Rampat, Radhika; Gupta, Ankur; Henderson, Hugo; Ezra, Daniel
Here, the authors present 2 rare cases of nontraumatic subperiosteal orbital hemorrhage during uncomplicated labor. Case 1 (Fig. 1) shows a 29-year-old primigravida Caucasian with an uneventful antepartum course that developed sudden-onset diplopia and right-sided proptosis during labor. She had no significant medical history including bleeding disorders or dyscrasias and was not on any medication. The patient reported noting double vision and dull ache during labor. Examination findings were within normal limits apart from a 5-mm proptosis and slight limitation in upgaze. The patient received conservative management, and by 2 weeks, full resolution had occurred clinically. Case 2 (Fig. 2) shows a 31-year old multigravid Caucasian with a very similar history. She was only diagnosed when she presented 3 days later to the authors’ eye casualty with double vision. Her visual parameters were also not affected just as in case 1; thus, an intervention was not performed. Both interestingly had a right superomedial nontraumatic subperiosteal orbital hemorrhage, which could be a defining clinical presentation in uncomplicated labor-induced nontraumatic subperiosteal orbital hemorrhage.
Rai, Ravneet S.; Rowlands, Megan A.; Kally, Peter M.; Warren, Floyd
The authors describe the case of a 19-year-old female who suffered posttraumatic emphysema of the optic nerve sheath. She suffered massive head trauma requiring emergent neurosurgery and was incidentally found to have air in her optic nerve sheath on CT scan. At 6 weeks follow up, her visual acuity (20/25 uncorrected) and color perception in the affected eye were excellent. Her examination was notable for an afferent pupillary defect, mild disc pallor, and optic nerve atrophy on optical coherence tomography. This is a case of a patient with posttraumatic optic nerve sheath emphysema who recovered excellent visual function and received follow-up ophthalmic imaging.
Wang, Yao; Ryu, Christina L.; Mokhtarzadeh, Ali; Lee, Michael; Harrison, Andrew; McClelland, Collin
The authors report the case of a 75-year-old man with preexisting glaucoma and recurrent retinal detachment who underwent intraocular silicone oil placement OD resulting in subsequent retrolaminar silicone oil migration to the optic chiasm and vision loss OS. MRI showed silicone oil tracking posteriorly along the right optic nerve to the chiasm. He was placed on high-dose corticosteroids and underwent a successful optic nerve sheath fenestration with improvement of vision in the contralateral eye. Clinicians should be cognizant of the potential for translaminar posterior migration of intraocular silicone oil, as well as the utility of optic nerve sheath fenestration to decompress the anterior visual pathways and restore vision.
Chaugule, Sonal S.; Putambekar, Anirudha; Gavade, Smita; Deshpande, Rahul
A 71-year-old male presented with a history of noticing gradual painless progressive proptosis along with a pinkish mass seen on the outer aspect of his left eyeball. Orbital CT revealed a fairly defined homogenous lesion, abutting the left eyeball and involving the lateral orbit reaching almost till orbital apex. Histopathology analysis aided with immunohistochemistry after an incision biopsy was consistent with leiomyosarcoma. Positron emission tomography scan ruled out presence of any distant primary or metastatic tumor. He underwent eyelid sparing total orbital exenteration with confirmed tumor free soft-tissue margins. He is doing well at 5 months of follow-up with no sign of local recurrence or distant metastasis. Primary orbital leiomyosarcoma is a rare tumor. It is mainly found in older woman; it is even rarer in males. Complete surgical excision with tumor free margins is the recommended treatment. Histopathology and immunohistochemistry are valuable in diagnosis and management.
Slentz, Dane H.; Nelson, Christine C.
Purpose: To describe the use of cryopreserved ultra-thick human amniotic membrane for management of anophthalmic socket contracture.
Methods: A chart review was performed to identify patients undergoing fornix reconstruction with cryopreserved ultra-thick human amniotic membrane for management of anophthalmic socket contracture. Patient demographics, disease etiology, and data regarding postoperative prosthesis fit and complications were collected.
Results: The technique is described in 3 female patients with anophthalmic socket contracture who underwent fornix reconstruction using cryopreserved ultra-thick human amniotic membrane. All patients had excellent prosthesis fit at final follow up (range, 10–14 months). There were no clinically significant complications and no reoperations were performed. One pyogenic granuloma developed and was excised without affecting ocular prosthesis fit.
Conclusions: Cryopreserved ultra-thick human amniotic membrane is easy to use, well tolerated, and produces good outcomes for management of anophthalmic socket contracture.
Idowu, Oluwatobi O.; Ashraf, Davin C.; Kalin-Hajdu, Evan; Ryan, Michael C.; Kersten, Robert C.; Vagefi, M. Reza
Purpose: Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions.
Methods: A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed.
Results: Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure.
Conclusions: Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.
Tooley, Andrea A.; Salomao, Diva R.; Bradley, Elizabeth A.; Garrity, James A.
Purpose: The authors aimed to determine key features of IgG4-related ophthalmic disease (IgG4-ROD) and Graves orbitopathy (GO) to aid in diagnosis.
Methods: The authors retrospectively identified ophthalmology patients seen between June 2009 and November 2013 with clinical overlap of GO and IgG4-ROD. Patient findings were reviewed to characterize the 2 conditions.
Results: Among 8 patients (7 male and 1 female), the mean age was 45.8 years. Time between diagnoses of GO and IgG4-ROD ranged from 1 month to 8 years. Imaging showed enlarged extraocular muscles in all patients. Enlarged infraorbital nerves were seen in 4 patients. Tissue biopsy showed CD20+ lymphocytes with a large proportion of IgG4 plasma cells in 7 of 8 orbital specimens. Six patients had a ratio of IgG4:IgG cells >40%.
Discussion: No pathognomonic clinical findings for GO or IgG4-ROD have been reported, but some key features can help distinguish the conditions. GO is likely if findings include increased thyrotropin receptor antibodies, lid retraction/lid lag, and enlarged extraocular muscles with typical tendon-sparing morphology. Findings suggestive of IgG4-ROD include history of asthma and progressive orbital disease in patients with previous diagnosis of GO, disproportionately large lateral rectus muscle, and enlarged infraorbital nerves. Increased serum IgG4 level and biopsy showing >10 IgG4+ plasma cells/high-power field and IgG4:IgG ratio >40% will support the diagnosis of IgG4-ROD.
Conclusions: GO and IgG4-ROD are complicated inflammatory processes affecting the orbit and present diagnostic challenges. The authors recommend biopsy for patients who do not follow the usual clinical course of GO or have clinical characteristics of IgG4-ROD.