Marginal Full Thickness Blepharotomy for Management of Orbital Compartment Syndrome.

PURPOSE: To assess the utility of a marginal full thickness blepharotomy (MFTB) for the treatment of orbital compartment syndrome. METHODS: An experimental study design employing a cadaver model for orbital compartment syndrome was used to assess the efficacy of an MFTB. Elevated orbital compartment pressures were created in 12 orbits of 6 fresh cadaver heads. Intraocular pressure, as an analog of orbital pressure, was measured before and after inferior and superior MFTBs were performed. Statistical analysis was performed on the collected data to assess the efficacy of the procedure. RESULTS: Both procedures were found to significantly lower the orbital compartment pressure. MFTB of the inferior lateral eyelid decreased orbital compartment pressure by an average of 62.2 mm Hg (95% CI, 56.9-67.5). MFTB of the superior lateral eyelid following MFTB of the inferior lateral eyelid decreased the orbital compartment pressure by an additional average of 10.3 mm Hg (total average reduction of 72.5 mm Hg; 95% CI, 68.1-76.9). CONCLUSIONS: Orbital compartment syndrome is a time-sensitive vision-threatening emergency that requires prompt diagnosis and intervention to prevent irreversible vision loss. The authors describe the MTFB, a simple one-step procedure that when performed correctly results in a significant decrease in orbital compartment pressure, making it a viable option when canthotomy and cantholysis fails or is unable to be performed.

[Interdisciplinary Management of Orbital Diseases]. / Interdisziplinäre Therapie der Erkrankungen der Orbita.

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Orbital Giant Cell Reparative Granuloma: A Case Report.

Giant cell reparative granuloma has a very low incidence and is thought to be a response to trauma. While there have been only a few reported cases of orbital giant cell reparative granuloma, we recently observed such a case and analyzed 16 previously reported cases of this type. It is important to note that further investigation is necessary to fully understand the relationship between giant cell reparative granuloma and trauma.

Rapid progression of orbital abscess requiring lateral canthotomy in a pediatric patient.

Subperiosteal abscess (SPA) is a rare complication of acute sinusitis in children that may develop rapidly. In this case report, we describe an 11 year-old boy who presented with a large SPA 2 days after being diagnosed with conjunctivitis. The patient required emergent lateral canthotomy and cantholysis (LCC), IV antibiotics, and emergent surgery. It is crucial that emergency physicians be able to identify and treat this vision-threatening complication.

Pediatric Orbital and Skull Base Pathology.

Pediatric orbital and skull base pathologies encompass a spectrum of inflammatory, sporadic, syndromic, and neoplastic processes that require a broad and complex clinical approach for both medical and surgical treatment. Given their complexity and often multicompartment involvement, a multidisciplinary approach for diagnosis, patient and family counseling, and ultimately treatment provides the best patient satisfaction and clinical outcomes. Advances in minimally invasive surgical approaches, including endoscopic endonasal and transorbital approaches allows for more targeted surgical approaches through smaller corridors beyond more classic transcranial or transracial approaches.

Clinical Evaluation and Surgical Management of Ocular Malakoplakia of the Caruncle and Periorbital Region: A Report of Two Case and Literature Review.

Ocular malakoplakia, a rare inflammatory disorder characterized by Michaelis-Gutmann bodies, is presented in 2 unique cases involving uncommon anatomical sites-the orbit and caruncle. The first case describes a 10-year-old girl with localized subconjunctival swelling near the caruncle, prompting surgical excision, and revealing characteristic malakoplakia features. Despite medical management, surgical intervention provided symptom relief. The second case involves a painless swelling below the lower lid in a 23-year-old female, initially suggestive of lymphoma. Excision biopsy confirmed malakoplakia, emphasizing the potential for clinical misdiagnosis. Histopathological examination showcased Michaelis-Gutmann bodies, von Hansemann cells, and chronic inflammation, confirming the ocular malakoplakia diagnosis. These cases underscore the rarity of ocular malakoplakia, particularly in pediatric patients, and highlight the importance of accurate diagnosis and appropriate management.

Primary Orbital Respiratory Epithelial Cyst: A Systematic Review and Two Case Reports.

