Limitation Of Extraocular Movements Research Articles

The Comparison Between Traditional Versus 3D Printing Combined With Computer Navigation Technique in the Management of Orbital Blowout Fractures.

Three-dimensional printing (3D printing) technology and computer navigation technology have been gradually applied in surgeries for orbital blowout fractures. This study compared the efficacy of traditional techniques (group I) and 3D printing combined with computer navigation technology-assisted techniques (group II) in the management of orbital blowout fractures. All patients treated for orbital blowout fractures in the Affiliated Hospital of Yangzhou University from March 2018 to February 2021 were reviewed. The primary predictive variable was surgical techniques used for orbital fractures (traditional techniques or 3D printing combined with computer navigation technology-assisted techniques). Outcome variables included diplopia, limitation of extraocular muscle movement, and enophthalmos orbital volume. All the surgeries were successfully performed without serious complications. Six months after the operation, the degree of diplopia and limitation of extraocular muscle movement in the traditional techniques group and 3D printing combined with computer navigation technology-assisted techniques group were significantly improved (the former Z= -2.670, P=0.008, the latter Z=-3.584, P<0.001 and the former Z=-4.852, P<0.001, the latter Z=-5.427, P<0.001, respectively). There were no significant differences in the degree of diplopia and limitation of extraocular muscle movement between the 2 groups before the operation (the former Z=-0.842, P=0.400; the latter Z=-0.567, P=0.571), and there were significant differences after the operation (the former Z=-2.773, P=0.006; the latter Z=-2.892, P=0.004), and the 3D printing combined with computer navigation technology-assisted techniques group showed an advantage over the traditional techniques group. The difference in bilateral enophthalmos and orbital volume in traditional techniques groups and 3D printing combined with computer navigation technology-assisted techniques groups was dramatically decreased (the former t=12.558, P<0.001, the latter t=12.659, P<0.001, and the former t=19.194, P<0.001, the latter t=17.770, P<0.001, respectively). There were no significant differences in bilateral enophthalmos and orbital volume between the 2 groups before the operation (the former t=-0.410, P=0.683; the latter t=0.311, P=0.756), and there were significant differences after the operation (the former t=4.081, P<0.001; the latter t=4.078, P<0.001). There were statistically significant differences in surgical time and cost between the traditional technology group and the 3D printing combined with computer navigation technology-assisted technology group (the former t=8.445, P<0.001, and the latter t=3.534, P<0.001); 3D printing combined with computer navigation technology-assisted techniques group spent more surgical time and money than the traditional techniques group. The application of 3D printing combined with computer navigation techniques in the management of orbital blowout fractures can significantly improve the accuracy and safety of the operation. 3D printing combined with computer navigation technology-assisted techniques group spent more surgical time and money.

Lateral Rectus Muscle Entrapment in Complex Orbital Fracture in a Child.

A 6-year-old boy presented with a lateral rectus muscle entrapment in a complex orbital fracture sustained during bicycle riding. He was diagnosed with a skull-base fracture with pneumocephalus and zygomatic and inferior orbital wall fractures at another hospital. The zygomatic fracture and pneumocephalus were treated conservatively. Although a detailed ocular motility examination could not be performed due to pain and inability to open the eyelid, the inferior wall fracture was surgically repaired. Postoperatively, persistent extraocular movement limitation prompted a referral to our clinic. Orbital CT imaging demonstrated a fracture at the greater wing of the sphenoid with a hypoattenuated area in the adjacent middle cranial fossa. Orbital MRI taken thereafter revealed lateral rectus and orbital fat prolapse into the middle cranial fossa, indicating entrapment of these structures through the lateral wall fracture. The incarcerated lateral rectus was released using an endoscopic transorbital approach via an upper lid crease, resulting in the recovery of extraocular movement.

Prediction of substantial closed-globe injuries in orbital wall fractures.

