Orbital apocrine hidrocystoma. Report of two cases

INTRODUCTION

We report the clinical features and the management of two cases of orbital hidrocystoma in the setting of an enlarging orbital mass.

CASES DESCRIPTION

A 48-year-old man presented with a mass in the right upper medial orbital quadrant, firmly attached to the supraorbital incisure. A 70-year-old man had a well demarcated lesion in the upper lateral orbital quadrant adherent to the lacrimal gland. There was no history of previous orbital trauma. In both cases histopathology confirmed a diagnosis of apocrine hidrocystoma. Following surgery, the first patient complained of mild hypoesthesia in the territory of the supraorbital nerve that resolved spontaneously within 3 weeks. Surgery was uneventful in the other patient. No recurrence was seen during the follow up.

CONCLUSIONS

Apocrine hidrocystomas have been rarely described in the orbit, but should be considered in the differential diagnosis of orbital cystic masses. Recurrence is rare following complete surgical excision.

Endoscopic transnasal approach to remove an intraorbital bullet: systematic review and case report

Introduction

Intraorbital foreign bodies (IOFBs) represent a clinical challenge: surgical management can be controversial and different strategies have been proposed. When removal is recommended, depending on the location and nature of the IOFB both external and endoscopic approaches have been proposed, with significantly different surgical corridors to the orbit and different morbidities.

Methods

We performed a literature review of cases of IOFBs that received exclusive endoscopic transnasal surgical treatment to evaluate the role of this surgery in these occurrences. We also present a case of an intraorbital intraconal bullet that was successfully removed using an endoscopic transnasal approach with good outcomes in terms of ocular motility and visual acuity.

Results

A limited number of cases of IOFBs have been treated with an exclusive endoscopic transnasal approach. When in the medial compartment, this approach appears to be safe and effective. In our case, two months after surgery the patient showed complete recovery with no significant long-term sequelae.

Conclusions

When feasible, an endoscopic transnasal approach for intraorbital foreign bodies represents a valid surgical technique with optimal outcomes and satisfactory recovery.

Long term follow-up of congenital infantile fibrosarcoma of the orbital region

We present the long-term follow-up of a case of periorbital congenital infantile fibrosarcoma (CIFS) treated with chemotherapy and surgery. The tumor was detected on a routine prenatal ultrasound at 30 weeks of gestation and diagnosed via an orbital biopsy day 9 postnatal age. The patient underwent chemotherapy and surgical debulking within the first 3 months of life and has maintained complete tumor remission for 7 years. The case highlights that early recognition and prompt treatment of periorbital CIFS can lead to complete long-term remission of this uncommon malignancy.

Lacrimal hyperalgesia: a case series of post-operative painful lacrimation

Lacrimal hyperalgesia is a rare type of periorbital neuralgia triggered by tear production. Two female patients in their mid-forties underwent orbital surgery and, several weeks following their procedures, developed pain when they produced tears. The symptom was described as a sharp, debilitating, and transient periocular pain. A possible mechanism for this lacrimal hyperalgesia is through the formation of an artificial synapse along the superolateral aspect of the orbit. Two mechanisms for this type of hyperalgesia are described herein, which include potential mechanical compression or direct disruption of the normal nerve pathways and microvascular disruption causing ischemic nerve injury. Currently, there is no accepted treatment for this aberrant neuropathic pain caused by lacrimation. Gabapentin therapy was trialed in one of these two patients, who experienced partial improvement with nightly use. In this case series, we describe the clinical and radiographic features associated with this unique type of neuralgia, emphasizing the importance of recognizing it as a complication following orbital surgery.

Newly Developed Resorbable Magnesium Biomaterials for Orbital Floor Reconstruction in Caprine and Ovine Animal Models-A Prototype Design and Proof-of-Principle Study

BACKGROUND

orbital floor fractures have not been reconstructed using magnesium biomaterials.

METHODS

To test technical feasibility, ex vivo caprine and ovine heads (n = 5) were used. Head tissues were harvested from pubescent animals (n = 5; mean age: 3.2 years; mean mass: 26.3 kg) and stored below 11 degrees for 7-10 days. All procedures were performed in a university animal resource facility. Two experienced maxillofacial surgeons performed orbital floor procedures in both orbits of all animals in a step-by-step preplanned dissection. A transconjunctival approach was chosen to repair the orbital floor with three different implants (i.e., magnesium implants; titanium mesh; and polydioxanone or PDO sheets). The position of each implant was evaluated by Cone-beam computed tomography (CBCT).

RESULTS

Axial, coronal, and sagittal plane images showed good positioning of the magnesium plates. The magnesium plates had a radiographic visibility similar to that of the PDO sheets but lower than that of the titanium mesh.

CONCLUSIONS

The prototype design study showed a novel indication for magnesium biomaterials. Further testing of this new biomaterial may lead to the first resorbable biomaterial with good mechanical properties for extensive orbital wall defects.

Endoscopic diagnostic and surgical orbital approach in canines

The aim of this study is to describe new diagnostic and surgical orbital approaches using video endoscopy in canines. Four different endoscopic approaches were investigated in this study of video endoscopy in cadavers: dorsal transorbital ligament approach via incision of the orbital ligament (DTOLA), dorsal subpalpebral transconjunctival approach (DSTA), ventral subpalpebral transconjunctival approach (VSTA), and transoral orbital approach (TOA). Two additional approaches, the ventral transpalpebral approach (VTA) and dorsal caudal transmuscular approach (DCTA) along with the DTOLA and DSTA were used in clinical patients. The most technically demanding approach was DTOLA; however, it provided the best visualisation of different anterior and posterior orbital structures. Visualisation of primarily the dorsal orbital wall, dorsal portion of the eye globe, and dorsal extraconal space also was achieved by DSTA. The VSTA enabled good visualisation of the ventral orbital floor and the ventral extraconal and intraconal space. In contrast, the TOA provided relatively poor visualisation of orbital structures, limited to the ventral orbital quadrant. Meanwhile, the VTA provided visualisation similar to the VSTA, while DCTA visualisation was limited to the dorsal and caudal orbital space. Orbital endoscopy is an effective and minimally invasive procedure that can be used for diagnostic and surgical orbital procedures.

Intraoperative hemostatic agents in orbital surgery

PURPOSE

While preoperative optimization and post-operative management of hemorrhagic complications are increasingly clear, intraoperative control of bleeding during orbital surgery has received less attention. Thanks to advances in other fields, new technologies may be employed during these interventions. This review was designed to discuss these modalities.

