Retrocaruncular Approach Research Articles

Assessing effectiveness of endoscope-assisted medial orbital wall fracture repair vs. no surgery using benefit-risk metrics and literature review

PurposesTo evaluate clinical usefulness of endoscope-assisted medial orbital wall fracture repair via the retrocaruncular approach (rc-EAMOWFR) vs. no surgery (NS), and to perform a narrative review of relevant literature. MethodsThis was a retrospective cohort study enrolling isolated medial orbital wall fracture (IMOWF) eyes presented to two German level 1 trauma centers during a 7-year interval. The predictor variable was treatment type (rc-EAMOWFR vs. NS), and the main outcomes were late enophthalmos (LE) and retrobulbar hemorrhage (RH) assessed at 9–15 posttraumatic months. Descriptive and bivariate statistics were computed at α = 95%. Binary adjustments enabled calculation of number needed to treat (NNT), to harm (NNH), and likelihood to be helped or harmed (LHH) for demonstrating benefit-risk tradeoffs. Moreover, a narrative review was also performed. ResultsThe sample comprised 502 patients (28.3% females; mean age, 46.5±19.2 years) with 541 IMOWF eyes (5.9% NS; 7.2% LE; 1.3% RH). Operated eyes had significantly lower LE events than NS eyes (symptomatic IMOWF: P < .0001; 95% confidence interval [CI], .03 to .16; NNT = 2 [95% CI, 1.1 to 6.1]; asymptomatic IMOWF: P < .0001; 95% CI, .01 to .07; NNT = 2 [95% CI, 1.1 to 1.8]). There were 7 (1.5%) RH events following rc-EAMOWFR (P = .99; 95% CI, .06 to 17.4; NNH = 68 [95% CI, 38.3 to 254.2]). LHH calculations posited that rc-EAMOWFR was 34 times more likely to prevent LE than to cause RH, regardless of fracture symptoms. Our results conformed to those of other 15 studies. ConclusionsThe results of this study suggest that all IMOWFs be treated. rc-EAMOWFR performed in every 68 IMOWFs would be at risk of one RH event, but prevent 34 eyes from LE due to untreated fractures. Nearly 72% of untreated IMOWFs develop LE after 9 months.

Bases anatomiques de la voie rétro-caronculaire et ses applications cliniques en oculoplastique : étude sur cadavre

To describe the anatomical landmarks of the retro-caruncular approach and its clinical applications based on a cadaveric study. A dissection of 8 orbits providing from 4 fresh cadavers was carried out at the anatomical laboratory of the University Hospital of Nice, France between October 2018 and January 2019. Main anatomical relationships encountered are anteriorly the Duverney-Horner muscle and the lacrimal sac, posteriorly the anterior and posterior ethmoidal arteries, superiorly the pulley of the superior oblique muscle, inferiorly the lacrimonasal duct and the tendon of the inferior oblique muscle. The retro-caruncular approach allows a safe surgical access behind the lacrimal sac and Duverney-Horner muscle. Many oculoplastic surgical procedures can be performed through this approach: dacryocystorhinostomy, medial orbital fractures repair, "médial" orbital "décompression", biopsy of medial and extraconal tumours, medial periosteal fixation in third-nerve palsy. The retro-caruncular approach is a safe procedure avoiding skin incision. It allows a wide surgical space even if it is reduced compared to a more conventional skin route. It requires a great anatomical knowledge and a longer surgical learning curve.

A single surgeon's experience with retrocaruncular approach for access to isolated medial orbital fractures

Background: A series of 39 consecutive cases using the retrocaruncular approach for management of isolated medial orbital fractures is presented. This approach proves to be safe and provides good access.

Biopsy and resection of skull base tumors using transorbital endoscopic approaches: primary results

Transorbital neuroendoscopic surgery is a new skull base surgery technique that uses the orbit as an artificial corridor to the anterior and middle skull base. The space is created between the periorbita and orbital walls by their additional resection and gentle traction of the orbital contents. Skull base structures are reached using cosmetic incisions. The major advantages of transorbital endoscopic approaches include their variety, possibility of their combination, and access to the central and lateral skull base lesions. The aim of this study was to analyze the primary results of transorbital endoscopic biopsy and resection of skull base lesions, which were performed at the N.N. Burdenko National Medical Research Center for Neurosurgery (Moscow, Russia). In 2017-2018, the authors operated on 12 patients with skull base lesions using transorbital endoscopic approaches. The series included ten female and two male patients. The patient's age varied between 24 and 78 years. All patients were admitted for the first time. Half of them underwent biopsy, while the other half underwent tumor resection. The upper-lateral transorbital approach with an eyebrow incision was used in most (8/12) patients; the retrocaruncular approach was used in two cases; the lateral retrocanthal approach was applied in one case; the upper-medial approach with an eyebrow incision was used in one patient. The histological diagnosis was established in all six biopsies: 3 pseudotumors, 2 WHO Grade I meningiomas, and 1 clear-cell kidney cancer. Tumor resection was successful in 5 out of 6 patients; repeated surgery was required in one patient. In one case, the transorbital approach was combined with the transnasal one for treatment of supraorbital mucocele. One patient developed a persistent neurological deficit (dysfunction of the fifth and sixth nerves) after upper-lateral transorbital surgery. There were no poor cosmetic results in the series. Transorbital neuroendoscopic surgery needs an interdisciplinary approach and a sufficient amount of surgical experience. Surgical skills setting includes microsurgical and endoscopic tumor resection, harvesting and positioning of free and vascularized grafts for skull base reconstruction and prevention of postoperative enophthalmos, and facial incisions and their cosmetic closure. Implementation of new local vascularized flaps may significantly improve the results of transorbital endoscopic procedures and extend the spectrum of indications.

