Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease.

PURPOSE: Rim-off lateral wall decompression may be associated with functional and cosmetic deficit. Our objective, therefore, was to describe the functional and cosmetic results of deep lateral orbital decompression with and without anterior rim repositioning for thyroid eye disease. METHODS: In this retrospective comparative case series all consecutive thyroid eye disease patients who underwent deep lateral wall decompression at the Royal Victorian Eye and Ear Hospital between 1990-2007 and the Goldschleger Eye Institute, Sheba Medical Center between 2008-2011 were included. Patients were divided into two groups: the "rim-on" group in which the anterior lateral orbital rim was repositioned and the "rim-off" group in which it was left off. Main outcome measures were: proptosis reduction, postoperative oscillopsia and diplopia, presence of visible or palpable lateral orbit depression. RESULTS: One hundred and twelve patients who underwent 186 orbital decompressions were included in the final analysis. The average proptosis reduction for two- and three-wall decompressions ranged between 4.6-4.9 mm in the rim-on and 4.6-5.7 mm in the rim-off group respectively. The prevalence of postoperative oscillopsia was similar in both groups. The preoperative diplopia worsened in 17 patients (32.1 %) in the rim-on group and in seven patients (12.3 %) in the rim-off group (P = .02, chi-square test). None of the patients developed visible or palpable lateral orbit depression. CONCLUSIONS: Deep lateral orbital decompression without anterior rim repositioning may be an effective approach to enhance functional and cosmetic outcomes in thyroid eye disease patients without increasing the risk of lateral wall depression or postoperative oscillopsia.

[Dacryocystorhinostomy (DCR) under local anesthesia].

INTRODUCTION: Dacryocystorhinostomy (DCR) is performed using an external or endoscopic endonasal approach under general anesthesia (GA) or under sedation. In our department these operations are performed mainly under local anesthesia (LA) without sedation. PURPOSE: To examine the intraoperative and postoperative success rates of primary DCR under LA and GA using the external or endonasal approach. METHODS: The study group of this retrospective research included all patients who underwent a primary DCR in our department in 2009-2012 due to an acquired nasolacrimal duct obstruction. The main outcome measure was postoperative success defined as complete or significant improvement in tearing and a patent ostium. Intraoperative success rate was defined as the ability to complete the operation under LA. RESULTS: The study group included 139 patients. The success rate was 87.1% (121 patients). Success rates were similar for the external and endoscopic approaches (88.6% vs. 82.4%, respectively, p = 0.348). The success rate for surgeries performed under GA was higher than LA (96.7% vs. 84.9%, respectively, p = 0.019). The mean age of patients who were operated under GA was significantly younger than those under LA (43.6 vs. 65.7 years, respectively, p < 0.005). Conversion GA was only needed in 1 patient (0.7%). CONCLUSION: Most DCR surgeries can be performed under LA without sedation. Success rates found in our study are comparable with previous publications, similar for external or endoscopic approaches, and better under GA than LA. This difference may be related to the age difference between the two groups.

[Congenital orbital teratoma].

Congenital orbital teratoma is a rare benign tumor, composed of all three germ cell layers. The Lesion presents clinically as uniLateral proptosis in the newborn. In order to diagnose the tumor correctly a multidisciplinary approach is needed, including ophthalmologists, neurosurgeons, pediatrics, radiologists, and pathologists to eventually diagnose the lesion. Early detection and treatment is needed in order to prevent mechanical destruction of adjacent tissues, and blindness from mechanical pressure on the optic nerve. Surgical excision is the treatment of choice. We present a case report of a newborn, diagnosed with congenital orbital teratoma, and discuss the clinical and histological characteristics of the tumor.

Gunshot wound to the eye and orbit: a descriptive case series and literature review.

