Sub-brow Incision Research Articles

A Modified Subbrow Blepharoplasty for Correction of Severe Upper Eyelid Skin Laxity.

Periorbital aging is characterized by dermatochalasis, lateral hooding and malformation of multiple eyelid creases. Rejuvenation of periorbital region is of great concern in aging Asians, especially for the females. However, the conventional subbrow blepharoplasty was indicated for mild or moderate skin laxity. For severe laxity, double-eyelid incision is necessarily to be involved. This study aims to improve the severe upper eyelid dermatochalasis through an extended subbrow single-incision approach with desirable outcomes. Patients underwent this surgical method from October 2020 to April 2022 were retrospectively reviewed. The redundant skin and orbicularisoculimuscle were excised through a spindle-like subbrow incision delicately designed in the sitting position. Surgical outcomes were evaluated by heights of designed line from the palpebral margin to the pupil center (HPPC), medial cornea (HPMC), and lateral canthus (HPLC) at different follow-ups. The overall satisfaction score of cosmetic outcomes was assessed by an independent surgeon and patients themselves based on the evaluation of: subbrow scar, eyelid symmetry, lateral hooding lifting, visual block improvement and brow shape. A total of 75 cases were reviewed, including 3 men and 72 women. The preoperative HPPC, HPMC, and HPLC were 4.27 ± 0.40, 4.72 ± 0.45 and 3.41 ± 0.35 mm. The values were postoperatively improved to 7.01 ± 0.46, 6.57 ± 0.34 and 5.69 ± 0.26 mm, respectively, presenting significantly different (p<0.05). The mean surgeon satisfaction scores were 3.6 ± 0.6 (range, 2.0-4.0), and patient satisfaction scores were 3.5 ± 0.6 (range, 2.0-4.0). No hypertrophic scar, sunken upper eyelids or other complications was found. The modified subbrow blepharoplasty method is an effective and safe alternative for correcting severe upper eyelid skin laxity, which can achieve both good cosmetic outcomes and functional improvement. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases

BackgroundTwo cases of orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles were reported to understand image findings, clinical and histopathologic features of orbitofrontal cholesterol granuloma to improve its diagnosis and treatment.Case presentationTwo East Asian patients aged 41 and 27 without personal or familial medical or trauma history presented with the common complaint of proptosis and inferomedial displacement of the eyeballs. The computed tomography (CT) of both cases showed an irregularly shaped, well-defined lesion in the left frontal bone associated with bony erosion. The lesions resulted in the bone absorption of frontal bone and orbital roof, which extended into the superior orbital space. Anterior orbitotomy through subbrow incision by drainage and curettage resulted in a curative outcome. The histopathological examination revealed inflammatory granulation tissues, fibrous capsule wall, cholesterol clefts with altered blood pigments, and calcifications, consistent with the diagnosis of cholesterol granuloma. No recurrence was observed for one year after surgery in one case and three years in the other.ConclusionsWhen the following features are observed: orbital CT exhibits cystic lesion with irregular bone destruction in the superolateral orbit, magnetic resonance imaging (MRI) depicts lesions are hyperintense signals on T1 weighted images (T1WI), and T2 weighted images (T2WI), and the contrast-enhanced imaging reveals that the most of tumor is showed a non-significant enhancement, orbitofrontal cholesterol granuloma should be considered.

Evaluation of sub-brow approach to the frontozygomatic suture for Open Reduction and Internal Fixation (ORIF) of Zygomatico maxillary complex (ZMC) fractures: A prospective cohort study.

