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Echinococcus Cysts of the Orbit and Substernum
676
AMERICAN JOURNAL OF OPHTHALMOLOGY
polyglactin (Vicryl) are used to accomplish this, and the skin is closed with 6-0 silk sutures. (The reason for incorporating the suborbicularis fas cia to the eyelid crease is to cover the levator aponeurosis with suborbicularis fascia and thereby to prevent a high crease from forming.) Lowering of an elevated eyebrow by the de scribed technique has been successful in three patients with unilateral brow elevation secon dary to trauma (two cases; Figure) or sinus surgery (one case). The brow has remained in a satisfactory position for more than a year in all cases. There has been no superior orbital nerve injury or other complications. However, the procedure does have the drawback of not being able to help lower an elevated nasal brow be cause the dissection has to be carried out tem poral to the supraorbital nerve. There also have been several cases of initial puckering of the skin at the suture sites, but this has resolved spontaneously.
November, 1994
the patient a month before the eye complaint. Her visual acuity was 20/20 in both eyes; applanation tensions were within normal lim its. Hertel exophthalmometry disclosed a 5mm proptosis at 22 mm in the right eye, and 17 mm in the left eye, with a base diameter at 100 mm. The right eye was pushed down and out with markedly limited upward gaze. Slit-lamp examination showed hyperemic conjunctiva and punctate epitheliopathy of the cornea in the right eye. Results of ophthalmoscopic ex amination were within normal limits. The pa tient also had a 3 x 3-cm suprasternal mass, deep to the sternocleidomastoid muscle (Fig. 1, top). Abdominal ultrasonography showed a nor-
References 1. Stasior, O. G., and Lemke, B. N.: The posterior eyebrow fixation. Adv. Ophthalmic Plast. Reconstr. Surg. 2:1/93, 1983. 2. McCord, C. D., and Doxanas, M. T.: Browplasty and browpexy. An adjunct to blepharoplasty. Plast. Reconstr. Surg. 86:248, 1990. 3. Bowman, C. B., Tanenbaum, M., and McCord, C. D.: Internal browlift. Browplasty and browpexy. In Putterman, A. M. (ed.): Cosmetic Oculoplastic Surgery, ed. 2. Philadelphia, W. B. Saunders, 1993, pp. 140-152.
Echinococcus Cysts of the Orbit and Substernum Abd El-Nasser Awad Mohammad, M.D., Courtney J. Ray, M.D., and Zeynel A. Karcioglu, M.D. Department of Ophthalmology, Assuit University (A.E.A.M.); and Department of Ophthalmology, Tulane University (A.E.A.M., C.J.R., Z.A.K.). Inquiries to Zeynel A. Karcioglu, Μ.Ό., Department of Ophthalmology, Tulane University Medical Center, 1430 Tulane Ave., Rm. 5016, New Orleans, LA 701122699. A 15-year-old girl with progressive right proptosis came to the Ophthalmology Clinic at Assuit University in Assuit, Egypt. Anterior neck swelling on the right side was noticed by
Fig. 1 (Mohammad, Ray, and Karcioglu). Top, Right proptosis and suprasternal swelling caused by hydatid disease. Bottom, Axial computed tomography depicting a unilocular cystic mass compressing on the globe and the medial orbital wall.
Vol. 118, No. 5
Letters to The Journal
mal-sized liver with a 2-cm intraparenchymal cystic area near its posterior capsule. Comput ed tomography disclosed a well-defined, unilocular cystic mass, which occupied the right orbit superomedially, encroaching on the medi al wall (Fig. 1, bottom). Excision of the suprasternal lesion disclosed a 3 x 3-cm cystic mass (Fig. 2, top). The histopathologic examination of the cyst demonstrat ed an outer, acellular laminated membrane sur rounded by a dense fibrous capsule. The
Fig. 2 (Mohammad, Ray, and Karcioglu). Top, Gross photograph of the suprasternal hydatid cyst showing multiple layers of its wall. Bottom, Scolex of E. granulosus identified from the spun fluid of the orbital cyst. The hooklets are seen in the upper right of the photograph (unstained, x 400).