A primary orbital respiratory cyst is a congenital choristoma that presents in the orbit and with different signs and symptoms depending on the location, which might also change the surgical approach. The aim of this report is to describe 2 new cases of primary respiratory epithelial cysts and to review the literature on presentation, management, and risk factors with different surgical approaches and complications. Two cases presenting with gradually increased proptosis had a confirmed diagnosis of a respiratory epithelial cyst. CT and MRI imaging revealed a thin-walled intraconal cystic lesion. Complete surgical removal was not possible and an incisional biopsy of the wall was performed. Rarely, orbital respiratory epithelium cysts are primary lesions. The high risk of breaking the capsule during surgery and the presence of residual epithelial cells within the orbit may cause cyst's recurrence. Indeed, we recommend careful attention during dissection maneuvers and a long-term follow-up.

Fibrous dysplasia with aneurysmal bone cyst-like change occurring in pediatric orbit: case report and literature review.

PURPOSE: We report a case of fibrous dysplasia (FD) with aneurysmal bone cyst (ABC)-like change in a child with orbital involvement, review the related cases, and discuss clinical features, therapy, and prognosis of this disease. CASE PRESENTATION: A 10-year-old girl had right proptosis (degree of exophthalmos: OD 16 mm, OS 13 mm) and limited vision (visual acuity: OD 1.0, OS 0.8) without trauma. Preoperative CT showed a 5.0*4.3 cm right-sided crania-orbital communicating tumor. MRI indicated a well-defined multicystic mass with scattered fluid levels and soap bubble-like alterations. The child underwent total tumor resection and orbital parietal titanium mesh reconstruction. At 20 months of follow-up, the child has recovered from ocular problems, and the tumor has not recurred. CONCLUSION: FD combined with ABC rarely occurs in orbit and generally begins with ocular symptoms. The etiology is uncertain. Early diagnosis and surgery are essential. Complete resection is suggested whenever possible because residual lesions may recur.

Fundus torsion following inferior oblique muscle weakening.

PURPOSE: To determine the postoperative fundus torsion following surgical inferior oblique (IO) weakening in patients with inferior oblique overaction (IOOA). METHODS: In this interventional case series, 37 patients with IOOA ≥ +1 and reliable preoperative fundus photographs were included. IO weakening was accomplished through myectomy or anterior transposition. Fundus photography was repeated at 3 months' follow-up. The primary outcome was change of disk foveal angle (DFA), measured as the angle between the line connecting the center of the fovea and optic disk and horizontal. Success or normal fundus torsion was defined as a postoperative angle of 0° to 8° of extorsion. Residual extorsion was defined as postoperative extorsion of > 8°. Postoperative intorsion was defined as any amount of induced intorsion. RESULTS: Mean age of patients (56% females) was 6.46 ± 6.79 years. At follow-up at least 3 months after surgery, the mean change of DFA was 7.79 ± 6.24° of reduction of extorsion after IO myectomy (P < 0.001) and 6.05 ± 6.07° after IO anterior transposition (P = 0.005). Normal fundus torsion was achieved in 50% of patients after myectomy and 36.4% of patients after anterior transposition. Residual extorsion was observed in 49% of patients; induced intorsion in 5%. CONCLUSIONS: Using objective measurement of fundus photographs, fundus extorsion was decreased in 94.7% of patients after myectomy or anterior transposition.

Craniofacial Fibrous Dysplasia in Fronto-Orbital Region: A Single-Center Retrospective Study of 38 Cases.

OBJECTIVE: This study presents the clinical characteristics, imaging manifestations, and surgical experience in 38 patients diagnosed with craniofacial fibrous dysplasia in fronto-orbital region (foFD). METHODS: We retrospectively analyzed the clinical data from 38 patients who had surgery for foFD. The surgical procedure typically involved extensive tumor removal, followed by immediate reconstruction of the frontal bone and orbit using synthetic materials. Additionally, 9 patients underwent simultaneous microscopic decompression of the optic canal. RESULTS: Common clinical manifestations included progressive fronto-orbital bone deformity (35), proptosis (28), orbital dystopia (21), and visual impairment (9). The disease primarily affecting the frontal bone (38), the sphenoid bone (28), and the ethmoid bone (24). The optic canal was involved in 9 patients with functional impairment. Computed tomography scans in all 38 cases revealed satisfactory repair material positioning and complete resolution of frontal deformities. Among the 9 patients who underwent optic canal decompression, 7 experienced partial recovery of visual acuity after surgery. CONCLUSIONS: In the surgical treatment of foFD, it is crucial to achieve maximal bone resection and repair skull defects, while decompressing the optic canal can provide significant benefits for patients with decreased visual function preoperatively. The use of preformed artificial materials offers advantages in aesthetic restoration after lesion excision.

