A simple transconjunctival technique for the management of intraconal orbital hydatid cyst.

PURPOSE: To present a simple transconjunctival technique for the excision of intraconal orbital hydatid cysts. METHODS: This retrospective, non-comparative, clinical intervention case study was conducted between April 2018 and October 2023. The study included five patients presented to the Orbital unit of Assiut University Hospital with an intraconal orbital cyst, which histologically proved to be a hydatid cyst. In all cases, a conjunctival incision near the fornix was made depending on the cyst location as revealed by computed tomography (CT) or magnetic resonance imaging (MRI). A traction suture was applied to the two relevant recti muscles to guide the globe toward the desired direction. Blunt orbital dissection was made toward the cyst until exposing its anterior surface. A 20-gauge needle was introduced into the cyst and followed by aspiration of its content. The collapsed cyst was then removed by non-toothed forceps and followed by copious irrigation of the field. The follow-up period ranged from 11 to 58 months. RESULTS: The age of patients ranged from 11 to 44 years. Three were males and two were females. The cyst was iso-dense to the vitreous on CT and iso-intense to the vitreous on MRI. In all cases after aspiration of the content, the collapsed cyst was easily removed. None of the five patients developed recurrence during the follow-up period. CONCLUSION: The removal of the collapsed orbital hydatid cyst in the intraconal space after the aspiration of its content via transconjunctival anterior orbitotomy is a simple, fast technique with early recovery and maximum cosmesis.

Peri-levator Betamethasone Versus Triamcinolone Injection in Management of Thyroid Eye Disease-related Upper Eyelid Retraction Without Proptosis.

PURPOSE: To compare the efficacy of peri-levator injection of both betamethasone and triamcinolone in the management of thyroid eye disease-related upper eyelid retraction without proptosis. METHODS: This prospective, double-blind, randomized clinical trial was conducted at Assiut University Hospital, Upper Egypt in the period between December 2021 and October 2023. The study included 47 patients (56 eyes) and was divided into 2 groups. In group A, 1 ml betamethasone was injected into the peri-levator area, while in group B, 1 ml triamcinolone was injected. The injection was repeated every month for up to 5 injections if there was an improvement in margin reflex distance 1 (MRD1). The injection was stopped if MRD1 reached the normal value or if 2 successive injections caused no improvement in MRD1. The postinjection outcome was divided into: 1) effective if MRD1 reached the normal ≤4.5 mm; 2) partially effective if MRD1 was improved but did not reach the normal; and 3) ineffective if there was no improvement in MRD1. The follow up ranged from 6 to 20 months. RESULTS: In group A, the injection was effective in 26 eyes (92.9%) and partially effective in 2 eyes (7.1%). In group B, the injection was effective in 17 eyes (60.7%), partially effective in 6 eyes (21.4%), and ineffective in 5 eyes (17.9%). The mean number of injections was significantly lower in group A than in group B: 1.61 ± 0.50 versus 2.36 ± 1.16. CONCLUSIONS: This study results suggest that betamethasone is more effective with a smaller number of injections than triamcinolone in the management of thyroid eye disease-related upper eyelid retraction.

A simplified technique for correction of complete ptosis secondary to palpebral neurofibromatosis.

PURPOSE: To present a simplified technique in management of complete ptosis secondary to neurofibromatosis. METHODS: This prospective, non-comparative, clinical interventional study included 13 patients with complete ptosis secondary to histologically proved plexiform neurofibromas. It was conducted at the Orbital Unit of Assiut University Hospital, the referral center of Upper Egypt in the period between June 2013 and October 2021. In all cases, a simplified technique of 5 surgical steps was applied: (A) Division of the involved eyelid surgically into three parts by drawing 2 curvilinear lines, the superior line 11 mm below and parallel to the lower eyebrow hairline and the inferior one 10 mm above the lid margin, (B) Resection (full-thickness) of the large middle part which involves the main pathology and lies between the 2 lines, (C) Preservation of the upper part with identification, dissection and clamping of the levator muscle, (D) Refinement of the lower part by removal of any tissue between the skin and the debulked tarsus and (E) Re-suturing of the upper and lower parts in layers; conjunctiva to conjunctiva, levator to tarsus (after resection of a part that corrects the ptosis) and skin to skin. RESULTS: Ptosis was completely corrected in 8 cases (61.5%) and residual mild ptosis occurred in 5 patients (38.5%). No exposure keratopathy or tumor growth was reported during the follow-up period of minimum 1 year. CONCLUSIONS: This simplified technique could be considered as a surgical basis for correction of complete ptosis in neurofibromatosis.

Expanded use of transconjunctival orbitotomy in management of different orbital tumors at different locations.

PURPOSE: To assess the surgical outcomes of transconjunctival approach in management of different orbital tumors at different locations. METHODS: This prospective, non-comparative, clinical interventional study was conducted in the period between March 2017 and January 2020 and included 61 patients with histologically proved orbital tumors. In all cases, a conjunctival incision near the fornix was made depending on the tumor location as revealed by CT or MRI. A traction suture was applied to one or two relevant recti muscles to guide the globe toward the desired direction. Blunt orbital dissection was made toward the tumor until exposing its anterior surface. The procedure was considered successful if the predetermined decision (total excision with improved clinical manifestations for benign and biopsy for diagnosis in malignant tumors) was achieved without causing permanent complications. The procedure was considered a failure if the predetermined decision was not achieved or if permanent complications developed. RESULTS: The patients were divided into: Group A of 47 patients (77.05%) with benign tumors and Group B of 14 patients (22.95%) with malignant tumors. The overall success rate of the approach was 98.36% (60 out of 61 patients), while failure occurred in one case (1.64%). CONCLUSIONS: The transconjunctival orbitotomy is an excellent approach to manage different tumors at different orbital locations with rapid recovery and maximum cosmetic results. It is the only approach that can access intra-conal, mid-orbital tumors whatever their relation to the optic nerve without crossing it.

