Orbital Soft Tissue Research Articles

Evaluation of the navigation system for orbital wall reconstruction in unilateral orbital fractures

To evaluate the efficiency of navigation system for orbital wall reconstruction in unilateral orbital fractures. Fifteen patients (7 male and 8 female) with unilateral orbital fracture underwent orbital reconstruction with the help of intraoperative navigation system. The average age was 34.3 ± 9.5 years. All patients underwent spiral CT scanning preoperatively, and the CT data was imported to the BrainLab navigation system (Germany, BrainLab company). The orbit of the intact side was mirrored to the opposite side as the reference for pre-operative planning. The titanium mesh was mounted on the resin template made by rapid prototyping machine based on the mirrored CT data. When the injury was limited, the hydroxyapatite sheet was used for the orbital wall reconstruction. During the operation, the real-time navigation helped to ensure precise placement. The re-establishing result was assessed based on the postoperative CT data with the following four variables: the volumetric difference between the bilateral orbit, the volume of the herniated soft tissue, the global projection and the discrepancy between the simulated and the achieved position of the reconstructed orbital wall. The reconstructive discrepancy was measured only in the titanium plate grafting cases. There were no serious complications such as infection, graft rejection and optic nerve injury in any case. Preoperatively, the average degree of enophthalmos was (3.5 ± 1.6) mm, the average volumetric difference between the injured and the unaffected orbit was (4.5 ± 1.8) ml, and the average volume of the herniated orbital soft tissue was (2.1 ± 0.7) ml. Postoperatively, the three values were respectively reduced to (1.3 ± 0.6) mm, (1.8 ± 0.9) ml and (0.7 ± 0.3) ml. The discrepancy of the medial and inferior wall were (2.5 ± 0.6) mm and (2.1 ± 0.4) mm. The intraoperative use of navigation system for the orbital wall reconstruction in unilateral orbital fractures can provide reliable accuracy and achieve satisfactory results.

Tetanus following ocular wooden foreign body in incompletely vaccinated patient: a case report

Tetanus is now encountered rarely in clinical practice. There were no reported cases of tetanus due to ocular injuries in Sri Lanka. We report of a case of tetanus following an ocular injury which can be at least partly attributed to the disruption of immunization programmes due to political unrest. A 13 year-old Sri Lankan Tamil schoolgirl who had a splinter prick injury to left orbit was treated for intraorbital abscess and orbital cellulites. She developed clinical tetanus while on intravenous antibiotics. Following intensive care and ventilatory support she achieved an uncomplicated recovery. Ocular injury is a rare cause of tetanus worldwide. Adequate debridement of orbital soft tissue injuries can be difficult and demanding. Even in countries with high immunization coverage, tetanus can still occur due to lapses in immunization with conflict and war.

Customized Orbital Floor Soft Tissue Retractor

For the correction of blow out fractures of the orbit, the retraction of orbital floor contents are necessary. We are here in presenting a customized orbital floor soft tissue retractor to overcome the disadvantages of the conventional Rows orbital floor retractor.

Subcaruncular Approach for the Reconstruction of Blowout Fractures of Medial Orbital Walls

To obtain a wide and clean operative field for anatomic reconstruction of medial orbital blowout fractures, an alternative method called the subcaruncular approach has been performed. Between March 2008 and June 2010, this method was applied to the orbits of 41 patients with isolated pure medial orbital blowout fractures. A medial half conjunctival incision was made and extended meticulously to the subcaruncular area through preseptal plane under direct vision. Pre- and postoperative computed tomographic scans and ophthalmic examinations were performed, and clinical results were assessed. Postoperatively, computed tomographic scans revealed anatomic reduction of orbital soft tissues and the reconstructed medial orbital wall to be in proper position in all cases, and diplopia and eyeball motility limitation were resolved in most patients. There were no complications except severe chemosis in one case. We believe that this method can be a useful alternative option for the anatomic reconstruction of medial orbital blowout fractures.