To determine risk factors for substantial closed-globe injuries in orbital fractures (SCGI) and to develop the best multivariate model for the prediction of SCGI. A retrospective study was performed on patients diagnosed with orbital fractures at Farabi Hospital between 2016 and 2022. Patients with a comprehensive ophthalmologic examination and orbital CT scan were included. Predictive signs or imaging findings for SCGI were identified by logistic regression (LR) analysis. Support vector machine (SVM), random forest regression (RFR), and extreme gradient boosting (XGBoost) were also trained using a fivefold cross-validation method. A total of 415 eyes from 403 patients were included. Factors associated with an increased risk of SCGI were reduced uncorrected visual acuity (UCVA), increased difference between UCVA of the traumatic eye from the contralateral eye, older age, male sex, grade of periorbital soft tissue trauma, trauma in the occupational setting, conjunctival hemorrhage, extraocular movement restriction, number of fractured walls, presence of medial wall fracture, size of fracture, intraorbital emphysema and retrobulbar hemorrhage. The area under the curve of the receiver operating characteristic for LR, SVM, RFR, and XGBoost for the prediction of SCGI was 57.2%, 68.8%, 63.7%, and 73.1%, respectively. Clinical and radiographic findings could be utilized to efficiently predict SCGI. XGBoost outperforms the logistic regression model in the prediction of SCGI and could be incorporated into clinical practice.

Primary isolated extranodal NK/T-cell lymphoma of the orbit: A case report and diagnostic dilemma

Natural killer T-cell lymphoma (NKTL) is associated with Epstein-Barr virus, a highly malignant tumor that typically arises in the nose and/or paranasal sinuses isolated orbital involvement by NKTL is extremely rare. Herein, we report a case of primary orbital NKTL in a young female patient. A 32-year-old female presented with gradually increasing painful swelling of the right eye. On examination, abaxial proptosis, inferolateral displacement of the eyeball, restricted extraocular muscle movement, and solid mass in the subconjunctival fornix and superior quadrant. The rest of the ocular and systemic examination was unremarkable. Magnetic resonance imaging with contrast of the orbit shows a lobulated mass lesion 35×30×18 mm involving the medial aspect of the right orbit extraconal and superior intraconal space extending up to the preseptal region. Informed consent and biopsy were done and sent for histopathology examination. Histopathological examination shows the spectrum of atypical lymphoid cells, indented or cleaved nuclei and pale to clear cytoplasm, few histiocytes, giant cells, and apoptotic body. To rule out lymphoma, immunohistochemistry (IHC) was advised. On IHC, tumor cells were positive for CD3, D56, CD4 focally, CD7, Ki-67–90% and negative for CD20, CD2, Tdt, PAX5, CD34, CD5, Cd8 leading to a diagnosis of extranodal NKTL of the orbit. To the best of our knowledge, around 20 cases of isolated orbital extranodal NKTL were reported in the literature review. Polymorphic lymphoid cell in a young patient often mimics the inflammatory conditions of orbit. The rarity of this tumor and inflammatory signs make it challenging to identify these tumors early.

Orbital pseudolymphoma: a benign condition mimicking malignancy

Orbital lymphomas are not a rare condition that causes systemic and ocular morbidity, in which vision loss often occurs due to compressive optic neuropathy, and whose treatment is complex, involving chemotherapy and radiotherapy. We report a 54-year-old male with protrusion of the right eye associated with mild diminution of vision for one year, limitation of extraocular movements, and a relative afferent pupillary defect with optic disc edema. Imaging revealed a well-defined soft tissue lesion filling the retro-orbital intraconal space, suggestive of orbital lymphoma. Incisional biopsy and fine needle aspiration cytology revealed the lesion to be a reactive lymphoid hyperplasia. Following the administration of oral steroids, the patient showed significant improvement. To our knowledge, a benign lesion with an aggressive presentation is rare, and histopathology plays an important role in diagnosis and management.

Eyeing risks: Navigating ophthalmic challenges in sinus surgery

This is a descriptive case report of a 25-year-old male who presented with right eye diminution of vision associated with ophthalmoplegia and strabismus following functional endoscopic sinus surgery (FESS) for deviated nasal septum. On examination, he had a large angle right exotropia with enophthalmos and restricted extra ocular movements. Pupils were dilated and fixed suggestive of optic neuropathy and fundus revealed a central retinal artery occlusion. Multimodal radiological imaging revealed optic nerve sheath hematoma, fracture of medial orbital wall and orbital floor along with medial rectus disinsertion with posterior discontinuation. Due to delayed presentation at our clinic, he was managed conservatively with intravenous and oral corticosteroids. The patient displayed mild improvement in ocular movement and vision. He was advised orbital reconstruction of the medial wall and floor for enophthalmos correction and cosmesis. Although a relatively safe procedure, FESS can result into varied orbital complications, including damage to the extraocular muscles, optic nerve and its vascular supply. This case report, to the best of our knowledge is the first of its kind to document ophthalmoplegia due to medial rectus disinsertion along with central retinal artery occlusion. It also highlights the perioperative risk factors and provides insight into the intraoperative signs to be cautious of during sinus surgeries

