Orbital Surgeons Research Articles

CT definition of the surgical apex in the orbit

The orbital apex is an undefined but well understood concept of Orbital Surgeons. We sought to determine the surgical apex area specifically where the volume ratio decreases significantly impacting on the optic nerve. A retrospective analysis using PACS program processing, measured the right retrobulbar space volume changes in 100 randomly selected cases without orbital pathology where CT was performed for non-ophthalmic indications. Volume of the retrobulbar space was measured between two recognizable landmarks. The first landmark being the point of exit of the optic nerve from the eye and the second landmark the optic nerve's point of exit from the orbit. The measured length between these two points was divided into five equal segments, V1-V5. The volumes of all 5 segments were compared and the most significant area of volume depletion was established. The mean numeric value of measured orbital volumes was compared. A ratio difference of V1/V2 was less than 2, V2/V3 was 2.32 (± 0.27), V3/4 was 3.24 (± 0.39), and V4/V5 was 5.67 (± 1.66). The most remarkable difference in ratio was between V4 and V5 (mean 5.67 ± 1.66 with p < .0001). The V3 segment (the posterior 3/5 of the retrobulbar space volume) is the location where decrease in orbital volume impacts, and measured ratios are statistically significant. We defined the surgical apex as the posterior 3/5 of the retro-bulbar orbital space. It is consequently the area of higher risk for optic nerve compression. This definition could be routinely utilized by ophthalmologists and neuroradiologists when evaluating masses affecting the orbit.

Surgical management of the orbit in thyroid eye disease: lateral orbital decompression.

Lateral orbital wall decompression is one of many well established techniques available to surgeons in management of patients with clinically significant thyroid eye disease (TED). Several different surgical approaches have been described in the literature and are reviewed herein. Lateral orbital wall decompression remains a popular technique for surgical management of TED, with a recent American Society of Ophthalmic Plastic and Reconstructive Surgery survey showing that 22.6% of respondents preferred a single-wall procedure, with 36.8% of that subset preferring lateral wall decompression alone. Surgical techniques for lateral orbital wall decompression differ based on several steps, such as the incisional approach, whether to take an ab-interno versus ab-externo approach, and whether to remove orbital fat to achieve further decompression. In addition, technological advances have produced an array of tools available to the orbital surgeon to achieve efficient and accurate bone removal. Lateral orbital wall decompression for TED, despite being an older technique, remains a popular and well established procedure for orbital decompression. Though no randomized controlled clinical trial supports one decompression technique over another for TED, lateral orbital wall decompression offers many benefits such as its ease of access and visualization of the orbital space.

Transnasal Endoscopic Sclerotherapy for Orbital Apex Lymphatic Malformation.

Orbital lymphatic malformations are benign, slowly progressive vascular malformations. Management of these malformations is challenging due to their infiltrative and diffuse nature. The authors present a case with orbital apex lymphatic malformation treated with transnasal endoscopic sclerotherapy.

Graves' orbitopathy: a multidisciplinary approach.

Orbitopathy is the main extra thyroidal manifestation of Graves' disease. It is a very challenging condition, which requires a cooperation between many specialists (endocrinologists, ophthalmologists, radiologists, radiotherapeutic, orbital surgeons) for an optimal clinical management. An accurate diagnostic assessment is required, in order to plan an adequate treatment of Graves' orbitopathy. Medical therapy, radiotherapy or surgery may be necessary to control the disease. In this review, the authors analyze the various therapeutic strategies, as well the more recent therapies based on pharmacologic immunomodulation.

Navigation-guided surgery in orbital trauma

There are times in an orbital surgeon's life when experience and instincts seem inadequate and there is a need for some extra guidance and technical support. High-velocity injuries with shattered orbits are one such instance. In these cases, the entire orbit is disrupted and there are no bony landmarks to guide placement of implants and restoration of volume. Orbital walls have complex curvatures and it is extremely difficult to reestablish and symmetrize this complex three-dimensional (3D) anatomy. Inadequate reductions and poor implant placements are common causes of postoperative persistent enophthalmos. Intraoperative navigation guidance has greatly aided in accurate localization of bony landmarks, in planning complex reconstructions and verifying adequate reconstruction and symmetry, and in planning patient-specific or customized 3D-printed implants. It has brought in a revolution in the treatment of orbital trauma in current times.

