Orbital Congestion Research Articles

Worsening of cavernous sinus dural arteriovenous fistula with incomplete superior ophthalmic thrombosis after palliative transarterial embolization

Worsening of ocular symptoms in cavernous sinus dural arteriovenous fistulae (CSDAVF) is rarely due to superior ophthalmic vein (SOV) thrombosis after palliative transarterial embolization and may resolve spontaneously. We present a unique case of a 38-year-old female whose ocular symptoms worsened three days after palliative embolization. Repeat angiography revealed incomplete thrombus of SOV and severe orbital venous congestion. Complete occlusion of the CSDAVF was achieved by urgent transvenous embolization through the SOV and the patient's ocular symptoms and visual impairment recovered. In such situations repeat angiogram may be needed in evaluating the subtle angiographic changes and curative embolization may be necessary.

Isolated superior ophthalmic vein thrombosis with orbital congestion: a variant of idiopathic orbital inflammatory disease?

Isolated superior ophthalmic vein thrombosis with orbital congestion: a variant of idiopathic orbital inflammatory disease?

Superior Ophthalmic Vein Thrombosis in a Patient With Dacryocystitis-Induced Orbital Cellulitis

A 71-year-old-man presented with chronic left-sided epiphora and a 5-day history of progressive left orbital swelling that had started with a "bump" on the left side of his nose. Orbital CT revealed left-sided preseptal and postseptal inflammation, along with marked thickening of the left superior ophthalmic vein. Orbital MRI with gadolinium enhancement and fat suppression revealed a low-intensity signal in the left superior ophthalmic vein, consistent with a superior ophthalmic vein thrombosis. There was no cavernous sinus involvement. A diagnosis was made of left-sided dacryocystitis-induced orbital cellulitis and superior ophthalmic vein thrombosis. Treatment consisted of intravenous vancomycin, followed by early dacryocystorhinostomy and postoperative intravenous dexamethasone. Anticoagulation was not used. Within 1 week after surgery, the orbital congestion had dramatically improved. Though rare, isolated superior ophthalmic vein thrombosis can be a harbinger of cavernous sinus thrombosis; therefore, early detection is the key to avoiding cavernous sinus thrombosis.

An Arteriovenous Malformation Masquerading as a Carotid-Cavernous Sinus Fistula

To describe a case of an occipital arteriovenous malformation (AVM) presenting with unilateral signs mimicking a carotid-cavernous sinus fistula (CCF). Interventional case report. A 67-year-old normotensive male presented with loss of vision, pain, and proptosis of the right eye. Best-corrected visual acuity was right eye 6/36 and left eye 6/5. Examination of the right eye revealed orbital congestion with arteriolization of the episcleral vessels and an intra-ocular pressure of 44 mm Hg which was refractory to medical treatment. Computed tomography (CT) angiogram and cerebral angiography found an occipital AVM draining into the right sphenoparietal sinus and thereafter the right ophthalmic vein, bypassing the cavernous sinus. Embolization followed by excision of the AVM resulted in recovery of vision, reversal of proptosis, and normalization of intraocular pressure. Rapid diagnosis and immediate intervention resulted in a rewarding visual recovery despite a persisting left homonymous hemianopia.

Commentary

Vascular malformations in and around the brain and skull base are not rare, and many cause neurological and neuro-ophthalmic signs and symptoms. When the orbit is involved, arteriovenous malformations (AVMs) may manifest with primary orbital signs, including proptosis, chemosis, and dystopia. Secondary signs may include problems associated with optic nerve function and morbidity related to orbital venous congestion. Digital subtraction angiography remains the gold standard of diagnosis, but the past 15 years have provided a revolution in neurointerventional therapeutic techniques. Small tracker catheters and more experienced neuroradiologists can maneuver into small feeders, embolizing AVMs transarterially or even transvenously.

Cavernous sinus fistulas: carotid cavernous fistulas and dural arteriovenous malformations.

