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Orbital fractures secondary to blunt trauma, and their complications, have been the subject of numerous reports, with little mention of an association with severe orbital infection. Conversely, studies of severe (postseptal) orbital infections rarely make reference to orbital fractures as being a significant pathogenetic factor. In a retrospective study of 130 orbital infections, three cases of severe orbital infection were identified as being associated with an orbital fracture, and are thus presented. In the literature, only anecdotal reports and inconclusive studies address this problem, and its possible prevention. The consequences of a pathologic communication between the paranasal sinuses and the orbit secondary to blunt facial trauma are discussed, along with recommendations for prophylactic management.
Dissection deep within the orbit is a cause for concern to surgeons because of the perceived risks of injuring critical structures such as the contents of the superior orbital fissure and the optic nerve. Although "safe distances" (those distances within which it is considered safe to dissect within the orbit) have been described, these are of limited value if the orbit is severely disrupted or is congenitally shallow. In addition, traumatic defects in the orbital floor, in particular, often extend beyond these distances. Reliable landmarks based on the relations between anatomical structures within the orbit, rather than absolute distances, are described that permit safe dissection within the orbit. We present the concept of the deep orbit and describe its relevance to repair of injuries.
PURPOSE: Orbital cholesterol granuloma in a 51-year-old man is described. METHODS: Computed tomography (CT) and magnetic resonance imaging (MRI) were done. RESULTS: Both studies showed a mass in the left orbit, with evidence of orbital roof destruction in the CT scan. On the basis of clinical and imaging findings, a diagnosis was made of malignant orbital tumor with destruction of the lateral orbital roof. Surgical exploration revealed a thickly encapsulated mass densely adherent to the left superior orbital bone and periosteum. Although the dura mater was intact, bone destruction in the lateral orbital roof was seen. The entire mass was successfully excised and histopathological evaluation was performed. Histopathology showed numerous inflammatory cells, blood degradation products, and cholesterol clefts. The absence of epithelial elements led to the diagnosis of cholesterol granuloma. CONCLUSIONS: Care must be taken to differentiate cholesterol granuloma from malignant orbital tumor. CT scan and MRI imaging seem well-suited to detecting the characteristic findings of cholesterol granuloma.
Introduction: In recent years a new perforated PDS (poly-p-dioxanon) foil (0.15 mm) has become available and has not yet been proven to be successful in reconstruction of the orbital floor after blow-out-fractures in randomized studies. The main aim of this clinical trial is to compare this new PDS foil with titanium dynamic mesh (0.3 mm) (TD), which is well established in reconstruction of the orbital floor. Patients and Methods: In a prospective multicentre randomized trial, conducted between 1997 and 1998, out of 42 patients with fractures of the orbital floor, 28 patients needing material for reconstruction were randomized to receive either PDS foil or TD. In a comprehensive preoperative and postoperative protocol patients were monitored by the surgeon, radiologist and ophthalmologist with a postoperative follow-up of least 6 months. Results: Maximum defects of the orbital floor were comparable in both groups (PDS group: 13.3 mm, TD group: 13.9 mm). In both groups the surgical procedure was well tolerated, and functional and cosmetic results were evaluated as satisfactory by all patients. Ophthalmological evaluation, performed up to 6 months postoperatively, revealed double vision or vertical strabismus in nine patients (five PDS group, four titanium group). This was not confirmed subjectively in each single patient. Also ex- or enophthalmos, registered in seven patients of the PDS and four of the TD group (mainly +/-1 mm) were not considered as relevant by the patients. Conclusion: The new 0.15 mm perforated PDS foil was comparable to 0.3 mm titanium mesh concerning functional and cosmetic outcome. Obviously, persisting ophthalmometric disorders were compensated very well in both groups. PDS foil is felt to be the preferred material since it is bioresorbable and more convenient to handle. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.
