Deep Lateral Wall Research Articles

Changes in angle of optic nerve and angle of ocular orbit with increasing age in Japanese children

PurposeTo study changes in the opening angle of the optic nerve and the angle of the ocular orbit with increasing age in normal Japanese children.MethodsWe studied 147 normal children (aged...

Surgical effects of various orbital decompression methods in thyroid-associated orbitopathy: Computed tomography-based comparative analysis

ObjectivesTo evaluate the surgical effects of orbital fat decompression and bony decompression in each orbital wall using computed tomography (CT) in thyroid-associated orbitopathy (TAO). MethodsIn 27 TAO patients (48 orbits) with exophthalmos who underwent orbital wall decompression combined with fatty decompression, we recorded the resected orbital fat volume intraoperatively and estimated the decompression volume of the orbital wall in the deep lateral, medial and inferior walls using postoperative orbit CT images. Then, the correlation between exophthalmos reduction by Hertel reading and decompression volume in each area was analyzed to validate the surgical predictability, surgical efficiency and contribution level to total exophthalmos reduction. ResultsThe decompression volume in orbital fat and the deep lateral wall showed relatively high correlation with exophthalmos reduction (surgical predictability) compared to medial and inferior wall. The surgical efficiency was highest at deep lateral wall (2.704 ± 0.835 mm/cm3), followed by medial wall (0.892 ± 0.527 mm/cm3), orbital fat (0.638 ± 0.178 mm/cm3) and inferior wall (0.405 ± 0.996 mm/cm3). The actual contribution level to total exophthalmos reduction was highest in fatty decompression, followed by deep lateral decompression. ConclusionIn TAO patients with exophthalmos, orbital fat and deep lateral orbital wall are more predictable and contributory surgical targets for postsurgical exophthalmos reduction.

Outcome of Deep Lateral Wall Rim-Sparing Orbital Decompression in Thyroid-associated Orbitopathy: A New Technique and Results of a Case Series

Purpose: To describe a new technique for deep lateral (single) wall orbital decompression surgery, developed by Mr. Geoffrey Rose, for proptosis in patients with thyroid-associated orbitopathy and to analyse the results achieved in our series.Methods: The study is an interventional, retrospective, non-comparative case series. Twenty-one eyes of seventeen patients underwent the described technique of deep lateral wall orbital decompression for thyroid-associated orbitopathy. All patients had controlled thyroid functions and underwent surgery for cosmetic rehabilitation, with analysis of the reduction in proptosis, changes in visual acuity and post-operative complications. The surgery involved removing the lateral orbital wall whilst preserving the lateral rim, the lateral wall being approached through a horizontal skin incision placed lateral to the lateral canthus. After reflecting the periosteum, most of the bone (deep lateral wall) between the skull base and inferior orbital fissure is removed.Results: A mean reduction in proptosis of 4.81 mm ±1.23 (SD) (p < 0.0001) with a median of 5.0 mm (range 3–7 mm) was achieved and the best-corrected visual acuity was maintained in all patients. There were no complications during surgery, and post-operative complications included worsening of pre-existing diplopia in one patient (6%) and transient cheek/temple numbness seen in three patients (18%).Conclusions: This technique of deep lateral wall orbital decompression developed by Mr. Rose is a safe and effective procedure for patients with mild to moderate proptosis. It carries a low risk of morbidity and avoids complications associated with decompressing the floor and medial wall, including new onset of motility disorders.