Contemporary incisions used to access the frontozygomatic (FZ) sutures are the lateral brow and upper blepharoplasty incisions which are associated with specific limitations and complications. The authors describe the use of sub-brow incision as an alternate approach for exposure of the FZ region. This is a prospective cohort study involving patients requiring surgical management of zygomatico maxillary complex (ZMC) fractures with fixation at FZ suture alone or along with fixation at infra-orbital rim and/or zygomaticomaxillary buttress. A sub-brow incision was used to expose the fracture and fixation was done with a 4-hole miniplate. The parameters evaluated were specific to the FZ region (sub-brow incision), namely surgical access, bleeding, fracture exposure time, post-operative scar, and pain. Each patient was reviewed on 1st, 5th, 7th, 10th, 30th, and 90th day. The study sample included eight male patients. The mean age was 30 years. The sub-brow incision demonstrated favorable postoperative outcomes; adequate exposure was achieved in all 8 patients. The scar formation was found to be higher on the 7th day and the least scar formation was seen by the third month. The mean pain score was found to be high on first post-operative day and the least pain was seen by the 10th day. The mean score of surgical field bleeding was found to be 1.75 which signified mild bleeding according to Fromme's scale. The mean time taken for adequate exposure of the fracture was 6.62 min. All the assessment parameters were statistically significant (P value <0.01). Sub-brow incision is an effective approach for ORIF of zygomatic fractures at FZ suture. The technique is quick, simple, and associated with minimal complications.

Reduction of comminuted fractures of the anterior wall of the frontal sinus using threaded Kirschner wires and a small eyebrow incision.

Frontal sinus fractures are relatively rare. Their surgical management significantly differs depending on whether the posterior wall is invaded and the clinical features vary. A bicoronal incision or endoscopic approach can be used. However, the minimally invasive approach has been attracting attention, leading us to introduce a simple and effective surgical method using multiple-threaded Kirschner wires. All patients had isolated anterior wall fractures without nasofrontal duct impairment. The depth from the skin to the posterior wall was measured using computed tomography to prevent injury. The edge of the bone segment on the skin was marked, a threaded Kirschner wire was inserted into the center of the bone segment, and multiple Kirschner wires were gently reduced simultaneously. Surgery was performed on 11 patients. Among them, seven patients required additional support for appropriate fracture reduction. Therefore, a periosteal elevator was used as an adjunct through a small sub-brow incision because the reduction was incomplete with the Kirschner wire alone. The reduction results were confirmed using facial bone computed tomography 1 to 3 days postoperatively. The follow-up period was 3 to 12 months. The patients had no complications and were satisfied with the surgical results. Here we demonstrated an easy and successful procedure to reduce a pure anterior wall frontal sinus fracture via non-invasive threaded Kirschner wire reduction.

Sub-brow lift combined with orbicularis oculi folding for periorbital rejuvenation

The study aimed to evaluate a new method of periorbital rejuvenation in which periorbital muscle manipulation is utilised. Patients (n = 82) who underwent eyebrow lifting surgery in Yichang Central People's Hospital were retrospectively included. All the patients had drooping eyebrows and lateral hooding of the upper eyelids combined with a flat or depressed outer-upper side of the eyebrow arch. Data were collected on the position of the eyebrow relative to the eye before and after surgery and the postoperative satisfaction of patients. The study included 43 patients in the traditional group and 39 patients in the combined group. The postoperative results showed that the combined approach group had more aesthetically pleasing mean (SD) ratio of the position of eyebrows relative to eyes (1.6 ± 0.2 vs 1.7 ± 0.2, p = 0.021). Furthermore, the satisfaction of the patients in the combined group was significantly higher than that of the traditional group (37/39 vs 34/43, p = 0.036). The periorbital rejuvenation through the sub-brow incision, combined with supraorbital orbicularis muscle folding had more aesthetically pleasing ratio of the position of eyebrows relative to eyes and the satisfaction of the patients in the combined group was significantly higher.

Double-Incision approach with suspension of the orbicularis oculi muscle and relieving of tension for upper eyelid rejuvenation in Asian women

In Asian women, upper eyelid skin laxity, lateral hooding, and upper eyelid and brow asymmetry in the aging upper eyelid are prominently and frequently seen. It is difficult to completely resolve these problems with the classical single-incision method. In this study, we investigate the utility of a double-incision approach to address aging-related changes of the upper eyelid. From September 2017 to March 2019, 51 patients underwent this procedure. Through a sub-brow incision, the skin and subcutaneous tissue were excised and the orbicularis oculi muscle (OOM) flap and muscular-cutaneous flap were separated. The OOM flap was lifted and fixed to the periosteum through the sub-brow fat pad and covered by the upper muscular-cutaneous flap. Through an eyelid crease incision, the supratarsal upper eyelid skin, muscle, and orbital fat were excised, excessive tension was alleviated, and double-fold eyelids were adjusted and reshaped if needed. The results were evaluated by asking the surgeon and patient involved to allocate a categorical (poor, fair, good, very good, excellent) scores and comparisons between pre- and postoperative brow position. The average follow-up period was 12 months. Most patients were satisfied with the results, barring two cases each of vomiting and transient numbness over the forehead region and three revisions. The mean surgeon and patient categorical scores associated with satisfaction with the overall outcome at 6 months were 4.2 ± 0.6 (range 3.0-5.0) and 4.0 ± 0.7 (range 2.0-5.0), respectively. The brow position was stable during follow-up period. A double-incision approach is a safe, effective, durable, and esthetic way for treating patients presenting with upper eyelid aging.

