Inferomedial Orbit Research Articles

Anatomical Reconstruction of Extensive Inferomedial Blow-Out Fractures Involving the Inferomedial Orbital Strut Using a Single Fan-shaped Titanium-Reinforced Porous Polyethylene Plate.

Extensive inferomedial blow-out fractures involving the inferomedial orbit strut frequently result in severe ophthalmic complications. Therefore, anatomical reconstruction is essential but is still technically challenging. Thus, the authors have used a novel technique using a combination of single fan-shaped titanium-reinforced porous polyethylene (TR-PPE) implants and a bidirectionally extended transconjunctival approach. Herein, the authors describe our surgical technique and discuss its effectiveness. First, the transconjunctival approach was performed and was subsequently extended medially using the transcaruncular approach and laterally using lateral blepharotomy. After the origin of the inferior oblique muscle was identified, a trimmed fan-shaped TR-PPE implant was inserted into the orbital floor. It was subsequently rotated and bent at the site of origin of the IO muscle and moved upward to cover the superior bony ledge of the medial wall. Finally, the implant was fixed to the orbital rim. Anatomical orbital reconstruction was confirmed by a computed tomographic scan. The preoperative diplopia in 19 patients, resolved within 1 week in 16 patients and in 3 to 6 months in the remaining 3 patients. Preoperative enophthalmos >2mm in all patients improved to <2mm in 67 patients and 3mm in 2 patients (>7mm preoperatively). The postoperative course was uneventful, and no severe complications were observed. The authors believe that the placement of a fan-shaped TR-PEE implant into the orbit through the bidirectionally extended transconjunctival approach could be a viable option for the anatomical reconstruction of extensive inferomedial blow-out fractures involving the inferomedial orbital strut.

Transcaruncular medial orbitotomy: A globe sparing intervention in management of COVID associated mucormycosis [CAM

To describe a novel method of transcaruncular medial orbitotomy, local debridement and amphotericin B irrigation into orbit for COVID-19-associated rhino-orbital mucormycosis. Also to evaluate its its outcome in controlling the disease, increasing the survival rate and as a globe-sparing intervention in them. A total of ten COVID-19-associated mucormycosis patients with clinical and radiological evidence of orbital involvement with necrotic tissue localized in medial orbit were considered for our study. A transcaruncular modified medial orbitotomy with medial and inferomedial orbit debridement was done along with placement of scalp vein catheter by a single surgeon. Postoperatively 3.5 mg/ml liposomal amphotericin B irrigation through the catheter was done for 5 sittings. Correction of underlying systemic conditions and intravenous antifungals were given. Clinical response to the procedure was noted on postoperative week 1, week 4, and 3rd month (week 12). The mean age group was noted to be 49.9 years with a male: female ratio of 2.3:1. All patients were diabetics with 5 being newly detected diabetes after COVID infection. All the ten patients showed significant clinical improvement at the first follow-up (week 1). Five patients at 1st month showed clinical and radiological improvement, while one patient had worsening of orbital disease for which exenteration was done. Three patients succumbed to the disease due to altered cardiopulmonary status and 1 patient was lost to follow-up. All 6 survived patients were stable till the last follow-up. Hence, mortality rate accounted to 30% and globe survival of 40% in the current study. Transcaruncular approach to orbit for adequate debridement combined with amphotericin irrigation is a novel technique that can be considered for compartmental involvement of orbit in mucormycosis. Debridement removes the necrotic tissue, while local amphotericin irrigation directly reaches the target tissues that effectively halts the disease progression and hence can be considered an effective globe-sparing intervention without affecting the disease outcome.

464 Local Extension of a Solitary Extra Medullary Nasal Plasmacytoma into the Orbit

AimExtramedullary plasmacytoma are rare neoplasms, which mainly occur in the head and neck, the most common site being the nasal cavity or septum. Patients may present with epistaxis, nasal obstruction, or rhinorrhoea. Extension into the orbit is rare but can lead to visual disturbances.MethodThis case report pertains to a 69-year-old female patient who initially presented with a 6-week history of recurrent sinusitis, with left sided cheek pain and diplopia.ResultsA CT and MRI scan was performed, which showed opacification of the left maxillary, ethmoid and sphenoid sinuses with bony destruction of the medial and anterior maxillary walls and into the anterior soft tissues. The mass was completely obstructing the left nasal cavity extending into the inferomedial orbit. Staging CT scans also showed nodal disease in the neck.Biopsy with histology was positive for CD138, with diffuse proliferation of plasma cells of varying maturity and atypia. Additionally, mono IgG kappa was also positive as was CD45 suggestive of a lymphoid neoplasm. Bone marrow biopsy and PET scan confirmed there was no systemic involvement.Radiotherapy was initiated after the patient recovered from COVID -19. A repeat MRI scan 6 weeks post radiotherapy showed a partial response with reduction in the size of the tumour, resolution of the intra-orbital extension and disappearance of paraprotein.ConclusionsThis case report illustrates need for earlier consideration of EMP diagnostically to reduce the risk of conversion of the plasmacytoma to multiple myeloma, which is a known possibility and to ensure minimal delay in the commencement of treatment.

