Clinical-Pathological Case Study Section Editors: Neil R. Miller, MD Janet Rucker, MD
An Orbital Mass in a 5-Year-Old Girl Mark R. Melson, MD, Daniel Brat, MD, PhD, Patricia J. Hudgins, MD
Dr. Melson:
A
5-year-old girl presented for evaluation of a right orbital mass displacing the globe superiorly. She had a 5-week history of swelling around her right eye. Her medical history and ocular history were unremarkable. She was adopted at the age of 7 months, and there was no known history of prenatal or perinatal problems. She was home-schooled and enjoyed playing outdoors. She had no preceding illness or trauma and no known contact with anyone ill. Her pediatrician diagnosed a blocked tear duct and referred her to an ophthalmologist. She failed empiric treatment for orbital cellulitis and was subsequently referred to an orbital surgeon. Computed tomography (CT) of the orbits was performed.
Dr. Hudgins: Noncontrast axial and coronal CT images of the orbits show a poorly defined mass, that is both intraconal and extraconal in the lateral and inferior quadrants of the right orbit (Fig. 1). There is soft tissue present on superior and medial maxillary sinus walls.
Dr. Melson: The family was told that the child probably had cancer and needed urgent treatment and was referred to our service. In the week before seeing us, her family began giving the patient commercially marketed supplements for cancer treatment. In the meantime, she complained of swelling around the right eye, mild discomfort along the right inferior orbital rim, and intermittent, binocular horizontal diplopia. On examination at our institution, the patient’s visual acuity was 20/40, right eye, and 20/20, left eye. There was limitation of infraduction and abduction of the right eye and 3 mm of relative right proptosis with superior displacement Department of Ophthalmology and Visual Sciences (MRM), Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Pathology & Laboratory Medicine (DB) and Department of Radiology and Imaging Sciences (PJH), Emory University School of Medicine, Atlanta, Georgia. Supported by an unrestricted departmental grant from Research to Prevent Blindness, Inc., New York, NY. The authors report no conflicts of interest. Address correspondence to Mark R. Melson, MD, Vanderbilt Eye Institute, 2311 Pierce Avenue, Nashville, TN 37232; E-mail: mark.r. [email protected] Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
of the globe (Fig. 2). There was no relative afferent pupillary defect. The anterior segment and funduscopic examinations were unremarkable. Magnetic resonance imaging (MRI) of the orbits was obtained (Fig. 3).
Dr. Hudgins: Unenhanced T1 coronal image (Fig. 3A) again shows the poorly defined and diffuse orbital mass. There has been interval worsening of the maxillary sinus opacification since the CT. This image is an excellent example of the value of the precontrast images, as the orbital mass is clearly seen against the high signal intensity of intraconal fat. After intravenous contrast, the T1 image with fat saturation shows robust enhancement in the mass (Fig. 3B). Note that the inferior and lateral rectus muscles cannot be differentiated from the lesion, implying invasion and probable inflammation of the muscle. The lacrimal gland remains normal and symmetric compared with the contralateral gland. Enhancement in the superior ophthalmic vein is normal. The maxillary sinus contents do not enhance, which likely implies that the sinus is filled with benign fluid. Figure 3C, obtained slightly posterior to Figure 3B, shows enhancement in the pterygomaxillary fissure. The process is diffuse, not discrete, and is now extra-orbital.
Dr. Melson: The MRI report described a “large, enhancing, ill-defined mass arising from the inferior rectus muscle . invades right maxillary and right ethmoid sinuses . abuts posterior wall the globe and inferior optical nerve sheath . most likely represents rhabdomyosarcoma.” Because of concern for a malignancy, we performed a right anterior orbitotomy at which time we identified a firm, white orbital mass that appeared to extend through the orbital floor. A biopsy of the lesion was performed, with frozen sections interpreted as a “moderately cellular spindle cell lesion with mixed inflammatory infiltrate.”