Direct and indirect carotid cavernous sinus fistulas are uncommon vascular anomalies that result in increased pressure in the cavernous sinus. The subsequent changes in blood flow lead to orbital venous congestion, cranial neuropathies, and glaucoma. The following review summarizes knowledge of the clinical features, natural history, diagnostic testing, and therapy for carotid cavernous sinus fistulas.

A Red Eye and Then a Really Red Eye

A 90-year-old woman presented with a 4-week history of a presumed infectious conjunctivitis resistant to topical antibiotic medications. Examination revealed tortuous, dilated conjunctival vessels in the right eye, retinal hemorrhages, and an orbital bruit suggestive of a carotid-cavernous sinus fistula (CCF). While awaiting a magnetic resonance imaging study, she returned to the clinic the next day with a painful, swollen right eye and an intraocular pressure of 69 mm Hg. A cerebral arteriogram confirmed a direct CCF. Because of the tortuosity of the systemic vascular anatomy, a right carotid artery cut-down with balloon occlusion was performed with successful closure of the fistula and prompt resolution of the orbital congestion. This case illustrates the spectrum of subtle to conspicuous ocular manifestations that can be seen in patients with CCF and its potential to present as an emergency. CCF should be included in the differential diagnosis of an “atypical” red eye. Recognition of arteriolized conjunctival vessels and auscultation of an orbital bruit raises the possibility of a CCF, requiring prompt diagnostic studies.

Oxidative stress and Graves' ophthalmopathy: in vitro studies and therapeutic implications.

Graves' ophthalmopathy (GO) is a disorder of autoimmune origin caused by a complex interplay of endogenous and environmental factors. After recognition of one or more antigens shared by thyroid and orbit, activated T lymphocytes infiltrating the orbit trigger a cascade of events leading to production of cytokines, growth factors and oxygen reactive species. Proliferation of adipocytes and fibroblasts then follows, with an increased synthesis of glycosaminoglycans (GAG), which attract water and cause edema of orbital structures and venous congestion. Proliferation of orbital fibroblasts and adipocytes, both in the retroocular tissue and in the perimysium of extraocular muscles, are among the most important events leading to the increased volume of orbital structures (fibroadipose tissue and extraocular muscles). The contribution of oxygen reactive species to the changes occurring in the orbit is underscored by in vitro studies. Superoxide radical stimulates orbital fibroblasts to proliferate and to produce GAG. Furthermore, hydrogen peroxide induces expression of HLA-DR and heat shock protein-72, involved in antigen recognition and T-lymphocyte recruitment. Cigarette smoking, which is probably the most important environmental factor associated with GO occurrence and maintenance, might also act, among other mechanisms, by enhancing generation of oxygen reactive species and reducing antioxidant production. Substances such as nicotinamide, allopurinol and pentoxifylline reduce superoxide- or hydrogen peroxide-induced proliferation of fibroblasts, GAG production and HLA-DR or HSP-72 expression by GO orbital fibroblasts, possibly through scavenging oxygen free radicals. Two small, non-randomized and/or uncontrolled studies investigated the effects of nicotinamide, allopurinol or pentoxifylline on GO. Favorable results were reported, but data are not fully convincing and the true effectiveness of these agents needs to be verified in randomized, controlled trials enrolling a larger number of patients. It currently seems unlikely that they may find a relevant place in the limited armamentarium available for the management of severe GO.

Interference analysis applied to a double site diversity Earth‐space system: Rain height effects and simple regression‐derived formulas

Site diversity is considered to be an effective technique to overcome potential large rain fade margins in satellite communication links. In addition, because of the expected orbital and frequency congestion, the aggravation of the signal leakage from an adjacent Earth‐space system operating at the same frequency due to potential differential rain attenuation will be considered as a dominant source of interference. In this paper, an existing method to predict the differential rain attenuation statistics with respect to a double‐diversity system is properly modified after assuming a more realistic model for the rain height. Some simple regression‐derived formulas appropriate for use by the system designer and concerning both existing and proposed analysis are also presented. Further, the difference between existing results and the ones deduced from the use of the modified procedure for various availabilities and frequencies is examined, and some useful conclusions are derived.