METHODS

A literature search was performed to identify manuscripts that are related to the management of intraoperative bleeding. The bibliographies of these studies were also assessed to identify additional references. Data was abstracted from these studies.

RESULTS

Multiple hemostatic agents are currently used in orbital surgery, and related surgical fields have carefully assessed these interventions. Direct mechanical, flowable, and pro-thrombotic medications may all play key roles in achieving hemostasis.

CONCLUSIONS

Orbital surgeons have several potential technologies to facilitate hemostasis, and the armamentarium continues to grow. Future investigations will yield more targeted medications that may be delivered in novel manners to enhance the intraoperative experience.

Health related quality of life of patients treated with bilateral enucleation for retinoblastoma

PURPOSE

Bilateral enucleation is rarely used to manage retinoblastoma (Rb). We present the health-related quality of life (HQL) and the associated factors among individuals who underwent bilateral surgical enucleation for retinoblastoma.

METHODS

Patients were interviewed via telephone in January 2020. A retinoblastoma registry was used to select patients who underwent bilateral enucleation/exenteration during 33 years. Data included age, gender, literacy, occupation, marital status, and health issues. Patients were asked eight questions on HQL. The responses were graded as 0-10. The percentage proportion of the HQL score was correlated to the determinants.

RESULTS

Twenty-one out of 24 participants were interviewed (median age, 23 years). Fourteen participants answered the HQL question themselves, and for 7, their parents answered. Twenty patients (95%) had an ocular prosthesis. The median HQL score was 58 (out of a maximum score of 80) (interquartile range (IQR): 49; 70; minimum, 0 and maximum, 74). The HQL score was positively correlated to: self-reporting than parents reporting (Mann Whitney U (MW) p = 0.05); among students versus individuals in other occupations (MW p = 0.03); interval between eye removal and interview (p = 0.02). Age at enucleation of the second eye (p = 0.001), students (p < 0.001), and self-responders (p < 0.001) were independent predictors of a high HQL score.

CONCLUSIONS

HQL of individuals having bilateral eye enucleation for retinoblastoma was reasonably good and positively correlated to self-reporting, learning as students to cope and age at 2nd eye removal. Anaplasty services to improve cosmetics seem to benefit such disabled persons.

Use of computer-assisted surgery in the orbit

PURPOSE

To present the application of computer-assisted surgery (CAS) in pre-operative planning, intra-operative navigation, and post-operative assessment as an adjunct tool in orbital surgery.

METHODS

An IRB-approved, retrospective review was performed to identify patients who had undergone orbital surgery by a single surgeon from July 2013 to December 2019 with attention to pre-operative virtual surgical planning, intra-operative navigation, and post-operative assessment. The reasons and methods of CAS use were classified.

RESULTS

The use of computer-assisted technologies was identified in 91 cases out of 464 orbital surgeries (19.6%). This included 23 (25.3%) orbital decompression surgeries, 39 (42.9%) fracture repairs, and 25 (27.5%) orbital tumors. In all cases, pre-, intra-, and post-operative CAS allowed for increased operative efficiency and safety with good outcomes.

CONCLUSIONS

Use of CAS in orbital surgery can allow for complex radiographic analysis and in select cases is a great tool to add to the orbital surgeon's armamentarium.

Medulloepithelioma in newborn: Advanced clinical status

We report three cases of congenital medulloepithelioma, which is an extremely rare clinical pattern of a tumor rare by definition. The aim of this study is to underline the clinical features of advanced medulloepithelioma in newborns.

Recurrent contracted sockets treated with personalized, three-dimensionally printed conformers and buccal grafts

Purpose:

Recurrent contracted sockets are complex situations where previous surgeries have failed, disabling the wear of an ocular prosthesis. A combined method of surgery and long-term fixation using custom-made, three-dimensional (3D) printed conformers is evaluated.

Methods:

Retrospective case series of nine patients with recurrent excessive socket contraction and inability to wear a prosthesis, caused by chemical burns (n = 3), fireworks (n = 3), trauma (n = 2) and enucleation and radiotherapy at childhood due to optic nerve glioma (n = 1) with three average previous socket surgeries (range 2–6). Treatment consisted of a buccal mucosal graft and personalized 3D-printed conformer designed to be fixated to the periosteum and tarsal plates for minimal 2 months. Primary outcome was the retention of an ocular prosthesis. Secondary outcome was the need for additional surgeries.

Results:

Outcomes were measured at final follow-up between 7 and 36 months postoperatively (mean 20 months). Eight cases were able to wear an ocular prosthesis after 2 months. Three cases initially treated for only the upper or only the lower fornix needed subsequent surgery for the opposite fornix for functional reasons. Two cases had later surgery for cosmetic improvement of upper eyelid position. Despite pre-existing lid abnormalities (scar, entropion, lash deficiency), cosmetic outcome was judged highly acceptable in six cases because of symmetric contour and volume, and reasonably acceptable in the remaining two.

Conclusions:

Buccal mucosal transplant fixated with a personalized 3D-designed conformer enables retention of a well-fitted ocular prosthesis in previously failed socket surgeries. Initial treatment of both upper and lower fornices is recommended to avoid subsequent surgeries for functional reasons.

A prospective randomized double-blinded study of dexmedetomidine versus propofol infusion for orbital surgeries

PURPOSE:

Orbital surgeries are traditionally taken up under general anesthesia. Local anesthesia combined with moderate sedation can also be considered as an alternative option. This study was performed to compare the safety and efficacy of dexmedetomidine and propofol infusion for orbital surgeries under local anesthesia.

METHODS:

Twenty patients undergoing orbital surgery by a single surgeon were enrolled in this prospective randomized study. Selected patients were randomly administered dexmedetomidine (Group D) or propofol (Group P). Hemodynamic and respiratory effects, sedation levels, recovery profile, analgesic properties, and satisfaction levels of the patients and the surgeon were assessed.

RESULTS:

There was a significant decrease in mean arterial pressures following drug administration compared to initial measurements in both the groups. However, a statistically significant decrease in heart rate was observed only in Group P. The sedation score at the end of loading dose was 3.3 ± 0.82 in Group D and 2.5 ± 0.52 in Group P and this difference was also statistically significant (P value-0.027). The surgeon's satisfaction score was 6.5 ± 0.71 in Group D and 5.6 ± 1.07 in Group P (P value – 0.045). There were no statistically significant differences observed in patients' satisfaction, pain, and anxiety scores in either group. No major hemodynamic changes or complications were noted in either of the groups.