Cholesterol granuloma of the orbit: a case report

Background: Orbital cholesterol granuloma is a rare but well-defined entity that occurs due to a foreign body reaction with cholesterol crystals, predominantly involving the diploe of the frontal bone, and usually presenting in the superolateral orbit. Its pathogenesis is unclear; however, it is usually seen in young to middle-aged males with history of trauma. Case presentation: This study presents a 50-year-old male who presented with a superolateral orbital mass that was diagnosed as cholesterol granuloma after excision biopsy. The patient was operated and the lesion was excised through anterolateral orbitotomy via a sub-brow skin incision with dissection of the soft tissue until reaching the mass. Curettage of the affected bony surface was also carried out. The patient was then discharged. Conclusion: Ophthalmologists and otolaryngologists should be aware that cholesterol granulomas might be presented as orbital mass lesions in patients with a history of sinusitis or sinus surgery.

Review of periorbital nerve enlargement and biopsy techniques

ABSTRACTPeriorbital nerve enlargement commonly indicates perineural invasion of malignancy or inflammatory conditions. This study reviews the role of supraorbital and infraorbital nerve biopsies in patients presenting with radiographic enlargement and to elucidate the surgical technique involved.A retrospective chart review (1997-2014) was performed at a single tertiary center. Patients with radiographic confirmation of enlarged supraorbital/infraorbital nerves that underwent biopsy were included. Charts were reviewed for: patient demographics and history, clinical symptoms and findings, radiographic findings, surgical method, and treatment.Five patients (4 female, 1 male) met inclusion criteria. Average age was 72.4 years (range 36-90). Four patients had history of cutaneous malignancy. All presented with diplopia and/or dysesthesias. Clinical examination confirmed decreased V1 and/or V2 sensation for 4 patients. Imaging revealed enlargement of V1, V2, and/or V3 in all patients.Infraorbital nerve biopsies were performed in 3 patients via transconjunctival fornix-based orbitotomy with subperiosteal dissection along orbital floor followed by unroofing of infraorbital canal. The remaining 2 underwent supraorbital nerve biopsy via sub-brow incision onto superior orbital rim with reflection of periosteum. Biopsies confirmed squamous cell carcinoma(3), mucoepidermoid carcinoma(1), and idiopathic orbital inflammation(1). Three patients initiated treatment in <1 month. One decided to follow-up closer to home, one was lost to follow-up.For patients presenting with enlarged supraorbital/infraorbital nerves, biopsy can rapidly confirm the underlying condition and facilitate early treatment. A sub-brow approach offers direct access to supraorbital nerve while transconjunctival fornix-based anterior orbitotomy with canal unroofing allows access to infraorbital nerve.

External angular dermoid cyst: An unusual case report with surgical intervention and clinico-pathological analysis.

Dermoid and epidermoid cysts which belong to choristomas, usually manifest clinically as superficial and deep cystic movable formations, most often with a slow and intermittent growth. In the present article we report a case of an external angular dermoid cyst in a 13-year-old boy, the growth of which was steady on progression. Surgical excision of the cyst was done by approaching through an external sub-brow incision. Dermoid cysts are unusual neoplasms that often seen in children with the most commonly affected site being the orbit in the head and neck region. Such cysts may cause compression to the eye lobe and the optic nerve. Hence, operative procedures may be suggested in the case of such cysts which have a constant progression. Keywords: Choristoma; Dermoid; Sub-brow incision.

