Orbital Surgeons Research Articles

Benign Orbital Apex Tumors Treated with Multisession Gamma Knife Radiosurgery

The orbital apex is an important anatomic landmark that hosts numerous critical neurovascular structures. Tumor resection performed at this complex region poses a therapeutic challenge to orbital surgeons and often is associated with significant visual morbidity. This article reports the efficacy and safety of multisession gamma knife radiosurgery (GKRS) in benign, well-circumscribed tumors located at the orbital apex. Retrospective interventional case series. Five patients with visual disturbances resulting from a benign, well-circumscribed orbital apex tumor (3 cases of cavernous hemangioma and 2 cases of schwannoma). Each patient treated with GKRS with a total radiation dose of 20 Gy in 4 sessions (5 Gy in each session with an isodose line of 50%) delivered to the tumor margin. Best-corrected visual acuity, visual field changes, orbital imaging, tumor growth control, and side effects of radiation. All patients demonstrated improvement in visual acuity, pupillary responses, color vision, and visual field. Tumor shrinkage was observed in all patients and remained stable until the last follow-up. No adverse events were noted during or after the radiosurgery. None of the patients experienced any radiation-related ocular morbidity. From this experience, multisession GKRS seems to be an effective management strategy to treat solitary, benign, well-circumscribed orbital apex tumors.

‘Radiology of the Orbit and Visual Pathways’

Jonathan J. Dutton ‘Radiology of the Orbit and Visual Pathways’ Saunders Elsevier 408 pages Price £129 ISBN: 978-1-4377-1151-6 Jonathan J. Dutton is a well-known Oculoplastic and Orbital surgeon. He has now written a book about the radiology of the orbit and the visual pathways. I have always admired clinicians who approach their subspeciality from a different angle, even a site that is usually dominated by another speciality. The following are the strengths of this book: Mr. Dutton is a clinican, he describes the typical clinical picture in most of the orbital diseases and then demonstrates the typical CT scan and MRI for those disease categories. The text is concise, but easy to understand. The pictures are as expected. In addition to that, the first 50 pages of the book describe the basic principles of the computed tomography and magnetic resonance imaging, the anatomy of the orbit and the intracranial visual pathways, nice chapters that are very well illustrated. At the same time, this book is available on the internet at expertconsult.com. It contains an activation code, and you can study it in your computer. The problem with books is that they are in one shelf, usually in one room, but many doctors have quite a few working stations, and it therefore handy to have such a book on the internet. While this book has been lying on my table waiting to be reviewed, I have found it useful and been using it in my clinical practice and teaching. That is the best recommendation I can give a book, it is practical, nice book indeed. I would like to extend my gratitude to the author.

Morphometric and Geometric Anatomy of the Caucasian Orbital Floor

Introduction: To describe the morphometric and geometric relationships of the orbital floor in a Caucasian population.Materials and Methods: Exenterations of 47 orbits from 24 formalin fixed cadavers were performed. Morphometric measurements were taken between anatomical landmarks located along the orbital floor and the orbital apex. The mean measurements were used to calculate geometric data. These results were analysed according to sex and side and compared to results from other ethnic populations.Results: The average distances from the infraorbital foramen to the nasolacrimal fossa, inferior orbital fissure, optic canal and inferior orbital rim were 20.67 mm (± 2.42), 25.40 mm (±2.70), 43.23 mm (±3.35) and 8.95 mm (± 1.53), respectively. The average distances from the tip of the infraorbital groove to the tip of the inferior orbital fissure, lateral aspect of the inferomedial strut, optic canal and the intersection with the inferior orbital fissure were 14.08 mm (±2.41), 12.12 mm (±2.42), 35.02 mm (±3.17) and 20.05 mm (± 2.87), respectively. The distances from the tip of the inferior orbital fissure to the optic canal and the intersection with the inferior orbital groove were 29.56 mm (±2.73) and 13.37 mm (±2.76), respectively.Discussion: Orbital surgeons should be aware of the morphometric relationships of the orbital floor due to the degree of variation that exists between different ethnic groups. Geometric data may be used to provide orbital surgeons with a navigational template that can be used to plan surgery and as a guide intraoperatively.