BACKGROUND: The objective of this study is to report ocular and orbital findings in a series of six patients (8 eyes) with gunshot wounds and to review the literature on the pathophysiology, management, and outcome of such patients. METHODS: Retrospective case series and review of the literature. Main outcome measures were ocular and orbital injury, surgical intervention, and presenting and final visual acuity. RESULTS: Six male patients (mean age, 32 years) were enrolled. Three patients with globe concussion and low presenting visual acuity were treated by observation. Two patients (25%) underwent primary enucleation or evisceration. Retinal detachment developed in one patient who had a globe perforation, and he underwent vitrectomy and lensectomy with silicone oil injection. Visual acuity remained unchanged in all but one patient who underwent retinal detachment surgery. Final visual acuity was poor in all patients, with five eyes ending in no perception of light. Four patients had orbital fractures, two of whom underwent orbital reconstruction. One of these patients also underwent drainage of orbital abscess, eyelid surgery, and a dacryocystorhinostomy. The mean follow-up time was 26 months. CONCLUSIONS: Gunshot wounds to the eye and orbit cause severe open and closed ocular injuries with guarded outcome and poor visual acuity. When feasible, initial wound closure may preserve the globe and allow further surgical rehabilitation. Primary evisceration may be required in cases of a severely ruptured globe. Orbital surgery may be needed in cases of infection, orbital wall disruption with disfigurement, or late enophthalmos.

Orbital decompression in thyroid related orbitopathy.

Thyroid related orbitopathy is the most common extra-thyroid manifestation of Graves' disease. Most patients suffer from mild ocular discomfort and local eye symptoms; however sight threatening conditions such as optic neuropathy or corneal exposure can occur. Orbital decompression allows orbital tissue expansion with globe repositioning. It is effective in alleviating pressure symptoms such as pain and compressive neuropathy. Surgery should be offered to patients with cosmetic disfigurement and functional disability.

Triamcinolone acetonide injection for persistent atypical idiopathic orbital inflammation.

PURPOSE: To report a patient with atypical idiopathic orbital inflammation who was successfully treated with intra-orbital injections of triamcinolone acetonide. METHODS: Interventional case report and literature review. MAIN OUTCOME MEASURES: Resolution of orbital inflammation. RESULTS: A 71-year-old female with right orbital mass and conjunctival inflammation underwent orbital biopsy that was consistent with the diagnosis of atypical idiopathic orbital inflammation. Inflammation has deteriorated despite oral steroids. The patient underwent two additional orbital biopsies that confirmed the initial diagnosis. Intra-orbital injections of triamcinolone acetonide resulted in significant improvement and cessation of active inflammation. CONCLUSIONS: Intra-orbital injections of triamcinolone acetonide may be an effective alternative in patients with atypical idiopathic orbital inflammation unresponsive to systemic steroids.

Very long term success of pterygium surgery with conjunctival graft.

PURPOSE: To examine to the very long term prognosis (16 years in average) of pterygium surgery with superior or inferior conjunctival graft. METHODS: Clinical data for patients that underwent pterygium surgery with conjunctival graft by two surgeons at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between the years 1997-2001 were retrieved from medical records. For all the included patients, data about their eye examinations was summarized and a questionnaire about their eye history was done. RESULTS: Twenty four patients were included in the study. Eleven with superior conjunctival flap (Group 1), and thirteen with inferior conjunctival graft (Group 2). In group 1, there was one surgery for recurrent pterygium, and two in group 2. In all cases the grafts were sutured and Mitomycin C was not used. No recurrence of pterygium was found in either group. No eye complications or side effects were found after sixteen years in average. CONCLUSIONS: After a very long follow-up of almost two decades there are no recurrences of pterygium or complications when using upper conjunctival flap or lower conjunctival graft during the surgery. It seems that lower graft is as good as upper flap for preventing recurrence of pterygium. Larger studies are required in order to confirm these results.

Eyelid splitting and extirpation of hair follicles using a radiosurgical technique for treatment of trichiasis.

BACKGROUND AND OBJECTIVE: To describe a new, simple, and rapid surgical modification for the treatment of trichiasis. PATIENTS AND METHODS: In this noncomparative, prospective, interventional case series, 12 eyelids of 8 consecutive patients suffering from acquired trichiasis were treated by splitting the eyelid margin using a radiosurgical technique and then extirpating the hair follicles. The main outcome measure was successful resolution of trichiasis without recurrence during a follow-up period of at least 1 year. RESULTS: Complete recovery of the trichiatic eyelashes at the site of the treatment occurred in 10 of the 12 eyelids treated. There were no complications during or after healing of the surgical wound during the follow-up period. CONCLUSION: Radiosurgery provides a simple and rapid modification of the surgical treatment for acquired trichiasis, with good functional results.

