Lateral Orbit Research Articles

Temporalis Muscle Abscess With Secondary Extension Into the Orbit.

A 33-year-old woman presented with intermittent left-sided periorbital swelling and facial pain. She had a history of dental procedures to the left upper and lower molars a few months prior. MRI revealed an abscess within the left temporalis muscle measuring 1.5 × 1.9 × 3.9 cm with associated mild inflammation involving the left lateral orbit (Fig. 1). An ultrasound-guided aspiration of the abscess revealed Streptococcus, Prevotella, and Propionibacterium species. After treatment with intravenous piperacillin/tazobactam for 4 days, her eye exam continued to worsen with a new abduction deficit on the left side and 1 mm of proptosis. Repeat MRI demonstrated a distinct, 1.3 cm subperiosteal abscess along the lateral orbit (Fig. 2). The patient was taken to the operating room for orbitotomy and drainage of abscess with placement of a Penrose drain. A culture of the contents showed no growth as she had received several days of intravenous antibiotics. The patient subsequently had an uncomplicated postoperative course and was discharged 1 week later.FIG. 1.: Initial axial MRI showing a large abscess (arrow) within the left temporalis muscle and associated inflammatory changes within the preseptal and postseptal tissues.FIG. 2.: Repeat axial MRI demonstrating a subperiosteal abscess of the left lateral orbit (arrow) adjacent to the temporalis abscess causing unilateral proptosis.This is a case of a temporalis muscle abscess with likely secondary extension into the orbit. To the authors’ knowledge, this presentation has never been described previously. The authors suspect that the route of infectious extension into the orbit was via the zygomaticotemporal foramen which is located at the anterolateral wall and transmits the zygomaticotemporal neurovascular bundle.

Theoretical and experimental analysis of an unbalanced and cracked cardan shaft in the vicinity of the critical speed

This paper presents a theoretical and experimental analysis of a coupled lateral and torsional vibrations of two identical rotors interconnected by a flexible Hooke’s joint and modelled as a multibody system with a small misalignment angle. Using energy principle and a Lagrangian transformation, the governing equation of the propeller shaft system is established by considering a nonlinear elastic shaft time-dependent perturbation. To study the sensitivity of the crack for a rotating shaft, the model is enriched by considering the periodical feature of the time-varying stiffness deriving from the crack breathing model. The nonstationary response of a cracked rotor system in the presence of unbalance has been evaluated using orbit patterns and Fast Fourier Transform. The highly oscillated feature of the rotors system is theoretically obtained and experimentally analysed. The analysis demonstrated that the crack parameters in the input shaft tend to inhibit the occurrence of unstable oscillations in lateral deflection, orbit and frequency spectrum of the secondary response. It is also found that the passage of the cracked primary shaft near to an integral multiple of the critical speed leads to the phenomenon of sup-harmonic resonance. Subsequently, the experimental analysis conducted equally indicated that the quantitative relation between the faults and the performance of the transmission is impacted by the time-varying stiffness and is the main cause of the frequency-modulated feature in the Cardan shaft system. Finally, the experimental results were informative for the transient response exploration and comparable to the theoretical findings for validating the proposed twin-rotor model.

Composite submental flaps in facial reconstructive surgery involving the zygoma and orbit