Diagnostic pitfalls in pediatric orbital entrapment fractures

Prompt diagnosis and management of orbital entrapment fractures in the pediatric patient have been advocated. This retrospective study analyzed a cohort of orbital entrapment fractures in pediatric patients with regard to diagnostic pitfalls, treatment and outcomes in a Level I trauma center in Germany.Based on medical records and radiological imaging, patients under the age of 18 years who presented with orbital fractures during 2009–2021 were analyzed. Overall, 125 patients presented with orbital fractures, of whom 29 patients (23.2%) had orbital entrapment fractures. The majority of patients presented with monocle hematoma (n = 23), diplopia (n = 20), and/or restricted extraocular eye movement (n = 14). While all patients with orbital entrapment fractures underwent three-dimensional imaging, 10 radiological reports (34.5%) did not include findings on orbital entrapment fractures. All patients underwent surgical exploration in less than 24 h. In 12 patients, clinical symptoms such as diplopia and restricted ocular elevation were documented upon postoperative evaluation before discharge.Considering the significant proportion of orbital entrapment fractures that are not noted on radiological imaging, prompt clinical examination should be initiated in pediatric patients at risk for orbital fractures. Urgent surgical intervention should be recommended in entrapment fractures.

A case series of surgical outcomes for orbital blowout fracture with extraocular muscle entrapment.

Although early surgical intervention to avoid muscle degeneration in patients with blowout fractures (BOFs) and extraocular muscle entrapment is recommended, there is still no gold standard for the surgical timing of extraocular muscle release. This study aimed to present our 10-year experience with surgical outcomes in BOF patients with extraocular muscle entrapment to provide supporting data for determining the surgical timing for better outcomes. We conducted a retrospective study of patients with BOFs with extraocular muscle entrapment who underwent surgery at a tertiary hospital between December 2009 and October 2019. Their demographics, causes of injury and clinical features including limitation of extraocular movement (EOM) and diplopia were collected. Patients diagnosed with BOF with extraocular muscle entrapment accounted for 3.08% (21/681) of all cases of BOFs over a 10-year period. The patients comprised 20 males and 1 female, with a median age of 17.0 years (IQR, 13-25 years). All 21 patients had diplopia preoperatively, and 20 had EOM limitations. Nausea and vomiting were observed in 5 patients (23.8%). Surgery was performed within 48 hours after injury in 19 cases (within 24 hours in 13 cases), with a median of 17.0 hours (IQR, 11-27). The median operative time was 47.5 minutes (IQR, 31.2-73.7 minutes). The median follow-up period was 9.0 months (IQR, 7-12). At the last follow-up, 4 patients still had EOM limitations and 3 had residual diplopia; however, this did not interfere with their daily activities. Early diagnosis through facial computed tomography and physical examinations and early intervention showed successful surgical outcomes of BOF with extraocular muscle entrapment.

Misplaced Intracystic Lacrimal Implant- An Unusual Cause of Failed External Dacryocystorhinostomy.

Various techniques of dacryocystorhinostomy (DCR) by an external or endonasal endoscopic approaches are in practice of ophthalmologists and otorhinolaryngologists. The purpose of this paper is to report a case of misplaced intracystic implant in the orbit following external DCR leading to persistence of watering, diplopia and visual diminution. A thirty nine year old female patient presented with recurrent left eye pain, swelling over medial side of the left eye, watering, progressive blurring of vision and diplopia after revision external DCR. The ophthalmology examination revealed bilateral decreased vision, left side restricted extraocular eye movements, sub capsular cataract. The computed tomography dacryocystograph (CT-DCG) revealed tubular foreign body in the extra-conal space abutting the medial rectus with proximal block in the nasolacrimal duct. This is the first reported case of misplaced implant following external DCR in the literature. It may be suggested that patients undergoing intracystic larimal implant shall be on close follow up for such an occurrence later for timely intervention.