BACKGROUND: Pseudotumors of the orbit comprise a group of idiopathic inflammatory processes and are, except for endocrine orbitopathy, the most common reason for exophthalmos in adults. Orbital pseudotumors, also called idiopathic orbital inflammatory syndrome (IOIS), can be determined from orbital involvement in systemic fibrosing diseases. Finding the correct diagnosis can be challenging. Due to the topographic relations of the orbit to neighbouring structures, a multidisciplinary cooperation is highly recommended. CASE REPORT: We report a case of a 42-year-old woman with unilateral exophthalmos. Additionally we found impaired motility of the affected bulbus, ptosis and reduction of visual acuity. Orbital MR imaging demonstrated dense fibrotic masses filling the whole orbita including the extraocular muscles as well as the optic nerve. Tissue specimens were extracted while performing orbital decompression via a lateral orbitotomy. Histological examination revealed a lymphatic infiltration and fibrotically destroyed tissue containing the lacrimal gland. After surgical decompression, oral steroid therapy and immunotherapy, a recovery of the visual loss could be seen. CONCLUSIONS: Intraorbital fibrosclerosing pseudotumors often require a difficult long-term treatment. Therapeutic options are steroid therapy, immunotherapy, radiotherapy and surgery. The diagnostic steps include blood tests, ultrasound, CT and/or MRI as well as histological differentiation. Solid tumors and orbital involvement in diseases of the hematopoetic system have to be excluded. Since intraorbital fibrosis can be accompanied by manifestations in various other organs, a complete investigation of the body and thorough follow up are crucial.
Although many problems may present with unilateral proptosis, a careful clinical investigation can narrow the differential diagnosis to those problems which can be treated best by the neurosurgeon. The primary indication for transcranial exploration is when the pathological process is found to involve both the orbit and the cranial cavity as in all cases of optic nerve glioma, orbital meningioma, encephalocele, and some mucoceles, hemangiomas, aneurysmal bone cysts, and ossifying fibromas. Transcranial exploration may also be indicated for some tumors which crowd the orbital apex, such as, neurofibromas and osteomas; tumors in this location can be more widely exposed and safely dealt with by this route. A prime objective in these cases, however, must be preservation of function with a good cosmetic result. It is of equal importance to be aware that many conditions producing exophthalmos can be cured by direct orbital exploration, radiotherapy, or medical management. Malignant orbital tumors should never be exposed to the cranial cavity by transcranial exploration, whereas, radical exenteration may be curative in some carefully studied cases. Accuracy in clinical diagnosis and the proper selection of treatment modality for conditions in the orbit requires a clear understanding of this regional anatomy. I hope that this brief review of the pertinent microsurgical anatomy of the orbital apical region has helped to substantiate a strong neurosurgical claim to all primary optic nerve tumors; and, incidentally, I hope it provides an explanation for why I sent so many other patients back to Dr. Algernon Reese with the recommendation that transcranial surgery did not seem indicated. The success of this attitude may be attested to by the fact that we performed no unnecessary craniotomies nor did we pass by problems which would have best been treated by transcranial orbital exploration.
BACKGROUND: Hyperaesthesia involving the infra-orbital nerve is rarely associated with orbital floor fracture. METHODS: An 11-year-old boy and a 34-year-old man had persistent and severe hyperaesthesia in the distribution of the infra-orbital nerve 12 and 26 months, respectively, after blunt orbital trauma. RESULTS: Surgical decompression of the infra-orbital nerve resulted in rapid and complete resolution of the hyperaesthesia in both cases. CONCLUSION: Persistent hyperaesthesia of the infra-orbital nerve is another indication for exploration of the orbital floor following blunt orbital trauma.
In cases of malignant diseases situated within the orbit and threaten to extend beyond it, removal of the orbit and periorbital contents may be indicated, followed by adjuvant chemotherapy or irradiation. An effective radiotherapy device for treatment of residual or suspicious cancer in the enucleated orbit consists of an external-beam radiation source (60Co) and an intraoperatively fitted mould as a guide for the flexible afterloading tubes using a 192Ir source. Considering the physical dose distribution and the local situation, this therapy permits a high dose with homogeneous dose distribution to the target area of the orbit but also allows significant dose reduction to adjunctive critical structures. Four patients with different orbital malignancies were treated by means of a combination of percutaneous radiotherapy with afterloading brachytherapy following orbital exenteration. The individual mould of the orbital cavity is modeled at the end of the operation. The technique of radiotherapy, dose distribution, and follow-up of the disease are demonstrated. Orbital malignancies with an extremely poor prognosis may profit from the application of this combined radiotherapy to avoid supraradical surgical intervention.
We examined two patients with acute orbital myositis associated with orbital hemorrhage and eyelid ecchymosis. Both patients were young women (aged 22 and 30 years) who had painful proptosis, diplopia, and computed tomographic evidence of single extraocular muscle involvement with spillover of inflammatory edema into the adjacent orbital fat. Patient 1 showed contralateral preseptal eyelid inflammation and did not suffer an orbital hemorrhage until after an episode of vomiting. In Patient 2, the diagnosis of occult orbital varix was initially considered but an orbital exploration and a biopsy specimen showed no vascular anomaly. Both patients were treated successfully with high-dose systemic corticosteroids. Some cases of idiopathic orbital inflammation may be related to preexisting vascular anomalies or orbital phlebitis.
