Gaze Diplopia Research Articles

Solitary Sclerosis Presenting as Progressive Brainstem Symptoms

A woman in her 30s, presented with left facial weakness, left eyelid droop, left gaze diplopia as well as right facial and upper limb numbness; which progressively worsened over 1 month. She also developed dizziness, dysphonia, dysphagia, and an imbalanced gait. On exam, she had hoarseness, dysarthria, anisocoria; left pupil miosis, left eyelid ptosis, left gaze diplopia, left lower face weakness, deviation of the palate and uvula towards the left side, right eye nystagmus, right sided facial numbness, right upper limb numbness, right dysmetria, brisk reflexes all-over and an unsteady gait. The work up was positive for OCBs in the CSF analysis and MRI brain revealed a single progressive left medulla oblongata and left cerebellar peduncle hyperintensity lesion.

Patient-Specific Orbital Implants Vs. Pre-Formed Implants for Internal Orbital Reconstruction

ABSTRACT Purpose To compare the outcome of orbital blowout fracture repair by means of pre-formed porous-polyethylene titanium implants (PFI) vs patient-specific porous-polyethylene implants (PSI). Methods Retrospective cohort study. Baseline characteristics, ophthalmic examination results, ocular motility, fracture type, the timing of surgery, implant type, and final relative enophthalmos of all patients operated on for blow-out fractures in a single center were collected and analyzed. Results Twenty-seven patients (mean age 39 years, 9 females) were enrolled. Sixteen underwent fracture repair with PFI and 11 with PSI at 11 months (median) post-trauma. Mean follow-up duration was 1.1 years. Both groups showed significant postoperative improvement in primary or vertical gaze diplopia (P = .03, χ2). Relative enophthalmos improved from −3.2 preoperative PFI to −1.7 mm postoperative PFI, and from −3.0 mm preoperative PSI to −1.1 mm postoperative PSI (P= .1). PSI patients had non-significantly less postoperative enophthalmos and globe asymmetry than PFI patients. The outcome was not influenced by previous surgery, age, sex, number of orbital walls involved in the initial trauma, or medial wall involvement (linear regression). Both groups sustained complications unrelated to implant choice. Conclusion Both PSI and PFI yielded good outcomes in this study. PSI may be a good alternative to PFI in primary or secondary orbital blowout fracture repair with less enophthalmos and globe asymmetry, in spite of the possible disadvantages of production time, a relatively larger design, and challenging insertion. Since it is a mirror image of the uninjured orbit, it may be beneficial in extensive fractures.

Strabismus Surgery in Orthophoric Patients With Symptomatic, Asymmetric Vertical or Horizontal Incomitance

To report the indications, operative strategies, and surgical outcomes of patients who undergo vertical and horizontal rectus muscle surgery for incomitant strabismus despite being orthophoric in primary gaze. Retrospective, interventional case series. The setting for this study was an academic practice at Boston Children's Hospital. The patient population comprised 8 orthophoric patients who underwent strabismus surgery to treat vertical/horizontal incomitance. Observation procedures included review of surgical strategies, strabismus measurements in diagnostic gaze positions, and development of postoperative diplopia. The main outcome measures were preserved single vision in primary gaze, comitance, reoperation rate, and patient/surgeon satisfaction. Surgical strategies included the following: (1) simultaneous recession of ipsilateral antagonist rectus muscles; (2) recession or resection of 1 rectus muscle with balancing surgery on the fellow eye; (3) restricting the range of 1 muscle (combined resection and recession or posterior fixation suture); and (4) creating an acceptable deviation in primary gaze. Mean follow-up was 5.4 months (median, 2 months; range, 2-25 months). No patient had new-onset primary gaze diplopia. The median incomitance improved by 9.5 prism diopters. No patient required additional surgery. Patient satisfaction and surgeon assessment of outcomes were high. Although the risk of operating on orthophoric patients with incomitant strabismus may discourage surgeons from offering treatment, the use of specific strategies to address incomitance can preserve alignment in primary gaze while improving patient satisfaction. These strategies may also benefit patients with incomitant strabismus that is symptomatic in primary gaze.

Management strategies for pediatric patients with tectal gliomas: a systematic review.

