Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

Efficacy of teprotumumab therapy in patients with long-duration thyroid eye disease.

PURPOSE OF REVIEW: Teprotumumab, an inhibitor of the insulin-like growth factor 1 receptor (IGF-1R), was approved by the US Food and Drug Administration in January 2020 for the treatment of thyroid eye disease (TED). The clinical trials leading to its approval enrolled patients with recent disease onset and significant inflammatory symptoms and signs. Subsequent real-world teprotumumab use in patients with longer duration of disease also may be effective, and there have been several publications reporting on experience in these patient groups. RECENT FINDINGS: TED results in disfiguring changes such as ocular proptosis and affects visual function by altering extraocular muscle function, leading to diplopia. Compressive optic neuropathy also may occur, and disease manifestations may persist for years. Teprotumumab treatment in cases of TED in which prior interventions (medical or surgical) had failed, or in treatment-naïve patients whose disease had been stable for years, has been reported to improve both clinical signs and symptoms (proptosis, diplopia) and to reduce the pathologic orbital changes as assessed by orbital imaging. SUMMARY: Teprotumumab may be an appropriate treatment for TED regardless of disease duration and irrespective of the presence or absence of markers of active inflammation within the orbit.

Embryology of the Orbit.

The orbit houses and protects the ocular globe and the supporting structures, and occupies a strategic position below the anterior skull base and adjacent to the paranasal sinuses. Its embryologic origins are inextricably intertwined with those of the central nervous system, skull base, and face. Although the orbit contains important contributions from four germ cell layers (surface ectoderm, neuroectoderm, neural crest, and mesoderm), a significant majority originate from the neural crest cells. The bones of the orbit, face, and anterior cranial vault are mostly neural crest in origin. The majority of the bones of the skull base are formed through endochondral ossification, whereas the cranial vault is formed through intramembranous ossification. Familiarity with the embryology and fetal development of the orbit can aid in understanding its anatomy, as well as many developmental anomalies and pathologic conditions that affect the orbit.

Orbital Floor Implant Causing Loss of Parasympathetic Lacrimal Gland Innervation.

Many postoperative complications are known to occur as a result of orbital floor fracture repair, but loss of lacrimal gland function has not been reported. The authors present a patient who lost reflex tearing after undergoing orbital floor fracture repair by an outside surgeon. CT scan showed placement of the posterolateral edge of the implant through the inferior orbital fissure, which presumably transected the parasympathetic fibers innervating the lacrimal gland.

Orbital Neuromas Associated With Chronic Inflammatory Demyelinating Polyneuropathy.

Chronic inflammatory demyelinating polyneuropathy is known to cause enlargement of the cranial nerves, particularly the trigeminal nerve. Several cases of orbital neuromas associated with this condition have been published, but surgical treatment has not been reported. The authors present a case of bilateral supraorbital neuromas associated with chronic inflammatory demyelinating polyneuropathy that underwent surgical excision and histopathologic examination.

Comparative Analysis of the Exposure and Surgical Freedom of the Endoscopic Extended Minipterional Craniotomy and the Transorbital Endoscopic Approach to the Anterior and Middle Cranial Fossae.

BACKGROUND: Numerous minimally invasive approaches to the skull base have been successively developed. Knowledge of the surgical nuances of a specific approach may facilitate approach selection. This study sought to compare the nuances of an extended version of the minipterional craniotomy (EMPT) with those of the transorbital endoscopic approach (TOEA) to the anterior and middle cranial fossae (ACF and MCF, respectively). OBJECTIVE: To quantitatively analyze and compare the area of exposure and surgical freedom between EMPT and TOEA to the ACF and MCF. METHODS: EMPT and TOEA were carried out in 5 latex-injected cadaveric heads, bilaterally (10 sides). For each approach, the area of exposure, surgical freedom, and angle of attack were obtained with neuronavigation and statistically compared. RESULTS: No significant difference was found between the mean area of exposure of EMPT and TOEA at the ACF and MCF (P = .709 and .317, respectively). The mean exposure area at the ACF was of 13.4 ± 2.6 cm2 (mean ± standard deviation) and 13.0 ± 1.9 cm2 for EMPT and TOEA, respectively. Except for the crista galli, EMPT afforded a larger area of surgical freedom at all targets. EMPT also achieved significantly greater attack angles in vertical axis except to the crista galli. The horizontal attack angles to all targets were similar between approaches. CONCLUSION: EMPT and TOEA offer a comparable area of exposure at the ACF and MCF in the cadaver; however, the instrument maneuverability afforded by EMPT is superior. Further studies are necessary to better define their precise surgical application.

