Abordagem cirúrgica de fratura blow-out através de acesso transconjuntival: relato de caso / Surgical approach to blow-out fracture through transconjunctival access: case report

Introdução: a região orbitária é bastante suscetível a fraturas, devido a sua posição exposta e a ossos frágeis. As fraturas do tipo blow-out caracterizam-se pela fratura do assoalho orbitário com ou sem herniação de conteúdo para o seio maxilar, gerando consequências funcionais e estéticas. Relato do caso: paciente do sexo feminino, 48 anos de idade, vítima de queda da própria altura, compareceu ao Hospital Geral do Estado da Bahia com queixa de diplopia, apresentando fratura de assoalho de órbita direita. Foi programada uma abordagem transconjuntival e instalação de tela de titânio para reconstrução. Na alta hospitalar, a paciente negou diplopia, não apresentando prejuízos funcionais ou estéticos. Conclusão: o acesso transconjuntival possibilita uma adequada exposição do assoalho de órbita, para colocação de telas, deixando uma cicatriz imperceptível na conjuntiva. Apesar das vantagens, este acesso cirúrgico apresenta maior complexidade técnica, sendo pouco realizado pelos cirurgiões

Introduction: the orbital region is very susceptible to fractures due to its exposed position and fragile bones. Blow-out fractures are characterized by fractures of the orbital floor with or without herniation of contents to the maxillary sinus, generating functional and aesthetic consequences. Case report: a 48-year-old female patient, victim of a fall from her height, presented to the General Hospital of the State of Bahia complaining of diplopia, presenting with a fracture of the floor of the right orbit. A transconjunctival approach and installation of titanium mesh for reconstruction were scheduled. At hospital discharge, the patient denied diplopia, with no functional or aesthetic impairments. Conclusion: the transconjunctival approach allows adequate exposure of the orbital floor for mesh placement, leaving an imperceptible scar on the conjunctiva. Despite the advantages, this surgical approach presents greater technical complexity and is rarely performed by surgeons.

Role of apparent diffusion map in the evaluation of retinoblastoma

ABSTRACT Purpose: This study aimed to analyze the association between magnetic resonance imaging apparent diffusion coefficient map value and histopathological differentiation in patients who underwent eye enucleation due to retinoblastomas. Methods: An observational chart review study of patients with retinoblastoma that had histopathology of the lesion and orbit magnetic resonance imaging with apparent diffusion coefficient analysis at Hospital de Clínicas de Porto Alegre between November 2013 and November 2016 was performed. The histopathology was reviewed after enucleation. To analyze the difference in apparent diffusion coefficient values between the two major histopathological prognostic groups, Student's t-test was used for the two groups. All statistical analyses were performed using SPSS version 19.0 for Microsoft Windows (SPSS, Inc., Chicago, IL, USA). Our institutional review board approved this retrospective study without obtaining informed consent. Results: Thirteen children were evaluated, and only eight underwent eye enucleation and were included in the analysis. The others were treated with photocoagulation, embolization, radiotherapy, and chemotherapy and were excluded due to the lack of histopathological results. When compared with histopathology, magnetic resonance imaging demonstrated 100% accuracy in retinoblastoma diagnosis. Optic nerve invasion detection on magnetic resonance imaging showed a 66.6% sensitivity and 80.0% specificity. Positive and negative predictive values were 66.6% and 80.0%, respectively, with an accuracy of 75%. In addition, the mean apparent diffusion coefficient of the eight eyes was 0.615 × 103 mm2/s. The mean apparent diffusion coefficient value of poorly or undifferentiated retinoblastoma and differentiated tumors were 0.520 × 103 mm2/s and 0.774 × 103 mm2/s, respectively. Conclusion: This study revealed that magnetic resonance imaging is useful in the diagnosis of retinoblastoma and detection of optic nerve infiltration, with a sensitivity of 66.6% and specificity of 80%. Our results also showed lower apparent diffusion coefficient values in poorly differentiated retinoblastomas with a mean of 0.520 × 103 mm2/s, whereas in well and moderately differentiated, the mean was 0.774 × 103 mm2/s.

Lacrimal gland pleomorphic adenoma: a narrative review / Adenoma pleomórfico de glândula lacrimal: uma revisão narrativa

ABSTRACT We present a literature review of 57 publications describing this pathology, published from the year 2012. In all these studies patients were reported to depict a slow-growing, motionless mass, which is painless at most times. All cases were managed by total excision, except for one report where adjuvant radiotherapy was applied. Among the several therapeutic strategies, the total tumor resection, preserving the tumor pseudocapsule intact, appears to be a consensus in treating the disease efficiently. Furthermore, fine-needle aspiration biopsy, including the assessment of genetic alterations, has proved to be a valuable tool in the diagnosis of challenging cases. Our literature survey also suggests that an incisional biopsy before the surgery may lead to the pseudocapsule disruption, thus considerably increasing the chances of adenoma recurrence, enabling its malignization. At present, genetics studies indicate that the molecular aberrations involved in the adenoma are similar to those represented in the salivary gland tumor pathogenesis. Further, in the recurrent cases, the pathology becomes difficult to treat and multiple surgeries may be required, occasionally, leading to radical surgery treatment.