A Review of Subbrow Approach in the Management of Non-Complicated Anterior Table Frontal Sinus Fracture.

Frontal sinus fractures, particularly anterior sinus fractures, are relatively common facial fractures. Many agree on the general principles of frontal fracture management; however, the optimal methods of reduction are controversial. The subbrow approach enables accurate reduction and internal fixation of the fractures in the anterior table of the frontal sinus by allowing direct visualization of the fracture. Given the surgical success in reduction and rigid fixation, patient satisfaction, and aesthetic benefits, the transcutaneous approach through a subbrow incision is superior to other reduction techniques used in the management of an anterior table frontal sinus fracture.

Combined Subbrow Excision with Upper Blepharoplasty Using a Tadpole Shaped Excision for Blepharochalasis

Background In efforts to solve blepharochalasis, induced by aging process, various surgical methods have been developed over the years. Among them, classical upper blepharoplasty has a problem that severe lateral hooding may be restricted in making correction, cause of difference in thickness between the pretarsal skin and subbrow skin. And also subbrow excision (SE) blepharoplasty cannot be easily corrected in severe drooping of the medial skin. In an effort to make up for the disadvantages of these methods, we attempted SE-tadpole shaped excision blepharoplasty (TSEB). Methods Fifteen patients underwent SE-TSEB from January 2013 to November 2014. SE-TSEB was performed the following cases: 1) patients who showed moderate to severe blepharochasis with severe lateral wrinkles; 2) patients with a history of pre-existent SE blepharoplasty; 3) patients with a tattoo on the eyebrows, who want to make revision; and 4) patients with eyelid skins that are thick or have overly protuberant fat pads of the retro-orbicularis oculi fat (ROOF), and have a plan to extirpate them. Results During the follow-up observation period, most patients showed amicable correction of visibility difficulty and were aesthetically satisfied with the postoperative results with respect to correction of the lateral wrinkles. Scars formed in the subbrow incision line were within the scope of management. Conclusions SE-TSEB is a treatment modality that overcomes the disadvantages and limitations of classical upper blepharoplasty and SE blepharoplasty. Furthermore, maximizing the advantage of each surgical approach is another innovative approach for correction of changes in the upper eyelid, induced by aging. Keywords: Blepharochalasis, Blepharoplasty, Eyelids

Subbrow approach as a minimally invasive reduction technique in the management of frontal sinus fractures.

BackgroundFrontal sinus fractures, particularly anterior sinus fractures, are relatively common facial fractures. Many agree on the general principles of frontal fracture management; however, the optimal methods of reduction are still controversial. In this article, we suggest a simple reduction method using a subbrow incision as a treatment for isolated anterior sinus fractures.MethodsBetween March 2011 and March 2014, 13 patients with isolated frontal sinus fractures were treated by open reduction and internal fixation through a subbrow incision. The subbrow incision line was designed to be precisely at the lower margin of the brow in order to obtain an inconspicuous scar. A periosteal incision was made at 3 mm above the superior orbital rim. The fracture site of the frontal bone was reduced, and bone fixation was performed using an absorbable plate and screws.ResultsContour deformities were completely restored in all patients, and all patients were satisfied with the results. Scars were barely visible in the long-term follow-up. No complications related to the procedure, such as infection, uncontrolled sinus bleeding, hematoma, paresthesia, mucocele, or posterior wall and brain injury were observed.ConclusionsThe subbrow approach allowed for an accurate reduction and internal fixation of the fractures in the anterior table of the frontal sinus by providing a direct visualization of the fracture. Considering the surgical success of the reduction and the rigid fixation, patient satisfaction, and aesthetic problems, this transcutaneous approach through a subbrow incision is concluded to be superior to the other reduction techniques used in the case of an anterior table frontal sinus fracture.

Recurrent Cholesterol Granuloma of the Orbit

A 40-year-old woman presented with a 1-year history of left proptosis and hypoglobus. Eight years ago, she had undergone the surgical removal of left orbital cholesterol granuloma by Krönlein lateral orbitotomy. MRI showed a lesion of high T1-signal intensity and heterogeneous T2-signal intensity, which did not demonstrate gadolinium enhancement. The lesion was excised via a sub-brow skin incision, and careful drilling and curettage of the affected bony surface of the superolateral orbit were also performed. The diagnosis of orbital cholesterol granuloma was made by histopathologic examination. There was no evidence of tumor recurrence after 2 years of follow up. The authors present a rare case of recurrent cholesterol granuloma of the orbit and its successful surgical treatment with complete excision of the tumor and the surrounding bony base.

