Orbital Compartments Research Articles

Peripheral giant cell granuloma of orbit: A case report

Giant cell reparative granuloma (GCRG) is a rare locally aggressive benign lesion of orbit with a total of less than 15 reported cases worldwide. A 35-year-old male presented with a left upper eyelid mass. Contrast-enhanced computed tomography orbit revealed a soft-tissue density lesion of the extraconal compartment of the left orbit. Wide local excision was done. Histopathology showed peripheral giant cell granuloma of the orbit with fibroosseous component. No recurrence has been seen after eight months. Definite diagnosis of GCRG is only possible by excision biopsy. Early intervention is important to differentiate from malignant lesion.

Granular cell tumor: A rare presentation as intraconal orbital space occupying lesion

Granular cell tumor (GCT) is a rare benign soft tissue tumor. They have been reported in several regions of the body but mostly in the skin and subcutaneous tissue of head and neck. It may involve the orbit, periocular skin, lacrimal sac, optic nerve, ciliary body, conjunctiva and caruncle. Here we present a rare case of intraconal GCT in a 45 year old woman who presented with unilateral proptosis. She presented with forward protrusion of right eye for the past 3 months,MRI orbit revealed a well defined T1/T2/FLAIR hypointense lesion in the inferolateral aspect of intraconal compartment of right orbit. Transconjunctival excision of the lesion was done. Histopathological Examination (HPE) and immunohistochemistry confirmed the diagnosis of Granular cell Tumor.

Successful Management of an Acute Case of Orbital Cellulitis of Odontogenic Origin.

Sir, Dental infections left untreated can progress through tissue planes into the orbital space through sinuses and result in orbital abscess which is an ophthalmic emergency. We describe the case of a 47-year-old female, a known diabetic who presented with complaints of severe swelling and pain in periorbital region, associated with fever, vomiting, and prostration for 20 days’ duration. She gave a history of repeated episodes of dental pain arising out of her impacted upper third molar tooth for the past 2 months. Ocular examination of the right eye showed significant proptosis of 24 mm, restriction of extraocular movements in all directions, normal pupillary reaction with best-corrected visual acuity of 6/24, and intraocular pressure of 21 mm of Hg [Figure 1a]. Magnetic resonance imaging (MRI) showed heterogeneous multifocal lesions in the right orbit with T1 hypointensity, T2 hyperintensities with internal septation in the intra-conal and extraconal compartments producing compression over the globe [Figure 1b]. Dental X-ray was suggestive of impacted right maxillary third molar tooth [Figure 1c]. On the second day of her hospital stay, she developed multiple upper and lower eyelid pre-septal and post-septal abscesses which were drained, and the pus was sent for culture and sensitivity. Systemic antibiotics were started in the form of intravenous piperacillin/tazobactam (4.0/0.5 g) 8 hourly, metronidazole (500 mg/100 ml) 8 hourly, and oral linezolid (600 mg) 12 hourly. Blood sugars were monitored and insulin was administered as per her requirement. She was referred to dental surgeon for extraction of the impacted molar tooth. She recovered completely with best-corrected visual acuity of 6/9 and intraocular pressure of 16 mm of Hg. She showed remarkable improvement at 2 weeks after tooth extraction [Figure 1d].Figure 1: (a) Clinical photograph at presentation showing severe proptosis, complete ptosis, erythema, restricted extraocular movements, and pus pointing over lower eyelid skin. (b) MRI sagittal section T1 image showing multiloculated abscesses in intraconal and extraconal compartment of right orbit causing compression of eyeball. (c) Right maxillary posterior intraoral periapical radiograph showing impacted upper third molar tooth. (d) Clinical photograph of the same patient after two weeks with complete resolution of edema, proptosis, and extraocular movements. MRI: Magnetic resonance imagingOrbital cellulitis secondary to dental infection is rare accounting for 2%-5% of all cases of orbital infections.[1] To add to its rarity, orbital abscess constitutes less than 1.3% of abscesses seen in maxillofacial region.[2] Surgical drainage of the abscess and pus sample collection is a recommended modality of treatment as reported by many authors.[3,4] Empirical antibiotics and proper intravenous fluid hydration are mainstay of treatment. Systemic corticosteroids fasten the resolution of inflammation and duration of hospital stay.[5] A multidisciplinary approach with dentists, diabetologists, and ophthalmologists is required to prevent serious complications of venous sinus thrombosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A new impact assessment model to integrate space debris within the life cycle assessment-based environmental footprint of space systems