CONCLUSION:

Dexmedetomidine, in comparison to propofol, provides better sedation levels with good hemodynamic stability. It also offers better surgeon satisfaction, thus providing a useful alternative for general anesthesia in selective patients undergoing orbital surgery.

Restriction of eye motility in patients with RETINA IMPLANT Alpha AMS

PURPOSE

To evaluate the motility of the eye in patients with the RETINA IMPLANT Alpha AMS.

METHODS

Eye motility was determined in eight gaze directions in ten blind retinitis pigmentosa patients, who had received the RETINA IMPLANT Alpha AMS, before implantation of the subretinal implant and at six time-points up to one year after.

RESULTS

The analysis of eye motility showed a restriction in the upgaze and gaze to the temporal side directly after surgery in eight of the nine patients included. The degree of motility restriction decreased continuously with recovery during the observation time. One year after surgery, eye motility was still restricted in the majority of patients, especially in the upgaze to the temporal side at 20° (five of seven patients).

CONCLUSION

Retinal implants with intraorbital parts (e.g. connecting cables) caused restriction in the temporal and superior viewing directions in the majority of patients. Although this restriction might be cosmetically visible, this limitation in eye motility has no effects on the monocular vision and the implant's efficacy for daily use.

Orbital and periorbital dermoid cysts: Comparison of clinical features and management outcomes in children and adults

PURPOSE

To compare differences in clinical presentation and management outcomes of orbital and periorbital dermoid cysts in children and adults.

METHODS

A retrospective interventional comparative consecutive case series. 203 patients in (148 children [Age ⩽18 years] and 55 adults [Age >18 years]), who underwent excision biopsy for orbital/periorbital dermoid cyst were included. Outcome measures included the differences in demography, clinical presentations, radiological features, surgical outcomes and histopathology of cysts between children and adults with dermoid cysts.

RESULTS

The mean age noted at excision was 15 years in this cohort of 148 children and 55 adults. Commonest clinical finding observed was a subcutaneous painless mass (94%) and external angular dermoids were commonest in both groups 1 and 2 (51% and 56%). Diminution of vision (p = 0.007), proptosis (p = 0.008), extraocular motility limitation (p = 0.001), strabismus (p = 0.003) and relative afferent pupillary defect (p = 0.02) were significantly more in adults. Orbital involvement and dumbbell dermoids were not significantly different between children and adults. Radiologically, bony fossa formation (p = 0.03), temporal fossa extension (p = 0.04), full thickness bony defect (p = 0.03) and intraosseous presentation (p = 0.005) were significantly more in adults. Comparison of proportion of lesions having intra-operative rupture of dermoid cyst (p = 0.009) and evidence of inflammation on histopathology (p = 0.01) were significantly more in adults. However, recurrence rates were not different between children and adults.

CONCLUSIONS

Dermoid cysts are commoner in children, but can also present in adulthood. Secondary visual, orbital, radiologic changes and intra-operative rupture of dermoid cyst are more common in adults compared to children.

Principles of Protection of the Eye and Vision in Orbital Surgery

Orbital surgery can result in damage to ocular and orbital structures, leading to a range of structural and visual sequelae, including corneal abrasions, globe malposition, diplopia, and blindness. Vision loss in particular is the most feared and devastating complication, occurs with an overall incidence of 0.84%, and can occur secondary to direct injury, optic nerve compression, or ischemic events. Different types of orbital surgery and surgical approaches carry their own hazards, and it is important to be mindful of these risks in addition to having a thorough understanding of individual risk factors and anatomical variations for each patient. Although universal guidelines for preserving vision in orbital surgery do not yet exist, there are concrete steps that every surgeon can take at the preoperative, intraoperative, and postoperative stages to minimize the risk of injury and maximize the likelihood of preserving the eye and visual function.

The Alberta standardized orbital technique in the management of spheno-orbital meningiomas

PURPOSE

To describe a standardized orbital resection technique and outcomes for spheno-orbital meningiomas with soft-tissue invasion of the orbit.

METHODS

A retrospective case review of patients with spheno-orbital meningioma that underwent resection utilizing the Alberta Standardized Orbital Technique (ASOT) between 2008 and 2017 was performed.

RESULTS

Twenty patients met the inclusion criteria. Fifteen females and five males, with an average age of 53.4 years (SD ± 13.1 years). Mean follow-up was 57.3 months (SD ± 29.5 months). Eight cases (40%) had attempted resection prior to referral. Based on pre-operative plan, patients were divided into two groups based on goal of resection. Of those with planned complete resection (Group I), 11/13 patients (84.6%) underwent complete excision, with no cases of orbital recurrence. Incomplete resection in two cases occurred because of unexpected involvement of critical intra-cranial structures. Thus, in total 9/20 patients (Group II and 2 from Group I) underwent subtotal resection. Of these incomplete resections, five cases of orbital recurrence were observed; four patients required adjuvant external beam radiotherapy (EBRT) and one patient underwent further debulking surgery. Orbital control was achieved in three of these recurrent cases. Complications reported were persistent postoperative diplopia (three cases/15%) and wound infection (one case/5%). Overall, stable orbital disease was obtained in 18 patients (90%).

CONCLUSION

The ASOT demonstrated to be effective, achieving the pre-operative plan of complete resection in 11/13 cases (84.6%) with no recurrence in those with clear orbital margins.

Surgery around the Orbit: How to Select an Approach

Orbital region pathologies may be safely and effectively treated through a various number of approaches. As the concept of "outcome" and minimally invasive surgery keeps gaining popularity in neurosurgery, these approaches-each with specific indications and limitations-together provide the best surgical options.

Multimodal imaging of chorioretinal folds induced by orbital vascular malformation in two cases

PURPOSE

To investigate the alterations in the retinal pigment epithelium (RPE) in the crest and trough portions of chorioretinal folds (CRFs) induced by an orbital vascular tumor.

METHODS

Review of multimodal imaging in two eyes of two patients with globe compression and CRFs from an orbital vascular tumor.