Large orbital masses due to longstanding hydrogel retinal explants.

AIM: To describe the features of orbital masses occurring as a late complication of hydrogel retinal explants. PATIENTS AND METHODS: Retrospective review of patients presenting with orbital masses at decades after retinal surgery. RESULTS: Two patients with huge orbital masses are described, their presenting 25 and 28 years after retinal detachment repair with expansile hydrogel explants. In one case, the preoperative diagnosis was pleomorphic adenoma, and the other-with extreme distortion of the globe-was considered to be lymphoma or chronic inflammation arising around prior retinal explants. At orbitotomy, the masses were found to be grossly expanded hydrogel explants that were removed piecemeal from their fibrous capsules. Histopathology showed very mild inflammation with occasional multinucleate giant cells and patchy capsular calcification, and an eosinophilic amorphous material staining strongly with Alcian-blue. Surgery was uncomplicated and both orbits healed with marked functional improvement. CONCLUSION: Expansile hydrogel retinal explants were largely used in the 1980s and can present, often decades after the retinal surgery, with impaired orbital functions due to large parabulbar masses. The hydrophilic material appears to expand very slowly over decades, leading to gross distortion of neighbouring structures and a tumour-like mass.

Ophthalmology and oculoplastics for the rhinologist.

PURPOSE OF REVIEW: As the management of ophthalmic and sinus disease advances, it is important to stay abreast of all current management options. This involves knowledge of adjacent anatomy and disease processes, and collaboration between multiple specialties. The authors provide a review of relevant ophthalmic and oculoplastic topics for the rhinologist. RECENT FINDINGS: The scope and surgical skills of oculoplastic and rhinologist specialists have grown in conjunction with medical and technological advancements. Familiarity with the presentations of sinus disease in the orbit can decrease the time to disease recognition, and improve morbidity and mortality. Collaborative approaches provide improved access to areas of interest throughout the orbit and sinuses. Multiportal, transorbital, and endoscopic techniques can improve patient morbidity and mortality compared to conventional open approaches. Familiarity with all medical and surgical treatment options can help tailor treatments to patients' needs. SUMMARY: Multidisciplinary approaches to sinus and orbit disease and the incorporation of new surgical technologies can improve patient options and outcomes.

Survival benefit of exenteration in COVID-19-associated rhino-orbital mucormycosis.

PURPOSE: There has been a sudden increase in the number of rhino-orbital mucormycosis cases, primarily affecting patients recovering from COVID-19 infection. The local health authorities have declared the current situation an epidemic. In this study, we assess the role of exenteration in preventing disease progression and improving survival in patients with rhino-orbital mucormycosis. METHODS: The patients undergoing exenteration were grouped into the exenteration arm and those denying exenteration were grouped into the nonexenteration arm. The patients were followed at 1 month and 3 months. The 6-month survival data were collected telephonically. Continuous data were presented as Mean ± SD/Median (IQR) depending on the normality distribution of data, whereas the frequency with percentages was used to present the categorical variables. Kaplan-Meier survival curves were created to estimate the difference in survival of patients with exenteration in rhino-orbital mucormycosis versus those without exenteration. RESULTS: A total of 14 patients were recruited for our study based on the inclusion and exclusion criteria. All the patients were qualified for exenteration; however, only eight patients underwent exenteration and six patients did not consent to exenteration. At the end of 3 months in the exenteration group, four (50%) patients died. Two patients died within a week of exenteration, whereas two patients died after 2 weeks of exenteration. The deaths in the first week were attributed to septic shock and the deaths happening beyond 2 weeks were attributed to severe meningitis. The Kaplan-Meier survival analysis showed the cumulative probability of being alive at 1 month in the exenteration arm to be 85%, and it decreased to 67% by 53 days and subsequently remained stable until the end of 3 months. CONCLUSION: The Kaplan-Meier survival analysis did not show a survival benefit of exenteration at 3 months and 6 months in COVID-associated rhino-orbital mucormycosis.

Outcomes of inferior oblique myectomy versus recession combined with lateral rectus recession in V-pattern exotropias.