677
acellular membrane was strongly positive with the periodic acid-Schiff reaction. Smears of the luminal fluid from the cyst contained a large number of scoleces typical of Echinococcus granulosus (Fig. 2, bottom). A few months later, the orbital cyst was excised through an anteromedial approach. The cyst was ruptured during surgery and the fluid was aspirated immediately. Following the aspi ration, a complete excision of the ectocyst was accomplished and the operative field was thor oughly irrigated. The structure of the orbital cyst was the same as the structure of the supra sternal cyst, but without the fibrous capsule. Postoperatively, the patient was given systemic corticosteroids; the inflammatory reaction in the orbit was mild and without any sign of recurrence after 24 months of follow-up. Although systemic hydatid disease may be common in endemic regions such as the Middle East and East Africa, orbital hydatid disease is rare, comprising less than 1% of all cases. Most cases occur in children and young adults, with more than 50% between the ages of 10 and 39 years. 1 It can be caused by E. granulosus, E. multilocularis (an organism ranging over the north and central United States), or E. oligoarthusP Hydatid disease is most commonly encoun tered in the liver (60% to 70%) and lungs, but may spread hematogenously by way of the inferior vena cava into the systemic circulation and settle in multiple extrahepatic sites. 2 Once in the orbit, most lesions lay within the muscle cone. 3 The diagnosis of orbital hydatid disease is suggested with signs and symptoms of a unilat eral orbital space-occupying mass, such as gradual progressive proptosis and diminished extraocular motility. Eosinophilia is present in approximately 25% of cases. 4 Computed tomographic findings usually include a hypodense, nonenhancing, often unilocular (but occasion ally multilocular) cystic lesion, well delineated by a thin capsule that may or may not show enhancement with contrast studies. 4,5 Magnetic resonance imaging discloses ι low intensity signal on Τ,-weighted images and a high inten sity signal on T 2 -weighted images. 5 Microscopic examination of the cyst fluid demonstrating daughter cysts with scoleces is diagnostic. In our case, the patient had clinical and radiologie signs consistent with hydatid disease with intrahepatic intramuscular and orbital in volvement. Microscopic examination of the as pirate containing scoleces established the diag-
678
AMERICAN JOURNAL OF OPHTHALMOLOGY
nosis. The surgical approach to excise the cyst intact was attempted but not accomplished be cause of technical difficulties. Although others have reported seeding, recurrence, severe orbit al inflammation, postoperative anaphylaxis, and optic atrophy, our patient tolerated the operation well with mild postoperative reaction and no signs of recurrence two years after the procedure. 3,5 The ultrasonographically demon strated cystic area within the liver did not enlarge in size but showed increased calcifica tion in repeat studies.
References 1. Jain, G. C, Gupta, A. P., Purohit, B. N., Lodha, S. K., and Jain, S.: Hydatid cyst of orbit. An unusual cause of proptosis. Ind. Pediatr. 20:605, 1983. 2. Schantz, P. M.: Echinococcosis. In Steele, J. H. (ed.): Parasitic Zoonoses. Boca Raton, Florida, CRC Press, 1983, pp. 231-277. 3. Morales, A. G., Croxatto, J. O., Crovetto, L., and Ebner, R.: Hydatid cysts of the orbit. A review of 35 cases. Ophthalmology 95:1027, 1988. 4. Alparslan, L., Kanberoglu, K., Peksayar, G., and Cokyüksel, O.: Orbital hydatid cyst. Assessment of two cases. Neuroradiology 32:163, 1990. 5. Lerner, S. F., Gomez Morales, A., and Croxatto, J. O.: Hydatid cyst of the orbit. Arch. Ophthalmol. 109:285, 1991.