Pediatric tectal gliomas generally have a benign clinical course with the majority of these observed radiologically. However, patients often need treatment for obstructive hydrocephalus and occasionally require cytotoxic therapy. Given the lack of level I data, there is a need to further characterize management strategies for these rare tumors. We have therefore performed the first systematic review comparing various management strategies. The literature was systematically searched from January 1, 2000, to July 30, 2020, to identify studies reporting treatment strategies for pediatric tectal gliomas. The systematic review included 355 patients from 14 studies. Abnormal ocular findings-including gaze palsies, papilledema, diplopia, and visual field changes-were a common presentation with between 13.6 and 88.9% of patients experiencing such findings. CSF diversion was the most performed procedure, occurring in 317 patients (89.3%). In individual studies, use of CSF diversion ranged from 73.1 to 100.0%. For management options, 232 patients were radiologically monitored (65.4%), 69 received resection (19.4%), 30 received radiotherapy (8.4%), and 19 received chemotherapy (5.4%). When examining frequencies within individual studies, chemotherapy ranged from 2.5 to 29.6% and radiotherapy ranged from 2.5 to 28.6%. Resection was the most variable treatment option between individual studies, ranging from 2.3 to 100.0%. Most tectal gliomas in the pediatric population can be observed through radiographic surveillance and CSF diversion. Other forms of management (i.e., chemotherapy and radiotherapy) are warranted for more aggressive tumors demonstrating radiological progression. Surgical resection should be reserved for large tumors and/or those that are refractory to other treatment modalities.

Statin-Induced Diplopia: A Rare Side Effect

Statin is one of the most effective medication to date in treating dyslipidemia. Moreover, statin is the most available in health clinics due to its cost-effectiveness. However, statin must be used with caution due to its severe rare side effects. Ocular disorder secondary to statin is rarely reported. In this case, statin-induced lateral gaze diplopia, worst on the left lateral gaze, was noted in a middle-aged Malay man. He had underlying dyslipidemia and was started on simvastatin 20mg at night three days before developing diplopia. He was otherwise well and had no other medical illnesses. There were no other neurological signs and abnormal ocular signs. Investigations were done and revealed no other abnormalities. The patient's symptom resolved gradually over eight weeks after discontinuation of the statin. Thus, this case highlights the important key point of anticipating this severe rare side effect of statin, which may be irreversible.

Orbital wall decompression in the management of Graves' orbitopathy: a systematic review with meta-analysis.

To systematically review outcomes of orbital bony wall decompression for Grave's orbitopathy according to the surgical approach. A systematic search for studies published in "Ovid MEDLINE", "Web of Science" and "Embase" of patients with surgical treatment of Grave's orbitopathy was performed. The overall postoperative change in Hertel exophthalmometry was calculated by random-effect meta-analysis model with 95% confidence interval (CI). A total of 33 studies, including 1686 patients and 2946 procedures, were included. The weighted mean Hertel value overall reduction was - 4.56 mm (95% CI - 5.05 to - 4.07 mm). According to surgical techniques the reduction was - 4.36 mm (95% CI - 5.22 to - 3.50) for infero-medial technique, - 4.88 mm (- 5.68 to - 4.08) for medial-lateral technique, - 4.32 mm (- 4.80to - 3.84) for lateral technique, - 5.45 mm (- 6.16 to - 4.74) for three-wall technique and - 3.47 mm (- 5.81 to - 1.12) for medial technique. The overall rate of new-onset of primary gaze diplopia was reported in 23 studies. The included procedures were 653 and results were heterogeneous (heterogeneity: Q = 78.8 df = 22, I2 = 72.09%, p<0.01). The pooled proportion (95% CI) rate of new-onset of primary gaze diplopia was 12% (7-16). Our metanalysis highlights that orbital bony wall decompression represents an effective surgical procedure. The three wall approach was associated with the best results in terms of exophthalmos reduction. Data suggest that an exclusive lateral approach may help to avoid the new-onset of primary gaze diplopia during the postoperative period.

Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery.

Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete. We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself. Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia. Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis.

Unilateral proptosis, scleral injection and superior gaze diplopia secondary to spontaneous ophthalmic artery to superior ophthalmic vein fistula – Case report and review of literature (P2.145)

Unilateral proptosis, scleral injection and superior gaze diplopia secondary to spontaneous ophthalmic artery to superior ophthalmic vein fistula – Case report and review of literature (P2.145)

SEQUENTIAL HEMORRHAGE IN TWO LESIONS OF MULTIPLE CEREBRAL CAVERNOUS MALFORMATIONS: A CASE REPORT

We present the case of a 64-year old female, with a 5 year history of symptomatic multiple cerebral cavernomas, who developed paresthesia in the right leg and arm, followed by vertigo, slurred speech and forward gaze diplopia. Brain investigation revealed two lesions with supra- and infratentorial localization with signs of recent hemorrhage of different ages. The localization of the lesions in the midpons and the basal ganglia imposed a conservative approach.

