Lateral Orbit Research Articles

Evaluation and Management of 2 Ferocactus Spines in the Orbit

A 49-year-old woman, who had fallen face first in a cactus 1 week earlier, presented with a small, mobile, noninflamed subcutaneous nodule at the rim of her right lateral orbit with no other functional deficits. A CT scan was obtained, which revealed a 4-cm intraorbital tubular-shaped foreign body resembling a large cactus spine. A second preoperative CT scan, obtained for an intraoperative guidance system, demonstrated a second cactus spine, which was initially not seen on the first CT scan. Both spines were removed surgically without complication. The authors discuss factors that can cause diagnosis delay, review the radiographic features of cactus spines, and discuss the often times benign clinical course of retained cactus spine foreign bodies. To the authors' knowledge, this is the first case report of cactus spines in the orbit. Health-care professionals should have a low threshold for imaging in cases of traumatic injuries involving cactus spines.

A Prospective Assessment of Biomechanical Changes in Skin after the Injection of Onabotulinum Toxin

Objectives: Although primarily used as a neuromodulator, a recent case series suggests that botulinum toxin A (onabotulinum) may also improve skin elasticity. The purpose of this study was to test the hypothesis that the administration of onabotulinum for lateral orbital and glabellar rhytides will result in an increase in patient’s skin elasticity and reduce the pliability. Methods: Forty patients were prospectively enrolled for administration of onabotulinum to their lateral orbit and glabella. To assess skin biomechanics, we used the Cutometer MP580. All patients were assessed pre-treatment and at 2-weeks and 2-months post-treatment. An analysis of variance (ANOVA) with repeated measures was used to assess for differences between assessments. Results: There was a significant increase in both skin elasticity (f = 46.9, P = 0.001) and pliability (f=46.8, P < 0.001) with a mean (+/-SE) increase in elastic recoil of the skin by 20% (4.4%) for the glabellar region ( P < 0.001) and 18% (4.0%) for the lateral orbit ( P < 0.0001) while there was an increase in skin pliability of 26% (5.4%) for the lateral orbit ( P = 0.001) and 52% (8.3%) for the glabellar region ( P < 0.001). There was no significant difference on the patients forearm (control site) for both elasticity ( P = 0.57) and pliability ( P = 0.16). Conclusions: Injection of onabotulinum results in skin that has increased pliability as well as increased elastic recoil. Although this study demonstrates the positive effect of onabotulinum on skin elasticity, it is unclear whether this is due to specific histological changes.

Facial soft tissue thickness in the Brazilian population: New reference data and anatomical landmarks

Facial soft tissue thickness measurement can be useful among several medico-legal techniques that aim to establish the identity of skeletal remains. This study examined the soft tissue thickness that covered the faces of autopsied cadavers sent to the Medico-Legal Institute of Guarulhos from September 2010 to September 2011. Forty-nine anatomical facial landmarks were measured in cadavers less than 24h after death; these data were analysed using two-tailed t-tests. This project was approved by an ethics committee. One hundred cadavers were studied (74 males and 26 females). A majority of these individuals had died between 41 and 60 years old. Of the 49 anatomical landmarks, only five differed between the sexes (i.e., p-value less than 0.05): upper lip margin (p=0.006), superior labial sulcus (p=0.006), stomion (p=0.001), right lateral orbit (p=0.008), and left cheilion (p=0.009). The inclusion of additional anatomical landmarks allowed us to establish more precise facial thickness parameters that have the potential to be applied to cadaver facial approximations in Brazil; furthermore, some anatomic landmarks presented a higher discriminant power with regard to sex.

Diplopia From Pleomorphic Lipoma of the Orbit With Lateral Rectus Muscle Involvement

A-55-year-old man with a 2-year history of left proptosis with painless swelling of the upper and lateral bulbar conjunctiva was referred. He had developed diplopia in left gaze. Orbital CT showed left proptosis with a mass measuring 2 × 1 cm in the superolateral and lateral left orbit, with lateral rectus muscle infiltration. The lesion was excised and was found to be diffuse, and an infiltrative mass affecting the anterior portion of the lateral rectus muscle was also removed. The histopathologic diagnosis was pleomorphic lipoma. Only 7 cases of pleomorphic lipomas occurring in ocular adnexal tissues or in the orbit have been previously reported, but in none of the cases had an infiltration of the lateral rectus muscle or diplopia been described before. The histopathologic features and differential diagnosis of this type of soft tissue tumor are also described.

