Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment.

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was "rounded" relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically.

Surgical management of an optic nerve glioma with perineural arachnoidal gliomatosis growth pattern.

We describe a vision sparing surgical approach for optic nerve glioma. A 7-year-old girl experienced declining academic performance and social withdrawal attributed to progressive disfiguring proptosis. Three years earlier, she had undergone a limited biopsy, a course of chemotherapy, and orbital radiation therapy for a right optic nerve glioma with perineural arachnoidal gliomatosis (PAG). Because of marked proptosis, another surgery was performed via a lateral orbitotomy. After cutting a window in the thickened dura of the optic nerve, rouge colored spongy tissue was suctioned from the subarachnoid space. Small, more solidified areas were excised with unipolar cautery. Care was taken to avoid identifiable blood vessels and the optic nerve, and approximately 60%-70% of the tumor was removed. The dural window was approximated with interrupted sutures. Postoperatively, there was 9 mm reduction in right proptosis and visual acuity improved to from 20/70 to 20/60. This case illustrates the possibility of debulking optic nerve gliomas without sacrificing vision. It should be stressed that this technique is only applicable to gliomas with PAG and the durability of the surgical benefit is unknown.

Long-term management of orbital and systemic reactive lymphoid hyperplasia with rituximab.

Rituximab, a monoclonal antibody to the B cell marker CD20, is becoming increasingly popular in the treatment of various orbital disorders. In this university-based interventional case series, we describe two patients with bilateral orbital and extra-orbital reactive lymphoid hyperplasia (RLH) treated with rituximab. Initially both had favorable responses; but roughly a year later recurrent disease necessitated maintenance therapy in both cases. Both again responded to additional courses of rituximab. Although recalcitrant disease may persist after treatment, rituxmab may play a role in the management of RLH with widespread involvement.

Evisceration in the modern age.

Evisceration is an ophthalmic surgery that removes the internal contents of the eye followed usually by placement of an orbital implant to replace the lost ocular volume. Unlike enucleation, which involves removal of the entire eye, evisceration potentially causes exposure of uveal antigens; therefore, historically there has been a concern about sympathetic ophthalmic (SO) associated with evisceration. However, critical review of the literature shows that SO occurs very rarely, if ever, as a consequence of evisceration. Its clinical applications overlap with those of enucleation in cases of penetrating ocular trauma and blind painful eyes, but it is absolutely contraindicated in the setting of suspected intraocular malignancy and may be preferred for treatment of end-stage endophthalmitis. From a technical standpoint, traditional evisceration has a limitation in the orbital implant size. Innovations with scleral modification have overcome this limitation, and accordingly, due to its simplicity, efficiency, and good cosmetic results, evisceration has once again been gaining popularity.

Orbital trapdoor fractures.

Orbital trapdoor fractures are commonly encountered in children. Awareness of trapdoor fractures is of particular importance. This is because early recognition and treatment are necessary to prevent permanent motility abnormities. In this article, we will provide a brief overview of orbital fractures. The clinical and radiographic features of trapdoor fractures will then be reviewed, followed by a discussion on their proper management.