Contralateral Orbit Research Articles

Combined Transconjunctival and Transcaruncular Approach for Repair of Large Medial Orbital Wall Fractures

To describe the combined transcaruncular and transconjunctival approach in isolated large medial orbital wall fractures and to study the implications of uncorrected posterior orbital volume on postoperative enophthalmos. A retrospective medical record review was performed of 23 consecutive patients who underwent reduction surgery for isolated large medial orbital wall fractures using the combined transcaruncular and transconjunctival approach between February 1, 2003, and October 31, 2007. The unaffected contralateral orbital volume was assumed to represent the pretrauma volume of the affected orbit, and the uncorrected posterior orbital volume after reduction was determined using a software program. The mean (SD) volume of the affected orbit changed from 26.00 (2.01) cm3 to 24.08 (2.06) cm3 after reduction, which was still larger than the contralateral unaffected orbit by 1.48 (0.83) cm3. Despite the uncorrected volume in the most posterior portion of the medial wall, the mean (SD) postoperative enophthalmos measured only 0.17 (0.29) mm using Hertel exophthalmometry at a mean follow-up of 8.5 months. The combined transconjunctival and transcaruncular approach results in excellent outcomes in terms of prevention of postoperative enophthalmos of the large medial wall fracture without substantial complications. The far posterior medial volume may not contribute significantly to the development of posttraumatic enophthalmos.

Clinical Implications of Orbital Volume Change in the Management of Isolated and Zygomaticomaxillary Complex–Associated Orbital Floor Injuries

Orbital floor injuries can occur in isolation or in association with zygomaticomaxillary complex fractures. Volumetric computed tomographic measurements of affected orbits are investigated for utility in guiding management in these two groups. The medical records of all patients with craniomaxillofacial injuries (2003 to 2005) were reviewed. Of 522 total patients, 45 patients had isolated orbital floor fractures, 13 of whom underwent repair (29 percent), and 64 had zygomaticomaxillary complex fractures, 36 of whom underwent reconstruction (56 percent) and 10 of whom underwent orbital floor repair (16 percent). Radiographic criteria for floor exploration included 50 percent area fracture in isolated injuries and 10-mm estimated zygomaticomaxillary complex compression in zygomaticomaxillary complex-associated floor injuries. Volume measurements of the affected orbits were obtained and compared with the uninjured contralateral orbit. Before treatment in the operative zygomaticomaxillary complex group, there was an average decrease in orbital volume of 18.3 percent. In the isolated orbital floor group, there was an average increase in orbital volume of 28.3 percent. Zygomaticomaxillary complex-associated orbital floor injuries can be compressive injuries associated with loss of volume, whereas isolated injuries generally result in volume expansion. Radiographic criteria are often considered in the decision to proceed with orbital floor exploration to avoid late enophthalmos. The literature suggests that a 20 percent change in orbital volume results in perceptible deformity. Therefore, a radiographic criterion of 50 percent floor area (28 percent volume increase) in isolated injuries may be too stringent; an estimated 10 mm of compression (18.3 percent volume change) is a reasonable operative criterion for floor exploration in zygomaticomaxillary complex-associated injuries.

Colour Doppler imaging evaluation of blood flow parameters in the ophthalmic artery in acute and chronic phases of optic neuritis in multiple sclerosis

Optic neuritis (ON) is a common manifestation of multiple sclerosis (MS). It is caused by the immune-mediated inflammation of the optic nerve. Some vascular factors that may influence blood flow in the ophthalmic artery (OA) have also been suggested as factors in the pathogenesis of ON. The purpose of our study was to evaluate blood flow velocities and resistance (RI) and pulsatile (PI) indices in the OA in both orbits in patients in the acute and chronic phases of unilateral ON and to compare these with equivalent findings in healthy control subjects. Orbital colour Doppler imaging (CDI) was performed in 40 consecutive MS patients during acute unilateral ON prior to corticosteroid treatment. Optic neuritis was diagnosed on the basis of clinical presentation and facultative assessment of visual evoked potentials (VEPs). The peak systolic (PSV) and end-diastolic (EDV) velocities and RI and PI were measured in the OA in both eyes. We compared results from affected and unaffected orbits using the paired t-test. The same measurements were performed in 114 MS patients with a history of acute unilateral ON that occurred > 1 year prior to ultrasound examination. We also measured the same parameters in the middle cerebral arteries (MCAs) on both sides in all subjects in both groups. The same measurements were obtained in healthy controls. The PSV (p < 0.0001), RI (p < 0.0001) and PI (p < 0.0001) in the OA in the eye affected with acute ON were significantly higher than in the unaffected eye. There was no difference in EDV in the OA between affected and unaffected eyes (p > 0.05) in the group with acute ON. We did not observe any significant differences between eyes in either blood flow velocities or the RI or PI (p > 0.05) in the group in the chronic phase of ON or in the control group. All the parameters in the MCAs on both sides were normal in both the acute and chronic groups, as well as in the control group. Pathophysiological changes during acute unilateral ON influence orbital haemodynamics, as is indicated by increased PSV, RI and PI in the OA in eyes affected with ON. However, these changes do not persist over longer periods.