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 81/2 x 11-inch bond paper with ll/2-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Pupillary Block During Cataract Surgery EDITOR: In the article, "Pupillary block during cata ract surgery," by S. A. Updegraff, G. A. Peyman, and M. B. McDonald (Am. J. Ophthal mol. 117:328, March 1994), the authors reviewed an entity that we previously reported in our description of multilamellar hydrodis
November, 1994
section. 1 Although their second case illustrates this phenomenon of pupillary block associated with hydrodissection, we believe their first case is incorrectly characterized. In our initial cases using multilamellar hy drodissection, we occasionally experienced ep isodes of sudden iris prolapse caused by sharp increases in intraocular pressure. We thought the cause was entrapment of the injected fluid in the posterior chamber, specifically within the capsule and between the iris and the lens; this fluid increased pressure in the posterior chamber (and in the eye in general) and hydraulically forced the iris anteriorly toward the incision. As we noted, this problem was partic ularly associated with highly retentive viscoelastic agents (that is, those with low pseudoplasticity). Updegraff, Peyman, and McDonald speculat ed that the cause is an O-ring-type seal pro duced by viscoelastic agent trapped between the anterior capsule and posterior iris surface. Although this may be the case, we believe that the cause could be any form of pupillary block. We suspect that a large volume of viscoelastic agent retained in the anterior chamber me chanically obstructs fluid flow from the poster ior to anterior chambers, compresses the iris against the lens, or both. We have also seen this occur when hydrodissecting through the side-port incision in the absence of viscoelastic agent; in this situation the self-sealing incision traps aqueous in the anterior chamber, which prevents sufficiently rapid escape of injected fluid from the posterior chamber. In the second case of Updegraff, Peyman, and McDonald, the mechanical disruption of iris-lens apposition equalized pressures in the anterior and posterior chambers, and the intra ocular pressure became normal. In their first case, however, after posterior depression of the lens, the anterior chamber remained shallow and the globe was "firm to the touch." The failure of intervention to alleviate the pressure increase is inconsistent with either the authors' or our proposed mechanism for the develop ment of pupillary block. We believe that the primary problem in this case was the choroidal effusion or hemorrhage that was later noted on B-scan ultrasonography. The increase of intravitreal pressure by the increased choroidal vol ume produced the shallow anterior chamber and firm globe and responded as expected to the reduction in posterior segment pressure from the pars plana vitrectomy. The choroidal effusion might have resolved by the time of
AMERICAN JOURNAL OF OPHTHALMOLOGY
polyglactin (Vicryl) are used to accomplish this, and the skin is closed with 6-0 silk sutures. (The reason for incorporating the suborbicularis fas cia to the eyelid crease is to cover the levator aponeurosis with suborbicularis fascia and thereby to prevent a high crease from forming.) Lowering of an elevated eyebrow by the de scribed technique has been successful in three patients with unilateral brow elevation secon dary to trauma (two cases; Figure) or sinus surgery (one case). The brow has remained in a satisfactory position for more than a year in all cases. There has been no superior orbital nerve injury or other complications. However, the procedure does have the drawback of not being able to help lower an elevated nasal brow be cause the dissection has to be carried out tem poral to the supraorbital nerve. There also have been several cases of initial puckering of the skin at the suture sites, but this has resolved spontaneously.
November, 1994
the patient a month before the eye complaint. Her visual acuity was 20/20 in both eyes; applanation tensions were within normal lim its. Hertel exophthalmometry disclosed a 5mm proptosis at 22 mm in the right eye, and 17 mm in the left eye, with a base diameter at 100 mm. The right eye was pushed down and out with markedly limited upward gaze. Slit-lamp examination showed hyperemic conjunctiva and punctate epitheliopathy of the cornea in the right eye. Results of ophthalmoscopic ex amination were within normal limits. The pa tient also had a 3 x 3-cm suprasternal mass, deep to the sternocleidomastoid muscle (Fig. 1, top). Abdominal ultrasonography showed a nor-
References 1. Stasior, O. G., and Lemke, B. N.: The posterior eyebrow fixation. Adv. Ophthalmic Plast. Reconstr. Surg. 2:1/93, 1983. 2. McCord, C. D., and Doxanas, M. T.: Browplasty and browpexy. An adjunct to blepharoplasty. Plast. Reconstr. Surg. 86:248, 1990. 3. Bowman, C. B., Tanenbaum, M., and McCord, C. D.: Internal browlift. Browplasty and browpexy. In Putterman, A. M. (ed.): Cosmetic Oculoplastic Surgery, ed. 2. Philadelphia, W. B. Saunders, 1993, pp. 140-152.
