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OCULAR FINDINGS in CASES with CHRONIC RHINOSINUSITIS Mohammad M

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OCULAR FINDINGS in CASES with CHRONIC RHINOSINUSITIS Mohammad M AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 4 , OCTOPER 2015 SUPPL-2 OCULAR FINDINGS IN CASES WITH CHRONIC RHINOSINUSITIS Mohammad M. Gab-Allah1 and Nehal M. Samy El Gendy2 1Ear, nose and throat Department, Hearing and speech institute 2Ophthalmology Departement, Kasr Al Ainy medical school, Cairo University ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Purpose: To elaborate causes of blurred vision and any other related ocular findings in cases with chronic rhinosinusitis. Material and Method: Cases with chronic rhinosinusitis complaining of blurred vision or ocular discomfort were referred to Ophthalmology clinic for assessment. Ocular examination included full ophthalmic examination,Hertleexophthalmolmeter assessment, field of vision and tear film evaluation. Results: one hundred and sixty cases were included: 45 % had frontoehmoidal sinusitis, 52.5% had pansinusitis and 2.5 % had isolated sphenoidalsinusitis.Unilateral cases contributed to 51.9% of our sample (83 cases). CT findings divided into: sinonasal polyposis 71.8% (115 cases), osteomeatal complex obstruction 22.5% (36 cases) ,frontoehmoidalmucocele 3.1% (5 cases), isolated fungal sphenoiditis 2.5% (4 cases).1.26 % showed enlarged blind spot in field examination. Mean Schirmer test was 20+/- 5.1 mm. Comparing both eyes in unilateral cases ,the average Schirmer results was 19.7+/-5.3 vs 24.1+/- 4.7 mm (p=0.007).Mean tear meniscus height on slit lamp was 599+/-179.3µm. Both eyes comparison in unilateral cases was 493.1+/-155 vs 598+/- 186µm.(P= 0.0001).Mean tear break up time(BUT)for all cases was 10.6+/-1.3 sec . Both eyes comparison in unilateral cases was 10.1+/-1.8 vs 11 3+/-1.6 sec (p=0.004%) .5.6 % complained of diplopia in extreme gaze, 2.5% showed silent sinus syndrome, 1.87% showed mild proptosis.Conclusion: Dryness, extra ocular muscle dysfunction, silent sinus syndrome and mild proptosis can be other causes ( other than optic nerve affection) that causes ocular manifestations in cases with chronic sinusitis. INTRODUCTION institute were referred to ophthalmic Chronic rhinosinusitis (CRS) is referred to as examination at KasrAlainy ophthalmology chronic inflammation of sinuses that persists for clinic. more than 12 weeks despite treatment. Inclusion criteria: Cases with unilateral or (1)Diagnosis of CRS depends on bilateral CRS with symptoms persisting for at symptomatology and/or endoscopic and least 3 months .Adults aging between 30 and 50 radiological classification. Symptomatology is years old. usually divided into: major factors like facial Exclusion Criteria:Cases with known ocular congestion and nasal purulence, and minor diseases causing diminution of factors like headache, cough and ear fullness. vision,Established cases of dry eye (BUT <5 sec Systems either subjective like SNOT-22 or or Schirmer’stest of <5 mm), history of Eye objective like Lund-Mackay staging system are surgeries or contact lens use, eyelid disorders used to detect the severity of disease (2). including blepharitis , conjunctival diseases Although stated by many cases of CRS; Ocular (e.g. symblepharon andpteryguim) .Cases with complains are usually overlooked, except for dacrocystitis(acute or chronic), lacrimal isolated sphenoid sinusitis fearing from optic punctastenosis and with history of systemic neuritis. With the exclusion of optic neuritis; illness like diabetesmellitus,hypertension, physicians stand clueless about the reason of collagen vascular disorders or any use of disturbed vision in other CRS cases. Subtle systemicmedications were also excluded.Cases decrease or increase in tear film thickness can with previous sinus surgery were excluded. affect vision quality and quantity. Changes in Cases with abuse of ephedrine or tear film composition can also affect vision pseudoephedrine containing medications were quality. Change in eye position may also also excluded. contribute to such changes. We conducted this Base line examination included: study to elaborate various ophthalmic findings ENT complete evaluation: this included that may explain vision disturbance in cases full ENT outpatient examination with with CRS. endoscopic examination of the nasal MATERIAL AND METHODS cavity. Routine CT examination of the This study was conducted in accordance with paranasal sinuses was ordered to all cases. the Declaration of Helsinki. Protocol was Eye complete examination: This included approved by local ethical committee. Cases with BCVA, Schirmer test, tear film evaluation CRS and ocular discomfort represented to a (Tear break up time [BUT] test, regurge tertiary referral