Acute unilateral orbital varix thrombosis in preexisting bilateral orbital varices: illustrative case.

OBJECTIVE: Orbital varix is a rare distensible orbital venous malformation. Most patients present with unilateral intermittent periorbital pain and positional proptosis that is exacerbated by the Valsalva maneuver. Complications include hemorrhage and thrombosis, leading to sudden painful proptosis and visual disturbance. OBSERVATIONS: A 42-year-old female with a history of bilateral intermittent painless proptosis that was accentuated by a postural head-down position presented with acute painful proptosis in her right eye. Ophthalmic examination revealed right eye proptosis with a bluish mass at the right upper eyelid, and another bluish mass at the left lower eyelid that was prominent during the Valsalva maneuver. Computed tomography scans of the orbits indicated right orbital varix thrombosis and left orbital varix. Surgical excision of the right thrombosed varix was performed along with intralesional bleomycin injection in the left orbital varix. Histopathological examination confirmed the right thrombosed varix diagnosis. The patient had good clinical improvement at the 6-month follow-up. LESSONS: Orbital varices have a spectrum of clinical manifestations, from asymptomatic to severe visual loss. Most cases are successfully treated conservatively; however, in complicated cases, interventions with a multidisciplinary team approach such as sclerotherapy, embolization, and surgical excision should be considered.

Bilateral Posterior Ischemic Optic Neuropathy Due to Bilateral Anterior-Drainage Dural Carotid-Cavernous Fistulas: A Case Report.

Purpose: To report a case of bilateral posterior ischemic optic neuropathy (PION) due to bilateral anterior-drainage dural carotid-cavernous fistulas (CCFs). Case Description: We report on a 62-year-old woman with a history of poorly controlled hypertension who presented with sudden bilateral visual loss and headache for 5 days. She denied a history of head trauma. On examination, her visual acuities were no light perception (NLP) with fixed pupils in both eyes. The ocular motility of both eyes was limited in all directions. Both eyelids were difficult to open. Anterior segment examination revealed bilateral chemosis and episcleral corkscrew vessels. Intraocular pressures were 45 and 48 mmHg in her right and left eyes, respectively. Gonioscopy revealed blood in Schlemm's canal at the nasal angle of the right eye. Fundus examination showed slightly dilated and tortuous retinal veins with normal-appearing optic discs in both eyes. The cup-to-disc ratios were 0.3 bilaterally. Other neurological examinations were unremarkable. Magnetic resonance imaging demonstrated dilation of the bilateral superior ophthalmic veins (SOVs), and marked orbital and periorbital congestion bilaterally. However, there was no compression or stretching of the bilateral optic nerves. Diffusion restriction on diffusion-weighted imaging, with corresponding reduced apparent diffusion coefficient, in the entire bilateral orbital segment of the optic nerves was revealed, consistent with bilateral PION. Magnetic resonance angiography revealed arterialization of the bilateral cavernous sinuses and SOVs. Cerebral angiography confirmed the diagnosis of bilateral anterior-drainage dural CCFs. Treatment with transvenous coil embolization was successful. Three months after embolization, ophthalmic examination demonstrated progressive improvement of aforementioned ophthalmic signs; however, her visual acuities remained NLP in both eyes. Conclusion: To our knowledge, this is the first reported case of bilateral PION due to bilateral anterior-drainage dural CCFs. In spite of its rarity, PION should be considered as a severe, irreversible ophthalmic complication of anterior-drainage dural CCF.

Endogenous panophthalmitis in a patient with COVID-19 during hospitalization in an intensive care unit: A case report.

Purpose: To report a case of endogenous panophthalmitis in a patient with COVID-19 during treatment in an Intensive Care Unit. Observation: A 64-year-old woman with COVID-19 and Salmonella septicemia presented with decreased visual acuity, ocular pain, and proptosis in her right eye after treatment with favipiravir, intravenous dexamethasone, and ceftriaxone. An ocular examination of her right eye revealed periorbital tenderness, exophthalmos, and corneal haze. The ultrasonography showed a subretinal abscess. Her right eye lost light perception vision and underwent enucleation. Microbiologic evaluation of the enucleated right eye was negative for organisms. Conclusions and importance: Patents with COVID-19 may develop severe ocular involvement after COVID-19 due to a generalized reduction in immunity. Comorbidities and intensive care unit treatments can predispose COVID-19 patients to endogenous panophthalmitis.

