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Show LETTERS TO THE EDITOR Orbital Subperiosteal Hematoma After Thrombolysis and Anticoagulation for Acute Myocardial Infarction Orbital subperiosteal hematoma is a known compli-cation of trauma ( 1). We are reporting for the first time its occurrence after the combination of thrombolysis and anticoagulation. A 44- year- old man presented with a head injury and brow laceration caused by syncope due to a myocardial infarction. No other ocular problems were noted. He underwent thrombolysis with 40 mg intravenous tenecte-plase and was also treated with an infusion of intravenous heparin at a rate of 18 units/ kg/ h, 300 mg aspirin, 300 mg clopidogrel, and intravenous glyceryl trinitrate at an initial rate of 2.4 mL/ h and titrated according to the patient's pain. Seven hours later he complained of headache and double vision. Visual acuity at the bedside was 20/ 25 in the right eye and 20/ 20 in the left eye. Ishihara plate color vision was normal. The pupils were of normal size and reactivity. The right eye appeared displaced inward and downward ( Fig. 1). He had reduced supraduction and abduction of the right eye and normal ductions in the left eye. There was mild resistance to retropulsion, although no difference in globe displacement was found on Hertel exophthalmometry. He had some bruising and discolor-ation of his right upper lid. Intraocular pressure using a handheld applanation tonometer was 16 mm Hg in the right eye and 12 mm Hg in the left eye. Results of ophthalmoscopy were normal. Brain and orbit CT revealed a frontal extradural hematoma, a temporal subdural hematoma, and a right orbital roof subperiosteal hematoma, with no evidence of an orbital roof fracture ( Fig. 2). He was treated with 1 g tranexamic acid daily to inhibit fibrinolysis. All other medications were continued after a long discussion about the risks and benefits of withdrawing medical therapy. Two days later visual acuity was 20/ 20 in both eyes and pupil reactions remained normal. Ophthalmoscopy revealed superotemporal choroidal folds of the right eye. A follow- up brain and orbit CT showed no change in the size of the hematomas. All ocular motility examinations were comparable to his examination on presentation. The diplopia was alleviated with a 30 D base up Fresnel prism in the right spectacle. Four weeks after the onset of his symptoms, the ocular alignment ( Fig. 3) and movements had returned to normal, the diplopia had resolved, and the subperiosteal hematoma had decreased in size. The fact that our patient had no visual symptoms on presentation but developed them 7 hours after thrombolysis leads us to believe that the combination treatment consisting of a fibrinolytic, an anticoagulant, and a high-dose antiplatelet agent was responsible for the development of a subperiosteal hematoma. The orbital hematoma was unlikely to have been an extension of the frontal hematoma, as there was no evidence of an orbital roof fracture or FIG. 1. Seven hours after thrombolysis and anticoagula-tion, the patient complained of diplopia. In primary gaze position, the right eye is displaced downward and inward. The right upper lid is mildly ecchymotic. FIG. 2. Precontrast sagittal CT shows a superior orbital subperiosteal hematoma ( arrow). FIG. 3. Four weeks after thrombolysis and anticoagulation, the eyes are in normal position and aligned. 250 J Neuro- Ophthalmol, Vol. 29, No. 3, 2009 communication between the intracranial and orbital compartments. Although early surgical management of subperiosteal hematomas by needle aspiration or surgical evacuation of the hematoma ( 2- 4) may be important for the prevention of significant ocular morbidity, in this case there was no optic nerve compromise and no progression of the ductional deficits, so intervention was not necessary. Kwesi N. Amissah- Arthur, MBChb Victoria Eye Unit Hereford County Hospital Hereford, UK Birmingham and Midland Eye Centre City Hospital Birmingham, UK Markus Groppe, MBBS, MRCOphth Victoria Eye Unit Hereford County Hospital Hereford, UK Prince Charles Eye Unit King Edward VII Hospital Windsor, UK Stephen Scotcher, MBChb, MRCP, FRCOphth Victoria Eye Unit Hereford County Hospital Hereford, UK kaarthur@ doctors. net. uk REFERENCES 1. Wolter JR. Subperiosteal hematomas of the orbit in young males: a serious complication of trauma or surgery in the eye region. Trans Am Ophthalmol Soc 1979; 77: 104- 20. 