BackgroundThe submental island flap (SIF) is a reliable option for reconstructing defects in the facial region and offers several advantages when compared to free-flap alternatives. While the reconstructive applications of the SIF have been demonstrated in the lower face, there are limited reports on its utility as a composite flap for reconstructing defects of the upper facial skeleton. To our knowledge, we report the first cases of composite (osteocutaneous) SIFs used for reconstruction of complex facial defects involving the zygoma and lateral orbit respectively.Case presentationsThree consecutive cases are presented. All were performed following resection of skin cancers with invasion of the upper facial skeleton. The first case was a 68-year-old male with a longstanding history of non-melanoma skin cancers who presented with a 7 cm recurrent basal cell carcinoma (BCC) with bicortical invasion of the left zygoma. The second case was an 88-year-old female with several squamous cell carcinomas (SCC), including a dominant 7.1 cm SCC on the right temple with orbital invasion. A third case was a 75-year-old immunosuppressed male with a 6.5 cm SCC of the right cheek with invasion of the orbit and zygoma following prior resection as well as high dose radiotherapy. The operative management of all cases involved harvesting the SIF on its vascular pedicle alongside the inferior portion of the mandible with rigid fixation to address the bony defects. The first case was robust throughout adjuvant radiotherapy with no flap complications after 2 year follow up. The second patient received adjuvant radiation therapy to an area that was previously radiated. Although the flap remained viable for a year, the patient experienced delayed soft tissue loss over the bony segment and eventual devitalization of the distal flap. The third case achieved a satisfactory result with no complications.ConclusionsOur case series outlines a unique application of the composite (osteocutaneous) submental island flap (SIF) for reconstruction of complex facial defects involving the upper facial skeleton. The osteocutaneous SIF should be used with caution in patients receiving adjuvant radiotherapy who have a history of previous radiation to the same or overlapping field.Graphical abstract

Erratum. Quantitative analysis of the surgical exposure and surgical freedom between transcranial and transorbital endoscopic anterior petrosectomies to the posterior fossa.

Object This study proposes a variation of the transorbital endoscopic approach (TOEA) that uses the lateral orbit as the primary surgical corridor, in a minimally invasive fashion, for the posterior fossa (PF) access. The versatility of this technique was quantitatively analyzed in comparison with the anterior transpetrosal approach (ATPA), which is commonly used for managing lesions in the PF. Methods Anatomical dissections were carried out in 5 latex-injected human cadaveric heads (10 sides). During dissection, the PF was first accessed by TOEAs through the anterior petrosectomy, both with and without lateral orbital rim osteotomies (herein referred as the lateral transorbital approach [LTOA] and the lateral orbital wall approach [LOWA], respectively). ATPAs were performed following the orbital approaches. The stereotactic measurements of the area of exposure, surgical freedom, and angles of attack to 5 anatomical targets were obtained for statistical comparison by the neuronavigator. Results The LTOA provided the smallest area of exposure (1.51 ± 0.5 cm2, p = 0.07), while areas of exposure were similar between LOWA and ATPA (1.99 ± 0.7 cm2 and 2.01 ± 1.0 cm2, respectively; p = 0.99). ATPA had the largest surgical freedom, whereas that of LTOA was the most restricted. Similarly, for all targets, the vertical and horizontal angles of attack achieved with ATPA were significantly broader than those achieved with LTOA. However, in LOWA, the removal of the lateral orbital rim allowed a broader range of movement in the horizontal plane, thus granting a similar horizontal angle for 3 of the 5 targets in comparison with ATPA. Conclusions The TOEAs using the lateral orbital corridor for PF access are feasible techniques that may provide a comparable surgical exposure to the ATPA. Furthermore, the removal of the orbital rim showed an additional benefit in an enhancement of the surgical maneuverability in the PF.

S12-12 SESSION 12: FACIOCRANIOSYNOSTOSIS – PART II MONOBLOC MINUS LEFORT II: THE ROLE OF DIFFERENTIAL DISTRACTION FOR TREATMENT OF THE APERTS CRANIOFACIAL PHENOTYPE

