Correspondence 9. Saornil MA, Blanco G, Sarasa JL, Gonzalez-Sansegundo C, Rabano G. Isolated metastasis of gastric adenocarcinoma to the retina: ﬁrst presentation of systemic disease. Acta Ophthalmol Scand. 2004;82: 86-8. 10. Apte RS, Dibernardo C, Pearlman JR, et al. Retinal metastasis presenting as a retinal hemorrhage in a patient with adenocarcinoma of the cecum. Arch Ophthalmol. 2005;123:850-3. 11. Kim CY, Ha CW, Lee SC. Vitreous and retinal metastasis from gastric cancer. Eur J Ophthalmol. 2010;20:615-7.
12. Coassin M, Ebrahimi KB, O'Brien JM, Stewart JM. Optical coherence tomography for retinal metastasis with unknown primary tumor. Ophthalmic Surg Lasers Imaging. 2011;42:e110-3.
Isolated orbital ﬂoor fracture lateral to infraorbital nerve: report of 2 pediatric patients
The ﬁrst patient was a 15-year-old male who hit his left eye on an opponent’s head during a rugby match. At the initial examination, his binocular single vision ﬁeld was limited to 30 degrees in downward gaze. The patient did not show enophthalmos or numbness in the left cheek region. Coronal computed tomographic (CT) images revealed a left isolated trapdoor orbital ﬂoor fracture lateral to the infraorbital nerve with orbital fat incarceration (Fig. 1A). The ﬂoor medial to the nerve was slightly displaced downward. The left inferior rectus muscle was pulled toward the fracture site by the incarcerated orbital fat. We measured the bone thickness in relation to the infraorbital nerve on the contralateral side on 3 consecutive coronal CT images using the caliper tool of the viewer (ShadeQuest/ViewR; Yokogawa Medical Solutions, Tokyo, Japan). The thinnest part was located in the lateral portion (lateral: 1.32 2.11 mm; medial: 1.55–1.92 mm). Although apraxia of the inferior rectus muscle was a possible cause of the downward restriction, traction of the inferior rectus muscle toward the fracture site was also a possible cause. We reduced the fracture 4 days after the injury, conﬁrming that the fracture site was located lateral to the infraorbital nerve (Fig. 1B). The medial segment of the orbital ﬂoor was not fractured. One month later, his binocular single vision ﬁeld improved to within the normal range. The second case was a 4-year-old male who fell and hit his right eye against a chair. At the ﬁrst examination, he noticed diplopia in all eye positions, although we were not able to examine his binocular single vision ﬁeld using
Orbital ﬂoor fractures usually occur medial to the infraorbital nerve.1 The bone posteromedial to the infraorbital nerve has been reported to be thinner than that lateral to the nerve,1,2 which translates into a predilection for an orbital ﬂoor fracture in the posteromedial area. Although orbital ﬂoor fractures sometimes occur in the portion lateral to the infraorbital nerve, to date they have been reported in the literature to occur together with a medial segment fracture or fracture of an orbital rim, or both.3 One previous report examined the site of isolated ﬂoor fractures and referred to a fracture lateral to the infraorbital nerve, but it did not include a detailed description of the case.4 We retrospectively reviewed all patients with orbital fracture treated in our department from March 2009 to February 2015. Among the 449 patients (334 male, 115 female; mean age 34.9 years, range 1–91 years; 450 sides: 207 right and 243 left) were 76 pediatric patients (aged r15 years). Two of these patients (2 sides) had an isolated orbital ﬂoor fracture lateral to the infraorbital nerve. The Institutional Review Board of Aichi Medical University approved this study, which followed the tenets of the Declaration of Helsinki. Written, informed consent to publish these case reports was obtained from the patients’ guardians.
