Vibha Baldev, Shailja Tibrewal, Soveeta Rath, Suma Ganesh
Temporal bone fractures are often associated with damage to middle or inner ear structures, facial nerve, and cerebrospinal fluid (CSF) leak, and rarely with abducens nerve palsy. Isolated abducens nerve palsy is not known to occur following temporal bone fracture and is most commonly associated with concurrent facial nerve injury. We report a case of an 11-year-old girl who presented with isolated right abducens nerve palsy following head trauma. The child had incurred injury following a fall from a bicycle. The presence of postauricular ecchymosis was suggestive of possible temporal bone fracture. High-resolution computed tomography scan revealed undisplaced fracture of the right temporal bone at the petrous apex. Identification of temporal bone fracture prompted toward complete neurological and otological evaluation to detect life-threatening complications like CSF otorrhea. The child was managed conservatively with occlusion therapy to alleviate diplopia and showed complete resolution of the nerve palsy after 4 months. Isolated abducens nerve palsy following the temporal bone fracture is a rare finding. Additional clinical findings like postauricular ecchymosis should be looked for, and appropriate otological evaluation sought in such cases.
Ho-Min Chen, Sherine Jue Ong, An-Ning Chao, Kuan-Lyin Liou, Shih-Ming Jung, Ling-Yuh Kao
PURPOSE: The aim is to describe histopathologic observations in eyes enucleated after selective ophthalmic arterial injection (SOAI) of melphalan for retinoblastoma (RB). STUDY DESIGN: This is retrospective clinical study. PATIENTS AND METHODS: Histopathologic analysis of 14 eyes (13 patients) from May 2008 through January 2015 at Chang Gung Memorial Hospital. RESULTS: The eyes after SOAI were enucleated due to tumor viability (n = 7, 2 with vitreous hemorrhage), neovascular glaucoma (n = 4), lens drop to vitreous with total hyphema and elevated intraocular pressure (n = 1), retinal detachment (RD) progressed (n = 1), and persistent RD with phthisis change (n = 1). Almost all of the eyes showed vitreous seeding (n = 11 eyes) before treatment. After the treatment of SOAI, the histopathological examination revealed complete regression in four eyes with one was clinically diagnosed as viable tumor and progression, one with RD progression, and two as neovascular glaucoma. Six eyes showed invasion into the optic nerves, reaching the lamina cribrosa in five eyes, and six eyes with invasion into the choroid were observed. All of the cases with lamina cribrosa involvement showed tumor progression before enucleation, four cases with lamina cribrosa involvement expired later. CONCLUSION: Although some cases of RB can be controlled effectively with SOAI, but for refractory cases after SOAI, earlier decision of enucleation may be needed.
Vrushali Athavale, Vikas Khetan
Retinoblastoma, the most common primary intraocular malignancy of the young, is a prototype hereditary cancer. Due to its fairly predictable Mendelian inheritance, easily examinable tumors, and early age of presentation, RB has served as the most extensively studied model for genetics in cancer. The genetic strides in RB have progressed at an exponential rate since the 1970s. The highly morbid, reasonably curable and distinctly predictable inheritance pattern of RB; not to mention its propensity to affect our young, forms the basis of aggressively encouraging genetic diagnosis in all patients of RB. In this article, we present the basic and clinically relevant concepts of the genetics retinoblastoma.
Chia-Jui Chang, Shih-Jen Chen, De-Kuang Hwang, Catherine Jui-Ling Liu
Immune checkpoint blockade therapy is relatively a new treatment for cancer which has shown promising results. However, immune-related side effects including uveitis have occasionally been reported during this therapy. Herein, we report the case of a 65-year-old male who suffered bilateral anterior uveitis after immune checkpoint blockade therapy with pembrolizumab and ipilimumab for malignant melanoma. His symptoms and signs improved after topical treatment with corticosteroids. Clinicians should be aware that uveitis can be an immune-related adverse event of immunotherapy.
