Dysthyroid optic neuropathy: atypical initial presentation and persistent visual loss.

PURPOSE: Dysthyroid Optic Neuropathy (DON) can lead to irreversible visual loss. We report risk features correlated with poor visual recovery despite an intensive treatment in a series of patients with DON. DESIGN: Retrospective analysis of a non-comparative interventional series. METHODS: Between 1997 and 2007, 300 consecutive patients with Graves' orbitopathy were seen at the Rothschild Foundation (Paris). Medical records of all consecutive patients who developed a DON were reviewed. Demographic, clinical features and visual function were collected at the time of the first onset, one month follow-up after medical and sometime surgical treatment and at the last examination. Statistical analysis (reflected as p values) gathered the significant observations into detrimental visual recovery prognostic factors for DON. RESULTS: Fifty-six eyes of 29 patients developed a DON. Sixteen eyes (28%) did not improve vision despite usual treatment (intravenous steroids and surgical decompression when necessary). An inferior altitudinal visual field defect (AVF, p=0.0004) and/or a lack of response to intravenous steroids boluses (p= 0.011) were related to a poor recovery. CONCLUSION: DON prognosis is highly variable. Our results suggest that a non-inflammatory element, probably vascular could be involved in atypical DONs. An earlier recognition could prompt to rapid surgical treatment for these patients.

Orbital cyst associated with ocular pit in an adult without microphthalmos.

We describe an adult without microphthalmos who developed an acquired compressive optic neuropathy secondary to an orbital cyst which showed direct communication with an optic disc pit. Such pits may be revealed by late complications such as orbital compressive cyst of the optic nerve, even in previously normal adult patients.

Successful treatment of idiopathic orbital inflammation with infliximab: an alternative to conventional steroid-sparing agents.

Therapy for orbital pseudotumor, also called idiopathic orbital inflammation, is nonspecific and mainly based on the use of corticosteroids. Two patients with steroid-dependent idiopathic orbital inflammation, one with myositis and the other with dacryoadenitis, and intolerant of standard steroid sparing agents (methotrexate or azathioprine), were treated with infliximab, a monoclonal antitumor necrosis factor alpha antibody. In both patients, orbital manifestations disappeared following treatment. After follow-up for at least 20 months, the 2 patients still receiving infliximab remained event free. Infliximab enabled steroid tapering to less than 5 mg per day, suggesting that infliximab could constitute an alternative to conventional steroid sparing agents.

Complications of blepharoplasty.

The complications of blepharoplasty are infrequent, most often minor and transient, and rarely major and permanent with functional or aesthetic consequences. Treatment is above all preventive with screening of "at risk" patients in whom blepharoplasty would be contra-indicated. Patients must be informed of possible risks through informative booklets stressing the most important points. The complications may affect vision. Partial or complete visual loss due to ischemic optic neuropathy, or rarely to compression of the ocular globe by intraorbital hemorrhage, is the most serious complication. Other visual complications include oculomotor disorders, keratoconjunctivitis sicca, epiphora, and chemosis of lymphatic origin. Eyelid complications are more frequent: ptosis of the upper eyelid or lagophthalmia caused by incorrect resection of the skin, scarring, and eyelid fold anomalies. The most severe aesthetic complication is the malposition of the lower eyelid resulting in retraction, lagophthalmia, ectropion, deformation of the external canthus, or lower eyelid tissue relaxation. These malpositions are often minor, sometimes reversible, but they can be major, with psychological, aesthetic, and functional consequences. Other local complications include enophthalmia and hypo- or hypercorrection. General complications may include pigmentation anomalies or infections extending as far as the orbital fat tissue. Finally, complications observed after the newer procedures of laser surgery include ectropion, burns and residual redness. Complications related to periocular injections of filling material are also mentioned. The discussion of these complications is followed by a comprehensive review of the prevention, diagnosis and management of the complications after blepharoplasty.

[Evaluation of the surgery results of Müller's muscle-conjunctival resection in the treatment of blepharoptosis]. / Avaliação dos resultados cirúrgicos com a técnica da ressecção do músculo de Müller-conjuntiva no tratamento da blefaroptose.

OBJECTIVE: To evaluate the results of Müller's muscle-conjunctival resection for correction of blepharoptosis and to discuss the advantages of this procedure. METHODS: 38 patients (39 eyelids) were submitted to Müller's muscle-conjunctival resection. Blepharoptosis varied from 1.0 mm to 3.0 mm (mean: 2.0 mm). The amount of eyelid elevation produced by phenylephrine guided the amount of tissue to be resected. RESULT: 33 eyelids (85%) treated with this procedure were cosmetically acceptable. CONCLUSIONS: Müller's muscle-conjunctival resection procedure is a relatively simple technique for blepharoptosis, with good levator function and positive 10% phenylephrine test. The advantages are: preservation of tarsus and predictable results.