RESULTS

Fundus photography demonstrated obliquely extending CRFs with alternating hyperpigmented and hypopigmented linear alterations in both eyes. Fundus autofluorescence (AF) imaging showed obliquely oriented hypoAF lines, incompletely alternating with hyperAF lines. In Case 1, the hyperAF lines had interspersed hypoAF segments and Case 2 had peripapillary mottling of AF. Fluorescein angiography (FA) showed alternating hyper and hypofluorescent lines in the late phase in Case 1. Optical coherence tomography (OCT) documented relative thinning of RPE at the folded crests in Case 1 and preservation of RPE in Case 2. Swept-source OCT angiography (SS-OCTA) demonstrated oblique hyporeflective lines in the outer retina and choriocapillaris layers in Case 2. These findings suggest that the crest of a CRF represents thinned or rarified RPE with hypoAF, transmission hyperfluorescence (FA), partially attenuated RPE layer (OCT), and isoreflectivity (SS-OCTA) while the trough represents compressed RPE with irregular hyperAF, transmission hypofluorescence (FA), thickened RPE layer (OCT), and hyporeflectivity (SS-OCTA).

CONCLUSION

The anatomic and functional status of the RPE in CRFs based on multimodal imaging reveals normal to attenuated RPE with hypofunctionality at the fold crest and compacted, thickened RPE at the trough with segmental functional impairment on AF imaging. Anatomic information regarding CRFs is evident on OCT, FA, and SS-OCTA while the functional status is depicted on AF.

Infection After Endoscopic Dacryocystorhinostomy: Incidence and Implications

BACKGROUND

Endoscopic dacryocystorhinostomy (EN-DCR) is an increasingly common procedure performed by otolaryngologists. While EN-DCR has a high rate of success at relieving blockage of the lacrimal system, little is known regarding associated postoperative infection (POI) rates and risk factors.

OBJECTIVE

The purpose of this study was to identify factors associated with the occurrence of postoperative orbital and rhinologic infection in a large cohort of patients undergoing EN-DCR.

METHODS

A retrospective review of 582 patients who underwent EN-DCR was performed. All patients received antibiotic prophylaxis as a single intraoperative intravenous administration and a ten-day postoperative oral course. Clinical and demographic information was reviewed, including the occurrence of acute orbital or rhinologic infection within 30 days of surgery. Multivariable analysis was performed to identify risk factors associated with POI.

RESULTS

Fifteen of 582 patients (2.6%) developed POI following EN-DCR. The most common POI was acute rhinosinusitis (10/15, 66.7%), followed by acute dacryocystitis (2/15, 13.3%), preseptal cellulitis (2/15,13.3%), and acute bacterial conjunctivitis (1/15, 6.7%). The majority of patients (464/582, 79.7%) underwent concurrent endoscopic sinus surgery (ESS). In most cases (302/464, 65.1%), ESS was performed to address comorbid rhinosinusitis, whereas 7.8% (36/464) of patients underwent surgery to enhance surgical access to the lacrimal sac. Patients who underwent concurrent ESS were less likely to develop POI (OR: 0.17, CI: 0.04-0.80, p < 0.05). Evidence of mucopurulence at surgery increased the likelihood of POI (OR: 6.24, CI: 1.51-25.84, p < 0.05).

CONCLUSION

Mucopurulence at the time of surgery significantly increased the risk of POI, whereas concurrent ESS, performed most commonly to address comorbid rhinosinusitis, significantly decreased the risk of POI. Awareness of risk factors for POI and appropriate surgical management of concurrent rhinosinusitis can lead to reduced infectious complications after EN-DCR.

The Lateral Orbitotomy Approach for Intraorbital Lesions

The lateral orbitotomy approach (LOA) was first described by Kronlein in 1888 and has since been subject to many modifications and variations. When considering orbital approaches, the location of the pathology is often more important in decision making than the type of pathology. The LOA is best suited for access to intraconal and extraconal lesions lateral to the optic nerve. Pathologies treated via the LOA include primary orbital tumors, extraorbital tumors with local extension into the orbit, and distantly metastatic lesions to the orbit. These all often initially manifest with vision loss, oculomotor deficits, or proptosis. The expertise of a multidisciplinary team is needed to execute safe and effective treatment. Collaboration between many specialties may be required, including ophthalmology, neurosurgery, otolaryngology, plastic surgery, oncology, and anesthesiology. The modern technique involves either a lateral canthotomy or eyelid crease incision with removal of the lateral orbital wall. It affords many advantages over a pterional craniotomy, primarily a lower approach morbidity and superior cosmetic outcomes. Reconstruction is fairly simple and the rate of complications-vision loss and extraocular muscle palsy-are low and infrequently permanent. Deep orbital apex location and intracranial extension have traditionally been considered limitations of this approach. However, with increased surgeon comfort, modern technique, and the adoption of endoscopy, these limits have expanded to even include primarily intracranial pathologies. This review details the LOA, including the general technique, its indications and limitations, reconstruction considerations, complications, and recent data from case series. The focus is on microscopic access to intraorbital lesions.

Combined neurosurgical and orbital intervention for spheno-orbital meningiomas - the Manchester experience

PURPOSE

Surgical resection of spheno-orbital meningioma (SOM) is challenging, requiring a multidisciplinary surgical approach. We present our experience of the surgical management of patients with SOM.

METHODS

A retrospective analysis of patients with SOM who underwent joint neurosurgical and orbital surgical procedures between January 2000 and June 2017. Pre-operative clinical signs, indication for surgery, surgical complications and post-operative outcomes were recorded.

RESULTS

Twenty-four operations were performed. Mean age was 49.5 years. Ninety-two percent of patients were female. Pre-operatively mean Snellen acuity vision was 6/12; 13 (54%) had an RAPD; 12 (50%) had reduced colour vision; 16 (67%) had a visual field defect. The majority (21 patients, 88%) had proptosis (average 4.5 mm ± 2.8 mm). The indication for surgery was evidence of visual dysfunction in 17 (71%), the remaining 7 (29%) had high risk of visual loss clinically or radiologically. Three-months post operatively, vision was stable in 13 (58%), improved in 6 (21%) and worse in 5 (17%). Average long-term follow-up was 82 months (1-220). Fourteen (58%) maintain improved or stable visual function. Four (17%) had reduced vision due to regrowth of the tumour at an average of 24 months.

CONCLUSION

SOMs are very challenging to treat surgically. In this cohort the patients were predominantly young females with aggressive disease. Visual function was improved or stabilised in 79% of the patients.

Orbital fat necrosis following a revision endoscopic dacryocystorhinostomy

INTRODUCTION

This report details a case of a preseptal fat necrosis in a 55-year old female, following a revision endoscopic dacryocystorhinostomy (DCR).

