Open-door extended endoscopic transorbital technique to the paramedian anterior and middle cranial fossae: technical notes, anatomomorphometric quantitative analysis, and illustrative case

OBJECTIVE

The superior eyelid endoscopic transorbital approach (SETOA) provides a direct and short minimally invasive route to the anterior and middle skull base. Nevertheless, it uses a narrow corridor that limits its angles of attack. The aim of this study was to evaluate the feasibility and potential benefits of an "extended" conservative variant of the "standard" endoscopic transorbital approach-termed "open-door"-to enhance the exposure of lesions affecting the paramedian aspect of the anterior and middle cranial fossae.

METHODS

First, the authors described the technical nuances of the open-door extended transorbital approach (ODETA). Next, they documented its morphometric advantages over standard SETOA. Finally, they provided a clinical-anatomical application to demonstrate enhanced exposure and better angles of attack to treat lesions occupying the paramedian anterior and middle cranial fossae. Five adult cadaveric specimens (10 sides) initially underwent standard SETOA and then extended open-door SETOA (ODETA to the paramedian anterior and middle fossae). The adjunct of hinge-orbitotomy, through three surgical steps and straddling the frontozygomatic suture, converted conventional SETOA to its extended open-door variant. CT scans were performed before dissection and uploaded to the neuronavigation system for quantitative analysis. The angles of attack on the axial plane that addressed four key landmarks, namely the tip of the anterior clinoid process (ACP), foramen rotundum (FR), foramen ovale (FO), and trigeminal impression (TI), were calculated for both operative techniques and compared.

RESULTS

Hinge-orbitotomy of the extended open-door SETOA resulted in several surgical, functional, and esthetic advantages: it provided wider axial angles of attack for each of the target points, with a gain angle of 26.68° ± 1.31° for addressing the ACP (p < 0.001), 29.50° ± 2.46° for addressing the FR (p < 0.001), 19.86° ± 1.98° for addressing the FO (p < 0.001), and 17.44° ± 2.21° for addressing the lateral aspect of the TI (p < 0.001), while hiding the skin scar, avoiding temporalis muscle dissection, preserving flap vascularization, and decreasing the rate of bone infection and degree of orbital content retraction.

CONCLUSIONS

The extended open-door technique may be specifically suited for selected patients affected by paramedian anterior and middle fossae lesions, with prevalent anteromedial extension toward the anterior clinoid, the foremost compartment of the cavernous sinus and FR and not completely controlled with the pure endoscopic transorbital approach.

Modified vertical lid split orbitotomy: a case series and literature review

PURPOSE

To describe the modified vertical lid split (VLS) technique for anterior orbitotomy and report surgical outcomes in patients with intraconal lesion removal using this surgical technique.

METHOD

Retrospective review of medical records and orbital images.

RESULTS

A total of four (female = 3) patients with intraconal orbital lesions underwent modified VLS orbitotomy from January 1, 2019 to June 30, 2021 in Hong Kong East Cluster. The average age was 49.3 years old (range: 35-65). Complete excision of intraconal orbital lesion was performed in all four cases. All cases were cavernous haemangioma histologically. All patients were satisfied with their cosmesis postoperatively and most had satisfactory postoperative extraocular movement.

CONCLUSION

Modified VLS approach is simple and provides good intraoperative surgical exposure for intraconal lesions, giving the additional advantage of better scar camouflage.

The transconjunctival orbitotomy: A versatile approach to the orbit and beyond

In the management of orbital disorders and defects, minimally invasive surgical approaches have become increasingly efficient for their reduction of operative trauma and access without compromise of therapeutic benefit or diagnostic yield. Various approaches have focused on bone- and canthal-sparing techniques and concealed and small skin incisions. We review the current state of knowledge of procedures to enter the orbit via the conjunctiva. Any quadrant of the orbit can be accessed via the conjunctiva. Surgical incisions involve the orbital palpebral, forniceal, and bulbar conjunctiva. According to the location, nature, and size of the lesion, the transconjunctival orbitotomy can be used as a single procedure, in combination with a caruncular approach or as an adjunct in a multidisciplinary procedure for lesions extending deep into or outside the orbit. The working space and field of operating view can be expanded by releasing the horizontal tension of the eyelid with a lateral cantholysis, lateral paracanthal blepharotomy, or medial lid split procedure. Complications related to the conjunctival incision are reduced to dry eye disease.

Infraorbital mass long after dermal filler injection: A report of two cases

BACKGROUND

Hyaluronic acid fillers have been increasingly used throughout the world in the management of aging skin in the periocular region and other areas.

