Proptosis in a Patient With Known Graft Versus Host Disease.

A retrospective review of the medical reports of a patient who was undergoing treatment for graft versus host disease following bone marrow transplant for acute myeloid leukemia was conducted. The patient presented with persistent ocular irritation and injection. For an unclear period of time, he developed proptosis and binocular diplopia with limitation of extraocular motility insidiously. MRI revealed gross enlargement of extraocular muscles and bone marrow aspiration trephine confirmed relapse of leukemia. He then underwent chemotherapy with marked improvement of proptosis and extraocular motility. This case report highlights the importance of the eye care provider's careful assessment of patients with a history of malignancy. The presence of ocular irritation must not distract from the detection of other signs. Proptosis and extraocular motility limitation are rarely associated with graft versus host disease. The presence of these signs warrants orbital imaging to rule out recurrence of the primary malignancy.This case report highlights how proptosis and extraocular motility limitation seen in a patient with graft versus host disease may point to recurrence of the primary malignancy.

Methotrexate as an Adjuvant in Severe Thyroid Eye Disease: Does It Really Work as a Steroid-Sparing Agent?

PURPOSE: To compare the efficacy and safety of adjunctive oral methotrexate with intravenous pulsed methylprednisolone against methylprednisolone alone in the treatment of severe thyroid eye disease. METHODS: Retrospective review of clinical data of patients with severe sight-threatening thyroid eye disease with compressive optic neuropathy treated with methylprednisolone with and without methotrexate. Eye disease outcome measures (e.g., VISA inflammatory score and vision) at 0, 3, 6, 12, and 18 months were recorded. RESULTS: There were 72 subjects including 33 who had methylprednisolone alone and 39 with methylprednisolone with methotrexate. There were no statistical differences in demographics and baseline measures of disease activity or vision between the 2 treatment groups. No significant statistical differences in the cumulative dosage of methylprednisolone or occurrence of restrictive myopathy, raised intraocular pressure, proptosis, and exposure keratopathy between the groups at 0, 3, 6, 12, and 18 months were found. However, subjects who received methylprednisolone with methotrexate had better visual acuity of more than 2 lines on Snellen chart (p = 0.026) and VISA inflammatory score (p = 0.034) at 3 months, but no differences at 6, 12, and 18 months. Three patients who received methylprednisolone with methotrexate had transient worsening of liver function. No patient developed severe adverse reaction. CONCLUSIONS: The results demonstrated improved vision and disease activity at 3 months in the combination treatment group. This may suggest that the addition of methotrexate to methylprednisolone is beneficial for accelerating suppression of disease activity and hastens visual recovery. Addition of methotrexate to methylprednisolone did not reduce the requirement for steroids.

The tear cytokine profile in patients with active Graves' orbitopathy.

PURPOSE: The primary aim of this study is to isolate cytokines specific for active Graves' orbitopathy (GO) in the tears of affected patients. The secondary aim is to identify other cytokines of interest and to look at the profile of their levels over time. METHODS: This is a prospective pilot study conducted at the Singapore National Eye Centre. A total of 10 patients with active GO and 10 patients from each of 3 control groups were recruited. The 3 control groups were the following: age-matched normal female patients, patients with GO who were clinically inactive and patients with bilateral viral conjunctivitis. Tears from patients from the control groups were collected on a single visit. For patients with active GO, tears were collected on presentation, at 6 months, 12 months and 18 months. RESULTS: Of all the cytokines examined, only IL-7 yielded a difference when the concentration in patients with active GO was compared with concentrations in all the control groups. This difference was most significant at the 18-month follow-up visit. CONCLUSIONS: Low concentrations of IL-7 in tears exhibit specificity for active GO in patients nearly 2 years from the clinical onset of activity. Although using IL-7 in tears as a biomarker for disease activity may be limited due to its late manifestation, targeting immune restitution using IL-7 may have disease modifying effects.

Clinical Features and Treatment Outcomes of Orbital Inflammatory Disease in Singapore: A 10-Year Clinicopathologic Review.

