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PubMed2005

Minimally invasive orbital decompression: local anesthesia and hand-carved bone.

OBJECTIVE: To investigate the safety and efficacy of a conservative orbital decompression using sharp-curette bony decompression and intraconal fat debulking through a transconjunctival incision in patients with thyroid-related orbitopathy and mild to moderate proptosis. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS AND METHODS: Data from all patients undergoing minimal orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, over a period of 4(1/4) years were collected and analyzed. Data included visual acuity, exophthalmometry measurements, intraocular pressure, complete slitlamp examination results, ocular ductions, new-onset primary or downgaze diplopia, and patient satisfaction. Conservative decompression was performed through a transconjunctival incision using a manual curette and by removing cortical bone from the zygomatic marrow space on the anterior rim of the inferior orbital fissure; intraconal fat was bluntly dissected and excised or suctioned with a Frasier tip aspirator. MAIN OUTCOME MEASURES: Patient perception of pressure pain and ocular discomfort, proptosis, visual acuity, intraocular pressure, postoperative complications, and new-onset primary or downgaze diplopia. RESULTS: Eighty minimally invasive orbital decompression surgeries were performed in 48 patients (6 male, 42 female). Six surgeries (4 patients) were performed for prominent globes with relative proptosis and no thyroid-related orbitopathy (non-Graves proptosis). All patients had improvement in congestive orbitopathy and pressure pain associated with thyroid-related orbitopathy. Exophthalmos decreased by a mean +/- SD of 2.4 +/- 2.6 mm from 22.7 +/- 2.5 mm (range, 17-29 mm) to 20.3 +/- 2.3 mm (range, 14-25 mm) (P<.001 [95% confidence interval, 1.8-3.0]). Mean visual acuity improved after surgery (P = .02). One patient (2.1%) developed postoperative primary or downgaze diplopia; he underwent successful eye muscle surgery at a later stage. No complications were associated with orbital decompression. CONCLUSIONS: Minimally invasive orbital decompression surgery with intraconal fat debulking in this group of patients was effective in proptosis reduction; improvement in subjective pressure pain and high patient satisfaction were noticed. Surgery was associated with a low rate (2.1%) of new-onset primary or downgaze diplopia. Proptosis reduction using a graded approach accounting for 4 mm of retrodisplacement was achieved.

Adipose Tissue↗

PubMed1985

Quantitative computed tomography of Graves' ophthalmopathy. Extraocular muscle and orbital fat in development of optic neuropathy.

Quantitative assessment of computed tomographic (CT) scans was performed on 98 orbits of 49 patients with Graves' ophthalmopathy. Extraocular muscle volume and orbital fat volume were determined, according to whether optic neuropathy was absent, had developed during follow-up, or was present at the time of scanning. No differences in muscle volume were found between the group already having optic neuropathy and the group in which optic neuropathy developed during follow-up. Both optic neuropathy groups, however, had significant increases in extraocular muscle volume compared with the group without optic neuropathy. The absolute amount of orbital fat was the same for all groups, but the relative amount of orbital fat tended to decrease as total orbital volume increased with development or presence of optic neuropathy. This study establishes a quantitative relationship between optic neuropathy and extraocular muscle enlargement in Graves' ophthalmopathy. Orbital fat, however, does not play an important role in the disease.

Adipose Tissue↗

PubMed1998

Reconstruction of orbital floor fractures with maxillary bone.

OBJECTIVE: To evaluate the use of autogenous maxillary bone for the repair of orbital floor defects secondary to blunt facial trauma. DESIGN: Retrospective case series of 41 patients with a mean follow-up of 1.7 years. SETTING: Major metropolitan teaching hospital. PATIENTS: Forty-one consecutive patients who underwent repair of orbital floor fractures with maxillary antral wall bone grafts. MAIN OUTCOME MEASURES: Presence of diplopia, orbital dystopia, implant extrusion, enophthalmos, infection, and donor site complications. RESULTS: On follow-up clinical examinations, none of the 41 patients presented with any evidence of orbital dystopia or complications relative to the implant or donor site. Two patients had persistent enophthalmos, and 4 had persistent infraorbital nerve paresthesia. Postoperative computed tomographic scans in 12 patients revealed an adequate maintenance of orbital volume without any evidence of resorption of the graft. CONCLUSION: The use of maxillary antral wall bone for the repair of orbital floor fractures is a highly reliable technique that carries minimal morbidity.

Adolescent↗

PubMed2005

Porous high-density polyethylene for orbital reconstruction.