By analogy to conventional environmental impacts, the potential release of debris or generation of fragments can be considered as the emission of an environmental stressor damaging the orbital ‘natural’ resource which supports space activities. Hence, it appears relevant to integrate systematically the impact of the emission of debris on the orbital resource within the life cycle impact assessment (LCIA) step to broaden the scope of life cycle assessment (LCA) for space systems. The main objective of this article is to propose a set of characterization factors to compute the impact caused by the generation of debris within the orbital environment. To do so, the proposed approach follows the methodology of emission-related characterization models in LCIA. the characterization model enables to link the emission of debris and final economic damages to space activities through a complete impact pathway including the fate of debris in downstream orbital compartments, the exposure of targeted space objects to this debris, and the economic damage in case of collision between the debris and the space object. The model is computed for different compartments of the low earth orbit (LEO) region thanks to a discretization of the orbital environment. Results show that the potential damages are the highest for orbital compartments located in the orbital bands of altitude/inclination: 550–2000 km/52–54°, 1,200–2000 km/86–88°, 400–2000 km/96–100°, because of the downstream location of Starlink constellation, OneWeb constellation, and earth observation satellites, respectively. The proposed set of CFs can be used in the LCA of different space systems in order to include impacts and damages related to space debris, along with other environmental impacts. This original development fully in line with the standardized LCIA framework would have potential for further integration into harmonised sector-specific rules for the European space sector such as product environmental footprint category rules (PEFCR).

MRI EVALUATION OF ORBITAL PATHOLGIES

Background: Imaging plays an important role in the evaluation of orbital diseases especially neoplasms. USG and CT remained as primary imaging modalities for most of suspected orbital neoplasms. However, use of MRI is especially valuable for assessing its extent. Precise descriptions of lesion location, involved orbital compartments, spread to orbital apex, perineural and intracranial spread and also provide information beyond what can be seen by fundoscopy, thus facilitates appropriate treatment. Materials And Methods: The present study is a hospital based cross sectional study on 100 patients who were requested MRI for various signs and symptoms of orbital pathologies over 2 years' period. Out of 100 patients, Maximum patients we Results: re found amongst the age group of 41 to 50 years with frequency 27 (27 %) while least number of cases recorded in age group >70 years was 3 (3 %). There was equal distribution of various orbital pathologies among both males(50%) and females(50%).Maximum (77%) cases were unilateral and (23%) cases were bilateral. Maximum patients 52(52%) had secondary orbital involvement while 48(48%) had primary orbital involvement. Maximum 65(65%) patients had orbital pathologies conned to single compartment and 35(35%) patients had multispatial involvement both of which were predominantly unilateral. Amongst unicompartmental pathologies maximum patients had exclusively extraconal involvement. Nature wise maximum cases were infective / inammatory (52%) which were predominantly unilateral. Least cases were endocrine/ systemic and vascular in nature accounting (2%) each. MRI is an excellent imaging modality for comprehensive assessment Conclusion: of various orbital pathologies thereby, allowing the clinician regarding further management, prognosis & follow up

Misdiagnosis of Orbital Foreign Body as Glaucoma Drainage Device

BackgroundSight-threatening complications from retained orbital and intraocular foreign bodies are frequently reported in literature. Delays in diagnosis can result in severe complications, including choroidal neovascularization, infection, and irreversible vision loss. Therefore, it is imperative that emergency physicians consider the possibility of orbital and intraocular foreign bodies when evaluating patients with acute facial trauma. Case ReportA 91-year-old woman with a history of laser-treated glaucoma and cataracts presented to an outside emergency department after a ground-level fall. A maxillofacial noncontrast computed tomography scan showed no facial fractures or hemorrhage, but a 41 mm × 4 mm foreign body within the intraconal compartment of the right orbit was identified. The object was presumed to be an implanted glaucoma drainage device, and the patient was discharged without antibiotics. One day after discharge, the patient developed right periorbital swelling and erythema with increasing purulent discharge and skin thickening, ultimately requiring transfer to our facility for management of complex right orbital cellulitis, orbital compartment syndrome, and surgical foreign body removal. Despite globe exploration and surgical intervention, the patient developed a frozen globe with no light perception in the right eye.Why Should an Emergency Physician Be Aware of This? Subtle ophthalmologic emergencies such as sight-threatening foreign bodies can be challenging to diagnose on imaging, particularly with the advent of implantable ocular technology. When an orbital foreign body is discovered in the context of facial trauma, early ophthalmology consultation should be considered.