THU668 Euthyroid Graves’ Ophthalmopathy: Case Series

Abstract Disclosure: S.S. Alfadl: None. A.A. Asiri: None. A.A. Jammah: None. O. Alsagheir: None. Introduction: Graves’ ophthalmopathy is an autoimmune disorder that affects the eyes, characterized by swelling, proptosis, lid lag, inflammation and eyelid retraction. A significant proportion of cases are associated with thyrotoxicosis and positive serum TSH receptor antibody tests. Case Description: We present a case series of euthyroid Graves’ ophthalmopathy in patients with a negative TSH receptor antibody. The first case is of a 37-year-old lady who was recently diagnosed with idiopathic intracranial hypertension due to history of recurrent headaches and was found on CT brain to have an incidental empty sella syndrome and findings highly suggestive of thyroid associated orbitopathy. A dedicated MRI orbit showed bilateral mild proptosis with bilateral medial and inferior recti thickening, sparing the tendinous insertion. The involved extraocular muscles show mild peripheral high T2 signals and minimal enhancement on post gadolinium images. The enlarged extraocular muscle demonstrates diffusion restriction with low Apparent Diffusion Coefficient (ADC) value. Clinically, the patient did not exhibit any symptoms of hyperthyroidism or hypothyroidism. She did not notice any changes in her eyes’ appearance, nor any changes in vision or double vision. On examination, she had mild proptosis, no restriction of extraocular movement or provoked double vision. Consequently, she was referred to Ophthalmology for further management. Investigations included a pituitary panel which did not reveal any abnormalities and a thyroid panel which revealed that she was biochemically euthyroid with a negative TSH receptor antibody test. The second case is of a 24-year-old male who is medically free and initially visited the ophthalmology clinic complaining of double vision, without any additional ophthalmic complaints. He was subsequently referred to our care to rule out thyroid eye disease. Clinically, the patient had no indications of thyroid dysfunction. Upon examination, he exhibited severe right eye proptosis with dystopia and early left eye proptosis. CT orbit showed swelling of the right-sided superior rectus, medial rectus, lateral rectus and left-sided superior rectus muscles. The left-sided superior rectus muscle was abutting the optic nerve. Nevertheless, all tendons were spared. Biochemically, he was euthyroid with unremarkable laboratory results. Conclusion: These findings provide insight into the clinical presentation of euthyroid Graves’ ophthalmopathy in patients without thyrotoxicosis or detectable circulating levels of TSH receptor antibodies. Thus, suggesting that thyroid ophthalmopathy might present earlier than Graves’ disease and even earlier than the presence of TSH receptor antibodies. We conclude that a high index of suspicion and proper follow up is recommended in similar patients for the development of Graves’s disease. Presentation: Thursday, June 15, 2023

Grease-gun injury of the orbit: two cases report and literature review

BackgroundThe grease-guns injury is an uncommon injury to the orbit. We present the twelfth and thirteenth cases of grease-gun injury to the orbit to be reported in the English language literature since 1964. Here we discus and review the presentation, investigation, and treatment of this unusual trauma.Case presentationCase 1 was a 29-year-old man who presented 1 day after a grease-gun injury of the left orbit with severe pain, marked periorbital swelling, and proptosis. Computed tomography (CT) revealed penetration of grease into his left orbit. Following surgical removal, proptosis decreased. The limitation of extraocular movement and loss of visual acuity to finger count was discovered after the initial surgery. Motility gradually returned. Visual acuity recovered after phacoemulsification, capsular tension ring and intraocular lens implantation for traumatic cataract and subluxation. Case 2 was a 6-year-old boy who was referred 2 months after a grease-gun injury for worsening swelling with sinus, necrosis and slight ptosis of the upper left eyelids. This is a case of orbital chronic inflammation from grease-gun injuries masquerading as orbital cellulitis. The imaging findings of CT and magnetic resonance imaging (MRI) are not typical. Surgical exploration and debridement was inevitable and actually relieved the symptoms.ConclusionsGrease-gun injuries can damage the orbit in different degrees. Careful history inquiry and taking is important to establish the diagnosis. Imaging examinations using CT or MRI are helpful to determine depth of trauma and foreign bodies in the orbit at diagnosis. We suggest that surgical exploration and debridement is a key step in the management.