Acute post-surgical bilateral orbital gas-producing infection — a case report and literature review

The presence of visible gas on radiography, computed tomography (CT), or magnetic resonance imaging (MRI) is associated with various pathological conditions, ranging from severe infections caused by gas-producing organisms to cutaneous and subcutaneous tissue disruption that allows an interface with the air [1]. A high index of suspicion surrounds the finding of gas because of the virulence of conditions such as gas gangrene and necrotizing fasciitis [1–12]. Gas dissecting into the orbital soft tissues as a result of bacterial activity is a rapidly progressive, extremely serious, life-threatening ophthalmological emergency [1–12]. Gas gangrene (myonecrosis) and necrotizing fasciitis can cause necrosis of tissues and systemic shock with multiorgan failure, sometimes within a matter of hours [1–3, 13]. It is well known that the usual causative organisms in gas-producing infection from a contaminated wound are clostridial species: Clostridium perfringens accounts for the majority of cases (over 80 %), while most other cases are caused by other Clostridium species [1–3]. Clostridial infection is always associated with necrosis, and very often associated with poor functional and anatomical outcome [1–4]. However, a variety of other non-clostridial organisms, both aerobes and anaerobes, may also produce infections in which gas is demonstrable: Escherichia coli, Proteus species, Pseudomonas aeruginosa, Bacteroides, Klebsiela pneumoniae, Prevotella species, Staphylococcus aureus, Peptostreptococcus species, Fusobacterium species, and Streptococcus pyogenes are only the species reported most often in the literature [2]. Non-clostridial infections may take various forms, which lead to difficulties in making accurate and prompt diagnoses and are also related to the confusion between gas gangrene and various (bacterial and nonbacterial) lesions that simulate gas gangrene. Aside from the fact that non-clostridial organisms usually involve subcutaneous tissues, they may also involve muscle and simulate clostridial myonecrosis [2, 3]. However, non-clostridial gas infections accompanied by gangrene are not very common, even in immunosuppressed individuals [2, 3]. Since the initial report by Chiari (1893), which concerned a non-clostridial gas-forming infection due to a colon bacillus in the gangrenous lower limb of a diabetic patient [4], fewer than 40 cases of non-clostridial gas-forming infections have been described. Only four such cases have been described in the orbit [5–7, 12], and these are quite different from the present case. With regard to the pathogenesis of gas bubbles of clostridial or non-clostridial etiology, they are liberated by the bacterial fermentation of glucose [4]. In addition, impaired microcirculation may also contribute to gas formation [3, 4]. It is also necessary to mention the benign, non-infectious presence of gas in the orbit, which is known as orbital emphysema. Orbital emphysema is a well-known entity that can arise from nose-blowing, tumor presentation, or after fractures of the orbital floor, and may be self-induced in psychiatric patients [15]. There are no research contracts or any kind of financial support (grants) for this study. No authors have any conflicts of interest.

Orbito-Ocular Soft Tissue Measurements in Young Adults—An Indigenous Negro Population Study

Aim: This study was named at determining normal orbital soft tissue parameters in young adults in an indigenous black population.Methodology: Prospective study on consentimg young adults in a Nigerian University with no previous orbito-facial trauma/surgery, strabismus, ptosis, telecanthus, and history of neurological diseases or previous ocular trauma were excluded. The age, sex and height of each participant were recorded. With the aid of a manual Sliding Vernier Caliper, the inner canthal distance (ICD), outer canthal distance (OCD), right horizontal palpebrae fissure length (RHPFL), left horizontal palpebrae fissure length (LHPFL). The results were imputed, analyzed and reported as simple frequency, means and standard deviations using the SPSS version 11 and statistical significant accepted at P < 0.05.Results: Two hundred and four of participants of which 136 (66.7%) were males constituted the study population. Their ages ranged between 17–38 years with a mean and standard deviation of 23.6 ± 3.2 years. Their height ranged from 1.43–1.94 m with a mean and standard deviation of 1.70 ± 0.81 m. The mean and standard deviation for OCD, ICD, RHPFL and LHPFL were 99.6 ± 5.5 mm, 36.5 ± 3.3 mm, 32.5 ± 1.8 mm and 31.7 ± 1.9 mm, respectively. The range and mean ICD (28.2–45.4 mm and 36.5 mm) is greater than the range and mean palpebrae fissure lengths in either eye. Statistcally significant gender based differences were recorded in the mean OCD and ICD with higher values in in males.Conclusion: Normal soft tissue orbit-ocular parameters are presented for young adults in the population showing statistically significant mean larger values for males compared with female subjects.