Orbital Cholesterol Granuloma: A Rare Case Report

Orbital cholesterol granuloma is a rare entity which can cause proptosis, diplopia and extraocular movement restriction. It is often mistaken for other entities such as epidermoid, dermoid cysts and lacrimal gland tumours. Here authors report a case of a 36- year-old male who presented with proptosis of right eye and diplopia on upward gaze. Computed Tomography (CT) scan showed an extraconal lesion in superotemporal compartment of right orbit with erosion of bony wall. On imaging findings, epidermoid and dermoid cysts were considered as probable diagnoses. On histology, the lesion showed cholesterol clefts, foamy and haemosiderin laden macrophages and foreign body giant cells. Lesion was diagnosed as cholesterol granuloma. While being very rare at this site, this lesion carries a good prognosis with complete surgical excision. Patient showed marked postoperative improvement and was asymptomatic at discharge.

O04 Orbital lymphoma in a 72-year-old lady with rheumatoid arthritis: an argument for rituximab

O04 Orbital lymphoma in a 72-year-old lady with rheumatoid arthritis: an argument for rituximab

Transconjunctival and Transcaruncular Approaches to the Orbit

Transcaruncular and transconjunctival approaches are commonly used by ophthalmic plastic surgeons to access various orbital compartments. These approaches are versatile and may be combined with transnasal or transcranial approaches to the orbit to gain optimal access to challenging locations. A major advantage of the transcaruncular and transconjunctival approaches is the lack of a visible skin incision with excellent postoperative cosmesis. As with all orbital surgery, an in-depth knowledge of orbital anatomy and physiology, as well as meticulous hemostasis, is needed to prevent complications including globe injury, permanent vision loss, diplopia, and retrobulbar hemorrhage. This article reviews the surgical steps of these approaches. The indications for each approach and case examples are illustrated.

Three Simple Steps for Refining Transcutaneous Lower Blepharoplasty for Aging Eyelids: The Indispensability of Micro-Autologous Fat Transplantation

BackgroundLower blepharoplasty has been used for rejuvenating lower eyelids, and diverse modifications have been used to treat conjunct deformities at the tear trough/lid-cheek junction. Strategies for recontouring prominent tear trough/lid-cheek junctions, including orbital fat manipulation, have been reported with good results in the literature. Micro-autologous fat transplantation (MAFT) is a previously unevaluated, potentially advantageous approach to blending the prominent tear trough/lid-cheek junction.ObjectivesWe determined the long-term results after 3-step transcutaneous lower blepharoplasty with MAFT for patients with aging eyelids and prominent tear trough/lid-cheek junctions.MethodsWe evaluated 205 patients with aging lower eyelids who underwent transcutaneous lower blepharoplasty with MAFT between October 2010 and September 2016. The 3-step procedure involved a subciliary elliptical skin excision, resection of 3 orbital fat compartments, and MAFT for the tear trough/lid-cheek junction employing a MAFT-GUN under intravenous anesthesia.ResultsThe mean patient age was 52 years (range, 34-78 years). The mean operating time was 61 minutes. The mean fat volumes delivered to the tear trough/lid-cheek junctions were 2.80 mL and 2.76 mL for the left and right sides, respectively. The average weights of the 3 resected orbital fat compartments were 0.58 g for the left side and 0.56 g for the right side. Patients showed significant improvement and maintenance at an average follow-up of 60.2 months (range, 18-90 months).ConclusionsThree-step transcutaneous lower blepharoplasty with MAFT is an effective, reliable, and promising method with high patient satisfaction and minimal risk of complications. Long-term results demonstrated its utility for aging lower eyelid treatment.Level of Evidence: 4

The interperiosteodural concept applied to the jugular foramen and its compartmentalization.