A comprehensive review of biopsy techniques for oculoplastic and orbital surgeons from ophthalmic pathologists' perspective

This narrative review aims to discuss different modalities for obtaining diagnostic orbital biopsies, compares the available updated methods, and provides recommendations on the choice of technique. It also highlights special precautions in the handling of orbital specimens from various pathologies. A search was performed in PubMed and Google Scholar with no language or study type restriction. The keywords orbital biopsy, core biopsy, fine-needle aspiration biopsy, and orbit were used, and titles and abstracts were screened for relevance.

A comprehensive review of biopsy techniques for oculoplastic and orbital surgeons from ophthalmic pathologists' perspective.

This narrative review aims to discuss different modalities for obtaining diagnostic orbital biopsies, compares the available updated methods, and provides recommendations on the choice of technique. It also highlights special precautions in the handling of orbital specimens from various pathologies. A search was performed in PubMed and Google Scholar with no language or study type restriction. The keywords orbital biopsy, core biopsy, fine-needle aspiration biopsy, and orbit were used, and titles and abstracts were screened for relevance.

Localization of Trochlear Spine &amp; Fovea in Human Skulls

Introduction: Many otolaryngologist and the orbital surgeons have been devoted to finding a better way to achieve optimal outcome in fields of the paranasal sinuses and surgery on medial orbital wall. This could be achieved when the surgeon gives sufficient consideration to orbital anatomy. The cartilaginous pulley of superior oblique muscle is vulnerable during the operations on frontoethmoidal sinus. This pulley passes through an anatomical landmark called trochlear fovea and spine. Aims &amp; Objectives: To describe proper location of trochlear fovea and spine by using the measurements of frontal and sagittal plane. Place and duration of study: The study was conducted at King Edward Medical University, Lahore in 2020 on 61 dry skulls. Material &amp; Methods: Four measurements were taken in frontal plane using two lines passing at right angle through supra orbital notch and fronto zygomatic suture while in sagittal plane the distance of fovea/spine was measured from orbital margin anteriorly and optic canal posteriorly. Results: The distance of fovea and spine from the lines along supra orbital notch and fronto zygomatic suture was 7.22 ± 0.93mm and 6.14 ± 0.83mm respectively. It was 3.77 ± 0.73mm behind the margin and 38.22 ± 2.98mm in front of optic canal. Conclusion: To prevent unwanted injury to superior oblique pulley surgeons should know the topographic location and variation of fovea and spine so that the postoperative diplopia could be prevented while approaching the paranasal sinuses and surgery on medial orbital wall.

Twentieth EUGOGO Anniversary Symposium

The European Group on Graves’ Orbitopathy (EUGOGO) organized a highly successful international 20th anniversary meeting on November 7–9, 2019, in the beautiful city of Pisa, Italy. More than 200 experts and key opinion leaders in the field of Graves’ orbitopathy (GO) or thyroid eye disease and thyroid autoimmunity gathered in Tuscany to discuss the latest findings in experimental research, animal models, pathogenesis, genetics, and immunology of this complex orbital disease. Further, developments of diagnostic procedures, for example, imaging and serology, as well as surgical approaches were extensively presented. Basic scientists, immunologists, endocrinologists, thyroidologists, specialists in nuclear medicine, ophthalmologists, and orbital and ENT surgeons actively participated. The scientific program was an elegant mixture of reviews and updates delivered by acknowledged international experts and sessions focused on recent advances in GO. These oral sessions offered young investigators the opportunity to present their novel data to the plenary audience as no parallel activities were foreseen. The only exception was an excellently organized, well-attended lively session for patients with GO (mostly from Italy), which took place on Saturday morning, November 9, 2020, and which was moderated by the local organizers and other Italian colleagues.