Dr. Hudgins: The images do not show a discrete mass but rather a process, that is diffuse, both intraconal and extraconal, and now in the extra-orbital pterygomaxillary fissure. The maxillary sinus disease is likely related, but because it does not enhance, it probably is fluid and not part of the mass. 83
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Clinical-Pathological Case Study
FIG. 1. Noncontrast axial (A) and coronal (B) computed tomographic images of the orbits show a poorly defined mass, that is both intraconal and extraconal. The mass is located in the lateral and inferior quadrants of the right orbit, with the lateral and inferior rectus muscles being inseparable from the mass. Mucoid density soft tissue is present on the roof and the medial wall of the right maxillary sinus.
Dr. Melson:
Dr. Melson:
The patient recovered uneventfully and was discharged home. The pediatric oncology service was contacted about meeting the patient once final pathology was known. On postoperative day 3, the patient’s parents reported increased swelling and chemosis around the child’s right eye. On the same day, we received the pathology report from the initial biopsy.
Permanent sections were read as showing a fungal process. Accordingly, we contacted the family and had them bring the patient back to the hospital immediately so that she could be admitted for surgical debulking. At the time of surgery, the bulk of the mass was removed. The floor of the maxillary sinus was intact except for a focal area of dehiscence.
Dr. Brat: Dr. Brat: Histologic sections show an active inflammatory process with extensive necrosis and a reactive spindle cell response (Figs. 4A, 4B). Pockets of chronic inflammatory cells are intermingled with necrobiotic material and a dense fibroblastic and collagenous response. The inflammatory infiltrate is composed predominantly of lymphocytes and plasma cells with only a vague granulomatous appearance. There are no well-formed granulomas. Special stains for fungus (Gomori methenamine silver) reveal fungal hyphae intermixed within the inflammatory infiltrates (Figs. 4C, 4D). The morphology is most consistent with Aspergillus species. or zygomycosis, but definitive speciation is not possible based on histologic examination.
Histologic sections and special stains obtained on the specimen from the debulking procedure showed findings identical with those from the first specimen and were consistent with an active, necrobiotic fungal infectious disease.
Dr. Melson: At surgery, a catheter was placed in the orbit for direct orbital and sinus irrigation with antifungal medication. Amphotericin B was given intravenously and intraorbitally until catheter was dislodged on postoperative day 2. Immunologic evaluation was performed that revealed no evidence of systemic immune compromise. Posaconazole was added, and the patient was discharged home 10 days after the surgery, once it was clear that her disease was not clinically progressing. She subsequently received intravenous amphotericin B as an outpatient for 3 months and oral posaconazole for 15 months, during which time her examination normalized and imaging evidence of disease resolved (Fig. 5). Cultures from the surgical specimens never grew any organism. The patient’s examination normalized and follow-up MRI showed gradual resolution of her orbital infection.
Dr. Hudgins: FIG. 2. There is mild swelling of the right upper and lower lids associated with right hyperglobus and proptosis.
84
Contrast-enhanced T1 coronal MRI shows that the infectious process has decreased in extent but is still present (Fig. 5). Imaging findings, especially in the setting of infection, often lag behind the clinical examination. In light of the Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Clinical-Pathological Case Study
FIG. 3. Magnetic resonance imaging, coronal sections, performed 5 weeks after the onset of symptoms. A. Noncontrast T1 image shows a poorly defined, diffuse orbital mass and worsening of the maxillary sinus opacification since the previous computed tomographic scan. B. Postcontrast T1 image with fat saturation shows enhancement in the mass. Note that the neighboring rectus muscles cannot be differentiated from the lesion. C. Image slightly posterior to (B) shows enhancement in the pterygomaxillary fissure (arrows).
improvement in the patient’s physical examination, persistent disease should not be interpreted as treatment failure.
Final Pathologic Diagnosis: Invasive fungal orbital cellulitis in an immunocompetent child.