En-Bloc Resection Versus Resection After Evacuation and Suction of the Content for Orbital Optic Nerve Glioma Causing Visual Loss and Disfiguring Proptosis.

PURPOSE: To evaluate the surgical outcomes of two different techniques of resection for optic nerve gliomas confined to the intra-orbital segment. METHODS: This prospective, comparable, clinical interventional case series was conducted at the orbital clinic of Assiut University Hospital, the referral centre of Upper Egypt in the period between 2006 and 2018. The study included 10 children with optic nerve gliomas confined to the intra-orbital part without intracanalicular or intracranial extension and causing severe visual loss and disfiguring proptosis. In all cases, lateral orbitotomy was performed to expose the mass. In 5 cases (group A), the glioma was resected en-bloc. In 5 cases (group B), a new technique of resection was introduced. The wall of the glioma was incised, the content was evacuated and suctioned and followed by resection under good visualization of the markedly reduced mass in size. RESULTS: In the 2 groups, no tumour regrowth was reported during the follow-up period of 3-12 years. In group A, the 5 cases developed postoperative third nerve damage with paralytic ptosis and one case had severe neurotrophic keratitis ended by dense corneal opacity. In group B, a healthy ipsilateral eye was preserved in all cases and no one case developed postoperative paralytic ptosis. CONCLUSIONS: Reduction of size of an intra-orbital optic nerve glioma by evacuation and suction of the content before resection is highly recommended. This makes the surgical field during resection more visible and minimizes the possibility of third or other nerves damage.

Microphthalmia with huge cyst: a simple technique for excision.

PURPOSE: Is to present a simple technique for complete excision of microphthalmia and its huge cyst. PATIENTS: Five patients with microphthalmia and huge cyst were included. The pathology was bilateral in one case. Lateral canthotomy was performed in all cases. The 4 recti of the small eye were exposed and dis-inserted with application of 4 tractional sutures at the insertion sites. Gentle traction and blunt dissection with protection of the cyst by malleable retractor were used to release the cyst gradually. The optic nerve was clamped and cauterized. By cutting the optic nerve, the microphthalmic eye and its huge cyst came out easily. RESULTS: In no patient was the cyst was ruptured or incompletely excised. CONCLUSION: This technique is simple, fast and effective for complete excision of the microphthalmia and its huge cyst completely.

Intralesional steroid injection for management of acute idiopathic dacryoadenitis: a preliminary result.

PURPOSE: To evaluate the efficacy of intralesional injection of steroid as a new line of therapy in treatment of the acute form of an isolated idiopathic dacryoadenitis. METHODS: Five patients with unilateral isolated acute idiopathic dacryoadenitis were included in the study. In 2 patients, the pathology was recurrent. Intralesional injection of 2 to 4 ml betamethasone suspension (1 ml contains 2 mg betamethasone sodium phosphate and 5 mg betamethasone dipropionate) was followed by cold compression for 6 hours. Systemic nonsteroidal anti-inflammatory drugs were given for 2 weeks after the injection. RESULTS: Dramatic response was achieved within 7 days after injection in all cases. No patient had recurrence during the follow-up period of 8 to 19 months. CONCLUSIONS: The excellent preliminary results make this new line of therapy highly promising. However, more study and long-term follow-up are recommended.

Treatment of primary lymphoma of the lacrimal gland by surgical excision alone: A 5-year follow-up study.

PURPOSE. To evaluate the long-term efficacy of surgical excision alone in the treatment of non-Hodgkin(1)s lymphoma localized to the lacrimal gland. MATERIALS AND METHODS. Thirteen patients with primary lacrimal gland lymphoma were included. The presumptive diagnosis was based on: (1) The painless and relatively slow onset of unilateral lacrimal gland swelling, mostly in elderly adults; (2) The CT pattern of a soft tissue mass in the lacrimal gland region with defined margins and molds to the globe; (3) The negative results of systemic work-up. The involved lacrimal gland was excised via an anterior trans-septal approach in 12 cases and by lateral canthotomy, upper cantholysis, and a trans-periosteal approach in one case. Following histopathologic confirmation of the diagnosis, no supplemental therapy was given. The patients were followed for a minimum of 5 years (5-8 years). RESULTS. In all patients, the excised lacrimal gland lymphoma was firm, nodular and appeared encapsulated. The histologic subtypes of the excised masses were: low-grade lymphomas in 11 cases (7 small lymphocytic, 3 plasmacytoid lymphocytic, 1 follicular small cleaved) and intermediate grade in 2 cases (1 follicular large cell and 1 diffuse small cleaved). No evidence of local recurrence or systemic dissemination was reported during the follow-up period in any of the patients. CONCLUSIONS. Surgical excision of the tumor is a new curative technique for lymphoma localized to the lacrimal gland without any other orbital or systemic involvement. By this technique, orbital radiotherapy and its potential ocular complications can be avoided. However, more study is recommended.