Introduction: Apert patients often require differential advancement of the forehead, orbits, and midface to correct fronto-orbital retrusion, lengthen the midface and nose, and close the anterior open bite. While traditionally done in stages, the Monobloc + Le Fort II distraction addresses these differential movements in a single operation. Advancement of the forehead and midface is accomplished with the monobloc, while the nose and central midface is inferiorly advanced and rotated using the Le Fort II distraction. The purpose of this study is to evaluate the skeletal 3D cephalometric changes utilizing this technique in the management of Aperts syndrome. Methods: A retrospective review was performed of the senior surgeons experience utilizing this technique in patients with Aperts syndrome. Pre and post distraction 3D CT cephalometrics were analyzed and compared to a historical published cohort of Aperts patients. Vertical and axial facial ratios were calculated before and after distraction, and these ratios were also compared between cohorts. Results: 3 patients with Aperts syndrome underwent a Monobloc + lefort II differential distraction at an average age of 8 years, and with an average length of follow up of 30 months. The following 3D cephalometric landmarks and angles were measured: Glabella, nasion, incisor midline, ANS, sella, lateral inferior orbit, SNA, SNB, occlusal plane, and maxillary mandibular incisor relationship (see chart). Average Vertical Facial Movements ANS to N: 16.3mm N to Lateral inferior orbit (LIO): 3.81mm; Average Axial Facial Movements and Ratios ANS to Sella: 31.1mm Sella to LIO: 9.05mm Sella to LIO/S to ANS: 0.290 Comparison to historical control in the literature: Lefort II distraction with zygomatic repositioning. Axial facial movement ratio: Sella to LIO/S to ANS Monobloc/Lefort II mean: 0.292 Lefort II/Zygoma Repositioning: 0.276 P = 0.43 (NS) Vertical Facial Movements Ratio: N to LIO/N to ANS Monobloc/Lefort II: 0.241 Lefort II/Zygoma Repositioning: 0.203 Conclusion: Differential distraction with the Monobloc + Lefort II allows for resolution of exorbitism, improvement in negative canthal tilt, lengthening of the nose, and closure of the anterior open bite in patients with Apert syndrome. The increased distraction and rotation of the central midface results in more normal facial ratios that are not observed with traditional monobloc distraction.

S13-05 SESSION 13: HYPERTELORISM / CRANIOFACIAL CLEFTS A NOVEL ORBITO ENCEPHALO CRANIAL DYSPLASIA VARIANT TESSIER 9 FACIAL CLEFT

Introduction: We present a group of patients with dysplasia involving mesencephalon, prosencephalon, calvarium, scalp, hairline and lateral orbit. These features are classifiable as a variant Tessier 9 cleft. Clinical and radiologic findings are presented, as well as outcomes of treatment. Methods: Retrospective chart review, clinical photographs, 3D CT and MRI exams. Results: 15 patients were included. 9 patients were treated for congenital hydrocephalus due to aqueductal stenosis, and 7/9 had residual craniomegaly. Radiologic findings include pontine or quadrigeminal plate “lipoma” (n=4), squamosal bone dysplasia (n=3), Supernumerary intra-parietal suture (n=7), partial or total synotosis of the coronal or lambdoid sutures (n=5). Hairline findings include a pathognomonic temporal hairline “Omega-dot” or “atoll-like” deformity (n=12), temporal hairline peak (n=2), interrupted lateral eyebrow (n=6) and absent frontal process of the zygomatic bone (n=1). Using the following diagnostic algorithm: 2 findings = possible/tentative diagnosis, 3 or more findings = positive/confirmed diagnosis, our group was divided into 13 positive and 2 possible diagnoses. Conclusion: These patients display a constellation of rare/pathognomonic clinical symptoms with associated radiologic findings and prognostic implications. Patients with congenital hydrocephalus that harbor this anomaly may retain a craniomegalic skull when treated with standard protocols. We present the diagnostic criteria used in this series. Further radiologic examination of brain anomalies and genetic sequencing are ongoing.

Orbital cellulitis clinically mimicking rhabdomyosarcoma.

