Orbital Pathology Research Articles

Chronic Lymphocytic Leukemia with Orbital and Sinonasal Manifestations.

Background: Chronic lymphocytic leukemia (CLL) is a slowly progressive disease most often affecting older patients. Although CLL is typically identified on routine blood work, unique manifestations of the disease have been described both at the time of diagnosis and in the setting of indolent disease. Methods: We present on 3 CLL patients with previously stable oncologic disease who presented with orbital pathologies including dacryocystitis, epiphora, proptosis, and diplopia. Results: All 3 cases were found to have recurrences of CLL confirmed on pathology and were managed both surgically and medically with collaboration from ophthalmology and medical oncology. All patients experienced significant improvement in their symptoms. Conclusions: Otolaryngologists should be suspicious of local active disease in CLL patients with orbital complaints. Awareness of rare orbital and sinonasal manifestations of the disease can improve early detection of CLL.

Trainee experience in virtual reality simulation in orbital surgery

ABSTRACT Purpose To demonstrate the role of Virtual Reality (VR) in orbital surgery as an educational tool for surgical trainees. Methods A single-center prospective study was conducted from February 2021 to April 2023. Pre-operative magnetic resonance imaging and computed tomography scans were used to create patient-specific VR models of the orbit using ImmersiveTouch Software. Accuracy of the models was qualitatively assessed by an attending oculofacial surgeon. Surveys regarding understanding of the surgical plan were distributed to trainees before the VR simulation, after its use, and following surgery. Results VR models were made for 28 cases, and 52 surveys were completed by residents in ophthalmology, otolaryngology, plastic surgery, and by oculofacial fellows. The VR models for 93% of the cases were rated as accurate by the attending physician. Assigned trainee tasks included measurement of an orbital fracture (n = 1, 1.9%), measurement of orbital tumors (n = 12, 23.1%), and drilling of the orbital bone to simulate an orbital decompression (n = 10, 19.2%). The tumor measurements made by trainees using the VR system were not significantly different than those recorded by the radiologists (p > 0.05). Early trainees (i.e. residents and the first year oculofacial fellow) noted significant improvement in their understanding of the pathology relative to important anatomical landmarks within the orbit after utilizing the VR models prior to surgery (p < 0.001). Conclusions Patient-specific VR models accurately simulate orbital pathology and may improve trainees’ understanding of orbital anatomy early in their careers.

Nasal and temporal intraconal orbital fat densities differ on computerized tomographic scans of normal orbits

AbstractBackground and AimThe anatomy and function of different areas within the intraconal fat remain poorly understood. A potential difference between nasal and temporal orbital fat densities in normal eyes may assist clinicians and radiologists in more accurately interpreting computerized tomographic (CT) scans and making more informed diagnostic and therapeutic decisions for patients with orbital pathologies.Patients and MethodsData from randomly selected patients who underwent orbital CT scans at Sheba Medical Center in 2022 were analyzed. Patients with abnormal imaging findings in either orbit were excluded. Intraconal orbital fat density was measured in six nasal and temporal sites by means of Hounsfield units (HU).ResultsThe study included 54 patients (mean age 45.3 ± 25.5 years, 29 [54%] females) who were scanned for ophthalmologic etiologies unrelated to the orbit. Non-contrast-enhanced (NCE)-CT scans were available for 36 patients (67%), CE-CT scans for 31 patients (57%), and both CE and NCE scans for 13 patients. HU values were significantly higher in the nasal orbit compared to the temporal orbit on both NCE-CT (−75.8 ± 7.5 nasal vs. −78.1 ± 8.4 temporal, P &lt; 0.001) and CE-CT (−72.7 ± 6.7 nasal vs. −74.6 ± 8.6 temporal, P = 0.02). Age, sex, and laterality had no effect on the HU values.ConclusionsThe density of nasal intraconal fat is higher compared to temporal intraconal fat, as observed on both CE and NCE-CT scans of normal eyes.These results suggest the presence of anatomical differences between these compartments and could have significant clinical implications in the diagnosis of various orbital pathologies.

