Indications for orbital exenteration in mucormycosis.

PURPOSE: To determine whether evidence-based standards exist regarding the indications for orbital exenteration in patients with orbital mucormycosis. METHODS: A literature review was performed of 113 articles (1943 to 2004). Factors possibly related to patient survival were analyzed. Additionally, a survey was sent to all ASOPRS Fellowship Preceptors to ascertain the frequency, outcome, treatment modalities, and indications for exenteration by these practicing physicians. RESULTS: For published cases, parameter estimates (PE 46 years, frontal sinus involvement, and fever were less likely to survive compared with patients without these conditions. Patients treated with amphotericin B (OR, 4.476) and those with diabetes (OR, 4.987) were more likely to survive compared with patients without these conditions. Exenterated patients with fever were more likely to survive compared with nonexenterated patients with fever (P=0.0468). Thirty-four ASOPRS Fellowship Preceptors received surveys; 26 (76%) completed the survey. Responses to specific survey questions showed a varied experience and indication for exenteration throughout the country. CONCLUSIONS: : Our study underscores the lack of adequate data regarding the evaluation of treatment of orbital mucormycosis. No standard of care currently exists to guide physicians on when exenteration may benefit a mucormycosis patient. Further study is needed to determine which variables indicate the extent of disease and which variables or analytic scheme might predict the progression of orbital mucormycosis with or without exenteration.

Brown's Syndrome in the absence of an intact superior oblique muscle.

Brown's Syndrome was initially described as a superior oblique tendon sheath syndrome-a short anterior tendon resulting in a restricted elevation of the globe in the nasal field. Brown believed that a congenital paralysis of the inferior oblique muscle resulted in this secondary shortening of the anterior sheath of the superior oblique tendon. The definition of Brown's Syndrome has changed over time. It is currently defined as the inability to elevate the eye in the adducted position, both actively and passively on force duction testing, and can be acquired. The pathophysiology of acquired Brown's Syndrome may involve an abnormality of the superior oblique trochlea/tendon complex. However, it may also result from other causes unrelated to the superior oblique tendon or muscle, such as tumors of the superior nasal orbit, inferior orbital mechanical restriction, or an inferiorly displaced lateral rectus muscle and pulley. We present two cases in which a Brown's Syndrome was diagnosed after the superior oblique muscle had been disinserted or removed.