Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.

Capillary hemangiomas are the most common periocular and orbital tumors of childhood that typically arise in infancy. Though the diagnosis is frequently made on clinical examination, various diagnostic modalities may be helpful in initial evaluation and follow-up. Tests may be necessary in diagnosing suspect cases or aid in the differentiation of potential malignant tumors. In the vast majority of cases these tumors undergo spontaneous involution without sequelae. However, some periocular and orbital capillary hemangiomas require intervention to prevent serious complications. Other tumors require treatment to lessen the surgical burden for cosmetic repair. When treatment is necessary, there are a number of therapeutic options available. As there is no standard, potential risks and benefits must be discussed with the family and treatment should be specific in each case. A complete understanding of the natural history of the tumor, indications for treatment, and response to different therapies is imperative in managing this common lesion.

Ptosis refers to vertical narrowing of the palpebral fissure secondary to drooping of the upper eyelid to a lower than normal position. Ptosis is considered congenital if present at birth or if it is diagnosed within the first year of life. Correction of congenital ptosis is one of the most difficult challenges ophthalmologists face. Multiple surgical procedures are available including, frontalis sling, levator advancement, Whitnall sling, frontalis muscle flap, and Mullerectomy. Selection of one technique over another depends on the consideration of several factors including the surgeon experience, the degree of ptosis in the patient, as well as the degree of levator muscle function. Current recommendations for the correction of congential ptosis vary based on clinical presentation. Advantages and disadvantages of each of these procedures are presented with recommendations to avoid complications.

Pediatric preseptal and orbital cellulitis are infectious disorders that result in periorbital inflammation. Preseptal cellulitis is often associated with breaches in the skin barrier whereas orbital cellulitis is commonly associated with paranasal sinusitis. Orbital cellulitis may be associated with subperiosteal abscess. It is important to distinguish between preseptal from orbital cellulitis. Clinical examination and diagnostic imaging are useful in determining appropriate management. Patients are usually treated with broad spectrum antibiotics and surgery when indicated.

Orbit fractures are common in the context of orbital trauma. Fractures of the orbital floor without orbital rim involvement are known as indirect orbital floor fractures, pure internal floor fractures, and orbital blowout fractures. In this paper, we have reported a meta-analysis of orbital floor fractures focusing on indications and timing of surgical repair, outcomes, and complications.

Development of facial nerve palsy (FNP) may lead to dramatic change in the patient's facial function, expression, and emotions. The ophthalmologist may play an important role in the initial evaluation, and the long-term management of patients with new-onset of FNP. In patients with expected temporary facial weakness, no efforts should be wasted to ensure proper corneal protection. Patients with permanent functional deficit may require combination of surgical procedures tailored to the patient's clinical findings that may require good eye comfort and cosmesis.

Retinopathy of prematurity (ROP) is one of the leading causes of preventable blindness in childhood. Early posterior pole vascular signs of severe ROP have been studied since the first description of the disease. The progressive changes that take place in the posterior pole vessels of an extremely premature baby occur in a predictable fashion soon after birth. These vascular changes are described as plus disease and are defined as abnormal dilation and tortousity of the blood vessels during ROP that may go on to total retinal detachment. The ophthalmological community now has a better understanding of the pathology and cascade of events taking place in the posterior pole of an eye with active ROP. Despite many years of scientific work on plus disease, there continue to be many challenges in defining the severity and quantification of the vascular changes. It is believed that understanding of the vascular phenomenons in patients with ROP will help in designing new treatment strategies that will help in salvaging many of the eyes with severe ROP.

Background : Anophthalmia in childhood whether congenital or acquired is not just a question of cosmesis. Loss of an eye can effect the maturation of the soft tissues and bony structure surrounding the affected orbit. Therefore, a comprehensive approach including medical and surgical interventions is required to rehabilitate a child early in life. Materials and Methods : A literature survey of the past 40 years on the topic of congenital anophthalmia with focus on medical and surgical volume augmentation of the orbit was conducted. Results : Newer technologies including hydrogel implants and saline-filled tissue expanders have allowed for more rapid expansion of the pediatric orbit often with minimally invasive surgical procedures. However, traditional approaches including conformer therapy are still the primary intervention in these complicated cases. Conclusion : Anophthalmia in childhood requires a close interaction between ophthalmologist and ocularist as well as a motivated patient and family. With early intervention a good cosmetic outcome with periocular symmetry is obtainable.

Purpose: To evaluate the results of reconstruction of large defects in the upper lid using two composite contra-lateral eyelid margin grafts. Methods: This is an interventional case series in which a large full thickness defect of the upper lid was reconstructed in 7 patients using two composite eyelid margin grafts and myocutaneous advancement. The grafts were taken from both eyelids of the contra lateral eye and the final outcome was evaluated. Results: Cosmetic results were achieved in both donor and recipient eyes satisfying to all patients; no graft sloughing was seen. Transient edema, punctate epithelial erosions, lid notching, madarosis and ptosis were seen in the early postoperative period. Conclusion: Reconstruction of a large defect in the upper lid with two composite eyelid-margin grafts is an easy, safe, effective technique with minimal complications.