PURPOSE: To compare outcomes of bilateral lateral rectus recession (BLRc) paired with either bilateral inferior oblique myectomy (BIOm) or bilateral inferior oblique recession (BIOc) to correct V-pattern exotropia. METHODS: The medical records of children (≤18 years) who underwent BLRc with BIOm or BIOc (10 mm) for V-pattern intermittent exotropia between December 2020 and May 2022 and who had at least 6 months' postoperative follow-up were reviewed. Outcomes included horizontal alignment, bilateral inferior oblique action, stereopsis, postoperative exotropia control score, and additional strabismus surgeries. Analysis was stratified by preoperative V pattern into subgroups of 10Δ-14Δ and ≥15Δ. RESULTS: Fifty patients underwent BLRc with BIOm (n = 26) or BIOc (n = 24), with no difference in age, sex, or follow-up length. Preoperatively, there were no differences in stereopsis, horizontal or vertical deviations in primary position, strabismus control, or inferior oblique overaction (IOOA). The BIOc group had greater preoperative V pattern than the BIOm group (18.1 ± 6.8 D vs 14.3 ± 7.0 D, resp. [P = 0.03]). There was no difference in BLRc surgical dose. At final follow-up (mean, 448 ± 189 days), both groups showed a postoperative decrease in horizontal deviation, amount of V pattern, and IOOA. For patients with ≥15Δ V pattern, BIOm decreased V pattern amount at distance (P = 0.02) and IOOA (P = 0.0035) more than BIOc, and BIOm patients had better control of residual strabismus at distance (P = 0.03) compared with the BIOc group overall, as well as for both V pattern subgroups. Two patients with BIOm and one with BIOc underwent additional strabismus surgery. CONCLUSIONS: BIOm or BIOc in combination with BLRc decreased the angle of exotropia and improved control. However, BIOm, especially with large V patterns, had a greater effect on decreasing the V pattern and IOOA and showed better control of residual strabismus.

Transnasal endoscopic drainage of neonatal orbital abscess.

Neonatal orbital complications are rare and potentially fatal, demanding prompt diagnosis and adequate treatment. A 25-day-old neonate presented with rapidly progressive orbital complications as evidenced by proptosis, chemosis, lid oedema and restricted eye movements, developing within 3 days. There was no significant medical history or risk factors for developing infection. An initial conservative approach with antimicrobial therapy failed to show any resolve. An MRI brain, orbits and paranasal sinuses demonstrated that there were features suggestive of right orbital cellulitis with possibility of abscess formation with right ethmoidal mucoinflammatory disease and mass effect on the optic nerve causing stretching and compression by the surrounding inflammation.The patient was treated successfully with transnasal endoscopic drainage and decompression. Endoscopic access was challenging owing to the restrictive anatomy. Postoperatively, the patient showed improvement, with gradual decrease in proptosis and resolve in eye movements.

Abscess volume as a predictor of surgical intervention in children hospitalized with orbital cellulitis: A multicentre cohort study.

IMPORTANCE: Orbital cellulitis with subperiosteal or orbital abscess can result in serious morbidity and mortality in children. Objective volume criterion measurement on cross-sectional imaging is a useful clinical tool to identify patients with abscess who may require surgical drainage. OBJECTIVE: To determine the predictive value of abscess volume and the optimal volume cut-point for surgical intervention. DESIGN: We conducted an observational cohort study using medical records from children hospitalized between 2009 and 2018. SETTING: Multicentre study using data from 6 children's hospitals. PARTICIPANTS: Children were included if they were between 2 months and 18 years of age and hospitalized for an orbital infection with an abscess confirmed on cross-sectional imaging. EXPOSURE: Subperiosteal or orbital abscess volume. MAIN OUTCOME AND MEASURES: The primary outcome was surgical intervention, defined as subperiosteal and/or orbital abscess drainage. Multivariable logistic regression was performed to assess the association of abscess volume with surgery. To determine the optimal abscess volume cut-point, receiver operating characteristic (ROC) analysis was performed using the Youden Index to optimize sensitivity and specificity. RESULTS: Of the 150 participants (mean [SD] age, 8.5 [4.5] years), 68 (45.3%) underwent surgical intervention. On multivariable analysis, larger abscess volume and non-medial abscess location were associated with surgical intervention (abscess volume: adjusted odds ratio [aOR], 1.46; 95% CI, 1.11-1.93; abscess location: aOR, 3.46; 95% CI, 1.4-8.58). ROC analysis demonstrated an optimal abscess volume cut-point of 1.18 mL [AUC: 0.75 (95% CI 0.67-0.83) sensitivity: 66%; specificity: 79%]. CONCLUSIONS AND RELEVANCE: In this multicentre cohort study of 150 children with subperiosteal or orbital abscess, larger abscess volume and non-medial abscess location were significant predictors of surgical intervention. Children with abscesses >1.18 mL should be considered for surgery.