PURPOSE: 1) To assess the clinical profile and treatment outcomes of orbital inflammatory disease in the local population, and 2) classify patients using current histopathological criteria. METHODS: Ten-year retrospective clinicopathologic review of patients diagnosed with orbital inflammatory disease who underwent tissue biopsy from January 2001 to December 2011 at a tertiary referral centre in Singapore. Data collection included patient demographics, clinical presentation, investigations, systemic disease, histopathology review, clinical classification, medical and surgical management, response to treatment and recurrence rates. RESULTS: The study comprised 70 patients. Thirty-seven (52.9%) had nonspecific inflammation distributed as follows: lacrimal (n = 23), diffuse (n = 5), anterior (n = 5), myositic (n = 4). Thirty-three (47.1%) had specific inflammation of the following subtypes: idiopathic sclerosing inflammation (n = 9), granulomatous disorders (n = 8), transitional lesions (n = 5), vasculitis (n = 4), and others (n = 7). A total of 76.8% of patients received oral prednisolone, with a median duration of three months. Response to treatment was good in 71.9% of patients. Recurrence occurred in 22 (32.8%) patients at a mean interval of 20 months after completion of treatment, and was higher in myositic and vasculitic subtypes. There was no significant correlation between duration of treatment and recurrence. CONCLUSIONS: This study has re-emphasized the importance and utility of orbital biopsy and histopathologic typing for optimal management of orbital inflammatory disease. It has also improved the knowledge of the rate and response to treatment of its various subtypes.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

"Walk the Rim, Feel the Bone" Technique in Superior Sulcus Filling.

Superior sulcus filler injection is a nonsurgical method to rejuvenate the upper face. Blindness and stroke are devastating complications of facial filler injection. This study describes an injection technique that minimizes the risk of blindness and includes a case study demonstrating the cosmetic benefits of this procedure. To avoid retrograde injection of filler embolus into the ophthalmic artery, we advocate a "'walk the rim, feel the bone" approach. Small boluses of hyaluronic acid filler are given in preperiosteal plane, avoiding the superior orbital foramen.

The Looi suture technique for anchoring the lateral tarsal strip to the lateral orbital wall.

INTRODUCTION: The lateral tarsal strip procedure (LTS) was first reported by Anderson and Gordy in 1979 for the management of paralytic or senile eyelid laxity. Since its description, the LTS procedure has been subject to several modifications by various authors. In this study, we described the Looi suture technique, a small modification in the technique of suturing the LTS to the lateral orbital wall periosteum. Using this technique, the surgeon achieves a larger area of contact between the anterior surface of the tarsal strip and the lateral orbital wall periosteum, promoting a stronger adhesion. With a double-armed suture, the technique also allows for adjustment of the lower lid tension to avoid over- or under-correction of horizontal lid laxity. This study aimed to evaluate the technique. MATERIALS AND METHODS: This was a retrospective non-comparative case series of 39 eyelids of 31 patients who underwent LTS with Looi suturing technique for the correction of involutional lower lid laxity which had resulted in either entropion or ectropion. In this procedure, a novel technique utilising a double armed 5/0 Ethibond suture is used to secure the LTS to the lateral orbital rim, with the aim of increasing appositional contact between the LTS and periosteum. RESULTS: In 36 eyelids with entropion, the procedure was combined with lower lid retractor repair, and in 3 eyelids with ectropion, with medial tarsoconjunctivoplasty. Surgery was successful in 37 of 39 eyelids (94.87%) after one procedure. The remaining 2 eyelids required repeat procedures to achieve anatomical success. Both cases had been performed by trainee surgeons under supervision. Postoperative follow-up period ranged from 1 day (in a visiting overseas patient) to 2 years. CONCLUSION: This study described the Looi suturing technique in performing the LTS procedure and we found it a simple and effective modification when dealing with lower lid laxity.

Ocular manifestations and the clinical course of carotid cavernous sinus fistulas in Asian patients.