RESUMO Uma revisão narrativa da literatura de 57 publicações que descrevem esta patologia, publicada a partir de 2012. Os pacientes têm uma massa de crescimento lento e imóvel, que na maioria das vezes é indolor. Todos os casos foram tratados por excisão total, com exceção de um relatório de radioterapia adjuvante. Entre as estratégias terapêuticas encontradas, a ressecção total do tumor, preservando a pseudocápsula tumoral intacta, parece ser um consenso. Alternativamente, a biópsia por aspiração de agulha fina incluindo a avaliação de alterações genéticas pode representar uma ferramenta valiosa nos casos diagnósticos desafiadores. Uma biópsia incisional antes da cirurgia não é recomendada, pois a ruptura da pseudocápsula aumenta consideravelmente a recorrência do adenoma, permitindo até mesmo sua malignização. Com relação à genética, estudos atuais indicam que as aberrações moleculares envolvidas no adenoma são semelhantes às da patogênese do tumor da glândula salivar. Para casos de recorrência, a patologia torna-se difícil de tratar e múltiplas cirurgias podem ser necessárias, às vezes levando a um tratamento cirúrgico radical.

Trauma ocular pediátrico y repercusiones visuales. Revisión sistemática

Introducción: En 2016, aproximadamente 55 millones de pacientes en todo el mundo sufrieron lesiones oculares. La carga de sufrimiento tras las lesiones oculares es muy alta, sobre todo por las consecuencias de estas lesiones, que son en gran parte responsables de la ceguera monocular. Objetivo: Sistematizar los referentes teóricos sobre el trauma ocular pediátrico y su impacto en los resultados visuales. Método: Se realizó una revisión sistemática del trauma ocular pediátrico y su impacto en los resultados visuales, basada en la literatura publicada en PubMed, Trip Medical Database y British Medical Journal en el periodo 2018-2022. El nivel de evidencia se evaluó mediante la escala de Oxford y se determinó el sexo, la edad, el tipo de lesión ocular, lugar de ocurrencia del trauma ocular y secuelas postlesión reportadas. Resultados: La evidencia recolectada fue principalmente de estudios retrospectivos de corte transversal que corresponde a nivel de evidencia según escala de Oxford 2b. El trauma ocular fue más común en niños (77 %) que en niñas (23 %) y la edad promedio fue de 10,5±1,96 años. Hubo mayor incidencia de trauma ocular cerrado (56%). Los lugares fuera del domicilio fueron los más reportados (64%). En lo que refiere a las consecuencias de los traumatismos oculares en edades pediátricas se pudo observar que la mayor frecuencia reportada fue la no presencia de secuelas (52,16 %), contra el 48,47 % de los repostados con secuelas. Conclusiones: Existen consideraciones básicas que se pueden comunicar al paciente que pueden prevenir efectos graves o permanentes en la visión. El examen oftalmológico profesional permite una evaluación temprana y evita complicaciones por subestimar la lesión ocular aguda.

Introduction: In 2016, approximately 55 million patients worldwide suffered eye injuries. The burden of suffering after eye injuries is very high, especially due to the consequences of these injuries, which are largely responsible for monocular blindness. Objective: To systematize the theoretical references on pediatric ocular trauma and its impact on visual results. Method: A systematic review of pediatric ocular trauma and its impact on visual outcomes was carried out, based on the literature published in PubMed, Trip Medical Database and British Medical Journal in the period 2018-2022. The level of evidence found was evaluated using the Oxford scale and the sex, age, type of ocular injury, place of occurrence of the ocular trauma and reported post-injury sequelae were determined. Results: The evidence collected was mainly from retrospective cross-sectional studies that correspond to the level of evidence according to the Oxford 2b scale. Ocular trauma was more common in boys (77%) than in girls (23%) and the average age was 10.5±1.96 years. There was a higher incidence of blunt ocular trauma (56%). Places outside the home were the most reported (64%). Regarding the consequences of ocular trauma in pediatric ages, it could be observed that the highest frequency reported was the absence of sequelae (52.16%), compared to 48.47% of those refueled with sequelae. Conclusions: There are basic considerations that can be communicated to the patient that can prevent serious or permanent effects on vision. Professional ophthalmological examination allows early evaluation and avoids complications due to underestimation of acute eye injury.

Introdução: Em 2016, aproximadamente 55 milhões de pacientes em todo o mundo sofreram lesões oculares. A carga de sofrimento após lesões oculares é muito elevada, especialmente devido às consequências destas lesões, que são em grande parte responsáveis pela cegueira monocular. Objetivo: Sistematizar os referenciais teóricos sobre trauma ocular pediátrico e seu impacto nos resultados visuais. Método: Foi realizada uma revisão sistemática sobre trauma ocular pediátrico e seu impacto nos resultados visuais, com base na literatura publicada no PubMed, Trip Medical Database e British Medical Journal no período 2018-2022. O nível de evidência encontrado foi avaliado pela escala de Oxford e foram determinados sexo, idade, tipo de lesão ocular, local de ocorrência do trauma ocular e sequelas pós-lesão relatadas. Resultados: As evidências coletadas foram principalmente provenientes de estudos transversais retrospectivos que correspondem ao nível de evidência da escala Oxford 2b. O trauma ocular foi mais comum em meninos (77%) do que em meninas (23%) e a idade média foi de 10,5±1,96 anos. Houve maior incidência de trauma ocular contuso (56%). Os locais fora de casa foram os mais relatados (64%). Quanto às consequências do trauma ocular em idade pediátrica, pôde-se observar que a maior frequência relatada foi a ausência de sequelas (52,16%), contra 48,47% dos reabastecidos com sequelas. Conclusões: Existem considerações básicas que podem ser comunicadas ao paciente e que podem prevenir efeitos graves ou permanentes na visão. O exame oftalmológico profissional permite avaliação precoce e evita complicações por subestimação da lesão ocular aguda.