Treated Choroidal Melanoma with Late Metastases to the Contralateral Orbit

Choroidal melanoma is the commonest adult primary intraocular tumour,1 and usual sites of secondary spread are to liver, bone and lung. Although delayed recurrence of ipsilateral orbital melanoma is well documented, metastasis to the contralateral orbit is a rarely encountered phenomenon. We describe a case of metastatic spread to the contralateral orbit in a patient 12 years after proton beam radiotherapy of choroidal melanoma.

Intensity-modulated radiation therapy for orbital lymphoma

Orbital manifestations of non-Hodgkin's lymphoma (NHL) are rare and accounts for only 1% of all cases of NHL. There have been no reports of treating orbital lymphoma using intensity-modulated radiotherapy (IMRT). Four patients were treated at our institution for orbital lymphoma using IMRT. Radiotherapy (RT) plans using wedged pair fields were developed for comparison. Clinical results using IMRT are presented and a dosimetric analysis between IMRT and RT was performed. All patients had a complete response based on their physical examinations and post-IMRT imaging. Symptoms that had been present at initial presentation resolved in all patients during the course of the treatment. All four patients experienced only grade 1 dry eye syndrome and keratitis. The average dose to the contralateral orbit, lacrimal gland, and lens were all significantly reduced (P < 0.01) in IMRT patients as compared to the RT patients. IMRT reduced the V5 and V10 for the contralateral lens, orbit, and lacrimal gland and the optic chiasm (P < 0.05). IMRT is feasible when treating orbital lymphoma and reduces dose to critical structures while providing excellent dose coverage of target volumes. IMRT offers patients with orbital lymphoma excellent clinical outcomes, similar to conventional RT, with no increased toxicity.

Computer-aided Volume Measurement of Posttraumatic Orbits Reconstructed With AO Titanium Mesh Plates: Accuracy and Reliability

To prospectively evaluate the accuracy and reliability of "freehand" posttraumatic orbital wall reconstruction with AO (Arbeitsgemeinschaft Osteosynthese) titanium mesh plates by using computer-aided volumetric measurement of the bony orbits. Bony orbital volume was measured in 12 patients from coronal CT scan slices using OsiriX Medical Image software. After defining the volumetric limits of the orbit, the segmentation of the bony orbital region of interest of each single slice was performed. At the end of the segmentation process, all regions of interest were grouped and the volume was computed. The same procedure was performed on both orbits, and thereafter the volume of the contralateral uninjured orbit was used as a control for comparison. In all patients, the volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 1.85 cm3 (7%). This preliminary study has demonstrated that posttraumatic orbital wall reconstruction using "freehand" bending and placement of AO titanium mesh plates results in a high success rate in re-establishing preoperative bony volume, which closely approximates that of the contralateral uninjured orbit.

Prediction of Enophthalmos by Computer-Based Volume Measurement of Orbital Fractures in a Korean Population

To estimate posttraumatic enophthalmos using computer-based volume measurement of the orbital fracture to provide information on surgical guidelines. The fracture volume of orbital wall fractures in 35 patients who did not undergo surgery was measured using a Rapidia work station system. Hertel ophthalmometry, diplopia, and ocular motility were investigated. The fracture volume measurements relative to the intact contralateral orbit were correlated with enophthalmos, diplopia, and ocular motility. Patients were examined at the initial visit, then at 1 week, 1 month, and 3 months. There was a correlation between the fracture volume and enophthalmos. Late enophthalmos increased in size in proportion to the volume of the fractured site. The predicted orbital fracture volume with an enophthalmos measurement of 2 mm or more was 2.30 ml. Computer-based measurements of orbital fracture volume can be used to predict overall enophthalmos and provide useful information to surgeons.