At Birth, Tarsiers Lack a Postorbital Bar or Septum

Among primates, partial or complete posterior closure of the orbit has been widely accepted as a shared derived characteristic justifying an exclusive tarsier‐anthropoid clade, while some regard the tarsier lateral orbit as an elaborated postorbital bar (POB). To test these competing hypotheses while minimizing the confounding effect of tarsier orbital hypertrophy, we compared tarsiers and other primates at early (fetal and newborn) ages using dissection, micro‐CT scans and soft tissue histology. Our findings demonstrate unanticipated variation in the anatomy and development of the zygomaticofrontal (ZFA) articulation, which forms the orbit's lateral framework. Tarsiers uniquely exhibit a combination of two features: absence of a pre‐ and peri‐natal frontal spur to join with the zygomatic to form the ZFA; and, the spur's substitution by an elaborate ligament, which envelops the eye laterally as an expansive postorbital membrane (POM) that merges with the anterolateral fontanelle of the lateral cranial vault. In lacking a frontal spur, tarsiers are distinct from strepsirhines, while the ligamentous structure of the POM distinguishes its ZFA from that of anthropoids, which is a typical facial suture at and prior to birth. The POM of tarsiers may be thought of as an accessory fontanelle, a structural compromise that provides flexible stability and spatial separation of bones while anticipating rapid postnatal growth of an enormously enlarged eye. We regard the tarsier POM as part of a neomorphic eyeball hypertrophy complex, and reject the hypothesis of derived homology of the postorbital septa of adult tarsiers and anthropoids on histological, developmental and functional grounds. © 2013 Wiley Periodicals, Inc.

At Birth, Tarsiers Lack a Postorbital Bar or Septum

Among primates, partial or complete posterior closure of the orbit has been widely accepted as a shared derived characteristic justifying an exclusive tarsier-anthropoid clade, while some regard the tarsier lateral orbit as an elaborated postorbital bar (POB). To test these competing hypotheses while minimizing the confounding effect of tarsier orbital hypertrophy, we compared tarsiers and other primates at early (fetal and newborn) ages using dissection, micro-CT scans and soft tissue histology. Our findings demonstrate unanticipated variation in the anatomy and development of the zygomaticofrontal (ZFA) articulation, which forms the orbit's lateral framework. Tarsiers uniquely exhibit a combination of two features: absence of a pre- and peri-natal frontal spur to join with the zygomatic to form the ZFA; and, the spur's substitution by an elaborate ligament, which envelops the eye laterally as an expansive postorbital membrane (POM) that merges with the anterolateral fontanelle of the lateral cranial vault. In lacking a frontal spur, tarsiers are distinct from strepsirhines, while the ligamentous structure of the POM distinguishes its ZFA from that of anthropoids, which is a typical facial suture at and prior to birth. The POM of tarsiers may be thought of as an accessory fontanelle, a structural compromise that provides flexible stability and spatial separation of bones while anticipating rapid postnatal growth of an enormously enlarged eye. We regard the tarsier POM as part of a neomorphic eyeball hypertrophy complex, and reject the hypothesis of derived homology of the postorbital septa of adult tarsiers and anthropoids on histological, developmental and functional grounds.