Surgical Anatomy of Deep Lateral Wall by Adults Cadavers and Computed Tomography

Surgical Anatomy of Deep Lateral Wall by Adults Cadavers and Computed Tomography

Total Lateral Orbitotomy

Purpose: The goal of this study was to evaluate the safety and efficacy of performing a total lateral orbitotomy (TLO) to enhance the surgical exposure of the deep orbit.Materials and Methods: Ten orbits of five fresh-frozen cadaver heads were dissected to evaluate TLO surgical techniques. Through an eyelid approach, a bone flap extending from the supraorbital nerve to the infraorbital nerve was removed to enhance exposure to the orbital apex. The surgical exposure was further augmented by removing bone with the high-speed burr from the greater wing of sphenoid bone along the deep lateral wall. Anatomic landmarks that identified various compartments within the lateral wall and orbital roof were noted and measured. Five patients with posterior orbital tumors underwent TLO utilizing extended bone flaps and their surgical results and clinical outcomes were recorded.Results: The findings from this study demonstrate that the entire orbital rim from the supraorbital nerve to the infraorbital nerve may be removed without damaging critical neurovascular structures or creating a dural defect. Strategic removal of bone from the deep lateral wall can further enhance the exposure to the orbital apex. Five patients with deep orbital lesions underwent TLO with excellent surgical outcomes.Conclusions: By utilizing TLO techniques in a patient with a deep orbital lesion, the modern orbital surgeon can access the orbital apex safely and predictably through an eyelid approach.

Transorbital endoscopic surgery

Orbital surgery is traditionally performed through an open approach and often involves bone removal for better visualization. The use of an endoscope obviates the need for bone removal in certain situations, particularly for lesions involving the orbital roof. Transorbital use of the endoscope also provides better visualization when one is working deep within the orbit, for instance, on the deep lateral wall. However, the endoscope can only be situated in the subperiosteal space, thus limiting its utility. In the article, the authors describe their technique for transorbital endoscopic surgery and review the uses and limitations of transorbital endoscopic surgery.

Strabismus after Deep Lateral Wall Orbital Decompression in Thyroid-Related Orbitopathy Patients Using Automated Hess Screen

To evaluate the effect of deep lateral wall orbital decompression with intraconal fat debulking on strabismus in thyroid-related orbitopathy (TRO) patients using automated Hess screen (AHS). Prospective nonrandomized clinical study. Eleven TRO patients (19 surgeries) operated on at the Jules Stein Eye Institute from January, 2004, through December, 2004. Automated Hess screen testing was performed in all patients before surgery and 3 months after surgery; all patients received surgery in the nonactive phase of the disease. Amplitude of horizontal and vertical deviations (prism diopters) in all standard positions of gaze. Eleven TRO patients (7 females; mean age, 47 years) were included in the study; 8 patients underwent bilateral surgery. After surgery, exophthalmos decreased an average (+/-standard deviation) of 2.7 mm (+/-2.5 mm; P = 0.003). Before surgery, 7 patients (63%) reported primary gaze diplopia, whereas only 2 patients (18%) showed diplopia in primary gaze after surgery (P = 0.03, chi-square analysis). Orbital decompression had no statistically significant effect on horizontal and vertical ocular deviations measured by AHS. Mean amplitude of deviation in primary gaze was 1.2 prism diopters (PD) esotropia and 0.07 PD hypotropia before surgery, and 2.5 PD exotropia with 0.6 PD hypertropia after surgery (delta = 3.7 PD for horizontal deviation and -0.7 for vertical deviation; P = 0.051, paired samples t test for horizontal difference and P not significant for vertical difference). Nonsignificant P values were obtained in all 9 positions of gaze. Most patients had periocular numbness that resolved spontaneously 2 to 6 months after surgery. Deep lateral wall orbital decompression with intraconal fat debulking had no statistically significant effect on horizontal and vertical deviations measured by the AHS. Patients may demonstrate small angle exotropia shift, but this finding was not clinically significant.

The Removal of the Deep Lateral Wall in Orbital Decompression: Its Contribution to Exophthalmos Reduction and Influence on Consecutive Diplopia

The Removal of the Deep Lateral Wall in Orbital Decompression: Its Contribution to Exophthalmos Reduction and Influence on Consecutive Diplopia

The Removal of the Deep Lateral Wall in Orbital Decompression: Its Contribution to Exophthalmos Reduction and Influence on Consecutive Diplopia