PURPOSE: We evaluated the results of the 2-wall and 3-wall orbital decompression in patients with Graves' disease. PATIENTS AND METHODS: In this study, we present a consecutive series of 12 patients (18 orbits) who were submitted to orbital decompression by endoscopic transnasal medial wall combined with transantral inferior wall approach and 7 patients (8 orbits) who were submitted to orbital decompression by endoscopic transnasal medial wall, transantral inferior wall combined with transcutaneous lateral wall approach. The degree of exophthalmos was evaluated with the Hertel exophthalmometer preoperatively and postoperatively in the 24th hour, and first, third, and ninth months. RESULTS: At the end of the third month, the exophthalmos decreased by a mean of 4.38 mm (range, 3 to 7 mm) with the 2-wall decompression and 7.75 mm (range, 5 to 12 mm) with the 3-wall decompression. Visual acuity maintained or improved during the follow-up period. Ocular motility disturbance occurred in 1 patient after 2-wall decompression and in 1 patient after 3-wall orbital decompression. Postoperatively, new-onset diplopia was seen in only 1 patient after 2-wall orbital decompression. CONCLUSION: The 3-wall (endoscopic transnasal medial wall, transantral inferior wall combined with transcutaneous lateral wall) approach is as safe as the 2-wall approach. Proptosis reduction is much better with the 3-wall orbital decompression.
BACKGROUND: Osteoblastoma is an uncommon benign osteogenic neoplasm that rarely involves the orbit. Intracranial and intraorbital extension causing neurologic and ophthalmologic symptoms and signs is very unusual. We report the case of an osteoblastoma of the orbital cavity with ethmoidal and anterior cranial fossa extension presenting as unilateral proptosis. Manifestations and management of this rare fronto-orbital lesion are discussed, and the relevant literature is reviewed. CASE DESCRIPTION: This 22-year-old man experienced a 3-month history of progressive left proptosis without neurologic symptoms. Computed tomography and magnetic resonance imaging scans demonstrated a bony mass involving the roof of the left orbit and extending laterally to the adjacent ethmoid cells and upward to the lower part of the homolateral frontal convexity without parenchymal abnormality. A presumptive diagnosis of osteoma was considered. A left fronto-orbital craniotomy was performed. At surgery, the tumor was well circumscribed by a sclerotic margin. It was granular with bony spicules, destroying the orbital roof and involving the orbital cavity, ethmoidal cells, and anterior cranial fossa. The lesion was totally removed, and the anterior cranial base reconstructed. The histologic features were typical of benign osteoblastoma. After a follow-up period of 12 months, the patient has remained well without evidence of recurrence. CONCLUSION: Osteoblastoma should be considered in the differential diagnosis with other fronto-orbital bone-forming lesions. Although generally regarded as benign, a complete resection is recommended to prevent the possibility of postoperative recurrence and malignant transformation. Twelve previously reported cases were also reviewed.
Infections of the orbit in children usually present as a complication of sinusitis and may result in blindness or even death. Orbital cellulitis (OC) and subperiosteal abscess (SPA) represent different pathologies within the spectrum of orbital infections. The differentiation between OC and SPA is important, since it implies two different therapeutic modalities. While SPA is usually treated by incision and drainage and parenteral antibiotics, OC may be treated with antibiotics alone. Contrast enhanced CT scan is commonly used in the diagnosis of orbital infections, but does not always prove accurate in differentiating between these two conditions. MRI is superior to CT in the resolution of soft tissue pathology and may be more precise in such situations, but is less available imaging tool outside North America and Europe. There have been a few reports in the early 1980's on the use of standardized orbital ultrasound (SOU) in these two conditions. We have used SOU in seven children with sinus induced orbital infections--four with SPA and three with OC. We reviewed our experience in these patients and compared the imaging characteristics of OC and SPA on SOU with those of conventional imaging modalities, used in orbital infections. In four of the cases, CT scan was inconclusive, while SUO was diagnostic. In this preliminary report, we conclude that SOU may be useful in the diagnosis of orbital infections.