Treatment of orbital lymphatic malformation with oral sirolimus: a case report / Malformação linfática orbital tratada com sirolimo oral: relato de caso

ABSTRACT It is estimated that lymphatic malformations in children account for 6% of all benign vascular malformations. New medical therapies have been developed for the management of lymphatic orbital disease. The purpose of this article was to describe a clinical case of orbital venolymphatic malformation in a 10-year-old boy, causing proptosis and palpebral edema. The lesion was initially treated with local sclerotherapy. However, the lesion relapsed, and was successfully treated with oral sirolimus. Prospective studies are warranted to determine the appropriate dose and extend the indications of sirolimus in these patients.

RESUMO A incidência de malformações linfáticas em crianças é estimada em 6% de todas as malformações vasculares benignas. Têm sido desenvolvidos novos tratamento para doenças linfáticas orbitárias. Nosso objetivo é descrever um caso clínico de malformação venolinfática orbitária em um menino de 10 anos de idade, causando proptose e edema palpebral. A lesão foi tratada inicialmente com escleroterapia local. No entanto, a lesão teve recidiva e foi tratada com sucesso com sirolimo oral. Ainda são necessários estudos prospectivos para estabelecer a dose apropriada e a duração do tratamento com sirolimo nesses pacientes.

La lipotransferencia como complemento seguro en la reconstrucción orbitaria / Lipotransfer as a Safe Adjunct in Orbital Reconstruction

Los defectos periorbitarios independientemente de su causa, suelen relacionarse con los servicios médicos oftalmológicos; sin embargo, en ocasiones requieren de la intervención del cirujano plástico. La pérdida de un globo ocular tiene repercusiones funcionales, estéticas y psicológicas en las personas que la sufren. Puede exponer asimetrías de los tejidos subyacentes más profundos que mejoran con el lipoinjerto al devolver los contornos de los tejidos blandos alrededor del ojo. El objetivo de presentar esta serie de casos es mostrar la utilidad del lipoinjerto autólogo asistido con células madre del tejido adiposo como complemento de la reconstrucción de la órbita. Se presentan tres casos que acudieron al servicio de Cirugía Plástica del Hospital Clínico Quirúrgico Hermanos Ameijeiras remitidas desde el servicio de Cirugía Plástica Ocular del Instituto Cubano de Oftalmología Ramón Pando Ferrer por atrofia de la grasa periorbitaria por cirugía de cavidades anoftálmicas. Se verificó que cumplieran con los criterios de selección de pacientes para cirugía plástica y se citaron para tratamiento quirúrgico con técnica de lipotransferencia asistida con células madre. La lipotransferencia asistida con células madre derivadas del tejido adiposo constituye un complemento terapéutico seguro y necesario para obtener mejores resultados estéticos en la reconstrucción de la órbita. El éxito final está en lograr una buena apariencia de los párpados, con la capacidad para retener una prótesis ocular que permita el crecimiento adecuado del hueso facial y mejorar el aspecto estético(AU)

Periorbital defects, regardless of their etiology, are usually related to ophthalmologic medical services; however, sometimes they require the intervention of the plastic surgeon. The loss of an eyeball has functional, aesthetic and psychological repercussions in those who suffer it. It can expose deeper underlying tissue asymmetries that improve with lipografting by restoring the soft tissue contours around the eye. The purpose of presenting this case series is to show the utility of autologous adipose tissue stem cell-assisted lipograft as an adjunct to orbital reconstruction. Three cases are presented that came to the Plastic Surgery Service of the Hospital Clínico Quirúrgico Hermanos Ameijeiras referred from the Ocular Plastic Surgery Service of the Instituto Cubano de Oftalmología Ramón Pando Ferrer for atrophy of the periorbital fat due to surgery of anophthalmic cavities. It was verified that they met the criteria for selection of patients for plastic surgery and they were scheduled for surgical treatment with stem cell-assisted lipotransfer technique. Stem cell assisted lipotransfer is a safe and necessary therapeutic complement to obtain better aesthetic results in the reconstruction of the orbit. The ultimate success lies in achieving a good appearance of the eyelids, with the ability to retain an ocular prosthesis that allows adequate growth of the facial bone and improve the aesthetic appearance(AU)

Comparación Placas de Titanio vs. Placas Reabsorbibles en Fracturas de Orbita: Revisión de literatura / Comparison of Titanium Plates vs. Resorbable Plates in Orbital Fractures: Literature Review