Orbital cavernous hemangioma associated with juxtapapillary exophytic retinal capillary hemangioma.

A 32-year-old man presented with coexisting orbital hemangioma and juxtapapillary exophytic capillary hemangioma. Fluorescein and indocyanine green angiography revealed exophytic juxtapapillary retinal capillary hemangioma. The orbital cavernous hemangioma was surgically removed, and the retinal capillary hemangioma was observed without treatment. Subretinal hemorrhage gradually absorbed and clinical symptoms improved. Juxtapapillary exophytic capillary hemangioma can cause subretinal bleeding secondary to external pressure from an adjacent orbital cavernous hemangioma. Coexistence of both tumors suggests a common etiology.

Intrascleral implantation of glass beads during evisceration.

BACKGROUND AND OBJECTIVE: To review the results after small glass bead implantation in the scleral cavity during evisceration. MATERIALS AND METHODS: In this retrospective study, we retrieved the follow-up data of 17 patients who underwent evisceration with glass bead implantation from 1993 to 1996. RESULTS: All patients achieved good cosmetic results with good motility of the prosthesis. Complications included transient chemosis at the early postoperative period in 3 patients (17.6%), 1 patient (5.9%) with local dehiscence of the wound, 1 patient developed a cyst in the socket (5.9%), and 1 patient was afflicted with thinning of the conjunctiva over the surgical wound. CONCLUSION: The use of glass beads to fill the scleral cavity during evisceration has the advantage of an excellent fit in accordance with the scleral cavity volume, as well as ease of treatment in case of extrusion. The prosthesis movement is good because of its engagement with the scleral bulges caused by the glass beads.

[Thyroid orbitopathy].

Thyroid Orbitopathy (T.O) is the most common orbital disease caused by a systemic illness. The clinical manifestations of T.O are a result of inflammation, edema and scarring of orbital tissue, and include exophthalmos, soft tissue edema, lid retraction, chemosis, exposure keratitis that can lead to corneal ulceration and perforation, ocular motility disorders and strabismus, and compressive optic neuropathy. T.O is an autoimmune disease but the exact etiology is yet to be revealed. Most cases resolve spontaneously without the need for medical or surgical intervention, but more severe cases may result in devastating visual and cosmetic results. In recent years, there has been a significant progress in the understanding of the disease and the medical and surgical treatment of T.O. This work reviews new aspects of T.O and it's surgical treatment, and include clinical photographs of patients operated on in our department.

[Ptosis--etiology, diagnosis and management].

Ptosis is a common complaint in patients who refer to ophthalmologists especially oculoplastic surgeons. Occasionally, ptosis may be the presenting sign or symptom of a systemic disease. Therefore, it is of great importance to know the causes of ptosis, its clinical presentation, and the systemic evaluation that one must undergo before going into surgery. This review presents the common causes of ptosis according to age of appearance, systemic diseases that must be ruled out, and the surgical options that exist.

Strabismus after inferior-medial wall orbital decompression in thyroid-related orbitopathy.

PURPOSE: To evaluate the rate and pattern of new-onset diplopia after inferior-medial wall orbital decompression in thyroid-related orbitopathy (TRO) patients. METHODS: Medical records of TRO patients who underwent orbital floor and medial wall decompression at the Goldschleger Eye Institute, Sheba Medical Center between 1/1986 and 12/2007 were reviewed and analyzed. MAIN OUTCOME MEASURES: primary- and down-gaze diplopia, strabismus (prism diopter [PD]). RESULTS: Fifty-one TRO patients (30 females, mean age of 51 years) underwent 102 bilateral inferior-medial wall orbital decompressions. Preoperatively, 29 patients (57%) reported primary gaze diplopia. Of these, 13 patients (45%) had persistent or worsened diplopia postoperatively, all of which required strabismus surgery. Fifteen patients had no primary gaze diplopia preoperatively. Of these, five patients (33%) had new-onset diplopia postoperatively, and only one patient (7%) required strabismus surgery. No data regarding pre-existing diplopia were available in seven patients. Orbital decompression had a significant effect on horizontal ocular deviations with increasing esotropic shift. Primary position esotropia increased from 11.1 (± 22.5) PD preoperatively to 23.8 (± 20.5) PD after surgery (p = 0.01, paired samples t-test). No severe complications were encountered in this group of patients. CONCLUSIONS: Inferior-medial wall orbital decompression is associated with a relatively high rate of new-onset diplopia of up to 33%. Patients with pre-existing primary and/or downgaze diplopia are more likely to have persistent symptoms postoperatively that may require strabismus surgery.