Bilateral orbital signs predict cortical venous drainage in cavernous sinus dural AVMs. Steibel-Kalish H, Setton A, Berenstein A, Kalish Y, Nimii Y, Kupersmith MJ. Neurology 2002;58:1521-1524.

Cavernous sinus dural arteriovenous malformations (CSdAVM) cause a spectrum of ophthalmic signs and symptoms ranging from a purely ocular or orbital syndrome to less common aggressive neurologic dysfunction due to intracerebral hemorrhages or cerebral venous infarction. Most CSdAVMs have a benign clinical course, but those that drain into cortical veins have an increased risk for neurologic complications. The objective of this study was to determine whether a specific clinical sign predicts cortical venous drainage in CSdAVMs. The records of 118 patients with CSdAVMs were evaluated for the clinical features of the disorder and tested for predictive value of cortical venous drainage. Clinical signs that predicted the presence of cortical venous drainage included bilateral orbital signs (P = 0.004 OR = 23.84) and presence of a postauricular bruit (P = 0.035 odds ratio (OR) = 23.8). No other clinical sign predicted the presence of cortical venous drainage, including extraocular muscle dysfunction, abducens or oculomotor nerve dysfunction, increased intraocular pressure, venous stasis retinopathy, chroroidal effusion, optic neuropathy, subjective bruit, and objective orbital bruit. The authors concluded that patients who present with or develop bilateral orbital congestion from CSdAVMs should be recognized as being at increased risk for cortical venous drainage and venous infarction. These patients should have a contrast-enhanced MRI scan and be considered strongly for timely cerebral angiography and endovascular therapy if cortical venous drainage is found.—Nancy J. Newman

Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature.

This article reviews the contemporary literature for septic cavernous sinus thrombosis (CST) with a focus on anticoagulation. Modern emphasis is placed on suspecting and treating this condition early, which is aided by recognizing clinical features attributable to sepsis, orbital venous congestion, and involvement of cranial nerves within each cavernous sinus. Established treatments include high dose broad-spectrum parenteral antibiotics, and selective surgery for concurrent suppurations. The role of anticoagulation is contentious because its efficacy is undetermined and it may cause or exacerbate concurrent intracranial haemorrhage in patients with septic CST. Moreover, prospective trials of anticoagulation may never be performed due to the rarity of this condition. Nevertheless, retrospective reviews of published reports indicate that haemorrhage caused by anticoagulation is rare, and that early adjunctive anticoagulation is beneficial in these patients if commenced after excluding the haemorrhagic sequelae of CST radiologically.

Cavernous sinus dural arteriovenous malformations: Patterns of venous drainage are related to clinical signs and symptoms

Objective To provide evidence that venous congestion and drainage patterns are responsible for the manifestations of cavernous sinus area dural arteriovenous malformations (CSdAVMs). Design Retrospective observational case series. Participants Records of 85 patients with complete clinical and angiographic evaluations of CSdAVMs were evaluated for the clinical features of the disorder. A neuroradiologist analyzed patterns of venous drainage to and from the cavernous sinus without knowledge of the clinical features. Four venous drainage patterns (reversal of flow from the CSdAVMs into the anterior cavernous sinus, ophthalmic vein thrombosis, drainage into the inferior petrosal sinus or drainage into the superior petrosal sinus) were statistically tested for their predictive value of signs and symptoms using logistic regression. Main outcome measures The power of prediction of orbital congestion, elevated IOP, extraocular muscle dysfunction, optic neuropathy, venous-stasis retinopathy, choroidal effusion, anterior chamber shallowing, bruits, cranial nerve paresis, and central nervous system dysfunction from four patterns of venous drainage. Results Reversal of drainage into the anterior cavernous sinus and ophthalmic veins was highly predictive ( P = 0) of orbital congestion, which was seen in 77 (91%) patients. In contrast, eight (9%) patients without orbital congestion had shunts that did not drain into the anterior cavernous sinus and ophthalmic veins. Cavernous sinus dural arteriovenous malformation drainage into the anterior cavernous sinus and ophthalmic veins also predicted elevated IOP ( P = 0.0023) and optic neuropathy ( P = 0.047). Ophthalmic vein thrombosis significantly predicted cases with choroidal effusion ( P = 0.002) and anterior chamber shallowing ( P = 0.01). Third nerve paresis could be predicted from flow toward the inferior petrosal sinuses ( P = 0.017). Central nervous system symptoms or dysfunction, occurring in 7 (8%) patients, was predicted by venous drainage into the superior petrosal sinus ( P = 0.0008). Conclusions The clinical features found in patients with CSdVAMs are related to the abnormal venous drainage and can be predicted by these venous drainage patterns. Venous congestion and hypertension seem to cause the clinical dysfunction in this disorder.