OBJECTIVE The dura mater is made of 2 layers: the endosteal layer (outer layer), which is firmly attached to the bone, and the meningeal layer (inner layer), which directly covers the brain and spinal cord. These 2 dural layers join together in most parts of the skull base and cranial convexity, and separate into the orbital and perisellar compartments or into the spinal epidural space to form the extradural neural axis compartment (EDNAC). The EDNAC contains fat and/or venous blood. The aim of this dissection study was to anatomically verify the concept of the EDNAC by focusing on the dural layers surrounding the jugular foramen area. METHODS The authors injected 10 cadaveric heads (20 jugular foramina) with colored latex and fixed them in formalin. The brainstem and cerebellum of 7 specimens were cautiously removed to allow a superior approach to the jugular foramen. Special attention was paid to the meningeal architecture of the jugular foramen, the petrosal inferior sinus and its venous confluence with the sigmoid sinus, and the glossopharyngeal, vagus, and accessory nerves. The 3 remaining heads were bleached with a 20% hydrogen peroxide solution. This procedure produced softening of the bone without modifying the fixed soft tissues, thus permitting coronal and axial dissections. RESULTS The EDNAC of the jugular foramen was limited by the endosteal and meningeal layers and contained venous blood. These 2 dural layers joined together at the level of the petrous and occipital bones and separated at the inferior petrosal sinus and the sigmoid sinus, and around the lower cranial nerves, to form the EDNAC. Study of the dural sheaths allowed the authors to describe an original compartmentalization of the jugular foramen in 3 parts: 2 neural compartments-glossopharyngeal and vagal-and the interperiosteodural compartment. CONCLUSIONS In this dissection study, the existence of the EDNAC concept in the jugular foramen was demonstrated, leading to the proposal of a novel 3-part compartmentalization, challenging the classical 2-part compartmentalization, of the jugular foramen.

The Lymphatic Anatomy of the Lower Eyelid and Conjunctiva and Correlation with Postoperative Chemosis and Edema.

There are minimal data in the literature regarding the lymphatic drainage of the conjunctiva and lower eyelid and the relationship with postoperative chemosis and edema. Injection, microdissection, and histologic and radiologic studies were conducted on 12 hemifacial fresh cadaver specimens. Indocyanine green lymphography was conducted in five volunteers. Histology identified lymphatic vessels superficial and deep to the orbicularis oculi. Cadaveric dissection, injection, and radiographic studies identified interconnecting superficial and deep facial lymphatic systems and a conjunctival lymphatic network draining through the tarsal plate to the deep lymphatic system. The superficial lymphatic collectors traveled in subcutaneous fat within the lateral orbital and nasolabial fat compartments. The lateral deep lymphatic collectors traveled beneath orbicularis oculi, then through the superficial orbicularis retaining ligament, and into the sub-orbicularis oculi fat in the roof of the prezygomatic space. These vessels descended to preperiosteal fat at the level of zygomaticocutaneous ligaments to travel adjacent to the facial nerve into preauricular nodes. Indocyanine green lymphography identified correlating draining pathways laterally to the parotid nodes and medially to submandibular nodes. The authors have found that the lower eyelid and conjunctiva are drained by interconnecting superficial and deep lymphatic systems of the face. The superficial system is vulnerable to damage in incisions and dissection in the infraorbital area. The deep system is vulnerable to damage in dissection around the orbicularis retaining ligament and the zygomaticocutaneous ligaments. The authors suggest that concurrent damage to both the superficial and deep lymphatic systems, especially laterally, may be responsible for postoperative chemosis and edema.