RESUMEN Introducción: Los tratamientos para fracturas de órbita se basan en la corrección del defecto de las lesiones orbitarias de tipo blow in y blow out (o de estallido), mediante diversas placas y mallas biocompatibles con el organismo, dándose una cicatrización de primera generación evitando un callo óseo y una fijación más rígida. Para el diagnóstico de este tipo de lesiones tenemos inflamación periorbitaria, enoftalmos, diplopía, equimosis, hemorragia subconjuntival. Existen diversos materiales reconstructivos siendo estos compuestos por distintas materias primas, como son los aloplásticos y autógenos; donde encontramos varios tipos como placas de titanio y las placas reabsorbibles siendo estas las más comunes y usadas actualmente, por su bajo estímulo a reabsorciones óseas y evitando efectos secundarios a largo plazo. Estas placas presentan diversos grados de ductilidad y resistencia. Se informó sobre varias complicaciones según el tipo de placas como es la cicatrización, las cirugías postquirúrgicas en caso de placas de titanio, etc. El objetivo de esta revisión es la evaluación de la eficacia las placas reabsorbibles versus placas de titanio en fracturas de órbita. Materiales y métodos: La investigación es de carácter documental, descriptivo y no experimental. En el cual se emplea una metodología de identificación e inclusión de artículos científicos tipo prisma. Resultados y conclusiones: Se verificaron las ventajas y desventajas tanto de las placas reabsorbibles como las de titanio siendo estas similares en la biocompatibilidad con el organismo humano, así como también varias diferencias como el soporte, fuerzas, resistencia de estas, concluyendo que es debatible el material ideal para tratar fracturas de órbita. Se seleccionaron artículos tomando en cuenta el título y objetivos; considerando estudios comparativos, revisiones sistemáticas, revisiones de literatura, los cuales comprendían criterios con respecto a fracturas de órbita y tratamientos quirúrgicos. La búsqueda arrojó 55 artículos en PubMed, 65 en Google, 4 en Scielo y 29 en Science direct, de los cuales se excluyeron libros, monografías, estudios experimentales, dando como resultado 21 artículos para el desarrollo de esta revisión bibliográfica. Y que fueron leídos y analizados en su totalidad, estudiando los objetivos, metodología y conclusión de cada uno de ellos para la posterior comparación.

ABSTRACT Introduction: Treatments for orbit fractures are based on the correction of the defect of blow in and blow out orbital injuries, by means of various plates and meshes biocompatible with the organism, giving a first-generation healing avoiding a bony callus and a more rigid fixation. For the diagnosis of this type of lesions we have periorbital inflammation, enophthalmos, diplopia, ecchymosis, subconjunctival hemorrhage. There are several reconstructive materials being these composed of different raw materials, such as alloplastic and autogenous, where we find several types such as titanium plates and resorbable plates being these the most common and currently used, for its low stimulus to bone resorption and avoiding long-term side effects. These plates have different degrees of ductility and resistance. Several complications have been reported depending on the type of plates, such as scarring, post-surgical surgeries in the case of titanium plates, etc. The objective of this review is to evaluate the efficacy of resorbable versus titanium plates in orbital fractures. Materials and methods: This research are a documentary, descriptive and non-experimental nature. A prism-type methodology of identification and inclusion of scientific articles was used. Results and conclusions: The advantages and disadvantages of both resorbable and titanium plates were verified, being these similar in biocompatibility with the human organism, as well as several differences such as support, forces, resistance of the same, concluding that it is debatable. The ideal material to treat orbital fractures. Articles were selected considering the title and objectives; considering comparative studies, systematic reviews, literature reviews, which included criteria regarding orbital fractures and surgical treatments. The search yielded 55 articles in PubMed, 65 in Google, 4 in Scielo and 29 in Science direct, from which books, monographs, experimental studies were excluded, resulting in 21 articles for the development of this bibliographic review. The 21 articles were read and analyzed in their entirety, studying the objectives, methodology and conclusion of each one of them for subsequent comparison.

Correção secundária de Fratura Blow-Out: relato de caso / Secondary correction of Blow-Out Fracture: case report / Corrección secundaria de Fractura Blow-Out: reporte de caso

Objetivo: Discutir o tratamento cirúrgico secundário de uma fratura de órbita tipo Blow-Out, explorando os desafios e limitações relacionados a este padrão de fratura. Relato de Caso: Paciente sexo masculino, 50 anos, ASA I relatando histórico de agressão física e quatro cirurgias prévias em região orbitária direita. Clinicamente foram observados sinais como enoftalmo, hipoftalmo, encurtamento da pálpebra inferior, dificuldade de oclusão palpebral, entrópio, hiperemia em conjuntiva, além de presença de secreção purulenta, todos em região orbitária à direita. Diante do exposto, uma nova intervenção cirúrgica foi proposta pela Cirurgia e Traumatologia Bucomaxilofacial, na tentativa corrigir alguns problemas listados, além de encaminhamento a outras especialidades. Encontra-se em acompanhamento de um ano, com boa evolução. Conclusão: O tratamento de fraturas orbitárias é um dos mais desafiadores, especialmente quando se trata sequelas. A definição pelo melhor momento para realização destes procedimentos não é um consenso, sendo necessário uma avaliação clínica criteriosa. Apesar da utilização dos enxertos autógenos ser amplamente recomendada, os materiais aloplásticos vem se tornando a primeira escolha para tratamento das correções secundárias pelas diversas vantagens oferecidas.

