A 54-year-old woman complained of repeated episodes of painless, gaze-evokedamaurosis of the right eye of 3 months' duration. Within 20 seconds afterabduction of her right eye, her visual field would rapidly constrict fromthe periphery toward the center. On resuming primary eye position, her visionreturned to normal within 30 seconds. She had a medical history of "sinusproblems" but was otherwise healthy. Acuity, color vision, pupils, eye movements, and visual fields werenormal. She had 3 mm of proptosis in her right eye. On abduction her visiondeteriorated to no light perception OD; the pupil slightly enlarged and becameunresponsive to light. Intraocular pressure was 20 mm Hg OU and it increasedto 50 mm Hg OD on abduction. A computed tomographic scan showed a 3-cm calcificmass in the ethmoid sinus and anterior medial orbit (Figure 1). The tumor was approached through a modified Lynch incisionand excised through an external ethmoidectomy and anterior orbitotomy. Itwas histopathologically shown to be an osteoma (Figure 2). The transient vision loss resolved after surgery. Figure 1. View LargeDownload Orbital computed tomographicaxial scan (A) and coronal (B and C) computed tomographic scan show a 3 ×2.5-cm calcific mass in the right ethmoid sinus and medial anterior orbitin close proximity to the medial optic nerve and slightly compressing theglobe. Figure 2. View LargeDownload Histopathologic features of osteomaat ×20 (A) and ×180 (B). Orbital ultrasound (Figure 3),fundus photographs (Figure 4), andfluorescein angiography (Figure 5)obtained in primary gaze and in abduction of the right eye demonstrated themechanism of vision loss. There was an obstruction of the retinochoroidalblood flow on abduction caused by (1) direct compression of the central retinaland medial posterior ciliary arteries and (2) an acute rise in intraocularpressure induced by bulbar compression. A similar case was previously describedby Wilkes et al in 19791 and by others.2 Figure 3. View LargeDownload B scan ultrasound of the orbitof the right eye showing the relationship of the tumor (left side in eachpart of the figure) with the optic nerve in adduction (A) and abduction (B).In abduction, the tumor compresses and kinks the medial anterior optic nerveshown by the arrowhead. Figure 4. View LargeDownload Fundus photographs of the righteye in primary position (A) and abduction (B). In abduction, the disc is morecongested and elevated, the nasal peripapillary retina is pushed forward,and the vasculature of the retina and optic nerve head become engorged. Figure 5. View LargeDownload Fluorescein angiography of theright eye. A, At 23 seconds, there is a segmental delay in filling of thenasal choroid supplied by the medial posterior ciliary artery. B, At 43 secondsthere is a marked delay in the arterial phase. C, At 61 seconds, taken shortlyafter the patient momentarily resumed primary gaze, retinal blood flow isrestored as the patient enters the arteriovenous phase. D, At 73 seconds,about 15 to 20 seconds after returning to abduction from primary gaze, thereis stasis (box-carring) due to obstruction of the arterial and venous circulation. Corresponding author and reprints: Patrick Sibony, MD, Departmentof Ophthalmology, SUNY Stony Brook, Health Sciences Center Level II, 152,Stony Brook, NY 11794. The authors have no relevant financial interest in this article. Mary Salvas obtained the fundus photographs and fluorescein angiography.Fred Miller, MD, provided the histopathologic evaluations. References 1. Wilkes SRTrautmann JCDeSanto LWCampbell RJ Osteoma: an unusual cause of amaurosis fugax. Mayo Clin Proc. 1979;5458- 260PubMedGoogle Scholar 2. Bradbury PGLevy ISMcDonald WI Transient uniocular visual loss on deviation of the eye in associationwith intraorbital tumours. J Neurol Neurosurg Psychiatry. 1987;50615- 619PubMedGoogle ScholarCrossref
Archives of Ophthalmology – American Medical Association
Published: May 1, 2004
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