Short and long duration transcranial direct current stimulation (tDCS) over the human hand motor area

The aim of the present paper is to study effects of short and long duration transcranial direct current stimulation (tDCS) on the human motor cortex. In eight normal volunteers, motor evoked potentials (MEPs) induced by transcranial magnetic stimulation (TMS) were recorded from the right first dorsal interosseous muscle, and tDCS was given with electrodes over the left primary motor cortex (M1) and the contralateral orbit. We performed two experiments: one for short duration tDCS (100 ms, 1, 3 or 5 mA) and the other for long duration tDCS (10 min, 1 mA). The stimulus onset asynchrony (SOA) between the onset of tDCS and TMS were 1-7 and 10-120 ms for the former experiment. In the latter experiment, TMS was given 0-20 min after the end of 10 min tDCS. We evaluated the effect of tDCS on the motor cortex by comparing MEPs conditioned by tDCS with control MEPs. Cathodal short duration tDCS significantly reduced the size of responses to motor cortical stimulation at SOAs of 1-7 ms when the intensity was equal to or greater than 3 mA. Anodal short duration tDCS significantly increased MEPs when the intensity was 3 mA, but the enhancement did not occur when using 5 mA conditioning stimulus. Moreover, both anodal and cathodal short duration tDCS decreased responses to TMS significantly at SOAs of 20-50 ms and enhanced them at an SOA of 90 ms. Long duration cathodal tDCS decreased MEPs at 0 and 5 min after the offset of tDCS and anodal long duration tDCS increased them at 1 and 15 min. We conclude that the effect at SOAs less than 10 ms is mainly caused by acute changes in resting membrane potential induced by tDCS. The effect at SOAs of 20-100 ms is considered to be a nonspecific effect of a startle-like response produced by activation of skin sensation at the scalp. The effect provoked by long duration tDCS may be short-term potentiation or depression like effects.

Comparison of Orbital Volumes in Enucleated Patients With Unilateral Retinoblastoma: Hydroxyapatite Implants Versus Silicone Implants

To compare the difference in volume between enucleated and contralateral, uninvolved orbits in patients with unilateral retinoblastoma treated with primary enucleation who received either hydroxyapatite or solid silicone implants. In this retrospective, comparative interventional case series, data were reviewed for all patients (N = 33) with retinoblastoma at St. Jude Children's Research Hospital who underwent unilateral enucleation and received either hydroxyapatite or solid silicone implant from 1969 to 1999. Patients who received external beam radiation or systemic chemotherapy were excluded. CT and/or MRI were used to compare the difference in orbital volumes between the enucleated orbit and the contralateral orbit in 13 patients who underwent enucleation with hydroxyapatite implants vs. 20 patients who underwent enucleation with silicone implants. The main outcome measure was the difference in volume between enucleated and contralateral, uninvolved orbits correlated to implant material, which we determined using the Wilcoxon rank sum test. The median difference in orbital volumes between enucleated and contralateral, uninvolved orbits was 0.9 cm (range, -3.78 to 3.09 cm; quartiles, -0.37, 2.72 cm; mean +/- standard error [SE], 0.76 +/- 0.64 cm; 95% confidence interval [CI], -0.49 to 2.01 cm) for patients treated with hydroxyapatite implants vs. 0.63 cm (range, -4.43 to 3.91 cm; quartiles, 0, 2.13 cm; mean +/- SE, 0.8 +/- 0.41 cm; 95% CI, -0.004 to 1.6 cm) in patients treated with silicone sphere implants. The median differences did not differ between the 2 types of implant (p = .74). The median follow-up time was 137 months (range, 10-244 months; quartiles, 37, 179 months; mean +/- SE = 118.31 +/- 22.83 months; 95% CI, 73.56-163.06 months) and 144 months (range, 57-251 months; quartiles, 98, 154 months; mean +/- SE, 136.1 +/- 10.78 months; 95% CI, 114.97-157.23 months), respectively. In unilateral retinoblastoma patients treated with primary enucleation, hydroxyapatite-integrated orbital implants provide no better symmetry of orbital volume than do more traditional silicone implants.

