The role of computed tomography in the immediate workup of open globe injury.

PURPOSE: Immediate primary closure is indicated in cases of traumatic open globe injury. Orbital computed tomography (CT) is performed prior to primary closure in order to rule out possible intraocular foreign bodies (IOFB) and/or damage to adjacent extraocular as well as intraocular structures. The aim of the present study is to evaluate the yield of orbital CT scan in immediate clinical decision-making in cases of open globe injury. METHODS: All cases of open globe injury treated in our institute during a 10-year period were reviewed. All underwent a CT scan before any surgical intervention, regardless of trauma severity. The influence of the CT scan results on decisions regarding the immediate treatment of the open globe injury was analyzed. RESULTS: A total of 125 cases of open globe injury were included in the present study. In none of these cases did the CT scan results have any influence on immediate treatment. The CT scan results did influence decisions that were made after the immediate operative stage. CONCLUSIONS: Computed tomography scan has limited value in immediate clinical decision-making in cases of open globe injury scheduled for primary closure. While not crucial prior to the initial procedure, it is of value in managing the case during the following few days as well as later on. This study suggests that a CT scan performed after the initial globe exploration and suturing procedure is a valid alternative to stalling the definite globe suturing process until a CT scan is obtained and interpreted.

Topical glaucoma therapy as a risk factor for nasolacrimal duct obstruction.

PURPOSE: To investigate a possible association between primary open-angle glaucoma (POAG) and primary acquired nasolacrimal duct obstruction (PANDO). DESIGN: Retrospective, comparative study. METHODS: The study group consisted of 209 consecutive eyes (178 patients) whose lacrimal system had PANDO in patients more than 50 years of age during the 10-year study period. The control group consisted of 183 consecutive eyes (183 patients) that underwent cataract surgery during the same period. The main outcome measures were prevalence of POAG in study and control groups and the effect of topical glaucoma therapy use profile on PANDO prevalence. Medical records of all patients included in the study were reviewed. Data collected included demographic details and history and characteristics of POAG treatment. RESULTS: The prevalence of POAG in the PANDO group (23%) was significantly higher than that of the control group (6%; P < .0001). The average history of POAG was longer in the PANDO group (14.10 +/- 5.59 years) compared with the control group (9.55 +/- 7.23 years; P = .025). The average number of topical glaucoma therapy drugs per glaucomatous eye in the PANDO group (1.58 +/- 0.92) was significantly higher than that of the control group (0.73 +/- 0.90; P = .002). Bilateral nasolacrimal duct obstruction (NLDO) was more common among glaucoma patients in the PANDO group (38.23%) compared with nonglaucoma patients in the same group (11.80%; P = .0002). A significantly higher percentage of glaucoma patients in the PANDO group (69%) were treated with timolol, compared with glaucoma patients in the control group (18%; P = .005). CONCLUSIONS: Chronic use of timolol-containing topical glaucoma therapy preparations in glaucoma patients is associated with an increased risk for the development of NLDO. Large-scale prospective studies are needed to ascertain this association.

Congenital combined orbito-nasal lipoblastoma: clinico-pathologic study.

The authors present the clinical picture, histopathologic findings and surgical treatment of an infant born with a lipoblastoma involving an unusual combined orbito-nasal location. To the best of our knowledge, this is the first report of congenital lipoblastoma extension from orbit to the nasal cavity. Transconjunctival orbitotomy with excisional biopsy of tumor was performed. Histology specimen that demonstrates the small embryonal fat cells in different stages of maturation and the characteristic lobulation of the fat tissue are presented. The embryonic origin, timing of development of the tumor during gestation, as well as the route of propagation from orbit to nose are discussed. The authors conclude that complete excision of this tumor, with preservation of normal tissue, may bring cure to the young patient without gross functional deformity.

Effect of timing of external dacryocystorhinostomy on surgical outcome.

PURPOSE: To present our experience with external dacryocystorhinostomy (DCR) outcome and to compare cases of early and late DCR. METHODS: Retrospective data review of all patients who had external DCR with silicone intubation in a 7-year period. Data were collected and analyzed concerning patients' preoperative and postoperative symptoms, and the lacrimal drainage system examination before, during, and after surgery. RESULTS: In all, 162 patients underwent 195 DCR surgeries for nasolacrimal duct obstruction. Success was achieved in 81% of surgeries. Success rates were higher in patients who had early DCR (tearing only or early inflammatory signs of the lacrimal sac, 84% success) than in cases that had late DCR (more than 6 months after inflammation started, 77% success). These differences were statistically insignificant. Failure of DCR was much higher in posttraumatic DCR than in DCR for other etiologies. Complications (in 9% of surgeries) were generally mild and infrequent, except 1 case of meningitis. CONCLUSIONS: In experienced hands, external DCR has good postoperative success with a low complication rate. Early DCR does not have a substantial advantage over late surgery with regard to surgical outcome.

Orbital fractures complicated by late enophthalmos: higher prevalence in patients with multiple trauma.

PURPOSE: To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma. METHODS: Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period. RESULTS: Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance. CONCLUSIONS: The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

[Globe subluxation in thyroid orbitopathy].