Visual outcomes endorse surgery of patients with spheno-orbital meningioma with minimal visual impairment or hyperostosis

AbtractBackgroundMost spheno-orbital meningioma series span multiple decades, and predictors of visual outcomes have not yet been systemically assessed. We describe visual outcomes in a recent cohort and assess predictors of postoperative visual outcomes.MethodsConsecutive case series operated by a team of a neurosurgeon and orbital surgeon between May 2015 and January 2019. Best corrected visual acuity (BCVA), visual fields (static perimetry), and relative proptosis were measured preoperatively and postoperatively at 3/6/12 months after which it was assessed yearly. Predictors were assessed with linear regression analysis.ResultsNineteen patients (all WHO grade I) were operated by the pterional approach (median follow-up 2.4 years). Preoperative visual acuity deficits (n = 10) normalized in 70% and improved in 10% (median preoperative: 0.8, postoperative: 1.2, p = 0.021). Preoperative visual field deficits (n = 8) normalized in all patients (preoperative: − 6.5 dB, postoperative: − 1.5 dB, p = 0.008). Preoperative proptosis (n = 16) normalized in 44% and improved in 56% (preoperative: 5 mm, postoperative: 2 mm, p < 0.001). BCVA and visual fields remained stable at longer follow-up in 95% of patients, while 21% showed progression of proptosis. Predictors for worse longer-term (> 12 months) BCVA were worse preoperative BCVA (p = 0.002) and diagnosis of multiple meningioma (p = 0.021). Predictors for worse longer-term visual fields were higher diameter of hyperostosis (p = 0.009) and higher Simpson grade (p = 0.032). Predictor for short-term (3 months) proptosis was preoperative proptosis (p = 0.006).ConclusionWe recommend surgery, even of patients with minimal visual impairment or hyperostosis, as patients who present with deteriorated visual function or extensive hyperostosis are less likely to have postoperative visual outcomes restored to normal.

Assesing Intraoperative Virtual Navigation on My Craniofacial Surgery Fellowship for Orbital Fractures Repair: Is it Useful?

Orbital fractures pose specific challenge in its surgical management. One of the greatest challenges is to obtain satisfactory restoration of normal orbital volume and globe projection following traumatic injury, due to the inability of the surgeon to gain adequate visibility and to verify proper implant position and placement during the operation. Surgical navigation is a very helpful tool when dealing with the reconstruction of such orbital fractures. During the training of the craniofacial fellowship learning to recognize the orbital floor boundaries is essential for the correct implant placement for reconstruction, their identification is a critical step, which may be assisted by intraoperative virtual navigation. Six patients were surgically treated for orbital floor fracture with intraoperative virtual navigation. The clinical evaluation showed no complications such as enophtalmos, exophtalmos or dystopia in all the patients 2 months post operatively and a correct implant/graft position.During surgery, navigation provides exact determination of transverse, cranio-caudal and postero-anterior dimensions within the orbit and precise control of the position of implants/bone grafts.This tool aids consistently on the craniofacial surgery fellow's formation, as it facilitates the identification of the bony floor boundaries and verifies the correct placement of the implants/bone grafts. It is routinely use could help to avoid implants/bone grafts misplacement not only for craniofacial surgeon's fellow, but for all the orbital surgeons.

Orbital Implants in Orbital Fracture Reconstruction: A Ten-Year Series.