Dr. Melson: Orbital zygomycosis in immunocompetent patients, especially children, is a rare cause of an orbital mass mimicking cellulitis (1,2). Management usually includes surgical debulking, long-term antifungal medication, and evaluation for immune suppression dysfunction (1,3). Emerging organisms, such as Apophysomyces elegans, may make these presentations more common in the future. These cases typically are associated with some form of traumatic inoculation. In others, the mechanism of disease may not be evident, as in our case (4,5). Although our patient’s family noted that she enjoyed playing outside and particularly in the dirt, they could not
recall an episode where she had any sort of injury that could have caused her infection. Invasive fungal disease was one of our diagnostic considerations but so were other orbital inflammatory disorders, including Langerhans cell histiocytosis and idiopathic orbital inflammatory disease, (orbital pseudotumor). Our patient’s family had been told that she had an orbital malignancy by the first orbital surgeon; the first MRI report stated that she likely had rhabdomyosarcoma, and the intraoperative frozen section pathology was inconclusive. The child had no signs or symptoms of systemic infection and the orbital mass appeared solid with no evidence of purulence or tissue necrosis. Therefore, treatment for fungal disease was not initiated after the first surgery and cultures were not obtained. Once the final pathologic diagnosis was known, we chose to debulk the lesion and institute intraorbital irrigation and systemic treatment with antifungal medication. Duration of treatment was determined in consultation with the infectious disease specialists whose recommendations were guided by clinical and imaging findings in her orbit. Once she showed no evidence of residual
FIG. 4. Histopathology of orbital mass. A. Low-magnification section shows an active inflammatory process, with regions of reactive stroma and granulation tissue, chronic inflammation, and necrosis (hematoxylin and eosin, ·40). B. Higher magnification shows necrobiotic material, dense spindle cell proliferation, and chronic inflammation composed mostly of lymphocytes and plasma cells (hematoxylin and eosin, ·200). C. Numerous fungal hyphal elements are present (Gomori methenamine silver, ·40). Inset: Fungal morphology from area indicated by arrow is consistent with Aspergillus sp. or zygomycosis (Gomori methenamine silver, ·400). Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
85
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Clinical-Pathological Case Study Institute of Allergy and Infectious Disease, and a clinical trial (NCT01386437) currently is under way to identify genetic factors that may predispose patients to these types of infections even when no primary immune deficiency has been identified with conventional testing (6). The study proposes to use information gathered from patients to help gain new insights into the pathogenesis of these infections in immunocompetent hosts and to identify potential targets for novel therapies. It is critical that the clinician consider the possibility of fungal disease in any patient who develops an orbital process, regardless of their immune status.
REFERENCES
FIG. 5. Three months after treatment with antifungal agents, postcontrast T1 coronal magnetic resonance imaging with fat suppression shows almost complete resolution of the right orbital process.
disease, all antifungal medications were discontinued and she was discharged from ongoing care. The patient’s fungal cultures never grew any organism. The spectrum of invasive fungi typically includes zygomycoses, such as Mucor and Rhizopus species as well as Aspergillus species. It has been suggested that the incidence of these infections in immunocompetent patients may be increasing (4). Such infections have drawn the attention of the National
86
1. Margo C, Rabinowicz I, Kwon-Chung KJ, Zimmerman LE. Subacute zygomycosis of the orbit. Arch Ophthalmol. 1983;101:1580–1585. 2. Seiff SR, Choo PH, Carter SR. Role of local amphotericin B therapy for sino-orbital fungal infections. Ophthal Plast Reconstr Surg. 1999;15:28–31. 3. Rutar T, Cockerham KP. Periorbital zygomycosis (mucormycosis) treated with posaconazole. Am J Ophthalmol. 2006;142: 187–188. 4. Fairley C, Sullivan TJ, Bartley P, Allworth T, Lewandowski R. Survival after rhino-orbital-cerebral mucormycosis in an immunocompetent patient. Ophthalmology. 2000;107:555–558. 5. Liang KP, Tleyjeh IM, Wilson WR, Roberts GD, Temesgen Z. Rhino-orbitocerebral mucormycosis caused by apophysomyces elegans. J Clin Microbiol. 2006;44:892–898. 6. National Institute of Allergy and Infectious Diseases. Natural History of Individuals With Immune System Problems That Lead to Fungal Infections. Available at: http://www.clinicaltrials.gov/ ct2/show/NCT01386437?term=NCT01386437&rank=1. Accessed April 23, 2013.
Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
An Orbital Mass in a 5-Year-Old Girl Mark R. Melson, MD, Daniel Brat, MD, PhD, Patricia J. Hudgins, MD
Dr. Melson:
A
5-year-old girl presented for evaluation of a right orbital mass displacing the globe superiorly. She had a 5-week history of swelling around her right eye. Her medical history and ocular history were unremarkable. She was adopted at the age of 7 months, and there was no known history of prenatal or perinatal problems. She was home-schooled and enjoyed playing outdoors. She had no preceding illness or trauma and no known contact with anyone ill. Her pediatrician diagnosed a blocked tear duct and referred her to an ophthalmologist. She failed empiric treatment for orbital cellulitis and was subsequently referred to an orbital surgeon. Computed tomography (CT) of the orbits was performed.
Dr. Hudgins: Noncontrast axial and coronal CT images of the orbits show a poorly defined mass, that is both intraconal and extraconal in the lateral and inferior quadrants of the right orbit (Fig. 1). There is soft tissue present on superior and medial maxillary sinus walls.
Dr. Melson: The family was told that the child probably had cancer and needed urgent treatment and was referred to our service. In the week before seeing us, her family began giving the patient commercially marketed supplements for cancer treatment. In the meantime, she complained of swelling around the right eye, mild discomfort along the right inferior orbital rim, and intermittent, binocular horizontal diplopia. On examination at our institution, the patient’s visual acuity was 20/40, right eye, and 20/20, left eye. There was limitation of infraduction and abduction of the right eye and 3 mm of relative right proptosis with superior displacement Department of Ophthalmology and Visual Sciences (MRM), Vanderbilt University School of Medicine, Nashville, Tennessee; and Department of Pathology & Laboratory Medicine (DB) and Department of Radiology and Imaging Sciences (PJH), Emory University School of Medicine, Atlanta, Georgia. Supported by an unrestricted departmental grant from Research to Prevent Blindness, Inc., New York, NY. The authors report no conflicts of interest. Address correspondence to Mark R. Melson, MD, Vanderbilt Eye Institute, 2311 Pierce Avenue, Nashville, TN 37232; E-mail: mark.r. [email protected] Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
of the globe (Fig. 2). There was no relative afferent pupillary defect. The anterior segment and funduscopic examinations were unremarkable. Magnetic resonance imaging (MRI) of the orbits was obtained (Fig. 3).
Dr. Hudgins: Unenhanced T1 coronal image (Fig. 3A) again shows the poorly defined and diffuse orbital mass. There has been interval worsening of the maxillary sinus opacification since the CT. This image is an excellent example of the value of the precontrast images, as the orbital mass is clearly seen against the high signal intensity of intraconal fat. After intravenous contrast, the T1 image with fat saturation shows robust enhancement in the mass (Fig. 3B). Note that the inferior and lateral rectus muscles cannot be differentiated from the lesion, implying invasion and probable inflammation of the muscle. The lacrimal gland remains normal and symmetric compared with the contralateral gland. Enhancement in the superior ophthalmic vein is normal. The maxillary sinus contents do not enhance, which likely implies that the sinus is filled with benign fluid. Figure 3C, obtained slightly posterior to Figure 3B, shows enhancement in the pterygomaxillary fissure. The process is diffuse, not discrete, and is now extra-orbital.
Dr. Melson: The MRI report described a “large, enhancing, ill-defined mass arising from the inferior rectus muscle . invades right maxillary and right ethmoid sinuses . abuts posterior wall the globe and inferior optical nerve sheath . most likely represents rhabdomyosarcoma.” Because of concern for a malignancy, we performed a right anterior orbitotomy at which time we identified a firm, white orbital mass that appeared to extend through the orbital floor. A biopsy of the lesion was performed, with frozen sections interpreted as a “moderately cellular spindle cell lesion with mixed inflammatory infiltrate.”