Shin-Yu Chang, Shawn H Tsai, Lee-Jen Chen, Wei-Chun Chan, Yeou-Ping Tsao
We presented a rare case of a sole choroidal metastatic tumor from esophageal squamous cell carcinoma (ESCC) without other organ metastasis in Taiwan. A 43-year-old male with ESCC was referred for a 1-month history of decreased vision in his left eye. A 5.7 mm thick, yellow choroidal tumor occupied posterior pole, featured with pinpoint hyperfluorescence on angiography and subretinal fluid on optical coherence tomography. Positron emission tomography showed a singular hypermetabolic focus in the left eye. The tumor regressed with complete response and the vision preserved after radiation with total 57.60 gray applied by tomotherapy. The gastrointestinal system is the third most common metastatic origin in Taiwan while esophageal cancer metastasizing to choroid is rare. The discrepancy between the high prevalence of primary ESCC and the rareness of choroidal metastasis from ESCC is undetermined.
Chao-Wen Lin, Ta-Ching Chen, Jieh-Ren Jou, Lin-Chung Woung
Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Autoantibodies to the acetylcholine receptor or, less frequently, to muscle-specific kinase, attack against the postsynaptic junctional proteins, resulting in fluctuating and variable weakness of muscles. Extraocular, levator palpebrae superioris, and orbicularis oculi muscles are particularly susceptible. The majority of patients with MG present with purely ocular symptoms including ptosis and diplopia initially. About half of these patients progress to generalized disease within 2 years. The prevalence of MG in Taiwan is 140 per million with male to female ratio of 0.7. The incidence rate is higher in the elderly. Several immune-related diseases such as lymphoid malignancy, diabetes, and thyroid diseases are associated with MG in the national population-based studies in Taiwan. Ice pack test, rest test, Tensilon/neostigmine test, circulating antibody measurement, and electrophysiological studies are useful diagnostic tools with variable sensitivity and specificity. For the patients with ocular MG, acetylcholinesterase inhibitors are usually the first-line treatment. Corticosteroids and immunosuppressant could provide better disease control and may reduce the risk of conversion to generalized form although there is still some controversy. A thymectomy is also beneficial for ocular MG, especially in refractory cases. The correction of ptosis and strabismus surgery could improve the visual outcome but should be performed only in stable disease.
Hsin-Yu Yang, Cheng-Hsien Wu, Chieh-Chih Tsai, Wei-Kuang Yu, Shu-Ching Kao, Catherine Jui-Ling Liu
A 64-year-old male presented with progressive proptosis of the left eye for 3 months. Orbital computed tomography (CT) demonstrated a 3.9 cm infiltrative mass over the superotemporal quadrant of the left orbit. Pathology of biopsy revealed a ductal adenocarcinoma of lacrimal gland with positive immunohistochemical staining for androgen receptor (AR), cytokeratin-7 (CK7), and gross cystic disease fluid protein 15 (GCDFP-15). The patient received orbital exenteration and adjuvant chemoradiotherapy. No recurrence or metastasis was noted 27 months after treatment. Another case was a 64-year-old male who came for proptosis of the right eye and diplopia for 3 weeks. Orbital CT revealed a 5 cm infiltrated right superotemporal orbital mass with destruction of the lateral and inferior orbital walls. Biopsy showed primary ductal adenocarcinoma of lacrimal gland with positive immunohistochemical staining for CK7, AR, and epidermal growth factor receptor. The patient underwent exenteration and concomitant chemoradiotherapy. However, lung and neck metastasis was noted 21 months after surgery. Collectively, 26 cases in the literature were reviewed. The mean age was 57 years old and male was prevalent (73%). Most immunohistological staining showed positive for AR (46%), CK7 (46%), Ki-67 (38%), and GCDFP-15 (35%). More than half of the patients developed metastasis and one-third of the patients died of disease. Early diagnosis, treatment, and long-term follow-up are required for this aggressive tumor.