clinic at Hearing and speech test, John tests) , complete 136 | P a g e Mohammad M. Gab-Allah1 and Nehal M. Samy El Gendy2 AAMJ ,VOL 13 , NO 3 , JULY 2015 – suppl 1 ophthalmological examination including micrometer. Comparing both eyes slit lamp examination, extraocular muscle of unilateral cases, affected side evaluation(EOM) and fundus examination showed mean height of 493.1+/- . Field of vision using 30.2 pattern 155 compared to 598+/-186 (Humphrey Field Analyzer; Humphrey microns on the other side . The Instruments, Dub-lin, CA, USA). difference was statistically Subjects with unreliable visual field tests significant. P= 0.0001 (fixation loss > 20%, false negative or o Tear break up time: mean BUT false positive responses> 33%) were time for all cases was 10.6+/-1.3 excluded. The visual field data were sec . Unilateral cases had a mean of obtained from print-out the machine 10.1+/-1.8 sec, compared to the providesHertleExophthalmometer other side eye ,mean BUT was 11 assessment of eye balls. 3+/-1.6 sec . The difference was Statistics: Statistical data were described in statistically significant p=0.004 frequency and percentages for categorical data, o Regurge test: This was negative in and mean ± SD for numerical data using SPSS all cases version 24 (SPSS Inc., Chicago, IL, USA). Fundus examination: Nothing specific to RESULTS chronic sinusitis was revealed in all cases. Our study included 160 cases with Field of vision results: Three eyes out of unilateral and bilateral chronic sinusitis, the 237 eyes(1.26%) showed enlargement 39.4% were females,. The patients' age blind spot , despite a 6/6vision.(fig 1) ranged from 34 to 49 years with mean age EOM evaluation: Nine cases complained value 42± 5.2 years. of diplopia in extreme lateral gaze(5.6%). Cases with pansinusitis represented 52.5 Mild superior oblique underaction was % of our sample, where as 45% of recorded in these cases. patients had frontoethmoidal sinusitis, HertleExophthalmometer assessment: and 2.5% had isolatedsphenoidal Four cases of unilateral cases(4.8% of sinusitis. unilateral case, 2.5% from total cases) Unilateral cases contributed to 51.9% of showed mild enophthalmoswith a our sample(83 cases). difference of more than 2 mm between CT findings divided into: sinonasal the two eyes .Three cases from the polyposis 71.8% (115 cases), osteomeatal unilateral group(1.87% of the total) complex obstruction 22.5% (36 cases) , showed mild proptosis(difference of frontoehmoidalmucocele 3.1% (5 cases), 3mm), these case showed superior isolated fungal sphenoiditis 2.5% (4 oblique underaction in EOM assessment. cases) DISCUSSION Opthlamological assessment data It is common to encounter patients with visual included in our statistics included 237 disturbance in cases with chronic sinusitis. This eyes of the 160 patients. In the same time could be explained by optic nerve affection in data harvested from unilateral cases, were cases with sphenoidal sinusitis or spread of compared to the other normal side of the infection. Still some patients are not same patient. comfortable with their vision, despite normal BCVA ranged from 6/6 to 6/12. Whereas optic nerve function. It has been reported that 10.8%(9 cases) of the unilateral cases had acute sinusitis can trigger trigeminal neuraligia a difference of one or two lines between and affection, in a case report study (3). If this is the two eyes. true then chronic sinusitis may affect the Tear film evaluation results: trigeminal nerve in another way resulting into o Schirmer test: mean Schirmer test tear film disturbance. In a study by Galor et al was 20+/- 5.1 mm. We compared (4), dry eye was addressed as a pain disorder. eyes in unilateral cases with the They summarized the evidence that chronicity other side. The average Schirmer of dry eye is more likelyto occur in patients with results for the unilateral eye was dysfunction in their ocular sensory apparatus 19.7+/-5.3 mm compared to (ie, chronic ocular pain).Another hypothesis is 24.1+/- 4.7 mm .The difference that the pathology affecting nasal mucosa was statistically significant ( (allergy,infection) can logically affect p=0.007) conjunctival mucosa which is similar o Tear Meniscus height on slit histologically. On the other hand it has been lamp:had a mean of 599+/-179.3 suggested that chronic corneal pain, resulting 137 | P a g e AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 4 , OCTOPER 2015 SUPPL-2 from dry eye, may contribute to increased severity of other components of oculofacial pain. The neuropathic processes underlying chronic ocular pain may lead to increased afferent inputs to the trigeminal system, including neurons in the trigeminal ganglion, second-order neurons in the trigeminal brainstem, and third-order neurons in the thalamus (5).This
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