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PubMed1993

A simplified technique of orbital decompression for severe retrobulbar hemorrhage.

Severe retrobulbar hemorrhage may occur as a complication of a retrobulbar injection or from blunt or sharp injury to the orbit during an orbital or periorbital operation. When the patient with a severe retrobulbar hemorrhage does not respond to intermittent ocular massage, or paracentesis, or a lateral canthotomy, prompt orbital decompression becomes necessary. A simple and effective surgical technique that is applicable in such urgent situations was used in this study. The procedure does not entail waiting for computed tomography or the availability of an orbital surgeon and requires only minimal local anesthetics. A small mosquito clamp is inserted into the orbit through a small opening in the inferior fornix. The clamp is advanced into the orbit along the medial orbital floor until a depth of about 20 mm is reached. Pressure is applied to the clamp to break the orbital floor and maxillary sinus mucosa, and to decompress the orbit. I successfully used this technique on five patients in the past five years.

Adult↗

PubMed1996

Orbital fractures in women due to sexual assault and domestic violence.

PURPOSE: Because domestic violence and sexual assault have a widespread societal and medical impact, this retrospective study was designed to determine the frequency of sexual assault and domestic violence as causes of orbital fractures in women. METHODS: The records of 54 consecutive patients with orbital fractures presenting to the Ophthalmic Plastic and Orbital Surgery service of Penn State University's Department of Ophthalmology were reviewed. The type of trauma resulting in each patient's orbital injury was identified. The frequency of orbital fractures resulting from sexual assault or domestic violence was determined. RESULTS: The study included 35 male and 19 female patients, ranging in age from 27 months to 63 years. Orbital fracture was the result of sexual assault or domestic violence in one third of the female patients, but no male patients. Motor vehicle accidents accounted for another 31.6 percent of orbital fractures in female patients. CONCLUSIONS: Based on this retrospective study, sexual assault and domestic violence are frequent causes of orbital fractures in women. Healthcare workers evaluating female patients with orbital fractures should have a high index of suspicion regarding sexual assault or domestic violence as a possible origin of the injury. A pointed but sensitive approach may be necessary to elicit this history from the patient.

Accidents, Traffic↗

PubMed2002

Demographics and treatment options for orbital roof fractures.

OBJECTIVE: The purpose of this article was to review the frequency, germane anatomy, management modalities, and complications associated with the treatment of orbital roof fractures in the pediatric and the adult population. STUDY DESIGN: A review of the past 30 years of the English-language maxillofacial surgical literature was undertaken. Important concepts were coupled with the authors' experience to provide a synopsis of contemporary thought on this topic. RESULTS: More than 235 articles in the oral and maxillofacial, plastic and reconstructive, otolaryngology-head and neck, ophthalmologic, oculoplastic, neurologic, and pediatric surgical literature were reviewed and assessed. From this group, 50 articles were found to contain useful information. CONCLUSIONS: It has been estimated that 1% to 9% of all facial fractures involve the orbital roof. The typical adult with an orbital roof fracture is a man (89%-93%) who has been involved in a high-energy impact and who has sustained concomitant multisystem injuries (57%-77%). Orbital roof fractures most commonly coexist with other craniofacial injuries. In contrast, in pediatric patients with an orbital roof injury, we see nearly equal sex distribution; the typical patient in this case has a frontobasal fracture that is minimally displaced or nondisplaced (53%-93%) and has sustained concomitant multisystem injuries. The pediatric patient is usually managed by means of observation alone (53%-86%). For the adult patient, a subcranial approach to the orbital roof by means of a bitemporal flap or superior blepharoplasty incision offers wide access with minimal morbidity. Currently available titanium microscrew and miniscrew and mesh systems offer a near-ideal modality for orbital roof reconstruction. The coexisting neurocranial, frontal sinus, and supraorbital rim fractures take priority over the management of orbital roof fractures. Complications associated with orbital roof injuries can be categorized as those attributed to the following: concomitant injury, surgical access, postreconstruction volume discrepancy, muscle entrapment, hemorrhage, and/or infection.

Adult↗

PubMed2000

Orbital abscess masquerading as a rhabdomyosarcoma.

Although orbital cellulitis is the most common cause of acute-onset proptosis with inflammatory signs in a child, the clinician should always be alert to the possibility of rhabdomyosarcoma. We describe an unusual presentation of acute-onset nonaxial proptosis of the left orbit without sinus disease or systemic toxicity in a 6-year-old boy. Our clinical differential diagnosis included orbital cellulitis, metastatic disease, capillary haemangioma, lymphangioma with cyst, ruptured dermoid cyst, and orbital rhabdomyosarcoma. Only after orbital biopsy and subsequent microbiologic confirmation were obtained was a diagnosis of chronic orbital abscess tenable. Features in our patient included paucity of symptoms and signs of inflammation. This case illustrates the difficulty in differentiating a chronic orbital infection from orbital rhabdomyosarcoma on the basis of clinical, laboratory, and orbital imaging findings. Possible causes of this unusual presentation are discussed.