Retrospective comparative interventional series of all patients who had undergone orbital fracture repair by 2 senior orbital surgeons in a single tertiary trauma center from January 2005 to December 2014. To compare the outcomes of different implants used for various types of orbital fractures. Patients were evaluated by age, gender, etiology of fracture, clinical findings, type of fractures, and implant used. Main outcome measures included restoration of premorbid state without morbidity and complications including enophthalmos, diplopia, infraorbital hypoesthesia, and ocular motility restriction 1 year after fracture repair. Implant-related complications were collected for analysis. There were a total of 274 patients with 307 orbits reconstructed. Thirty-three (12.0%) patients sustained bilateral injuries; 58.0% (n = 178) of orbits had simple fractures (isolated orbital floor, medial wall, or combined floor and medial wall). The distribution of implants used were bioresorbable (n = 117, 38.1%) and prefabricated titanium plates (n = 98, 31.9%) depending upon the nature of fracture. Bioresorbables, titanium plate, and porous polyethylene were used significantly more than titanium mesh for simple fractures, and prefabricated anatomic titanium implants were used significantly more than the other implants for complex fractures. There was a statistically significant improvement in diplopia, enophthalmos, ocular motility, and infraorbital hypoesthesia (p-value < 0.001) 1 year following orbital fracture reconstruction. When used appropriately, diverse alloplastic materials used in orbital fracture repair tailored to the indication aid orbital reconstruction outcomes with each material having its own unique characteristics.

Personal protective equipment (PPE) during the COVID-19 pandemic for oculofacial plastic and orbital surgery

ABSTRACT Purpose: To review the current literature on Coronavirus Disease 2019 (COVID-19) virology and transmission; to present a decision tree for risk stratifying oculofacial plastic and orbital surgeries; and to generate personal protective equipment (PPE) recommendations by risk category. Methods: A comprehensive literature review on COVID-19 was conducted. A two-stage modified Delphi technique involving 18 oculofacial plastic and orbital surgeons across Canada was used to determine consensus risk-stratification criteria and PPE recommendations for surgeries performed in the North American context. Results: COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We summarize COVID-19 virology and transmission, as well as practice considerations for oculofacial plastic and orbital surgeons. Although SARS-CoV-2 is known to be transmitted predominantly by droplet mechanisms, some studies suggest that transmission is possible through aerosols. Among common procedures performed by oculofacial and plastic surgeons, some are likely to be considered aerosol-generating. Risk of transmission increases when manipulating structures known to harbor high viral loads. We present an algorithm for risk-stratification based on the nature of surgery and the anatomical sites involved and offer recommendations for PPE. Conclusions: Although universal droplet precautions are now recommended in most healthcare settings, some clinical situations require more stringent infection control measures. By highlighting high-risk scenarios specific to oculofacial plastic and orbital surgery, as well as PPE recommendations, we hope to enhance the safety of continued care during the COVID-19 pandemic.

Ophthalmic and orbital considerations in the evaluation of skull base malignancies.

The orbital contents, afferent and efferent visual pathways, and the cranial nerves involved in eye movement, corneal sensation and eyelid closure traverse the skull base, a region bounded by the intracranial cavity, the paranasal sinuses, and the deep spaces of the face and head. As such, tumors from above or below have potential to affect some aspect of the visual system. We discuss here the clinical ophthalmologic and orbital considerations in the evaluation of patients with these tumors, as well as the ophthalmic sequelae of treatment with radiation or surgery (or both). And for the surgeon, we discuss the ophthalmic and orbital considerations in surgical planning, the role of the orbital surgeon in skull base surgery, and briefly discuss transorbital approaches to the skull base. Ophthalmic and orbital dysfunction may be the main source of disability in patients with skull base malignancy; it is thus incumbent on those who manage patients with tumors of this region to be aware of the ophthalmic, neuro-ophthalmic and orbital manifestations, so as to best tailor therapy and monitor treatment outcomes.

Orbital Bone Decompression for Non-Thyroid Eye Disease Proptosis.

To report a multicenter large case series of orbital decompression for non-thyroid eye disease proptosis. Retrospective chart review of cases of orbital decompression performed by 9 experienced orbital surgeons from different countries from 2014 to 2017 for non-thyroid eye disease proptosis. Patients were divided into 3 groups: 1) negative vector (high axial length or shallow orbit), 2) inflammatory, and 3) tumor. Types of orbital decompression and Hertel exophthalmometry (preoperative and minimum 6 months postoperative) were recorded. Charts were also assessed for serious complications. The amount of exophthalmometry improvement was recorded according to the above groups. The analysis included 41 orbits of 29 patients (14 women and 15 men) with a mean age of 38.9 years (ranging from 9 to 74; standard deviation (SD) 15.66). There were 17 orbits of 11 patients in the negative vector group, 16 orbits of 10 patients in the inflammatory group, and 8 orbits of 8 patients in the tumor group. The mean reduction of proptosis was 2.95 mm in the negative vector group, 2.54 mm in the inflammatory group, and 5.75 mm in the tumor group. There were no serious complications. Orbital decompression was safe and effective in reducing proptosis for non-thyroid eye disease indications in this series. The amount of exophthalmometry improvement was less in the inflammatory orbitopathy group compared with other proptosis etiology groups.Orbital decompression may have a role in improving proptosis in non-thyroid eye disease entities.