Echinococcus Cysts of the Orbit and Substernum Abd El-Nasser Awad Mohammad, M.D., Courtney J. Ray, M.D., and Zeynel A. Karcioglu, M.D. Department of Ophthalmology, Assuit University (A.E.A.M.); and Department of Ophthalmology, Tulane University (A.E.A.M., C.J.R., Z.A.K.). Inquiries to Zeynel A. Karcioglu, Μ.Ό., Department of Ophthalmology, Tulane University Medical Center, 1430 Tulane Ave., Rm. 5016, New Orleans, LA 701122699. A 15-year-old girl with progressive right proptosis came to the Ophthalmology Clinic at Assuit University in Assuit, Egypt. Anterior neck swelling on the right side was noticed by
Fig. 1 (Mohammad, Ray, and Karcioglu). Top, Right proptosis and suprasternal swelling caused by hydatid disease. Bottom, Axial computed tomography depicting a unilocular cystic mass compressing on the globe and the medial orbital wall.
Vol. 118, No. 5
Letters to The Journal
mal-sized liver with a 2-cm intraparenchymal cystic area near its posterior capsule. Comput ed tomography disclosed a well-defined, unilocular cystic mass, which occupied the right orbit superomedially, encroaching on the medi al wall (Fig. 1, bottom). Excision of the suprasternal lesion disclosed a 3 x 3-cm cystic mass (Fig. 2, top). The histopathologic examination of the cyst demonstrat ed an outer, acellular laminated membrane sur rounded by a dense fibrous capsule. The
Fig. 2 (Mohammad, Ray, and Karcioglu). Top, Gross photograph of the suprasternal hydatid cyst showing multiple layers of its wall. Bottom, Scolex of E. granulosus identified from the spun fluid of the orbital cyst. The hooklets are seen in the upper right of the photograph (unstained, x 400).
677
acellular membrane was strongly positive with the periodic acid-Schiff reaction. Smears of the luminal fluid from the cyst contained a large number of scoleces typical of Echinococcus granulosus (Fig. 2, bottom). A few months later, the orbital cyst was excised through an anteromedial approach. The cyst was ruptured during surgery and the fluid was aspirated immediately. Following the aspi ration, a complete excision of the ectocyst was accomplished and the operative field was thor oughly irrigated. The structure of the orbital cyst was the same as the structure of the supra sternal cyst, but without the fibrous capsule. Postoperatively, the patient was given systemic corticosteroids; the inflammatory reaction in the orbit was mild and without any sign of recurrence after 24 months of follow-up. Although systemic hydatid disease may be common in endemic regions such as the Middle East and East Africa, orbital hydatid disease is rare, comprising less than 1% of all cases. Most cases occur in children and young adults, with more than 50% between the ages of 10 and 39 years. 1 It can be caused by E. granulosus, E. multilocularis (an organism ranging over the north and central United States), or E. oligoarthusP Hydatid disease is most commonly encoun tered in the liver (60% to 70%) and lungs, but may spread hematogenously by way of the inferior vena cava into the systemic circulation and settle in multiple extrahepatic sites. 2 Once in the orbit, most lesions lay within the muscle cone. 3 The diagnosis of orbital hydatid disease is suggested with signs and symptoms of a unilat eral orbital space-occupying mass, such as gradual progressive proptosis and diminished extraocular motility. Eosinophilia is present in approximately 25% of cases. 4 Computed tomographic findings usually include a hypodense, nonenhancing, often unilocular (but occasion ally multilocular) cystic lesion, well delineated by a thin capsule that may or may not show enhancement with contrast studies. 4,5 Magnetic resonance imaging discloses ι low intensity signal on Τ,-weighted images and a high inten sity signal on T 2 -weighted images. 5 Microscopic examination of the cyst fluid demonstrating daughter cysts with scoleces is diagnostic. In our case, the patient had clinical and radiologie signs consistent with hydatid disease with intrahepatic intramuscular and orbital in volvement. Microscopic examination of the as pirate containing scoleces established the diag-
678
AMERICAN JOURNAL OF OPHTHALMOLOGY
nosis. The surgical approach to excise the cyst intact was attempted but not accomplished be cause of technical difficulties. Although others have reported seeding, recurrence, severe orbit al inflammation, postoperative anaphylaxis, and optic atrophy, our patient tolerated the operation well with mild postoperative reaction and no signs of recurrence two years after the procedure. 3,5 The ultrasonographically demon strated cystic area within the liver did not enlarge in size but showed increased calcifica tion in repeat studies.