IntroductionProptosis in children with acute-onset accompanied by signs of inflammation is commonly caused by orbital cellulitis, however, the possibility of rhabdomyosarcoma should always be considered by the clinician. This is a case report of a five-year-old boy presenting with an acute-onset of proptosis without a history of trauma and systemic infection. Our clinical differential diagnosis included orbital cellulitis and orbital rhabdomyosarcoma.PurposeTo report a case of orbital cellulitis that clinically and radiologically mimics rhabdomyosarcoma.Case presentationA five-year-old boy presented with rapid-onset proptosis, periorbital edema, pain and visual loss in the left eye for two weeks without a history of trauma, upper respiratory tract infection, sinusitis or immunosuppression. Our clinical differential diagnosis includes rhabdomyosarcoma and orbital cellulitis. Complete blood count reveals a leukocytosis. Multislice computed tomography (MSCT) scan shows lesions involving the lateral orbit and the retro bulbar space. Antibiotics combination and adjunct anti-inflammatory intravenously shows excellent clinical resolution.ConclusionsThe study demonstrates difficulty in differentiating acute orbital cellulitis from rhabdomyosarcoma based on clinical findings. In addition, the case highlights that antibiotic combination of cephalosporin and aminoglycosides together with an adjuvant corticosteroid as an anti-inflammatory was effective in the case of acute orbital cellulitis.

Three-Dimensional Computed Tomographic Study on the Periorbital Branches of the Ophthalmic Artery: Arterial Variations and Clinical Relevance.

Filler injection is a popular cosmetic procedure, but it can entail vascular complications. Periorbital injections have the highest risk within the entire injection area. The authors sought to systematically screen for periorbital arterial variations prior to treatment. The external carotid arteries of 10 cadaveric heads were infused with adequate lead oxide contrast. The facial and superficial temporal arteries of another 11 cadaveric heads were injected with the contrast in sequential order. Computed tomography (CT) scanning was performed after injection of contrast, and 3-dimensional (3D) CT scans were reconstructed using validated algorithms. Three types of periorbital blood vessels were found to derive from the ophthalmic artery, including 30% directly originating from the ophthalmic artery, 65% originating from its trochlear branch, and 5% originating from its supraorbital branch. In the forehead, the ophthalmic artery, originating from the internal carotid arteries, formed anastomoses between the frontal branch of the superficial temporal artery, originating from the external carotid artery, with the deep and superficial branches of the supratrochlear and supraorbital arteries, respectively. The lateral orbit and malar plexus can be classified into 4 types based on the trunk artery: the zygomatic orbital artery (27%), the transverse facial artery (23%), the premasseteric branch of the facial artery (19%), and all 3 contributing equally (31%). Postmortem 3D CT can map periorbital arterial variations. The branching pattern of the ophthalmic artery, the ophthalmic angiosome in the forehead, and the distribution of the lateral orbit and malar plexus were identified at high resolution to guide clinical practice.

Combined Lid Crease and Endoscopic Approach to Lateral Frontal Sinus Disease With Orbital Extension.

Functional endoscopic sinus surgery for frontal sinus disease has obviated the need for external approaches. Special circumstances such as acute infection with orbital involvement or significant lateral sinus disease frequently require adjunct access. We describe the clinical outcomes of a combined upper eyelid crease and endoscopic approach for lateral frontal sinus disease with orbital extension. A retrospective case series of 7 patients who underwent a combined lid crease approach for frontal sinus disease with orbital extension between April 2012 and October 2016 was performed. All patients had the presence of lateral frontal sinus disease as well as orbital extension as seen on a preoperative computed tomography (CT) scan. Patient demographics, indications for surgery, and perioperative findings were examined. Six of the 7 patients were male. Mean age was 61 years, and the indication for surgery was primarily drainage of mucopyocele and inverting papilloma (IP) in 1 patient. The frontal sinus and orbit were successfully accessed, and the respective pathology was addressed in both locations. No intraoperative or postoperative complications were encountered. There was no postoperative or cosmetic complications. The combined lid crease and endoscopic approach is a safe and effective technique for accessing the lateral frontal sinus and orbit.

Orbital Decompression for Thyroid-Related Orbitopathy During the Quiescent Phase.