Response to Dr McNab

Sir, We thank Dr McNab1 for his comments on our report of isolated eyelid edema in Melkersson–Rosenthal Syndrome (MRS).2 He suggests that our cases are better considered examples of acne rosacea, and cites his own study3 and the case report of Lai et al4 in support of this. In Dr McNab's case series, histopathological examination of eyelid skin from five patients with a clinical diagnosis of acne rosacea and chronic eyelid edema showed some degree of granulomatous inflammation in three specimens.3 The granulomas were not illustrated but were described as ‘poorly formed' (case 4), ‘single' (case 11) and ‘surrounding dilated lymphatics' (case 15). Lai et al4 also referred to the presence of ‘ill-defined perivascular granulomas' but did not illustrate them. Other studies of chronic eyelid edema in rosacea did not mention dermal granulomas.5, 6 In none of our cases was rosacea felt to be the primary underlying cause, either clinically or histopathologically. In our practice, we do not regard poorly defined granulomas as indicative of any specific diagnosis. Granulomatous rosacea is typically characterised by a tuberculoid (necrotising) or sarcoid-like response, possibly to the contents of hair follicles. In our series, the granulomas were neither tuberculoid nor sarcoid-like but were sharply defined, perivascular, and perilymphatic, often with an intralymphatic component. In addition, and illustrated in our paper, discrete granulomas were identified in orbicularis muscle and anterior orbital soft tissue, which does not appear to have been described in rosacea. Dr McNab may be correct in saying that MRS is over diagnosed in cases of isolated eyelid edema.1 Nevertheless, the clinico-pathological pattern that we and other authors have ascribed to monosymptomatic MRS appears quite distinct. Until our understanding of the etiology and pathogenesis of oro-facial granulomatosis, of which MRS is one part, increases, we see no justification for regarding these cases as a form of granulomatous rosacea.

Morphometry of the Orbital Region Soft Tissues in Down Syndrome

The orbital region of subjects with Down syndrome (DS) has been scanty described so far. We wanted to detail the morphologic characteristics of the soft tissue orbital region in Italian and North Sudanese subjects with DS. The three-dimensional coordinates of 10 landmarks on the orbital soft tissues were obtained using computerized anthropometry in 53 Italian and 64 North Sudanese subjects with DS aged 4 to 52 years, and in 461 (Italian) and 682 (North Sudanese) sex- and age-matched controls. From the landmarks, linear distances, ratios, areas, and angles were calculated, z scores computed, and compared by t-tests and analyses of covariance. In North Sudanese DS subjects, intercanthal width and height-to-length ratio were increased; biorbital width, eye height, length, and area were reduced. Eye fissure and orbital inclinations relative to Frankfort plane were reduced, whereas orbital inclinations versus the true horizontal were increased. In Italian DS men, orbital height and height-to-length ratio were increased, eye length was decreased; orbital inclination versus the true horizontal was increased. For almost all measurements, a significant effect of age was found. No effects of sex were found. Ethnic group influenced orbital height, area, and orbital inclination versus Frankfort plane. All paired measurements had similar discrepancies on both sides. The orbital soft tissues of North Sudanese DS subjects differed from those of their reference subjects, but this was only partially true for Italian subjects. The 2 ethnic groups had different alterations in their soft tissue orbital regions that were influenced by age, but not by sex.

