Pneumocephalus after Orbital Decompression Surgery for Thyroid Eye Disease.

A cerebrospinal fluid (CSF) leak is a rare complication after orbital surgery. We reported a 49-year-old man who presented with CSF leakage after transcaruncular medial wall decompression for proptosis due to thyroid eye disease. He underwent an endoscopic endonasal approach to surgical repair of the defect with nasoseptal flap. Rhinorrhea was stopped immediately after endoscopic repair.

STARGARDT DISEASE: Beyond Flecks and Atrophy.

PURPOSE: To identify changes in the outer retina in areas without atrophy or flecks of Stargardt disease (STGD) using spectral-domain optical coherence tomography. METHODS: Twenty-three STGD patients and 26 control subjects were assessed for outer retina (from the outer border of Bruch membrane [BrM] to the inner border of the inner segment ellipsoid zone [EZ]), BrM-retinal pigment epithelium apex, the EZ thickness, and apical process interdigitation zone. RESULTS: Patients with STGD had increased BrM-EZ thickness in areas without apparent disease versus control subjects at 1,000, 1,500, 2,000, and 2,500 µm superior and 1,500 µm, 2,000 µm, and 2,500 µm inferior to the fovea (P < 0.05 to P < 0.001), greatest difference (3.4 µm) at 2,500 µm superiorly. The BrM-retinal pigment epithelium segment showed larger fractional contribution of 0.48 to 0.51 to the overall BrM-EZ thickness compared with 0.35 to 0.42 in control subjects. The thickness of EZ and the interspace between the retinal pigment epithelium apex and EZ were smaller in the STGD patients (P < 0.05 to P < 0.001). Patients with STGD displayed an interrupted interdigitation zone in 16 (84.2%) of 19 eyes versus 6 (23.1%) of 26 eyes of the control subjects (P < 0.001). The BrM-EZ segment of the outer retina of STGD patients lacked the typical normal trilaminar pattern. CONCLUSION: Subtle changes are present within the BrM-EZ segment of the outer retina of STGD patients in areas that are devoid of atrophy and flecks. These findings suggest that pathologic changes in STGD are more widespread than that seen by clinical examination.

Evaluation of Lamina Cribrosa and Choroid in Nonglaucomatous Patients With Pseudoexfoliation Syndrome Using Spectral-Domain Optical Coherence Tomography.

PURPOSE: To evaluate the lamina cribrosa (LC) and peripapillary choroid in patients with pseudoexfoliation syndrome (PXS). METHODS: In this cross-sectional study, one eye each of 32 nonglaucomatous PXS cases and 29 healthy volunteers were enrolled. The optic discs were scanned using enhanced depth imaging spectral-domain optical coherence tomography, and measurements were obtained using HEYEX software 6.0. LC and other related variables at three areas (mid-superior, center, and mid-inferior) and peripapillary choroidal thickness were determined. Linear mixed modeling was used to adjust the variables. RESULTS: After adjustment for age, sex, and axial length, there was no significant difference between the two groups in peripapillary choroidal thickness or in retinal nerve fiber layer thickness. The LC was significantly thinner in all three areas in the PXS group when compared with the control group, even after adjustment. Although no significant difference in central laminar depth was observed between the two groups (P = 0.74), the superior and inferior laminar depth were significantly deeper in the PXS group when compared with the control group (P = 0.04 and P = 0.006, respectively). Although there was a significant negative association between age and central choroidal thickness in the control group (ß = -2.820, P = 0.02), this correlation was not significant in the PXS group. CONCLUSIONS: We found that LC is significantly thinner in all three areas of the optic nerve head in nonglaucomatous PXS patients than in controls. Although no significant difference in peripapillary choroidal thickness was observed between the two groups, peripheral posterior displacement of LC in nonglaucomatous PXS eyes was noted.

Adjustable superior oblique tendon spacer with application of nonabsorbable suture for treatment of isolated inferior oblique paresis.

PURPOSE: To evaluate and report the outcomes of a superior oblique tendon spacer procedure using nonabsorbable adjustable sutures in patients with inferior oblique (10) paresis. METHODS: This interventional case series included 6 eyes of 6 patients with 10 paresis. All met Bielschowsky/Parks Three-step Test criteria to identify an isolated 10 paresis. In all patients, the superior oblique tendon was exposed; 2 nonabsorbable polyester sutures were placed 3 mm apart, and the tendon was cut. With the use of a slipknot, the cut ends of the tendon were separated 5 to 7 mm. Tendon separation was adjusted intraoperatively according to the fundus torsion and exaggerated traction test. RESULTS: The mean duration of follow-up was 8.1 months (range, 5-12 [corrected] months). Four patients had congenital 10 paresis and 2 had iatrogenic 10 paresis following denervation/myectomy of 10. Mean primary position hypotropia improved from 15.2 prism diopters (PD) before surgery to 2.7 PD in congenital 10 paresis and from 11.5 PD to 2.5 PD in iatrogenic 10 paresis. In congenital 10 paresis, mean preoperative superior oblique overaction and 10 underaction was +2 and -2, which decreased to 0 and -1.25 respectively; fundus incyclotorsion resolved in all patients. Superior oblique overaction and 10 underaction improved in iatrogenic 10 paresis as well. In no patient did an overcorrection develop. CONCLUSIONS: The adjustable superior oblique tendon suture spacer procedure is an effective and safe option for correcting 10 paresis without developing iatrogenic superior oblique paresis.