Subtotal Excision With Adjunctive Sclerosing Therapy for the Treatment of Severe Symptomatic Orbital Lymphangiomas

Orbital lymphangiomas are congenital malformations with abnormal and dead-end lymphatic channels and present management challenges to ophthalmologists and orbital surgeons. Recurrent hemorrhage and expansion can lead to vision loss and disfigurement. We report our technique that uses adjunctive intraoperative injection of sodium morrhuate, 5%, under direct visualization into lymphangioma channels prior to excision. We believe that in the hands of experienced orbital surgeons, and with appropriate preoperative evaluation and careful surgical technique, this procedure is useful in saving vision and avoiding complications from orbital lymphangiomas.

A Cadaveric Study of the Morphometric and Geometric Relationships of the Orbital Apex

Introduction: To define the morphometric and geometric relationships which exist at the orbital apex.Materials and Methods: Forty-seven orbits from twenty-four formalin-fixed Caucasian cadavers were exenterated and the relevant sutures, fissures and foramina identified. Measurements were taken from the optic canal to anatomical landmarks located along the medial wall, inferior wall and lateral wall of each orbit. Based on the mean results the geometric angles between the different anatomical structures were calculated and used to create three-dimensional models.Results: The mean distances from the midpoint of the optic canal to the superior orbital fissure, inferior orbital fissure and anterior ethmoidal foramen were 10.22 mm, 29.56 mm and 21.65 mm, respectively. The mean distances from the anterior ethmoidal foramen to the superior and inferior orbital fissures were 24.27 mm and 31.93 mm, respectively. The mean distance between the tips of the superior and inferior orbital fissures was 27.70 mm. The mean distances directly from the tips of the superior and inferior orbital fissures and the anterior ethmoidal foramen to the orbital rim were 39.23 mm, 17.11 mm and 18.94 mm, respectively. These values were used to calculate geometric values and create three-dimensional models.Discussion: The orbital apex is a congested structure and the practicing orbital surgeon must have an intimate knowledge of its contents. We have presented novel data, which in conjunction with radiology may be used as both a navigational aid to plan orbital surgery and to guide the surgeon intraoperatively to assess proximity to key anatomical structures.

Endoscopic Transnasal Cryo-Assisted Removal of an Orbital Cavernous Hemangioma: A Technical Note

The cryoprobe device is commonly used by orbital surgeons for the extraction of intraorbital lesions. Cryoprobes provide a safe mechanism to manipulate fluid-filled tumors. Such lesions can present in locations in which intraoperative neurosurgical assistance is essential. The authors describe a technique whereby removal of an orbital hemangioma was facilitated by the aid of an endoscopic, transnasal cryoprobe while standard microsurgical dissection was performed concurrently via a transconjunctival approach.

Lesions mimicking lacrimal gland pleomorphic adenoma

AimTo report a series of patients with lacrimal gland lesions simulating the clinicoradiological features of lacrimal gland pleomorphic adenoma (LGPA).MethodsMulticentre retrospective, interventional case series. Clinical records of all patients with...

Indeterminate Orbital Masses: Restricted Diffusion at MR Imaging with Echo-planar Diffusion-weighted Imaging Predicts Malignancy

To determine whether magnetic resonance (MR) imaging with diffusion-weighted (DW) imaging can help discriminate between radiologically indeterminate benign and malignant orbital masses and to identify optimal apparent diffusion coefficient (ADC) thresholds for such discrimination. Informed consent was waived for this HIPAA-compliant institutional review board-approved retrospective study. Forty-seven orbital masses imaged with echo-planar DW imaging were identified in 47 patients (25 female patients, 22 male patients; average age, 35 years). A fellowship-trained orbital surgeon determined reference-standard diagnoses on the basis of chart review, and a neuroradiology fellow and senior neuroradiologist who were blinded to the diagnoses selected a region of interest for each lesion by consensus. ADC was calculated from signal intensity on DW images obtained with b = 1000 and b = 0 sec/mm(2). Lesion ADC was also compared with that of normal-appearing white matter (ADC ratio). The Student t test was used to compare groups. Receiver operating characteristic analysis was performed. Intraobserver agreement was assessed with a repeat data collection. Malignant lesions had lower ADCs than benign lesions, irrespective of patient age (P < .02) and in adults specifically (P < .05). Lymphomas had lower ADCs than pseudotumors (P < .001). An ADC of less than 1.0 x 10(-3) mm(2)/sec and an ADC ratio of less than 1.2 were optimal for predicting malignancy (sensitivity, 63% for both; specificity, 84% and 90%, respectively; and accuracy, 77% and 81%, respectively). Lymphoma was differentiated from pseudotumor with 100% accuracy (in 16 of 16 cases) by using these values. Infiltrative lesions that were hypointense on T2-weighted images were better characterized with DW imaging than lesions that were hyperintense or well defined. Echo-planar DW MR imaging can help characterize indeterminate orbital masses.