CASE DESCRIPTION

Upon initial examination, significant right eyelid swelling, tenderness, and pain in the peritrochlear area, was observed. An overlying skin edema was noted in the supero-medial portion of the right upper eyelid. This edema was palpable, firm, and tender. Orbital computed tomography revealed heterogeneous infiltration including an ill-defined margin in the preseptal regions of the clinically evident location. Marked, soft tissue edema and thickening in the inner preseptal area were demonstrated through magnetic resonance images (MRI). An excision biopsy was required as the lesion did not respond to medical treatment. A necrosis of adipose tissue surrounded by abundant foamy macrophages and inflammatory infiltrates, was exposed.

CONCLUSION

This is an exceptionally rare case of orbital fat necrosis following a DCR. Four possible mechanisms for the development of fat necrosis are discussed.

All India Ophthalmological Society - Oculoplastics Association of India consensus statement on preferred practices in oculoplasty and lacrimal surgery during the COVID-19 pandemic

Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis.

The effect of intravenous high-dose glucocorticoids and orbital decompression surgery on sight-threatening thyroid-associated ophthalmopathy

AIM

To report the effects of intravenous high-dose glucocorticoids (ivGC) and orbital decompression (OD) surgery for treatment of sight-threatening thyroid-associated ophthalmopathy (TAO).

METHODS

A retrospective review of medical records from patients with sight-threatening TAO [definite or highly suspected dysthyroid optic neuropathy (DON)] treated with ivGC (60 cases) and OD (25 cases) was conducted at the Zhongshan Ophthalmic Center between January 2001 and January 2009. Patients were initially treated with ivGC (ivGC group). If no significant improvement in visual function was obtained, they then received OD surgery (OD group). The pre- versus post-treatment efficacies of either ivGC or OD in these patients were assessed using several indices, including visual acuity, intraocular pressure, ocular alignment, ocular motility, and exophthalmos.

RESULTS

Nighty-one eyes had definite DON while 79 were considered to have highly suspected DON. In the ivGC group, 51 individuals (85.0%) eventually demonstrated normal vision, while 10 patients (16.7%) demonstrated a reduction in deviation (P<0.01), and 35 cases (58.3%) showed slight improvements in ocular motility (P<0.01). In OD group, visual acuity improved in 24 cases (96.0%, P<0.01) and all patients showed varying reductions of exophthalmos (mean: 4.35±1.13 mm, P<0.01). Eight cases (32.0%) experienced an 8-15 PD reduction of deviation and ocular motility improved in 12 cases (48.0%), while 3 patients (12.0%) developed new-onset strabismus with diplopia post-surgically (P<0.01). Patients were followed up at an average of 1.55±1.07y.

CONCLUSION

Both ivGC and OD show good therapeutic efficacy in the treatment of sight-threatening TAO. The presence of extremely poor eyesight (≥0.5logMAR) was corrected in some patients with ivGC alone, thus sparing these patients from subsequent OD surgery. In patients who were refractory to steroids, subsequent OD surgery often provided satisfactory outcomes, however, new-onset strabismus with diplopia was observed in 12.0% of these cases.

Primary orbital teratoma - case study

Teratomas are tumours deriving from embryonal stem cells. They consist of elements of all three germinal layers. Orbital localization of this type of tumour is very rare. Symptoms develop in the first months of life, rarely later, as cystoid components of the tumour grow in size. Surgical treatment is extremely difficult, eye is spared in individual cases. In our case study, we present baby girl with a diagnosis of primary intraorbital teratoma, who underwent partial resection of the tumour with not just the eye globe spared, but also with visual functions present after the surgery.

Transnasal endoscopic resection of orbital cavernous hemangiomas: our experience with 23 cases

BACKGROUND

The aim of this work was to present our single-center experience on orbital cavernous hemangiomas managed using an endonasal endoscopic approach.

METHODS

The study design used was one-institutional retrospective review. Twenty-three cases of orbital cavernous hemangioma were analyzed and followed up.

RESULTS

There were 10 males and 13 females, with an average age of 46.1 years, included in our study. Seven cases were extraconal, 16 cases were intraconal, and in 10 of the patients the optic nerve was involved and compressed. Total resection of the tumor was achieved in 16 cases; of the remaining 7 cases, partial tumor resection and orbital decompression were conducted, orbital decompression was conducted in 2 cases, and orbital decompression and optic nerve decompression were conducted in 3 cases. Visual acuity in 9 patients improved significantly, as 16 of the 20 patients with a preoperative visual field defect had a smaller defect after surgery.

CONCLUSION

This study adds to the literature showing that endoscopic transnasal surgery is likely a reasonable option for patients with the orbital cavernous hemangiomas medial of the optic nerve. With greater experience, skilled surgical technique, and careful operation, better clinical efficacy can be achieved.

Imaging characteristics and surgical management of orbital neurilemmomas

AIM

To review imaging characteristics and surgical outcomes of orbital neurilemmoma.

METHODS

Retrospective review of 21 patients with orbital neurilemmoma managed at the Zhongshan Ophthalmic Center of Sun Yat-sen University from June 2005 to December 2016. All patients underwent surgical excision following preoperative imaging including ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

Among these patients, 11 were male and 10 were female, with age ranging from 12 to 75y (average, 40.3y). Ultrasound of the orbit showed a roundish well-demarcated orbital mass with low or middle internal reflectivity in each case. Dark inner liquid fields were detected in 28.6% of these cases. Doppler ultrasound demonstrated blood flow signals in these masses. CT showed that the tumors were either homogeneous or heterogeneous. MRI of T1WI revealed isointense or hypointense tumors, while the T2WI indicated heterogeneous hyperintense lesions. Gd contrast MRI demonstrated heterogenous or homogeneous enhancement initiating from the wide area of the lesion. Six patients underwent lateral orbitotomy and 15 anterior orbitotomy. All tumors were completely removed. After a mean follow-up of 1.8y, 3 patients experienced reduced vision while the remaining 10 patients showed improved vision after surgery. One patient experienced a mild limitation of upward motility. No recurrence occurred.

CONCLUSION

Orbital neurilemmoma is a relatively rare, benign orbital tumor. Effective diagnosis requires a combination of ultrasonography, CT and/or MRI. These imaging techniques are also vital to differentiate neurilemmomas from other orbital masses like that of cavernous hemangiomas and meningiomas. Successful treatment requires complete resection of the neurilemmomas as performed either by lateral or anterior orbitotomy. Recurrence is rare after complete removal.