Recurrent orbitofrontal cholesterol granuloma in pediatric patient: case report and review of the literature

Orbitofrontal cholesterol granuloma is a rare entity which typically involves the lateral part of the supraorbital ridge. It causes progressive expansion and erosion of the inner and outer tables of the frontal bone. We describe a case of recurrent orbitofrontal cholesterol granuloma in a 17-year-old girl. In June 2002 this patient had originally presented to an eye clinic with a small palpable mass in the right superolateral orbit, limitation on upgaze, and progressive proptosis. MRI of the orbit revealed an intraorbital extraconal mass with smooth border, high signal on both T1- and T2-weighted magnetic resonance images. She underwent an anterior orbitotomy via a subbrow incision. The lesion was removed completely, and histopathological examination confirmed a cholesterol granuloma. She remained asymptomatic until her presentation in August 2005. On second admission (3 years later), she complained of a tender palpable mass in the superolateral aspect of the right orbit. Her right eye was 4 mm proptosed and 4 mm inferomedially displaced with limited elevation. The rest of the examination was normal. MRI of the orbit showed a large intraorbital but extraconal mass with smooth border, high signal on both T1- and T2-weighted images without enhancement after gadolinium injection. She underwent complete surgical excision by means of a bicoronal approach. Histopathological diagnosis revealed cholesterol granuloma. No recurrence of the lesion has been observed during the last 6 years following the second operation.

ANATOMY OF THE SUPERIOR OPHTHALMIC VEIN APPROACH FOR DIRECT ENDOVASCULAR ACCESS TO VASCULAR LESIONS OF THE ORBIT AND CAVERNOUS SINUS

The superior ophthalmic vein (SOV) provides an alternative venous access for the treatment of carotid-cavernous fistulae. Its direct surgical exposure and cannulation can be difficult. This study was performed to identify anatomic landmarks to facilitate localization and exposure of the SOV. The vascular tree of 6 formalin-fixed human cadaveric heads was injected with colored silicone. The SOV was exposed using a periorbital incision. The diameter of the SOV, its distance to the inferior border of the incision, and the angle formed by the SOV and sagittal midpupillary line were measured. The tributaries of the SOV and its orbital anatomy and relationship to the supraorbital notch/foramen were evaluated. The SOV was located in the superomedial quadrant of the orbit. Its mean diameter was 2.2 mm (standard deviation, +/-1.2 mm). The mean distance from the SOV to the superior sulcus of the eyelid nasally was 5.9 mm (standard deviation, +/-2.0 mm). The mean angle formed by the SOV and the sagittal midpupillary line was 27.9 degrees (standard deviation, +/-5.4 degrees). The tributaries of the SOV were the angular vein and supraorbital vein (SPOV). The SPOV, identified in all 12 dissections, could be followed to the SOV within the orbit. The SPOV was always located inside the supraorbital notch/foramen when the latter was present. The SOV is located at the superomedial quadrant of the orbit. The SPOV is a reliable reference during surgical exposure. A lid crease or subbrow incision centered over the supraorbital notch simplifies identification of the SOV.

A Case of Simultaneous Orbital Cellulitis and Intracranial Complication

Purpose: To report a case of simultaneous orbital cellulitis and intracranial complications of acute sinusitis in a young patient. Case summary: The 11-year-old male presented with a one-day history of left periorbital erythematous swelling, fever and headache. He was diagnosed with acute sinusitis at the department of otorhinolaryngology, and endoscopic sinus drainage of pus was performed. However, the patient's symptoms did not improve. The next day, a subdural abscess was found on brain computed tomography. He was treated by external drainage of the periosteal abscess via a subbrow incision and systemic antibiotics, as well as anticonvulsant medication. Conclusions: Twenty days after external drainage and beginning systemic antibiotics and anticonvulsant treatment, he was discharged with improved orbital cellulitis symptoms and a resolved subdural abscess.