To describe historical and modern surgical approaches to orbital decompression in patients with thyroid-related orbitopathy in the quiescent phase. A literature review of published techniques using the National Institutes of Health PubMed database. Historically, orbital decompression has been accomplished via transantral, transcranial, transnasal, and orbital approaches. Current techniques use predominately periocular incisions to achieve effective decompression and proptosis reduction. Based on exophthalmometry and desired proptosis reduction, the authors propose a graded surgical approach to decompression for thyroid orbitopathy beginning with fat reduction, followed by deep lateral orbit via a superior eyelid crease incision, then medial wall by retro-caruncular approach, then posterior medial orbital floor either via transconjunctival or swinging eyelid approach, and finally with lateral orbital rim removal by superior eyelid crease incision as needed. These approaches can result in a range of proptosis reduction of up to 10 mm. A structured approach to orbital decompression results in predictable and effective outcomes in proptosis reduction.

Radiological Analysis of Orbital Cavernous Hemangiomas: A Review and Comparison Between Computed Tomography and Magnetic Resonance Imaging.

Cavernous hemangiomas are the most common benign orbital tumors in the orbit, but radiological differentiation from other solitary orbital masses can still be challenging at times. While there have been previous studies describing the radiological characteristics of cavernous hemangiomas on computed tomography (CT) and magnetic resonance imaging (MRI), there have not been any studies comparing the 2 imaging modalities. The purpose of our study was to evaluate CT and MRI findings of orbital cavernous hemangiomas and compare both modalities.We performed a cross-sectional study of patients with a histopathological diagnosis of cavernous hemangioma over a 20-year period from January 1997 to December 2016 in a single tertiary institution.Our study included 77 patients; mean age was 46.6 ± 11.2 years, and females comprised 68.8%. The lateral orbit (23.4%) was the most common location. The masses were well-defined, with 55.8% being ovoid, 27.3% round, and 16.9% lobulated. The most common enhancement pattern on CT was a small point starting in the periphery, progressing to heterogeneous filling in the late phase. The most common enhancement pattern on MRI was multiple patchy starting points, widespread across the tumor, with a final homogeneous filling in the late phase.Significant differences between CT and MRI were found in terms of area, location, and number of starting points of contrast enhancement in the early phase. We also found that the use of MRI is limited in differentiating fast-filling cavernous hemangiomas from other orbital tumors and in such cases, contrast-enhanced CT would be helpful.

Primary orbital Ewing sarcoma family of tumors: a study of 12 cases.

PurposeThe purpose of this study is to discuss the clinical presentation, management, and outcomes of patients with primary orbital Ewing sarcoma family of tumors (ESFTs).Patients and methodsRetrospective study of 12 patients with biopsy-proven primary orbital ESFT.ResultsThe mean age at presentation of primary orbital ESFT was 12 years (median, 8 years; range, 5 months to 28 years). There were seven (58%) females and five (42%) males. The presenting complaints included proptosis (n=10; 83%) and swelling in the upper eyelid (n=2; 17%). The mean duration of symptoms was 9 weeks (median, 5 weeks; range, 2-24 weeks). Tumor epicenter was located in the superior orbit (n=6; 50%), lateral orbit (n=3; 25%), inferior orbit (n=2; 17%), and medial orbit (n=1; 8%). Computed tomography of the orbits revealed predominant bony lesion (n=10; 83%) or isolated soft tissue/extraosseous lesion (n=2, 17%). At presentation, extraorbital extension was noticed in 10 patients including intra cranial extension (n=7; 58%), extension into temporal fossa (n=4; 33%), nasal cavity (n=2; 17%), maxillary sinus (n=2; 17%), and ethmoid sinus (n=1, 8%). Systemic metastases at presentation was detected in five (42%) patients involving the bone marrow (n=4; 33%), kidney (n=1; 8%), and retroperitoneal lymphnode (n=1; 8%). Multi-modal treatment including a combination of neoadjuvant chemotherapy, excision biopsy/debulking, and/or radiotherapy was given. Over a mean follow-up period of 21 months (median, 7 months; range, 1-152 months), disease-related death occurred in 11 (92%) cases.ConclusionPrimary orbital ESFT is aggressive at presentation and is associated with poor prognosis.

