Intramuscular cavernous venous malformation of extraocular muscles. Fractionated stereotactic radiotherapy as a therapeutic alternative. / Malformación venosa cavernosa en musculatura extrínseca ocular. Radioterapia estereotáctica fraccionada como alternativa terapéutica.

Intramuscular cavernous venous malformations affecting extraocular muscles are extremely uncommon. Due to their location, complete resection could be difficult. A clinical case is presented of an inferior rectus muscle orbital cavernous malformation treated with fractionated stereotactic radiotherapy after post-surgical excision recurrence. The malformation responded to radiotherapy with a reduction in size and symptoms. Fractionated stereotactic radiotherapy is an alternative and effective treatment for cavernous venous malformations that are surgically challenging due to their radiotherapy sensitivity.

Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone.

AIM: To evaluate the efficacy of periocular triamcinolone acetonide for the treatment of thyroid associated ophthalmopathy (TAO), and the presence of ocular or systemic adverse effects. METHODS: A multicentre prospective pilot study was performed on patients diagnosed with Graves' ophthalmopathy less than 6 months before entry to the study. Patients were admitted to the study and were randomised into two groups: treatment and control. The treatment group received four doses of 20 mg of triamcinolone acetate 40 mg/ml in a peribulbar injection to the inferolateral orbital quadrant. Both groups were evaluated by measuring the area of binocular vision without diplopia on a Goldmann perimeter and the size of the extraocular muscles on computed tomography (CT) scans. Ophthalmological and systemic examinations were done to rule out ocular and systemic adverse effects. Follow up was 6 months for both groups. RESULTS: 50 patients were eligible for the study. 41 patients completed the study. There was an increase in the area of binocular vision without diplopia in the treatment group (Sigma initial: mean 231.1 (SD 99.9) and final absolute change, mean 107.1 (SD 129.0)) compared to the control group (Sigma initial: mean 350.7 (SD 86.5) and final absolute change, mean -4.5 (SD 67.6)). The sizes of the extraocular muscles were reduced in the treatment group (mean (inferior rectus initial values): 1.3 (0.7), final percentage change: -13.2 (25.7), medial rectus initial values: 1.2 (0.6), final percentage change: -8.2 (20.7), superior rectus-levator palpebrae initial values: 1.2 (0.6), final percentage change: -9.5 (29.1), lateral rectus initial values: 1.0 (0.4), final percentage change: -11.5 (20.6)) compared to the control group (inferior rectus initial values: 0.9 (0.3), final percentage change: -4.0 (21.5), medial rectus initial values: 0.9 (0.3), final percentage change: 0.6 (22.4), superior rectus-levator palpebrae initial values: 0.9 (0.3), final percentage change: 12.5 (37.5), lateral rectus initial values: 0.9 (0.4), final percentage change: -0.5 (31.6)). Both measurements (degree of diplopia and muscle thickness) were statistically significant between groups (initial - final). No systemic or ocular adverse effects were found. CONCLUSIONS: Triamcinolone administered as a periocular injection is effective in reducing diplopia and the sizes of extraocular muscles in TAO ophthalmopathy of recent onset. This form of treatment is not associated with systemic or ocular side effects.

The modified rhomboid transposition flap in periocular reconstruction.

The traditional rhomboid transposition flap has been widely used in reconstructive surgery. The authors have modified the original technique by eliminating the creation of the rhomboid defect and by directly transposing the flap into the original postexcisional defect. These changes allow maximum flexibility in flap design and minimize normal tissue loss. The authors retrospectively reviewed the charts of patients who underwent periocular reconstruction with flaps from 1990 through 1995. The authors selected those patients in whom the modified rhomboid flap was used. Functional and cosmetic results and complications were reviewed. Two hundred thirty-two patients were identified in whom 242 flaps were performed. The modified rhomboid flap was used in 101 patients (41.7%). Complications occurred in 23 patients (23%), 19 of whom (19%) were treated medically and four of whom (4%) required an additional surgical procedure. Cosmetic and functional results were classified as very good or excellent in 96 patients (96%). The use of a modified rhomboid flap in the reconstruction of the periocular area offers ample versatility in flap design and minimal normal tissue loss. Functional and cosmetic results are satisfactory in the vast majority of cases.

Hering's law and eyebrow position.

A patient with bilateral but asymmetrical brow ptosis is presented in whom the frontalis action on the relative position of the eyebrows could be demonstrated to obey Hering's law of equal innervation. The neurological basis for this finding is discussed, along with the implications for the surgical management of brow ptosis.