A Case of Malignant Peripheral Nerve Sheath Tumor of the Orbit

Purpose: To present a case of malignant peripheral nerve sheath tumor (MPNST) in the orbit. Case summary: A 66-year-old man was evaluated for swelling of the left upper eyelid without pain that developed 2 months earlier. ACT scan and MRI of the orbit showed a large superior orbital mass with adjacent bony erosion, which had a central necrotic area. Incisional biopsy of the orbital mass was performed through a sub-brow incision. Histopathologic examination revealed a hypercellular tumor composed of spindle-shaped pleomorphic cells arranged in a fascicular pattern with necrotic foci. High-power magnification showed mitotic figures and nuclear pleomorphism. Subsequently, a malignant peripheral nerve sheath tumor was diagnosed. Conclusions: The possibility of malignant peripheral nerve sheath tumor should be considered in the differential diagnosis of an orbital mass which grows rapidly and shows bone invasion. Salvage surgery should be performed promptly to increase the likelihood of long-term survival.

Current Trends in the Surgical Management of Orbital Dermoid Cysts Among Pediatric Ophthalmologists

To survey the membership of the American Association for Pediatric Ophthalmology and Strabismus on their preferences in the management of dermoid cysts. The 689 active members of the American Association for Pediatric Ophthalmology and Strabismus were surveyed by mail on their preferences in the management of dermoid cysts. The survey addressed use of imaging, timing of surgery, surgical approach, use of corticosteroids, and satisfaction with results. Of the 689 members surveyed, 62.4% responded. Of these, 75.8% performed orbital dermoid excisions in their pediatric ophthalmology practices. Imaging was always obtained by 9.5%, never obtained by 9.5%, and obtained for specific reasons by 81.0%. Computed tomography scan was the preferred imaging modality of 66.2% of respondents. Surgery was deferred until older than 6 months by 68.9%, and 71.9% cited anesthetic risk as the reason for waiting. Surgical approaches used were sub-brow incision only (53.9%), eyelid crease incision only (15.8%), or either (22.6%). Ninety-six percent of respondents never used adjunct corticosteroids, and 99.2% of respondents were satisfied with their surgical results. The majority of American Association for Pediatric Ophthalmology and Strabismus members defer orbital dermoid surgery until 6 months of age due to anesthesia risk, use the sub-brow incision, and obtain imaging only for specific reasons. Most respondents never use systemic corticosteroids at the time of surgery, and are satisfied with their results.

Orbitofrontal cholesterol granuloma: distinct diagnostic features and management.

To describe the distinct clinical, radiologic, and histopathologic findings of orbitofrontal cholesterol granuloma and treatment approaches. We also present 2 atypical cases of cholesterol granuloma, one of which we believe represents the smallest and one of which the most extensive lesion among the previously reported cases in the literature. The records of 8 patients with orbital cholesterol granuloma were reviewed retrospectively. Mean age at presentation was 45 years. Six of 8 patients were male. The most common symptom at presentation was proptosis (50%). Computerized tomography of orbits showed a lytic lesion in the superolateral bony orbit with an extraconal soft tissue mass in 2 patients and a cystic lesion eroding the superolateral orbital roof in 4 patients. One patient had a small lytic lesion in the frontal bone without associated soft tissue mass and one patient had a very large destructive mass with extensive intracranial and orbital extension. Magnetic resonance imaging was obtained in 2 patients and showed a non-contrast-enhancing lesion with high signal intensity on both T1- and T2-weighted images. Seven patients were treated by aspiration of the contents and curettage of the lining by an extraperiosteal approach through a subbrow incision. One patient who was clinically thought to have a frontal mucocele was treated by frontal sinus exploration, removal of the lesion, and obliteration of the sinus. Two of 7 patients required lateral orbitotomy for better exposure of the tumor. Only one patient had recurrent symptoms and required a second surgery. Orbitofrontal cholesterol granulomas have typical clinical and radiologic features. Surgical excision has a high success rate with a low incidence of recurrence.

Management of Cavernous Sinus-Dural Fistulas

To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience. Retrospective clinical review. University tertiary referral hospital and eye institute. Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings. Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization. Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar. All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein. When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.