Abscess↗

PubMed1994

Efficacy of lateral canthotomy and cantholysis in orbital hemorrhage.

Emergent orbital decompression in tense orbital hemorrhage with compromised ophthalmic blood flow may be achieved with lateral canthotomy, defined as incision of the lateral canthal tendon, and cantholysis, defined as canthotomy combined with disinsertion of at least the inferior crus of the lateral canthal tendon. This study was performed to determine which procedure, canthotomy, canthal tendon disinsertion, or cantholysis, produced the largest reduction in intraocular pressure after simulated orbital hemorrhage in 10 closed ruminant orbits with retrobulbar injections of normal saline. Intraocular pressure (IOP) reductions were measured after canthotomy in five orbits, after lateral canthal tendon disinsertion in five orbits, and after completion of cantholysis in all 10 orbits. Canthotomy produced a mean IOP reduction of 14.2 mm Hg. Canthal tendon disinsertion (CTD) produced a mean IOP reduction of 19.2 mm Hg. Cantholysis produced a mean IOP reduction of 30.4 mm Hg, a significantly (p < 0.05) greater reduction in IOP than that produced by canthotomy or canthal tendon disinsertion alone. Cantholysis in acute orbital hemorrhage may produce significantly greater reduction in IOP, and thus in intraorbital pressure, and allow better perfusion of orbital tissues than either lateral canthotomy or CTD.

Animals↗

PubMed2002

Pterional orbita decompression in orbital hemorrhage and trauma.

BACKGROUND: This article presents a series of patients with traumatic retrobulbar hematoma and orbital trauma, treated with extended pterional orbital decompression. METHODS: Fifteen patients, showing symptomatic retrobulbar hematoma or symptoms of orbital injury after various trauma mechanisms, were treated with deep lateral orbital decompression and removal of orbital blood/bone fragments via this approach. Preoperative and postoperative course, neuroradiologic findings, additional brain or facial injuries, and outcome of eye function are analyzed in detail. RESULTS: Mean delay between trauma and decompression was 70 hours (3 days), with a range from 2 hours to 15 days. Proptosis decreased in all patients and visual acuity improved or remained normal in nine patients and stayed defective in four. Impaired extraocular movements and pupillary changes recovered in 10 patients. Apart from one case of permanent deficit of the frontal branch of the facial nerve, no severe complications were seen. CONCLUSION: The presented pterional orbital decompression represents an effective alternative approach for patients with sight-threatening retrobulbar hematoma or orbital trauma, especially in cases that require direct access to damaged structures and maximal decompression of the orbit. Immediate detection and treatment of orbital hematomas is mandatory for acceptable outcome of eye function.

Adolescent↗

PubMed2003

Computer-assisted orbital volume measurement in the surgical correction of late enophthalmos caused by blowout fractures.

PURPOSE: To evaluate the use of computer-assisted volumetric measurement for the prediction of late enophthalmos and for volume estimation of implant material in the correction of late enophthalmos secondary to orbital blowout fractures (BOF). METHODS: This is a prospective observational study of 16 patients. Computer-assisted orbital volume measurements were made with the use of axial CT scans. Hertel exophthalmometry was used for the measurement of enophthalmos. The Lancaster test was used for measurement of diplopia. Autogenous bone or hydroxyapatite composite material was used for the repair of orbital defects and the correction of orbital volume expansion in 16 patients with enophthalmos caused by BOF. The volume of implant material was calculated from the orbital volume increment. Patients were followed for an average of 8 months after surgery. RESULTS: There is a high correlation between the increment of orbital volume and the degree of enophthalmos; 1 cm3 orbital volume increment causes 0.89 mm of enophthalmos. Before surgery, 10 of the 16 patients had moderate enophthalmos (3 to 4 mm) and 6 patients had severe enophthalmos (> or = 5 mm). Six months after surgical intervention, 13 patients (81%) achieved satisfactory results; 3 patients had no enophthalmos and 10 had mild enophthalmos (1 to 2 mm). Three patients had moderate to severe enophthalmos. CONCLUSIONS: The measurement of orbital volume in patients with BOF can be used to predict the degree of late enophthalmos. Use of the orbital volume increment to determine the amount of implant material can improve the therapeutic outcome in the correction of late enophthalmos caused by BOF.