Colour Doppler Imaging of Superior Ophthalmic Vein in Thyroid-Associated Eye Disease

Purpose: One of the possible etiologies of proptosis in patients with thyroid-associated eye disease is stated to be passive orbital venous congestion caused by the occlusive and constrictive changes of the superior ophthalmic vein (SOV). In an attempt to clarify the validity of this claim, quantitative information on the flow velocity of the SOV was obtained by colour Doppler imaging in 24 patients with thyroid-associated eye disease and compared with data from the control group. Methods: On clinical examination, ocular motility, proptosis, soft tissue involvement, and the presence of optic neuropathy were evaluated. The interaction of these signs with the flow velocity of the SOV was investigated in conjunction with computed tomographic (CT) findings such as extraocular muscle enlargement, dilatation of the SOV, and apical crowding of the orbit. Results: The mean blood flow velocity was significantly decreased in patients compared to the control group ( P < .05). The CT measures that contributed to significant decreases in SOV blood flow velocity were apical crowding ( P < .05) and the coexistence of horizontal and vertical extraocular muscle involvement ( P < .05). Among the clinical measures, significant decreases could be attributed to soft tissue findings ( P < .01) and to optic neuropathy ( P < .05). Conclusions: External compression of the SOV may contribute to the SOV blood flow decrease in orbits afflicted with thyroid eye disease, but proptosis is not relevant to the SOV blood flow decrease.

Bilateral orbital signs predict cortical venous drainage in cavernous sinus dural AVMs.

Most cavernous sinus dural arteriovenous malformations (CSdAVM) have a benign clinical course. Those CSdAVM that drain into cortical veins have an increased risk for neurologic complications. To find whether a specific clinical sign predicts cortical venous drainage (CVD) in CSdAVM. The records of 118 patients with CSdAVM were evaluated for the clinical features of the disorder and tested for predictive value of CVD demonstrated angiographically or suggested by MRI using logistic regression and odds ratio (OR) analysis. Clinical signs that predicted the presence of CVD included bilateral orbital signs (p = 0.004, OR = 23.84) and presence of a postauricular bruit (p = 0.035, OR = 23.8). No other clinical sign predicted the presence of CVD, including extraocular muscle dysfunction, abducens or oculomotor dysfunction, increased intraocular pressure, venous stasis retinopathy, choroidal effusion, optic neuropathy, subjective bruit, and objective orbital bruit. Patients who present with or develop bilateral orbital congestion should be recognized as being at increased risk for CVD.