Efficacy of combined surgical approaches in the management of sinonasal and orbital pathologies: innovations in minimally invasive techniques and their impact on postoperative outcomes

Sinonasal and orbital pathologies present unique challenges due to their anatomical complexity requiring advanced surgical approaches for optimal management. This systematic study demonstrates the effectiveness of combined surgical interventions based on advancements in minimally invasive approaches. An electronic literature search was performed on articles reporting patient outcomes after combined surgical management in sinonasal and orbital pathologies through the PubMed, Scopus, and Cochrane databases. Under the inclusion criteria, randomized controlled trials, literature reviews, cohort studies, and case reports published in the last decade on reputable journals were taken under consideration. Complications and functional outcomes were improved as compared to the conventional surgery techniques when looked into the previous evidences. Heterogeneities of the study designs and duration of follow-up did not permit a meta-analysis. The endoscopic orbital decompression, and other such sinonasal surgeries were now performed with less intraoperative blood loss, shorter hospital stays, and quicker recovery times. After all research, it can be concluded that combined surgical techniques do improve outcomes, but more high-quality, standardized work needs to be done to establish long-term efficacy. Our research findings support this trend of minimalization of invasive techniques to treat pathologies within the sinonasal and orbital spaces and stress their overall capacity to enhance postoperative results. Future research should focus on standardizing protocols and longer follow up periods to evaluate recurrence and long-term complications better.

Orbital Complications of Sino Nasal Tumors.

Orbital involvement in Sinonasal tumours most commonly present as proptosis, epiphora and/or visual symptoms. We aimed to enumerate the orbital manifestations of Sino nasal tumours, to describe strategies employed to manage orbit and vision, to evaluate outcomes, vision preservation and survival rates. This retrospective study spanning ten years identified 147 Sino nasal pathologies with clinic-radiological involvement of the orbit. Of the 147 cases, 35 were diagnosed as Sino nasal tumours with orbital involvement. Patients with sinonasal symptoms without clinical involvement of orbit and those with primary orbital pathology were excluded. Of the 35 patients, histopathology revealed benign and malignant tumours in 17(48.6%) and 18(51.4%) patients respectively. Inverted papilloma and squamous carcinoma were the most common benign and malignant diagnoses, respectively. Proptosis was the most common orbital symptom (42.9%) and reduced ocular motility were noted in 22.8%. Orbit preservation was achieved in all 17 cases with benign disease. Among those with malignant disease, 15 (83%) underwent globe-sparing surgeries and 3(17%) underwent orbital exenteration. Normal orbital function was retained in 6(33%) of the 15 patients. Orbital involvement in sinonasal tumours can be indicators of either chronicity or aggressive disease course. Compressive symptoms were common in benign aetiologies. In our series, orbital preservation was obtained in resection of all benign tumours. Orbital preservation was achieved in most patients with malignant disease. Histology, extent of surgery and follow up determined overall outcome in these patients.

Sinus surprise: The rare encounter of frontal mucocele with optic nerve compression

Mucoceles are epithelial-lined cavities filled with sterile mucus that develop due to the obstruction of a sinus ostium. Frontal mucocele is one of the most common among mucoceles. Most of them present with ophthalmic manifestations. Here, we present such a case with ocular symptoms. Despite the absence of thyroid-related symptoms or significant medical history, her examination revealed left eye proptosis, limited ocular motility, optic disc edema, and significant visual loss due to optic nerve compression. Further investigations, including orbital computed tomography, confirmed a frontal mucocele extending into the left orbit. Following endoscopic sinus surgery with mucocele excision, the patient experienced significant improvement in vision, resolution of optic disc edema, and proptosis. This case underscores the importance of considering mucoceles in the differential diagnosis of orbital pathologies. It also highlights the efficacy of endoscopic management in achieving favorable outcomes and emphasizes the significance of interdisciplinary collaboration in optimizing patient care.

Thyroid Eye Disease: Advancements in Orbital and Ocular Pathology Management.

Thyroid Eye Disease (TED) is a debilitating autoimmune condition often associated with thyroid dysfunction, leading to significant ocular and orbital morbidity. This review explores recent advancements in the management of TED, focusing on both medical and surgical innovations. The introduction of Teprotumumab, the first FDA-approved drug specifically for TED, marks a pivotal development in medical therapy. Teprotumumab targets the insulin-like growth factor-1 receptor (IGF-1R), effectively reducing inflammation and tissue remodeling. Clinical trials demonstrate its efficacy in reducing proptosis and improving quality of life, making it a cornerstone in the treatment of active, moderate-to-severe TED. Surgical management remains critical for patients with chronic TED or those unresponsive to medical therapy. Advancements in orbital decompression surgery, including image-guided and minimally invasive techniques, offer improved outcomes and reduced complications. Innovations in eyelid and strabismus surgery enhance functional and cosmetic results, further improving patient satisfaction. The management of TED necessitates a multidisciplinary approach involving endocrinologists, ophthalmologists, oculoplastic surgeons, radiologists, and other specialists. This collaborative strategy ensures comprehensive care, addressing the diverse aspects of TED from thyroid dysfunction to ocular health and psychological well-being. Future directions in TED treatment include emerging pharmacological therapies targeting different aspects of the disease's pathophysiology and advanced surgical techniques aimed at enhancing precision and safety. This review underscores the importance of a personalized, multidisciplinary approach in managing TED, highlighting current advancements, and exploring potential future innovations to improve patient outcomes and quality of life.

