Quality of life in patients with blepharospasm.

The aim of this prospective study was to analyse the quality of life in patients with blepharospasm grade III and IV and to explore whether Botulinum neurotoxin type A treatment improves their quality of life. We used a WHOQOL-BREF questionnaire, based on the existing WHO recommendation and its meaningful metric characteristics. The study included 37 patients with either grade/type III or IV blepharospasm who were treated with Botulinum neurotoxin Type A. Each patient completed the WHOQOL-BREF questionnaire by themselves just before the Botulinum Neurotoxin Type A (BT-A) therapy application, when the clinical symptoms of blepharospasm were most manifest and a month and a half after, when the regression of symptoms appeared. Consequently, the application of BT-A resulted in improved changes in terms of quality of life in 3 of the 4 measured fields (psychical and physical health as well as the environmental living conditions).

Prostatic carcinoma metastatic to the optic nerve.

Optic nerve can be infiltrated with various tumors and inflammatory processes, with a considerable prevalence of primary over secondary tumors. Metastases of gastric carcinoma to the optic nerve are less frequently, and those of prostatic carcinoma very infrequently observed. A 66-year-old man presented with metastasis to the optic nerve with consequential vision loss to the level of light perception developed two years after prostatic surgery. Systemic therapy with methylprednisolone resulted in a satisfactory vision function recovery. According to literature data, prostatic carcinoma metastases to the optic nerve occur very rarely. In our patient with the optic nerve infiltration found on the first clinical examination, papillary edema was associated with the signs of optic nerve functional impairment (visual acuity, visual field, unilateral RAPD). An infiltrative process involving a distal portion of the optic nerve usually does not cause papillary alterations, and produces a clinical picture of retrobulbar optic neuropathy, such as that observed in our patient on the second clinical examination, showing the signs of optic nerve damage.

A case of lacrimal gland dirofilariasis.

A patient with a diagnosis of chronic and idiopathic unilateral dacryoadenitis was submitted to our clinic for diagnostic reasons from a regional hospital. Within a period of 1 year, this was the second onset of a swelling in the region of the lacrimal gland which - unlike the first time - showed resistance to antibiotic treatment. The patient's general and ophthalmic condition was good, and his only complaint was of cosmetic nature because of the disfiguring swelling in the lateral part of the left upper eyelid. Basic laboratory findings showed no abnormalities and radiographic imaging showed enlargement of the left lacrimal gland without bony destruction. Guided by epidemiological data for noninfectious dacryoadenitis we decided to perform excisional biopsy of the left lacrimal gland. To our surprise, the pathologist verified the presence of a worm of the genus Dirofilaria, which is, to the best of our knowledge, the second reported case of lacrimal gland dirofilariasis in the literature and the second reported case of such a disease in Croatia.

[Orbital-bony decompression in patients with dysthyroid orbitopathy--first Croatian experiences]. / Kostana orbitalna dekompresija u pacijenata s distireoidnom orbitopatijom--prva hrvatska iskustva.

INTRODUCTION: Dysthyroid orbitopathy or Graves's orbitopathy is an entity made of symptoms and signs found within ocular apparatus, orbit and adnexal tissue in patients with thyroid dysfunction. Orbital pathogenesis is based on organ-specific autoimmune reaction, resulting in extra ocular muscle dysfunction and retro bulbar tissue changes. These changes are characterized by different stages of orbital inflammation, swelling and passive congestion. No infiltrative or inactive stage of the disease is most commonly seen in younger population as mild, orbital inflammation, lid retraction, variable proptosis and retro bulbar discomfort. Infiltrative or active stage of the disease usually affects older people and is characterized by a broad spectrum of clinical symptoms such as moderate or severe orbital inflammation, retro bulbar pain, lid retraction, periocular edema, proptosis with corneal exposure, extra ocular muscle dysfunction, conjunctival and episcleral congestion and optic nerve compression with loss of visual acuity. The current treatment concept for dysthyroid orbitopathy is to achieve euthyroidism with antithyroid drugs, radioiodine and thyroidectomy. Subsequently, for the treatment of dysthyroid orbitopathy immunosuppressive drugs such as corticosteroids, cyclophosphamide, methotrexate, cyclosporine, octreotides, orbital radiotherapy and surgical decompression can be used. Indications for orbital decompression are differentiated as urgent and elective. Current opinion is that only severe proptosis with corneal exposure and damage and compressive optic neuropathy urge orbital bony decompression combined with aggressive medical treatment. Persistent, active orbitopathy, retro bulbar discomfort or pain and disfiguring proptosis are indications for elective orbital bony decompression. Orbital bony decompression is a surgical method based on principle of opening the confined orbital bony space and allowing herniation of orbital fat into paranasal sinuses, thus decreasing orbital pressure. PATIENTS, METHODS AND RESULTS: A series of patients surgically treated for dysthyroid orbitopathy from July 2004 till November 2005, were followed-up. The group included 8 patients previously treated for thyroid dysfunction. Five patients (10 eyes) were operated on by the "swinging eyelid" approach (group 1) and three patients (6 eyes) by "inferomedial approach" (group 2). In group 1 proptosis reduction occurred in all patients, varying from 4 to 6 mm within 6-10 months postoperatively; retrobulbar pain or discomfort decreased in all patients few days after the surgery; and 2 patients still felt numbness in the n. infraorbitalis innervation area at 10 months of follow up. In group 2, all patients had proptosis reduction by 3-4 mm within 6-10 months postoperatively; retro bulbar discomfort disappeared in all patients a few days after the surgery. In this group none of the patients complained of infraorbital numbness 6 months of the surgery. All patients filled out a brief questionnaire before and 4 months after the surgery, ranking their symptoms and complaints. CONCLUSION: Our patient series was rather small and selected, the data obtained are not representative of larger series. Based on these preliminary results and current literature data, we believe that orbital bony decompression is a highly effective, safe and quick procedure, easily adjustable to the surgeon as well as to the patient in achieving optimal results. We also believe that there is a need of better education of our patients considering the disease itself and treatment modalities through patient support groups or better physician-patient-nurse communication.