Geriatric patients are predisposed to strabismus following thyroid-related orbital decompression surgery: A multivariate analysis

ABSTRACTGeriatric patients (age ≥ 65) are prone to complications after surgery and are at risk for severe thyroid eye disease (TED). In this study, we aim to identify preoperative demographic and TED patterns associated with geriatric patients who underwent decompression surgery, to examine the effect of age on postoperative strabismus rates, and to identify factors that may contribute to postoperative strabismus in the geriatric subgroup. We retrospectively reviewed patients who underwent thyroid-related orbital decompression surgery at the Kellogg Eye Center, University of Michigan, between 1999 and 2014. Primary outcome was postoperative strabismus requiring palliation with prisms and/or strabismus surgery. Descriptive, univariate, and multivariable logistic regression analyses were used to define association of geriatric age with postoperative strabismus and determine predictors of postoperative strabismus. Of 241 patients, 41 (17.0%) were geriatric. They were less likely to undergo bilateral decompression (P = 0.012), less likely to be current smokers at time of decompression (P = 0.002), and more likely to have preoperative primary gaze diplopia (P = 0.001). Postoperative strabismus rates for geriatric patients (≥ 65 years of age), ages 50–65, 30–50, and < 30, were 73.2%, 41.3%, 31.9%, and 15.8%, respectively (P = 0.002). On multivariable analysis, geriatric age remained an independent risk factor for postoperative strabismus when compared to each age group (P ≤ 0.001). Among geriatric patients in subgroup multivariable analysis, balanced as opposed to lateral wall decompression (P = 0.038) and shorter TED duration (P = 0.031) were independently predictive of postoperative strabismus.

Multi-wall orbital decompression for disfiguring proptosis in patients with mild or moderate thyroid eye disease

1. Hertel value was 14-23 mm or over 2-7 mm than contralateral eye; 2.Orbitalpathy has been inactive with normal thyroid function for at least 6 months; 3.Orbital pressure is normal or (+). Clinical outcomes were recorded including best-corrected visual acuity, exophthalmometry, margin-to-central distance of upper and lower lids, diplopia, and CT scans before and 3 months after surgery. Results: The mean protosis of pre-and postoperation were (19.2±2.3) mm and (14.7±1.4) mm with mean reduction was (4.6±1.7) mm (t=14.08, P<0.01). Margin-to-central distance of the upperlid of pre- and postoperation were (5.1±1.2) mm and (4.9±1.3) mm with mean reduction was (0.2±0.5) mm (t=1.73, P=0.095). Margin-to-central distance of the lowerlid of pre-and postoperation were (5.9±0.9) mm and 4.3±0.7 mm with mean reduction was (1.6±0.8) mm (t=10.09, P<0.01). The difference of bilateral exophthalmos after surgery is 0-2.5 mm (median=1 mm). None of the patients showed new-onset diplopia at primary gaze and two patient showed surrounding gaze diplopia postoperatively. Two patients with diplopia relieved after surgery (Z=743.00, P=0.458). Conclusions: Transconjunctival and transpalpebral medial, inferior, and lateral walls decompression with a hidden incision was a controllable, safe, effective technique with minimal complications in relieving not only mild, moderate proptosis, but also retraction of lowerlid, and swollen eyelids. (Chin J Ophthalmol, 2017, 53: 128-135).

The functional outcome of blow-out fractures managed surgically and conservatively: our experience in 100 patients.