Intraoperative Imaging With a 3D C-Arm System After Zygomatico-Orbital Complex Fracture Reduction

During the repair of zygomatico-orbital complex (ZMC) fractures, the lateral orbital wall and/or the orbital floor is often reduced by merely reducing the zygoma. Intraoperative 3D imaging can help surgeons decide whether the orbit must be reconstructed as well. The purpose of this study was therefore to assess the usefulness of intraoperative 3D C-arm imaging in evaluating the adequacy of fracture reduction. A total of 21 patients with unilateral ZMC fractures were enrolled in this retrospective study. Four fractures were treated with a closed reduction technique. Seventeen fractures were repaired with open reduction and internal fixation of the zygomaticomaxillary buttress area. Intraoperative 3D C-arm imaging was performed in all cases. All patients underwent postoperative computed tomography and a clinical examination no earlier than 5 months after the procedure. After reduction of the ZMC fractures, intraoperative 3D scans showed inadequate repair of the orbital floor in 2 patients and inadequate repair of the lateral orbit in 1 patient. Zygoma and zygomatic arch fracture reduction had to be corrected in 1 further case. The other 17 patients did not need an additional procedure. Postoperative imaging showed that no patient required a secondary operation. No postoperative diplopia or enophthalmos developed in any patient. Intraoperative 3D C-arm imaging appears to be an effective tool for evaluating ZMC fracture reduction. It helps avoid additional procedures and thus helps reduce morbidity. In addition, there appears to be no need for postoperative imaging.

Soft-tissue thickness of South Korean adults with normal facial profiles

ObjectiveTo standardize the facial soft-tissue characteristics of South Korean adults according to gender by measuring the soft-tissue thickness of young men and women with normal facial profiles by using three-dimensional (3D) reconstructed models.MethodsComputed tomographic images of 22 men aged 20 - 27 years and 18 women aged 20 - 26 years with normal facial profiles were obtained. The hard and soft tissues were three-dimensionally reconstructed by using Mimics software. The soft-tissue thickness was measured from the underlying bony surface at bilateral (frontal eminence, supraorbital, suborbital, inferior malar, lateral orbit, zygomatic arch, supraglenoid, gonion, supraM2, occlusal line, and subM2) and midline (supraglabella, glabella, nasion, rhinion, mid-philtrum, supradentale, infradentale, supramentale, mental eminence, and menton) landmarks.ResultsThe men showed significantly thicker soft tissue at the supraglabella, nasion, rhinion, mid-philtrum, supradentale, and supraglenoid points. In the women, the soft tissue was significantly thicker at the lateral orbit, inferior malar, and gonion points.ConclusionsThe soft-tissue thickness in different facial areas varies according to gender. Orthodontists should use a different therapeutic approach for each gender.

Skull Metastasis From Intrahepatic Cholangiocarcinoma: Report of 3 Cases and Review of the Literature

Skull metastases occur in patients with various malignancies; however, those resulting from intrahepatic cholangiocarcinoma (ICC) have been rarely reported. In our hospital, 324 patients were diagnosed with metastatic brain or skull tumors from June 1969 to June 2011, but only 3 of them (0.9%) developed skull metastases from ICC. We report the case of 3 patients with skull metastases from ICC. A combination of computed tomography (CT), contrast-enhanced magnetic resonance imaging (MRI), 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), and methionine-PET were used for imaging. Sites of tumors were the lateral left orbit and right parietal bone in case 1, the left parietal bone, left temporal bone, and lateral left orbit in case 2, the right petrous bone, right occipital bone, and upper cervical vertebra in case 3. The metastases were confirmed to have originated from ICC by biopsy in two of the cases and diagnosed by MRI and FDG-PET in case 2. Radiosurgery and radiotherapy had positive effects on symptom improvement and cosmetic problems.