Adult↗

PubMed2006

Combined transcutaneous transethmoidal/transorbital approach for the treatment of medial orbital blowout fractures.

BACKGROUND: The transcutaneous transorbital approach to medial orbital wall fractures facilitates placing a large implant or autogenous graft. However, its major disadvantage is the difficulty of accurately reducing the fractured medial orbital wall and herniated soft tissues with minimal morbidity. METHODS: To resolve this problem, a combined transcutaneous transethmoidal/transorbital approach through the same skin incision was developed at the Chonnam National University Medical School. Between 1997 and 2003, this approach was used in 54 patients with pure medial orbital blowout fractures. All fractures were larger than 2 cm in defect size and had 3 mm or more of bone displacement. RESULTS: Postoperative computed tomographic scans showed complete release of entrapped soft tissues and accurate reconstruction of bone defects in all cases. Complications related to the operation such as intraorbital and intramuscular hemorrhage, infection, and eyeball and optic nerve injuries were not observed, except in two cases with slight implant displacement. Follow-up ranged from 2 to 22 months, with an average of 9 months. Forty-one patients were evaluated 6 months or more after their reconstructive procedure. At the time of surgery, diplopia was present in 39 patients, eyeball movement limitation in 35 orbits, and enophthalmos of more than 2 mm in 16 orbits. Postoperatively, diplopia and eyeball movement limitation were resolved in most cases. Two patients had persistent diplopia for more than 1 year after surgery, and one of these needed extraocular muscle surgery. Enophthalmos of more than 2 mm developed in three orbits, but enophthalmos of more than 3 mm was not observed in any orbit. Cosmetic results at the incision site were acceptable in all patients. CONCLUSIONS: The combined transcutaneous transethmoidal/transorbital approach is a safe procedure that can be performed with minimal morbidity; it offers the advantages of both the transcutaneous approach and the trans-nasal approach. Therefore, the authors suggest that this method be considered as a surgical alternative for the treatment of medial orbital blowout fractures, especially large and combined fractures of the medial wall and other parts of the orbit.

Accidents, Traffic↗

PubMed2005

Long-term outcomes of ultra-thin porous polyethylene implants used for reconstruction of orbital floor defects.

PURPOSE: The objective of this article is to present the long-term outcomes of ultra-thin polyethylene implants used for orbital floor reconstruction in facial trauma patients. MATERIALS AND METHODS: From 1998 to 2004, 38 patients underwent orbital floor reconstruction with porous polyethylene implants with a mean follow-up of 4 years. A subciliary incision and preexisting facial wounds or scars were used. The boundaries of the maxillofacial injury and the orbital volumes of both orbits were assessed by computed tomography images obtained pre- and postoperatively. In all patients, ultra-thin porous polyethylene implants in various sizes were used to reconstruct the orbital floor defect. RESULTS: None of the patients needed removal of the implants during the follow-up. The volume increase of the traumatized orbits ranged from 0.04 to 6.18 (average 3.12 +/- 1.48) mL compared with the intact orbit (P < 0.01). This difference was not significant postoperatively (P > 0.01). Postoperative ectropion in three cases was corrected under local anesthesia. Persistence of complications were as follows: enophthalmos, 3 in 28; diplopia, 1 in 16; dystopia, 1 in 4; and infraorbital nerve hypoesthesia, 3 in 31. One patient underwent late enucleation of the globe because of initial penetrating trauma. CONCLUSIONS: We recommend the use of ultra-thin porous polyethylene implants in the reconstruction of the orbital floor defects in facial trauma patients. The implants are durable in the long-term and mimic the anatomy of the thin orbital floor and avoid the morbidity of autogenous bone grafts.

Adult↗

PubMed2006

Novel strategy for orbital tumor resection: surgical "displacement" into the maxillary cavity.

Surgical intervention consisting of lateral orbitotomy, the indication of which is extremely wide for orbital tumor surgery, has been applied in cases of large, retrobulbar cavernous hemangioma. However, no method exists involving displacement of the tumor from the crowded orbital contents, with the exception of tumor traction toward the outer side. The impact of traction force on the fragile hemangioma is extremely traumatic and dangerous. The authors examined how a tumor might be "displaced" in the absence of traction force effect, into an appropriate cavity neighboring the orbit. The maxillary sinus may afford the most suitable space to shift the laterally situated orbital tumor. Thus, the osteotomy level was extended to the lateral half of the inferior orbital floor and orbital rim in order to displace the tumor through an "escape window" of sufficient size between the orbit and maxilla. This report describes the treatment of two cases with long histories of progressive proptosis associated with retrobulbar large cavernous hemangiomas. This novel procedure resulted in a successful outcome. The current approach and management, which involves displacement of the tumor into the maxillary sinus through the orbital floor escape window, is a novel procedure for orbital tumor surgery.

