Antonio Augusto V. Cruz, Bruna S. N. Equiterio, Barbara S. A. Cunha, Fabiana Batista Caetano & Roque Lima Souza
To systematically review the literature on the deep lateral orbital decompression (DLD).
The authors searched the MEDLINE, Lilac, Scopus, and EMBASE databases for all articles in English, Spanish, and French that used as keywords the terms orbital decompression and lateral wall. Two articles in German were also included. Data retrieved included the number of patients and orbits operated, types of the approach employed, exophthalmometric and horizontal eye position changes, and complications. The 95% confidence intervals (CI) of the mean Hertel changes induced by the surgery were calculated from series with 15 or more data.
Of the 204 publications initially retrieved, 131 were included. Detailed surgical techniques were analyzed from 59 articles representing 4559 procedures of 2705 patients. In 45.8% of the reports, the orbits were decompressed ab-interno. Ab-externo and rim-off techniques were used in 25.4% and 28.8% of the orbits, respectively. Mean and 95% CI intervals of Hertel changes, pooled from 15 articles, indicate that the effect of the surgery is not related to the technique and ranges from 2.5 to 4.5 mm. The rate of new onset of diplopia varied from zero to 8.6%. Several complications have been reported including dry eye, oscillopsia, temporal howling, lateral rectus damage, and bleeding. Unilateral amaurosis and subdural hematoma have been described in only one patients each.
The low rate of new-onset diplopia is the main benefit of DLD. Prospective studies are needed to compare the rate of complications induced by the 3 main surgical techniques used.
Sven Holger Baum, Roman Pförtner, Anke Manthey, Nikolaos Emmanouel Bechrakis & Christopher Mohr
This study aimed to analyse the disease-free survival (DFS), overall survival (OS) and risk factors after orbital exenteration in patients with periorbital, conjunctival and primary intraorbital carcinomas.
Patients undergoing orbital exenteration due to a primary carcinoma between March 2000 and March 2018 were included in this retrospective study. Risk factors in all the patients were evaluated using univariate and multivariate analyses.
In total, 97 patients were enroled in this study. The most common tumours were conjunctival carcinoma (35 cases), squamous cell carcinoma of the skin (27 cases) and basal cell carcinoma (20 cases). The median follow-up period was 36 months. The average age of the patients was 67.3 years (range, 29–93 years). In all the patients, OS was 85% after 1 year and 69% after 5 years, while DFS was 71% after 1 year and 55% after 5 years. Univariate analysis of OS revealed that the following parameters were predictive of a poor prognosis: localisation, neck dissection, lymph node metastases, lymphatic invasion, perineural invasion, resection margins and immunosuppression. Multivariate analysis revealed resection margins as the only independent risk factor.
Orbital exenteration is rarely necessary in patients with periorbital, conjunctival and primary intraorbital carcinomas; however, it can be performed as an ultima ratio treatment with a curative intent. Clear margins can be achieved in most cases. OS and DFS are not significantly different in the subgroups. In most cases, recurrence occurs within the first 2 years.
Judy Gaffar, Georges Nassrallah, Matthew Kondoff, Michael Ross, Jean Deschênes
With increasing constraints on our publicly funded health care system, appropriate triage of trauma patients is becoming pivotal, making the primary care assessment (PCA) invaluable. Our study aims to compare the initial assessment of patients with orbital fractures with that conducted by the ophthalmology service.
Retrospective chart review.
243 patients with 277 fractured orbits presenting to a level 1 trauma centre seen between August 2015 and January 2018.
Key elements of the PCA, including subjective vision loss, visual acuity, intraocular pressure, pupil examination, and extraocular movements, were documented and compared with the assessment by the ophthalmology service as the control. The primary outcome was inter-rater reliability as estimated by Cohen’s kappa (κ) coefficient. Secondary outcomes included the sensitivity and specificity, as well as the rate of completion of examination components.
PCA examination findings agreed with the ophthalmology service on most components of the examination with the highest agreement with relative afferent pupillary defects and detection of hyphemas (κ = 1). Primary care physicians less often performed most aspects of the assessment. Among performed components of the examination, the average sensitivity was 60.6%, and the average specificity was 84.2%.