AIMS: To describe the value of monoclonal antibodies in the differential diagnosis of orbital lymphoproliferative disorders. METHODS: A total of 200 sequential cases of malignant lymphoma diagnosed at St Bartholomew's Hospital as part of the ocular lymphoma service at Moorfields Eye Hospital and the Institute of Ophthalmology have been examined. Cases were acquired between January 1998 and June 2005. Each case had detailed immunophenotypic analysis using a panel of monoclonal antibodies and was classified using the WHO classification of lymphoma. These cases are discussed in relation to earlier studies of orbital lymphoma reported by our group. RESULTS: Lymphomas fell into three main categories. Extranodal marginal zone lymphoma was the largest group with 151 cases, arising within the orbital soft tissue, conjunctiva and lacrimal gland. Cases arising in the conjunctiva and lacrimal gland showed a higher female predominance than those arising within the deeper soft tissue. A small number of cases were associated with organ specific autoimmunity, including thyroid eye disease complicating Graves' disease. Follicular lymphoma and diffuse large B-cell lymphoma formed the next two groups, occurring with equal frequency. Many of the follicular lymphomas had evidence of disseminated disease on completion of staging. A miscellaneous group of T-cell and B-cell lymphomas formed a minority of cases during the study period. CONCLUSION: Extranodal marginal zone lymphoma is the most frequent type of primary orbital and orbital adnexal lymphoma. Its major differential diagnosis is with orbital lymphoid hyperplasia, chronic dacryoadenitis, and follicular conjunctivitis. Systemic types of lymphoma may present within the orbit or involve the orbit secondarily.
Objectives: Acute pansinusitis is rarely seen in the maxillofacial surgery field, but often occurs in combination with orbital and intracranial involvement. Clinically this entity is of great importance, since it represents a severe disease with possibly disastrous consequences. Patients: Aetiology, diagnosis and therapy of acute pansinusitis and its complications were analysed in 36 patients treated surgically from 1987 to 1996. Results: Eighteen patients were aged between 3 and 21-years-old. Only eight suffered from pure pansinusitis, and three of an isolated purulent orbital infection. Of these 25 patients 20 had (pan-)sinusitis with orbital, three with intracranial, and two with both orbital and intracranial complications. Intracranial involvement included meningitis, empyema and brain abscess. Aetiology was rhinogenic in 26, odontogenic in six patients, and traumatic in two cases. Radiological work-up included conventional radiographs and CT in most cases, MRI was only used with special indications. Microbiological examination detected single or multiple species of micro-organisms with equal frequency. If multiple species were found, infection was mostly aerobic/anaerobic in combination. Conclusion: These purulent processes, frequently seen in young patients, require immediate surgical intervention and drainage with elimination of the cause of the disease if possible. Cooperation with other specialities is essential depending on the spread of the disease. In spite of the threatening acute symptoms, severe courses of disease or permanent defects should be avoidable. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.
Introduction: A combined extra-intracranial access for the operative exploration of tumours of the anterior and middle skull base is indicated when the tumour extends intracranially and simultaneously into the nasal cavity, the paranasal sinuses or the orbit. Methods: Two standardized modifications of the fronto-orbital osteotomy, the fronto-orbito-nasal and the fronto-orbito-zygomatic osteotomy, allow safe removal of skull base tumours in these locations. In extensive skull base tumours, a modified bilateral fronto-orbital-zygomatic osteotomy can be used. Results: Between February 1993 and July 2000 skull base tumours in 111 patients were resected using the presented methods. The most frequent tumour type was meningioma in 29 cases. Complications were encountered in 13 cases (11.7%). Conclusion: The advantages over other approaches are good extra- and intracranial overview and minimal cerebral trauma. Additional transfacial incisions are not usually necessary. Exact repositioning of the fronto-orbital segments leads to optimal aesthetic results. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.
PURPOSE: To report a case of a respiratory epithelial-lined, air-filled orbital cyst as a late complication of orbital fracture repair. METHOD: Case report. RESULTS: Recurrent episodes of diplopia and hyperophthalmia developed secondary to pneumatic inflation of a respiratory epithelial-lined orbital cyst 6 months after orbital fracture repair. This cyst remained in communication with an ethmoidal air cell and became inflated during pressurization of the ethmoid sinus. Removal of the cyst and orbital implant was curative. CONCLUSION: Air-filled, respiratory epithelial-lined orbital cyst is a rare cause of episodic diplopia and globe displacement after orbital trauma.