References 1. Jain, G. C, Gupta, A. P., Purohit, B. N., Lodha, S. K., and Jain, S.: Hydatid cyst of orbit. An unusual cause of proptosis. Ind. Pediatr. 20:605, 1983. 2. Schantz, P. M.: Echinococcosis. In Steele, J. H. (ed.): Parasitic Zoonoses. Boca Raton, Florida, CRC Press, 1983, pp. 231-277. 3. Morales, A. G., Croxatto, J. O., Crovetto, L., and Ebner, R.: Hydatid cysts of the orbit. A review of 35 cases. Ophthalmology 95:1027, 1988. 4. Alparslan, L., Kanberoglu, K., Peksayar, G., and Cokyüksel, O.: Orbital hydatid cyst. Assessment of two cases. Neuroradiology 32:163, 1990. 5. Lerner, S. F., Gomez Morales, A., and Croxatto, J. O.: Hydatid cyst of the orbit. Arch. Ophthalmol. 109:285, 1991.
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 81/2 x 11-inch bond paper with ll/2-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Pupillary Block During Cataract Surgery EDITOR: In the article, "Pupillary block during cata ract surgery," by S. A. Updegraff, G. A. Peyman, and M. B. McDonald (Am. J. Ophthal mol. 117:328, March 1994), the authors reviewed an entity that we previously reported in our description of multilamellar hydrodis
November, 1994
section. 1 Although their second case illustrates this phenomenon of pupillary block associated with hydrodissection, we believe their first case is incorrectly characterized. In our initial cases using multilamellar hy drodissection, we occasionally experienced ep isodes of sudden iris prolapse caused by sharp increases in intraocular pressure. We thought the cause was entrapment of the injected fluid in the posterior chamber, specifically within the capsule and between the iris and the lens; this fluid increased pressure in the posterior chamber (and in the eye in general) and hydraulically forced the iris anteriorly toward the incision. As we noted, this problem was partic ularly associated with highly retentive viscoelastic agents (that is, those with low pseudoplasticity). Updegraff, Peyman, and McDonald speculat ed that the cause is an O-ring-type seal pro duced by viscoelastic agent trapped between the anterior capsule and posterior iris surface. Although this may be the case, we believe that the cause could be any form of pupillary block. We suspect that a large volume of viscoelastic agent retained in the anterior chamber me chanically obstructs fluid flow from the poster ior to anterior chambers, compresses the iris against the lens, or both. We have also seen this occur when hydrodissecting through the side-port incision in the absence of viscoelastic agent; in this situation the self-sealing incision traps aqueous in the anterior chamber, which prevents sufficiently rapid escape of injected fluid from the posterior chamber. In the second case of Updegraff, Peyman, and McDonald, the mechanical disruption of iris-lens apposition equalized pressures in the anterior and posterior chambers, and the intra ocular pressure became normal. In their first case, however, after posterior depression of the lens, the anterior chamber remained shallow and the globe was "firm to the touch." The failure of intervention to alleviate the pressure increase is inconsistent with either the authors' or our proposed mechanism for the develop ment of pupillary block. We believe that the primary problem in this case was the choroidal effusion or hemorrhage that was later noted on B-scan ultrasonography. The increase of intravitreal pressure by the increased choroidal vol ume produced the shallow anterior chamber and firm globe and responded as expected to the reduction in posterior segment pressure from the pars plana vitrectomy. The choroidal effusion might have resolved by the time of