Residual Diplopia Research Articles

Analysis on the complications of Medpor repairment for the orbital blowout fracture

Objective To analyze the complications after orbital reconstruction with Medpor repairment for the treatment of orbital blowout fracture. Methods The data of 18 patients with complications after orbital reconstruction with Medpor were analyzed retrospectively. Results All cases were unilateral orbital blowout fracture.The visual acuity decreased significantly in 1 case, residual diplopia occurred in 5 cases, endophthalmos was undercorrection in 5 cases, eyeball deviation occurred in 2 cases, zygomatic cheek occurred in 2 cases, secondary dacryocystitis occurred in 2 cases and eyelid ectropion occurred in 1 case. The causes of postoperative complications of orbital reconstruction with Medpor repairment for orbital blowout fracture were related to the degrees of fracture injury process, location, operation time, doctor’s surgical techniques and experience. Conclusion The complications can be reduced or be avoided and the success rate of the operation will be improved with standardized surgical approach, timely detection and treatment measures. Key words: Fracture, blowout, orbital; Medpor; Surgery, repairment; Cause, complication

Comparison of clinicoradiological findings between patients with recovering diplopia and those with residual diplopia after surgery for pure orbital blowout fracture

PurposeDiplopia is a common symptom of blowout fracture (BOF), and can persist after proper surgical management. We compared clinicoradiological findings between patients with recovering diplopia and those with residual diplopia after surgery for orbital BOF. Materials and methodsWe retrospectively evaluated the CT images of 170 patients with orbital BOF and preoperative diplopia. We reviewed the following factors: sex, age, mechanism of injury, presence of diplopia before surgery, presence of enophthalmos before surgery, presence of an ocular motility abnormality before surgery, time interval between the trauma and surgery, fracture type, fracture size, volume of herniated orbital soft tissue, ratio of the volume of herniated orbital soft tissue to fracture size, number of points of contact between the extraocular muscle (EOM) and bony edge, EOM swelling, EOM swelling ratio, EOM displacement, EOM circling, EOM tenting, and EOM entrapment.The associations between the presence of diplopia 6 months after surgical repair and various clinicoradiological findings were analyzed using Wilcoxon rank-sum tests, Student's t-tests, Fisher's exact tests for univariable analysis, and logistic regression analysis for multivariable analysis. A Kaplan–Meier curve and log-rank test were used to identify the recovery status from diplopia. ResultsThe following findings were significantly different between patients with recovering diplopia and those with residual diplopia on univariable analysis (p < 0.05 for each): patient age, EOM entrapment, EOM circling, and EOM tenting. Multivariable analyses showed that patients who were older or those who had EOM circling or tenting on CT images had a greater probability of residual diplopia after surgery [p-values: 0.006, 0.013, and <0.001, respectively; odds ratio (95% confidence interval): 1.035 (1.010–1.061), 14.809 (1.775–123.556), and 4.851 (2.069–11.375), respectively]. The recovery rate for diplopia was significantly different between patients with EOM tenting and those without (p = 0.02). Additionally, young patients (0–12 years) showed a shorter recovery time from diplopia compared with older patients (>24 years) (p < 0.05). ConclusionPatients with residual diplopia after surgical management have different clinicoradiological findings compared with patients with recovering diplopia. Patients who are older, or those who have circling or tenting of the EOM on CT scans, are more likely to have residual diplopia.

The clinical course of diplopia associated with zygomaticomaxillary complex fractures before and after surgery

ObjectiveDiplopia is a common complaint following zygomaticomaxillary complex (ZMC) fractures. The present study was conducted to evaluate the prevalence of post-traumatic as well as port-operative diplopia, and the improvement of diplopia over time before and after surgery. MethodsA retrospective case series of diplopia associated with ZMC fractures was conducted to address the research purpose. Only subjects with isolated unilateral ZMC fractures were included. Demographic variables included age and gender of the patients. The primary outcome variable of this study was the presence of diplopia during different periods before and after surgery. Descriptive statistics were conducted for all variables studied. Analytical statistics were performed to measure the significance of change in the outcome variable during different stages of treatment. ResultsIn total, 231 patients were included, with a mean age of 23.78 (±5.11) years. Post-traumatic diplopia was diagnosed in 59% of patients. Only 13% of cases had pre-operative diplopia. Post-surgical diplopia was reported in 37% of cases. Post-operative follow-up diplopia showed a significant improvement over time with only 1 patient having residual diplopia 6 months after surgery. ConclusionsTraumatic diplopia in unilateral ZMC fractures is common. However, a significant resolution of diplopia over time should be expected. Residual diplopia is an unlikely outcome.