Orbital tuberculosis presenting as proptosis: A case report

A 53-year-old male complained of gradual, painless dimness of vision with swelling of the right eye (R/E) for 15 days. Best-corrected visual acuity in R/E: Hand movement, left eye: 6/9, abaxial proptosis, restricted extraocular movements in all directions, conjunctival injection, and high intraocular pressure R/E were noted. Fundus showed pale optic disc R/E and macular exudates in both eyes. The patient was diabetic and on oral hypoglycemic agents with raised erythrocyte sedimentation rate and C-reactive protein; random blood sugar: 152 mg/dL. Magnetic resonance imaging (MRI) showed right-sided orbital abscess involving extraconal compartment extending into the right orbital apex with compression of the right optic nerve. Mantoux test was positive and computed tomography thorax was normal. Histopathology of biopsy from middle turbinate showed granulomatous inflammatory cellular lesion. The patient was started on anti-tubercular therapy. He got relieved of symptoms. Repeat MRI showed reduction in disease process.

Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level I trauma centre

ObjectifEstimer l'incidence des affections ophtalmologiques détectées lors de l'examen initial de patients en proie à une fracture orbitaire qui se sont présentés dans un centre de traumatologie de niveau I, d'une part, et les facteurs de risque connexes les plus significatifs, d'autre part. MéthodesOn a recensé, pendant une période de 2 ans, 278 fractures orbitaires chez 244 patients examinés dans un centre de traumatologie de niveau I. Le paramètre principal était l'incidence d'affections ophtalmologiques urgentes devant être traitées sans délai. Ont été enregistrés les caractéristiques démographiques des patients, leurs antécédents ainsi que les résultats de l'imagerie radiographique et de l'examen physique lors de l'examen initial et des visites de suivi. Les rapports de cotes (RC) ont été calculés avec un intervalle de confiance à 95 %. RésultatsLors de l'examen initial et des visites de suivi, 9,7 % des orbites présentaient une affection ophtalmologique. Celle-ci était urgente (syndrome orbitaire aigu et rupture du globe oculaire, notamment) chez seulement 3 patients (1,1 %); 22 patients (7,9 %) présentaient une affection semi-urgente et 4 patients (1,4 %), une affection sans caractère d'urgence. Les RC de la baisse subjective de la vision (RC = 3,5; p = 0,021), des blessures résultant de voies de fait (RC = 2,4; p = 0,036), d'un accident de travail (RC= 7,7; p = 0,004), du déficit pupillaire afférent (RC = 19,2; p = 0,017), de l'anisocorie (RC = 7,8; p = 0,001), de la limitation des mouvements extraoculaires symétriques (RC = 5,2; p = 0,003) et de la fixité pupillaire (RC = 16,9; p < 0,001) témoignent d'un lien statistiquement significatif avec la présence d'une affection ophtalmologique. En revanche, le sexe du patient, l’œil touché, l'intoxication, la prise d'anticoagulants et d'antiplaquettaires ainsi que les antécédents de chirurgie oculaire n’étaient pas associés à la présence d'une maladie ophtalmologique. ConclusionsLa plupart des fractures orbitaires ne s'accompagnent pas d'une affection ophtalmologique. La baisse subjective de la vision, les antécédents de voies de fait ou d'accident de travail et les anomalies pupillaires notées lors de l'examen étaient les principaux facteurs de risque d'affection ophtalmologique. Nos résultats mettent en lumière les éléments clés qui, relevés lors de l'examen initial, doivent inciter les premiers intervenants à consulter d'urgence un ophtalmologiste.

Likelihood of spontaneous closure of cavernous sinus dural arteriovenous fistulas based on clinical and radiological findings.