An anatomical study on the applicability of direct endoscopic exclusion of the ethmoid arteries for devascularization of the anterior skull base structures

The study was conducted on anatomical specimens of 12 cadaveric heads of deceased people without pathology of the anterior skull base structures, orbits, nasal cavity, and paranasal sinuses (24 sides). In all specimens, the internal and external carotid arteries were stained with silicone. During anatomical dissection, four surgical approaches for exclusion of the ethmoid arteries were studied: 1) transorbital approach to the arteries using a bicoronal incision; 2) endoscopic retro-caruncular approach; 3) endoscopic endonasal transethmoidal approach to the ethmoid artery canals; 4) endoscopic endonasal transethmoidal transorbital approach to the ethmoid arteries in the orbit. We described a surgical technique for exclusion of the ethmoid arteries using the approaches and analyzed their advantages and disadvantages. We formulated an algorithm for choosing the method for direct endoscopic exclusion of the ethmoid arteries, depending on the surgical approach chosen for removal of the tumor and features of the tumor extracranial spread. The decision on tumor devascularization is based on assessment of tumor blood supply (CT angiography or MR angiography data). Our study demonstrated the advantages and disadvantages of various approaches to the ethmoid arteries for their exclusion in order to early devascularize anterior skull base tumors. All these approaches are less traumatic and characterized by a good cosmetic and functional outcome.

Reconstruction of medial orbital wall using a retrocaruncular approach

The purpose of the study was to analyze and describe the retrocaruncular approach to access medial orbital wall.A retrospective analysis was performed in patients referred for the treatment of orbital fractures between January 1st 2011 and July 31st 2017. The study included patients over 18 years old with isolated fractures of the medial orbital wall or combined with the orbital floor who underwent a transconjunctival approach with retrocaruncular extension and lateral canthotomy, and with a minimum follow-up of 6 months. Patients with fractures to the roof and/or lateral orbital wall were excluded.From a total of 319 orbits, 30 medial wall fractures were treated using a retrocaruncular approach, transconjunctival extension and lateral canthotomy. 7 of them were pure medial wall fractures and 23 were combined with orbital floor. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Only one patient developed a conjunctival granuloma in relation to the caruncle. No others patients had complications.This study concluded that this approach is a successful access for surgical treatment of medial orbital wall fractures because of their broad visibility without damaging structures, allowing adequate orbital reconstruction and excellent aesthetic results.

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.

Benefits of the Retrocaruncular Approach to the Medial Orbit

Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

Acceso retrocaruncular para la reconstrucción de la pared medial de la órbita

ObjectiveTo present a retrospective analysis of the use of retrocaruncular approach to access medial orbital wall reconstruction. Additionally, the technique for performing this access is described. Material and methodThe sample for this study was chosen from the population of patients referred to the Maxillofacial Surgery Service at the Hospital Clínico Mutual de Seguridad C.Ch.C (Santiago, Chile) for the treatment of orbital fractures between 1st of January 2011 and 31st of December 2014. Subjects eligible for study inclusion had age ≥18, either isolated medial orbital wall fractures or combined with floor fractures, uni or bilateral, with surgical indication, accessed with retrocaruncular approach and 6 month of follow up at least. Exclusion criteria: roof and/or lateral orbital wall fractures. ResultsBetween January 2011 and December 2014, a total of 168 orbits were treat. 27 orbits with medial wall fractures were accessed with retrocaruncular approach with transconjunctival extension and lateral canthotomy and were included in this study. Of them, 6 were pure medial wall fractures and 21 combined with floor fractures. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Except for a patient who developed a conjunctival granuloma in relation to the caruncle, no patients had complications related to retrocaruncular access. ConclusionesThe retrocaruncular approach presented allows asafe, wide and direct access for repairing medial orbital wall fractures with optimal aesthetics results and minimal functional complications.

Treatment of Orbital Medial Wall Fractures with Titanium Mesh Plates Using Retrocaruncular Approach: Outcomes with Different Techniques.