Lateral rectus muscle resection following maximal recession of the medial rectus muscle in thyroid eye disease

Rectus muscle restriction is a common finding in thyroid eye disease (TED). Typically, restricted muscles are recessed to address strabismus and diplopia. However, some patients have residual strabismus following maximal recession of a restricted muscle. The purpose of this study was to report outcomes following resection of the lateral rectus muscle after maximal recession of the medial rectus muscle in patients with TED. The medical records of patients with TED who underwent lateral rectus resection between 1998 and 2015 were reviewed retrospectively. Information regarding thyroid disease history and surgical treatment, including history of orbital decompressions, rectus muscle recessions, rectus muscle resections, and pre- and postoperative alignment was collected. Adjustable suture was used in all cases. Success was defined as a postoperative orthotropia with ≤2Δ of phoria at distance and a phoria at near. A total of 11 patients were included. Of these, 10 (91%) required postoperative adjustment. A successful outcome was achieved in 10 cases (91%). Lateral rectus muscle resection to address residual esotropia and diplopia was effective at reducing residual esotropia following medial rectus recession in our study cohort.

Late Complication of a Silicone Implant Thirty Years after Orbital Fracture Reconstruction.

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Single-stage soft tissue reconstruction and orbital fracture repair for complex facial injuries

Orbital fractures with open periorbital wounds cause significant morbidity. Timing of debridement with fracture repair and soft tissue reconstruction is controversial. This study focuses on the efficacy of early single-stage repair in combined bony and soft tissue injuries. Retrospective review. Twenty-three patients with combined open soft tissue wounds and orbital fractures were studied for single-stage orbital reconstruction and periorbital soft tissue repair. Inclusion criteria were open soft tissue wounds with clinical and radiographic evidence of orbital fractures and repair performed within 48h after injury. Surgical complications and reconstructive outcomes were assessed over 6 months. The main outcome measures were enophthalmos, pre- and post-CT imaging of orbits, scar evaluation, presence of diplopia, and eyelid position. Enophthalmos was corrected in 16/19 cases and improved in 3/19 cases. 3D reconstruction of CT images showed markedly improved orbital alignment with objective measurements of the optic foramen to cornea distance (mm) in reconstructed orbits relative to intact orbits of 0.66, 95% confidence interval [CI] (lower 0.33, upper 0.99) mm. The mean baseline of Stony Brook Scar Evaluation Scale was 0.6, 95%CI (0.30-0.92), and for 6 months, the mean score was 3.4, 95%CI (3.05-3.73). Residual diplopia in secondary gazes was present in two patients; one patient had ectropion. Complications included one case of local wound infection. An early single-stage repair of combined soft tissue and orbital fractures yields satisfactory functional and aesthetic outcomes. Complications are low and likely related to trauma severity.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury.

Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described. This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded. Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25-80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1-5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively. Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Predictive factors for residual diplopia after surgical repair in pediatric patients with orbital blowout fracture.

This study aimed to evaluate the clinical prognosis of diplopia and identify factors that are potentially predictive of residual diplopia postoperatively in pediatric patients with orbital blowout fracture. This was a retrospective study of clinical data from 135 children and adolescents less than 18 years of age who were diagnosed with orbital blowout fractures between January 2008 and June 2014 in the Department of Ophthalmology. A Kaplan-Meier curve and log-rank statistics were used to identify the recovery status from diplopia. Univariate and multivariate Cox proportional hazards analyses were conducted to identify the characteristics associated with residual diplopia. Recovery from diplopia was rapid and obvious within 1 year after surgical repair; nearly 80% of the patients were cured of diplopia at that time point, according to the curve. Approximately 85% of the patients would completely recover from diplopia over time, and the remaining patients would most likely have residual diplopia. Multivariate analysis demonstrated that patient age (p<0.001), the time interval between injury and surgery (p<0.001) and preoperative muscle swelling (p=0.028) were factors predictive of residual diplopia. Early intervention in pediatric patients with orbital blowout fracture is recommended to reduce the rate of residual diplopia. Swelling of the ocular muscle and younger age may result in a prolonged recovery time and a lower recovery rate from diplopia after surgery. The recovery from diplopia in pediatric patients appears to be stable 1 year after surgical repair. Therefore, a follow-up time of at least 1 year is recommended for an overall evaluation of residual diplopia in children.