The proportion of orbital blow-out fractures (BOFs) which are operated upon varies. The purpose of this study was to determine the treatment pattern of BOFs at our tertiary trauma centre and to evaluate the functional outcomes in patients according to whether they were managed surgically or conservatively. The study design is a retrospective cohort study and the setting is Tertiary care University Hospital. The participants include patients with isolated BOFs admitted to our Trauma Unit from 2010 to 2013. Of the 100 consecutive patients included, 60 had available follow-up data. The presence of diplopia and enophthalmus was determined by reviewing the medical records. Data from the patients' initial consultation and their 3-month follow-up were also collected. Of the 60 patients whose data could be analysed, 36 had been managed surgically and 24 conservatively. Of the patients managed surgically, 25 had diplopia in peripheral gaze before surgery and 12 at 3-month follow-up. Nine had diplopia in primary gaze before surgery and none at 3-month follow-up. Five had enophthalmus before surgery and two at 3-month follow-up. Of the patients managed conservatively, eight had diplopia in peripheral gaze initially and seven at 3-month follow-up. Three had diplopia in primary gaze initially and one at 3-month follow-up. One had enophthalmus initially which was still present at 3-month follow-up. Primary gaze diplopia disappeared while secondary gaze diplopia was present in about a third of patients, whether managed surgically or conservatively at the 3-month follow-up. Standardised follow-up as well as clear indications for and against surgery are warranted.

Orbital Myositis with Rapid Successful Treatment with Corticosteroids

A 41-year-old Japanese female was admitted to our hospital with a history of right abducens nerve palsy, right gaze diplopia, right eye pain and double vision. Thyroid function, thyroid autoantibody levels, and tests for other pathologies were normal. Orbital contrast-enhanced short-TI Inversion Recovery-magnetic resonance imaging before treatment showed contrast-enhanced, severe lateral rectus and rectus superior muscle swelling in the right eye. We therefore diagnosed this patient as orbital myositis. Intravenous glucocorticoid pulse therapy with methylprednisolone (mPSL) was initiated. After prescribing a daily dose of 1,000 mg of mPSL three times a week, all symptoms, including physical abnormalities, disappeared. The patient was discharged on day 14 after hospitalization and was prescribed oral PSL (30 mg/day). This report indicates that early and initial adequate treatment with a high dose of mPSL is very effective for orbital myositis treatment. However, the possibility of recurrences must be always considered at subsequent follow-up. Case Study Tetsuka et al.; BJMMR, 8(4): 362-366, 2015; Article no.BJMMR.2015.460 363

Characterization and Outcomes of Repeat Orbital Decompression for Thyroid-Associated Orbitopathy

Orbital decompression for thyroid-associated orbitopathy (TAO) is commonly performed for disfiguring proptosis, congestion, and optic neuropathy. Although one decompression typically achieves goals, a small percentage requires repeat decompression. We performed a 10-year retrospective chart review of all orbital decompressions for TAO at a single tertiary referral institution. Four-hundred and ninety-five orbits (330 patients) were decompressed for TAO, with 45 orbits (37 patients) requiring repeat decompression. We reviewed the repeat cases for indications, clinical activity scores, approach, walls decompressed, and outcomes. Nine percent of orbits required repeat decompression for proptosis (70%), optic neuropathy (25%) or congestion (45%). Sixty-four percent were for recurrence of disease, 36% were for suboptimal decompression. Three incisional approaches were used: lateral upper eyelid crease, inferior transconjunctival, and transcaruncular, with inferior transconjunctival being most common. Of the three walls removed, deep lateral, inferior, and medial, the deep lateral wall was most common (51%). A repeat lateral decompression was the most frequent pattern. Of 37 patients requiring repeat decompression, 40% had diplopia prior to repeat, and an additional 24% developed diplopia after the repeat. Whereas previous studies published by our group cited only 2.6% of deep lateral wall orbital decompressions leading to new-onset primary gaze diplopia, repeat orbital decompressions have a much higher rate of post-operative diplopia. The new onset primary gaze diplopia after repeat decompression group had a higher average preoperative CAS (3.3 vs. 2.4, p < 0.01), higher mean blood loss (56 vs. 19 mL, p = 0.04), more frequent medial wall decompressions (47% vs. 29%, p = 0.33), and greater proptosis reduction (2.4 vs. 1.7 mm, p = 0.24).