OBJECTIVE: To determine the safety and efficacy of using porous high-density polyethylene (PHDPE) in the repair of orbital defects. DESIGN: Retrospective case series. SETTING: Academic tertiary care trauma center. Patients One hundred seventy patients with orbital defects requiring surgical repair. Intervention Orbital defect repair with PHDPE. Main Outcome Measure Our review documents surgical results and complications associated with the use of PHDPE. RESULTS: There was a 6.4% complication rate associated with the use of PHDPE. The infection rate was 1.8%. The persistent orbital malposition rate was 3.5%. The extrusion rate was 0%. CONCLUSIONS: This report represents the largest case series in the literature using PHDPE for orbital reconstructions. The use of PHDPE resulted in a low complication rate and excellent functional and cosmetic reconstructive results. Because of our success with the use of PHDPE, we have changed our clinical practice to minimize the use of autologous graft material, thereby eliminating donor site morbidity in cases involving orbital reconstruction.

Biocompatible Materials↗

PubMed1996

Preservation of the eye in the treatment of sinonasal malignant neoplasms with orbital involvement. A confirmation of the original treatise.

OBJECTIVE: To continue the retrospective analysis reported in 1988 that supported preservation of the eye in the treatment of sinonasal cancers when bony erosion of the orbit was noted on pretreatment radiographic analysis. DESIGN: Using the eye-sparing protocol previously reported, which included preoperative radiotherapy (with or without chemotherapy, depending on tumor size, involvement, or other characteristic) for malignant neoplasms of the superior nasal vault that had eroded the bony orbit, retrospective analysis of the results of therapy for the additional 33 patients treated between 1986 and 1993 was performed. These data were added to those from the original series to provide a total of 74 patients. Forty-one patients (55%) showed bony erosion at initial evaluation and 14 (19%) had periorbital involvement. During surgery, the periorbita was evaluated by frozen section control. If tumor was found, that region of periorbita was resected and, if necessary, replaced with fascia or split-thickness graft. RESULTS: Five patients from the original series had orbital sacrifice. Of the remaining 36 patients, 4 (11%) had recurrent disease involving the orbit, but not at the primary site. Twenty (55%) of the 36 patients had no orbital complications, and only 1 (3%) had a permanent motility disturbance and 4 (13%) developed cataracts after radiotherapy. CONCLUSION: With the use of preoperative radiotherapy in resection of involved periorbita with frozen section control in tumors of the sinonasal vault that involve the bony orbit, the eye can be spared in most instances without compromising oncologic safety.

Adenocarcinoma↗

PubMed1996

Endoscopic vs external drainage of orbital subperiosteal abscess.

Periorbital cellulitis is frequently limited to the preseptal region. However, there may be associated postseptal inflammation and orbital subperiosteal abscess (SPA). Surgical management of orbital SPA includes open drainage through an external ethmoidectomy approach, although recently the use of endoscopic techniques has been reported. This study was undertaken to evaluate postseptal cellulitis and orbital SPA in patients with periorbital cellulitis and to assess the safety and effectiveness of endoscopic management of orbital SPA. From 1989 through 1994, 158 patients were admitted with a diagnosis of periorbital cellulitis. Nineteen of these patients were diagnosed with postseptal orbital inflammation, and 14 underwent surgical drainage via an external approach, an endoscopic approach, or a combination of both. Issues addressed include (1) the role of sinus disease as the cause of periorbital cellulitis; (2) the role of computed tomographic scanning; (3) the effectiveness of aggressive medical therapy; and (4) the results of endoscopic drainage of orbital SPA compared with the external approach.

Abscess↗

PubMed1997

Leiomyosarcoma metastatic to the orbit: diagnosis of fine-needle aspiration.

A 47-yr-old man with history of metastatic low-grade rectal leiomyosarcoma presented with progressive protrusion of his left eye due to an enlarging orbital mass. The differential diagnosis included tumor metastasis or orbital infection due to an unknown infectious agent. Diagnostic fine-needle aspiration (FNA) of the orbit was performed on an urgent basis to institute proper therapy and to save the patient's eyesight. Cytomorphologic examination of the material demonstrated a spindle-cell neoplasm consistent with metastatic leiomyosarcoma. It is a rare event for leiomyosarcoma to occur in the orbit. On our review of the literature, the cytology of primary orbital leiomyosarcoma on FNA has only been reported once. To our knowledge, this is the first report of the FNA cytomorphology of metastatic leiomyosarcoma to the orbit.

Biopsy, Needle↗

PubMed1983

Ocular and orbital complications following radiation therapy of paranasal sinus malignancies and review of literature.