Our results show good inter-rater reliability of the PCA compared with the ophthalmology examination but low rate of completion of examination components, suggesting a potential overdependence on the ophthalmology assessment. Given the limited resources of the public health care system, our study may highlight the PCA as a potential focus to improve effective and safe patient management.
Joel Caballero-García, Carlos Aparicio-García, Yurledys Jhohana Linares-Benavides, Misael López-Sánchez, Franklyn Alain Abreu-Perdomo, Juvenal Huanca-Amaru
To evaluate clinically the efficacy of 360-degree minimally invasive endoscopic surgery in patients with orbital intraconal tumors.
Retrospective interventional case series.
A series of consecutive patients with orbital intraconal tumors were treated with minimally invasive surgery using an endonasal endoscopic approach or an anterior endoscopic orbitotomy over a 5-year period between January 2015 and January 2020 at the National Institute of Oncology and Radiobiology of Cuba.
In 22 patients, the mean age was 52.3 ± 11 years (range 18-71 years) with a female to male ratio of 1.8:1. Visual loss was present in 3 patients and proptosis was present in 19 patients. The most common diagnosis was cavernous hemangioma (72.7%) followed by orbital sheet meningioma (9.1%). The lower-inner (type II) location was the most usual, followed by the lower-outer (type IV). A gross total resection was achieved in 95.5% of patients. In only 1 case with an orbital pseudotumor was the resection subtotal because of the fibrous consistency, irregularity, and adherences to the medial rectus muscle. All patients with visual loss improved to normal visual function after surgery at follow-up and orbital proptosis recovered in all patients with these symptoms. Both immediate and long-term morphologic and aesthetic results were good in all patients.
The minimally invasive 360-degree surgical approach with a full endoscopic visualization can be safe and efficient in patients with select orbital intraconal tumors. Optic nerve location constitutes the main aspect in the surgical approach selection. A large case series is necessary to standardize this surgical philosophy.
Jonathan E. Lu, Margaret L. Pfeiffer & Michael A. Burnstine
Purpose: To provide outcome data for transantral orbital decompression for functional and aesthetic rehabilitation for exophthalmos in stable thyroid eye disease (TED).
Methods: Retrospective, non-comparative chart review of consecutive TED patients who underwent primary-graded transantral orbital decompression for exophthalmos by a single surgeon (MAB) between 2005 and 2018. Additional inclusion criteria included follow-up >90 days and no prior orbital surgery. Outcome data collection included millimeters of proptosis reduction, postoperative complications, and patient satisfaction.
Results: A total 30 patients (47 orbits) were included. Average reduction in proptosis: 2.8 mm (range 0–9 mm, median 2.5 mm). Post-operatively, new onset diplopia occurred in four patients, V2 numbness in 15 patients (17 orbits), and sinusitis in 2 patients (2 orbits). Phone surveys reached 9/30 patients (14 orbits): cosmetic improvement was reported in 14/14 orbits, relief of orbital ache reported in 10/10 orbits with pre-operative ache, relief of dry eye in 8/13 orbits with preoperative dry eye, and overall satisfaction score: 8.9/10 (range 4–10, median 10).
Conclusions: Graded transantral orbital decompression is a viable option for stable TED patients with orbital ache, exophthalmos, and exposure keratopathy, resulting in a high degree of functional and cosmetic satisfaction in our cohort.
Ann Q. Tran, Sandy X. Zhang-Nunes, Kenneth Cahill, Chrisfouad R. Alabiad, Erin M. Shriver, Tiffany Ho, David A. Weinberg, Steven M. Couch, Dianne M. Schlachter, John Nguyen & Sara T. Wester
Purpose: To determine the clinical course of patients with chorioretinal folds (CRF) in thyroid eye disease (TED).
Methods: A multi-center retrospective case series of patients with TED who developed CRF.