Orbital wall restoring surgery with primary orbital wall fragments in blowout fracture

Most orbital surgeons believe that it’s difficult to restore the primary orbital wall to its previous position and that the orbital wall is so thin that cannot be firmly its primary position. Therefore, orbital wall fractures generally have been reconstructed by replacing the bony defect with a synthetic implant. Although synthetic implants have sufficient strength to maintain their shape and position in the orbital cavity, replacement surgery has some drawbacks due to the residual permanent implants. In previous studies, the author has reported an orbital wall restoring technique in which the primary orbital wall fragment was restored to its prior position through a combination of the transorbital and transantral approaches. Simple straight and curved elevators were introduced transnasally to restore the orbital wall and to maintain temporary extraorbital support in the maxillary and ethmoid sinus. A transconjunctival approach provided sufficient space for implant insertion, while the transnasal approach enabled restoration of the herniated soft tissue back into the orbit. Fracture defect was reduced by restoring the primary orbital wall fragment to its primary position, making it possible to use relatively small size implant, furthermore, extraorbital support from both sinuses decreased the incidence of implant displacement. The author could recreate a natural shape of the orbit with the patient’s own orbital bone fragments with this dual approach and effectively restored the orbital volume and shape. This procedure has the advantages for retrieving the orbital contents and restoring the primary orbital wall to its prior position.

Endoscopic orbital fat decompression for the management of proptosis in Grave's orbitopathy using a laryngeal skimmer blade.

Intraoperative handling and manipulation of orbital fat remains a challenge to orbital surgeons. We present a case series of endoscopic orbital fat decompression with medial orbital wall decompression for proptosis management in Grave's orbitopathy, describing a technique for fat excision using a laryngeal skimmer blade, reporting clinical and surgical outcomes, and complications. All patients who underwent endoscopic orbital fat decompression, with medial orbital wall decompression, for proptosis management in Grave's orbitopathy between 2011 and 2018, under the care of a single surgeon, were included in this retrospective interventional case series. Nineteen patients were included in this study. Using a laryngeal skimmer blade, orbital fat was excised endoscopically at the time of medial orbital wall decompression. The mean volume of orbital fat excised was 1.45 ± 0.63 ml and the mean reduction in proptosis was 4.5 ± 1.02 mm. There were no intraoperative complications. In this study, we describe our experience of using a laryngeal skimmer blade as a method of excising orbital fat for orbital decompression in patients with proptosis secondary to Grave's orbitopathy.

Endoscopic Transnasal Cryo-Assisted Removal of Orbital Cavernous Hemangiomas: Case Report and Technical Hints

Cryoprobe devices are used by ophthalmic and orbital surgeons for extraction of fluid-filled intraorbital lesions. No series has described cryodissection via an exclusively transnasal approach. We describe 2 cases of purely endoscopic transnasal removal of intraconal orbital hemangiomas with the aid of a dedicated cryoprobe. All transnasal endoscopic intraorbital procedures were collected and analyzed. In cases in which intraorbital dissection was performed with the use of an Optikon Cryo-line probe, clinical features, histology, size and location of the lesion, early and late complications, surgical procedure time, and hospital length of stay were analyzed. Patient follow-up included endoscopic endonasal evaluations performed at 2, 4, and 8 weeks after surgery and ophthalmologic and orthoptic evaluations performed 2 days and 2 months after surgery. Two transnasal intraorbital endoscopic procedures with the aid of the dedicated Cryo-line probe were collected. Lesions were located in the intraconal space, medial to the optic nerve. In both patients, the histologic evaluation was compatible with cavernous hemangioma, and complete resection was obtained. Mean hospital stay was 5.5 days. Postoperative ophthalmologic and orthoptic evaluations performed 2 months postoperatively revealed complete resolution of preoperative symptoms. Cryoprobes represent an adjunctive tool in the orbital surgeon's armamentarium useful in the extraction of fluid-filled intraorbital lesions. This preliminary experience suggests that their use can ease the removal of intraconal hemangiomas with an exclusively transnasal approach. The analysis of further cases is necessary to confirm safety and efficacy.