Treatment of ocular motility disturbances in Graves' disease with botulinum toxin A.

The aim of this study was to evaluate the efficacy of botulinum toxin-A injections on motility disturbance in patients with dysthyroid eye disease. In 36 patients (52 orbits) with active phase of Grave's ophthalmopathy with motility disturbance, botulinum toxin-A injections were applied. Ocular motility was measured before and after treatment in four main directions (elevation, depression, abduction and adduction) with Förster perimeter. In all patients 20 units of botulinum toxin-A in one single injection was applied in the projection of the inferior rectus muscle. Statistically, the degree of upgaze increased notably in all three groups, but mostly in the first group where it amounted up to 5.8-6.0 (z = 10.0;p = 0.68). We could not prove notable increase of the motility grade in the adduction in none of the groups of the tested patients. Due to the fact that eyeball motility can be objectively measured, effect of the applied therapy can be clearly evaluated.

Review and new insights on Wegener granulomatosis.

The purpose of this paper is to present Wegener granulomatosis manifesting in its periocular form. Review with new developments in understanding of the etiopathogenesis, clinical and laboratory findings as well as therapy modalities are shown through a series of patients gathered in collaboration with colleagues from UMC Utrecht, Netherlands. In the period from 1992 until 2004 the group of 54 patients with established diagnosis of Mb. Wegener were observed. 13 patients developed periocular form but only 2 presented it as initial symptoms. Lacrimal stenosis and orbital infiltration were predominant periocular symptoms while nasal manifestations were predominant systemic symptoms of the disease. Different treatment modalities were employed showing that orbital disease is difficult to treat in spite of satisfying systemic answer to immunosuppressives which calls for alternative solutions.

Endonasal endoscopic orbital decompression in patients with Graves' ophthalmopathy.

AIM: To present the results of endonasal endoscopic orbital decompression in patients with Graves' ophthalmopathy. METHODS: Endonasal endoscopic orbital decompression was performed in 32 orbits of 21 patients with Graves' ophthalmopathy. In 17 patients the surgery was performed because of active ophthalmopathy non-responsive to conservative treatment, and in 4 patients for esthetic reasons. Preoperative and postoperative examination included visual acuity, examination of the eyelids and cornea, ocular motility, cover testing, Hertel exophthalmometry, and applanation tonometry. RESULTS: Visual acuity improved from preoperative 0.81+/-0.28 (mean +/- standard deviation) to postoperative 0.92+/-0.21 (p=0.0032, Student t-test). Retraction of upper and lower eyelids, as well as exposure keratitis, was reduced after operation (p<0.001). Mean proptosis reduction in all orbits was 4.6+/-1.7 mm (p<0.001). An average reduction of intraocular pressure was 3.4+/-3.0 mmHg (p<0.001). New-onset diplopia developed in 8 patients. Diplopia persisted in 9 out of 11 patients who had preoperative diplopia. Two patients experienced postoperative relief of diplopia. Ocular motility was subsequently corrected by eye muscle surgery in 13 eyes, whereas prisms were used in other 5 manifestly strabic eyes. CONCLUSIONS: Endonasal endoscopic orbital decompression procedure improved visual acuity, decreased proptosis and intraocular pressure, and also had favorable cosmetic results in most patients. Post decompression diplopia and strabismus were successfully managed by either eye muscle surgery or application of prisms.

Long-term results of frontal lobe suspension in children with congenital dystrophic ptosis.

Long-term results achieved by our own operative technique in children with congenital dystrophic ptosis, with frontal muscle lobe shaping with or without shaping of corrugator muscle lobe attached to the tarsal plate, are presented. Data on 146 patients with congenital dystrophic ptosis operated on during the 1984-1998 period at Zagreb University Hospital Center were retrospectively analyzed. Postoperative success was defined as a situation with eyes open in which 1) upper eyelid covers the cornea at 12 o'clock position by 1-2 mm; 2) there is a good contour of the eyelid margin; 3) there is no lagophthalmos; and 4) there is symmetry with the other eye. Immediate re-operation due to undercorrection was required in 26 of 146 (18%) patients. Upon re-operation, 133 (91%) patients met the criteria for successful outcome at 6 months, 124 (85%) at one year, and 121 (83%) at 5 years. Correction of congenital dystrophic ptosis using a shaped frontal/corrugator lobe is an efficient and safe procedure ensuring long-lasting success.

Atypical lipoma: well-differentiated liposarcoma of the orbit with dedifferentiated areas.

Primary orbital liposarcoma is a very rare orbital tumor and dedifferentiation in the liposarcomas occurs rarely. Dedifferentiation is defined by development, in a well-differentiated tumor, of poorly differentiated, high-grade areas. The dedifferentiated liposarcomas (DDLS) have a better prognosis than pleomorphic sarcomas as a whole. The treatment of DDLS patients proves to be complicated due to the fact that the histopathological diagnosis usually becomes evident only after the surgery. In the present paper, the clinical presentation, histopathological features, radiological characteristics and clinical treatment of one case of well-differentiated liposarcoma with dedifferentiated areas, abruptly delimited from the well-differentiated adipocytic component, are reported.

Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement].

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 x 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a 'computed journey' through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.