Lateral canthotomy orbitotomy: a rapid approach to the orbit.

PurposeThe lateral compartment of the orbit can readily be accessed through a horizontal lateral canthotomy without the need to swing the lid or remove bone. In this paper the technique, accessible orbital territory, and duration of surgery are presented.Patients and methodsRetrospective, non-interventional descriptive case series for patients who underwent a lateral canthotomy to access pathology within the lateral orbit.ResultsA series of 18 patients are included, all presenting with pathology lateral to, or within, the optic nerve. Pathologies included amyloidosis (1), lymphoma (4), metastatic adenocarcinoma within the optic nerve (1), idiopathic lateral rectus muscle mysositis (4), meningothelial meningioma of the optic nerve (1), intraconal orbital meningioma (1), reactive lymphoid hyperplasia (1), optic nerve glioma (3), optic nerve meningioma (1), and cavernous haemangioma (1). The median surgical time was 36 min (range 23-75 min). No patient required detachment of the lower lid, the technique leaving both upper and lower 'arms' of the lateral canthal tendon attached to Whitnall's tubercle.ConclusionsThe lateral canthotomy approach orbitotomy is a rapid, safe, and minimally disruptive approach for accessing pathology in the lateral orbit and optic nerve. The lateral canthal tendon is split along the horizontal raphe without detachment of either limb from Whitnall's tubercle, no bone is removed, and the post-operative recovery is rapid with minimal associated inflammation or chemosis. This approach is also flexible, permitting the clinician to increase exposure to the orbit peroperatively by swinging the lower lid if required.

Cosmetic application of botulinum toxin on maxillofacial area

Cosmetic use of botulinum toxin in the maxillofacial area has increased. Lower facial contouring is mostly performed procedure. Treatment of dynamic lines of the forehead, glabella, lateral orbit is also popular. Specific injection sites and clinical guidelines are presented.

Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients.

Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa. To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa. Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’ clinical and radiographic records were retrospectively reviewed. Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1). The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

Metopic "ridge" vs. "craniosynostosis": Quantifying severity with 3D curvature analysis.

There has been an increased incidence of surgical treatment for metopic craniosynostosis (MCS) over the past decade. MCS presents as a wide spectrum, ranging from severe trigonocephaly on one end to an isolated metopic ridge on the other. Current surgical diagnosis relies upon subjective clinical assessment of patients' cranial shape, which is often combined with impressions from radiologic imaging. In our study, we have developed a semi-automated methodology using three-dimensional curvature analysis to rigorously separate the phenotypes along the spectrum. Three clinically distinct groups of patients with CT images were obtained: 1) Normal subjects without any deformity; 2) "Benign" metopic ridge (BMR) without classic trigonocephaly; 3) Severe trigonocephaly with MCS. CT scans were converted into three-dimensional skull surface images, and curvature analysis was performed using two user-defined regions of interest (mid-forehead and lateral orbit). Three-dimensional curvature analysis of mid-forehead strip, and right/left lateral orbital areas was performed in thirty patients. The difference in average mean curvature between true MCS and BMR was 10.5m(-1) and-18.6m(-1) for mid-forehead strip and right/left lateral orbital rim, respectively. The average mean curvatures of mid-forehead strip and right/left lateral orbit areas among the three groups were significantly different (p<0.0001). K-means clustering reliably classified patients into different severity groups based on average mean curvature of the two regions of interest. The described methods are effective in classifying severity of orbitofrontal deformity in the spectrum of MCS, which can aid providers in identifying an appropriate threshold for surgical treatments of MCS.

Transconjunctival Approach for Zygomatic Fracture: A Single Surgeon's Experience of More Than 20 Years.