Adult↗

PubMedDate not supplied

Idiopathic sclerosing orbital pseudotumor in seven cats.

OBJECTIVE: To review the clinical presentation and histopathologic findings on a series of cats with orbital fibrotic disease and compare the data to that of humans with sclerosing orbital pseudotumor. ANIMALS: A retrospective study was undertaken, which identified tissue samples from seven cats between 1997 and 2002 with a history of orbital mass effect and pathology characterized by fibrous tissue proliferation. PROCEDURE: Information was obtained from medical records for affected cats, including age, sex, clinical signs, management, and outcome, with histopathology re-examined. RESULTS: Six of seven cats presented with unilateral orbital involvement that progressed to bilateral orbital disease despite treatment. Onset was insidious, evolving over weeks to months and was associated with fixation of orbital structures. Owners of six of the cats opted for euthanasia because of disease progression and pain. Histopathology of affected orbital tissue included extensive fibrosis with encapsulation of normal tissues without characteristics of neoplasia. CONCLUSIONS: Clinical findings and histopathology of globes and orbital tissues in cats bore many similarities to idiopathic sclerosing orbital pseudotumor in humans. In cats, the prognosis for the globe appears to be poor but an elucidation of the pathogenesis and earlier diagnosis coupled with more aggressive treatment modalities as indicated in humans may be beneficial.

Animals↗

PubMed1989

Color Doppler flow imaging of the normal and abnormal orbit.

Twenty-six normal orbits (16 subjects) and seven patients with suspected orbital disease were studied with color Doppler flow imaging CDFI). Arterial structures consistently identified included the ophthalmic artery, central retinal artery, and posterior ciliary branches. The terminal lacrimal branch was seen in the majority of orbits (n = 19). Venous structures consistently seen included the central retinal vein and venae vorticosae; the superior ophthalmic vein was identified in the majority of normal orbits (n = 22). Response of the superior ophthalmic vein to the Valsalva maneuver was assessed in six of the normal subjects (12 orbits). Retrograde flow was typically seen during the maneuver and accentuated antegrade flow after cessation of the maneuver. Pathologic entities correctly diagnosed with CDFI included a dural arteriovenous malformation (AVM) with spontaneous carotid-cavernous fistula, an orbital AVM, and superior ophthalmic vein thrombosis. Vascular lesions were excluded in two patients with orbital masses. Bilaterally enlarged superior ophthalmic veins were identified in a patient with unilateral symptoms suggestive of a varix; CDFI results were confirmed with computed tomography, but orbital venograms were interpreted as normal. These findings suggest that CDFI may be helpful in the evaluation of suspected vascular orbital disease.

Adult↗

PubMed2006

Removal of an orbital apex hemangioma using an endoscopic transethmoidal approach: technical note.

OBJECTIVE: The posterior orbit contains a number of important and vulnerable structures, including the optic nerve, the ophthalmic artery and vein, and the ocular muscles and their motor nerves, which makes surgical access to the lesion in this region quite difficult. Transfrontal, transfrontal-ethmoidal, and transmaxillary procedures have the disadvantage of possible injuries to a number of nontumor structures, whereas an endoscopic transethmoidal approach is a minimally invasive surgery for the retrobulbar lesions. Retrobulbar cavernous hemangioma was successfully removed by a transethmoidal approach. METHODS: Tumor removal was performed in a patient with an intraconal cavernous hemangioma of approximately 15 mm in diameter. By a transethmoidal approach, the medial-inferior part of the orbit, as well as the apex of the orbit, were clearly visualized after endonasal ethmoidectomy. After the removal of the medial orbital bone, the orbital periosteum was incised and elevated. By elevating the orbital fat, the tumor could be identified separately from the orbital contents. RESULTS: Cavernous hemangioma at the orbital apex was removed without complications. CONCLUSION: An endoscopic transethmoidal approach, which requires no skin incision, is a minimally invasive surgery for retrobulbar orbital tumor, leading to excellent cosmetic results with less bleeding.

Adipose Tissue↗

PubMed2003

Invasive sino-orbital aspergillosis: surgical decisions and dilemmas.