Cavernous sinus dural arteriovenous fistula (CSDAVF) is a rare condition that radiologists would encounter in their careers. We aim to describe the clinical and radiological characteristics of this condition, and to provide a management workflow. In our retrospective study, we studied 27 patients with CSDAVF from January 2007 to August 2020. Patients with direct cavernous sinus AVFs and patients with incomplete date were excluded. Clinical and radiological data were collected and analyzed. Fourteen patients were conservatively treated with spontaneous resolution while 13 patients had endovascular intervention performed. In the intervention group, seven patients had intra-cranial reflux seen on radiological imaging and six patients had clinical deterioration, hence requiring intervention. Clinically, among our patients, 21 had proptosis, 20 had conjunctiva hyperaemia, 18 had extraocular movement limitation, 13 had raised intraocular pressure, 11 had chemosis, ten had ocular pain, nine had ocular bruit, eight had headache and six had worsening visual acuity. Radiologically, a concurrence was seen between superior ophthalmic vein thrombosis and spontaneous resolution of the CSDAVF, as compared to those who underwent intervention. A paradoxical increase of ocular symptoms was seen despite a decrease of flow or stagnation of contrast in radiological imaging of CSDAVF. In our study, 52% of CSDAVF closed spontaneously. As deterioration of ocular symptoms in patients with CSDAVF might also reflect spontaneous progressive occlusion, it warrants dynamic vascular imaging to check the status of venous outflow. Patients with CSDAVF with corticovenous reflux or deterioration of visual acuity need more urgent (endovascular) treatment.

Quantitative analysis of diplopia following orbital fracture repair

Orbital fractures can result in devastating functional complications to sight and well-being, yet our understanding of functional sequelae post reconstruction is not well understood in the literature. This research retrospectively analysed the activity of a specialist orbital surgeon over five years to evaluate the incidence of, and risk factors for, debilitating complications such as diplopia and restriction of extraocular movement. Orbital fracture cases repaired between 1 January 2015 and 31 December 2019 were retrospectively analysed. Demographics, orthoptic assessment, injury classification, timing, operative details, outcomes, and complications were recorded. Preoperative and postoperative binocular single vision scores (BSV) were recorded to calculate the effect of orbital repair on residual diplopia. Of 582 patients undergoing orbital access, 472 cases of orbital wall reconstruction satisfied the inclusion criteria, of which 162 (34%) were Jaquiéry 4 or 5. Overall, 10.6% had complications, 4.9% had diplopia, and 5.7% were returned to theatre. All those with residual diplopia had had it preoperatively, and had evidence of an improvement in BSV score. Time to surgery, material, and pure orbital fractures had a significant impact on the incidence of diplopia. Defect size did not. Whilst complication rates were low we conclude that strict adherence to a defined surgical protocol, postoperative imaging, and objective assessment of postoperative function are central to maintaining these standards. Objective orthoptic analysis of patients before and after orbital repair is critical to our understanding of this pathology. Whilst preoperative prediction of the persistence of long-term diplopia currently eludes us, further research should target it.

Clinical Profile and Management Outcomes among Patients with Carotid-Cavernous Fistula.

A carotid-cavernous sinus fistula (CCF) is an abnormal communication between the internal carotid artery and/or the external carotid artery and the cavernous sinus. There is a paucity of information on the ophthalmic outcomes of endovascular treatment for CCF in the Philippines. This study aimed to describe the clinical experience of CCF in our institution in order to further our understanding of the disease. This study described the demographic profile, risk factors, and clinical features of patients with CCF, and compared the data of patients according to the type of CCF. The study discussed the changes in clinical features over time in CCF patients who chose not to undergo endovascular treatment. The study also discussed the clinical outcomes of CCF patients who underwent endovascular treatment and compared the clinical outcomes to CCF patients who did not undergo endovascular treatment. A retrospective cohort study design was performed using a medical record review of patients clinically diagnosed with CCF from January 2011 to June 2019. One hundred twenty medical records of patients diagnosed with CCF were included. Based on angiographic findings, patients were grouped according to type of CCF, with 86 patients in Group 1 or Direct CCF, 23 patients in Group 2 or Indirect CCF, and 11 patients in Group 3 or Mixed type of CCF. The patients were also grouped according to treatment, with 109 patients in Group A, or patients who did not undergo endovascular treatment, and 11 patients in Group B, or patients who underwent endovascular treatment. There was a male predominance in CCF, most occurring in the age range of 26 to 35 years. Risk factors for CCF were trauma and hypertension. Clinical features included the presence of blurring of vision, proptosis, corkscrewing of conjunctival vessels, extraocular movement limitation, diplopia, audible bruit, elevated intraocular pressure, and pulsation. Findings on Computed Tomography scan included dilated superior ophthalmic vein, proptosis, and enlarged extraocular muscles. Direct CCF (Group 1) occurred mostly in males, with mean age of 39.1 years, and with trauma as the major risk factor. Indirect CCF (Group 2) occurred mostly in females, with mean age of 52.1 years, and with hypertension as the major risk factor. Regardless of the type of CCF, patients who did not undergo endovascular treatment can exhibit spontaneous improvement or worsening of clinical features. Patients who underwent endovascular treatment generally had favorable clinical outcomes, manifesting as either improvement or no worsening of features. There were minimal ophthalmic complications associated with treatment. Endovascular treatment is safe and effective in the improvement of visual acuity, corkscrewing of conjunctival vessels, amount of proptosis, extraocular movement limitation, diplopia, and presence of audible bruit.