The clinical characteristics and therapeutic effect of "white-eyed" blowout orbital fracture in children

Objective To investigate the clinical characteristics and surgical efficacy of ( without obvious ecchymosis of conjunctiva and eyelid) blowout fracture in children. Methods The clinical data of 59 patients with blowout orbital fractures, aging 3-18 years old, were retrospectively analyzed. The follow-up time was 6-9 months after the repair surgery for fracture. Results Fifty-nine (54.1%) cases had blowout orbital fracture in 109 children with orbital fractures. The main causes were accidental tumble, assault and car accident. Diplopia was noted in 56 patients accounting for 94.9%, ocular-heart reflex including nausea and vomiting was in 30 patients accounting for 50.1% and ocular motility muscle limitation was in all the patients. There were statistically significant differences in the grading constituent ratios of ocular dyskinesia between the primary position and different scales of ocular motilities (P=0.00). Proved by CT scan, the inferior orbital wall fracture was the most type and occurred in 45 cases (76.3%). Children aging less than 14 years old were more likely to have the inferior orbital wall fracture accounting for 85.0%, which was more than that 57.9% of children aging 14-18 years old (P=0.02). The final visiting was at 6-9 months after the surgery. Twenty-five cases (42.4%) had full ocular motilities and no diplopia. Twenty-four cases (40.7%) had residual diplopia only in peripheral visual field. Ten cases (16.9%) remained diplopia in the primary and reading position though ocular movements improved a lot. There were statistically significant differences in the constituent ratios of binocular single vision among the cases who underwent the surgery at different surgical time (P=0.03). The patients (71.4%) who underwent prompt orbital surgeries within 5 days after initial trauma appeared to have better ocular movement and binocular single vision. Conclusion White-eyed blowout orbital fracture frequently occurs in children and mainly involves the inferior orbital floor. The most important characteristics of white-eyed blowout orbital fracture include symptomatic diplopia with restricted ocular movement, ocular-heart reflex and soft tissue entrapment confirmed by CT scan. The patients who underwent prompt surgeries within 5 days had better ocular movement and binocular single vision. Key words: Orbital fracture, blowout, white-eyed, children; Ocular-heart reflex; Ocular movement; Diplopia

Analysis of complications after orbital reconstruction with Medpor implantation for the orbital blowout fracture

Objective To analyze the causes of complications after orbital reconstruction with high density porous polyethylene (Medpor) for the repair of orbital blowout fracture. Methods A retrospective analysis of patients with orbital blowout fracture treated with Medpor in our department was carried out. Results In 232 cases after postoperative follow up of 3 months, the visual function decreased significantly in 2 cases, endophthalmos was undercorrection in 7 cases, residual diplopia was observed in 2 cases and implant displacement was detected in 1 case. Conclusion There are many kinds of complications after orbital reconstruction with Medpor implantation for blow-out fracture of orbital floor wall, such as vision loss, enophthalmos, diplopia exacerbation, infection, and so on. The causes are related to the degrees of fracture, location, doctor's skill and experience, and postoperative functional training. The key points for successful repair of orbital fracture include effective prevention, correct analysis of causes and timely treatment. Key words: Blowout fracture, orbital; Medpor; Surgery, reconstrution; Effect, undesirable

The Role of Computer-Assisted Technology in Post-Traumatic Orbital Reconstruction: A PRISMA-driven Systematic Review.

Post-traumatic orbital reconstruction remains a surgical challenge and requires careful preoperative planning, sound anatomical knowledge and good intraoperative judgment. Computer-assisted technology has the potential to reduce error and subjectivity in the management of these complex injuries. A systematic review of the literature was conducted to explore the emerging role of computer-assisted technologies in post-traumatic orbital reconstruction, in terms of functional and safety outcomes. We searched for articles comparing computer-assisted procedures with conventional surgery and studied outcomes on diplopia, enophthalmos, or procedure-related complications. Six observational studies with 273 orbits at a mean follow-up of 13 months were included. Three out of 4 studies reported significantly fewer patients with residual diplopia in the computer-assisted group, while only 1 of the 5 studies reported better improvement in enophthalmos in the assisted group. Types and incidence of complications were comparable. Study heterogeneities limiting statistical comparison by meta-analysis will be discussed. This review highlights the scarcity of data on computer-assisted technology in orbital reconstruction. The result suggests that computer-assisted technology may offer potential advantage in treating diplopia while its role remains to be confirmed in enophthalmos. Additional well-designed and powered randomized controlled trials are much needed.