Making the Diagnosis

The metopic suture is the only calvarial suture which normally closes during infancy. Upon closure, a palpable and visible ridge often forms which can be confused with metopic craniosynostosis. Metopic ridging (MR) is treated nonsurgically while metopic craniosynostosis (MCS) is treated surgically. Differentiating between the two is paramount; however, consensus is lacking about where a clear diagnostic threshold lies. The goal of this study is to describe the physical examination and CT scan characteristics which may help to differentiate between physiological closure of the metopic suture with ridging (MR) and MCS. A retrospective chart review of all patients seen at Seattle Children's Hospital between 2004 and 2009 with the diagnosis of either MCS or MR (n = 282) was performed. Physical examination characteristics described by diagnosing practitioners were analyzed. Clinical photos were assessed by 3 expert raters to determine the importance of these characteristics. CT scan findings were abstracted and compared between the two diagnoses. The "classic" triad of narrow forehead, biparietal widening, and hypotelorism was present in only 14% of patients with MCS. Ninety-eight percent of patients in both groups had a palpable metopic ridge. The photographic finding of narrow forehead and pterional constriction was present in all patients with MCS, but only in 11.2% and 2.8% of patients with MR. On CT scan, the presence of 3 or more MCS findings was diagnostic of MCS in 96% of patients. Patients with MCS were more likely to present before 6 months of age (66% vs. 32%). Patients with MCS tend to present earlier than those with MR. Upon physical examination, the relationship between the lateral frontal bone and the lateral orbit is important in distinguishing between the two diagnoses. A CT scan can be helpful in making the diagnosis not to confirm a closed suture but to identify 3 or more MCS characteristics.

Transantral Approach to the Lateral Orbit

Objective: Depending on the type of pathology and location, various methods of access have been developed to overcome the obstacle of accessing the orbit. The endoscope provides minimally invasive surgical access to the medial and inferior orbit. Expanding endoscopic access to the lateral orbit transantrally could create a minimally invasive corridor. Method: Using late injected cadavers, endoscopic dissections of the infero-lateral orbit were undertaken. A sublabial transmaxillary ostomy was created and an endoscope was advanced into the sinus. The contents of the orbit were dissected laterally to the inferior optic nerve. Photographic evidence was obtained for review. Results: A 45° endoscope was required to adequately visualize the anatomy. The perpendicular nature of the corridor necessitated the use of angled instrumentation. This also created a challenge as the dissections were completed superiorly. Dissection was found to be facile until revealing the lateral rectus muscle. Proceeding superiorly past this point was limited by the length of the instruments. Tools of dissection with greater length could possibly overcome this limitation. Overall the transantral endoscopic approach to the orbit provided an adequate surgical window inferiorly and to a limited extent laterally. The relevant anatomy was identified without difficulty. Conclusion: An endoscopic transantral approach to the infero-lateral orbit is anatomically feasible. The morbidity associated with an open approach could possibly be avoided, improving patient outcomes. Further understanding of the endoscopic anatomy of the orbit can allow for advances in surgery with improved safety and efficacy.

Intraorbital foreign bodies – 5 own cases and review of literature

Five patients were surgically treated for intraorbital foreign body: a 14-year-old girl had a door glass splinter, a 23-year-old man a metallic foreign body – gunshot pellet, a 55-year-old man a splinter from a metallic bar, a 48-year-old patient the splinters of circular saw and 61-year-old man with shot. Two foreign bodies were removed using the Krönlein-Reese-Berk lateral orbitotomy, two others by Sewell medial orbitotomy and one with superior orbitotomy of Dandy-Naffziger. Radiographs and CT scans were used to identify and localize intraorbital foreign bodies. In one case we found coexistence foreign body (shot) and tumor – inflammation pseudotumor of the orbita. It is possible, that in this case long-time occupy foreign body in the orbita was a cause of that tumor. All foreign bodies were successfully removed, and postoperative course was uneventful. The Krönlein-Reese-Berk orbitotomy provides a satisfactory access to the lateral and posterior orbit, which is of particular importance in the case of a deeply penetrating foreign body (metallic or glass). Surgical removal of intraorbital foreign bodies is a classic example of an interdisciplinary therapeutic approach. Best outcome is usually a result of a team of an ophtalmologist, ENT surgeon, maxillary surgeon and possibly also neurosurgeon performing the operation.