OBJECTIVE

To evaluate very late-term orbital mass formation secondary to Hyaluronic acid filler injection into the inferior eyelid.

METHODS

We report two cases that presented with a subcutaneous palpable mass localized at the right medial lower infraorbital area. Following clinical and radiological examination, surgical excision was required for the differential diagnosis of tumor.

RESULTS

After pathologic examination and the finding of a foreign-body granulomatous reaction, both patients recalled that hyaluronic acid filler had once been injected into their lower eyelids approximately 10 years prior. This is consistent with the fact that dermal-filler-related granuloma formation may occur even years later in the differential diagnosis of mass lesions.

CONCLUSION

It is suggested that patients be informed about the possible but rare mass effect in the infraorbital region. Clinicians should also attend to delayed hypersensitivity reactions, since patients may not recall details due to the length of time since injection.

Bilateral orbital inflammation in a 6-month old with SARS-CoV-2 infection

A 6-month-old female presented with bilateral periorbital edema for 7 days. Laboratory testing was significant for active SARS-CoV-2 infection. Neuroimaging demonstrated soft tissue changes within the bilateral orbits and enlargement of the bilateral lacrimal glands. Although the patient initially improved with corticosteroid treatment, she later returned with recurrent left periorbital and eyelid edema. Orbital biopsy was performed and demonstrated findings in the lacrimal gland and the adjacent fibroconnective tissues that are similar to those of prior lung specimens seen in SARS-CoV-2 patients. Final diagnosis was bilateral orbital inflammation with features presumed secondary to SARS-CoV-2 infection. To the best of our knowledge, this is one of the first reports to document bilateral orbital inflammation as a sign of SARS-CoV-2 infection in the pediatric population with the associated pathological findings.

Surgical Approaches to the Orbit: Transpalpebral

The aim of this study is to provide an overview of the safe and effective incisional transpalpebral approaches to the orbit. The location of each approach and pertinent anatomy in each respective area, suggested approach techniques, recommended specialties, reconstruction options, intraoperative neurophysiology, complications, and approach limitations are discussed in detail.

Orbital cellulitis secondary to sinusitis in upstate New York: current incidence, seasonality, severity, management and outcomes

Purpose: While sinusitis carries a seasonal variation, the temporal features of sinusitis-related orbital cellulitis (SRC) are unclear. This study analyzes the incidence, seasonality, management, and outcomes of SRC in northeastern New York.Methods: A retrospective review of 79 patients was performed from January 2008 - December 2018. Cases of orbital cellulitis without comitant sinusitis were excluded. Demographic, radiographic, clinical features, month at presentation, interventions (surgical and nonsurgical), microbiology, and hospitalization duration were recorded. Fisher-exact test, Mann-Whitney test, and Kruskal Wallis test statistical analyses were performed in consultation with our institution's statistician via a dedicated software package (vassarstats.net).Results: 79 patients were admitted for SRC. 25 patients were treated with antibiotics only, 31 underwent orbitotomy exclusively and 23 received combined orbitotomy and functional endoscopic sinus surgery (FESS). Of the 31 patients who underwent orbitotomy only, 8 (26%) returned to the operating room. In contrast, of those who underwent concomitant orbitotomy and FESS, only one patient (4.3%) required re-operation (fisher exact test, p = .021). The median length of stay for the antibiotic-only group (4 days), orbitotomy-only group (6 days), and combined surgery group (5 days) were statistically different (Kruskal Wallis, p = .004, Figure 3). Interestingly, there was no significant relationship of incidence or severity of SRC related to seasonality (fisher-exact test, p = .76).Conclusion: Our findings suggest that cases requiring surgical management for SRC should undergo coinitial orbitotomy with FESS to reduce re-operation rates. Additionally, SRC incidence and severity did not correlate with season.

Primary chondromyxoid fibroma of the orbit: An orbital mass with calcification

Primary orbital chondromyxoid fibroma is a rarely reported entity. A 34-year-old lady presented with painless, non-axial proptosis of the left eye of 6 months duration. Orbital imaging showed a supero-temporal mass with calcific foci and bone erosion. The mass caused globe compression resulting in choroidal folds. Anterior orbitotomy with complete mass excision was performed. The histopathology revealed a chondromyxoid fibroma. At 12-months follow-up, the patient is doing fine with no clinical recurrence. Chondromyxoid fibroma is an important differential diagnosis for bony orbital tumors.