Maximal Levator Resection Beyond Whitnall's Ligament in Severe Simple Congenital Ptosis with Poor Levator Function.

PURPOSE: To evaluate the functional and cosmetic outcomes, as well as factors that influence surgical success of maximal levator resection beyond Whitnall's ligament in patients with poor levator function (LF) and severe simple congenital ptosis. METHODS: This retrospective interventional study included patients with severe simple congenital ptosis and LF of ≤4 mm who had undergone maximal levator resection beyond Whitnall's ligament with a minimum of 12 months follow-up. Postoperative marginal reflex distance-1 (MRD1) was assessed for functional outcomes as excellent, good, fair and poor. Eyelid contour and the difference in MRD1 between eyes were assessed for symmetrical cosmetic outcomes as excellent, good and poor. Demographic data, factors influencing surgical success and postoperative complications were analyzed. RESULTS: A total of 38 ptotic eyelids in 31 patients were included. Successful surgical outcomes (at least good functional and cosmetic outcomes) were achieved in 26 patients (83.87%) with the mean MRD1 of +3.61 ± 0.27 mm and +3.51 ± 0.17 mm at 1 week and 12 months after surgery, respectively. There were no significant differences in demographic and preoperative data between the successful and unsuccessful surgical outcome groups, mean preoperative ptosis measurements were 4.19 ± 0.20 mm versus 4.72 ± 0.36 mm (p = 0.242) and mean pre-operative LF were 3.16 ± 0.15 mm versus 2.29 ± 0.61 mm (p = 0.561), respectively. The only factor that significantly influenced the surgical success rate was the length of the resected levator muscle. The mean lengths in successful and unsuccessful groups were 18.15 ± 0.44 mm and 14.29 ± 0.94 mm, respectively (p = 0.011). CONCLUSION: Maximal levator resection beyond Whitnall's ligament is an effective procedure for severe simple congenital ptosis with poor LF. Refinement of surgical techniques and careful assessment of the optimal resected length for the levator muscle grants successful surgical outcomes.

Superior Ophthalmic Vein Embolism Following Forehead Augmentation with Autologous Fat Injection.

BACKGROUND: Facial rejuvenation and reconstruction with autologous fat injection are a common and effective procedure used worldwide. Most surgeons and patients are satisfied with the favorable outcomes. However, catastrophic complications from arterial and venous occlusion resulting in visual loss and stroke may occur. CASE PRESENTATION: We herein report a case of isolated venous occlusion from fat embolism. The patient developed acute painful proptosis and blurred vision of her right eye while undergoing an esthetic autologous fat injection into her forehead. Based on her clinical manifestations and radiologic findings, the patient was diagnosed with superior ophthalmic vein occlusion. Symptomatic and supportive treatments were given. Spontaneous clinical improvement occurred without secondary complications. Therefore, the initially planned endovascular therapy with transfemoral transvenous embolectomy of the right superior ophthalmic vein was canceled. CONCLUSIONS: Facial augmentation with autologous fat injection can cause superior ophthalmic vein embolism. Surgeons should therefore perform this procedure very cautiously. Prompt ophthalmological evaluation and proper management are important for improving clinical outcomes. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orbital lymphatic-venous malformation with concomitant spontaneous orbital arteriovenous fistula: case report.

The authors describe the case of an 11-year-old boy with no history of prior trauma, who experienced acute proptosis and visual loss while showering. Diagnostic carotid artery angiography revealed an orbital lymphatic-venous malformation (LVM) concomitant with an intraorbital arteriovenous fistula. The patient was treated with transvenous coil and N-butyl cyanoacrylate glue embolization, combined with direct percutaneous glue injection into the LVM followed by excision. There was good clinical and radiological response without recurrence at the 2-year follow-up. Diagnostic carotid angiography should be considered in cases of orbital LVM, as a concomitant arteriovenous fistula might be present in rare cases.