Chondromyxoid Fibroma of the Anterior Skull Base Invading the Orbit in a Pediatric Patient: Case Report and Review of the Literature

Chondromyxoid fibroma (CMF) is a rare bone tumor of cartilaginous derivation representing less than 1% of all benign bone neoplasms. It is a slow-growing, locally destructive tumor that usually affects the metaphyseal region of long bones of patients in their second or third decade of life. Involvement of the skull base and orbit is extremely rare. We present the first case of histopathology-proven CMF originating in the greater sphenoid wing and extending into the orbit in a 14-year-old boy. He complained of pain and swelling of his left lateral orbit for 4 months and had 3-mm nonaxial proptosis. Magnetic resonance imaging of the orbit revealed a well-defined lesion in the lateral wall of the left orbit, hypointense on T1-weighted images, and heterogenous hyperintense on T2-weighted images and enhanced after contrast media injection. Through a left semicoronal skin incision, the mass was removed totally and the lateral orbital wall was reconstructed. The clinical manifestations, imaging findings, and surgical treatment of the lesion are discussed with a review of the literature.

Orbital Inflammation: A Rare Association of Common Variable Immunodeficiency

Purpose: Ocular associations with common variable immunodeficiency (CVID) are very rare which include granulomatous uveitis, mulitfocal choroiditis and retinal vasculitis. However there have been no reports of orbital involvement, either inflammatory or neoplastic in association with CVID. We describe a unique case of a patient with CVID who developed orbital inflammation.Methods: Clinical, histological and radiological findings and the management of this case is presented.Results: A 58 year old male with known CVID treated with regular intravenous immunoglobulin infusion, presented with left peri-orbital redness, pain, proptosis and restriction of ocular movements. CT scan showed an ill-defined mass in the left lateral orbit, adjacent to the lacrimal gland. An orbital biopsy revealed a monomorphic lymphocytic infiltrate forming loose lymphoid aggregates in the lacrimal gland tissue. Immunocytochemistry confirmed this to be a reactive inflammatory infiltrate. The patient was successfully treated with a course of oral prednisolone which resulted in improvement of orbital inflammation, ocular movements and proptosis.Conclusion: To our knowledge this is the first reported case of non-granulomatous orbital inflammation in association with CVID. This case serves to remind ophthalmologists encountering a patient with CVID that they may have associated orbital inflammatory disease which is responsive to steroid therapy similar to sterile inflammatory masses described in other organs.

Measurement of width and distance of the posterior border of the deep lateral orbital wall using computed tomography

Introduction Techniques of orbital decompression for Graves’ ophthalmopathy continue to evolve. Recently the deep lateral orbital wall has been proposed as the most effective and safe site for a decompression procedure associated with the least complications. Anatomic variations with structures like the middle cranial fossa render decompression of the lateral wall more logical. We aimed to understand the anatomic localization and appearance of the lateral orbital wall by measuring the width and distance of the lateral wall on computed tomography (CT). Material and methods The medical records of all patients who underwent orbital CT scans for ocular trauma or for confirmation of orbital disease at the Korea University hospital between January 2005 and May 2008 were reviewed retrospectively. All patients had been scanned with the same CT scanner (Philips Brilliance 64 channel CT; Philips Healthcare Systems). Patients who had normal orbits bilaterally were included in this study. The cut in which the lateral rectus muscle was longest and the lateral bony orbit was thickest was selected from the axial and coronal slices. The point where the lateral rectus muscle contacted the the bone was measured on this axial slice. The width of the lateral wall was measured at the level of superior border of the lateral rectus muscle on thickest part of the coronal slice. Results A total of 334 orbits (167 patients) were included. Patients ranged in age from 7 years to 78 years (median age 41.1 years). The average distance of the lateral wall was 26.0 mm OD and 25.0 mm OS. The average width of the lateral wall was 16.0 mm OD 16.2 mm OS. There was no statistically significant difference between right and left. The patients were divided into 8 age groups by decades. There was no statistically significant difference between the groups in either measurement. Conclusion In this study, we measured the average width and length of the thickest segment of the greater wing of the sphenoid, which can be used as anatomic guidelines during deep lateral orbital decompression surgery, and the basic standard value of the lateral orbital wall.