The Role of Endoscopic Sinus Surgery in Children Undergoing External Drainage of Non-Medial Subperiosteal Orbital Abscess

BACKGROUND

The extent of surgery required in the management of pediatric non-medial subperiosteal orbital abscess (SPOA) due to medically refractory complicated acute sinusitis is unknown.

OBJECTIVES

The primary objective is to compare operative outcomes of children treated with combined endoscopic sinus surgery (ESS) and external orbital drainage (EOD) versus those treated with EOD alone.

METHODS

Retrospective case series from a tertiary children's hospital analyzing outcomes in children requiring surgical management for acute sinusitis complicated by non-medial SPOA between November 2007 and September 2019.

RESULTS

Sixteen children with a mean age of 9.4 years (95% CI: 7.3-11.4) met inclusion. Eleven (68.8%) underwent combined EOD and ESS, while five (31.2%) underwent EOD alone. Groups were similar in age, symptom duration, white blood cell count, C-reactive protein level, intraocular pressure, Lund-Mackay score, and abscess volume. There was no significant difference in median length of stay between patients treated with a combined approach versus those treated by EOD alone. Cultures identified non-beta-hemolytic Streptococcus species in 56.3% of patients, with Streptococcus intermedius representing the most common organism in 37.5%. In one case, ESS identified a pathogen not acquired via concomitant EOD, which did influence management. No child required a subsequent surgical procedure and there were no operative complications.

CONCLUSIONS

The addition of ESS in the management of pediatric non-medial SPOA was not associated with a statistically different duration of hospitalization. Cultures from concomitant ESS rarely aided in diagnosis or antibiotic therapy. Further study should delineate the indications for ESS in these cases.

Vision loss associated with orbital surgery - a major review

Purpose: Vision loss after orbital surgery is one of the most dreaded complications faced by the orbitofacial surgeon. This literature review was conducted in an attempt to determine the risk factors for severe vision loss and discuss the applied anatomy related to various types of orbital surgery - orbital tumor excisions, orbital decompression, and post-traumatic orbital reconstruction.Methods: A literature search was conducted via PubMed and Google Scholar. All cases of vision loss following orbital tumor biopsy or excision, orbital decompression, and orbital trauma reconstruction were reviewed.Results: The incidence of postoperative blindness appears to be more after orbital tumor excisions (4.7%), compared to post-traumatic orbital reconstruction (2.08%) and orbital decompressions for thyroid orbitopathy (0.15%).The causes of vision loss include ischemic optic neuropathy, traumatic optic neuropathy, retinal and ophthalmic artery occlusions, and orbital compartment syndrome.Conclusion: Apart from careful patient selection, proper counseling about the risk of postoperative blindness is of utmost importance. Detailed preoperative treatment planning, meticulous atraumatic intraoperative dissection under direct visualization, with attention to the danger zones and vital structures, close intraoperative and postoperative monitoring, and urgent management of potentially reversible compressive causes of vision loss can improve outcomes.

Orbital cavernous haemangioma; profile and outcome of 76 patients managed surgically

Background: Orbital cavernous haemangioma (OCH) is one of the most common primary orbital tumours in adults. They can encroach on intraorbital or adjacent structures and be considered 'anatomically' malignant. Aims: To report a series of patients that were all managed surgically, with possible specificities and propose predictors of treatment outcome. Methods: We realised a hospital-based retrospective case review including data from 76 patient files. Results: The mean age was 37.8 years. Unilateral proptosis was observed in all patients. Visual loss was found in 32 patients (42.1%). Findings on eye examination included lagophthalmos (76.3%), blepharoptosis (21.1%), complications of corneal exposure (19.6%), strabismus (13.2%) and fundoscopic abnormalities (60.5%). Abnormal fundoscopy was significantly associated with decreased visual acuity (VA) (p < .001). Small tumours were predominant (65.8%) and size was associated with VA (correlation coefficient r = -0.5, p < .001). Surgery was mainly by lateral orbitotomy (94.7%), with early post-operative complications in 18 patients (23.7%). Multivariable analysis showed that tumour size, preoperative VA and abnormal fundoscopy were significantly associated with postoperative VA. Conclusion: Clinical and radiological profiles are consistent. Tumour size, preoperative VA, and abnormal fundoscopy seem to be important factors that could influence outcome expectations. Surgical management is still predominantly by open approaches. Severe complications remain rare.

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.

A surgical approach for extensive orbital exenteration in dogs; a description of technique and its application in 4 cases

OBJECTIVE

To describe a surgical approach for preplanned orbital exenteration.