Reconstruction of Combined Orbital Floor and Medial Wall Fractures Using Custom-Made Titanium Alloy Implant.

The reconstruction of combined orbital floor and medial wall fractures is challenging due to the surgical approach and implant stability. A 0.5 mm thickness rigidity custom made titanium alley implant was created by 3-dimensional printing with electron-beam additive manufacturing. The implant was designed to cover the entire surface of the inferomedial orbit based on the flipped the contralateral orbit images. Although the cost was expensive, the use of three-dimensional printed implants for extensive orbital wall fractures was useful for decreasing operative time, and can be accessed with a limited surgical approach with a precise fit.

Transcranial Approaches to the Orbit.

Transcranial approaches to the orbit provide familiar and flexible approaches with wide access to the majority of the orbit, only limited in the inferomedial orbit. A pterional craniotomy is the predominant approach but can be expanded with an orbital or zygomatic osteotomy for even wider access. Minimally invasive approaches, such as the lateral supraorbital or "eyebrow" supraorbital approach, are options for selected pathologies and minimize morbidity related to the approach.

Trans-septal suture retraction for endoscopic orbital surgery

ABSTRACT Purpose We describe a novel technique for endonasal endoscopic orbital surgery. Previously described strategies for minimally invasive orbital surgery include mobilization of the medial rectus muscle and cryosurgical retraction of the pathologic lesion. Herein we describe endoscopic trans-septal suture retraction of an orbital cavernous hemangioma to facilitate intra-orbital dissection from an external approach. Methods A 36-year-old male presented with blurred vision in his left eye for several years, along with several months of progressive left proptosis and decreasing visual acuity. Imaging revealed a 2.5 cm orbital mass consistent with a cavernous hemangioma. The patient underwent a combined transconjunctival and endoscopic approach for resection. Results Following left medial orbital wall and floor decompression, endoscopic trans-septal suture retraction facilitated dissection of the lesion from intraorbital structures. A complete extracapsular resection of the lesion was achieved. The inferomedial orbit was reconstructed with a synthetic implant. Conclusion Trans-septal suture retraction is an effective adjunctive technique for endonasal endoscopic orbital tumor surgery. This technique facilitates safe retraction and dissection of soft tissue lesions from critical intraorbital structures.

Dacryocele in an adult presenting as facial cellulitis

A 47-year-old male presented with left sided facial cellulitis of one-week duration associated with a painful mass over the left medial canthal area. On examination, there was a firm, tender mass below the medial canthal tendon. Computed tomography scan revealed a bulky, cystic lesion at the left inferomedial orbit and medial maxilla with bony remodeling suggestive of a chronic dacryocele. The patient underwent marsupialization of the dacryocele at the inferior meatus with silicone tube intubation. His symptoms of epiphora resolved after surgery.&#x0D; We describe a rare clinical presentation of dacryocele in an adult and its simple, yet effective treatment option.

Magnetic resonance imaging of a phakomatous choristoma

Phakomatous choristoma is a rare congenital benign tumour in the inferomedial eyelid or orbit that is thought to be of lenticular anlage origin. We describe the MRI findings in an infant boy with histopathologically confirmed phakomatous choristoma.

A Case of Steatocystoma Simplex of the Orbit

Purpose: Steatocystoma is a cyst that originates embryologically from hair follicles and usually occurs on the face, chest, back and axillae as multiple lesions and rarely occurs as a solitary lesion. We experienced a case of steatocystoma simplex that developed in the orbit and present our case with a brief review of the literature. Case summary: A 44-year-old male presented with a history of palpable mass in the right inferomedial periorbital area that had been slowly growing for a few months. Physical examination revealed a non-tender, soft and round mass. Magnetic resonance imaging of the orbit showed 2.0 x 2.0 x 2.0 cm-sized mass in the right inferomedial orbit. We performed excisional biopsy of the orbital mass using transconjunctival approach. The pathological diagnosis was steatocystoma. There was no local recurrence during the postoperative follow-up. Conclusions: We experienced a rare case of steatocystoma simplex that developed in the orbit. Base on our results, steatocystoma simplex should be considered when diagnosing an orbital mass. J Korean Ophthalmol Soc 2015;56(11):1794-1797