Prognosis for Sixth Nerve Palsy Arising from Paranasal Sinus Disease

The abducens nerve, cranial nerve VI (CNVI), is the medial-most nerve in the cavernous sinus. Its close proximity to the sphenoid sinus makes it susceptible to injury, invasion, or compression from a sphenoid pathology leading to horizontal gaze diplopia. A wide range of literature describes myriad causes for CNVI palsy, but there is a lack of references that point to paranasal sinus pathology as an etiology, as well as the prognosis and timeline for resolution. Here, we describe a series of patients that presented with CNVI palsy, their management, and prognosis for recovery. This study was designed to evaluate and understand prognostic factors predicting disease course and likelihood of resolution in patients with abducens nerve palsy. A multi-institutional retrospective review was performed of all patients presenting with CNVI palsy between 2009 and 2012. The demographic data, radiological features, treatment regimens, and disease courses were analyzed. Fifteen patients at four institutions were identified. Seven patients had neoplasms originating from the paranasal sinuses, three suffered from allergic fungal sinusitis, three patients had invasive fungal sinusitis, one patient had fibrous skull base dysplasia, and one had chronic bacterial sinusitis. The average follow-up time from presentation was 9 months (range, 1-16 months). Thirteen patients underwent surgery, three received chemotherapy, and four had radiation therapy. CNVI palsy resolved in 50% of the cases, with an average time to resolution of 6 weeks (range, 2-12 weeks). Paranasal sinus pathology is a rare cause of CNVI palsy. A number of factors may help to predict prognosis in these patients. Masses compressing, but not destroying or invading, the cavernous sinus had optimal posttreatment outcomes with full resolution occurring as early as 2 weeks. Destructive lesions that invaded CNVI and its vasculature, i.e., invasive fungus, were negative indicators for recovery. Knowledge of factors that affect recovery can help clinicians predict disease course and prognosis for resolution of the defect.

Diplopia in blow out fractures

Sir, We read with interest the article by Ceylan OM et al.,[1] entitled ′Management of diplopia in patients with blow out fractures′. We would like to congratulate them on their report, and their excellent results regarding diplopia management. We would like to make a few comments on the report. Diplopia in orbital fracture might result from various causes[2] and because patients' complaints are often too subjective for meaningful comparisons, objective ways to evaluate diplopia are required.[3] To better study the effect of surgery, it is desirable to quantify the amount of diplopia. Reports have utilized quantitative evaluation of binocular visual field (BVF)[2] testing, Hess test (Hess area ratio),[3] and electronystagmography[4] equipment, as newer and innovative measures to quantify diplopia. We appreciate that Ceylan OM et al., utilized Hess screens and BVF, and would like to know if they applied any quantitative value to these tests. We understand that 6 patients were treated additionally with strabismus surgery or prisms for residual diplopia. We were interested in knowing if the persistent diplopia was less than, or equal to the initial diplopia measured prior to wall repair, and if there was any improvement in the diplopia post orbital repair in these patients. Though the mean time between trauma and strabismus surgery is mentioned as 10.5 months, the mean time between secondary strabismus surgery and the initial orbital wall reconstruction is not. We were interested in knowing how long should we wait after the primary orbital repair the surgery take place before opting to operate for residual diplopia. The study states that 7 patients underwent strabismus surgery. Even though the average deviation is mentioned as 14 prism diopters, the direction of deviation is not mentioned. Since the study mentions inferior-rectus recession as the commonest surgery, we infer that most of them had hypotropia in primary gaze. We would like to know if there is a difference in outcome between horizontal and vertical deviations. We wondered if the authors considered strabismus operation in the unaffected eye to resolve diplopia. We also wanted to know if there were any cases of diplopia in down gaze post strabismus surgery. The study mentions that primary gaze diplopia was eliminated in 73.9% of patients with no complication related to use of the Medpore® (Stryker Company, USA) implant. They also mention the possibility of flap tear in 2 of the patients. We would like to suggest, doing further investigation to find out the cause for the residual diplopia found in 26.1%, post wall repair. Various reports suggest the benefits of a post operative multi-positional high resolution MRI in such situations, to rule out mesh related complications.[5]

Strabismus After Inferior-Medial Wall Orbital Decompression in Thyroid-Related Orbitopathy