Diplopia of pediatric orbital blowout fractures: a retrospective study of 83 patients classified by age groups.

Orbital blowout fractures are relatively rare in patients under 18 years of age, but may lead to serious complications. We conducted this retrospective study to evaluate diplopia, clinical characteristics, and postoperative results in cases of orbital blowout fractures in the pediatric population.Eighty-three patients, all less than 18 years old, with orbital blowout fractures, were divided into 3 groups by age: 0 to 6 years old, 7 to 12 years old, and 13 to 18 years old. The cause of injury, fracture locations, diplopia grades, ocular motility restrictions, enophthalmos, and postoperative results were reviewed from their records. Chi-square tests, Fisher's exact analyses, analyses of variance, and logistic regressions were performed to determine characteristics associated with diplopia, and to identify factors related to residual diplopia in pediatric patients.The most common causes of injuries were traffic accidents in the 0 to 6 years old group, normal daily activities in the 7 to 12 years old group, and assaults in the 13 to 18 years old group. Floor fractures were the most common location in both the 0 to 6- and 7 to 12 years old groups, and medial-floor fractures were the most common location in the 13 to 18 years old group. The occurrence of preoperative diplopia was related to ocular motility restriction and enophthalmos, but not with the age group, the gender, the cause of injury, or the fracture locations. The time interval from injury to surgery was significant in the outcome of postoperative diplopia (P < 0.01). A statistical difference was also found in the recovery time from diplopia among the 3 age groups (P < 0.01).The characteristics of orbital blowout fracture varied among the different age groups. It was related to 2 factors, the cause of injury and fracture locations, which probably resulted from structural growth changes and differences in daily habits. Children had a slower recovery from orbital fractures, and the younger the patient, the longer it took for recovery from diplopia after surgery.

Double seronegative myasthenia gravis with low density lipoprotein-4 (LRP4) antibodies presenting with isolated ocular symptoms

The detection of low density lipoprotein-4 (LRP4) antibodies in double seronegative (dSN) myasthenia gravis (MG) patients has provided new insights in the diagnosis and treatment of MG. However, there are limited data regarding the clinical presentation and treatment response in dSN MG patients with LRP4-antibodies. We present a case series of three Caucasian dSN MG patients with positive LRP4-antibodies sharing a common ethnic background that presented with isolated ocular symptoms (MGFA I). The demographic and clinical characteristics, the diagnostic work-up as well as the treatment response during a follow-up period of 12–24 months are described in detail. All patients were treated successfully with acetylcholinesterase inhibitors (AcheI) and prednisone with two exhibiting full remission of their symptoms, while the remaining exhibited mild residual diplopia. Notably, we documented no signs of generalized disease progression, while no patient required immunosuppressive treatment. In conclusion, the distinct clinical phenotype of our patients highlights the clinical relevance of screening for LRP4-antibodies in patients presenting with isolated ocular MG independent of age and gender, since it may lead to the timely diagnosis of MG and prompt initiation of effective therapy with ACheI and corticosteroids.

Treatment of rectus recession-suspension on posterior sclera surgery for restrictive strabismus in thyroid associated ophthalmopathy

To evaluate the oblique angle, diplopia and stereoacuity before and after rectus recession-suspension on posterior sclera surgery in patients with restrictive strabismus caused by thyroid associated ophthalmopathy (TAO). Data from 18 patients (19 eyes) with restrictive strabismus caused by TAO, who underwent rectus recession-suspension on posterior sclera surgery from July 2010 to June 2013 in Xiangya Hospital, Central South University, were analyzed retrospectively. Eight patients (8 eyes) or 5 patients (5 eyes) with hypotropia were operated with inferior rectus recession or superior rectus recession. Two patients (2 eyes) with esohypertropia or 3 patients (4 eyes) with esotropia were operated with inferior rectus recession plus medial rectus recession or medial rectus recession. Two patients (1 hypotropia, 1 esotropia) underwent orbital decompression surgery before strabismus surgery. All patients were performed rectus recession-suspension on posterior sclera surgery, and the oblique angle, diplopia view and stereopsis test were examined before and after the operation. All patients were followed up for more than 6 months. The preoperative prism were 20(Δ)- 80(Δ) and postoperative prism were 2(Δ)-10(Δ). There was diplopia on the primary position before surgery in 16 patients. After surgery, the diplopia in 14 patients disappeared on the primary and 15° down gaze, and 2 patients had not diplopia on the primary position but residual diplopia on inferior field. Two patients had stereopsis before surgery, and the numbers of patients raised to 14 after surgery. Compared with pre-operation, changes of the above measured indexs in post-operation were significant difference (all P<0.05). The rectus recession-suspension on posterior sclera surgery is effective to improve oblique angle and diplopia in restrictive strabismus caused by TAO, which can improve patient's living quality.