Feasibility of reirradiation of recurrent sinonasal carcinoma in the periorbital region using hypofractionated image‐guided intensity‐modulated radiation therapy

Recurrent periorbital tumors pose management challenges because they are often unresectable and chemorefractory. Proximity to critical structures renders reirradiation difficult. With image-guided intensity-modulated radiation therapy (IG-IMRT), real-time corrections to patient setup are possible, enabling significant shrinkage of planning target volume margins and safe dose escalation with hypofractionation. Here, we present our experience with hypofractionated IG-IMRT in a patient with multiply recurrent sinonasal carcinomas in the periorbital region. The patient is a 67-year-old woman with sinonasal carcinoma, treated with surgery and 2 prior courses of high-dose radiotherapy. She developed a second tumor recurrence in the right lateral orbit, which was reirradiated using hypofractionated IG-IMRT (24 Gy in 3 fractions). Near-complete resolution of her ocular symptoms was observed at 4 months. Progress scans demonstrated a decrease in size of the orbital lesion. Preliminary results of reirradiation using hypofractionated IG-IMRT suggest that it is safe and effective.

Aneurysmal Bone Cyst Secondary to Ossifying Fibroma in the Orbit

A 28-year-old man presented with proptosis and medial displacement of the right eye, intermittent pain, and diplopia of 1 month's duration. Radiologic examination demonstrated a mass in the right lateral orbit resembling an aneurysmal bone cyst (ABC). Histopathologic evaluation of the surgically excised lesion via orbitotomy confirmed the radiologic diagnosis. Two months later, the patient presented again with a mass at the same location as the previous one, with a major component that was solid. The recurrent lesion was excised via frontal craniotomy. Histopathologic examination of the surgical specimen led to a diagnosis of ABC secondary to trabecular ossifying fibroma. During the follow up of 13 months, the lesion did not recur. To the best of the authors' knowledge, this is the first case of ABC secondary to ossifying fibroma in the orbit. ABC can dominate the radiologic appearance of the lesion and veil the primary neoplasm.

Fractures of the trigone – implications for visual loss

Displaced fractures of the trigone are uncommon. This central segment of the greater wing of the sphenoid in the lateral orbit and the adjacent lesser wing, combine to protect the contents of the superior orbital fissure and the optic nerve. Such injuries are the result of high-energy trauma and almost invariably there is an associated head injury.

Spin Texture in Quantum Point Contacts in the Presence of Lateral Spin Orbit Coupling

A non-equilibrium Green's function formalism is used to study in detail the ballistic conductance of asymmetrically biased side-gated quantum point contacts (QPCs) in the presence of lateral spin-orbit coupling and electron-electron interaction for a wide range of QPC dimensions and gate bias voltage. Various conductance anomalies are predicted below the first quantized conductance plateau (G0=2e2/h) which occur due to spontaneous spin polarization in the narrowest portion of the QPC. The number of observed conductance anomalies increases with increasing aspect ratio (length/width) of the QPC constriction. These anomalies are fingerprints of spin textures in the narrow portion of the QPC.

Primitive Neuroectodermal Tumor of the Orbit in Adults: A Case Series

To present the clinical, radiologic, and histopathologic features of orbital primitive neuroectodermal tumor (PNET) in 5 adult patients. Retrospective case series of 5 adult patients with orbital PNET. Orbitotomy was performed in all cases. The authors report clinical findings, radiologic features, histopathology, immunohistochemical analysis, management, and outcomes for 5 patients with orbital PNET. Five adult patients presented with progressive unilateral proptosis and visual impairment. Common radiographic findings included a heterogeneous mass without associated destructive features, located in the superior and/or lateral orbit. Four cases demonstrated strong immunohistochemical staining for CD99 in a membranous pattern. One case required chromosomal analysis with fluorescence in situ hybridization to confirm the diagnosis. All patients received chemotherapy and/or orbital radiation with resolution of proptosis but no improvement of vision. One patient died of disease. To the authors' knowledge, this is the largest series of orbital PNET in adults. This tumor has an age demographic wider than previously believed and should be considered in the differential diagnosis of a hypercellular small round cell orbital tumor in both children and adults. Current treatment regimens are not standardized but typically use a similar approach to the treatment of Ewing sarcoma. Orbital PNET appears to have less propensity for metastasis compared with PNET in other locations. However, long-term aggressiveness remains to be proven.