To evaluate the contribution of maximal removal of the deep lateral wall of the orbit to exophthalmos reduction in Graves' orbitopathy and its influence on the onset of consecutive diplopia. Case-control study. The medical records of two cohorts of patients affected by Graves' orbitopathy with exophthalmos > or = 23 mm, without preoperative diplopia, were retrieved at random from the pool of patients decompressed for rehabilitative reasons at our institution (01/1990 to 12/2003), and retrospectively reviewed. They had been treated with an extended (cases, group 1, n = 15) or conservative (controls, group 2, n = 15) 3-wall orbital decompression performed through a coronal approach. The deep portion of the lateral wall had been removed in the extended decompression group while preserved in the conservative decompression group. Demographics, preoperative characteristics, and surgical outcome were compared. The difference in mean exophthalmos reduction between groups 1 and 2 was considered to be the contribution of the deep lateral wall to reduction of exophthalmos. Groups 1 and 2 were drawn from a pool of 37 and 335 patients, respectively. Demographics and preoperative characteristics of the two groups were not significantly different. The mean contribution of the deep lateral wall to exophthalmos reduction was 2.3 mm. The onset of consecutive diplopia was not significantly different between the two groups (case n = 2/15, controls n = 5/15; P = .203). Diplopia resolved spontaneously in all the patients of group 1, while all the patients of group 2 required surgery. Removal of the deep lateral orbital wall as part of a coronal-approach, 3-wall decompression, enhances the degree of exophthalmos reduction without increasing the risk of consecutive diplopia.

Simultaneous Orbital Decompression and Correction of Upper Eyelid Retraction versus Staged Procedures in Thyroid-Related Orbitopathy

To evaluate the outcome of eyelid retraction surgery in thyroid-related orbitopathy (TRO) patients in 2 different surgical settings: done simultaneously with orbital decompression or as a staged procedure after orbital decompression. Retrospective, comparative, nonrandomized clinical study. Ninety-six patients (158 eyes). A review of electronic medical records of TRO patients who underwent surgery for upper eyelid retraction and orbital decompression at the Jules Stein Eye Institute in 1999 to 2003 was performed. Data regarding eyelid position, comprehensive eye examination, surgical outcome, and complications were analyzed. Anatomical and functional success based on margin reflex distance (MRD1; < or = 5 mm was graded as mild retraction; > 5 mm and < 7 mm, moderate; and > 7 mm, severe), and patients' discomfort. One hundred fifty-eight eyelid retraction surgeries were performed on 96 TRO patients (18 male and 78 female; mean age, 48 years); mean follow up time was 15 (+/-12) months. Group 1 consisted of patients undergoing simultaneous eyelid retraction surgery and orbital decompression and comprised 97 cases (surgeries). Group 2 included 61 cases of staged surgery: orbital decompression and eyelid retraction at a later stage. The groups had similar surgical outcomes, and > 85% had a better eyelid position postoperatively. Reoperation rates for residual or recurrent eyelid retraction were similar, overcorrection was higher in group 2 (5% vs. 0%, P = 0.03). Changes in MRD1, lagophthalmos, and exophthalmos were similar (P > 0.05, independent samples t test). Correction of eyelid retraction was effective in treating patients' discomfort and exposure keratopathy (P = 0.04, chi2). No severe complications occurred after orbital decompression or eyelid retraction surgery in this group of patients. Transconjunctival Muller's muscle recession for correction of eyelid retraction in mild to moderate TRO patients, performed simultaneously with deep lateral wall orbital decompression, resulted in acceptable eyelid position in two thirds of our patients. Overcorrection and consecutive ptosis occurred less often after combined orbital decompression and eyelid retraction surgery than after isolated eyelid repositioning surgery. If confirmed in prospective controlled studies, eyelid-repositioning surgery performed at the time of orbital decompression may decrease the number of total procedures and compress the time needed for surgical rehabilitation.