The Use of Titanium T-Plate as Platform for Globe Alignment in Severe Paralytic and Restrictive Strabismus

To evaluate the long-term effectiveness of improved ocular alignment using a suture/T-plate anchoring platform system. Retrospective, noncomparative, interventional case series. setting: Institutional. study population: Seven consecutive patients with large angle deviations attributable to paralytic and/or restrictive strabismus managed jointly by orbital and strabismus surgeons. intervention procedure: The T-plate base is anchored to the orbital rim with the shaft projecting toward the orbital apex to simulate the origin of the affected muscle. A nonabsorbable suture serves as the coupling element linking the muscle insertion to the tip of the T-plate such that the suture coincides with the axis of the dysfunctional muscle and yields a pull vector to simulate the passive tensile force of the muscle. Information analyzed included patient demographics, etiology of strabismus and characteristics, prior muscle surgeries, secondary interventions, subjective appraisal of diplopia, and final ocular alignment measurements. main outcome measures: Subjective appraisal of diplopia, final ocular alignment in primary gaze, and late stability. All 7 patients showed marked reduction in ocular deviation with a median change of 33 prism diopters (PD) and a range of 7 to 72 PD. For the 6 patients with medial rectus dysfunction, the final ocular alignment ranged from 6 to 18 PD of residual exotropia in primary gaze. The patient with sixth nerve palsy had 5 PD of residual esotropia. There were no failures after an average of 59.4 months of follow-up. A globe tethering technique using a suture/titanium T-plate anchoring platform system effectively treats refractory cases of paralytic and restrictive strabismus with large angles of deviation.

Total Lateral Orbitotomy

Purpose: The goal of this study was to evaluate the safety and efficacy of performing a total lateral orbitotomy (TLO) to enhance the surgical exposure of the deep orbit.Materials and Methods: Ten orbits of five fresh-frozen cadaver heads were dissected to evaluate TLO surgical techniques. Through an eyelid approach, a bone flap extending from the supraorbital nerve to the infraorbital nerve was removed to enhance exposure to the orbital apex. The surgical exposure was further augmented by removing bone with the high-speed burr from the greater wing of sphenoid bone along the deep lateral wall. Anatomic landmarks that identified various compartments within the lateral wall and orbital roof were noted and measured. Five patients with posterior orbital tumors underwent TLO utilizing extended bone flaps and their surgical results and clinical outcomes were recorded.Results: The findings from this study demonstrate that the entire orbital rim from the supraorbital nerve to the infraorbital nerve may be removed without damaging critical neurovascular structures or creating a dural defect. Strategic removal of bone from the deep lateral wall can further enhance the exposure to the orbital apex. Five patients with deep orbital lesions underwent TLO with excellent surgical outcomes.Conclusions: By utilizing TLO techniques in a patient with a deep orbital lesion, the modern orbital surgeon can access the orbital apex safely and predictably through an eyelid approach.

The use of osseointegration and rare earth magnetic coupling for oculofacial prosthesis retention in the exenterated orbit

The goal of the present review is to update ophthalmologists and oculoplastic surgeons with the role of osseointegration for oculofacial prosthesis retention in patients requiring orbital exenteration surgery. The biophysiology of osseointegration has been well established by our dentistry colleagues and is reviewed here. Using this technology, orbital surgeons can offer their patients an adhesive-free method of prosthesis retention. Recent literature discusses the difficulties of implant success in the irradiated orbit. Osseointegration with rare earth magnetic coupling provides patients with proper oculofacial prosthesis alignment and retention assisting in the rehabilitation of the exenterated orbit.