To let experts evaluate a single surgeon's experience with a combined transconjunctival and intraoral upper vestibular approach in the repair of zygomatic fractures encountered in 46 East Asian patients whom he treated over the past 20 years. Patients were identified from a database, and a retrospective case note review was conducted. A total of 67 conjunctival and secondary incisions were made on 46 patients for repair of zygomatic fractures. All operative procedures were performed using a combination of transconjunctival and intraoral upper vestibular approaches to repair zygomatic fractures. The infraorbital rim and/or lateral buttress and/or lateral orbit was stabilized with titanium miniplates in 28 patients and absorbable miniplates in 11 patients. Seven patients required only reduction technique with no need of plates. Four cases needed additional canthotomy besides a conjunctival approach. No ectropion or entropion developed in any of the patients. Complications included eyelid laceration during surgery (n = 1), herniation of the conjunctiva (n = 1), temporary pyogenic granuloma of the conjunctiva after surgery (n = 1), and temporary entropion in a secondary incision (n = 1). A combined transconjunctival and intraoral upper vestibular approach in repairing zygomatic fractures is simple, easy, and effective, leaving no conspicuous facial scars. It is vitally important, however, that the surgeon masters the technique of transconjunctival approach well before he has good results in East Asian patients.

Minimally Invasive Purely Endoscopic Approach to Pterygopalatine Fossa and Lateral Orbit through a Middle Fossa Extradural Route: A Cadaveric Study

Minimally Invasive Purely Endoscopic Approach to Pterygopalatine Fossa and Lateral Orbit through a Middle Fossa Extradural Route: A Cadaveric Study

Modified Transconjunctival Approach to the Lower Eyelid: Technical Details for Predictable Results.

The transconjunctival approach to the lower orbit is well described in the literature and has been used for both cosmetic and reconstructive purposes. When properly performed, it allows access to the orbital floor and inferior orbital rim with minimal lower lid morbidity and an inconspicuous scar. Many variations of this approach have been described and these can lead to confusion and uncertainty regarding the surgical technique including when and how to best utilize this approach in the traumatized eyelid. Residents and less experienced attendings employing this approach often fail to fully understand the technical and anatomic details that can make this a very fast and simple way to gain complete access to the inferior, medial, and lateral orbit while minimizing complications such as postoperative lid malposition and canthal deformities. We describe our method for transconjunctival access to the inferior orbital rim and orbital floor with specific attention to several precise surgical aspects that make this a fast and reliable technique with low morbidity and predictable architecture of closure.

Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease

Rim-off lateral wall decompression may be associated with functional and cosmetic deficit. Our objective, therefore, was to describe the functional and cosmetic results of deep lateral orbital decompression with and without anterior rim repositioning for thyroid eye disease. In this retrospective comparative case series all consecutive thyroid eye disease patients who underwent deep lateral wall decompression at the Royal Victorian Eye and Ear Hospital between 1990-2007 and the Goldschleger Eye Institute, Sheba Medical Center between 2008-2011 were included. Patients were divided into two groups: the "rim-on" group in which the anterior lateral orbital rim was repositioned and the "rim-off" group in which it was left off. Main outcome measures were: proptosis reduction, postoperative oscillopsia and diplopia, presence of visible or palpable lateral orbit depression. One hundred and twelve patients who underwent 186 orbital decompressions were included in the final analysis. The average proptosis reduction for two- and three-wall decompressions ranged between 4.6-4.9mm in the rim-on and 4.6-5.7mm in the rim-off group respectively. The prevalence of postoperative oscillopsia was similar in both groups. The preoperative diplopia worsened in 17 patients (32.1%) in the rim-on group and in seven patients (12.3%) in the rim-off group (P = .02, chi-square test). None of the patients developed visible or palpable lateral orbit depression. Deep lateral orbital decompression without anterior rim repositioning may be an effective approach to enhance functional and cosmetic outcomes in thyroid eye disease patients without increasing the risk of lateral wall depression or postoperative oscillopsia.