ANIMALS STUDIED

Indications included intraconal orbital mass lesions. Four dogs were included, 3 with neoplasia and one with retro bulbar nodular fasciitis.

PROCEDURE

To facilitate complete removal of lesions, exenteration was performed by a new procedure for wide access. The frontalis and temporalis muscles were elevated and retracted through a single U-shaped skin incision. Zygomatic arch osteotomy was performed, followed by a 360-degree peritomy and zygomatic process osteotomy. The eyelids were divided from each other through the lateral cantus and then folded forward to expose the globe. The orbit was exenterated by blunt and sharp dissection. Osteotomies were closed with cerclage wires, soft tissues closed and the skin wound sutured in a T-shape.

RESULTS

The present exenteration procedure gave excellent access to remove orbital contents flush with the optic foramen and orbital fissure. Postoperative swelling and pain were limited and healing uneventful. Two of the 3 neoplasia cases experienced tumor recurrence involving the brain at 18 and 20 months postoperatively, respectively. Both of these had optic canal or intracranial tumor extension preoperatively. Long-term complications included mild concavity of the operated side of the face.

CONCLUSIONS

The present approach for preplanned exenteration offers excellent access for complete removal of orbital contents to the level of the optic foramen. Complications due to the surgical method are few and limited.

Ectopic rhabdoid meningioma of the orbit in a child: case report and review of the literature

In August 2016, an 11-year-old boy presented to the authors' institution with a right orbital tumor that was located superotemporally (superolaterally) and adherent to the sclera. The patient's past medical history revealed that he had undergone 2 previous craniotomies elsewhere in June 2008 and July 2010 for a superomedially located orbital lesion that had been histopathologically diagnosed as a neurothekeoma. After the second craniotomy, the patient underwent adjuvant intensity modulated radiotherapy (IMRT) to the right medial orbit. At the authors' institution, total excision of the orbital tumor was performed via an anterior conjunctival orbitotomy. Histopathological examination revealed a rhabdoid meningioma. Review of the histopathology obtained at the time of previous tumor excisions showed that the lesion was misdiagnosed as neurothekeoma and instead represented a meningioma from the beginning. The patient was started on a regimen of oral sunitinib and remained free of recurrence at 1.5 years of follow-up. Ectopic meningioma of the orbit is a rare entity. Rhabdoid meningioma is a rarely seen subtype of meningioma, accounting for 1%-3% of all intracranial meningiomas. To the best of the authors' knowledge, this is the first case of an ectopic orbital rhabdoid meningioma reported in the literature. They suspect that tumor seeding during the previous surgeries might have played a role in the occurrence of the tumor in an orbital location not targeted by IMRT.

Intradiploic epidermoid cyst of the orbital roof: a case report

Intradiploic epidermoid cysts are uncommon in the orbital walls and typically present with chronic headaches. We present the unusual presentation of a 46-year-old man where a long-standing intradiploic mass of the orbital roof led to acute onset of pain and mechanical ptosis. Computed tomography and magnetic resonance imaging revealed an intradiploic cystic mass within the orbital roof. The cystic mass was extirpated and histological examination confirmed the diagnosis of an epidermoid cyst. This case illustrates the potential of long-standing intradiploic epidermoid cysts in producing an acute presentation.

The treatment results in patients with lmphoma disease in the orbit

INTRODUCTION

Lymphoma is a malignant disease that can affect several structures of the orbit and eye adnexa. In the area of orbit the non-Hodgkins lymphoma (NHL) is typical, which may be indolent or aggressive. Indolent subtypes include MALT (mucosa-associated lymphoid tissue), follicular lymphoma (FL), lymphoplasmocytic lymphoma (LPL). Conversely, subtypes such as diffuse large cell lymphoma (DLBCL), mantle cell lymphoma (MCL) and Burkitt lymphoma (BL) are aggressive. The disease can be presented as primary or secondary malignancy of the orbit.

MATERIAL AND METHODS

A group of 35 patients from the Department of Ophthalmology, Faculty of Medicine, Comenius University in Bratislava in the period from January 1 2009 to December 31 2016 with diagnosed non-Hodgkins lymphoma located in the area of the orbit. For all patients, the generally valid diagnostic criteria for the NHL in the eye area were met. We processed the first signs of disease, the proportion of women and men with NHL, the percentage of NHL types in the orbit area. Statistically, we evaluated the age at which NHL occurred in patients and evaluated the incidence of the disease over the reference period. We have statistically processed the forms of the applied therapy, their adverse effects, the recurrence of the disease, the presence of other malignancies in the lymphoma patient.