Transcranial Orbitotomy for Resection of Orbital Intraconal Arteriovenous Malformation: 2-Dimensional Operative Video

Intraorbital arteriovenous malformations (AVMs) are not common, and their prevalence is unknown. 1,2 They can cause significant morbidity, including vision loss, diplopia, chronic pain, and cosmetic deformity. 3 Treatment can be technically difficult because of the challenging anatomical location with multiple adjacent nerves and ophthalmic vascularity, and it may involve endovascular and open surgical procedures or both. 4-6 We present a video illustrating the case of a 45-year-old man with progressive right-sided proptosis and chemosis with intact vision. Magnetic resonance imaging demonstrated an orbital intraconal lesion in the superior lateral aspect. Angiogram confirmed the presence of an AVM fed by branches of the ophthalmic artery and draining to the superior ophthalmic vein. We performed a transcranial orbitotomy for resection of the AVM. Intraoperative angiogram confirmed complete resection of the AVM. The patient consented to the procedure and the publication of his images. Institutional review board approval is waived for single case reports. The patient did well postoperatively, and his proptosis and chemosis resolved. It is important for the skull base surgeon to be adept in treating orbital pathologies safely and effectively given the overlapping of pathologies that may involve the orbit and skull base such as this.

Oculoplastic Conditions in Covid-19 Patients: Case Series and Literature Review.

To investigate oculoplastic conditions in patients diagnosed with coronavirus disease 2019 (COVID-19) seen at ophthalmology departments of three tertiary referral centers in the United Kingdom and the United States, and review of the literature. Retrospective multicenter case series studied over 18 months. A total of four patients developed eyelid, orbital, or lacrimal gland pathology within four weeks of testing positive for COVID-19. All were male, and the mean age at presentation was 49 (range, 31-58 years). Suspected diagnoses included anterior idiopathic orbital inflammation, facial angioedema, dacryoadenitis, and anophthalmic socket inflammation. Three patients recovered fully and one patient recovered partially (mean 2.7 weeks) from ocular manifestations with steroids hastening recovery. Adnexal manifestations of COVID-19 include self-limiting orbital inflammation and eyelid lymphedema.

Semiautomated MRI-Based Method for Orbital Volume and Contour Analysis.

The architecture of the orbital cavity is intricate, and precise measurement of its growth is essential for managing ocular and orbital pathologies. Most methods for those measurements are by CT imaging, although MRI for soft tissue assessment is indicated in many cases, specifically pediatric patients. This study introduces a novel semiautomated MRI-based approach for depicting orbital shape and dimensions. A retrospective cohort study. Patients with at least 1 normal orbit who underwent both CT and MRI imaging at a single center from 2015 to 2023. Orbital dimensions included volume, horizontal and vertical lengths, and depth. These were determined by manual segmentation followed by 3-dimensional image processing software. Differences in orbital measurements between MRI and CT scans. Thirty-one patients (mean age 47.7 ± 23.8 years, 21 [67.7%]) females, were included. The mean differences in delta values between orbital measurements on CT versus MRI were: volume 0.03 ± 2.01 ml, horizontal length 0.53 ± 2.12 mm, vertical length, 0.36 ± 2.53 mm, and depth 0.97 ± 3.90 mm. The CT and. MRI orbital measurements were strongly correlated: volume (r = 0.92, p < 0.001), horizontal length (r = 0.65, p < 0.001), vertical length (r = 0.57, p = 0.001), and depth (r = 0.46, p = 0.009). The mean values of all measurements were similar on the paired-samples t test: p = 0.9 for volume (30.86 ± 5.04 ml on CT and 30.88 ± 4.92 ml on MRI), p = 0.2 for horizontal length, p = 0.4 for vertical length, and p = 0.2 for depth. We present an innovative semiautomated method capable of calculating orbital volume and demonstrating orbital contour by MRI validated against the gold standard CT-based measurements. This method can serve as a valuable tool for evaluating diverse orbital processes.

Pediatric orbital lesions: non-neoplastic extraocular soft-tissue lesions.