PURPOSE: To study the clinical course with regard to both the angiographic and visual outcomes of carotid cavernous fistulas (CCFs). BACKGROUND: Carotid cavernous sinus fistulas (CCFs) are conditions which often present with ocular signs and symptoms. The clinical presentation of CCFs is varied according to the anatomy, haemodynamics and size of the CCF. CCFs causing significant symptoms or vision loss should be treated with embolization. METHODS: This is a retrospective review of the medical records of all CCF cases seen in the Singapore National Eye Centre from September 2002 to December 2011. RESULTS: 45 patients who had confirmed CCF on conventional cerebral angiography were included. Anterior draining CCFs presented with orbital congestion while posterior draining CCFs presented with pain, diplopia and cranial nerve palsies. Mild residual symptoms were still present in 85% of treated direct CCFs despite complete angiographic closure however 52% of treated dural CCFs had complete resolution of symptoms despite only half of those achieving angiographic closure. Treated and untreated dural CCFs had similar outcomes (87% versus 76% recovered or improved (p > 0.05)). Poor outcomes can result from residual diplopia or vision loss from complications of the CCF itself (e.g. compressive optic neuropathy, glaucoma, retinopathy) or complications from CCF embolization treatment (e.g. central retinal artery occlusion). CONCLUSION: Presenting symptoms and signs are related to the angiographic drainage of CCFs. Angiographic outcomes after embolization treatment may not always correlate with clinical outcomes.

Prospective audit of ptosis surgery at the Singapore National Eye Centre: two-year results.

PURPOSE: To evaluate the demographics, presentation, and surgical outcomes of patients undergoing ptosis surgery in an Asian population in a prospective manner. METHODS: A prospective ptosis audit was conducted over a 2-year period from January 2010 to December 2011 in a tertiary eye hospital in Singapore. All patients undergoing ptosis surgery by, or under the supervision of, an oculoplastic-trained consultant in the institution were included. Institutional Review Board approval was obtained for the study. RESULTS: This study comprises 302 patients, of which 236 were acquired and 66 were congenital ptosis cases. Levator repair (77.2%) was the most commonly performed procedure, followed by levator resection (13.9%) and brow suspension (8.9%). Forty-seven (10.1%) eyes had readjustment within 2 weeks, the reasons for readjustment being eyelid height undercorrection (n = 35), eyelid height overcorrection (n = 9), and unsatisfactory eyelid contour (n = 4). Postoperatively, 93.8% of patients showed an increase in marginal reflex distance-1 (MRD1), 91.3% achieved symmetry or <1 mm of asymmetry in MRD1, 98.5% had good eyelid contour, and 74.3% had symmetric eyelid crease. On a scale of 1 to 10, 83.1% of patients gave a subjective grade of 7 or better. CONCLUSIONS: This study is the first prospective ptosis surgery audit in an Asian population and takes a leading step in assessing both subjective and objective surgical outcomes in a prospective manner. With the continuation of this audit in years to come, it will allow us to generate clinical outcomes in a robust manner and allow for more reliable benchmarking with major centers elsewhere.

A survey of the histopathology of lacrimal gland lesions in a tertiary referral centre.

PURPOSE: To describe the histopathological distribution of biopsied lacrimal gland lesions in a tertiary referral centre in Singapore. METHODS: This was a retrospective chart review. Clinical records of patients who underwent lacrimal gland biopsy at a tertiary referral centre in Singapore between 2000 to 2010, were reviewed. Data collated included patient demographics, clinical presentation, association with systemic disease and histopathological diagnosis. RESULTS: Sixty-nine patients were studied. Median age of presentation was 50 years. Forty patients (58%) were female and the majority (84%, n = 29) were Chinese. The mean follow-up duration was 35.0 ± 34.5 months. 30.4% (n = 21) of the patients had bilateral disease. Chronic dacryoadenitis (46%, n = 32) was the most common histopathological diagnosis, followed by lymphoproliferative disorders (38%, n = 26) and pleomorphic adenoma (10%, n = 7). The diagnoses in four other patients included adenoid cystic carcinoma, lacrimal gland hypertrophy, lacrimal duct cyst and orbital vascular malformation. CONCLUSION: Chronic dacryoadenitis and lymphoproliferative disorders are the two commonest causes of lacrimal gland lesions in our series. Although many cases remain non-specific, about 60% have a specific inflammation that may be associated with a systemic disease. As one third of our patients with lymphoproliferative disease of the lacrimal gland had an associated systemic lymphoma, patients with such lesions should be referred for investigation of possible systemic lymphoma. The results of our study can aid in providing a more targeted approach to patient management.