Purpose: To evaluate the rate and pattern of new-onset diplopia after inferior-medial wall orbital decompression in thyroid-related orbitopathy (TRO) patients.Methods: Medical records of TRO patients who underwent orbital floor and medial wall decompression at the Goldschleger Eye Institute, Sheba Medical Center between 1/1986 and 12/2007 were reviewed and analyzed. Main outcome measures: primary- and down-gaze diplopia, strabismus (prism diopter [PD]).Results: Fifty-one TRO patients (30 females, mean age of 51 years) underwent 102 bilateral inferior-medial wall orbital decompressions. Preoperatively, 29 patients (57%) reported primary gaze diplopia. Of these, 13 patients (45%) had persistent or worsened diplopia postoperatively, all of which required strabismus surgery. Fifteen patients had no primary gaze diplopia preoperatively. Of these, five patients (33%) had new-onset diplopia postoperatively, and only one patient (7%) required strabismus surgery. No data regarding pre-existing diplopia were available in seven patients. Orbital decompression had a significant effect on horizontal ocular deviations with increasing esotropic shift. Primary position esotropia increased from 11.1 (± 22.5) PD preoperatively to 23.8 (± 20.5) PD after surgery (p = 0.01, paired samples t-test). No severe complications were encountered in this group of patients.Conclusions: Inferior-medial wall orbital decompression is associated with a relatively high rate of new-onset diplopia of up to 33%. Patients with pre-existing primary and/or downgaze diplopia are more likely to have persistent symptoms postoperatively that may require strabismus surgery.

A rare case of malignant pediatric ectomesenchymoma arising from the falx cerebri

Malignant ectomesenchymoma is a rare tumor arising from mature ganglion cells with immature myogenous elements, with only 4 pediatric intracranial cases having been previously reported. The authors report a rare case of intracranial malignant ectomesenchymoma originating from the falx cerebri in a 10-year-old boy. The patient presented with a 2-week history of headache, nausea, and blurry vision, with mild lateral gaze diplopia. A CT scan revealed a solitary 7.2 × 3.8-cm dural-based mass that extended along the falx. No metastatic disease was identified, and the lesion was grossly resected without complication. Pathological investigation identified single and small groups of cells in a myxoid background, with polygonal or spindle-shaped cells containing eccentric nuclei and prominent nucleoli. Immunohistochemical staining of some cells was positive for smooth-muscle actin, CD99, and vimentin, whereas other cells (often process forming) were positive for S100 protein, synaptophysin, and neurofilament protein. Staining was negative for CD138, CD45, α-fetoprotein, CK AE1/3, glial fibrillary acidic protein, CK7, CK20, CD31, CD34, myoD, and desmin. Normal immunopositivity was seen for INI-1. The Ki 67 immunostaining had < 25% reactivity. The patient was treated with a sarcoma-based chemotherapy regimen and radiation to the craniospinal axis, and was found to be without recurrence or metastatic disease at 20 months.

Primary Orbital Hydatid Cyst

ABSTRACTThe authors want to highlight the importance of clinical, radiological and histopathological evaluation in unilateral proptosis. A 17-yearold male presented with left progressive nonpulsatile proptosis, lateral gaze diplopia and decreased visual acuity. It was diagnosed as orbital hydatid cyst on CT scan and MRI. The patient was successfully operated with near total recovery of the vision. Radiological investigation showed a circumscribed cystic lesion lateral to orbit separate from the lacrimal gland. Intraoperative cysts and postoperative histopathology confirmed the primary orbital hydatid cyst.Although rare there is always a possibility of a primary hydatid in patients with unilateral proptosis, restricted eye movements and lateral decreased visual acuity. This is possible even when the Casoni's test is negative. Surgical excision with postoperative albendazole is the effective treatment for the cure of disease.

Management of diplopia in patients with blowout fractures

Purpose:To report the management outcomes of diplopia in patients with blowout fracture.Materials and Methods:Data for 39 patients with diplopia due to orbital blowout fracture were analyzed retrospectively. The inferior wall alone was involved in 22 (56.4%) patients, medial wall alone was involved in 14 (35.8%) patients, and the medial and inferior walls were involved in three (7.6%) patients. Each fracture was reconstructed with a Medpore® implant. Strabismus surgery or prism correction was performed in required patients for the management of persistent diplopia. Mean postoperative follow up was 6.5 months.Results:Twenty-three (58.9%) patients with diplopia underwent surgical repair of blowout fracture. Diplopia was eliminated in 17 (73.9%) patients following orbital wall surgery. Of the 23 patients, three (7.6%) patients required prism glasses and another three (7.6%) patients required strabismus surgery for persistent diplopia. In four (10.2%) patients, strabismus surgery was performed without fracture repair. Twelve patients (30.7%) with negative forced duction test results were followed up without surgery.Conclusions:In our study, diplopia resolved in 30.7% of patients without surgery and 69.2% of patients with diplopia required surgical intervention. Primary gaze diplopia was eliminated in 73.9% of patients through orbital wall repair. The most frequently employed secondary surgery was adjustable inferior rectus recession and <17.8% of patients required additional strabismus surgery.