During the period from March 1963 through March 1978, 30 patients with malignant neoplasms of the paranasal sinuses were treated with supervoltage technique at the University of Rochester Medical Center. Twenty-one patients had at least the medial portion of the orbit within the effective treatment volume and the rest of the patients had whole eye irradiation. In paranasal sinus malignancies, orbital involvement with ocular symptoms and signs is quite common; in many patients it can be the presenting problem. Enucleation is necessary in patients with gross orbital tumor. Eye preservation is worthwhile in patients with minimal orbital tumor. Anterior complications are a minimal risk if the technique is good. Posterior complications occur in almost all patients, but are rarely clinically significant until doses of 6000 rad or above are reached. In patients without gross orbital involvement, preservation of the eye can be considered optional treatment. It includes shielding of the anterior structures, but it is usually not possible to protect medial and posterior portions of the eye and orbit. In advanced cases, it is worthwhile to preserve the eye as cure rate is low and posterior eye complications are often late. Because the aim of treatment is cure, dose should not be compromised to prevent complications. Radiation injury to the optic nerve and retina is the major factor in visual loss, but it can be prevented by limiting the retinal and optic nerve dose to less than 6000 rad.

Aged↗

PubMed2000

Preoperative imaging to predict orbital invasion by tumor.

BACKGROUND: Our purpose was to examine the accuracy of preoperative imaging in assessing tumor invasion of the orbit and nasolacrimal system. METHODS: Nineteen preoperative CT and 17 preoperative MR images from patients at risk for orbital invasion were retrospectively reviewed. Invasion was corroborated by pathologic and intraoperative assessment. RESULTS: Tumor adjacent to the periorbita was the most sensitive predictor of orbital invasion (90%) for both CT and MRI. Extraocular muscle involvement on MRI (100%) and orbital fat obliteration (80% MRI, 86% CT) had the highest positive predictive values of the criteria evaluated. Extraocular muscle displacement and enhancement were less accurate (<65%) predictors. No one criterion was >79% accurate in predicting orbital invasion. Six or more positive criteria predicted invasion with 67% sensitivity and 80% specificity (accuracy, 72%). CT was more accurate than MRI in seven of nine criteria. Invasion of the nasolacrimal system was predicted accurately (89%). CONCLUSIONS: Although preoperative imaging can aid in surgical planning, it should not replace intraoperative assessment in ambiguous cases of orbital invasion.

Adipose Tissue↗

PubMed2007

Microsurgical anatomy of the superior orbital fissure.

The microanatomy of the superior orbital fissure (SOF) was studied in 96 sides of cadaver specimens. The SOF is a narrow bony cleft that lies at the apex of the orbit between the greater and lesser wings of the sphenoid. Through this fissure, many important structures enter the orbit from the middle cranial fossa including the third, fourth, sixth cranial nerves, and the ophthalmic branch of the fifth nerve. In addition, the superior opthalmamic vein exits the orbit to drain into the cavernous sinus via the SOF. The fissure can be divided into three anatomical regions by the annulus of Zinn (common annular tendon): the lateral, central, and inferior regions. The lateral wall of the SOF can also be divided between the upper and lower segments, and the angle between them was measured to be 144.27 degrees +/- 20.03 degrees . Defining these regions is useful in describing the course and placement of the nerves and vasculature in the SOF. Managing lesions at the orbital apex requires an extensive knowledge of the cranial base and the intracranial and extracranial relationships of the anatomical structures coursing through the SOF. The goal of this study was to describe the microanatomy of the SOF region in detail and to provide a reference for surgical procedures involving the orbital apex.

Cavernous Sinus↗

PubMed2003

Radiation therapy for recurrent orbital hemangioma.

BACKGROUND: Surgical resection and corticosteroid therapy have traditionally been the preferred methods of treatment for orbital hemangioma. Radiation therapy is not usually indicated because of the potential for ocular complications. With modern radiation techniques, however, patients may experience substantial clinical improvement without significant radiation-induced morbidity. METHODS: A case of unresectable, recurrent orbital hemangioma is described. The clinical presentation, management protocol using radiation therapy, and 5-year follow-up are reviewed. RESULTS: The patient was initially seen with left orbital pain, diplopia, proptosis, and conjunctival edema caused by a recurrent left orbital hemangioma after failed previous surgery. CT scan and angiogram revealed a large, irregular, multilocular mass in the left orbit consistent with hemangioma. The patient was treated with a total of 2000 cGy in 10 treatments. Five-year follow-up revealed a stable, regressed hemangioma with no radiation complications. CONCLUSIONS: Radiation therapy may be used if appropriately indicated for function-threatening orbital hemangioma.

Hemangioma↗

PubMed1998

Assessment of rapid morphological changes associated with elevated cAMP levels in human orbital fibroblasts.