Osteotome as an adjunctive instrument in endoscopic dacryocystorhinostomy.

PURPOSE: To report the novel use of the osteotome as an adjunctive instrument in Endoscopic Dacryocystorhinostomy (DCR). MATERIALS AND METHODS: A retrospective interventional case series of 15 patients, underwent endoscopic DCR at the Singapore National Eye Centre, by a single ophthalmologist and rhinologist between April 2009 and April 2011.All patients' case records were reviewed and the information recorded included: patients' demographics, level of obstruction of the lacrimal system, operative time, postoperative symptoms and complications (if any), and the length of follow-up. All patients had preoperative syringing to determine the level of obstruction, and had postoperative syringing only if there were any complaints of epiphora.All surgeries were recorded on video. The osteotome and mallet were used in all patients to augment the bone removal, and Crawford stent (MIRA®) intubation was done in all patients and left in situ for 2 months. RESULTS: A total of 15 patients were reviewed and analyzed from April 2009 to August 2010. Ages ranged from 22 to 77 years of age underwent endoscopic DCR with Crawford stent (MIRA ®) intubation. All patients had syringing before surgery and all had only nasolacrimal duct obstruction except 1 patient who had common canalicular obstruction. The surgery was carried out as described above with no intraoperative or postoperative complications in any of the patients. Duration of surgery ranged from 22 to 65 minutes with a mean time of 42.6 minutes. All patients were followed up from 2 to 11 months with resolution of epiphora in all cases. CONCLUSION: The use of the osteotome and mallet, in combination with the Kerrison rongeur and diamond drill, has been found to be useful in creating a large osteotomy in endoscopic DCR. It has allowed greater ease and speed in performing this procedure, especially for patients with thicker bone and narrower nasal cavities.

Neuroendocrine tumors of the orbit--clinicopathological findings in 3 more cases of this rare entity and review of the literature.

INTRODUCTION: Neuroendocrine orbital tumors are rare occurrences. They are poorly characterized histologically and a spectrum of different cell types exists. This short case series studies the various tumor morphologies as well as the patients' clinical profiles. METHODS AND MATERIALS: Patients treated and followed up at the Singapore National Eye Centre over a period of 8 years from 1(st) January 2002 to 31(st) December 2009 were identified from the orbital tumor board results. The case notes of patients with the diagnosis of neuroendocrine tumors were analysed, and a review of the literature performed. RESULTS: Three patients are described in this series. The history, clinical examination findings, imaging findings as well as tumor histology were described. The mean age was 63 years, and 2 patients were male. All presented with proptosis. Only one patient had systemic symptoms on presentation. All patients had surgical excision of the tumor and two had adjuvant radiotherapy of the orbit. Median follow-up period was 3.5 years. DISCUSSION: Patients with a biopsy-proven diagnosis of orbital neuroendocrine tumors should be monitored even when systemic examination fails to identify peripheral disease. Such examination should always include a full endoscopic gastrointestinal review.

An unusual causative agent for an orbital abscess: Granulicatella Adiacens.