Orbital pathologies can be broadly classified as ocular, extraocular soft-tissue (non-neoplastic and neoplastic), osseous, and traumatic. In this paper, we discuss the key imaging features and differential diagnoses of congenital and developmental lesions (dermoid cyst, dermolipoma), infective and inflammatory pathologies (pre-septal cellulitis, orbital cellulitis, optic neuritis, chalazion, thyroid ophthalmopathy, orbital pseudotumor), and non-neoplastic vascular anomalies (venous malformation, lymphatic malformation, carotid-cavernous fistula), emphasizing the key role of CT and MRI in the imaging work-up. In addition, we highlight the adjunctive role of ocular ultrasound in the diagnosis of dermoid cyst and chalazion, and discuss the primary role of ultrasound in the diagnosis of vascular malformations.

Pediatric orbital lesions: bony and traumatic lesions.

Orbital pathologies can be broadly classified as ocular lesions, extraocular soft-tissue pathologies (non-neoplastic and neoplastic), and bony and traumatic lesions. In this paper, we discuss the key imaging features and differential diagnoses of bony and traumatic lesions of the pediatric orbit and globe, emphasizing the role of CT and MRI as the primary imaging modalities. In addition, we highlight the adjunctive role of ocular sonography in the diagnosis of intraocular foreign bodies and discuss the primary role of sonography in the diagnosis of traumatic retinal detachment.

A Continuous Red Eye: Case Report of Indirect Carotid Cavernous Fistula

Abstract&#x0D; Introduction : Carotid cavernous fistula (CCF) is a type of arteriovenous shunt in the cavernous sinus. Indirect CCF symptoms are not typical that can outwit us. Ocular manifestations occur because of venous and arterial stasis around the eye and orbit. The aim of this report is to increase awareness of the existence of other causes if there is no improvement after treatment.&#x0D; Case Illustration : A 59-year-old male presented with prolong conjunctival hyperemia on both eyes for two months that been diagnosed and treated as conjunctivitis. The ophthalmologic examination showed dilated episcleral vessels on both eyes with no evidence of infection and inflammation, this became a suspicion about the existence of a suppression from retro orbital region. The magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) brain examination were performed anda right CCF was diagnosed. The patient was referred to interventional neurology, digital subtraction angiography (DSA) examination showed a fistula in the right cavernous sinus and embolization was conducted.&#x0D; Discussion : The patient categorized as spontaneous, low flow, indirect CCF Barrow type D. On this type of CCF conjunctival injection is often the most prominent feature, and patients are commonly treated for other conditions, such as conjunctivitis, before a correct diagnosis is made.&#x0D; Conclusion : Carotid cavernous fistula can be characterized by the insidious onset of symptoms, diagnosis is based on the angiographic examination. When a sign suggestive of orbital or cavernous sinus pathology is present, a more thorough examination is crucial. Early diagnosis and appropriate management are essential to avoid vision and life threatening complications.

Pediatric orbital lesions: ocular pathologies.

Orbital pathologies can be broadly classified as ocular, extra-ocular soft-tissue (non-neoplastic and neoplastic), osseous, and traumatic. In part 1 of this orbital series, the authors will discuss the differential diagnosis and key imaging features of pediatric ocular pathologies. These include congenital and developmental lesions (microphthalmos, anophthalmos, persistent fetal vasculature, coloboma, morning glory disc anomaly, retinopathy of prematurity, Coats disease), optic disc drusen, infective and inflammatory lesions (uveitis, toxocariasis, toxoplasmosis), and ocular neoplasms (retinoblastoma, retinal hamartoma, choroidal melanoma, choroidal nevus). This pictorial review provides a practical approach to the imaging work-up of these anomalies with a focus on ocular US as the first imaging modality and additional use of CT and/or MRI for the evaluation of intracranial abnormalities. The characteristic imaging features of the non-neoplastic mimics of retinoblastoma, such as persistent fetal vasculature and Coats disease, are also highlighted.

Combined Orbital and Cranial Vessel Wall Magnetic Resonance Imaging for the Assessment of Disease Activity in Giant Cell Arteritis.