Echinococcus in the Orbit: An Unusual Hideout

Isolated involvement of the orbit by hydatidosis is extremely rare. It is a parasitic infestation due to a tapeworm called Echinococcus Granulosus. It is an uncommon disease in head and neck region as it commonly manifests in the lungs and liver. When seen in head and neck, it has been found in the orbit, paranasal sinuses and salivary glands. Orbital hydatidosis per se forms only 1% of all types of hydatid disease. It is endemic in Africa, Middle East and Southeast Asian countries including India. In orbital hydatid disease, patients usually present with unilateral proptosis and diminution of vision. Proptosis is classically painless. Total surgical removal remains the mainstay of treatment. A 30-year-old female belonging to lower socio-economic status, presented with left eye proptosis since 2 years. There was a gradual increase in proptosis associated with diminution of vision over the last 4 months. This finally led to complete loss of vision in a period of two months. Computed tomography scan showed two soft homogenous non-enhancing cystic structures present in the orbit abutting the optic nerve without any intracranial extension; most likely differentials are a developmental cyst, hydatid cyst, epidermoid cyst, rhabdomyosarcoma or a nerve sheath tumor. Magnetic resonance imaging showed two T1 hypointense non-enhancing, T2 hyperintense soft cystic capsulated space-occupying lesions present in the extraconal compartment of orbit abutting the optic nerve, likely to be lymphangioma or a hydatid cyst. Surgery was planned and endoscopic orbital decompression was done. Sago grain-like granules were seen pouring out of the cysts. Cyst walls were completely removed in piecemeal and the specimen was sent for histopathology. Immediate intra-operative reduction of proptosis was seen. The final histopathological report was suggestive of hydatid cyst.

A Rare Case of An Atypical Solitary Fibrous Tumour of Orbit

Solitary fibrous tumours are of mesenchymal origin and comprise of uncommon spindle cell neoplasias. Most commonly the lesions arise from pleura but other rarer sites include lungs, peritoneum, pericardium, nasal cavities, thyroid, parotid gland and orbit. We report the case of a 41-year-old male patient who presented to us with a painless, progressive growth of a mass in the superior part of left orbit with proptosis and inferotemporal displacement of the left eye. Computed Tomography (CT) scan revealed homogeneous enhancing lesion in the superior compartment of left orbit in the extraconal region, extending intraconally and distorting the globe. Upon imaging, the differential diagnosis were lacrimal gland tumour, atypical cavernous haemangioma and nerve sheath tumour. Surgical treatment included complete excision of the mass with the intraoperative finding of mass extending upto the superior oblique tendon, a part of which was excised. Histopathological examination revealed CD34 positive, Bcl-2 and MIC-2 positive tumour with the diagnosis of a solitary fibrous tumour with atypical features but no malignant features. After a follow-up of 18 months, no recurrence was detected.

Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis.

In patients with acute bacterial rhinosinusitis severe orbital and intracranial complications can occur. This review will illustrate the anatomic relationship between the paranasal sinuses and the orbital and intracranial compartments. Subsequently, the spectrum of orbital and intracranial complications of rhinosinusitis and related imaging findings will be discussed and illustrated by case material from daily practice.Teaching Points• Acute bacterial rhinosinusitis can cause severe orbital and intracranial complications.• If orbital or intracranial complications are suspected, cross-sectional imaging is mandatory.• Infection can spread from the ethmoid sinus to the orbit through the lamina papyracea.• Frontal sinusitis can spread intracranially through dehiscences or osteomyelitis.• Radiologists must recognize imaging findings of complications of acute bacterial rhinosinusitis.

Intermembranaceous spaces of human optic nerve intracanal part

AbstractPurpose Purpose of research ‐ to reveal laws of structure and distribution of intermembranaceous spaces of optic nerve intracanal part.Methods 43 bone blocks including optic canal with located in them membranes (dura, arachnoidea, pia), ophthalmic artery of people aged from 26 weeks of prenatal development till 75 years were histologically studied. The structure of optic nerve membranes and intermembranaceous spaces in the cranial, transitive and orbital compartments of optic canal were established. The received data were compared to optic canal MRI results of 27 patients (54 optic canals) aged from 2 months till 75 years on the "VISTA" МР‐tomograph 1 T intensity of magnetic field.Results Wide, uniform, continuous intermembranaceous spaces are characteristic for optic canal cranial compartment, medially and laterally of optic nerve they are more expressed. In optic canal orbital compartment subdural space is the narrowest, non‐uniform on MRI and bone blocks research. The subarahnoidal space is most expressed in cranial compartment of canal laterally of optic nerve above of it, and on MRI medially of nerve it is absent or narrow, non‐uniform, faltering crack (the similar data is received on histologic research). In transitive optic canal compartment there are separate fragments of subarahnoidal space or its absence in different directions from optic nerve (according to histologic research ‐ above of nerve). In orbital compartment this space in the most cases is closed above and below of optic nerve (by results of research of bone blocks ‐ on all circle of optic nerve).Conclusion The laws of intermembranaceous space structure and their distributions in optic canal were revealed. MRI was effective method in study of intermembranaceous spaces of optic nerve intracanal part.