Dr. Hudgins: The images do not show a discrete mass but rather a process, that is diffuse, both intraconal and extraconal, and now in the extra-orbital pterygomaxillary fissure. The maxillary sinus disease is likely related, but because it does not enhance, it probably is fluid and not part of the mass. 83
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Clinical-Pathological Case Study
FIG. 1. Noncontrast axial (A) and coronal (B) computed tomographic images of the orbits show a poorly defined mass, that is both intraconal and extraconal. The mass is located in the lateral and inferior quadrants of the right orbit, with the lateral and inferior rectus muscles being inseparable from the mass. Mucoid density soft tissue is present on the roof and the medial wall of the right maxillary sinus.
Dr. Melson:
Dr. Melson:
The patient recovered uneventfully and was discharged home. The pediatric oncology service was contacted about meeting the patient once final pathology was known. On postoperative day 3, the patient’s parents reported increased swelling and chemosis around the child’s right eye. On the same day, we received the pathology report from the initial biopsy.
Permanent sections were read as showing a fungal process. Accordingly, we contacted the family and had them bring the patient back to the hospital immediately so that she could be admitted for surgical debulking. At the time of surgery, the bulk of the mass was removed. The floor of the maxillary sinus was intact except for a focal area of dehiscence.
Dr. Brat: Dr. Brat: Histologic sections show an active inflammatory process with extensive necrosis and a reactive spindle cell response (Figs. 4A, 4B). Pockets of chronic inflammatory cells are intermingled with necrobiotic material and a dense fibroblastic and collagenous response. The inflammatory infiltrate is composed predominantly of lymphocytes and plasma cells with only a vague granulomatous appearance. There are no well-formed granulomas. Special stains for fungus (Gomori methenamine silver) reveal fungal hyphae intermixed within the inflammatory infiltrates (Figs. 4C, 4D). The morphology is most consistent with Aspergillus species. or zygomycosis, but definitive speciation is not possible based on histologic examination.
Histologic sections and special stains obtained on the specimen from the debulking procedure showed findings identical with those from the first specimen and were consistent with an active, necrobiotic fungal infectious disease.
Dr. Melson: At surgery, a catheter was placed in the orbit for direct orbital and sinus irrigation with antifungal medication. Amphotericin B was given intravenously and intraorbitally until catheter was dislodged on postoperative day 2. Immunologic evaluation was performed that revealed no evidence of systemic immune compromise. Posaconazole was added, and the patient was discharged home 10 days after the surgery, once it was clear that her disease was not clinically progressing. She subsequently received intravenous amphotericin B as an outpatient for 3 months and oral posaconazole for 15 months, during which time her examination normalized and imaging evidence of disease resolved (Fig. 5). Cultures from the surgical specimens never grew any organism. The patient’s examination normalized and follow-up MRI showed gradual resolution of her orbital infection.
Dr. Hudgins: FIG. 2. There is mild swelling of the right upper and lower lids associated with right hyperglobus and proptosis.
84
Contrast-enhanced T1 coronal MRI shows that the infectious process has decreased in extent but is still present (Fig. 5). Imaging findings, especially in the setting of infection, often lag behind the clinical examination. In light of the Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Clinical-Pathological Case Study
FIG. 3. Magnetic resonance imaging, coronal sections, performed 5 weeks after the onset of symptoms. A. Noncontrast T1 image shows a poorly defined, diffuse orbital mass and worsening of the maxillary sinus opacification since the previous computed tomographic scan. B. Postcontrast T1 image with fat saturation shows enhancement in the mass. Note that the neighboring rectus muscles cannot be differentiated from the lesion. C. Image slightly posterior to (B) shows enhancement in the pterygomaxillary fissure (arrows).
improvement in the patient’s physical examination, persistent disease should not be interpreted as treatment failure.
Final Pathologic Diagnosis: Invasive fungal orbital cellulitis in an immunocompetent child.