Multidisciplinary Management of Lacrimal Sac/Nasolacrimal Duct Carcinomas

To determine the rates of globe-sparing treatment and useful final visual function in patients with primary lacrimal sac/nasolacrimal duct carcinomas treated with multidisciplinary therapy. The medical records of 14 patients with primary lacrimal sac/nasolacrimal duct carcinoma treated at 1 institution were retrospectively reviewed. The patients were 9 men and 5 women; the median age at diagnosis was 58.5 years (range, 45-73 years). Seven patients presented with epiphora, 7 with a palpable mass in the inferomedial orbit, and 2 with dacryocystitis. In 3 patients, the diagnosis of cancer was not considered until during or after dacryocystorhinostomy. Seven patients had squamous cell carcinoma, 2 transitional cell carcinoma, 2 adenoid cystic carcinoma, and 1 each adenocarcinoma, poorly differentiated carcinoma, and inverted papilloma with carcinoma in situ transformation. Nine patients underwent surgical resection of the lacrimal sac and nasolacrimal duct and resection of the medial upper and lower eyelids, including canaliculi, partial ethmoidectomy, and medial maxillectomy. One patient underwent lacrimal sac biopsy only as another primary malignancy was discovered during the work-up for systemic disease. Four patients underwent orbital exenteration because of extensive involvement of the orbital soft tissue. Radiotherapy was recommended for 13 patients; in 1 patient, radiotherapy was not recommended because the patient had an inverted papilloma with carcinoma in situ transformation that was completely excised. The median radiation dose was 60 Gy. Eight patients received chemotherapy either concurrent with radiation therapy (5 patients), as neoadjuvant treatment (1 patient), or for progressive or metastatic disease (3 patients). The median follow-up time was 27 months (range, 6-96 months). In 10 patients, the globe was spared. In 9 of these 10 patients, visual acuity was the same as at baseline or better than 20/40 at last follow up. With multidisciplinary therapy, the eye can be spared and reasonable visual function can be preserved in most patients with primary lacrimal sac/nasolacrimal duct carcinomas.

Mechanical Oscillopsia After Lower Eyelid Blepharoplasty With Fat Repositioning

Blepharoplasty with fat repositioning is a technique used to fill the tear trough in the aging lower eyelid. We describe a patient who underwent transcutaneous lower eyelid blepharoplasty with fat repositioning who subsequently developed mechanical oscillopsia in the right eye exacerbated by facial movement. Surgical exploration revealed cicatrix between the inferior oblique muscle and the anterior superficial musculoaponeurotic system. Excision of the scar bands led to immediate amelioration of symptoms. When performing blepharoplasty with fat repositioning, it is essential to be aware of the anatomic location of the inferior oblique in the anterior inferomedial orbit to avoid incarceration of this muscle.

Orbital Cyst of Lacrimal Derivation Presenting as a Recurrent Orbital Abscess in a Pediatric Patient

A 2-year-old girl presented with inflammatory eyelid swelling in the left eye over a 2-week period. Ophthalmologic examination showed hyperemia and swelling, with a palpable mass at the inferior orbital rim. Orbital magnetic resonance imaging showed periorbital edema and a cystic lesion located in the inferomedial orbit. Histopathologic evaluation showed an orbital cyst of lacrimal derivation.

Eosinophilic angiocentric fibrosis of the orbit

A 30-year-old woman complained of right-sided epiphora for 2 years. She also reported diplopia on certain gaze positions and felt a hard mass behind the right medial inferior orbital rim. Magnetic resonance imaging studies demonstrated a relatively well-delineated mass in the right inferomedial orbit with minimal ethmoid sinus involvement. Histopathological evaluation following a large incisional biopsy showed massive eosinophilic infiltration and fibrosis with the final diagnosis of eosinophilic angiocentric fibrosis. She was then discovered to have significant peripheral eosinophilia and elevated serum IgE levels and clinical findings of allergic rhinitis and sinusitis. She was treated with systemic fluorocortolon and desloratadin for 4 months. She remained stable without recurrence for 32 months. The patient with this exceptionally rare tumour of the orbit benefited from debulking surgery followed by systemic corticosteroids and antihistaminics.

Unusual recurrent orbital tumour

Abstract Purpose: We present a case of an unusual CD34+ recurrent orbital tumour. Methods: A 62‐year‐old male presented with progressive left proptosis and preserved visual acuity. CT scans showed a circumscribed mass at the inferomedial orbit. After incisional biopsy, the patient preferred conservative treatment and the lesion was debulked. Further debulking was necessary in other two occasions. With radiological signs of bone invasion, left orbital exenteration was agreed in the fourth relapse. Results: The lid skin sparing exenteration revealed a tumour mass (45 x 29 x 27 mm) in the inferomedial orbit. There was no evidence of invasion of either the globe or the optic nerve. In all occasions, the tumour consisted of spindle cells alternating vague storiform areas with patternless areas. The tumour was very cellular, showed low mitotic count and no necrosis or ulceration. There was focal invasion of fibrous tissue, extra‐ocular muscle, fat and bony fragments. The tumour was diffusely and consistently positive for CD34, S100 and vimentin. EMA and CD99 were focally positive. Several other markers were negative. This slow growing lesion with low grade histological appearance and EM suggestive of Schwannian processes was diagnosed as a CD34 positive Schwannoma on the first debulking. In the next two recurrences, experts agreed with a diagnosis of a DFSP based on the diffuse positivity for CD34. In the exenteration specimen, due to the exceptional location of the presumable DFSP, this diagnosis was disputed and after EM and further reviews the case was concluded as variant of low grade MPNST. Conclusions: The consistent positivity for CD34 in our case has lead to diagnostic disagreement. Only after the fourth recurrence the final diagnosis of a CD34 positive low grade PNST could be made.