골미전두동염의 합병증으로 발생한 상부 안와 골막하 농양 1예

Subperiosteal orbital abscess is one of common complications of sinusitis and can lead to exopthalmosis, diplopia or visual loss if not treated. Usually this abscess is occurred medial or inferior side of the orbital compartment due to the ethmoid or maxillary sinusitis, while orbital abscess which is located superiorly of the orbit is rare. We report our experience with subperiosteal abscess, located superiorly to the orbital compartments with orbital roof erosion, which is successfully treated by endoscopic transnasal and external approach. (J Clinical Otolaryngol 2011;22:102–105)

Correlation of intraocular pressure with intracranial pressure in children with severe head injuries*

To determine whether there was a correlation between tonometric measurements of the intraocular pressure and transducer measurements of the intracranial pressure in the acute setting, and whether intraocular pressure can be used as a surrogate measure of intracranial pressure. Children with traumatic brain injuries commonly develop increased intracranial pressure requiring surgical placement of a pressure transducer to measure the intracranial pressure during the acute recovery period. The increased intracranial pressure may cause engorgement of the orbital compartments via dilation of the episcleral veins and manifest as increased intraocular pressure. Prospective study. Tertiary academic pediatric intensive care unit. Children admitted with severe traumatic brain injury. Tonometric intraocular pressure measurements. We performed an Institutional Review Board-approved, prospective study on 36 children (age range, 2.9-15.1 yrs) with traumatic brain injuries, requiring intracranial pressure monitoring. A total of 274 intraocular pressure measurements were made after placement of the pressure transducer, and concordance between the sites of injury and measurement was documented. The average age of the patients was 8.3 yrs. The mean intraocular pressure, intracranial pressure difference was -0.5 +/- 0.68 cm H2O, and the variance was 29.88 (sd, 5.47). The 95% confidence interval was between -11.22 and 10.22. With concordance between the sites of measurement and injury, the mean IOP, intracranial pressure difference was -0.02 +/- 0.61 cm H2O (variance, 23.28; sd, 4.82; 95% confidence interval, - 9.47 to 9.42). Concordance reduced the variance of the intraocular pressure, intracranial pressure discrepancy by 20.3%. The Pearson intraocular pressure-intracranial pressure regression coefficient and the Krippendorff's alpha reliability estimate analyses indicated good agreement. The patient's age or Paco2 did not influence the intraocular pressure, intracranial pressure difference. Using 20 cm H2O as a normal intracranial pressure cutoff, the intraocular pressure had a specificity of 0.7 and sensitivity of 0.97; with concordance, the values improved to 0.78 and 0.96, respectively. Tonometry is a useful screening surrogate measure of intracranial pressure in children with traumatic brain injuries, but seems to lack the accuracy necessary for close management of intracranial pressure in the acute posttraumatic period.

Small Versus Coronal Incision Orbital Decompression In Graves’ Orbitopathy

Ideally the planning of decompression surgery should be adequate to the severity of the orbitopathy, its possible “lipogenic” or “myopathic” variants, the patient’s specific orbital osteology and possible previous surgeries. Due to surgeon’s experience and local traditions, however, a standardized rather than a tailored approach is often offered to the patient. An inferior fornix incision can be used for infero medial bony decompression and/or for removing fat from the medial and lateral inferior orbital quadrants. Through the same route a lateral osteotomy can also be performed although an upper skin crease incision offers a wider access to the lateral orbital wall. As an alternative the swinging eyelid technique, offering an adequate access to the bony orbit and to the orbital fat compartments is a versatile technique that can virtually be used as a standard approach for the greatest majority of patients needing decompression surgery. Orbital decompression by coronal incision is an invasive technique and for this not to be used as a standard approach to orbital decompression. Nevertheless, it is not to be abandoned as it can be an additional tool in surgeons’ hands when dealing with patients who can better benefit out of a particular, tailored rather than a standardised approach. Many are the circumstances in which this may happen. Major complications associated with the coronal approach have been mainly described in small series, where only a few patients per year were operated. In this respect it is therefore unavoidable to emphasize that each technique has its own learning curve and it may be difficult to differentiate the effects of each technique from the experience of the surgeon.