We present a patient who developed an orbital abscess secondary to a retained organic (wooden) foreign body after a fall. Clinically, he had a right sub brow fistula exuding purulent discharge, four millimetres of proptosis, limitation of ocular motility in all directions of gaze, but no signs of optic neuropathy. Preoperative computed tomography and magnetic resonance imaging of the orbits was performed to localise the abscess and to facilitate surgical planning. He underwent exploration, drainage of the abscess and removal of the wooden foreign body with good postoperative recovery. Cultures isolated Ganulicatella Adiacens, a nutritionally variant streptococcus. This is an unusual causative organism and to our knowledge, this is the first reported case of a posttraumatic orbital abscess associated with Granulicatella Adiacens. Clinical suspicion, isolation of the organism and appropriate microbial treatment requires a multidisciplinary approach, with input from the ophthalmologist, microbiologist and infectious disease team. This will ensure a good outcome in patient management.

A 5-year retrospective review of Asian ectropion: how does it compare to ectropion amongst non-Asians?

INTRODUCTION: This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes. MATERIALS AND METHODS: Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Preand postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis. RESULTS: Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes. CONCLUSIONS: Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians.

Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers.

BACKGROUND: Preliminary experience with the use of hyaluronic acid fillers as a nonsurgical alternative in the management of upper eyelid crease asymmetry and superior sulcus hollowing in Asian patients has proven promising. METHODS: This retrospective, interventional case series included seven patients (11 eyes) of various Asian ancestries. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. Upper eyelid crease asymmetry and hollowing of the superior sulcus were assessed before and after treatment. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juvéderm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Pretreatment and posttreatment photographs were taken. Outcomes were assessed by the total volume injected; masked, independent assessment using preoperative and postoperative photographs; and the subjective assessment of results by the patient. RESULTS: The average age was 43.1 years. The average volume of hyaluronic acid filler injected was 0.61 cc per eye. All seven patients were satisfied with the cosmetic improvement after hyaluronic acid filler injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 18 months. CONCLUSIONS: Hyaluronic acid filler injections into the upper eyelid and superior sulcus are effective in providing volume to recreate the fullness natively present in the Asian upper eyelid. Furthermore, this fullness lowers the surgically created eyelid crease in those patients with eyelid asymmetry following cosmetic blepharoplasty. It should be considered in Asian patients presenting with upper eyelid hollowing or asymmetric eyelid creases.

Bilateral orbital subperiosteal hemorrhage following labor.

A 27-year-old woman presented with 13 days of bilateral periorbital swelling, discomfort, and visual loss, which developed immediately after labor. She had significant blood loss requiring blood transfusion. There was bilateral proptosis, left optic neuropathy, and a superior visual hemifield defect in the left eye. MRI of the orbits showed bilateral superior subperiosteal hematomas. She underwent bilateral orbitotomy and drainage of subperiosteal hematomas. Six months later, complete resolution of proptosis with normal ocular motility and visual acuity was observed; however, there was persistence of a left relative afferent pupillary defect with superior visual field loss. This case report highlights the need for a high index of diagnostic suspicion of subperiosteal hematoma arising in a nontraumatic setting, such as in the peripartum period, and consideration for emergent surgical management of optic neuropathy.

Normative measurements of the Chinese extraocular musculature by high-field magnetic resonance imaging.