Astigmatism in unilateral coronal synostosis: Incidence and laterality

Unilateral coronal synostosis alters orbital development and can be associated with strabismus, oblique muscle dysfunction, astigmatism, and amblyopia. While the ocular effects are most dramatic on the side of the fusion, the shape of the contralateral orbit is also abnormal and the effect of these changes on bilateral visual development has not been fully described. The purpose of this study was to analyze the incidence and laterality of astigmatism in children with unilateral coronal synostosis. We retrospectively reviewed the charts of 39 consecutive patients with unilateral coronal synostosis. Recorded data included the following: patient demographics, visual acuity, cycloplegic refraction, ocular motility, procedures for craniofacial and strabismus correction, and presence and treatment of amblyopia at each visit. Twenty-one of 39 patients (54%) had 1.00 D or more astigmatism in at least one eye at their last recorded refraction. Sixteen of the 21 (76%) had aniso-astigmatism of 1.00 D or more. Of the 16, 14 (88%) had the greater degree of astigmatism in the contralateral eye. Fifteen of the 39 studied (38%) had amblyopia and, in 12 of these 15 patients (80%), the amblyopic eye was contralateral to the synostosis. Nineteen of 39 patients (49%) had greater ipsilateral fundus excyclotorsion, whereas only 1 of 39 (3%) had greater contralateral excyclotorsion. Patients with unilateral coronal synostosis are at risk for developing a greater degree of astigmatism in the eye contralateral to the synostosis. Ocular disturbances in the contralateral eye, especially anisometropic amblyopia, must be considered when treating patients with this type of craniosynostosis.

Late Reconstruction of the Complex Orbital Fractures With Computer-Aided Design and Computer-Aided Manufacturing Technique

To construct three-dimensional (3D) imaging and computer generated models of complex orbital fractures, and develop a Computer-Aided Design/Computer-Aided Manufacture (CAD/CAM) system to help improve the surgical planning of complex orbital fracture and promote its outcome. A prospective study was carried out on 17 patients with unilateral complex orbital fractures from Mar 2003 to Mar 2006 at the Shanghai ninth people's hospital. The utilization of a CAD/CAM technique based on Helical computer tomography data, with stereolithographical (SLA) modelling as intermediate step, enabled surgeons to plan for the surgical progress of osteotomy, movement, reposition, fixation and material implanting. Orbital volume was calculated pre and post-operatively. Orbital fracture reconstruction and globe repositioning was performed and followed up 3-9 months post-treatment. Ocular function and aesthetic deformities such as enophthalmos, diplopia and extraocular motility problems were accessed. The data was processed with SAS 6.17 statistical software. 17 patients with complex orbital fractures underwent successful orbital fracture reconstruction surgery. The deformities of orbit, medial canthus, nose, zygomata, maxillary and frontal bone were well corrected. The volume of reconstructed orbit was approximately symmetrical with respect to the contralateral orbit. Enophthalmos was corrected and diplopia, extraocular movement were improved. CAD/CAM system enables the surgeon to predict reconstructive surgical steps before the operation, and can help to improve the outcome of surgery. This technique may be proved as one of the most useful clinical tools for orbital surgery.

The proprioceptive representation of eye position in monkey primary somatosensory cortex

The cerebral cortex must have access to an eye position signal, as humans can report passive changes in eye position in total darkness, and visual responses in many cortical areas are modulated by eye position. The source of this signal is unknown. Here we demonstrate a representation of eye position in monkey primary somatosensory cortex, in the representation of the trigeminal nerve, near cells with a tactile representation of the contralateral brow. The neurons have eye position signals that increase monotonically with increasing orbital eccentricity from near the center of gaze, with directionally selectivity tuned in a Gaussian manner. All directions of eye position are represented in a single hemisphere. The signal is proprioceptive, because it can be obliterated by anesthetizing the contralateral orbit. It is not related to foveal or peripheral visual stimulation, and it represents the position of the eye in the head and not the angle of gaze in space.

Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: A pilot study

Background and Purpose: Preliminary reports suggest that central stimulation may enhance the effect of conventional physical therapies after stroke. This pilot study examines the safety and methodology of using transcranial direct stimulation (tDCS) with robot-assisted arm training (AT), to inform planning a larger randomised controlled trial. Subjects: Ten patients, after an ischaemic stroke 4–8 weeks before study onset, no history of epilepsy, participated. Eight had a cortical lesion and 2 had subcortical lesions: all had severe arm paresis and, co-incidentally, 5 had severe aphasia. Methods: Over six weeks, they received thirty 20 min-sessions of AT. During the first 7 minutes, 1.5mA of tDCS was applied, with the anode over the lesioned hemisphere and the cathode above the contralateral orbit. Arm and language impairment were assessed with the Fugl-Meyer motor score (FM, full range 0–66) and the Aachener Aphasie Test. Results: No major side effects occurred. Arm function of three patients (two with a subcortical lesion) improved significantly, with FM scores increasing from 6 to 28, 10 to 49 and 11 to 48. In the remaining seven patients, all with cortical lesions, arm function changed little, FM scores did not increase more than 5 points. Unexpectedly, aphasia improved in 4 patients. Conclusions: These procedures are safe, and easy to use in a clinical setting. In future studies, patients should be stratified by degree of arm weakness and lesion site, also the unexpected aphasia improvement warrants following-up.

Evaluation of an Integrated Orbital Tissue Expander in an Anophthalmic Feline Model

To evaluate the anatomical effects and tissue biocompatibility in a feline model of an integrated orbital tissue expander (OTE) designed to stimulate bone growth in an anophthalmic socket. An animal study was performed in cats to assess orbital bone growth with and without an OTE. The OTE is an inflatable (0.5 to >6.0 cm(3)) polymeric globe sliding on a titanium T plate secured to the lateral orbital rim with screws. Eight cats had left eye enucleation at age two weeks, with five orbits receiving an OTE and the remaining three serving as nonimplanted controls. Serial transconjunctival implant inflation was performed by injecting normal saline solution into the OTE to a final volume of 3.5 ml. Serial computed tomographic scans were obtained to assess socket growth. All eight cats were euthanized at 18 weeks and dry skulls prepared. The effective orbital volume was measured by inflating an OTE in the orbit of a dry skull until it filled the cavity completely. Three cats periodically scratched open the tarsorrhaphy and conjunctiva to rupture the OTE, which resulted in implant exchanges. At 18 weeks, the OTE expanded orbital volume was approximately 18% smaller than the normal contralateral side. In the control animals, the anophthalmic orbital volume was approximately 66% smaller than the contralateral orbit. Histopathology of orbital tissues showed no evidence of foreign body reaction. This proof-of-concept pilot study demonstrated implant efficacy in cats, and no implant-related adverse effects were observed. OTE has the potential to stimulate bone growth in human anophthalmic orbits.

Anatomical 3-dimensional Pre-bent Titanium Implant for Orbital Floor Fractures

This cadaver study evaluates the use of pre-bent 3-dimensional titanium mesh implants for orbital floor and medial wall reconstruction. Nonrandomized comparative study. Eight human cadaveric heads (n = 16 orbits). Transcutaneous incisions were used to expose both orbital floors in each cadaveric head. Unilateral orbital floor and medial wall fractures were generated in each specimen. The contralateral orbit remained uninjured. The fractures then were repaired with pre-bent titanium mesh fan plates molded from aluminum templates presenting different sizes. The templates were generated from topographical computed tomography (CT) data previously obtained from normal subjects. The accuracy of orbital reconstruction was evaluated with postoperative CT scans. The mean value of the distances between the implant and the bony orbit was evaluated. The mean distance between all 16 plates and their respective orbital floors/medial walls was 0.81+/-0.74 mm. Mean values were 0.68+/-0.63 mm for the unfractured side and 0.93+/-0.82 mm for the fractured side. No significant differences were found between orbits when evaluated for side of injury, gender, or size of defect. Pre-bent 3-dimensional titanium mesh implants provide accurate reconstruction of orbital floor and medial orbital wall fractures. The mean implant error was <1 mm for all orbits studied.

