Temporal fossa orbital decompression for treatment of disfiguring thyroid-related orbitopathy.

OBJECTIVE: To describe a technique for treating disfiguring thyroid-related orbitopathy by bony decompression into the temporal fossa and to analyze results. DESIGN: Retrospective, noncomparative case series with description of a surgical technique. PARTICIPANTS: Thirty-three consecutive patients with disfiguring thyroid-related orbitopathy undergoing decompression into the temporal fossa with the described technique. INTERVENTION: Reduction in exophthalmos by removal of the lateral orbital wall and the greater sphenoid wing using an eyelid crease approach. MAIN OUTCOME MEASURES: Amount of reduction in exophthalmos after surgery and incidence of induced postoperative diplopia. RESULTS: The average reduction in exophthalmos was 4.51 mm (range, 3-6 mm; standard deviation, +/-0.95 mm). New-onset postoperative diplopia was observed in 1 patient. CONCLUSIONS: Bony decompression of the orbit into the temporal fossa via an eyelid crease approach is an effective treatment for disfigurement in patients with thyroid-related orbitopathy and no preoperative diplopia.

Devastating complications from alcohol cauterization of recurrent Rathke cleft cyst. Case report.

Rathke cleft cysts are commonly found on autopsy but are seldom symptomatic. Conventional treatment of these lesions consists of transsphenoidal drainage with partial excision of the cyst, and recurrence is rare. Alternatively, the instillation of absolute alcohol into the cyst has been described in several reports, with no complications. The authors report on a woman with Rathke cleft cyst that recurred three times after the initial treatment; the lesion was treated with alcohol cauterization on the final recurrence with devastating complications. This 51-year-old woman presented in 1992 with headaches and visual disturbances. Admission magnetic resonance imaging revealed a sellar/suprasellar lesion that was treated with conventional surgery and was subsequently confirmed to be a Rathke cleft cyst. The patient again presented with recurrence of the cyst at 22, 26, and 31 months after the initial presentation. On the final recurrence the cyst was treated with alcohol cauterization. Postoperatively, the patient awoke blind and suffered a seizure from leakage of the alcohol. The patient remains completely blind in both eyes and is also anosmic and has left lid ptosis and exotropia, which signify damage to the first through third cranial nerves. Rathke cleft cysts have been known to recur after primary surgery; however, this is the first report of a single cyst recurring three times despite conventional surgical treatment. Additionally, this is the first report in which devastating complications from alcohol cauterization of the cyst have been described. The authors therefore advocate caution when attempting alcohol cauterization and advise that meticulous care be taken to ensure the patency of the cyst.

Death associated with an indwelling orbital catheter.

We report a case of a 38-year-old woman who underwent revision of an orbital implant. A flexible indwelling orbital catheter was placed for postoperative anesthesia. Marcaine, administered to the patient through the 5.25-inch catheter while the patient was at home, led to respiratory arrest. After unsuccessful resuscitation, the patient died. At autopsy, it was noted that the catheter passed through the superior orbital fissure, with evidence of injection of marcaine in the subarachnoid space. This patient had signs and symptoms of Stickler syndrome. This leads us to believe that deficiencies in collagen II led to a weakness of the connective tissue surrounding the superior orbital fissure, leading to facilitated passage of the catheter into the subarachnoid space. This may be the first report of this type of outcome when using indwelling catheters for ophthalmic surgery. We recommend that placement of orbital indwelling catheters be performed in a controlled hospital setting.