Context: Leukemias may present with, or be associated with ocular disorders. Aims: To determine the rates of ophthalmic disorders in adult patients with leukemia. Settings and Design: A prospective study of ocular disorders in adult patients with leukemia at the University of Benin Teaching Hospital, Benin City, Nigeria, between July 2004 and June 2008 was conducted. Methods and Materials: The patients were interviewed and examined by the authors and the ocular findings were recorded. Statistical analysis was performed using Instat GraphPad™ v2.05a statistical package software. The means, standard deviation, and the Kruskal-Wallis non parametric test were performed. Results: Forty-seven patients with leukemias were seen. Nineteen patients (40.4%) had CLL, 14(29.8%) had CML, 9(19.1%) had AML and 5(10.6%) had ALL. Seven patients (14.9%) had ocular disorders due to leukemia. The ocular disorders due to the leukemia were proptosis in two patients (4.3%), retinopathy in one patient (2.1%), conjunctival infiltration in one patient (2.1%), periorbital edema in one patient (2.1%), retinal detachment in one patient (2.1%), and subconjunctival hemorrhage in one patient (2.1%). There was no significant difference in rate of the ocular disorders in the various types of leukemia (Kruskal-Wallis KW= 4.019; corrected for ties. P=0.2595). One patient (2.1%) was blind from bilateral exudative retinal detachment while 1 patient (2.1%) had monocular blindness from mature cataract. Conclusions: Ophthalmic disorders that are potentially blinding occur in leukemias. Ophthalmic evaluation is needed in these patients for early identification and treatment of blinding conditions.

Purpose: To assess the psychiatric and endocrinological changes in patients with Graves ophthalmopathy (GO). Design: A prospective, controlled, University Hospital based study Subjects and Methods: The current study comprised 60 patients diagnosed with GO at Mansoura Ophthalmic Center. Thirty five patients of them with moderate to severe GO formed the study group and twenty five patients with negligible to very mild GO formed the control group in the euthyroid state. The study group was further subdivided based on their predominant clinical signs into a proptosis subgroup and a muscle restriction subgroup . Psychiatric changes were assessed with the Middlesex Hospital Questionnaire (MHQ). Biochemical analyses included serum-free thyroxine and thyroid-stimulating hormone (TSH) concentrations, TSH receptor antibody (TRAb) activity and anti-thyroglobulin particle agglutination (TGPA) and antithyroid microsomal particle agglutination (MCPA). Results: The proptosis group reported significantly higher scores on anxiety, depression, and phobia than the muscle restriction group (P<0.0001). The proptosis and muscle restriction subgroups reported significantly higher scores on all subscales compared to the control group (P < 0.05). The scale scores of depression and phobia showed a positive correlation with scores of anxiety (P<0.0001). The serum TRAb activity showed a significant correlation with anxiety, phobia and hysteria (P < 0.0001). Conclusion: The psychiatric aspect of GO should be evaluated during routine follow-up and should be considered when making management decisions. Thyroid specific antibodies may be useful in confirming the diagnosis of GO.

Purpose: To evaluate the role of diffusion-weighted magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (MRS) in the diagnosis of different orbital masses and their advantages over conventional MRI. Materials and Methods: The study included 20 patients presenting with proptosis. Every patient was subjected to thorough clinical examination, conventional MRI "T1 weighted, T2 weighted, and postcontrast T1 weighted if needed," diffusion-weighted MRI, and proton MRS. Orbitotomy was performed, the orbital mass was excised, and histopathological examination was performed. Results: Diffusion-weighted MRI could differentiate between benign lesions and malignant tumors in 70% of cases; however, overlap occurred in 30% of cases with benign tumors showing restricted diffusion whereas proton MRS could differentiate between benign and malignant tumors in 90% of cases. Conclusion: Diffusion-weighted MRI and proton MRS can potentially increase the accuracy of diagnosis of orbital masses through in vivo tissue characterization. Magnetic resonance spectroscopy seems to be the more accurate modality.

An 8-year-old girl presented with complaints of bilateral epiphora since birth. The patient had congenital punctal and canalicular atresia combined with congenital fistula. She was treated successfully with surgery. A review of the literature indicated very few reports of surgical treatment of such cases.

Diffuse unilateral subacute neuroretinitis (DUSN) can be a diagnostic dilemma. Laser photocoagulation of the subretinal worm is an effective treatment for eradication. Early laser photocoagulation has been advocated. We report a case of a middle aged man who presented with decreased vision and a sub retinal macular worm that required two laser sessions for complete eradication of the worm.

Rosacea is a dermatologic condition that affects the midfacial region. Ocular rosacea is most frequently diagnosed when cutaneous signs and symptoms are also present. Ocular manifestations are essentially confined to the eyelids and ocular surface. Ocular involvement ranges from minor irritation, dryness, and blurry vision to potentially severe ocular surface disruption including corneal ulcers, vascularization and rarely perforation. We present a 49-year-old Saudi Arabian female with the diagnosis of rosacea who presented with a peripheral corneal performation. The perforation was successfully managed by surgical repair, oral doxycycline and topical steroid. The final best corrected visual acuity was 20/30 after treatment. Early referral to an ophthalmologist and careful long-term follow-up are recommended.