Fall 2017 Newsletter

Follow our latest updates in our Fall 2017 Newsletter

Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations

OTEP

OTEP

Ophthalmic Technician Education Program

LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

LARGEST STUDY ON CHINESE
AMERICANS PUBLISHED

USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: Push for a Solution

Shan Zhang-Nunes
Presenter: Meghan Shan, MD, PhD Discussant: Sandy Zhang-Nunes, MD
 

History

  • 62-year-old male, past medical history of hypertension, presents with binocular diplopia
  • 05/2016: presented to primary MD with left eye discomfort and diplopia; exam found EOM limitations OS
  • 12/2016: seen by neurology; MRI found sinus disease and mass extending into left orbit
  • 05/2017: seen by ENT; exam found mild-moderate s-shaped septal deviation
  • No past ocular, surgical or family history
  • Social history: worked as a MBA, former smoker, no alcohol use

Exam Findings

  • BCVA: 20/25 OD, 20/300 OS (was unremarkable at ENT visit 05/2017)
  • Pupils: round and reactive OU, +RAPD OS
  • Color plates 10/10 OD, 6/10 OS
  • IOP: 14 OD, 14 OS
  • EOM:
Figure 1: Extraocular motility on initial presentation. -4 abduction, -3 supraduction, -2 infraduction and adduction.
Figure 1: Extraocular motility on initial presentation. -4 abduction, -3 supraduction, -2 infraduction and adduction.
  • Anterior exam: remarkable for left eye proptosis, ptosis and medical conjunctival injection
Figure 2: Worm's eye view showing left eye proptosis. Hertel measured 16.5mm OD, 20mm OS.
Figure 2: Worm’s eye view showing left eye proptosis. Hertel measured 16.5mm OD, 20mm OS.
  • Posterior exam: Remarkable for congested and tortuous vessels OS
Figure 3: Fundus photos. Left eye vessels are congested and tortuous.
Figure 3: Fundus photos. Left eye vessels are congested and tortuous.

 

Differential Diagnosis

  • Benign growths (e.g. hemangioma)
  • Malignancies (e.g. lymphoma)
  • Idiopathic orbital inflammatory syndrome
  • Infectious (e.g. orbital abscess)
  • Cysts (e.g. mucocele)

Additional Investigations

Figure 4: CT scan. Left mass measures 3cm in diameter. Smaller mass is present in the right posterior ethmoid sinus. Mass effect is evident in the left orbit, affecting the medical rectus, inferior muscles as well as the optic nerve.
Figure 4: CT scan. Left mass measures 3cm in diameter. Smaller mass is present in the right posterior ethmoid sinus. Mass effect is evident in the left orbit, affecting the medical rectus, inferior muscles as well as the optic nerve.
Figure 5: MRI orbit, T2 axial. Left mass is uniform in texture, well contained within regular borders. Signal characteristics most consistent with mucocele. There is appreciable axial displacement of left globe.
Figure 5: MRI orbit, T2 axial. Left mass is uniform in texture, well contained within regular borders. Signal characteristics most consistent with mucocele. There is appreciable axial displacement of left globe.

 

Diagnosis

  • Ethmoid sinus mucocele

Pathophysiology

  • Benign cysts lined with ciliated columnar epithelial cells that secrete mucous
  • Typically occurs in 3rd to 4th decades of life
  • Commonly due to obstruction of sinus ostium ventilation (e.g. inflammation, allergy, trauma, mass, idiopathic)
  • 65 percent frontal sinus, 30 percent ethmoidal sinus and 1-10 percent maxillary or sphenoid sinus

Treatment

  • Surgical evacuation
Figure 6: Surgical evacuation. Top left: mucocele wall. Top right: initial incision showing immediate drainage of mucopurulent material. Bottom left: mucocele evaculation. Bottom right: mucocele wall biopsy.
Figure 6: Surgical evacuation. Top left: mucocele wall. Top right: initial incision showing immediate drainage of mucopurulent material. Bottom left: mucocele evaculation. Bottom right: mucocele wall biopsy.

 

  • Biopsied left middle turbinate and mucocele wall: chronic inflammation. No significant eosinophils, fungal organisms or malignancy
  • After opening up the mucocele endoscopically and removing a lot of the lining of the mucocele, the eye and orbit was “pushed” externally to aid in evacuation of the mucocele
  • Watch a clip of the procedure below:

Push for a Solution screenshot

 

Prognosis and Future Directions

  • Post-op week 2: visual acuity now baseline at 20/25 OD, 20/25 OS
  • We expect long-term good prognosis for this patient
Figure 7: Post-op week 2. Proptosis OS resolved. Extraocular motility intact in both eyes.
Figure 7: Post-op week 2. Proptosis OS resolved. Extraocular motility intact in both eyes.

 

References

  • Khan, S., Sepahdari, A.R. (2012) Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies Saudi J Ophthalmol. 26(4):373-383
  • Iannetti, G., Cascone, P., Valentini, V., Agrillo, A., 1997. Paranasal sinus mucocele: diagnosis and treatment. J Craniofac Surg 8, 391-398
  • Iliff, C.E., 1973. Mucoceles in the orbit. Arch. Ophthalmol. 89, 392-395
  • Loo, J.-L., Looi, A.L.-G., Seah, L.-L., 2009. Visual outcomes in patients with paranasal mucoceles. Ophthal Plast Reconstr Surg 25, 126-129.
  • Kim, Y.-S., Kim, K., Lee, J.-G., Yoon, J.-H., Kim, C.-H., 2011. Paranasal sinus mucoceles with ophthalmologic manifestations: a 17-year review of 96 cases. Am J Rhinol Allergy 25, 272-275.

Contact

 

Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel
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