Aim: To discuss the secondary surgical treatment of a Blow-Out orbit fracture, exploring the challenges and limitations related to this fracture pattern. Case report: Male patient, 50 years old, ASA I reporting a history of physical aggression and four previous surgeries in the right orbital region. Clinically, enophthalmos, hypophthalmos, shortening of the lower eyelid, difficulty in eyelid occlusion, entropion, hyperemia in the conjunctiva were observed, in addition to the presence of purulent secretion, all in the right orbit. In view of the above, a new surgical intervention was proposed by Buccomaxillofacial Surgery and Traumatology, in an attempt to correct some listed problems, in addition to referral to other specialties. He is being followed up for one year, with good progress. Conclusion: The treatment of orbital fractures is one of the most challenging, especially when dealing with sequelae. The definition of the best time to perform these procedures is not a consensus, requiring a careful clinical evaluation. Although the use of autogenous grafts is widely recommended, alloplastic materials are becoming the first choice for treating secondary corrections due to the several advantages offered.

Objetivo: Discutir el tratamiento quirúrgico secundario de una fractura orbitaria Blow-Out, explorando los desafíos y las limitaciones relacionadas con este patrón de fractura. Caso Clínico: Paciente masculino, 50 años, ASA I, que refi ere antecedentes de agresión física y cuatro cirugías previas en región orbitaria derecha. Clínicamente se observaron signos como enoftalmos, hipoftalmos, acortamiento del párpado inferior, difi cultad en la oclusión palpebral, entropión, hiperemia en la conjuntiva, además de la presencia de secreción purulenta, todos en la región orbitaria derecha. Ante lo anterior, se propuso una nueva intervención quirúrgica desde Cirugía Oral y Maxilofacial y Traumatología, en un intento de corregir algunos de los problemas enumerados, además de la derivación a otras especialidades. Está en seguimiento desde hace un año, con buena evolución. Conclusión: El tratamiento de las fracturas de órbita es uno de los más desafi antes, especialmente cuando se trata de secuelas. La defi nición del mejor momento para realizar estos procedimientos no es un consenso, lo que requiere una evaluación clínica cuidadosa. A pesar de que se recomienda ampliamente el uso de injertos autógenos, los materiales aloplásticos se han convertido en la primera opción para el tratamiento de correcciones secundarias debido a las múltiples ventajas que ofrecen.

Revisiting the orbital complications of acute rhinosinusitis

Abstract Objective: The present study revisited three classification systems of orbital complications of acute rhinosinusitis (ARS) (Chandler, Mortimore & Wormald, and Velasco e Cruz & Anselmo-Lima) and observed which of them presented the best clinical applicability. Methods: Clinical data and CT scan findings of patients with orbital infection were retrospectively collected. To compare the three classification systems, we revised and graded all CT images accordingly, and divided the patients into four groups: Eyelid cellulitis (EC), orbital cellulitis (OC), subperiosteal abscess (SA), and orbital abscess (OA). The groups were compared regarding the presence of sinus opacification, the need for hospitalization and/or surgical treatment, and the presence of further complications/sequelae. Results: 143 patients were included. The median number of sinuses involved in patients in the OC, SA, and OA groups was 2.0. ARS was rarely associated with signs of EC (present in both Chandler's and Mortimore & Wormald's classifications. The hospitalization rate was significantly lower in the EC group compared to the other three groups. Surgery was performed in all cases in the OA group, in 58.1% in the SA group, 19.4% in the OC group, and 12.5% in the EC group (p-value < 0.0001 ). Complications were present at higher rates in the OA group compared to the other three groups. Conclusions: ARS was rarely associated with Eyelid Cellulitis. The stratification in the other three groups showed to be clinically relevant. Velasco e Cruz & Anselmo-Lima's classification system proved valid, simple, and effective for categorizing orbital complications of ARS. Level of evidence: 3.

Primary orbital yolk sac tumor in an infant: A rare entity

We report a case of pure orbital yolk sac tumor (YST) in an 11-month-old infant, which is a rare entity. The child presented with progressive painless swelling of the right eye and on examination had proptosis, chemosis, and lid edema. Systemic examination was within normal limits. Magnetic resonance imaging (MRI) orbit revealed a lobulated heterogeneously enhancing right retroocular mass extending up to the orbital apex, displacing the optic nerve and eroding the medial orbital wall. Biopsy of the lesion revealed pure YST histology. Serum alpha-fetoprotein (AFP) was markedly raised at 76900 ng/mL. She was started on infant bleomycin etoposide cisplatin (BEP) chemotherapy protocol. There was a good clinical and radiological response. A high index of malignancy is required in young children presenting with orbital proptosis. A multidisciplinary approach and early intervention are essential to save both vision and life.

Venous malformation of the conjunctiva and orbit

A 28-year-old male presented with a large conjunctival lobulated, nonpulsatile, red vascular lesion involving a large part of the temporal quadrant of the left globe. There was no proptosis or globe displacement, but the left eye abduction was limited. T2-weighted magnetic resonance imaging scan of the brain and orbit revealed an extensive contrast-enhancing lobulated lesion in the left half of the face involving the upper lip, cheek, oral cavity, extraconal space of left orbit, and nasal cavity. He underwent surgical excision of the conjunctival lesion with amniotic membrane reconstruction.