Surgical management of medial wall orbital fractures should be considered to avoid diplopia and posttraumatic enophthalmos. Treatment of these fractures remains a challenge for the maxillofacial surgeon because of complex anatomy and limited vision. This article aims to retrospectively evaluate the outcomes in the repair of medial orbital wall fractures using a retrocaruncular approach and titanium meshes, comparing the placement of the titanium mesh with three different techniques: (1) conventional free hand under direct vision, (2) with the assistance of an endoscope, and (c) with the assistance of a navigation system. Eighteen patients who underwent surgery for orbital medial wall fracture were enrolled in the study. On the basis of the implant placement technique, three groups were identified: group 1 (CONV), conventional free hand under direct vision; group 2 (ENDO), endoscopically assisted; group 3 (NAVI), a navigational system assisted (BrainLab, Feldkirchen, Germany). The postoperative quality of orbital reconstruction was assessed as satisfactory in 12 cases, good in 4 cases, and unsatisfactory in 2 cases. Particularly in group 1 (CONV) in four patients out of eight, the posterior ledge of the fracture was not reached by the implant and in one patient the mesh hinged toward the ethmoid. In group 3 (NAVI), in one patient out of five, the posterior ledge of the fracture was not reached. In conclusion, titanium orbital mesh plates and retrocaruncular approach are a reliable method to obtain an accurate orbital medial wall reconstruction. The use of endoscopic assistance through the surgical incisions improves accuracy of treatment allowing better visualization of the surgical field. Navigation aided surgery is a feasible technique especially for complex orbital reconstruction to improve predictability and outcomes in orbital repair.

Retrocaruncular approach for the repair of medial orbital wall fractures: an anatomical and clinical study.

The aim of this article is to investigate a retrocaruncular approach for repairing medial orbital wall fractures. A total of 10 fresh cadaver orbits were dissected to investigate a transconjunctival approach to the orbit posterior to the caruncle. Medical records of consecutive patients with medial orbital wall fractures repaired via a retrocaruncular incision at Wilmer Eye Institute over a 10-year period were retrospectively reviewed. The study was approved by the Johns Hopkins Medical Institution's Institutional Review Board. Feasibility of this approach was clearly demonstrated on all cadavers. Horner muscle was observed to be directly attached to the caruncle and remained undisturbed throughout the retrocaruncular approach. For each of the 174 patients reviewed, this approach allowed successful access to the fracture and proper implant placement. The origin of the inferior oblique muscle was divided in only 19 patients. Sutures were not used for conjunctival incision closure in any patient. For 120 patients who underwent acute repair, the percentage with enophthalmos (≥ 2 mm) decreased from 34% preoperatively to 4% postoperatively; extraocular motility deficit decreased from 41 to 11%. Postoperative complications included recurrence of the preexisting retrobulbar hemorrhage, conjunctival granuloma, and temporary torsional diplopia, each in one patient. The retrocaruncular transconjunctival incision is an effective and safe approach for repairing medial orbital wall fractures with minimal complications. The retrocaruncular incision offers advantages over dividing the caruncle because Horner muscle is left undisturbed, and the incision heals well without suturing.

Retrocaruncular approach to isolated fractures of the medial orbit

Retrocaruncular approach to isolated fractures of the medial orbit

O.371 The endoscopically assisted retro-caruncular approach for medial orbital wall fracture

O.371 The endoscopically assisted retro-caruncular approach for medial orbital wall fracture

La voie d’abord rétro-caronculaire assistée par endoscopie pour le traitement des fractures de la paroi interne de l’orbite : étude préliminaire

The purpose of this study was to present our experience of endoscopically assisted retro-caruncular approach of medial wall fracture of orbital bone, notably concerning the accessibility and visibility. Five consecutive patients (4 men and 1 woman) with recent fracture (1 to 3 days), underwent medial wall reconstruction with a polydioxanone plate, endoscopically assisted via a retro-caruncular approach. The surgical technique and its results are described. Helpful hints are discussed. The plate did not have to be bent for introduction. Operative time was less than an hour for all patients. All patients were discharged the day after surgery. All experienced a mild degree of postoperative edema-related diplopia. None had persistent or secondary diplopia or enophthalmos at the one and six-month follow-up visits, respectively. Other postoperative complications, such as hematoma, nerve injury, or infection were not observed. All patients were satisfied with the outcome and especially the cosmetic result. The retro-caruncular approach with adjunctive endoscopic surgery should be the gold standard for posttraumatic isolated medial wall reconstruction of the orbit.

Retrocaruncular approach to the medial orbit for dacryocystorhinostomy.

The objective of this study was to present a versatile approach to the medial orbit behind the caruncula for dacryocystorhinostomy. This study was a retrospective, non-comparative, case series with a description of the surgical technique. We report 11 procedures carried out on 10 patients, who were operated on for DCR using the retrocaruncular approach (RCDCR). Surgical indications and complications were recorded for every patient. Lacrimal patency was obtained in 82% of the cases. The average follow-up was 2.81 months (1-6.5). DCR may be safely completed through a retro-caruncular approach. The retrocaruncular approach provides excellent and safe exposure of the posterior aspect of the lacrimal sac, and it avoids the scarring associated with the skin approach.