RESULTS

Of the total number of NHL patients in orbit region 13 (37%) were male and 22 (63%) female. The overall mean age at which lymphoma was diagnosed was 60 years. Median for the total age of patients was 61. In women, a slightly higher average age and median was found. On the other hand, lower values of both parameters were present in men. The modus of both sexes was the same, 70 years. We have seen various first symptoms in our group. We found that the most common symptom is red eye, and the rarest is the deterioration of the central visual acuity. The longest lasting symptom was swelling of eyelids (on average, up to 10 years) and the shortest described eye itching. Overall, the average duration of symptoms was 28 months, with a median of 13 months. In our group of patients were 3 % of LPL, 6 % of Burkitts lymphoma, 6 % of FL, 8 % of MCL, 17 % of DLBCL, and 60 % of malignant lymphoma. MALT lymphoma occurred in 62 % in orbital and 38 % in conjunctival localization. In 2 patients with MALT lymphoma of the conjunctiva to start with systemic therapy wasn't neccessary. In 21 patients with MALT lymphoma excisional biopsy or orbitotomy was the first step to diagnose lymphoma disease in 3 cases; in 18 patients the infiltration of the orbit or conjunctiva occured 1 to 3 years after primary diagnose of systemic lymphoma disease. In general, NHL localization was 29 % in conjunctiva and 71 % in the orbital area. In 9 % of the orbital lymphoma, we observed lymphoma ingrowth to the conjunctiva. Systemic therapy was initiated in patients in II. stage and higher stage of the disease according to the Ann Arbor system. Totally 63 % of the group were treated by systemic therapy. Recurrence occurred in 5 patients, representing 14 % of the observed, but only in one patient with MALT lymphoma. Preoperative and postoperative (excisional biopsy, orbitotomy) central visual acuity (CVA) stayed unchanged, postoperative swelling did not affect CVA, and CVA didn't change even during long-term follow-up.

CONCLUSION

Careful differential diagnosis determines the therapy of the disease, since the primary symptoms are usually nonspecific for ocular lymphoma. Significant factors for therapy include tumor grading and clinical staging by AJCC 2009 (American Joint Committee on Cancer, Chicago, Illinois). Correct evaluation of the symptoms is an important step to indicate excisional biopsy or orbitotomy: After histopathological results we can start adequate therapy in the cooperation with oncohematologist. Key words: conjunctival tumors, orbit, lymfoma, orbitotomy.

Orbital abscess following posterior subtenon injection of triamcinolone acetonide

Orbital cellulitis is a serious sight threatening and potentially life threatening condition which can be complicated by orbital abscess formation. Posterior subtenon (PST) injection of corticosteroid is commonly used in the treatment of posterior segment inflammation including post-operative macular oedema. We report a case of orbital abscess formation as a late complication of PST triamcinolone acetonide and discuss the presentation, diagnosis and management.

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.

Orbital reconstruction in the dog, cat, and horse

OBJECTIVE

To describe an adaptable method for reconstruction of the orbit following partial orbitectomy.

ANIMALS STUDIED

One horse, one cat, and four dogs.

PROCEDURE(S)

Following partial orbitectomy for removal of bone and soft tissue affected by pathologic processes, reconstruction was achieved. Cerclage wires were used to reconstitute the orbital rim and other salient facial contours involved in excisions. These wires were then covered with a prolene mesh, first inside the orbit and then outwards over the affected extraorbital areas. Thereafter, a collagen sheet was placed over the mesh. Finally, subcutis and skin were closed over the construct.

RESULTS

All operated eyes remained visual with normal position, direction, and mobility. Eyelid function, tear production, and nasolacrimal function were preserved. Side effects were mild and temporary, but animals requiring a lateral-posterior surgical approach experienced concavity to the side of the head posterior to the orbital ligament region. One bone tumor out of three recurred.

CONCLUSIONS

The reconstruction method presented offers excellent results tectonically, cosmetically, and functionally, even following extensive orbitectomy. By adapted application of three reconstruction steps using readily available materials, large defects may be surgically repaired. Once orbitectomy is mastered, reconstruction requires no additional specialized techniques or equipment.