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.

Are Severe Forms of Thyroid Eye Disease Common in the Indian Population? Clinical Characteristics of 136 Patients from a Tertiary Eye Care Centre.

Considerable evidence of gender, ethnicity, thyroid dysfunction, and environmental factors including smoking influencing the development and progression of thyroid eye disease (TED). Cross-sectional study of the clinical characteristics of 136 patients with TED who presented to the Orbit and Oculoplasty services at a tertiary eye care center in south India between October 2018 and June 2020. Among the 136 patients (M: 61, F: 75), the mean age was 47.04 (SD ± 13.24) years. Hyperthyroid disease was present in 53%, hypothyroid disease in 40%, and 7.3% were euthyroid. Active disease was noted in 25% and inactive disease in 75% of patients. Active disease was present in 25% of hyperthyroid, 18.5% of hypothyroid, and 15% of euthyroid patients. Active TED showed statistically significant association toward development of greater severity of proptosis (P = 0.001), optic neuropathy (P = 0.004), and extraocular movement restriction (P < 0.001) as compared to inactive disease. Mild, moderate to severe, and sight-threatening TED was noted in 34.6%, 59.6%, and 6% of patients, respectively. Nine eyes had dysthyroid optic neuropathy, of which eight had either mild or no proptosis while one had moderate to severe proptosis. Prevalence of active as well as severe thyroid eye disease is common in our population. Recommendation for ophthalmological examination of patients even with milder disease especially when associated with decreased vision and signs of inflammation. Active disease is less common in euthyroid patients, thus necessitating maintaining the euthyroid status toward reducing disease activity and progression.

COVID-19 disease presenting as orbital cellulitis – A case series

Coronavirus infection most commonly presents with mild influenza-like symptoms. The most common ocular presentation is conjunctivitis. We report four patients of COVID-19 infection presenting as orbital cellulitis. They all were incidentally found COVID-19 positive on reverse transcription polymerase chain reaction. All had painful edema of eyelids, extraocular movement restriction, and other symptoms of orbital cellulitis at presentation. Three of 4 had uncontrolled diabetes and one had coronary artery disease. Proven mucormycosis was present in two patients; cerebral involvement (abscess and stroke in 1 each) in two patients. Two of them died, one underwent orbital exenteration and one developed hemiplegia due to stroke. COVID can present as orbital cellulitis and carries a very grave prognosis.

Retrobulbar hemorrhage with occult globe rupture – A sinister confluence

Orbital compartment syndrome following blunt trauma is typified by an acute onset of proptosis and tight orbit, with retrobulbar hemorrhage (RBH) being the principal cause. A 9-year-old boy with blunt trauma to the left eye presented with sudden onset of pain and dramatic visual loss. Visual acuity was documented as perception of light. Examination revealed ecchymosis of eyelids, hemorrhagic chemosis, complete restriction of extraocular movements, exposure keratopathy, and relative afferent pupillary defect. A hazy view of the fundus revealed a normal optic disc. Although features favored RBH, the absence of “tight orbit” invoked suspicion. Computed tomography unveiled a hematoma in the superonasal aspect of the orbit with tenting of posterior aspect of the globe and altered globe contour, suggesting posterior globe rupture. This case highlights that an occult globe rupture should be suspected in traumatic proptosis with a “not so tight” orbit.