Extraocular muscle injury during endoscopic sinus surgery: a series of 10 cases at a single center.

Extraocular muscle (EOM) injury is a rare but serious complication of endoscopic sinus surgery (ESS). The aim of this study is to describe the clinical characteristics and course of EOM injury occurring during ESS. Retrospective case series. Medical records and CT images of patients who suffered from EOM injury after ESS between 2006 and 2012 were retrospectively reviewed. Patient demographics, endoscopic anatomy, type of surgery (primary or revision), predisposing risk factors, site and extent of injury on CT imaging, and associated complications were evaluated. In addition, data regarding ophthalmologic management and clinical outcomes were collected. Ten patients with EOM injuries after ESS were included in this study. One patient was undergoing revision ESS. All patients sustained medial rectus muscle injury and one patient suffered concurrent ipsilateral inferior rectus muscle injury. A microdebrider was used in nine cases. Right-sided injury (90% of patients) was more prevalent than left-sided injury, and 70% of injured medial rectus muscles were completely transected. After subsequent strabismus surgery, 8/9 patients regained binocular single vision in primary gaze despite residual diplopia in some gaze positions. Although proper ophthalmologic surgery after EOM injury may improve deviation in the primary gaze position, none of the patients regained normal EOM movement. Therefore, prevention of this complication through adequate surgical technique and precautions is important.

Symptomatic excyclotorsion following inferior transposition of both medial rectus muscles in patients with bilateral trochlear nerve palsy

To report the development of a large degree of excyclotorsion following inferior transposition of the medial rectus muscles in 5 patients with bilateral acquired trochlear nerve palsies that had previously undergone bilateral modified Harada-Ito procedures. The medical records of 5 patients who had undergone Harada-Ito procedure for bilateral trochlear nerve palsy between 2002 and 2010 and medial rectus muscle infraplacement surgery between 2004 and 2012 were retrospectively reviewed. All 5 patients underwent a Fells-modified Harada-Ito procedure. All remained symptomatic due to a V pattern (eso- or exodeviation). Bilateral inferior transposition of the medial rectus muscles of either half or full tendon width was performed to alleviate this residual diplopia. The vertical transposition resulted in a symptomatic large degree of excyclotorsion (mean of 20°), which required reversal of the procedure. After inferior transposition of both medial rectus muscles in patients with bilateral superior oblique palsy who previously had bilateral modified Harada-Ito surgery, a large excyclotorsion (>20°) can occur. This can be managed by reversing the medial rectus transposition procedure.

Medpor porous polyethylene implants in orbital blowout fracture repair

Objective To evaluate the efficacy of Medpor porous polyethylene implants in orbital blowout fracture repair.Methods 67 eyes of 67 cases with orbital blowout fractures underwent surgical repair with Medpor implants.Data about the degree of exophthalmos,motility and diplopia followed up for 6 months to 2 years were collected.Results Before surgery,the difference of exophthalmos between damaged and undamaged eyes was 1.0-8.0 mm,average (3.6 ± 1.4) mm.The difference was statistically significant(t =19.884,P =0.001).The difference of exophthalmos between before and after surgery on damaged eyes was 0.0-7.0 mm,average (3.2 ± 1.4) mm,The difference was statistically significant (t =19.192,P =0.000).There were 65 eyes combined with restriction of passive movement of the eye,and different degrees of diplopia before surgery.Of these 65 eyes,60 eyes had normal motility without diplopia at 3 months after surgery;5 cases still had residual diplopia outside 30° central visual field which would not affect daily life.Conclusion Medpor porous polyethylene implants in orbital blowout fracture repair is safe,effective and reliable. Key words: Medpor, polyethylene, porous ; Fracture, blowout, orbital ; Surgery, reconstuction