We report the clinical and radiographic findings of a female patient who presented to the emergency room in acute distress due to a subluxated globe. The patient had a 10 year history of poorly controlled Grave's disease and associated orbitopathy. In the past, one previous report dealt with this rare phenomenon in association with Grave's disease and attributed the mechanism of this acute event to enlargement of the orbital fat compartment and extensibility of nearly normal extraocular muscles ("lipogenic"--type I orbitopathy). To the best of our knowledge, this case is the first documented report of this unusual event occurring in a patient with significant involvement of the extraocular muscles which caused a resultant crowding of the orbital apex, disturbance to venous outflow and severe orbital congestion. In conclusion, acute globe subluxation may rarely happen in "myogenic" (type II) thyroid orbitopathy.

Delayed presentation of orbito-cerebral abscess caused by pencil-tip injury.

This report describes the clinical and radiologic findings of a child who was stabbed with a pencil tip in his right upper eyelid, in what initially appeared to be an innocuous injury. The child presented again 3 weeks later with a combined orbital and frontal lobe brain abscess. The mechanism of injury is discussed, the orbital and neuro-surgical interventions are detailed, and the medical treatment is presented. Ophthalmologists should have a high index of suspicion for orbital foreign bodies and possible intracranial injury in cases of penetrating eyelid trauma.

One medial triangular Tutoplast sling as a frontalis suspension for adult myogenic blepharoptosis.

PURPOSE: The treatment of choice for medium to severe blepharoptosis with minimal or no levator function is frontalis suspension with a sling, using a rectangular or rhomboid sling placement technique. We describe the short-term, follow-up results of frontalis suspension surgery for adult myogenic blepharoptosis using Tutoplast, a commercially available fascia lata allograft. METHODS: We conducted a consecutive, interventional case study. All adult (>25 years of age) patients operated for non-traumatic myogenic ptosis during a 1-year period were included. All underwent frontalis suspension using one medial triangular Tutoplast sling. Success was judged according to lid position and complications. RESULTS: Successful surgical results were judged by lid level, lid symmetry and lid contour. During a mean follow-up of 9 months, the success rate was 91% in all three criteria and 100% in at least two out of three. No major complications were observed. The most prevalent minor complication was the need for lubrication treatment in 26% of the operated patients. CONCLUSION: The use of Tutoplast for frontalis suspension in cases of adult myogenic ptosis is safe and has a high success rate in the early postoperative period. Further large-scale studies are necessary to ascertain the longterm results and the applicability of this material to other indications.

[Upper lid frontalis suspension as a treatment for essential blepharospasm].

BACKGROUND: Essential blepharospasm is a progressive disease of unknown etiology causing a significant decline in the quality of life of patients suffering from the disease. Currently used treatment for this condition is repeated injections of Botulinum toxin. Some of the patients' therapeutic response to Botox injections is insufficient, and some develop ocular complications. GOALS AND METHODS: This report presents our experience with sling frontalis suspension for essential blepharospasm in 4 patients with follow-up periods of six months to 2 years. A literature review is presented and discussed. RESULTS: A treatment trial with Botox injections was attempted in all four patients. Three of the patients showed insufficient treatment response. Three of the patients developed side effects of recurrent episodes of upper lid ptosis following injections. In all four patients that underwent operations significant reduction of blepharospasm was observed. In two of the patients Botulinum toxin could be discontinued, in one patient treatment intensity could be reduced, and in three--treatment complications were prevented. All four patients reported a high degree of satisfaction from treatment results. CONCLUSIONS: Our results indicate that sling frontalis suspension for essential blepharospasm is a safe and efficient treatment for essential blephrospasm with a high degree of patient satisfaction. Further large-scale studies are needed to substantiate our results.

Haptoglobin phenotype in age-related macular degeneration patients.

PURPOSE: To investigate a possible role of the haptoglobin phenotype in the development of exudative age-related macular degeneration (AMD) in human subjects. DESIGN: Prospective, observational, comparative population study. METHODS: The study was carried out in an institutional setting. All patients referred because of exudative AMD in one eye during an 18-month period were included in the study group. A group of patients treated for other ocular diseases and not having AMD in either eye served as control. Haptoglobin phenotype was determined from a blood sample drawn from each patient in both the study and control groups. The main outcome measure was the distribution of the haptoglobin phenotype in the study and control group. RESULTS: One hundred eighty-five participants were included in the study. Ninety-eight had exudative AMD, and 87 were AMD-free. The difference between the study and control groups in distribution of the haptoglobin phenotype was found to be statistically insignificant. CONCLUSIONS: Our results suggest that the haptoglobin phenotype has no effect on the prevalence of exudative AMD.

Posterior lamellar gold-weight extrusion.

We report a case of a man who had undergone gold eyelid loading for lagophthalmos 22 years earlier. During examination for a complaint of foreign body sensation in the operated eye, the gold weight was found under the palpebral conjunctiva. Although extrusion of a gold weight through the skin anteriorly is well recognized, posterior extrusion has not been previously reported. Although such an extrusion involves tarsal plate erosion, the patient's complaints in this case were minor, probably due to the chronic nature of the process. This finding should serve to draw the attention of surgeons using gold eyelid loading to the possible, albeit rare, complication of posterior extrusion.