Can J Ophthalmol 2015;50:e119–e121 0008-4182/15/$-see front matter & 2015 Published by Elsevier Inc on behalf of the Canadian Ophthalmological Society. http://dx.doi.org/10.1016/j.jcjo.2015.08.019
Fig. 1 — A, Coronal computed tomographic (CT) image of the 15-year-old male in case 1. A trapdoor orbital floor fracture (arrow) was located lateral to the infraorbital nerve (arrowhead) with orbital fat incarceration. The floor medial to the nerve was slightly displaced downward. The left inferior rectus muscle was pulled toward the fracture site. B, Intraoperative photograph after repositioning the incarcerated orbital fat in case 1 (bottom is cranial view; left is lateral view). The orbital floor fracture (arrows) was lateral to the infraorbital nerve (arrowheads). C, Coronal CT image of the 4-year-old male in case 2. Note that the orbital floor lateral to the infraorbital nerve (arrowhead) has caved in (arrow). CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015
Correspondence Goldmann perimetry because he did not understand the examination. He did not show enophthalmos or numbness in the right cheek region. Coronal CT images illustrated a right isolated orbital ﬂoor fracture lateral to the infraorbital nerve (Fig. 1C). We measured the bone thickness in relation to the infraorbital nerve on the contralateral side in the same manner as for case 1. The lateral portion was thinner (0.55–0.82 mm) than the medial portion (0.98–1.13 mm). We reduced the fracture 2 days after the injury because of diplopia in all eye positions. Three months later, he perceived no diplopia. In these 2 patients, the bone lateral to the infraorbital nerve was thinner than the medial portion. Although we measured bone thickness on the contralateral side in each case, the orbital structures were generally symmetrical.5 The medial portion has been thought to be thinner than the lateral portion, resulting in a predilection toward the ﬂoor fracture site. Our patients may be exceptions, but in the future we need to investigate the bone thickness in relation to the infraorbital nerve in a young population. Despite slight downward displacement of the medial segment in case 1, we found no fracture of the orbital ﬂoor medial to the nerve. Orbital ﬂoor fracture of the bone lateral to the infraorbital nerve has consistently been reported to accompany a medial segment fracture and/or fracture of an orbital rim.3 Because the facial skeleton in pediatric individuals is more elastic and ﬂexible than that in adults,6 bone rigidity may have contributed to the resistance of the medial segment to force in case 1, causing the isolated orbital ﬂoor fracture lateral to the infraorbital nerve.
In conclusion, we report 2 pediatric patients with an isolated orbital ﬂoor fracture lateral to the infraorbital nerve, possibly associated with an anatomical weakness of the affected site.
Delusional parasitosis involving the eyelid
had a woodpile beside her house and it likely had parasites within. Every time she picked at the growth she noted the suspected parasite move. She collected samples of the suspected parasite for us to examine (Fig. 1B). She also did some “Google research” and provided us with a name (acanthocephalan Corynosoma wegeneri) and a picture she located on the internet (Fig. 1C) that was (in her view) identical to what she had seen. On examination, there was a superﬁcial, elevated, ﬂaking lesion, nontender to touch involving the medial aspect of the left upper lid skin (Fig. 1B).There was an absence of pearly borders, central ulceration, and telangiectatic vessels. An excisional biopsy was performed. The patient’s specimen samples were also submitted. Histopathologic examination showed hyperkeratotic debris and fragments of skin consistent with an irritated seborrheic keratosis. There was no evidence of parasitic infestation in the main body or tissue fragments submitted. The patient was reassured of the benign nature of the lesion. There was no regrowth in the 6 months after biopsy. A provisional diagnosis of delusional parasitosis was made.
Delusional parasitosis is an uncommon and potentially debilitating disorder characterized by the patient’s ﬁxed belief that his or her skin and body is infested with parasites, although there is no medical or microbiological evidence for this.1–8 They rarely present to the ophthalmologist and more commonly are seen by general practitioners and dermatologists.1 It is important that ophthalmologists be aware of this entity because the eye and eyelids may be one of the sites involved.9–13 We present such a case involving the left upper eyelid. This Health Insurance Portability and Accountability Act–compliant case report was exempt from Institutional Review Board review and was performed in accordance with the tenets of the Declaration of Helsinki. A 68-year-old female was seen in consultation for a suspicious lesion involving the left upper lid of 6 weeks’ duration (Fig. 1A). In its early phase, the patient picked at it and it began to grow. She was quite certain she saw something moving on its surface. She volunteered that she
Hyera Kang, *,† Yasuhiro Takahashi, * Hirohiko Kakizaki *
Aichi Medical University, Aichi, Japan; †University of Seonam College of Medicine, Presbyterian Medical Center, Jeonju, Korea
Correspondence to: Hirohiko Kakizaki, MD: [email protected]
REFERENCES 1. Griepentrog GJ, Lucarelli MJ. Functions of the orbit and eyelids. In: Levin LA, Nilsson SFE, ver Hoeve J, Wu SM, Alm A, Kaufman PL, eds. Adler’s Physiology of the Eye. 11th ed. Philadelphia: Elsevier Saunders; 2011:334-5. 2. Jones DE, Evans JN. “Blow-out” fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol. 1967;81:1109-20. 3. Strong EB, Tollefson TT. Sinonasal trauma. In: Kennedy DW, Hwang PH, eds. Rhinology: Diseases of the Nose, Sinuses, and Skull Base. New York: Thieme Medical Publishers; 2012 (Chapter 36). 4. De Silva DJ, Rose GE. Orbital blowout fractures and race. Ophthalmology. 2011;118:1677-80. 5. Park JS, Lew H, Lee SY. Role of inferior orbital wall morphologic properties in isolated orbital blow-out fracture. Ophthalmic Res. 2012;47:1-6. 6. Hink EM, Wei LA, Durairaj VD. Clinical features and treatment of pediatric orbital fractures. Ophthal Plast Reconstr Surg. 2014;30:124-31. Can J Ophthalmol 2015;50:e121–e122 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2015.08.018
CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015