Niezwykłe izolowane złamanie dna oczodołu typu „blow-out” powikłane rozległą rozedmą podskórną: opis przypadku i przegląd piśmiennictwa.

Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event. A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired. Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.

A Case of Successful Conservative Management of Multiple Facial Bone Fractures in an Infant

Displaced facial fractures in infants are rare, with only limited published data, and management of such fractures remains controversial. Various authors have advocated managing severely displaced fractures by open reduction and rigid fixation. We describe our experience in successfully managing a case of multiple fractures of facial bones in an infant by conservative observation. A 17-month-old boy sustained multiple facial fractures in a car accident. A CT scan revealed a severely displaced left zygomatic fracture and an undisplaced mandibular angle fracture. There was no orbital floor defect with entrapment of orbital soft tissue. The patient was managed by conservative observation and the outcome was satisfactory. There was complete remodeling of the severely displaced zygomatic fracture. To our knowledge, there are few or no reports on the management of severe facial fractures in infants by conservative observation. The present case suggests the wisdom of deciding the treatment method for facial fractures in infants only after careful observation and consideration.

Severe Graves' Ophthalmopathy After Percutaneous Ethanol Injection in a Nontoxic Thyroid Nodule

Percutaneous ethanol injection (PEI) is used to treat cystic or mixed benign thyroid nodules. This treatment can result in rare complications, and three cases of Graves' disease (GD) without Graves' ophthalmopathy (GO) have been reported after PEI treatment of toxic thyroid adenomas. Here we present a 55-year-old male patient who developed GD and severe GO after PEI treatment of a mixed cystic-solid, nontoxic thyroid nodule. Six months after PEI, the nodule volume had decreased from 8.9 to 3.0 mL, but we observed severe hyperthyroidism with elevated serum free triiodothyronine, free thyroxine, and thyrotropin receptor antibody levels. We also observed ophthalmopathy with symmetrical orbit and soft tissue involvement (grade b/c) and a clinical activity score of 4/7. The diagnosis of GO was confirmed by bilateral corneal damage, increased intraocular pressure on upgaze, and inconstant diplopia. A computed tomography scan showed that the inferior, medial, and superior extraocular muscles were bilaterally enlarged, the perineural space at the orbital cone was slightly reduced and the ophthalmic vein was congested. A cause-effect relationship between PEI and GD/GO was likely in this patient because of the temporal sequence. Although the mechanism was unknown, we speculated that the thyroid tissue damage caused by PEI released a large amount of antigenic materials from follicular thyroid cells, including thyrotropin receptor protein, which triggered the autoimmune inflammatory response against the thyroid itself and the orbital soft tissues. The patient did not have any risk factors for either GD or GO. This observation raises the concern, therefore, that unpredictable and severe complications, such as GD and GO, may occur in a few patients treated with PEI.

Orbital Non Hodgkin Lymphomas. Features and Evolution of 63 Patients From Two Oncological Centers in Buenos Aires, Argentina: Marie Curie Hospital and Henry Moore Institute