Thyroid-associated orbitopathy: a clinicopathologic and therapeutic review

To review the literature related to thyroid-associated orbitopathy and to emphasize recent developments in its pathophysiology, diagnosis, and therapy. Current therapeutic trends and controversies are discussed. Expression of thyroid stimulating hormone receptor is highest in the fat and connective tissue of patients with thyroid-associated orbitopathy, where fibroblasts have the potential for adipogenesis. Electrophysiology can now detect subclinical optic neuropathy, and somatostatin-receptor scintigraphy can help justify immunomodulation. Other than steroids, radiotherapy can control inflammation, but its use is controversial. Current trends in orbital decompression are to camouflage incisions and to limit strabismus with balanced decompression, deep lateral wall techniques, fat removal, and onlay implants. Proptosis reductions of 0.9 to 12.5mm are possible by the use of various algorithms. Before or after decompression, botulinum toxin can correct strabismus, intraocular pressure elevation, and retraction. The latter is now also treated with full-thickness blepharotomy. As knowledge of the pathophysiology of thyroid-associated orbitopathy grows, there is a slow movement from nonspecific and invasive measures to more directed treatments causing less morbidity.

Primary-gaze diplopia in patients with thyroid-related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome.

Our goal was to investigate the incidence of postoperative primary gaze diplopia in patients with thyroid-related orbitopathy (TRO) undergoing deep lateral wall orbital decompression surgery with intraconal fat debulking in the Jules Stein Eye Institute over a period of 4(1/4) years. Overall 201 orbital decompression surgeries were performed in 116 patients (23 males, 93 females). All surgeries were performed by two of the authors (R.A.G. and J.D.M.) and in the noninflammatory phase of the disease. Exophthalmos decreased by an average of 3.4 +/- 2.7 mm from 23.8 +/- 3.2 mm (17-31) to 20.4 +/- 2.5 mm (14-29), p < 0.001, 95% confidence interval (CI) (3.0:3.8). 31% of patients had preoperative primary gaze diplopia and 28.4% had postoperative primary gaze diplopia. Thirty (83%) of the 36 patients with preoperative diplopia had also postoperative diplopia; 6 (16.7%) of the 36 patients had improvement in diplopia following deep lateral wall decompression. Of the 80 (69%) of patients without preoperative double vision 3 developed postoperative double vision in primary gaze (2.6% of all patients). These 3 patients were older (56 versus 46 years, p = 0.047), had more limitation in ocular movements (p = 0.017) and achieved more decrease in proptosis with surgery (6 versus 3.1 mm, p = 0.024). No complications were associated with orbital decompression. In conclusion deep lateral wall orbital decompression surgery with intraconal fat debulking is associated with a low rate (2.6%) of new-onset primary gaze diplopia. Some patients (5.2%) with preoperative diplopia actually had improvement in diplopia postoperatively. This surgery is effective in reduction of congestion and exophthalmos, and is not associated with detrimental effects on visual acuity.

The lacrimal keyhole, orbital door jamb, and basin of the inferior orbital fissure. Three areas of deep bone in the lateral orbit.

To calculate the volume of bone in 3 areas of the deep lateral orbit that are available for removal in decompression surgery and to demonstrate these 3 areas within a 3-dimensional computed tomographic reconstruction of the orbit. The 3 areas of bone in the deep lateral orbit were designated the lacrimal keyhole, the sphenoid door jamb, and the basin of the inferior orbital fissure. By means of digitized computed tomographic scans, these 3 areas of bone were analyzed by measuring preoperative and postoperative orbital volumes and predicted bony expansion volumes in 9 patients (17 orbits) who underwent deep lateral orbital decompression surgery. We also calculated the volume of bone that could be removed from 11 normal orbits. A 3-dimensional computer reconstruction of an orbital computed tomographic scan was created, and the 3 areas of potential bone were delineated within it. The average volumes of the basin of the inferior orbital fissure, the sphenoid door jamb, the lacrimal keyhole, and the total of the 3 regions were 1.2, 2.9, 1.5, and 5.6 cm3, respectively. The 3 areas of bone contributed variably to the total, with the door jamb contributing the most volume of the 3, nearly twice the value of the other 2. There was, however, a significant amount of interpatient variability, especially for the door jamb region. Orbital decompression surgery of the deep lateral wall can provide adequate volume expansion because of the amount and location of potential space that exists in the 3 areas of deep bone.