Pathology Quiz Case

A 47-YEAR-OLD MAN PRESENTED WITH A 2-week history of progressively worsening pain and swelling in his right eye, purulent right-sided nasal discharge, and subjective fever. He had been seen by a physician at an outside clinic 1 week earlier and had been placed on a regimen of amoxicillin-clavulanate for presumed acute sinusitis. He was a heavy smoker and had 2 to 3 alcoholic drinks per day. His medical and social histories were otherwise unremarkable. On examination, the soft tissue overlying the right maxilla was edematous, erythematous, and tender to palpation. Nasal endoscopy revealed purulence as well as a smooth mucosa-lined mass completely obstructing the right nasal cavity. The right eye was proptotic, injected, and chemotic, with restricted extraocular movements in all directions. Visual acuity was mildly impaired in the right eye. Lateral canthotomy with inferior cantholysis was performed because of markedly elevated intraocular pressure in the right eye. The findings of the rest of the physical examination were unremarkable. The results of blood studies were normal. A computed tomogram (CT) of the paranasal sinuses revealed a 5-cm heterogeneous mass of soft tissue and bone obliterating the right maxillary sinus and invading the right nasal cavity and orbit. No intraorbital fluid collection was suggested on the initial radiologic study. Intravenous antibiotic therapy was begun, and a Caldwell-Luc procedure was performed to decompress the mass and to obtain tissue for histologic analysis and culture. Histologic analysis of the specimen revealed the pathologic findings shown in Figure 1.Thirty-six hours after the initial surgical drainage, the patient’s condition had not improved, and a second CT (Figure 2) revealed an area in the inferomedial orbit that was suggestive of phlegmon or early abscess. A Lynch incision was then used to drain an orbital abscess, and combined endoscopic and Caldwell-Luc approaches were used to remove the mass via aggressive curettage. After the second surgical procedure and continued antibiotic therapy, the patient’s orbital and facial edema resolved and his extraocular movements and visual acuity returned to normal. What is your diagnosis?

涙嚢ｓｏｌｉｔａｒｙ ｆｉｂｒｏｕｓ ｔｕｍｏｒ例

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm typically arising in the pleura, but it has recently been reported in various extrapleural sites. We report a case of SFT arising in the lacrimal sac.A 32-year-old man presented with a 2-year history of slowly progressive right proptosis. Computed tomography demonstrated a well-circumscribed low density mass in the inferomedial orbit. Surgical excision was performed. Immunohistochemically, the tumor cells were stained for CD34 and bcl-2, leading to a diagnosis of SFT. There has been no evidence of recurrence 12 months postoperatively. Because SFT, especially with a high mitotic count, may recur after excision, careful follow-up over a prolonged period is important.

CT of the inferomedial orbit and the lacrimal drainage apparatus: Normal and pathologic anatomy

CT of the inferomedial orbit and the lacrimal drainage apparatus: Normal and pathologic anatomy

CT of the inferomedial orbit and the lacrimal drainage apparatus: normal and pathologic anatomy.

The normal and pathologic CT anatomy of the lacrimal drainage apparatus was examined during study of the orbits, nasal cavity, and paranasal sinuses in 100 patients with a variety of clinical complaints related to the inferomedial orbit. The bony lacrimal fossa, the nasolacrimal canal, and the fluid- or air-filled lacrimal sac and nasolacrimal duct were readily recognized in all cases. The lacrimal fossa and sac are found at the inferomedial orbit and are preseptal structures. Cystic expansion of the lacrimal sac (dacryocystitis) may mimic orbital abscess clinically; however, the radiographic recognition of a cystic, peripherally enhancing mass centered at the lacrimal fossa should exclude postseptal abscess and permit more conservative therapy. Obstruction or invasion of the drainage apparatus by tumor, infection, or posttraumatic scarring is readily depicted by CT. Sagittal/coronal images reformatted from thin transverse axial sections are often useful in defining the origin of an inferomedial orbital mass and its relation to the lacrimal sac when clinical studies and axial CT findings are equivocal.