Invasive aspergillosis, one of the common paranasal sinus fungal infections, often secondarily involves the orbit. We report six such cases with orbital extension, all occurring in apparently immunocompetent hosts, to specifically address the difficult diagnostic and therapeutic issues involved. Limited biopsy procedures were often inconclusive, necessitating wide surgical excision to establish the histopathological diagnosis. Conservative orbital debridement proved adequate for cases with disease limited to the infero-medial compartment of the orbit, but resulted in residual progressive disease in the two of the four cases with retro-orbital and apical extension. Orbital exenteration in this latter group, however, proved successful in controlling disease. The present report emphasizes the importance of near-complete extirpation and adjuvant chemotherapy in ensuring a favourable outcome in invasive Aspergillus infections. Orbital exenteration appears justified for posterior orbital disease, regardless of the functional status of the eye, but is inappropriate for anterior orbital disease.

Adult↗

PubMed1975

Axial hypocycloidal tomography of the orbits.

Axial hypocycloidal tomography has been applied to the investigation of 168 patients with suspected pathology in the orbit. Of these 75 had histological or angiographic confirmation of a space occupying lesion, and 55 patients showed positive evidence of abnormality. The X-ray changes observed include osteolysis and hyperostosis of the bony walls of the orbit, enlargement of the orbit-local and generalized, soft tissue abnormalities, and changes in the optic canal and superior orbital fissure. The most important evidence of the presence of a tumour or granuloma in the orbit was given by a positive "medial wall sign". This consists of a flattening or incurvation of the medial boundary of the orbit, best demonstrated by axial tomography. The sign was seen in 36.6 per cent of patients with proven intra-orbital space occupying lesions in the series. Axial hypocycloidal tomography is now an indispensable part of the diagnostic evaluation of patients with suspected orbital tumours and the procedure is complementary to other non-invasive investigations of the orbit, such as axial computerized tomography and ultrasonography.

Bone Diseases↗

PubMedDate not supplied

Isolated, bilateral orbital mass lesions during childhood.

A 9-year-old female developed bilateral orbital masses over four months without associated orbital inflammation or systemic disease. Orbital biopsy documented an unusual presentation of childhood pseudotumor. Nine days following surgery orbital inflammatory signs appeared suddenly and involved both the unoperated and biopsied orbits equally. These orbital lesions resolved completely after three months of systemic corticosteroid therapy. The sudden and progressive development of palpable bilateral orbital mass lesions rarely occurs in children without readily identifiable systemic disease. The 9-year-old girl described herein acquired bilateral orbital space-occupying lesions without evidence of ocular, orbital, or systemic abnormalities.

Adrenal Cortex Hormones↗

PubMedDate not supplied

[The characteristics of the clinical picture of lymphosarcoma and of a metastatic tumor of the orbit of another origin].

Clinical symptoms in patients with primary orbital lymphosarcoma, generalized lymphosarcoma involving the orbital tissues, and metastatic tumors of the orbit of another origin are analyzed. The orbital process has bee studied in 158 patients. The most frequent symptoms were ptosis and exophthalmos. Decreased visual acuity, pain, sensation of swelling in the orbit caused by rapid tumor growth were characteristic of metastases to the tumor and orbital lymphosarcoma in total system's involvement. In case of an isolated involvement of the orbit, lymphosarcoma ran a more swift course than metastases to the orbit and orbital lymphomas in systemic involvement which ran an aggressive course. These data cannot serve as differential diagnostic signs. The decisive information is provided by morphological examination of a biopsy specimen.

Adolescent↗

PubMed1984

[Surgical treatment of diplopia caused by fractures of the orbital floor].

Oculomotor disturbance resulting from orbital floor fractures have different etiologic factors, sometimes damage of one of the ocular motor nerves, caused by direct injury to the orbit; this damage occurs also to one or more of the extrinsic ocular muscles, especially the obliques; frequently, the diplopia is caused by prolapsed orbital tissues with or without muscle entrapment or by a muscle fibrosis; when the diplopia appears after orbital floor reconstruction there is often a palsy of the inferior rectus muscle in front of silicone implant or bone graft on the orbital floor. In oculomotor disturbance after orbital floor fracture, the first stage will be to recognize the mechanism of the diplopia by a clinical examination, motility in the nine positions, Hess Charts, binocular vision and field, forced duction, radiography and sometimes coronal computed tomography which also allow visualization of soft tissues densities, including all extraocular muscles. If there is an indication of orbital surgery, it will be done always in first; oculomotor surgery will be done if necessary at the second stage, if there is a permanent diplopia without evolution during six months. The purpose of the treatment is to obtain orthophoria in primary position and in down gaze. A series of cases of fracture of the orbital floor with resulting diplopia are described. The method, the time, and the indications of orbital or oculomotor surgery are discussed according the variety of cases.

Adult↗