Orbital fibroblasts exhibit a phenotype distinct from that of other types of fibroblasts. Addition of prostaglandin E2 (PGE2) to culture medium elicits a dramatic change in orbital fibroblast morphology. That response is mediated through the generation of cAMP. Orbital fibroblasts can generate high levels of PGE2 through induction by proinflammatory cytokines of prostaglandin endoperoxide H synthase-2 (PGHS-2). Here we compare the influence on fibroblast morphology of exogenous PGE2, forskolin, and 8-br-cAMP to that mediated through PGHS-2 induction by a lymphocyte-derived cytokine. Within a few hours, orbital fibroblasts treated with any of these test compounds appear under phase-contrast microscopy to exhibit a stellate morphology. When these changes were assessed quantitatively by electric cell-substrate impedance sensing (ECIS), it became evident that 8-br-cAMP, forskolin, and PGE2 initiated shape changes within 30 min of addition to the culture medium, while effects of the cytokine were first evident after approximately 3.5 h. Dermal fibroblasts failed to respond to any of these compounds with regard to changes in cellular morphology. Analysis of micromotion, manifested as small impedance fluctuations, revealed that orbital fibroblasts treated with 8-br-cAMP exhibit less motion than did untreated cells. These results suggest that orbital fibroblast shape can be altered by several compounds known to alter intracellular cAMP levels. They demonstrate the utility of ECIS in the assessment of very rapid and dynamic cellular events associated with changes in cell morphology.

8-Bromo Cyclic Adenosine Monophosphate↗

PubMed1989

Autonomic pathways in the orbit of the human fetus and the rhesus monkey.

In order to study the three-dimensional topography of the intra-orbital autonomic nerve plexuses and the input for these systems, human fetuses and adult rhesus monkeys were investigated. Specimens of the orbits were processed according to the histochemical acetylcholinesterase methods for staining of peripheral nerves. The nerve fibers enter the orbit along the following pathways: 1. bundles of nerve fibers from the pterygopalatine ganglion (mainly parasympathetic) by penetrating the orbital muscle (Müller); 2. perivascularly along the ophthalmic artery (sympathetic). In the orbit the nerve fibers intermingle. The pathways of the nerve fibers from this interwoven nerve plexus towards the target organs are: 1. perivascularly along branches of the ophthalmic artery; 2. perineurally along and in the branches of the ophthalmic and maxillary nerves; 3. independently of blood vessels and cranial nerve branches in Tenon's capsule. Moreover, bundles of nerve fibers from the ciliary ganglion contribute to the innervation of extraocular structures, e.g. the eyelids. It can be concluded that, as far as the autonomic innervation of the orbit is concerned, the monkey is a good animal model for neuroanatomical studies.

Acetylcholinesterase↗

PubMedDate not supplied

Plasmacytoma of the eye and orbit.

BACKGROUND: Plasmacytomas of the ocular and adnexal tissue are rare. The variation in their clinical manifestations and potential association with multiple myeloma are not well appreciated. METHODS: We reviewed the clinical features and laboratory data of five cases of plasmacytoma involving the eye and orbit. RESULTS: Plasmacytomas involved the conjunctiva in one case, the orbit in three cases, and the iris in one case. Plasmacytoma was the solitary plasma cell neoplasm in a patient with a conjunctival lesion and another patient with an orbital lesion. Two other patients who developed plasmacytomas of the orbit and iris, respectively, had a known history of multiple myeloma. An orbital plasmacytoma preceded the onset of systemic plasma cell neoplasia in the final patient. CONCLUSION: Plasmacytomas of the eye and orbit are rare. They may or may not be associated with multiple myeloma.

Aged↗

PubMed1996

Clinical and radiological presentation of 95 orbital lymphoid tumors.

BACKGROUND: Although most orbital lymphoid tumors are characterized by a slow, painless onset and a mass that molds to orbital structures, different presentations may occur. Intensity on T2-weighted MRI is a possible means for differentiating lymphoid tumors (hyperintense) from pseudotumors (hypointense). In addition, it is generally assumed that 75% of orbital lymphomas are at stage I on presentation. METHODS: The clinical, CT, and MRI presentation of 95 primary and secondary orbital lymphoid tumors (63 non-Hodgkin lymphomas and 32 lymphoid hyperplasias) and their histological grade and staging were reviewed. Immunohistochemistry and PCR were used to determine clonality. RESULTS: No significant differences were found between non-Hodgkin lymphomas and lymphoid hyperplasias, except for the mean age of the patients (6.3 years older in non-Hodgkin lymphomas). In both groups the most common presentation was a mass with an indolent course; visual impairment was seen in 13%, conjunctival redness in 25%, pain in 12%, and acute orbital inflammation in 15% of the patients. In most cases, the CT showed one or more lobulated or rounded masses, molding to adjacent structures, or a wedge-shaped enlargement of the lacrimal gland. Intramuscular lymphomas were rare and always associated with extramuscular masses. On T2-weighted MRI, only 35% of lymphoid tumors were hyperintense. Only 49% of lymphomas were at stage I on presentation. CONCLUSION: An inflammatory presentation is not uncommon in orbital lymphoid tumors. Shape, molding and multiple masses can help radiological diagnosis, whereas MRI T2 intensity is unreliable. Accurate staging can disclose systemic disease in more than 50% of cases of non-Hodgkin lymphoma.

