inferior recti transposition surgery without medial rectus recession or botulinum toxin injection. Details of surgery, preoperative and postoperative examinations including full orthoptic examination were obtained from an electronic database. Outcomes included the change in angle of deviation, the requirement for further surgery to the medial rectus and postoperative improvement in diplopia. SPSS software (Version 12.0.1, SPSS Inc. Chicago, IL) was used to summarize baseline characteristics and outcomes and to compare preoperative and postoperative deviation (paired t-test). RESULTS: Twenty-one patients (10 (47.6%) men and 11 (52.4%) women) with a mean age of 41 years (range 4 to 74 years) were operated in the period between April 1998 and November 2000. Eighteen patients had unilateral and three had bilateral acquired sixth nerve palsy. Nineteen patients required unilateral surgery and two had bilateral transposition procedures. In patients with unilateral sixth nerve palsy, mean esotropia in primary position before surgery was 46.7 prism-diopters (PD) (95% CI 35.9-57.4 PD) and improved to 14.6 PD after surgery (95% CI 6.4-22.7 PD). The angle of deviation was significantly reduced by an average of 32.1 PD (p < 0.001, paired t-test; 95% CI 22.6-41.6 PD). Over all, 10 patients (55.6%) had a well-controlled esophoria with a postoperative alignment of within 10 PD of orthophoria without diplopia in the primary position, for distance and near. A further six patients (28.6%) required additional medial rectus recessions to achieve success. The only complication observed was slippage of the inferior rectus in one patient (4.2%), who consequently required further surgery. CONCLUSION: Botulinum toxin infiltration of the medial rectus in vertical rectus transposition surgery may be unnecessary, incurring cost, additional attendances and interventions for patients. Less than a third of all patients in our series required additional medial rectus recession later.