Acute visual impairment is the most feared complication of giant cell arteritis (GCA) but is challenging to predict. Magnetic resonance imaging (MRI) evaluates orbital pathology not visualized by an ophthalmologic examination. This study combined orbital and cranial vessel wall MRI to assess both orbital and cranial disease activity in patients with GCA, including patients without visual symptoms. Patients with suspected active GCA who underwent orbital and cranial vessel wall MRI were included. In 14 patients, repeat imaging over 12 months assessed sensitivity to change. Clinical diagnosis of ocular or nonocular GCA was determined by a rheumatologist and/or ophthalmologist. A radiologist masked to clinical data scored MRI enhancement of structures. Sixty-four patients with suspected GCA were included: 25 (39%) received a clinical diagnosis of GCA, including 12 (19%) with ocular GCA. Orbital MRI enhancement was observed in 83% of patients with ocular GCA, 38% of patients with nonocular GCA, and 5% of patients with non-GCA. MRI had strong diagnostic performance for both any GCA and ocular GCA. Combining MRI with a funduscopic examination reached 100% sensitivity for ocular GCA. MRI enhancement significantly decreased after treatment (P < 0.01). In GCA, MRI is a sensitive tool that comprehensively evaluates multiple cranial structures, including the orbits, which are the most concerning site of pathology. Orbital enhancement in patients without visual symptoms suggests that MRI may detect at-risk subclinical ocular disease in GCA. MRI scores decreased following treatment, suggesting scores reflect inflammation. Future studies are needed to determine if MRI can identify patients at low risk for blindness who may receive less glucocorticoid therapy.

Transorbital Endoscopic Approach to the Foramen Rotundum for Infraorbital Nerve Stripping.

To develop and evaluate a transorbital endoscopic approach to the foramen rotundum to excise the maxillary nerve and infraorbital nerve branch. Cadaveric dissection study of 10 cadaver heads (20 orbits). This technique is predicated upon 1) an inferior orbital fissure release to facilitate access to the orbital apex and 2) the removal of the posterior maxillary wall to enter the pterygopalatine fossa (PPF). Angulations along the infraorbital nerve were quantified as follows: the first angulation was measured between the orbitomaxillary segment within the orbital floor and the pterygopalatine segment suspended within the PPF, while the second angulation was taken between the pterygopalatine segment and maxillary nerve as it exited the foramen rotundum. With refinement of the technique, the minimum amount of posterior maxillary wall removal was quantified in the final 5 cadaver heads (10 orbits). The mean distance from the inferior orbital rim to the foramen rotundum was 45.55 ± 3.24 mm. The first angulation of the infraorbital nerve was 133.10 ± 16.28 degrees, and the second angulation was 124.95 ± 18.01 degrees. The minimum posterior maxillary wall removal to reach the PPF was 11.10 ± 2.56 mm (vertical) and 11.10 ± 2.08 mm (horizontal). The transorbital endoscopic approach to an en bloc resection of the infraorbital nerve branch up to its maxillary nerve origin provides a pathway to the PPF. This is relevant for nerve stripping in the context of perineural spread. Other applications include access to the superior portion of the PPF in selective biopsy cases or in concurrent orbital pathology.

360 Degrees Endoscopic Access to and Through the Orbit.

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Infectious and Inflammatory Processes of the Orbits in Children.

Most primary orbital pathology in children is due to bacterial infection. Radiologists typically encounter these cases to evaluate for clinically suspected postseptal orbital involvement. Contrast-enhanced cross-sectional imaging is important for the detection and early management of orbital infection and associated subperiosteal/orbital abscess, venous thrombosis, and intracranial spread of infection. Benign mass-like inflammatory processes involving the pediatric orbit are rare, have overlapping imaging features, and must be distinguished from orbital malignancies.

Where Should We Focus in Emergency Orbital Trauma?

Aim: To describe the most common findings in orbital trauma and to support radiologic decision making by comparing them in 7 pathology regions.&#x0D; Material and Methods: A total of 190 patients (119 males and 71 females) participated in the study. Orbital injury pathologies were documented and compared in seven regions. The most typical results of orbital tomography were determined. Binominal regression analysis was also performed for each trauma region.&#x0D; Results: 190 orbital CT scans showed 13.7% orbital bone fractures (n=26), 7.9% bulbus pathology (n=15), 2.6% vitreous pathology (n=5), 2.1% extraocular muscle pathology (n=4), and 6.3% (n=13) retrobulbar pathology. The most common globe pathologies were lens displacement and globe rupture. Retrobulbar fat plane changes (4.2% n=8) were the most common pathology in the region. Periorbital edema was the most common periorbital disease in 86.3% of cases (n=164). When evaluated using cross-tabulations between the seven pathologic regions, the relationship between bone pathology and retrobulbar area and between globe and vitreous was statistically significant (p

Direct impact of the COVID-19 pandemic on rhinology practice.

The pandemic caused an increase in computed tomography imaging in patients with sinusitis, which persisted post-COVID. Nasal endoscopies significantly decreased during COVID but returned to pre-COVID levels in 2022. The management of cerebrospinal fluid leaks, tumors, and orbital pathology was not impacted by the pandemic.