Abstract 5201Orbital Non Hodgkin Lymphoma (NHL) represents 2 to 5% of extranodal NHL and 8 to 11% of orbital tumors. Published reports usually comprise a reduced number of patients.Out of a total of 668 extranodal NHL treated in the period 1991–2010, the orbital locations accounted for 63 patients (10.6%).This high value is due to selected referral from ophthalmologic centers. The diagnosis was made by cytology or surgical biopsy and immunohistochemistry. Staging included CT or MRI of the orbit and brain and bone marrow biopsy. Results:Age range:17 to 86 years (mean 60), only 5 < 40 years. The ratio M/F: 1/0.9.Location:right orbit: 50%,left: 36%, bilateral: 14%. Conjunctiva: 44.5%, orbit soft tissue: 23.8%, eyelid: 22.2%, lachrymal gland: 9.5%.Initial symptoms: orbital tumor: 47.6%, proptosis: 26.9%, ptosis: 11.1%, eyelid edema: 6.3%, diplopia: 4.7%, epiphora: 3.2%.Histology subtypes: MALT: 50.8%, lymphocytic: 30.1% LDGCB: 6.3%, follicular 6.3%, lymphoplasmacytic: 4.7%, angiocentric T: 1.6%. Time to diagnosis was above 12 months in 63.5%.Treatment in 49 patients (77.7%). Chemotherapy (CT) (CVP, CHOP, CLB) plus radiotherapy (RT) in 57,14 %, CT in 28.57%, radiotherapy: 12.24%, Rituximab:.28% (12.24% + QT, 2.04% alone).Complete remission (CR) was obtained in 87.77% and PR in 12.23%. Relapse in 16 (32.65%), local homo-or contralateral 9 (56.25%), systemic 6 (37.50%), 1 (6.25%) in breast (MALT). Died in progression: 4 (25%). The 46,93% of patients had survivals of 5 to 10 years, and 12.5% 11 to 15 years. ConclusionsThe outstanding features are: presentation in 5* to 6* decade, low grade subtypes, initial symptoms: painless mass and proptosis, prevalent location in conjunctiva and eyelid. Is remarkable the delay until diagnosis, due to its low frequency and low specificity of the initial symptoms. The high rate of complete remission obtained with chemotherapy and radiotherapy in frontline and relapse and prolonged survival, are characteristics that determine the good prognosis of this location of extranodal NHL. Disclosures:No relevant conflicts of interest to declare.

Open Reduction in Trapdoor-Type Blowout Fractures Using Absorbable Mesh Plates

In many cases of trapdoor-type orbital blowout fracture, the bony segment has a stable hinge consisting of a greenstick fracture and the sinus mucoperiosteum that is attached to the intact orbital wall. If the displaced bony segment opposite the hinge will be reduced into its original position and will be fixed onto the unaffected bone, the orbital fracture may be reconstructed via the internal fixation of the bony segment itself rather than requiring substitution with an alloplastic implant or a bone graft. A retrospective study was conducted from January 2008 to February 2010 in 34 patients with blowout fracture, via retrospective chart review, including detailed preoperative and postoperative evaluations, age, sex, symptoms, and signs, and based on the postoperative complications. The subciliary, transconjunctival, and transcaruncular approaches were used to expose the orbital floor under general anesthesia. The herniated orbital soft tissue was carefully reduced. The displaced bony segment was carefully pulled up and placed in its original anatomic position with a skin hook. A small absorbable mesh plate was inserted between the normal orbital wall and the bony segment, tangential to the edge of the bony defect at the dependent portion. Postoperative examinations such as the traction and forced duction tests showed no eye movement limitation and surgical complications. During the follow-up period, no complications occurred, and the orbital wall was accurately reconstructed in its original anatomic position, as confirmed by postoperative computed tomography scans. The advantages of internal fixation include anatomic reconstruction of the orbital wall, preservation of the original orbital bone and the mucoperiosteum of the sinus resulting in rapid wound healing and normal mucus drainage function of the sinus, simplicity of the procedure, and the absence of surgery-related complications. This technique is presented as one of the preferred treatments for trapdoor-type orbital blowout fracture.