Orbital Subperiosteal Hematoma After Thrombolysis and Anticoagulation for Acute Myocardial Infarction

Orbital subperiosteal hematoma is a known complication of trauma (1). We are reporting for the first time its occurrence after the combination of thrombolysis and anticoagulation. A 44-year-old man presented with a head injury and brow laceration caused by syncope due to a myocardial infarction. No other ocular problems were noted. He underwent thrombolysis with 40 mg intravenous tenecteplase and was also treated with an infusion of intravenous heparin at a rate of 18 units/kg/h, 300 mg aspirin, 300 mg clopidogrel, and intravenous glyceryl trinitrate at an initial rate of 2.4 mL/h and titrated according to the patient's pain. Seven hours later he complained of headache and double vision. Visual acuity at the bedside was 20/25 in the right eye and 20/20 in the left eye. Ishihara plate color vision was normal. The pupils were of normal size and reactivity. The right eye appeared displaced inward and downward (Fig. 1). He had reduced supraduction and abduction of the right eye and normal ductions in the left eye. There was mild resistance to retropulsion, although no difference in globe displacement was found on Hertel exophthalmometry. He had some bruising and discoloration of his right upper lid. Intraocular pressure using a handheld applanation tonometer was 16 mm Hg in the right eye and 12 mm Hg in the left eye. Results of ophthalmoscopy were normal.FIG. 1: Seven hours after thrombolysis and anticoagulation, the patient complained of diplopia. In primary gaze position, the right eye is displaced downward and inward. The right upper lid is mildly ecchymotic.Brain and orbit CT revealed a frontal extradural hematoma, a temporal subdural hematoma, and a right orbital roof subperiosteal hematoma, with no evidence of an orbital roof fracture (Fig. 2). He was treated with 1 g tranexamic acid daily to inhibit fibrinolysis. All other medications were continued after a long discussion about the risks and benefits of withdrawing medical therapy.FIG. 2: Precontrast sagittal CT shows a superior orbital subperiosteal hematoma (arrow).Two days later visual acuity was 20/20 in both eyes and pupil reactions remained normal. Ophthalmoscopy revealed superotemporal choroidal folds of the right eye. A follow-up brain and orbit CT showed no change in the size of the hematomas. All ocular motility examinations were comparable to his examination on presentation. The diplopia was alleviated with a 30Δ base up Fresnel prism in the right spectacle. Four weeks after the onset of his symptoms, the ocular alignment (Fig. 3) and movements had returned to normal, the diplopia had resolved, and the subperiosteal hematoma had decreased in size.FIG. 3: Four weeks after thrombolysis and anticoagulation, the eyes are in normal position and aligned.The fact that our patient had no visual symptoms on presentation but developed them 7 hours after thrombolysis leads us to believe that the combination treatment consisting of a fibrinolytic, an anticoagulant, and a high-dose antiplatelet agent was responsible for the development of a subperiosteal hematoma. The orbital hematoma was unlikely to have been an extension of the frontal hematoma, as there was no evidence of an orbital roof fracture or communication between the intracranial and orbital compartments. Although early surgical management of subperiosteal hematomas by needle aspiration or surgical evacuation of the hematoma (2-4) may be important for the prevention of significant ocular morbidity, in this case there was no optic nerve compromise and no progression of the ductional deficits, so intervention was not necessary. Kwesi N. Amissah-Arthur, MBChb Victoria Eye Unit Hereford County Hospital Hereford, UK Birmingham and Midland Eye Centre City Hospital Birmingham, UK Markus Groppe, MBBS, MRCOphth Victoria Eye Unit Hereford County Hospital Hereford, UK Prince Charles Eye Unit King Edward VII Hospital Windsor, UK Stephen Scotcher, MBChb, MRCP, FRCOphth Victoria Eye Unit Hereford County Hospital Hereford, UK [email protected]