Proptosis como presentación inicial de un fibroma osificante etmoidal en edad pediátrica / Proptosis as Initial Presentation of an Ethmoid Ossifying Fibroma in Pediatric Age

El fibroma osificante es un tumor óseo benigno poco común, cuya localización más frecuente son los huesos maxilofaciales, pero su origen en el seno etmoidal es raro. La mayor incidencia se describe entre la segunda y la cuarta décadas de la vida. Se efectuó una revisión en la literatura nacional sobre fibromas osificantes etmoidales con extensión orbitaria, y no se encontraron reportes publicados. Se presenta el caso de una paciente de 10 años de edad que fue remitida a consulta de Oculoplastia por notar protrusión ocular izquierda desde hacía tres meses. Se le realizó ultrasonido, tomografía computarizada y resonancia magnética en los que se evidenció una lesión tumoral de seno etmoidal con compromiso de órbita izquierda que ocasionaba proptosis, con características imagenológicas sugestivas de un probable fibroma osificante. La biopsia endoscópica nasal confirmó el diagnóstico(AU)

Ossifying fibroma is an uncommon benign bone tumor, whose most frequent location is the maxillofacial bones, but its origin in the ethmoid sinus is rare. The highest incidence is described between the second and fourth decades of life. A review of the national literature on ethmoid ossifying fibromas with orbital extension was carried out, and no published reports were found. We present the case of a 10-year old female patient who was referred to Oculoplasty consultation for noticing left ocular protrusion for three months. Ultrasound, computed tomography and magnetic resonance imaging showed a tumor lesion of the ethmoidal sinus with involvement of the left orbit causing proptosis, with imaging characteristics suggestive of a probable ossifying fibroma. Nasal endoscopic biopsy confirmed the diagnosis(AU)

Cranioplastia frontal com enxerto de parede anterior de seio frontal e retalho pericrânio têmporo-parietal: relato de caso / Frontal cranioplasty with bone graft from the anterior wall of the frontal sinus and temporo-parietal pericranium flap: case report

O osso frontal integrante do esqueleto craniano e que integra o terço superior da face, tem papel importante na proteção do conteúdo encefálico. Fazendo parte dessa referência, encontra-se uma cavidade sinusal de dimensões variáveis, o seio frontal. A localização anatômica do seio frontal permite que ele contribua para proteção do lobo frontal agindo como barreira absorvedora de choque, além da fisiologia sinusal. As fraturas craniofaciais podem afetar a parede anterior e/ou posterior, com ou sem envolvimento do ducto nasofrontal (DNF). O planejamento do tratamento é baseado na relação clínico-imaginológica. A tomografia computadorizada (TC) tem grande importância no processo decisório do planejamento. O tratamento pode ser do tipo não cirúrgico, quando há patência dos DNF e comprometimento estético não crítico para o paciente, ou cirúrgico quando há comprometimento dos DNF e/ou comprometimento estético crítico, ou ainda quando há envolvimento da parede posterior e necessidade de cranialização e obliteração ductal. O objetivo deste artigo é relatar uma cranioplastia secundária à sequela de fratura fronto-orbitária, com emprego de fragmentos osteotomizados do próprio sítio de fratura, fixados com miniplacas do Sistema 1.5mm e ainda o emprego de retalho de pericrânio têmporo-parietal para camuflagem de tecido mole por preenchimento.

The frontal bone, part of the cranial skeleton and part of the upper third of the face has an essential role in protecting brain content. As part of this reference, there is a sinus cavity of variable dimensions, the frontal sinus. The anatomical location of the frontal sinus allows it to contribute to frontal lobe protection by acting as a shock-absorbing barrier in addition to sinus physiology. Craniofacial fractures can compromise the anterior and(or) posterior wall, with or without the involvement of the nasofrontal duct (NFD). Treatment planning is based on clinical and imaging evaluation. Computed tomography (CT) is essential for planning and decision-making process. The treatment can be non-surgical, when there is patency of the FND and aesthetic impairment that is not critical for the patient, or surgical when there is impairment of the FND and/or critical aesthetic impairment, or even when there is involvement of the posterior wall and the need for cranialization and ductal obliteration. The objective of this article is to report a cranioplasty secondary to the sequelae of a frontal-orbital fracture, using osteotomized fragments from the fracture site itself, fixed with miniplates (1.5mm System), and the use of a temporoparietal pericranium flap to camouflage tissue soft for filling.

Systemic sarcoidosis presenting as acute rapidly progressive proptosis / Sarcoidose sistêmica apresentando-se como proptose aguda rapidamente progressiva

ABSTRACT Sarcoidosis is a generalized systemic chronic inflammation that rarely involves the orbit. As a chronic inflammation, sarcoidosis typically manifests with an insidious onset and slowly progressive course. We report a case of acute-onset proptosis resulting from a rapidly growing diffuse orbital mass that simulated malignant growth, which was biopsy proven to be the first manifestation of systemic sarcoidosis. The patient demonstrated complete resolution of proptosis and systemic involvement with long-term corticosteroid treatment.