Perceptions and use of computer-assisted surgery (CAS) in the orbit

Computer-assisted surgery (CAS) plays a prominent role in certain surgical disciplines. We investigated the current perceptions and use of this technology for orbital surgery. An online survey was emailed to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Society of Oculoplastic Surgery, and British Oculoplastic Surgery Society. Respondents were asked to describe their practice type and seniority, their frequency of orbital surgery, experience, use, and accessibility of CAS, and their opinion on the technology. There were a total of 151 responses across the societies. 105 respondents (69.5%) had been in attending/consultant practice for over 10 years, with over half (54.7%) working in academic/teaching hospitals. The majority (66.7%) had superficial or no experience with CAS. In total, 84.8% of respondents rarely or never use CAS for orbital surgery (n = 128). Posterior orbital surgery (64.2%) and orbital decompression (49.0%) were the two most useful reasons to implement CAS. Longer operating time (58.3%) and cost (54.8%) were the two most selected weaknesses for CAS, whereas improved accuracy in attaining surgical end point(s) (80.8%) and patient safety (63.6%) were the principal advantages. Type of practice was significantly associated with CAS availability/accessibility (p < 0.05). Proportion of orbital surgery performed in practice was significantly associated with both CAS experience and use (p < 0.05). Our study confirms an expected variation in the perception and use of CAS for orbital surgery. Demonstrated patient benefit and integration of refined and cost-effective CAS systems into operating room environments may influence its future role.

Development of the international orbital Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system

BACKGROUND

Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic-based staging system was developed.

METHODS

An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed.

RESULTS

Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty.

CONCLUSION

Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high-quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH.

Migration of retrobulbar wooden foreign body between diagnostic imaging and surgical extraction in a German shepherd dog

A 2-year-old, male castrated German shepherd dog was presented to the University of Tennessee Veterinary Medical Center (UTVMC) with periorbital swelling and conjunctival mucopurulent discharge 2 days following removal of a twig from the medial canthus by the owner. Diagnostic imaging was pursued due to the suspicion of a retrobulbar foreign body (FB). A cylindrical FB approximately 3.0 cm in length and 1.0 cm in diameter with concentric rings, suspected to be wooden material, was identified on computed tomography (CT) imaging. An attempt to remove the FB via a stab incision using ultrasound guidance was unsuccessful, and postmanipulation ultrasound confirmed the FB position was unchanged. An exploratory orbitotomy was performed, using the acquired CT images for guidance in locating the FB; however, the FB was not present at the predicted site. The CT imaging was repeated and showed that the FB had migrated rostrally approximately 3.0 cm, compared to the originally acquired study and its same location during attempted ultrasound-guided removal. A combination of CT-guided needle placement and contrast injection was then used with repeat imaging in an attempt to better localize the FB and its soft tissue tract. The dog was taken back into the operating room, and the wooden FB was successfully removed.

Five cases of orbital extramedullary plasmacytoma: diagnosis and management of an aggressive malignancy

Purpose: Multiple myeloma is an insidious haematological malignancy characterised by monoclonal proliferation of plasma cells in the bone marrow. Extramedullary plasmacytoma is a rare manifestation of multiple myeloma and usually occurs in the upper respiratory tract. Orbital involvement is particularly uncommon, but may be associated with devastating visual impairment and poor clinical outcomes. Therefore, this article aims to highlight the need for multidisciplinary management of orbital extramedullary plasmacytoma. Methods: This is a retrospective observational case series of five patients. All presented to the authors for management of orbital extramedullary plasmacytomas from 2004 to 2015 at Prince of Wales and Mater Hospitals in Sydney, Australia. Medical records were reviewed for pertinent information including demographics, disease features, management strategy, and clinical progress. The study met Medical Ethics Board standards and is in accordance with the Helsinki Agreements. Results: This case series of five patients underscores the poor prognosis of orbital extramedullary plasmacytoma. Despite aggressive multidisciplinary management, four of these five patients succumbed to their illness during the study period. However, multidisciplinary management did manage to minimise symptoms and preserve quality of life. Conclusions: On a case-by-case basis, patients may derive palliative benefit from orbital surgery in conjunction with radiotherapy and chemotherapy. Orbital surgeons are encouraged to work within a multidisciplinary framework of medical specialists, including haematologists and radiation oncologists, when determining the optimal management plan in cases of orbital extramedullary plasmacytoma.

"Push-Pull Technique" for the Management of a Selected Superomedial Intraorbital Lesion

Orbital lesions are traditionally managed through external approaches when laterally located, and through a transnasal approach or other external approaches when medially located. However, when the lesion is superomedially located, it may determine a technical challenge.

In this study, we present the case of a patient with a superomedial intraconal venous malformation of the left eye. We addressed the mass through a combined approach, using the transnasal route as the main approach, and the superior eyelid approach to push down the lesion to facilitate the excision. We have called this approach “push–pull technique.”

We achieved a complete resection of the lesion and did not observe any intraoperative or postoperative complications. The last follow-up at 6 months postoperatively showed no recurrence, and the patient was satisfied and completely recovered.

According to our experience, the “push–pull” technique seems to be a safe procedure and might be considered a valid alternative to address selected superomedial intraconal lesions.

Endoscopic and external approaches for orbital decompression: an analysis of trends from a U.S. perspective

BACKGROUND

Although the endoscopic approach has been increasingly utilized for a variety of sinonasal and skull base pathologies, there has been little inquiry into its adoption in the surgical management of orbital disease. Our objective was to evaluate nationwide temporal and geographic trends in approaches for orbital decompression.

METHODS

Data available from the Centers for Medicare and Medicaid Services (CMS) were evaluated, focusing on the use of open and endoscopic approaches for orbital decompression (CPT codes 67414, 67445, 31292, and 31293) among Medicare beneficiaries over a 10-year period. Regional data were also analyzed.

RESULTS

There were 8047 orbital decompressions billed to Medicare from 2007 to 2016. The number of external and endoscopic approaches increased by 73.0% and 29.2%, respectively, while the number of Medicare beneficiaries increased by 29.1%. Endoscopic decompression represented 23.5% of Medicare-billed orbital decompressions in 2016 (221 of 939), down from 29.2% in 2007 (171 of 586). The South had the greatest proportion of decompressions utilizing an endoscopic approach (30.2%).

CONCLUSION

There has not been a clear movement toward the endoscopic approach for orbital decompression, with modest growth when compared with external approaches. Potential explanations include the specialty-exclusive nature of approaches, as well as a lack of consensus; the latter idea is further reinforced by geographic variation. High-quality prospective trials may clarify the role of endoscopic approaches in these patients.

A new surgical technique for excision of orbital cavernous hemangioma: a 15-year experience

PURPOSE

To present a new surgical technique for excision of orbital cavernous hemangiomas (CHs).