Adnan Aslam Saleem, Sorath Noorani Siddiqui, Umair Wakeel, Muhammad Asif
OBJECTIVE: The objective of the study was to evaluate the refractive status and thereby assess anisometropia in children with unilateral congenital nasolacrimal duct obstruction (CNLDO). STUDY DESIGN: This study design was a descriptive cross-sectional study. PLACE AND DURATION: this study was conducted at the Department of Pediatric Ophthalmology and Strabismology, Al-Shifa Trust Eye Hospital, Rawalpindi; from August 2013 to July 2014. METHODOLOGY: This study assessed consecutive children with unilateral CNLDO. Cycloplegic refraction on all children with CNLDO was performed followed by appropriate intervention. Refractive errors of the affected and normal eyes were compared. RESULTS: One hundred and twenty-four children with a mean age of 29.69 ± 21.12 months (range, 2 months to 8 years) were studied. Based on spherical equivalent (SE), hypermetropia was more common in the affected eyes (P < 0.001). Anisometropia of >1.5 diopters (D) was present in n = 17 (13.7%). Interocular difference was significant for spherical error and SE (P < 0.001) but not cylindrical errors. CONCLUSION: Unilateral CNLDO is associated with statistically significant anisometropia, especially anisohypermetropia which has amblyogenic potential. It is vital to perform cycloplegic refraction routinely and counsel parents regarding prognosis and regular follow-ups.
PURPOSE: The purpose of this study is to compare the success rates of endoscopic endonasal dacryocystorhinostomy (EN-DCR) and external DCR (EX-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANLDO). DESIGN: This was a retrospective, comparative, nonrandomized clinical study. METHODS: Reviewed medical records of PANLDO underwent DCR at Far-Eastern Memorial Hospital from May 2011 to June 2017. Data regarding the lacrimal passage system, comorbidities, surgical outcomes, and postoperative complications were analyzed. Anatomical success was defined as patency confirmed by intranasal endoscopic inspection of the ostium and successful lacrimal irrigation; functional success was defined as complete resolution of epiphora and positive fluorescein dye disappearance test, which were assessed at postoperative 6th months. RESULTS: One hundred and seventy patients (37 males, 133 females, mean age 57 years) underwent 178 DCR surgeries for PANLDO. The overall anatomical success rate was 94.4% (93.5% in EN-DCR vs. 95.8% in EX-DCR, P = 0.511) and functional success rate was 90.4% (90.7% in EN-DCR and 90.1% in EX-DCR, P = 0.909). Surgical outcomes were comparable between two groups. Complication rate was low in both groups, including 11 cases of early canalicular stent dislodge (7 in EN-DCR, 4 in EX-DCR), one case of postoperative nasal bleeding in EN-DCR, and two skin wound dehiscence and three cutaneous keloid formation in EX-DCR. None of these cases were concluded into surgical failure at the final visit. The time to symptoms relief was statistical significantly shorter in EN-DCR group (1.7 vs. 3.7 weeks in EX-DCR, P < 0.001). CONCLUSIONS: Success rate of DCR for PANLDO in our study was high, and complication rate was low for both endoscopic and external approaches. There was no statistically significant difference between them. EN-DCR provided higher satisfaction due to quicker recovery and lack of external incision. Endoscopic DCR should be considered as the primary treatment of choice for PANLDO.
Yi-Ming Huang, Yu-Yun Huang, Hsin-Yu Yang, Chieh-Chih Tsai, Wei-Kuang Yu, Shu-Ching Kao, Hui-Chuan Kau, Catherine Jui-Ling Liu
PURPOSE: The purpose of the study was to evaluate the clinical features, treatment, and outcome of patients with conjunctival papilloma. MATERIALS AND METHODS: Twenty-two patients (22 eyes) with biopsy-proven conjunctival papilloma between January 2005 and January 2015 in a tertiary medical center were retrospectively reviewed. Clinical profiles, treatment, outcome, and factors related to recurrence were evaluated. RESULTS: There were 16 males (73%) and 6 females (27%), with a mean age of 47 years. The most common location of conjunctival papilloma was the caruncle (43%), followed by palpebral conjunctiva (29%), bulbar conjunctiva (14%), and fornix (14%). Recurrence developed in five patients (22.7%). The risk of postoperative recurrence was significantly related to the presence of bulbar conjunctival papilloma with corneal involvement (P = 0.043) and surgical excision alone (P = 0.039). One case with multiple recurrences developed nonkeratinizing carcinoma. Two young females developed conjunctival papilloma even after receiving human papillomavirus vaccinations. CONCLUSION: The recurrence of conjunctival papilloma is not uncommon, especially for those patients underwent surgical excision alone. Surgical excision with adjunctive therapy and long-term follow-up is rational for the treatment of conjunctival papilloma.