Bilateral Orbital Varices: An Approach to Management

The authors report a case of bilateral orbital varices in a 19-year-old man with a 7-year history of intermittent left proptosis and dystopia. CT demonstrated enhancing lesions with phleboliths and gadolinium-enhanced MRI showed characteristic hyperintense lesions. The asymptomatic right lesion was treated conservatively; the left lesion was excised following intralesional injection of cyanoacrylate. Bilaterality in orbital varices may not be obvious clinically and only diagnosed radiologically. A multidisciplinary approach involving the ophthalmologist and interventional radiologist using intraoperative fluoroscopy enabled accurate characterization, delineation, embolizationm, and excision of the lesion with good hemostatic control.

Atypical inflammatory lesions in the orbit and adnexae

Abstract Purpose The common use of an initial systemic steroid treatment trial in orbital and adnexal inflammatory disease is now more questionable and used less frequently. The increased availability of specialized oculoplastic and orbital surgeons has enabled us to biopsy masses of the orbit routinely in recent years. As a result unusual pathology appears more commonly than expected in previous years. We reviewed the diagnosis and presentation of unusual inflammatoty lesions of the orbit biopsied over the past 8 years in our oculoplastic and orbital clinic. Some interesting representative cases are presented. Methods A search of the operation register and recorded diagnosis of pathology specimens was carried out and a retrospective review was made of all patients with unusual orbital inflammatory lesions presenting at the oculoplastic surgical service in Meir Medical Center between 1999 and 2008. All cases had CT imaging of the orbits and underwent biopsy of the lesion. Pathology examination was performed on all specimens following biopsy. Results There were 5 cases of non caseating granulomas in the Orbit, 1 case of Churg Strausse syndrome, 2 cases of lymphoid hyperplasia, 1 case of infectious mononucleosis dacryoadenitis, 2 cases of Eosinophillic Granuloma, 1 case of malignant schwannoma, 2 cases of angiolymphoid hyperplasia, 1 case of Sclerosing type idiopathic orbital inflammatory disease and 1 orbital abscess with an unusual presentation Conclusion We recommend biopsy of all orbital inflammatory masses before beginning treatment with steroids. Unusual pathology is more likely than expected and may have significant implications for the well being of patients.

Posttraumatic Cellulitis and Ulcerative Conjunctivitis Caused by Yersinia enterocolitica O:8

A 55-year-old white man presented with orbital cellulitis and suspicion of an intraorbital foreign body after ocular trauma. He underwent orbital exploration, but no intraorbital foreign bodies were identified. Intraoperative orbital and conjunctival cultures grew Yersinia enterocolitica O:8. The patient's signs and symptoms resolved with intravenous antibiotic treatment after this exploratory orbitotomy. This is the first case, to our knowledge, of human orbital cellulitis caused by Y. enterocolitica O:8. The single visible interpalpebral conjunctival ulceration was suspected to be an entry wound by the patient's primary physician, the emergency room physician, and the orbital surgeon prior to surgical investigation, at which time all the other ulcerations were identified. Therefore, the physical manifestations of this rare but important infection are presented because they may mislead clinicians in suspecting an intraorbital foreign body.

Orbital endoscopic surgery

Minimally invasive "keyhole" surgery performed using endoscopic visualization is increasing in popularity and is being used by almost all surgical subspecialties. Within ophthalmology, however, endoscopic surgery is not commonly performed and there is little literature on the use of the endoscope in orbital surgery. Transorbital use of the endoscope can greatly aid in visualizing orbital roof lesions and minimizing the need for bone removal. The endoscope is also useful during decompression procedures and as a teaching aid to train orbital surgeons. In this article, we review the history of endoscopic orbital surgery and provide an overview of the technique and describe situations where the endoscope can act as a useful adjunct to orbital surgery.

Problems and countermeasures in orbital plastic and reconstructive surgery

The great progress in orbital plastic and reconstructive surgery (OPRS) in China has been reached since the 21st century. However, obvious disparities exist between China and the developed countries in terms of the insufficiency of quality and quantity of surgeons of OPRS, lack of standardized and systematic training in China. It is necessary to pay attention to the diagnosis, prevention and treatment of orbital deformities, master surgical techniques and selection of the right moment of OPRS, study on orbital repairing materials and tissue engineering bone. Other important measures to improve the level of OPRS in China would include considering the characteristic of OPRS, establishing standardized and systematic professional trainings for orbital plastic surgeon, and strengthening basic and clinical research in OPRS.