In vitro kinetics of delivery of tobramycin and ofloxacin from osmotic hydro gel expanders

High-hydrophilic osmotic self-inflating hydro gel expanders are well-accepted for implantation to achieve tissue expansion in defined parts of the body like skin, breast and orbital soft tissue. To prevent post-implantation infections effective antibiotic prophylaxis might be helpful. The suitability of this hydro gel consisting of a co-polymer of N-vinyl-pyrolidone and methyl-methacrylate as a drug delivery system for antibiotics was investigated in a laboratory setting simulating the orbit in a newborn. In a first setting the dry expanders were incubated in a 0.3% solution (5 ml) of tobramycin and ofloxacin for 24 h (n = 10 for each substance, adsorbing 2.4 ml of the 0.3% solution, i.e. 7,200 μg antibiotic). Addressing the release of both antibiotics, the concentrations in 15 ml elution medium (0.9% sodium chloride, renewed after every sampling) were measured after 0.25, 1, 2, 6, 24, 48 and 72 h of elution. To simulate the clinical use in a second setting the expanders were dried after incubation in a 0.3% and 0.03% solution of tobramycin (n = 5 for each concentration) before measuring the release. The cumulative amount of tobramycin released after 72 h reached 7,157 μg, i.e. 99% of the initially loaded antibiotic. The cumulatively released amount of ofloxacin was 5,505 μg (76% of loading dose). Main fraction of release (about two thirds) was detected for both antibiotics for a elution period 0 - 24 h. In the periods 24 - 48 and 48 - 72 h the released amount of tobramycin was significantly higher than for ofloxacin. The release from expander dried after loading tobramycin was comparable: The cumulatively released amount of 0.3% and 0.03% incubation solution was 99% and 79% of loading dose, respectively. The investigated hydro gel expanders soaked in antibiotic solution can store and further on release sufficient amounts of tobramycin or ofloxacin to produce antimicrobial effective concentrations in vitro in the surrounding environment according to the breakpoints reported by EUCAST [14]. This principle, when used in a clinical setting, might help to eliminate post-implantation infection, which is one of the major complications in clinical use.

Densities of Orbital Fat and Extraocular Muscles in Graves Orbitopathy Patients and Controls

To investigate CT densities of orbital soft tissue volumes in patients with Graves orbitopathy (GO) and to compare these with the densities of controls. Observational case series. Of 95 patients with GO and 150 controls, soft tissue volumes, mean densities, and ratios of fat volume to orbital volume and muscle volume to orbital volume were calculated with software. The 95% confidence intervals of the controls were used as reference values. The densities were plotted against age and volume ratios. For statistical analysis SPSS 16.00.2 was used. p values were calculated with the following tests: analysis of variance, Pearson correlation, Kruskal-Wallis, Mann-Whitney, and linear regression. The main outcome measurements were differences in orbital soft tissue densities. In GO patients the mean orbital fat density was significantly higher than in controls (p ≤ 0.001) and independent of age (p = 0.23). The mean extraocular muscle density of GO patients was within the range of controls and did not decrease with age (p = 0.16) as it did in controls (p ≤ 0.001). Mean fat density increased with decreasing fat volume (p = 0.001). Mean extraocular muscle density increased slightly with increasing muscle volume (p = 0.09). Muscle density correlated with fat density in both controls and GO patients. Orbital fat density in GO patients is significantly higher than in controls and negatively correlated to fat volume but positively correlated to muscle volume and muscle density.

Pediatric Orbital Fractures

The clinical presentation and management of pediatric orbital fractures have many unique features that differentiate them from orbital injuries encountered in the adult population. An understanding of the particular anatomic and mechanical properties of pediatric orbital bone and soft tissue helps to explain most of these differences. This article reviews the epidemiology, anatomy, growth implications, pathomechanics, particular clinical features, assessment, and surgical management of pediatric orbital fractures.

Oncocytic carcinoma of the nasolacrimal duct treated by transnasal endoscopic resection

Malignancies of the nasolacrimal apparatus are rare lesions that usually originate from the lacrimal sac. To the best of our knowledge, this is the first case of a primary oncocytic carcinoma of the nasolacrimal duct reported in the literature. A 43-year-old woman presented with a 3-month history of right epiphora. At nasal endoscopy, an exophytic lesion occupying the right inferior meatus was visible. Imaging studies showed an expansile lesion involving the nasolacrimal duct and the inferior meatus, but not invading the orbit or adjacent soft tissues. A biopsy was suggestive for an oncocytic lesion. A radical resection was obtained through an endoscopic extended medial maxillectomy with a definitive diagnosis of oncocytic carcinoma. Forty-two months after surgery there was no evidence of disease. In selected malignant lesions of the nasolacrimal duct not involving the adjacent soft tissues or lacrimal sac, an exclusive endoscopic approach can be considered.