Avaliação dos resultados cirúrgicos com a técnica da ressecção do músculo de Müller-conjuntiva no tratamento da blefaroptose / Evaluation of the surgery results of Müller's muscle-conjunctival resection in the treatment of ptosis

OBJETIVO: Avaliar os resultados obtidos com a ressecção do músculo de Müller-conjuntiva no tratamento da blefaroptose e analisar suas vantagens. MÉTODOS: Trinta e oito pacientes (39 pálpebras) foram submetidos à ressecção do músculo de Müller-conjuntiva. Blefaroptose no pré-operatório variou de 1,0 mm a 3,0 mm (média: 2,0 mm). O valor de elevação palpebral produzido pelo teste da fenilefrina indicou a quantidade de tecido a ser ressecado. RESULTADOS: 33 pálpebras (85 por cento) que foram tratadas com este procedimento tiveram resultado estético satisfatório. CONCLUSAO: Ressecção do músculo de Müller-conjuntiva é técnica relativamente simples para o tratamento da blefaroptose, quando houver boa função do músculo levantador da pálpebra superior e teste da fenilefrina 10 por cento positivo. Suas vantagens são a preservação do tarso e o resultado cirúrgico previsível.

[Graves' ophthalmopathy]. / Orbitopathie dysthyroïdienne.

Graves' ophthalmopathy (GO) is a chronic autoimmune process that affects the retrobulbar tissue and has strong etiological links with graves' disease. Pathogenesis is incompletely understood. Symptoms include proptosis, extraocular muscle dysfunction, eyelid swelling and retraction. In its severe expression, it is a disfiguring and potentially sight threatening disease that profoundly influences and impairs the quality of life of affected individuals. Only a minority of patients develop severe expressions of the disease, requiring aggressive treatments. Glucocorticoids, orbital radiotherapy and decompressive orbital surgery represent a mainstay and a well established treatment for severe and active GO.

Microftalmia com cisto colobomatoso orbitário: relato de casos / Microphthalmos with colobomatous orbital cyst: case reports

Microftalmia com cisto colobomatoso orbitário é raro diagnóstico diferencial dos tumores congênitos orbitários. O diagnóstico precoce e o tratamento adequado são importantes para bom crescimento órbito-palpebral. Descrevemos três casos de microftalmia congênita associada a cisto colobomatoso orbitário e analisamos a importância dos exames complementares. Ultra-sonografia, tomografia computadorizada, ressonância nuclear magnética e o estudo histológico da massa excisada estabeleceram o diagnóstico preciso de cisto colobomatoso.

Manejo de las alteraciones oculomotoras en la orbitopatía distiroidea / Oculomotor alterations handling in the thyroid orbithopaty

Objetivo: El objetivo es definir un protocolo operatorio reproductible frente a la diplopia en pacientes portadores de orbitopatía distiroidea (ODT). Material y Método: Estudio retrospectivo descriptivo que analiza una serie de 37 pacientes operados entre septiembre de 1998 y abril 2003 de cirugía de retroceso muscular, bajo anestesia general o anestesia tópica potencializada, frente una diplopia invalidante en posición primaria y en posición de lectura. La determinación de la cuantía de retroceso dependió de la evaluación perioperatoria dada por el test de ducción forzada (TDF) y el test de elongación muscular (TEM). Se definió como buen resultado post operatorio la desaparición de la diplopia en posición primaria y de lectura con un seguimiento mínimo de 3 meses. Resultados: 26 mujeres y 11 hombres, edad promedio 51 años y seguimiento de 9,4 meses. Se practicaron 27 cirugías sobre diplopias verticales y 14 sobre diplopias horizontales. En las diplopias verticales se siguió el protocolo de TEM (+), es decir, 1 mm retroceso por 1 mm hipoextensibilidad, con buen resultado en 25 pacientes. En las diplopias horizontales, 2 cirugías con suturas ajustables, con buen resultado y en el resto se practicaron 1 mm retroceso por 3 DP de desviación, ya que el TEM era levemente positivo o normal y el resultado fue bueno en 8 casos. Conclusiones: Pensamos que el hecho de realizar un retroceso muscular en relación a la cuantía de la fibrosis constituye un gesto fisiológico. Así 26/27 cirugías practicadas según protocolo de TEM tuvieron buen resultado. La cirugía ajustable nos parece una buena alternativa en el caso de diplopias horizontales con una fibrosis moderadas de rectos internos.