Congenital ptosis repair-surgical, cosmetic, and functional outcome: a report of 162 cases.

OBJECTIVE: To evaluate the surgical and functional outcome of congenital ptosis repair and the anisometropic changes after surgical repair of ptosis to determine the potential contribution of anisometropia to the development of refractive amblyopia. METHODS: The clinical records of 162 children with congenital ptosis that had been surgically repaired between 1995 and 2006 at the Goldschleger Eye Institute were reviewed and analyzed for functional and cosmetic outcome, visual acuity status, and presence of amblyopia. RESULTS: A total of 162 patients (mean age, 10 months) underwent surgical ptosis repair, of whom 120 (74%) had unilateral and 42 (26%) had bilateral ptosis. The surgeries were levator resection (47.5%), frontalis suspension (46.3%), and Fasanella-Servat (7.4%). Good functional and cosmetic outcomes were achieved in 130 (80.2%) patients, with unilateral cases showing more postoperative asymmetry. The reoperation rate was 10.4% (8/77) for levator resection, 29.3% (22/75) for frontalis suspension, and 20% (2/10) for Fasanella-Servat. There were no significant differences in visual acuity, spherical equivalent, or mean cylinder at 90° between the ptotic eyes before and after surgery (P = 0.33, P = 0.83, and P = 0.65, respectively), and compared with the sound eyes (P = 0.66, P = 0.78, and P = 0.08, respectively). The mean astigmatism correction by vector analysis after ptosis surgery was 1.1±0.68 D. CONCLUSIONS: Congenital ptosis repair yields good functional and cosmetic outcome, although the reoperation rate is relatively high (19.8%). Congenital unilateral ptosis was not associated with any differences in anisometropia or astigmatism between the ptotic and sound eye.

Relapsing migratory idiopathic orbital inflammation: six new cases and review of the literature.

AIMS: To present a case series of relapsing migratory idiopathic orbital inflammation. PATIENTS AND METHODS: Case series and review of the literature. The medical records of six patients with recurrent orbital myositis or idiopathic inflammation at different sites treated at the Goldschleger Eye Institute between April 2006 and December 2009 were collected and analysed; one patient treated at the orbital service in Priyamvada Birla Aravind Eye Hospital, Kolkata, India, was also included (June 2008 to August 2010). Orbital biopsy was performed in patients who failed to respond to steroids treatment. RESULTS: A total of six patients with recurrent episodes of orbital myositis or inflammation were identified. Four patients had orbital myositis of one extraocular muscle at the initial episode and recurrent myositis of a different extraocular muscle on the contralateral orbit. One patient had recurrent myositis of a different extraocular muscle on the same orbit. Two patients had a third episode of recurrence on a different site, that is, an extraocular muscle or an eyelid. One patient had eyelid and soft tissue involvement on one orbit and recurrence of orbital myositis on the contralateral eyelid. Histological findings in the latter case showed small perivascular lymphocytic aggregates and scattered histiocytes. The mean time for recurrence was 7.2 months. All patients were treated successfully with oral steroids and/or intralesional triamcinolone injection. CONCLUSIONS: Idiopathic orbital inflammation or orbital myositis can recur on a different extraocular muscle and on the contralateral orbit. These cases can be successfully treated with orally administered or intralesionally injected steroids.

Intralesional triamcinolone acetonide injection versus incision and curettage for primary chalazia: a prospective, randomized study.