PURPOSE: To establish the normal measurements of diameter and cross-sectional area of the Chinese extraocular muscles (EOMs) and optic nerve-sheath complex (ON) as seen on high-field (3-Tesla; 3T) magnetic resonance imaging (MRI). METHODS: Coronal 3T MRI of the orbit (TR, 700 ms; TE, 15 ms; FOV, 160 mm; matrix, 256 x 256; slice thickness, 1 mm; and slice gap, 0) was performed on 80 normal Chinese volunteers. T1-weighted images were analyzed with computer-assisted segmentation. The diameter and the cross-sectional area of EOMs and the ON were measured from the image plane at the posterior aspect of the globe and at 7 mm behind the globe. The maximum diameter of EOM was measured from their respective reconstructed images. RESULTS: The normal measurement (mean +/- SD) of diameter at the posterior aspect of the globe: medial rectus (MR), 3.6 +/- 0.4 mm; inferior rectus (IR), 3.7 +/- 0.8 mm; lateral rectus (LR), 2.3 +/- 0.5 mm; superior oblique (SO), 2.4 +/- 0.6 mm; and the ON, 5.4 +/- 0.7 mm. The normal measurement of diameter 7 mm behind the globe: MR, 3.2 +/- 0.6 mm; IR, 3.9 +/- 0.8 mm; LR, 4.0 +/- 0.8 mm; SO, 2.2 +/- 0.7 mm; and ON, 4.2 +/- 0.5 mm. The normal measurement of cross-sectional area at the posterior aspect of the globe: superior muscle group (SMG), 28.2 +/- 6.5 mm(2); MR, 25.5 +/- 3.2 mm(2); IR, 26.9 +/- 7.2 mm(2); LR, 17.3 +/- 3.9 mm(2); SO, 10.5 +/- 3.5 mm(2); and ON, 27.6 +/- 6.1 mm(2). The normal measurement of cross-sectional area 7 mm behind the globe: SMG, 24.1 +/- 6.6 mm(2); MR, 19.1 +/- 4.6 mm(2); IR, 29.5 +/- 6.6 mm(2); LR, 32.3 +/- 6.5 mm(2); SO, 9.7 +/- 3.9 mm(2); and ON, 17.1 +/- 2.9 mm(2). The normal measurement of maximum diameter: SMG, 4.8 +/- 1.1 mm; MR, 5.1 +/- 0.9 mm; IR, 5.4 +/- 1.0 mm; and LR, 4.5 +/- 0.9 mm. CONCLUSIONS: The Chinese 3T MRI EOMs and ON normative data may be useful in determining pathologic enlargement of the EOMs and ON in various orbital conditions. (ClinicalTrials.gov number, NCT00348413.).

Nasolabial fold angle measurement using anterior segment optical coherence tomography in normal subjects.

PURPOSE: The human nasolabial fold angle (NFA) has been measured using MRI and photogrammetry and has been shown to decrease with age. The authors aimed to evaluate a novel method using optical coherence tomography to measure the NFA. METHODS: In this cross-sectional observational series, the authors used anterior segment optical coherence tomography (ASOCT) to image the NFA of both cheeks of 126 subjects aged 21 to 79 years. A dental vinylpolysiloxane custom-designed mould was used as a chin rest. The mean of 3 scans on each side was calculated and analysis of variance, multiple comparisons, and multiple linear regression were carried out using SPSS 11.0. RESULTS: Sixty-one subject (48.4%) were men and 65 (51.6%) were women. Mean age was 50.6 +/- 16.8 years (range, 21-79 years). The ASOCT successfully imaged the NFA in all subjects. Mean right and left NFA were 144.4 degrees +/- 17.1 degrees and 145.4 degrees +/- 17.7 degrees. The NFA were dissimilar between the 6 age categories by decade (p < 0.001). Age was the significant predictor of NFA, accounting for 55% of NFA variation. Every year accounted for a decrease of 0.78 degrees (p < 0.001) and 0.80 degrees (p < 0.001) for the right and left cheeks, respectively. Male sex resulted in an increase in NFA of 5.4 degrees (p = 0.007) and 4.0 degrees (p = 0.06) in the right and left cheeks, respectively. CONCLUSIONS: The NFA decreases with age and increases with male sex and can be measured with ASOCT accurately and easily.

Onodi sinusitis presenting with orbital apex syndrome.

This article reports the unusual presentation of a patient with an intraconal abscess secondary to sinusitis in an onodi cell in a healthy 63 year old Chinese female. She presented with limited extraocular movements, decreased corneal sensation, rapid drop in visual acuity and signs of optic neuropathy, in the absence of any inflammatory signs in the right eye. MRI scans showed a well-encapsulated mass in the posterior two thirds of the orbit, with the presence of an onodi cell on the right side. She underwent an extended lateral orbitotomy, which revealed frank pus that was positive for Staphylococcus aureus. She was treated with intravenous antibiotics with complete resolution of her presenting signs.