Adolescent↗

PubMed1999

The superior orbital fissure and its contents.

Topographic landmarks for the superior orbital fissure are useful for general orientation and approach to the middle fossa, cavernous sinus and orbit. In this study, the microsurgical anatomy and morphometry of the superior orbital fissure and its related structures were examined in 57 disarticulated sphenoid bones, 102 skull bases and 58 adult cadaveric heads. The superior orbital fissure was observed in nine different shapes based on the classification of Sharma et al. (1988), and the most frequently observed was Type VI. The distance from the superomedial to the superolateral edge was measured as 17.3 +/- 3.4 mm on the right side and 16.9 +/- 2.9 mm on the left side, and from the superolateral to the inferior edge as 20.8 +/- 3.9 mm on the right side and 20.1 +/- 3.8 mm on the left side. The distance from the superomedial to the inferior edge of the fissure was measured as 9.5 +/- 2.2 mm on the right side and 9 +/- 2.4 mm on the left side. No right-left differences were observed for these measurements. Measurements regarding the relationship of the oculomotor, trochlear and abducent nerves, the ophthalmic branch of the trigeminal nerve and the superior orbital vein were performed and topographic aspects of the superior orbital fissure region were described.

Abducens Nerve↗

PubMed1982

Fine-needle aspiration biopsy in the diagnosis of orbital tumours.

Fine-needle aspiration biopsy was used for the diagnosis of 25 consecutive patients with orbital tumours. CT scan was used to locate the lesion accurately. In two cases of orbital sarcoma and three out of four cases of orbital meningeoma, pre-operative fine-needle biopsy provided the correct diagnosis for proper operative treatment. Post-operative histopathological examination of the tumours proved that the cytological diagnoses had been correct. Two cases were diagnosed as metastatic carcinomas, 4 as malignant lymphomas and 11 as chronic inflammatory lesions. Orbitotomies were performed in 3 cases only, and the cases were managed accordingly with radiation, chemotherapy or corticosteroids. With conservative treatment the results varied from arrest of the condition to total disappearance of the lesion. No complications were encountered as a result of orbital fine-needle biopsies. The procedure is simple, requiring only topical anaesthesia and if proper cytological service is available, invaluable diagnostic information is provided for proper clinical management. It can also be used if recurrence of orbital tumour is suspected and a new mass is seen by CT scan. The method may save the patient from unnecessary exploratory orbital surgery.

Adolescent↗

PubMed1999

Demonstration of thyrotropin receptor mRNA in orbital fat and eye muscle tissues from patients with Graves' ophthalmopathy by in situ hybridization.

There is a controversy regarding whether there are thyrotropin (TSH) receptors in orbital fat and eye muscle tissues that may play a role in the pathogenesis of Graves' ophthalmopathy. To elucidate whether there are TSH receptors in orbital fat and eye muscle tissues in patients with Graves' ophthalmopathy, we applied the method of in situ hybridization in orbital fat and eye muscle tissues obtained during the operation for patients with Graves' ophthalmopathy, to directly detect TSH receptor mRNA. To identify whether the cells with positive TSH receptor mRNA are fibroblasts, we also did vimentin immunoreactivity study. To further prove the transcript does have a full length of TSH receptor, the samples of total RNA preparations, extracted from orbital fat and eye muscle tissues, were used as a template for reverse transcriptase polymerase chain reaction (RT-PCR) using three primer sets to generate cDNA fragments and cloned for sequencing. The results showed that the expression of TSH receptor mRNA was demonstrated in adipocytes and fibroblasts of orbital fat, and perimysial fibroblasts within eye muscle tissues by in situ hybridization and vimentin immunoreactivity study. Also, by using the RT-PCR, cloning and sequencing, we further proved that the transcript does have a full length of TSH receptor. The present study suggested that there are TSH receptors expressed in orbital fat and eye muscle tissues.

Adipocytes↗