Analysis of eyelid fat pad changes with aging.

PURPOSE: Few studies have focused on the aging changes in the upper eyelid. This study evaluated the differential changes in the nasal and central fat pads of the upper eyelid associated with aging. METHODS: In this retrospective, consecutive series, the medical records and photographs of 77 patients were reviewed. The patients were grouped in 7 categories according to decade of life. Using a standardized scale, the volume grade of the nasal and central fat pads was graded from 0 to 3. Statistical evaluation correlating age with central and nasal fat pad change was performed. RESULTS: With aging, the central fat pad volume appeared to diminish, with relative sparing of the nasal fat pad. There was a positive correlation of the volume grade of the nasal fat pad with age and a negative correlation of the central fat pad with age. In addition, there was a statistically significant difference between the volume grades of the nasal and central fat pads in the groups 70 years and older. CONCLUSIONS: With aging, there appears to be a pattern of differential fat pad alteration. This study shows that in the upper eyelids of patients >70 years of age, the medial fat pad becomes prominent whereas the central fat pad atrophies. Teleologically, the relative preservation of nasal fat may be due to its higher abundance of neural-crest progenitor cells. Clinically, this finding has implications in esthetic and functional upper eyelid blepharoplasty.

Primitive neuroectodermal tumor of the orbit in adults: a case series.

PURPOSE: To present the clinical, radiologic, and histopathologic features of orbital primitive neuroectodermal tumor (PNET) in 5 adult patients. METHODS: Retrospective case series of 5 adult patients with orbital PNET. Orbitotomy was performed in all cases. The authors report clinical findings, radiologic features, histopathology, immunohistochemical analysis, management, and outcomes for 5 patients with orbital PNET. RESULTS: Five adult patients presented with progressive unilateral proptosis and visual impairment. Common radiographic findings included a heterogeneous mass without associated destructive features, located in the superior and/or lateral orbit. Four cases demonstrated strong immunohistochemical staining for CD99 in a membranous pattern. One case required chromosomal analysis with fluorescence in situ hybridization to confirm the diagnosis. All patients received chemotherapy and/or orbital radiation with resolution of proptosis but no improvement of vision. One patient died of disease. CONCLUSIONS: To the authors' knowledge, this is the largest series of orbital PNET in adults. This tumor has an age demographic wider than previously believed and should be considered in the differential diagnosis of a hypercellular small round cell orbital tumor in both children and adults. Current treatment regimens are not standardized but typically use a similar approach to the treatment of Ewing sarcoma. Orbital PNET appears to have less propensity for metastasis compared with PNET in other locations. However, long-term aggressiveness remains to be proven.

Radiographic analysis of extraocular muscle volumetric changes in thyroid-related orbitopathy following orbital decompression.

PURPOSE: To evaluate radiographic volume changes in extraocular muscles (EOM) following orbital decompression for thyroid-related orbitopathy (TRO). METHODS: Medical records of 22 orbits in 12 patients undergoing postoperative orbital CT after orbital decompression for TRO were retrospectively reviewed. All orbits demonstrated no signs of clinical reactivation of TRO. EOM volumes were determined by the summation of each EOM's cross-sectional area in the coronal plane of the CT scans and multiplying the sum by the slice thickness. Main outcome measure was a comparison of EOM volumes preoperatively and postoperatively. RESULTS: All orbits demonstrated proptosis reduction postoperatively with a mean of 4.8 mm +/- 2.1 mm (p < 0.0001). The significant increase in the medial rectus muscle (p = 0.0010) postoperatively accounted for the primary change in the postoperative enlargement of total EOM volume (p = 0.028). The medial rectus muscle increased 27% from the preoperative volume. The lateral rectus, superior rectus/levator complex, inferior rectus, and superior oblique muscles did not demonstrate a significant volume increase postoperatively (p = 0.23, 0.21, 0.17, 0.40, respectively). Two patients who underwent unilateral orbital decompression demonstrated EOM enlargement postoperatively in the operative orbit only. CONCLUSIONS: There is a significant increase in medial rectus muscle volume postoperatively in orbits undergoing orbital decompression for TRO despite lacking clinical evidence of disease reactivation.