METHODS

This retrospective case series study included patients with orbital CH who were operated from 2001 to 2016 at our referral center. Epidemiologic data, symptoms, signs, and images were reviewed from patients' files with at least one year of follow-up. Surgical results and complications were documented. We used the "index finger dissection" technique without grasping the tumor for release of adhesions and its removal.

RESULTS

We included 60 patients with orbital CH consisting of 36 (60%) female and 24 (40%) male patients with mean age of 40 ± 12.1 (range 9-66) years. The main complaint was proptosis with average size of 5.3 ± 2 millimeters. The surgical approach was lateral orbitotomy in 49 (81.7%) patients, medial transcutaneous in seven (11.7%) patients, inferior transconjunctival in three (5%) patients, and simultaneous lateral and medial orbitotomy in one (1.6%) patient. All tumors were removed intact; complications included ptosis in one subject, lower lid retraction in one case, and diplopia in two patients, all of which improved before 2 months. No optic nerve damage occurred.

CONCLUSION

The "index finger dissection" technique without grasping the tumor for excision of orbital CH, via any external approach to the tumor, is a safe technique with minimal complications.

Primary Orbital Melanoma: Presentation, Treatment, and Long-term Outcomes for 13 Patients

BACKGROUND

Periocular melanoma is a rare but often deadly malignancy that arises in the uvea (commonest origin), conjunctiva or orbit (rarest primary site). Melanoma accounts for 5-10% of metastatic/secondary orbital malignancies, but only a tiny proportion of primary orbital neoplasia. Primary orbital melanoma (POM) is exceedingly rare, with approximately 50 cases reported to date.

METHODS

All patients seen in the orbital unit at a tertiary referral hospital (1991-2016) with a biopsy-proven diagnosis of POM were identified from a diagnostic database and were studied. The case notes, imaging, surgical approach, and histology were reviewed.

RESULTS

Thirteen patients (five male; 38%) presented with isolated malignant melanoma of the orbit, for which no other primary site was identified at presentation or during an average follow-up of 44 months (median 22; range 0-13 years). The patients presented between the ages of 40 and 84 years (mean 55.5; median 48 years) and typically gave a short history of rapidly increasing proptosis and eyelid swelling. On the basis of history, a malignant lesion was suspected in most patients and all underwent incisional biopsy, with debulking of the mass in 10 (77%) patients, and skin-sparing exenteration in 3/13 (23%). Ten patients underwent orbital radiotherapy and the survival to date ranged from 9 months to 14 years (mean 55 months; median 23 months); two patients received solely palliative care for widespread disease and one patient refused orbital radiotherapy. Five of the 13 (38%) patients died from the disease.

DISCUSSION

POM is a very rare malignancy, but clinical analysis of this cohort gives insight into disease presentation and prognosis. The tumor typically presents with a rapidly progressive, well-defined mass that is, in some cases, amenable to macroscopically intact excision. Unusual for malignant melanoma, some of these patients can show an unusually long period of quiescent disease after surgical debulking and radiotherapy.

Progressive orbital granular cell tumour associated with medial rectus

Granular cell tumour is a rare soft tissue tumour that can occur in any part of the body, but seldom in ocular adnexa. It usually behaves in a benign fashion. We report a case of a 54-year-old man with a well-demarcated, solitary, slow-growing orbital tumour which lead to significant ocular symptoms. The case was a diagnostic and therapeutic challenge due to its location and difficulty in obtaining tissue for a histological diagnosis. Surgical biopsy attempts were made but they all failed to uncover the true identity of the lesion. A definitive diagnosis was revealed with complete surgical excision of the tumour, which was challenging due to its size and close association with rectus muscle. This case has highlighted that orbital granular cell tumour may result in significant ocular symptoms. Adequate exposure to the anatomical site is the key to obtaining diagnosis and complete excision of a lesion.

Cavernous venous malformation (cavernous hemangioma) of the orbit: Current concepts and a review of the literature

The cavernous venous malformation of the orbit, previously called cavernous hemangioma, is the most common primary orbital lesion of adults. Cavernous venous malformation occurs more often in women and typically presents in the fourth and fifth decades of life. It is a benign vascular malformation characterized by a well-defined capsule and numerous large vascular channels. The most common sign of cavernous venous malformation is progressive axial proptosis from the preferential involvement of the intraconal orbital space. Optic nerve damage and other signs of orbital pathology may be present, with a variable degree of visual impairment. The combination of ultrasound, computed tomography, and magnetic resonance imaging leads to an accurate diagnosis in the vast majority of cases. Surgical and nonsurgical treatments are required in case of symptomatic lesions, with a characteristic multidisciplinary management influencing optimal outcome. Orbitotomy represents the traditional surgical approach. Recently, the endoscopic transnasal approach to the orbital cavity has gained interest, representing a feasible and safe, less-invasive surgical technique for the management of cavernous venous malformation.

Expansive Extracranial Growth of Intracranial Meningioma in Neurofibromatosis Type 2

The purpose of this report is to detail three rare cases of neurofibromatosis type 2 (NF2) with symptomatic extracranial extension of intracranial meningioma. We present ocular findings, imaging techniques applied, pathological findings of the space-occupying lesions, and therapy. One of these patients, the daughter of one of the other individuals, presented with a large neck mass, but no surgically treatable findings associated with the external growth of the meningioma. The patients complained of symptoms associated with the extracranial portion of the intracranial meningioma, rather than of the intracranial primaries. However, facial and neck surgical care is very limited in patients with such advanced-stage tumours. The prolongation of life was unquestionably predominantly determined by the behaviour of the intracranial tumour. Head and neck surgeons should be aware of the rare possibility that solid tumours of this region could be extracranial-extending meningioma in an inherited disease.

Surgical anatomy of the superior orbit on ultra-high-resolution MRI at 9.4 Tesla

BACKGROUND

A good understanding of the anatomical details is required to ensure optimal results during surgery of the orbit. Several indications for orbital surgery require biopsy, resection, or reconstructive procedures. The intricate relationships between the orbital septum and adjacent structures of the upper orbit can cause difficulties in interpreting the surgical anatomy of this region. The purpose of this study was to acquire further insight into the anatomy of the superior part of the orbit, with special attention paid to the orbital septum.

METHODS

An ex-vivo study was performed using magnetic resonance imaging (MRI) at 9.4 Tesla (isotropic resolution = 20 μm) on six human cadaver specimens to examine the superior-medial half of the orbit. To visualise the posterior layers of the upper orbit, a dissection of three of the orbits was performed prior to the MRI examination, and a flexible PVC sheet was introduced above the levator muscle.