Ocular adnexal mucosa-associated lymphoid tissue lymphoma treated with radiotherapy

Forty-two patients with stage IE ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma were retrospectively analyzed. Five-year local control and progression-free survival rates were 100 and 77%, respectively. The most common relapsed site was the contralateral orbit. Thirty Gy of local irradiation seemed to be quite effective and safe.

Tumores malignos da cavidade nasal: tomografia computadorizada e ressonância magnética

OBJETIVO: Este estudo propõe-se a avaliar o papel da tomografia computadorizada e da ressonância magnética na caracterização da extensão profunda dos tumores malignos da cavidade nasal. MATERIAIS E MÉTODOS: Entre 1990 e 2000 foram avaliados, retrospectivamente, 12 pacientes com diagnóstico de tumores malignos da cavidade nasal atendidos nos Departamentos de Diagnóstico por Imagem e Cirurgia de Cabeça e Pescoço do Complexo Hospitalar Heliópolis, São Paulo, SP. Todos os casos foram confirmados com exame anatomopatológico. RESULTADOS: Foi identificada extensão para os seios maxilares e etmoidal em seis pacientes, para a cavidade nasal contralateral, órbita e lâmina crivosa em cinco pacientes, para a nasofaringe e espaço mastigatório em dois pacientes, e para o seio cavernoso, fossas cranianas anterior e média, fossa pterigomaxilar, fissuras orbitárias superior e inferior, seio frontal, seio etmoidal contralateral, lâmina crivosa contralateral, palato duro e fossa pterigopalatina em um paciente. CONCLUSÃO: A análise precisa da extensão local e disseminação tumoral dada pela tomografia computadorizada e ressonância magnética desempenha papel importante no planejamento terapêutico, influenciando também o prognóstico.

Traumatic Carotid-cavernous Fistula with Contralateral Proptosis: Case Report

Traumatic carotid-cavernous fistula frequently results in proptosis on the side of the fistula by retrograde drainage from the cavernous sinus to the superior ophthalmic vein. The involvement of the opposite orbit is due to the presence of connections between the cavernous sinuses on both sides, but exclusive contralateral orbit involvement is rare. We report a case in which the CCF with a contralateral proptosis developed in a 63 year-old man after a motor vehicle accident. MR angiography depicted the markedly dilated left cavernous sinus and left superior ophthalmic vein, sparing the right side. However, angiography showed a direct fistula between the right internal carotid artery and cavernous sinus with exclusive contralateral venous drainage via the intercavernous sinus. A detachable balloon was used to occlude the fistula, and the contralateral orbital symptom regressed.

Orbital Melanoma Metastatic From Contralateral Choroid: Management by Complete Surgical Resection

We discuss a clinicopathologic correlation of orbital metastasis from a contralateral choroidal melanoma wherein the orbital tumor was removed completely by surgical resection. In October 1982, a 29-year-old woman was treated with cobalt-60 plaque radiotherapy for a choroidal melanoma in her right eye. The tumor responded well but recurred after 9 years, necessitating enucleation. In August 1999, 17 years after initial presentation, metastatic melanoma to liver, lung, and brain were found and the patient had a favorable response to chemotherapy and brain irradiation. Five months later, in November 2000, an enlarging orbital mass was documented to be compressing the left optic nerve. Complete surgical removal of the tumor was achieved by a superotemporal orbitotomy. Histopathologically, the tumor was a malignant melanoma with features similar to the choroidal tumor. The contralateral orbit can be the site of late metastasis from choroidal melanoma. In rare instances, an orbital metastasis can be completely removed surgically without subjecting the patient to orbital irradiation.

Late recurrence of unilateral graves orbitopathy on the contralateral side

PURPOSE: To report a case of late recurrence of unilateral Graves orbitopathy on the contralateral side after 7 years. DESIGN: Interventional case report. METHODS: A 44-year-old woman with left unilateral Graves orbitopathy underwent two-wall orbital decompression on the left side. After strabismus surgery and left upper eyelid surgery, she was discharged. RESULTS: Seven years after discharge, the patient developed Graves orbitopathy on the right side, and she underwent two-wall orbital decompression on the right side. CONCLUSION: At least in patients with unilateral Graves orbitopathy, late recurrence of the disease in the contralateral orbit may occur.