Dr. Melson: Orbital zygomycosis in immunocompetent patients, especially children, is a rare cause of an orbital mass mimicking cellulitis (1,2). Management usually includes surgical debulking, long-term antifungal medication, and evaluation for immune suppression dysfunction (1,3). Emerging organisms, such as Apophysomyces elegans, may make these presentations more common in the future. These cases typically are associated with some form of traumatic inoculation. In others, the mechanism of disease may not be evident, as in our case (4,5). Although our patient’s family noted that she enjoyed playing outside and particularly in the dirt, they could not
recall an episode where she had any sort of injury that could have caused her infection. Invasive fungal disease was one of our diagnostic considerations but so were other orbital inflammatory disorders, including Langerhans cell histiocytosis and idiopathic orbital inflammatory disease, (orbital pseudotumor). Our patient’s family had been told that she had an orbital malignancy by the first orbital surgeon; the first MRI report stated that she likely had rhabdomyosarcoma, and the intraoperative frozen section pathology was inconclusive. The child had no signs or symptoms of systemic infection and the orbital mass appeared solid with no evidence of purulence or tissue necrosis. Therefore, treatment for fungal disease was not initiated after the first surgery and cultures were not obtained. Once the final pathologic diagnosis was known, we chose to debulk the lesion and institute intraorbital irrigation and systemic treatment with antifungal medication. Duration of treatment was determined in consultation with the infectious disease specialists whose recommendations were guided by clinical and imaging findings in her orbit. Once she showed no evidence of residual
FIG. 4. Histopathology of orbital mass. A. Low-magnification section shows an active inflammatory process, with regions of reactive stroma and granulation tissue, chronic inflammation, and necrosis (hematoxylin and eosin, ·40). B. Higher magnification shows necrobiotic material, dense spindle cell proliferation, and chronic inflammation composed mostly of lymphocytes and plasma cells (hematoxylin and eosin, ·200). C. Numerous fungal hyphal elements are present (Gomori methenamine silver, ·40). Inset: Fungal morphology from area indicated by arrow is consistent with Aspergillus sp. or zygomycosis (Gomori methenamine silver, ·400). Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
85
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Clinical-Pathological Case Study Institute of Allergy and Infectious Disease, and a clinical trial (NCT01386437) currently is under way to identify genetic factors that may predispose patients to these types of infections even when no primary immune deficiency has been identified with conventional testing (6). The study proposes to use information gathered from patients to help gain new insights into the pathogenesis of these infections in immunocompetent hosts and to identify potential targets for novel therapies. It is critical that the clinician consider the possibility of fungal disease in any patient who develops an orbital process, regardless of their immune status.
REFERENCES
FIG. 5. Three months after treatment with antifungal agents, postcontrast T1 coronal magnetic resonance imaging with fat suppression shows almost complete resolution of the right orbital process.
disease, all antifungal medications were discontinued and she was discharged from ongoing care. The patient’s fungal cultures never grew any organism. The spectrum of invasive fungi typically includes zygomycoses, such as Mucor and Rhizopus species as well as Aspergillus species. It has been suggested that the incidence of these infections in immunocompetent patients may be increasing (4). Such infections have drawn the attention of the National
86
1. Margo C, Rabinowicz I, Kwon-Chung KJ, Zimmerman LE. Subacute zygomycosis of the orbit. Arch Ophthalmol. 1983;101:1580–1585. 2. Seiff SR, Choo PH, Carter SR. Role of local amphotericin B therapy for sino-orbital fungal infections. Ophthal Plast Reconstr Surg. 1999;15:28–31. 3. Rutar T, Cockerham KP. Periorbital zygomycosis (mucormycosis) treated with posaconazole. Am J Ophthalmol. 2006;142: 187–188. 4. Fairley C, Sullivan TJ, Bartley P, Allworth T, Lewandowski R. Survival after rhino-orbital-cerebral mucormycosis in an immunocompetent patient. Ophthalmology. 2000;107:555–558. 5. Liang KP, Tleyjeh IM, Wilson WR, Roberts GD, Temesgen Z. Rhino-orbitocerebral mucormycosis caused by apophysomyces elegans. J Clin Microbiol. 2006;44:892–898. 6. National Institute of Allergy and Infectious Diseases. Natural History of Individuals With Immune System Problems That Lead to Fungal Infections. Available at: http://www.clinicaltrials.gov/ ct2/show/NCT01386437?term=NCT01386437&rank=1. Accessed April 23, 2013.
Melson et al: J Neuro-Ophthalmol 2014; 34: 83-86
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