RESULTS

The technique enabled a visualisation of anatomically important landmarks of the anterior and posterior parts of the upper orbit at a resolution near histological levels; to the authors' knowledge, this visualisation has not been reported previously. A posterior continuation of the orbital septum, which forms a distinct anatomical structure, is revealed.

CONCLUSIONS

The posterior aspect of the orbital septum separates the levator muscle and the orbital fat pad. Between these two structures, a surgical corridor is formed using MRI, enabling alternative access to the superior part of the orbit; this alternative access might be less invasive because the orbital septum remains undamaged.

A porcine model: surgical anatomy of the orbit for maxillofacial surgery

Due to its similarity to humans, the pig has proven to be a suitable biomodel for both research purposes and for training medical professionals, particularly in surgical specializations. For example, new implant materials have been tested on pig jaws and pigs have also been used in the development of new surgical techniques. For optimizing the effectiveness of such research or training, detailed data on the anatomy of their particular features are needed. At present, however, only limited information related to surgical and imaging anatomy of the facial and orbital areas of the pig and its comparison to human structures from the experimental surgery point of view is available in the literature. The aim of this study was to obtain such data and to compare the morphological structures of the porcine and human orbital regions and to lay down the foundation for practical use in experimental surgery. Ten pig heads were examined using computed tomography (CT) and magnetic resonance imaging (MRI) and, subsequently, a dissection of the orbit was carried out. Attention was focused on the structure of the orbit (floor, rim and nerves) frequently affected by pathological processes in humans (such as trauma, infection or tumours) and which consequently are frequently the subject of maxillofacial surgery. The porcine orbit is suitable for use in experimental medicine. However, if used in experiments, its anatomical peculiarities must be taken into consideration. Our study presents a foundation of basic knowledge for researchers who plan to use the pig as a biomedical model to investigate alternative treatments in the head region.

Ophthalmic plastic and orbital surgery in Taiwan

We describe in this paper the current status of ophthalmic plastic and orbital surgery in Taiwan. Data were collected from the Bureau of National Health Insurance of Taiwan, the Bulletin of the Taiwan Ophthalmic Plastic and Reconstructive Society, and the Statistics Yearbook of Practicing Physicians and Health Care Organizations in Taiwan by the Taiwan Medical Association. We ascertained that 94 ophthalmologists were oculoplastic surgeons and accounted for 5.8% of 1621 ophthalmologists in Taiwan. They had their fellowship training abroad (most ophthalmologists trained in the United States of America) or in Taiwan. All ophthalmologists were well trained and capable of performing major oculoplastic surgeries. The payment rates by our National Health Insurance for oculoplastic and orbital surgeries are relatively low, compared to Medicare payments in the United States. Ophthalmologists should promote the concept that oculoplastic surgeons specialize in periorbital plastic and aesthetic surgeries. However, general ophthalmologists should receive more educational courses on oculoplastic and cosmetic surgery.

Piezosurgery for osteotomies in orbital surgery: Our experience and review of the literature

INTRODUCTION

Piezoelectric bone surgery, simply known as Piezosurgery(®), is a new promising technique for bone cutting based on ultrasonic microvibrations that allows to perform precise and thin osteotomies with soft tissue sparing.

PRESENTATION OF CASE

A 45-years-old woman presenting with progressive left ocular pain, diplopia on the lateral left gaze, and visible exophthalmos was admitted to our department. CT scan and MRI images documented a left supero-lateral orbital lesion. A left lateral orbitotomy using the piezoelectric scalpel was performed. The tumour (lacrimal gland lymphoma) was completely removed with no injuries to the orbital structures and with a perfect realignment of the bone stumps.

DISCUSSION

High powered pneumatic osteotome are commonly used to perform craniotomies. Large bone cutting groove and high temperatures developing at the contact site could produce an uneasy bone healing. The use of a piezoelectric scalpel allows to realize precise and thin osteotomies, facilitating craniotomy's borders ossification and avoiding injuries to non-osseous structures.

CONCLUSION

Widely used in Oral and Maxillofacial Surgery, Piezosurgery(®) can also be useful in neurosurgical approaches in order to obtain a faster bone flap re-ossification, a better aesthetic result, and a lower risks of dural layer and soft tissue damage.

Combined endoscopic endonasal transorbital approach with transconjunctival-medial orbitotomy for excisional biopsy of the optic nerve: technical note

Background Access to the intraorbital optic nerve segment can be facilitated via a transcranial approach that allows access to the entire orbital cavity. The endoscopic endonasal approach (EEA) combined with a transconjunctival-medial orbitotomy represents an alternative technique to achieve the same goal.

Objective Report a surgical technique that allows total resection of the intraorbital optic nerve with minimal trauma and excellent results. Further extend and define the limits and indications of the EEA to orbital surgery.

Methods A patient with rapidly progressive, but asymmetric, vision loss underwent EEA for optic nerve biopsy. Due to the undetermined histopathological diagnosis and complete unilateral vision loss, diagnostic total optic nerve resection was indicated. The entire intraorbital length of the nerve was resected via an endoscopic endonasal transorbital approach combined with transconjunctival-medial orbitotomy.

Results A 2-cm intraorbital nerve segment was sent for pathological examination. The patient maintained normal extraocular movements and experienced no complications. The postoperative course was uneventful and the patient was discharged the next day.

Conclusion The EEA provides another option for access to the entire optic nerve. It is a safe and effective technique lacking cosmetic defects and providing an alternative corridor to traditional transcranial approaches to the orbit.

The management of orbital cysts associated with congenital microphthalmos and anophthalmos

AIMS

To study the management of the orbital cysts present in a group of patients with anophthalmos and microphthalmos.

METHODS

A retrospective study of 34 patients (40 orbits) treated for orbital cyst associated with microphthalmos and anophthalmos.

RESULTS

The two largest treatment groups comprised 17 orbits (42.5%) where the cyst was removed surgically and 17 orbits (42.5%) where the cyst was retained and conformers were used. The remaining cases comprised two orbits (5%) where the cyst was aspirated initially; two orbits (5%) with large cysts which will need to be excised after further orbital growth; one orbit (2.5%) in which a silicone expander was used initially, and one orbit (2.5%) in which a mildly microphthalmic eye had some vision and was monitored but required no surgery.

CONCLUSION

In this study 33 out of 34 patients had a good cosmetic result which illustrates that the orbital cyst in microphthalmos or anophthalmos performs a useful role in socket expansion and that the majority of patients with this condition can expect a good cosmetic outcome.