Sporadic Burkitt's lymphoma/acute B-cell leukaemia presenting with progressive proptosis and orbital mass in a child

Burkitt's lymphoma (BL) is an aggressive B-cell non-Hodgkin lymphoma that is found predominantly in children, with the highest incidence occurring in Africa. The sporadic form occurs in non-endemic areas and typically involves the ileo-caecum and the bowel, whereas orbital and paranasal sinus involvement is rare. Here, we present an unusual case of sporadic BL in a Caucasian male child with rapidly progressive painful proptosis of the right eye. Magnetic resonance imaging showed an oval-shaped, extraconal mass in the supero-lateral part of the right orbit that deformed and dislocated the eyeball antero-inferiorly. The patient underwent anterior orbitotomy, and a biopsy of the excised tissue revealed a starry-sky appearance characteristic of BL. Postoperative aggressive chemotherapy was initiated with a good response after one week.

Minimally invasive bone-saving orbitotomy for removal of optic nerve cysticercosis

A 32-year-old man previously being managed for multiple neurocysticercosis presented with a reduction in vision and pain on eye movement. Fundus examination revealed disc edema with venous dilatation. MRI showed a localized hypointensity on T1 weighted images and hyperintensity on T2 weighted images suggestive of a cyst in the optic nerve sheath. Medical therapy with albendazole and steroids did not improve vision. Surgical removal of the cyst was achieved by a modified lateral orbital exploration using a lateral canthal incision without bone removal, with full recovery of vision. Histopathological examination confirmed cysticercosis.

Refining the Indications for the Addition of Orbital Osteotomy during Anterior Cranial Base Approaches: Morphometric and Radiologic Study of the Anterior Cranial Base Osteology

Objectives In anatomic and radiologic morphometric studies, we examine a predictive method, based on preoperative imaging of the anterior cranial base, to define when addition of orbital osteotomy is warranted.

Design Anatomic and radiographic study.

Setting In 100 dry skulls, measurements in the anterior cranial fossa included three lines and two angles based on computerized tomography (CT) scans taken in situ and validated using frameless stereotactic navigation. The medial angle (coronal plane) was the intersection between the highest point of both orbits and the midpoint between the two frontoethmoidal sutures to each orbital roof high point. The oblique angle (sagittal plane) was the intersection at the midpoint of the limbus sphenoidale.

Results No identifiable morphometric patterns were found for our classification of anterior fossae; the two-tailed distribution pattern was similar for all skulls, disproving the hypothetical correlation between visual appearance and morphometry. Orbital heights (range: 6.6–18.7 mm) showed a linear relationship with medial and oblique angles, and they had a linear distribution relative to angular increments. Orbital heights > 11 mm were associated with angles ≥ 20 degrees and more likely to benefit from orbitotomy.

Conclusion Preoperative CT measurement of orbital height appears feasible for predicting when orbitotomy is needed, and it warrants further testing.

Co-occurrence of a cerebral cavernous malformation and an orbital cavernous hemangioma in a patient with seizures and visual symptoms: Rare crossroads for vascular malformations

Background:

Cerebral cavernous malformations (CCMs) are angiographically occult vascular malformations of the central nervous system. As a result of hemorrhage and mass effect, patients may present with focal neurologic deficits, seizures, and other symptoms necessitating treatment. Once symptomatic, most often from hemorrhage, CCMs are treated with microsurgical resection. Orbital cavernous hemangiomas (OCHs) are similar but distinct vascular malformations that present within the orbital cavity. Even though CCMs and OCHs are both marked by dilated endothelial-lined vascular channels, they are infrequently seen in the same patient.

Case Description:

We provide a brief overview of the two related pathologies in the context of a patient presenting to our care with concomitant lesions, which were both resected in full without complication.

Conclusion:

This is the first known report that describes a case of concomitant CCM and OCH and explores the origins of two pathologies that are rarely encountered together in neurosurgical practice. Recognition of disparate symptomatologies is important for properly managing these patients.

Inferolateral marginal orbitectomy: a simple adjuvant technique for orbital decompression

The number of patients with mild exophthalmos, without severe eye symptoms, who wish to undergo aesthetic orbital decompression, is increasing. Removal of the lateral and inferior orbital walls is a common procedure for mild to moderate exophthalmos. However, the limited space between the globe and the orbital wall is often troublesome for surgeons introducing surgical devices. As a result, the decompression tends to be insufficient in the posterior region of the orbit. We describe a simple adjuvant surgical technique to address this limitation. Through a laterally extended, transconjunctival approach, the inferior and lateral margins of the orbit are removed in a crescent shape before the actual decompression. This manoeuvre widens the working space and offers better visibility, enabling sufficient removal of the orbital walls. The technique presented facilitates the approach to the posterior regions of the orbit, enabling surgeons to more easily perform orbital decompression.