2001—An Ocular Odyssey: Lessons Learned from 25 Years of Surgical Treatment for Graves Eye Disease

Graves eye disease (GED) is a serious autoimmune disorder that often results in orbital congestion, massive extraocular muscle enlargement, mechanical strabismus, and severe diplopia. Surgical treatment of this condition has often yielded unsatisfactory results and unique or unusual complications. At the University of Michigan, I have had the opportunity to participate in an interdisciplinary Graves eye disease center and provide medical and surgical care for strabismus and diplopia in a large number of these patients. The purpose of this study was to retrospectively review my experience with the surgical treatment of these patients to determine what works, what to expect, and how to avoid the pitfalls and complications that have been common in the treatment of these patients.A retrospective review of the charts of all patients with GED and strabismus or diplopia seen between 1982 and 2001 and who had been followed for at least six months is reported. One hundred eighty-three charts were reviewed, of which 155 met inclusion criteria and 135 had undergone strabismus surgery. These provided the core population for this series.Charts were reviewed for demographics, clinical, and surgical characteristics with emphasis on the types of surgeries performed, surgical results, and complications. Results are organized in categories according to the lessons they have taught me. Special emphasis was placed on the relationship between orbital decompression and strabismus, between the size of strabismus angle and surgical success, and between the special features of GED as they relate to surgical complications and surgical success. I hope these lessons will assist others in the optimal care of these challenging patients.

Analysis of the Degradation of the Carrier-To-Noise Plus Total Interference Ratio Concerning a Dual Polarization Site Diversity System Suffering From Differential Rain Attenuation

For the modern satellite systems where frequency and orbital congestion will be an expectable fact the analysis of the interference effects is considered to be of utmost importance. In this paper, the differential rain attenuation from an adjacent satellite system as well as the rain cross-polarization (valid for frequency re-use systems) are assumed to be the dominant interference sources. A method to predict the carrier-to-noise plus total interference ratio statistics applied to a single-site system is extended to include systems operating under a site diversity protection scheme. The method is based on a model of convective raincells and the lognormal assumption for the point rainfall statistics. The numerical results examine the influence of various parameters upon the total availability performance and it is expected to be useful toward the optimum system design in the future.

Post-traumatic endophthalmitis involving Clostridium tetani and Bacillus spp

PURPOSE: To report a case of post-traumatic infectious endophthalmitis caused by Clostridium tetani and Bacillus spp. METHODS: Case report. RESULTS: A 25-year-old man developed endophthalmitis after a traumatic corneoscleral laceration of his right eye by a concrete reinforcement bar. He underwent pars plana lensectomy and vitrectomy with aspiration of vitreous fluid and a conjunctival swab for cultures. Cultures from the conjunctival swab were negative for organisms. Cultures of the vitreous aspirate were positive for Bacillus species and C. tetani. He had received a tetanus toxoid booster at the emergency department. By the time the culture results became available, he had developed severe eye pain associated with marked orbital congestion, increased swelling and erythema of the lids, marked injection and chemosis of the conjunctiva, and subsequently underwent evisceration. The inflammation resolved after evisceration of the right eye, and he was discharged to home on doxycycline 100 mg orally two times daily for 10 days. CONCLUSION: We are unaware of previous reports of endophthalmitis involving C tetani and could find none in a computerized MEDLINE search. Patients with penetrating eye injury should be assessed for tetanus immunization status, and early intervention with tetanus toxoid booster and/or tetanus immune globulin should be considered if cultures are positive.