2. Katz RS, Abrams G. Orbital subperiosteal hematoma ( epidural hematoma of the orbit). J Clin Neuroophthalmol 1981; 1: 45- 52. 3. Landa MS, Landa EH, Levine MR. Subperiosteal hematoma of the orbit: case presentation. Ophthal Plast Reconstr Surg 1998; 14: 189- 92. 4. Rojas MC, Eliason JA, Fredrick DR. Needle aspiration of a traumatic subperiosteal hematoma of the orbit. Br J Ophthalmol 2002; 86: 593- 7. See- Saw Nystagmus in a Patient with Septo- Optic Dysplasia Septo- optic dysplasia, also called deMorsier syndrome, is characterized by optic nerve hypoplasia, absence of the septum pellucidum, and thinning of the corpus callosum. Only once before has this rare form of nystagmus been reported in a patient with septo- optic dysplasia ( 1). We present such a case and document the findings with videography. FIG. 1. Fundus photography shows bilateral hypoplastic optic discs. FIG. 2. Humphrey visual fields ( protocol 30- 2, gray scale) show bitemporal hemianopic defects consistent with optic chiasmal dysfunction. FIG. 3. Optical coherence tomography shows bilateral thinning of the retinal nerve fiber layer in both eyes, which is more marked nasally. 251 Letters to the Editor J Neuro- Ophthalmol, Vol. 29, No. 3, 2009 A 37- year- old woman was referred because of bitemporal visual field defects detected on a routine exam-ination. The patient had no pertinent past medical history. Physical examination revealed a woman of normal stature and weight. Best- corrected visual acuity was 20/ 20 in the right eye and 20/ 40 in the left eye. The anterior ocular segment was unremarkable. Pupils constricted normally to direct light without an afferent pupillary defect. See- saw nystagmuswas present, manifesting intorsion of the elevating eye and extorsion of the depressing eye. ( Video, Supple-mental Digital Content 1, http:// links. lww. com/ WNO/ A2). Ophthalmoscopy showed bilateral small tilted hypoplastic optic discs with a temporal crescent in the right eye. There was no double- ring sign ( Fig. 1). Humphrey visual fields ( 30- 2 protocol) showed bitemporal defects that had partial respect for the vertical meridian in both eyes with a central island of retained field in the right eye temporally ( Fig. 2). Stratus III optical coher-ence tomography ( OCT) showed decreased thickness of the retinal nerve fiber layer superiorly and inferiorly ( Fig. 3). Brain MRI showed absence of the septum pellucidum and reduced optic nerve and chiasmal thickness, findings consistent with de Morsier syndrome ( Fig. 4). Our patient with septo- optic dysplasia presented with see- saw nystagmus, which is characterized by eleva-tion and intorsion of one eye with depression and extorsion of the other eye in one- half cycle, followed by reversal of those movements in the next half cycle. This type of nystagmus is believed to result from a defect that prevents the eyes from compensating for head rotations. Apart from this case of de Morsier syndrome, see- saw nystagmus is associated with isolated congenital absence or a decrease in the number of retinal ganglion cell axons crossing in the chiasm, parasellar masses, trauma to the optic chiasm, retinitis pigmentosa, rod cone dystrophy, midbrain lesions, and brain irradiation ( 3). Danielle S. Rudich, MD Mount Sinai School of Medicine Department of Ophthalmology New York, New York Robert L. Lesser, MD Departments of Ophthalmology and Visual Science and Neurology Yale University School of Medicine New Haven, Connecticut robert. lesser@ yale. edu Acknowledgment We thankMichael C. Brodsky, MD( Mayo Clinic Depart-ment of Ophthalmology, Rochester, MN) for his comments. REFERENCES 1. Davis GV, Shock JP. Septo- optic dysplasia associated with see- saw nystagmus. Arch Ophthalmol 1975; 93: 137- 9. 2. Lambert SR, Hoyt CS, Narahara MH. Optic nerve hypoplasia. Surv Ophthalmol 1987; 32: 1- 9. 3. Leigh RJ, Zee DS. The Neurology of Eye Movements. 4th ed. Oxford, UK: Oxford University Press; 2006: 496- 8. FIG. 4. Precontrast coronal brain MRI shows absence of the septum pellucidum ( asterisk) and moderate thinning of the optic chiasm ( arrow). 252 q 2009 Lippincott Williams & Wilkins J Neuro- Ophthalmol, Vol. 29, No. 3, 2009 Letters to the Editor |