Detection of extrascleral extension in uveal melanoma with histopathological correlation

ABSTRACTPurpose: Uveal melanoma is the most common primary intraocular malignancy. Extrascleral extension (ESE) is rare, but associated with an increased rate of orbital recurrence and an overall poor prognosis. Clinical studies show low rates when compared with histological studies. Due to the prognostic importance of ESE, we sought to compare our clinical, intraoperative, and histological detection rates.Design: A retrospective cross-sectional case series.Methods: A list of eyes enucleated for uveal melanoma was compiled from the admissions records of the London Ocular Oncology Service during the 28-month period, i.e. January 2010–April 2012. The surgical and clinical notes of patients with histopathology proven ESE were reviewed to determine when it was first diagnosed or suspected. The subsequent management of these cases is discussed.Results: A total of 16 out of 174 (9%) eyes had histologically proven ESE. Eight of 16 cases were detected preoperatively at clinical examination, including the use of ocular ultrasound, 3 of 16 were discovered intra-operatively, and 5 of 16 deemed microscopic ESE, were first detected on histological examination. Seven of 7 (100%) of cases with anterior ESE were detected clinically by slit lamp biomicroscopy, while only 1 out of 9 (11%) of cases with posterior ESE was detected preoperatively with ultrasound.Conclusions: Slit lamp biomicroscopy is sensitive for detecting anterior ESE. Most posterior ESE is microscopic, but macroscopic posterior ESE may also be missed by B-scan ocular ultrasound. Orbital surgeons should be suspicious of clinically undetected posterior ESE, and consider adjuvant orbital radiotherapy in cases with macroscopic ESE.

Orbital decompression for thyroid eye disease: methods, outcomes, and complications.

PurposeTo determine the safety and effectiveness of orbital decompression for thyroid eye disease (TED) in our unit. To put this in the context of previously published literature.Patients and methodsA retrospective case review of all patients undergoing orbital decompression for TED under the care of one orbital surgeon (SMS) between January 2009 and December 2015. A systematic literature review of orbital decompression for TED.ResultsWithin the reviewed period, 93 orbits of 55 patients underwent decompression surgery for TED. There were 61 lateral (single) wall decompressions, 17 medial one-and-a-half wall, 11 two-and-a-half wall, 2 balanced two wall, and 2 orbital fat only decompressions. For the lateral (single) wall decompressions, mean reduction in exophthalmometry (95% confidence interval (CI) was 4.2 mm (3.7-4.8), for the medial one-and-a-half walls it was 2.9 mm (2.1-3.7), and for the two-and-a-half walls it was 7.6 mm (5.8-9.4). The most common complications were temporary postoperative numbness (29% of lateral decompressions, 17% of other bony decompressions, OR 0.50, 95% CI 0.12-2.11) and new postoperative diplopia (9% of lateral decompressions, 39% of other bony decompressions, OR 6.8, 95% CI 1. 5-30.9). Systematic literature searching showed reduction in exophthalmometry for lateral wall surgery of 3.6-4.8 mm, with new diplopia 0-38% and postoperative numbness 12-50%. For other bony decompressions, reduction in exophthalmometry was 2.5-8.0 mm with new diplopia 0-45% and postoperative numbness up to 52%.ConclusionDiffering approaches to orbital decompression exist. If the correct type of surgery is chosen, then safe, adequate surgical outcomes can be achieved.