THE SURGICAL TREATMENT OF GRAVES' ORBITOPATHY: A Decade of Progress

The total rehabilitation of the patients with Graves' ophthalmopathy is sometimes possible only with sequential surgical procedures. Elective surgical treatment is normally delayed until the inflammatory phase subsides and stability is established, usually 1 to 3 years after onset. Additionally, the metabolic status should be well controlled before elective surgical treatment. Generally, eyelid and motility measurements should remain stable for a period of 6 months before any surgical intervention. 44 Exceptions to delaying surgical repair until stability are severe exposure keratopathy requiring eyelid surgery or progressive optic neuropathy unresponsive to corticosteroid or radiation therapy, which prompts orbital decompression. The overall risk of the need for surgery was estimated as 2.5 times greater in patients older than 50 years than in younger patients. 3 This may be related to the presence of more severe ophthalmopathy in older patients. 33 A systematic surgical approach was introduced in 1986. 75 The usual sequence of reconstruction of the Graves' patient with severe orbitopathy is orbital decompression and strabismus surgery followed by eyelid retraction surgery and other eyelid surgery. Orbital decompression may influence the muscle function and eyelid position. In addition, muscle surgery especially if it involves the vertical rectus muscles; may change eyelid retraction. Despite the usefulness of a systematic conceptual approach, the treatment must be individualized to each patient, as the disease does not follow a uniform course, and the manifestations differ in severity. The first stage of surgical rehabilitation, when necessary, is the orbital decompression. It is indicated to reduce excessive proptosis, to relieve orbital congestion, and to treat compressive optic neuropathy. 6,31,53,74 The goal of strabismus surgery in Graves' orbitopathy is usually to achieve single binocular vision in the primary and reading positions. Stable motility measurements should be achieved muscle surgery. Many patients have restriction of the inferior rectus muscles and benefit from some degree of bilateral inferior rectus recessions. Adjustable sutures frequently are used. Surgery for eyelid retraction and other abnormalities follows strabismus surgery. There are numerous eyelid abnormalities described in dysthyroid ophthalmopathy. The most frequent are upper and lower eyelid retraction, lagophthalmos, ptosis, dermatochalasis, lacrimal gland prolapse and mechanical medial lower eyelid entropion. The eyebrow fat pad may also be enlarged in patients with Graves' orbitopathy. In selected cases, the brow fat may need to be debulked when performing a blepharoplasty to achieve the desired aesthetic result. 21 Cosmetic reduction of herniated fat pads and eyebrow fat pads is generally performed last.

Prediction of the degradation of the carrier‐to‐noise plus total interference ratio applied to frequency reuse satellite systems suffering from differential rain attenuation and cross polarization

Interference effects are of utmost importance to the reliable design of satellite communication systems. In this paper, the differential rain attenuation from an adjacent Earth‐space system as well as the rain cross polarization (valid only for frequency reuse systems) are considered as the dominant interference sources. In particular, a method to predict the carrier‐to‐interference ratio statistics, used for noise dominant systems, is extended to include the general case when the calculation of the carrier‐to‐noise plus total interference ratio (CNIDR), in the presence of rain fading conditions, is needed. In this way, the total outage time of the interfered system can be calculated. The method is again based on a model of convective rain cells and on the lognormal assumption for point rainfall rate statistics. The numerical results examine the influence of various parameters upon the total availability performance. The deduced conclusions will be very useful toward the optimum design of modern satellite systems where frequency and orbital congestion is expected to be a serious problem.

Transvenous Embolisation of Spontaneous Carotid-Cavernous Fistulas by Sequential Occlusion of the Cavernous Sinus

There are two important pathological features associated with carotid-cavernous fistula (CCF): the retrograde cortical venous drainage that can cause intracranial haemorrhage and non haemorrhagic neurological deficit and the retrograde ophthalmic venous drainage that causes orbital venous congestion and visual impairment. We propose a sequential embolisation strategy by the selective occlusion of these two pathological features as the initial steps followed by occlusion of the rest of the cavernous sinus. Eight patients with spontaneous CCF were treated by transvenous embolisation using our embolisation strategy. The clinical features, angiographic findings, embolisation procedures, and clinical and angiographic outcomes were analyzed. The follow-up period ranged from one to 21 months. Clinical cure was achieved in six patients at one to two month follow-ups. One patient with bilateral CCFs had clinical cure of the right eye and clinical improvement of the left eye at three-month follow-up. Another patient had clinical cure at one-month follow-up except residual VI nerve palsy. Two patients had complete angiographic obliteration of the fistula immediately after the embolisation procedure. Another three patients underwent follow-up angiography at one to 16 months and all showed angiographic cure. There were no immediate or late complications. Our embolisation strategy offers a safe and effective option in the embolisation of spontaneous CCF as demonstrated by the clinical results of our eight patients.