Lymphoproliferative disease of the orbit

Malignant lymphoma of the ocular adnexa has been reported on for many years, but many steps forward have been recently made. This paper highlights the staging strategies and treatment options based on a review of the most updated and relevant bibliography. A relevant improvement in the management of ocular adnexal lymphoma is represented by PET, which improves the diagnosis and the staging of the disease. Acquisitions have been made in the treatment: low-dose radiotherapy is confirmed for primary orbital mucosa-associated lymphoid tissue lymphoma; oral chlorambucil is proposed as an alternative; immunotherapy is proposed for the treatment of systemic disease. Interestingly, the role of Chlamydia psittaci as the possible cause of mucosa-associated lymphoid tissue lymphomas and the efficacy of doxycycline for the treatment of ocular adnexal lymphomas have been investigated with promising results. A large series of natural killer/T-cell lymphoma has been described and its lethality despite aggressive conventional chemotherapy has been confirmed. Orbital lymphoma is the most common malignant tumor of the orbit and its incidence is increasing proportionally with the rise of the average survival rate of the general population. The combined efforts of orbital surgeons, hematologists, oncologists and radiotherapists have lately produced a mass of new information that can effectively improve the management of orbital lymphoma.

Management of Frontoethmoidal Mucoceles With Orbital Extension: Is Primary Orbital Reconstruction Necessary?

Sinus mucoceles with orbital extension are often managed primarily by an otolaryngologist to relieve the sinus obstruction. In this study, a series of patients was examined to determine whether or not reconstruction of the orbit was necessary at the time of the initial sinus surgery from the perspective of an orbital surgeon often involved in the comanagement of orbital complications of sinus mucoceles. A retrospective interventional case series of 5 patients with frontoethmoidal mucoceles comanaged by otolaryngology and oculoplastics. We reviewed symptoms, clinical findings, course, and treatment of our patients and reviewed the literature regarding management options for frontoethmoidal mucoceles. In extended follow-up, clinical resolution of presenting orbital symptoms and radiographic evidence of reformation of the bony orbit was noted without the need for orbital reconstruction at the time of the initial sinus surgery for a sinus mucocele with orbital extension. A specific subset of sinus mucoceles with orbital extension may resolve by primary sinus surgery alone. A decision on the relative merits of orbital surgery at the time of primary sinus surgery should be made on a case-by-case basis.

Evaluation of Patient Comfort with Outpatient Orbital Surgery

Purpose: To evaluate patient comfort with outpatient orbital surgery. Design: Prospective, non-randomized study. Methods: The experience of 34 consecutive outpatient orbital procedures in 30 patients was evaluated. The data obtained included subjective postoperative pain and discomfort at 3 time intervals (immediate, postoperative day 1 and 1 week) using a 100 mm visual analogue scale (VAS). Patients were also asked to rate the overall experience after one week of follow-up. Results: The average pain and discomfort scores in the immediate postoperative period measured 13.95 and 12.61, respectively. Overnight scores of 5.91 and 7.25 were determined for pain and discomfort, and at the one-week follow-up these were 0.91 and 3.42, respectively. All 30 patients reported that they were “satisfied with their overall experience.” The highest VAS score for pain at any time was 50. The highest VAS score for discomfort at any time was also 50. All 30 patients had recovered or improved their visual acuity at week one. There was no incidence of retrobulbar hemorrhage, significant loss of vision (greater than two lines), increased intraocular pressure or pupillary defects in any of the patients. None of the study patients required re-hospitalization. Conclusions: This study suggests that outpatient orbital surgery, in the hands of an experienced orbital surgeon, is safe and well tolerated by the patients regardless of the type of anesthesia or type of procedure.

Cosmetic orbital surgery

Current indications for orbital surgery primarily aimed at improving cosmesis are considered in the context of subspecialist orbital practice by an ophthalmologist. Thyroid eye disease, orbital vascular anomalies, and dermolipomas are common orbital diseases in which the symptoms can be purely cosmetic. Accurate anatomical awareness, preoperative scanning, control of medical factors including smoking and thyroid status, and endoscopic techniques have all contributed to the aesthetic outcome of orbital surgery. The threshold for performing reconstructive orbital surgery has also been lowered by public demand. Orbital surgeons can therefore offer the familiar techniques, such as orbital decompression, for pure cosmesis. Sensitive history taking and awareness of the psychological element are of paramount importance for the orbital surgeon who develops a cosmetic practice.