Results: Ten patients (17 eyes) with CRF related to TED were identified. The mean age of presentation was 59.3 ± 8.3 years old. The majority of patients were male (70%), hyperthyroid (70%), hyperopic (53%), had a history of radioactive iodine (60%), and currently on methimazole treatment (30%). Three patients (3 eyes) had unilateral involvement of CRF with bilateral TED. The average clinical activity score was 3.6 ± 2.1 at the time of presentation. The most commonly enlarged extraocular muscles were medial (76%), inferior (64%), superior (64%) and lateral rectus (35%). Compressive optic neuropathy was seen in 47% of eyes. Treatment included oral prednisone (70%), orbital decompression (59%), thyroidectomy (20%) and tocilizumab (10%). The CRF did not resolve over a follow up period of 24.7 ± 23.7 months in 70% of eyes. There was no significant difference in average axial length (25.7 ± 4.9 mm) and optic nerve to optic strut distance (37.8 ± 3.9 mm) between patients with CRF and the eight age-and sex-matched TED control patients without CRF (p = 0.81 and 0.65 respectively). A univariable and multivariable analysis found an enlarged inferior rectus as a factor in TED patients with persistent CRF.
Conclusions: CRF are often an indicator of visually threatening situations and often do not resolve despite treatment of TED.
Nitika Pandey & Apjit Kaur Chhabra
Purpose: The study evaluates the corneal biomechanical properties on Ocular Response Analyzer (ORA) and aims to establish their correlation with the clinical profile of patients with TAO.
Methods: A tertiary care centre-based cross-sectional observational study was conducted. Eighty patients with stage I and II TAO (EUGOGO classification), categorized as group A, were age and sex matched with 85 controls constituting group B. The disease activity was assessed using clinical activity score (CAS). The thyroid hormonal profile of within one-week duration was recorded for each patient of group A. Mean IOP-GAT (IOP using Goldmann applanation tonometer), IOPg (Goldmann-correlated IOP value), IOPcc (cornea-compensated IOP value), CRF (corneal resistance factor), and mean corneal hysteresis (CH) of group A and B were compared. The variation of CH with disease severity, activity, and thyroid status in group A was evaluated.
Results: Mean GAT, IOPg, and IOPcc of group A were significantly higher than that of group B (p < .001). Mean CH of group A i.e the visco-elastic dampening ability of cornea was significantly lower than that of group B (p < .001). In group A, mean CH of patients with stage 1 disease severity and CAS<3 was significantly higher than that of patients with stage 2 severity and CAS≥3 (p < .001). CH of hyperthyroid patients was significantly lower than CH of hypothyroid patients (p < .01).
Conclusion: TAO affects the biomechanical properties of the globe as reflected by the corneal biomechanics on ORA. The disease severity, activity, and hyperthyroid status are negatively correlated with the CH.
Ahmed Sheikh & Rand Rodgers
We describe a 75-year-old woman with rapid onset orbital inflammatory syndrome as her initial manifestation of relapsing polychondritis. Patient presented after the development of right eyelid swelling, erythema, and proptosis over a 48-hour period. Visual acuity was 20/30 in both eyes. Intraocular pressure was elevated in her right eye along with severe restriction of extraocular motility. Magnetic resonance imaging of the orbits revealed thickened right medial and inferior recti muscles. Serologic laboratory data was unrevealing. Patient demonstrated marked improvement within 12 hours of administration of intravenous corticosteroids. She was symptom-free after 1 week. A diagnosis of relapsing polychondritis was confirmed 3 weeks later after new onset complaints of right ear pain and a rash.
Tamer I. Gawdat & Mostafa M. Diab
Purpose: To report the outcomes of a transcutaneous surgical technique for orbital volume augmentation with secondary alloplastic implants in acquired anophthalmia.
Methods: Retrospective case note review of patients who underwent secondary orbital implant insertion through a subciliary incision between January 2006 and December 2017. Collected data included age, gender, type and cause of primary surgery, time interval before secondary implantation, and details of secondary implantation surgery. The main outcome parameters included postoperative appearance, grade of superior sulcus deformity (SSD), implant centration, and prosthesis function.
Results: Thirty-eight patients ranging from 2 to 54 years had undergone secondary alloplastic orbital implant placement through the subciliary approach. The mean follow-up was 5.3 years (range: 1–10 years). All the patients showed satisfactory orbital volume with the average SSD was grade 0.74. There were no cases with implant exposure or extrusion. Implant migration occurred in six cases (15.8%). Fitting a prosthesis was possible in all cases.
Conclusion: Subciliary secondary orbital implantation is proved to be effective in correcting volume deficiency in acquired anophthalmia with rapid rehabilitation while avoiding anterior surface breakdown and implant exposure.