RESUMO A sarcoidose é uma inflamação sistêmica generalizada que raramente envolve a órbita. Sendo uma inflamação crônica, a sarcoidose geralmente se manifesta com um início insidioso e uma evolução lentamente progressiva. Neste artigo, é relatado um caso de proptose de início agudo, resultante de uma massa orbitária difusa de rápido crescimento, simulando um crescimento maligno, mas cuja biópsia comprovou ser a primeira manifestação de uma sarcoidose sistêmica. O paciente apresentou resolução completa da proptose e do envolvimento sistêmico com tratamento de longo prazo com corticosteroides.

Corneal Perforation associated with "Silent Brain Syndrome" / Perfuração corneana associada à "síndrome do cérebro silencioso"

ABSTRACT This case report describes the clinical characteristics and ophthalmic management of a patient who developed corneal perforation due to severe enophthalmos consistent with "silent brain syndrome." A 27-year-old man with a history of congenital hydrocephalus and ventriculoperitoneal shunt was referred with complaints of "sinking of the eyeballs" and progressively decreasing vision in the left eye. Examination revealed severe bilateral enophthalmos in addition to superonasal corneal perforation with iris prolapse in the left eye. The patient underwent therapeutic keratoplasty the next day. Orbital reconstruction with costochondral graft and shunt revision of the intracranial hypotension were performed the next month to prevent further progression.

RESUMO Este relato de caso descreve as características clínicas e o manejo cirúrgico de um paciente que teve perfuração da córnea devido à enoftalmia grave consistente com a "síndrome do cérebro silencioso". Um homem de 27 anos com história de hidrocefalia congênita e derivação ventrículo-peritoneal foi encaminhado com queixas de "afundamento dos globos oculares" e diminuição progressiva da visão no olho esquerdo. O exame revelou enoftalmo bilateral importante, além de perfuração superonasal da córnea com prolapso iriano no olho esquerdo. A paciente foi submetida à ceratoplastia terapêutica no dia seguinte. Foi realizado no mês seguinte a reconstrução da órbita com enxerto costocondral e revisão do shunt para evitar progressão e piora do caso.

Removal of iatrogenic orbital foreign bodies with a 3D model

Facial foreign body (FB) is common after trauma, but iatrogenic orbital FB is a rare and unexpected complication of facial FB removal surgery. We present the case of a 43-year-old man with a glass FB in his nose. During the operation, this FB broke into two pieces, and the larger one pierced into the left orbit, close to the eyeball. A three-dimensional (3D) model was made that accurately recreated the shape and position of the FB in the orbit, according to which the FB was removed. 3D-printing technology is a great tool when dealing with complex facial FB.

Exoftalmos bilateral por compromiso orbitario debido a enfermedad relacionada con IgG4 / Bilateral exophthalmos due to orbital involvement due to IgG4-related disease

La enfermedad relacionada con IgG4 (ER-IgG4) se caracteriza por el compromiso fibrótico e infiltrado linfoplasmocitario con predominio de células IgG4 en uno o varios órganos. El fenotipo limitado a la cabeza y el cuello abarca el compromiso de las glándulas lagrimales y salivares, enfermedad orbitaria, paquimeningitis, hipofisitis, tiroiditis, mastoiditis y compromiso de senos paranasales. Las manifestaciones orbitarias pueden incluir proptosis uni o bilateral, miopatía cicatrizal de los músculos extraoculares, inflamación orbitaria y dolor que pueden simular a la oftalmopatía de Graves. La enfermedad oftálmica relacionada con IgG4 puede presentarse con compromiso de músculos extraoculares y de grasa orbitaria, y usualmente se confunde con afección orbitaria por enfermedad de Graves. Se presenta el caso de un varón de 58 años, con historia de exoftalmos bilateral de más de 15 años de evolución, en quien se arriba al diagnóstico de ER-IgG4 y cuya resonancia magnética de órbitas evidencia un patrón característico de compromiso de músculos extraoculares.

IgG4-related disease (IgG4-ER) is characterized by fibrotic involvement and lymphoplasmacytic infiltrate with IgG4 cells predominance in one or several tissues. The head and neck phenotype includes lacrimal and salivary gland involvement, orbital disease, pachymeningitis, hypophysitis, thyroiditis, mastoiditis, and sinus involvement. Orbital manifestations may include unilateral or bilateral proptosis, extraocular muscles scarring, orbital inflammation, and pain that may mimic Graves' ophthalmopathy. IgG4-related ophthalmic disease may present with extraocular muscles and orbital fat involvement and is often confused with orbital Graves' disease. We present the case of a 58-year-old man, with a history of bilateral exophthalmos of more than 15 years, in whom the diagnosis of IgG4-ER was reached and whose orbits magnetic resonance showed a characteristic pattern of extraocular muscle involvement.

Síndrome do ápice orbitário, apresentação aguda e implicações tardias: uma série de casos / Orbital apex syndrome, acute presentation and late implications: a series of cases

RESUMO O ápice orbitário é uma região na qual estão contidas estruturas ósseas, vasculares e neurais. Patologias que acometem essa região podem desencadear um conjunto de sinais e sintomas característicos, dando origem a síndrome do ápice orbitário. É uma entidade rara, que consiste em sinais de envolvimento das estruturas nervosas, que atravessam o forame óptico e a fissura orbitária superior, comprometendo os nervos oculomotor, troclear, abducente; a divisão oftálmica do nervo trigêmeo e o nervo óptico. Suas causas incluem afecções neoplásicas, vasculares, traumáticas, infecciosas, inflamatórias e idiopáticas. Muitas vezes, nós nos deparamos com patologias sem tratamento curativo, portanto deve-se atentar para o controle da sintomatologia e a prevenção das possíveis implicações tardias. O objetivo desta série de casos é relatar algumas das causas da síndrome do ápice orbitário e sua apresentação clínica aguda, além de alertar sobre as possíveis implicações crônicas.