PURPOSE: To compare treatment outcomes of intralesional triamcinolone acetonide (TA) injection with incision and curettage (I&C) for primary chalazia. DESIGN: Prospective, randomized clinical trial. SETTING: Institutional. STUDY POPULATION: Ninety-four patients with primary chalazia after failed conservative treatment were randomized to either intralesional TA injection (4 mg) or I&C performed under local anesthesia. All patients underwent comprehensive eye examinations that included digital photography of the lesion. Complete resolution was defined as lesion regression of 95% to 100%. Treatment was considered a failure if no resolution was achieved after the first attempted I&C or TA injection. MAIN OUTCOME MEASURES: Lesion resolution measured as 95% to 100% regression. RESULTS: Ninety-four patients participated in the study: 42 underwent I&C and 52 underwent TA injection as the first treatment. Complete resolution was achieved in 33 (79%) of 42 patients in the I&C group and in 42 (81%) of 52 patients in the TA group (P=.8, chi-square analysis). The average time to resolution in the TA group was 5 days, with most patients (48/52; 92%) having received a single injection and 4 (8%) of 52 patients having received 2 injections. TA precipitates were detected in 6 (11.5%) of 52 patients and resolved spontaneously. There were no complications, such as eyelid depigmentation, increased intraocular pressure, or any loss of vision, in either group. CONCLUSIONS: Intralesional TA injection is as effective as I&C in primary chalazia. Injection may be considered as an alternative first-line treatment in cases where diagnosis is straightforward and no biopsy is required.

Cryo-assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases.

PURPOSE: To describe and evaluate a cryo-assisted, minimally invasive, anterior approach for orbital tumour surgery. METHODS: Retrospective, non-comparative, consecutive, interventional case series of 103 patients who were operated on by the same surgeon for retroocular orbital tumours over the last 16 years. RESULTS: A cryo-assisted, minimally invasive, anterior approach was employed in 63 out of the 103 patients (61.2%). In 37 patients (35.9%), anterior orbitotomy without the use of cryoprobe was employed for biopsy or excision of small, anteriorly located lesions. Lateral orbitotomy was used in three patients (2.9%). In a subgroup of 61 patients with circumscribed lesions (mainly cavernous haemangiomas and schwannomas), cryoextraction was used in 51 (83.6%). None of the procedures required conversion to lateral orbitotomy and there were no intraoperative complications. CONCLUSION: In contrast to other reports on the treatment of orbital lesions, in the current case series surgery of most solid tumours and many other cystic or infiltrative lesions was achieved here via an anterior, cryo-assisted approach, and thus with minimal trauma to the orbit. This approach warrants more favourable consideration because the combination of the anterior approach with the use of cryoprobe and surgical microscope can yield successful results, even in patients with large or deeply located tumours - obviating in most of them the need for lateral or transcranial orbitotomies with bone flaps.

Induced corneal astigmatism by palpebral spring for the treatment of lagophthalmos.

PURPOSE: To report a patient with decreased vision after insertion of an upper eyelid palpebral spring. METHODS: Interventional case report. RESULTS: A 44-year-old man presented with decreased vision in his right eye. Several months before presentation, he underwent palpebral spring insertion in his upper eyelid for lagophthalmos. He had developed seventh cranial nerve palsy after removal of the right facial nerve neuroma. Decreased vision was related to induced astigmatism by upper eyelid pressure. Surgical replacement of the spring resulted in less astigmatism and improvement in visual acuity. CONCLUSIONS: Ocular rehabilitation surgery with insertion of a palpebral spring to the upper eyelid may induce corneal astigmatism and decrease vision in the normal eye. This may be reversible by replacing or repositioning the spring so that it will imply less corneal pressure.

Successful treatment with mitomycin C eye drops for conjunctival diffuse intraepithelial neoplasia with sebaceous features.

Conjunctival biopsy specimens from the right eye of a 66-year-old woman who had a 10-year history of an irritated and swollen right upper eyelid were diagnosed as diffuse intraepithelial neoplasia with sebaceous features. The treatment consisted of two courses, 2 weeks apart, of 0.02% mitomycin C eye drops. Biopsies performed after completion the second course showed no evidence of neoplastic involvement. Severe trichiasis that developed after the biopsies was managed surgically. Today, 46 months after completion of mitomycin C treatment, the conjunctiva shows no inflammation, the eyelid is not swollen or irritated, and there is no clinical indication of recurrence. This case report demonstrates that conjunctival diffuse intraepithelial neoplasia of the conjunctiva with sebaceous features can be successfully treated by treatment with mitomycin C drops.