Success rates of lateral canthotomy and cantholysis for treatment of orbital compartment syndrome.

PURPOSE: Vision loss after facial trauma can occur from orbital compartment syndrome (OCS). Orbital compartment syndrome is commonly treated surgically with a lateral canthotomy and cantholysis (C&C). Our study investigates success rates of lateral C&C for the treatment of OCS amongst emergency medicine (EM) and ophthalmology providers. METHODS: A retrospective cohort study was performed. Cases were identified and the electronic medical record of patients was interrogated for clinical and procedural information. Success of a lateral C&C was defined as a decrease in intraocular pressure (IOP) to <30 mmHg after the first attempt at the procedure. Inclusion criteria included documentation of a procedural attempt, a pre-procedure IOP >30 mmHg and a post-procedure IOP measurement; or alternatively if no pre-procedure IOP was documented but the IOP was >30 on arrival to the level 1 trauma center. Exclusion criteria included periprocedural use of ocular hypotensive medications and comorbid hyphema. RESULTS: The final analysis included 74 eyes from 64 patients. Emergency medicine providers performed the initial lateral C&C in 68% of cases compared to 32% by ophthalmologists, and success rates were comparable - 68% vs 79.2%, respectively (p = 0.413). Poorer visual outcomes were associated with the initial failure of a lateral C&C and head trauma without an orbital fracture. All patients treated with a vertical lid split procedure met the criteria for 'success' as defined by this study. CONCLUSIONS: The success rate of a lateral C&C is comparable amongst EM and ophthalmology providers. Improved training of physicians on the lateral C&C or other simpler procedures, such as the vertical lid split, could improve outcomes in OCS.

[Children's rhinosinusitis orbital complications]. / Orbital'nye oslozhneniya rinosinusita u detei.

The number of cases of children's sinogenic orbital complications does not reduce in spite of the advanced methods of paranasal sinuses visualization, wide use of antibacterial therapy against sinusitis, and preventive vaccination against pneumococcal disease. Orbital complications are more common with children than with adults, the basic reason of their development being ethmoiditis. The prevailing classification of orbital complications proposed by J. Chandler et al. divides these into preceptal and postceptal forms and gives description to 5 development stages of orbital complications in the order of their increasing severity. At an early age preceptal and orbital cellulites prevail, and these commonly need conservative treatment only. In case of orbital cellulitis, the major treatment method is endovenous antibiotic therapy in which the chosen antibiotic is to cover the whole spectrum of aerobic and anaerobic microbes often extracted in such cases. At small subperiostal abscesses (<0.5-1 ml), conservative treatment during 24-48 hours is possible. If there is no positive dynamics, or abscess grows in size, or eye symptoms progress, abscess and affected sinuses drain is recommended. Orbital abscess is to be given surgical treatment; at the same time endoscopic management of paranasal sinuses might by complemented with external surgical approaches (lateral and medial orbitotomy).

Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases.

BACKGROUND: Two cases of orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles were reported to understand image findings, clinical and histopathologic features of orbitofrontal cholesterol granuloma to improve its diagnosis and treatment. CASE PRESENTATION: Two East Asian patients aged 41 and 27 without personal or familial medical or trauma history presented with the common complaint of proptosis and inferomedial displacement of the eyeballs. The computed tomography (CT) of both cases showed an irregularly shaped, well-defined lesion in the left frontal bone associated with bony erosion. The lesions resulted in the bone absorption of frontal bone and orbital roof, which extended into the superior orbital space. Anterior orbitotomy through subbrow incision by drainage and curettage resulted in a curative outcome. The histopathological examination revealed inflammatory granulation tissues, fibrous capsule wall, cholesterol clefts with altered blood pigments, and calcifications, consistent with the diagnosis of cholesterol granuloma. No recurrence was observed for one year after surgery in one case and three years in the other. CONCLUSIONS: When the following features are observed: orbital CT exhibits cystic lesion with irregular bone destruction in the superolateral orbit, magnetic resonance imaging (MRI) depicts lesions are hyperintense signals on T1 weighted images (T1WI), and T2 weighted images (T2WI), and the contrast-enhanced imaging reveals that the most of tumor is showed a non-significant enhancement, orbitofrontal cholesterol granuloma should be considered.