The value of CT in the diagnosis of ocular trauma

Objective To evaluate CT examination in ocular trauma in the clinical application.Methods The data of 52 cases ( 84 eyes) of emergency CT examination of patients with ocular trauma was retrospectively analysed. Results CT examination of 52 cases ( 84 eyes ) were found abnormalities, including the orbital and intraocular foreign body, orbital bone fracture, orbital soft tissue injury, lens dislocation, lens extrusion, deformation and compound eye damage. Conclusions CT is the preferred method of examination for clinical ldiagnosis of ocular trauma and provide an important basis for surgery. Key words: Ocular trauma; computed tomography

Hypertensive choroidopathy in Castleman's disease

Castleman’s disease is a lymphoproliferative disorder characterized by angiofollicular lymph node hyperplasia [1]. Clinically, it is classified into localized and the multicentric types. In localized type, the disease is usually confined to one site and is rarely associated with systemic findings. The multicentric type is associated with generalized lymphadenopathy and concomitant systemic symptoms. The etiology and pathogenesis of Castleman’s disease remains unclear today. Reported ocular involvement of Castleman’s disease includes optic disc infiltration, choroidal infiltration and serous retinal detachment [2]. Orbital involvement such as bilateral enlargement of lacrimal gland and localized orbital soft tissue mass has also been reported [3]. In literature, there was one reported case of bilateral serous retinal detachment and punctate retinal pigment epithelium (RPE) epitheliopathy due to direct tumorous choroidal involvement [4], which was demonstrated histopathologically in another case report of a 69-year-old man with lymphadenopathy and bilateral choroidal infiltrates [5]. We herein report a patient with Castleman’s disease who, during the course of the disease, developed hypertensive choroidopathy mimicking direct tumor involvement of choroid.

EBV-Positive Extranodal Marginal Zone Lymphoma of Mucosa-associated Lymphoid Tissue in the Posttransplant Setting

The 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues defines monomorphic posttransplant lymphoproliferative disorders (M-PTLDs) as lymphoid or plasmacytic proliferations that fulfill the criteria for one of the B-cell or T/NK-cell neoplasms recognized in immunocompetent patients. However, indolent B-cell lymphomas, such as extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), are specifically excluded from this category. In this study, we describe the clinicopathologic features of 4 posttransplant lymphoma-like proliferations that were Epstein-Barr virus (EBV) positive, but were otherwise completely typical for a MALT lymphoma. The 4 patients (age, 12 to 71 y) had received solid organ transplants (2 hearts, 1 kidney, 1 kidney/pancreas) at a median of 116 months before presentation, and had been maintained on varying immunosuppressive regimens that included cyclosporine, azathioprine, tacrolimus, and sirolimus. Three of the 4 patients presented with solitary subcutaneous masses, whereas the fourth patient presented with a solitary orbital soft tissue mass. All the 4 cases were morphologically typical for MALT lymphoma, demonstrated plasmacytic differentiation with IgA heavy chain restriction (3 cases κ positive, 1 case λ positive), and were diffusely EBV-encoded small RNA positive. Patients were followed for a median of 44.9 months, and all achieved a complete response following various regimens that included reduced immunosuppression with or without antiviral therapy, local surgical excision, rituximab, or local radiation therapy. The uniform EBV positivity and response to immune reconstitution in some cases suggest that EBV-positive MALT lymphomas arising in the posttransplant setting should be included among PTLDs. Whether their distinctive subcutaneous/soft tissue localization and IgA positivity are uniform features will require identification of additional cases.