Results of diplopia and strabismus in patients with severe thyroid ophthalmopathy after orbital decompression

Purpose:It has been frequently stated that the orbital decompression, in patients with thyroid ophthalmopathy, does not usually improve extraocular muscles function and that after the operation there is often a deterioration of these functions. The purpose of this article is evaluation of extraocular muscles function after applying personal method of 3 wall orbital decompression.Materials And Methods:Retrospective review of case records of 119 patients with severe thyroid ophthalmopathy seen and treated by the author between December 1986 and December 2010. All patents underwent 3 wall orbital decompression combined with removal of the periorbital, intraorbital and retrobulbar fat. Correction of coexistent eyelid retraction and deformities were also performed.Results:Comparison of preoperative and postoperative results was conducted in 65 patients three months after 3 wall decompression. All patients showed a significant reduction of exophthalmos [5-11 mm, 7.2 mm on average], reduction of intraocular pressure, marked improvement in ocular muscle function as well as considerable reduction in or disappearance of subjective symptoms. There were no cases of subsequent impairment of ocular motility. Strabismus surgery was performed in 6 patients with residual diplopia. There was an improvement in vision in 68% patients who had impaired vision before the operation. Less evident relapse of exophthalmos was recorded in 3 cases only and only one patient required unilateral reoperation.Conclusion:It can be concluded that this method of orbital decompression is logical, based on an understanding of the pathology, has less complication rates, is relatively easy to perform, gives very good functional and aesthetic long term results and allows rapid recovery.

Extraocular muscle injury during endoscopic sinus surgery: A series of 10 cases at a single center

Extraocular muscle (EOM) injury is a rare but serious complication of endoscopic sinus surgery (ESS). The aim of this study is to describe the clinical characteristics and course of EOM injury occurring during ESS. Retrospective case series. Medical records and CT images of patients who suffered from EOM injury after ESS between 2006 and 2012 were retrospectively reviewed. Patient demographics, endoscopic anatomy, type of surgery (primary or revision), predisposing risk factors, site and extent of injury on CT imaging, and associated complications were evaluated. In addition, data regarding ophthalmologic management and clinical outcomes were collected. Ten patients with EOM injuries after ESS were included in this study. One patient was undergoing revision ESS. All patients sustained medial rectus muscle injury and one patient suffered concurrent ipsilateral inferior rectus muscle injury. A microdebrider was used in nine cases. Right-sided injury (90% of patients) was more prevalent than left-sided injury, and 70% of injured medial rectus muscles were completely transected. After subsequent strabismus surgery, 8/9 patients regained binocular single vision in primary gaze despite residual diplopia in some gaze positions. Although proper ophthalmologic surgery after EOM injury may improve deviation in the primary gaze position, none of the patients regained normal EOM movement. Therefore, prevention of this complication through adequate surgical technique and precautions is important.

Ocular Manifestations and the Clinical Course of Carotid Cavernous Sinus Fistulas in Asian Patients

Purpose: To study the clinical course with regard to both the angiographic and visual outcomes of carotid cavernous fistulas (CCFs).Background: Carotid cavernous sinus fistulas (CCFs) are conditions which often present with ocular signs and symptoms. The clinical presentation of CCFs is varied according to the anatomy, haemodynamics and size of the CCF. CCFs causing significant symptoms or vision loss should be treated with embolization.Methods: This is a retrospective review of the medical records of all CCF cases seen in the Singapore National Eye Centre from September 2002 to December 2011.Results: 45 patients who had confirmed CCF on conventional cerebral angiography were included. Anterior draining CCFs presented with orbital congestion while posterior draining CCFs presented with pain, diplopia and cranial nerve palsies. Mild residual symptoms were still present in 85% of treated direct CCFs despite complete angiographic closure however 52% of treated dural CCFs had complete resolution of symptoms despite only half of those achieving angiographic closure. Treated and untreated dural CCFs had similar outcomes (87% versus 76% recovered or improved (p > 0.05)). Poor outcomes can result from residual diplopia or vision loss from complications of the CCF itself (e.g. compressive optic neuropathy, glaucoma, retinopathy) or complications from CCF embolization treatment (e.g. central retinal artery occlusion).Conclusion: Presenting symptoms and signs are related to the angiographic drainage of CCFs. Angiographic outcomes after embolization treatment may not always correlate with clinical outcomes.