ABSTRACT Orbital apex is a region involving bone, vascular and neural structures. Pathologies involving this region may lead to several symptoms and signals and to orbital apex syndrome. It is a rare syndrome that is characterized by signals involving nervous ocular motor nerves through the optic foramen and the superior orbital fissure. This can affect the oculomotor, the third canal and abducens nerves; the ophthalmic division of the fifth cranial nerve and the optic nerve. Its causes include neoplastic, vascular, traumatic, infectious, inflammatory, and idiopathic conditions. We often deal with conditions with no treatment, so it is necessary to control the symptoms and prevent late implications. The purpose of this case series is to report on the causes of orbital apex disease and its potential chronic implications.

Impact of readout-segmented echo-planar imaging based on small field of view and saturation band on image quality of orbital diffusion weighted imaging / 中国医学影像技术

Objective To observe the impact of readout-segmented echo-planar imaging(RS-EPI)based on small field of view(FOV)and saturation band on image quality of orbital diffusion weighted imaging(DWI).Methods Orbital MR scanning were prospectively performed in 33 healthy subjects.T1W,RS-RPI and optimized RS-EPI(based on small FOV and saturation band)images were acquired.Imaging quality of RS-EPI and optimized RS-EPI on displaying intraorbital structures(eyeballs,optic nerve and intraconal compartment)and periorbital structures(nasal cavity,orbital gyrus,optic chiasma,pituitary and temporal lobe)were evaluated subjectively using 5-point method.The geometric parameters of eyeball,signal-to-noise ratio(SNR)and apparent diffusion coefficient(ADC)were compared between images of RS-EPI and optimized RS-EPI.Results The display of eyeball,nasal cavity,orbital gyrus,optic chiasm,pituitary and temporal lobe on optimized RS-EPI were all better than those on RS-EPI(all P＜0.01),whereas no significant difference of optic nerve nor intraconal compartment was found between optimized RS-EPI and RS-EPI images(P＞0.05).Deformations of eyeball volume,sphericity,surface area,3D maximum diameter,axial maximum diameter and sagittal maximum diameter of bilateral eyes on optimized RS-EPI images were all slighter than those on RS-EPI(all P＜0.01),whereas no significant difference of deformations of coronal maximum diameters was found between optimized RS-EPI and RS-EPI images(P＞0.05).SNR of left temporal lobe white matter and ADC of vitreous body on optimized RS-EPI images were both lower than those on RS-EPI(both P＜0.01),whereas no significant difference of ADC of left temporal lobe white matter nor that of pons was found between optimized RS-EPI and RS-EPI images(P＞0.05).Conclusion Optimized RS-EPI with small FOV and saturation band could be used to improve imaging quality of orbital DWI.

Application of the upper eyelid orbicularis oculi myocutaneous island flap in repairing secondary defects after resection of eyelid and periorbital skin tumors: a retrospective analysis of 28 cases / 中华皮肤科杂志

Objective:To summarize and analyze the efficacy of the upper eyelid orbicularis oculi myocutaneous island flap in repairing secondary defects after resection of eyelid and periorbital skin tumors.Methods:A retrospective analysis was carried out on clinical data collected from 28 patients, whose secondary eyelid and periorbital defects were repaired with the upper eyelid orbicularis oculi myocutaneous island flaps in the Department of Dermatology, Hangzhou Third People′s Hospital from August 2019 to June 2021. The survival condition of the flaps was observed after the operation, and the appearance of the upper eyelid and periorbital skin as well as tumor recurrence were evaluated during the follow up.Results:Among the 28 cases, there were 6 males and 22 females; their ages ranged from 47 to 87 years (70.5 ± 10.9 years), 7 patients were aged 80 - 89 years, 8 aged 70 - 79 years, 8 aged 60 - 69 years, 4 aged 50 - 59 years, and 1 patient was aged 40 - 49 years. Skin defects were distributed at the upper eyelid in 1 case, at the lower eyelid in 9 cases, at the inner canthus in 1 case, at the outer canthus in 3 cases, at the upper eyebrow in 1 case, at the dorsum of the nose in 3 cases, and at the junction of the external nose, inner canthus and lower eyelid in 10 cases. The skin defects varied from 1.0 cm × 0.5 cm to 3.1 cm × 2.3 cm in size. The designed upper eyelid orbicularis oculi myocutaneous flap was 0.5 - 1.8 cm in width and 3 - 4 cm in length, and the length of the subcutaneous tunnel was 1.2 - 2.5 cm. During the follow-up of 6 months to 1.5 years, all flaps survived; scars on the upper eyelid donor sites were not obvious; there was no upper eyelid ectropion, no trichiasis, and no eyelid closure abnormality after the operation.Conclusion:The medium- or small-sized defects of the eyelid and periorbital skin can be successfully repaired by the upper eyelid orbicularis oculi myocutaneous island flap, with a favorable cosmetic effect and concealed donor areas.