Correction of Recalcitrant Cicatricial Lower Lid Retraction and Entropion With Transverse Tarsotomy and Tarsoconjunctival Flap.

PURPOSE: To describe a novel technique to correct cicatricial lower lid entropion and retraction using a transverse lower lid tarsotomy with an interposed tarsoconjunctival flap posterior lamellar spacer. METHODS: Technique description and retrospective interventional case series. RESULTS: Four patients underwent the procedure-two with complications following treatment of sinonasal carcinoma and two with complications following orbital fracture repair. All patients had failed prior posterior lamellar spacer grafts, including donor sclera, dermis-fat graft, and hard palate mucosa. Average time to flap takedown was 20 (11-28) days, with an average follow-up interval of 8.4 (6.2-11.5) months. All patients had resolution of lower lid entropion and significant improvement of lower lid retraction with an average of 2.8 mm (2.0-4.3) of elevation. There were no serious complications, and all patients reported significant improvement in ocular surface symptoms. CONCLUSIONS: Transverse tarsotomy combined with a tarsoconjunctival flap is effective for the correction of cicatricial lower lid retraction and entropion in eyelids that have failed surgery with traditional posterior lamellar spacer grafts.

Undifferentiated Pleomorphic Sarcoma Metastatic to the Orbit.

Undifferentiated pleomorphic sarcoma is a malignancy of mesenchymal origin, which was previously known as malignant fibrous histiocytoma. It is known to occur on rare occasion as a primary orbital tumor, but no known cases of metastatic orbital involvement have been reported since 2002, when the reclassification of these tumors took place. The authors report a patient who presented with a metastasis to the left orbit 2 years after undergoing treatment of a high-grade undifferentiated pleomorphic sarcoma of the right thigh. Histopathology of the orbital mass was similar to the primary tumor biopsy prior to neoadjuvant chemotherapy and radiation. The appearance was markedly altered in the subsequent excisional tissue, which showed treatment changes. Immunohistochemistry and genetic testing also supported the metastatic nature of the orbital lesion. The patient's tumor progressed rapidly despite systemic targeted therapy and orbital exenteration was performed. At 2 years follow up, the patient remained without evidence of tumor recurrence in the socket.

Lateral orbitotomy for a maxillary nerve schwannoma: case report.

Authors of this report describe a Fukushima Type D(b) or Kawase Type ME2 trigeminal schwannoma involving the right maxillary division in a 59-year-old woman who presented with intermittent right-sided facial numbness and pain. This tumor was successfully resected via a right lateral orbitotomy without the need for craniotomy. This novel approach to a lesion of this type has not yet been described in the scientific literature. The outcome in this case was good, and the patient's intra- and postoperative courses proceeded without complication. The epidemiology of trigeminal schwannomas and some technical aspects of lateral orbitotomy, including potential advantages of this approach over traditional transcranial as well as fully endoscopic dissections in appropriately selected cases, are also briefly discussed.

Bilateral lacrimal gland disease: clinical features of 97 cases.

OBJECTIVE: Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. DESIGN: Case series. PARTICIPANTS: Ninety-seven patients with bilateral LG disease. METHODS: Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. MAIN OUTCOME MEASURES: Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. RESULTS: Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease. CONCLUSIONS: The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%.

Combined orbital floor and medial wall fractures involving the inferomedial strut: repair technique and case series using preshaped porous polyethylene/titanium implants.

Background Combined orbital floor and medial wall fractures can be technically challenging to repair, particularly when the inferomedial strut is involved. A surgical repair technique is described utilizing a single preshaped porous polyethylene/titanium implant to span both defects. Methods Retrospective interventional case series. Results Fracture repair was performed on 17 orbits (16 patients) between October 2009 and February 2012. Subsequent surgical revision was required in three cases (18%). Visual acuity was stable or improved in all cases. Of 7 patients with preoperative diplopia, 5 improved and 2 remained stable postoperatively, and there were no cases of new or worsened diplopia following surgery. Postoperative asymmetry in Hertel exophthalmometry averaged 1.0 mm (range 0 to 2 mm). Preoperatively, average orbital volume was 122.7% compared with control (range 109 to 147%, standard deviation [SD] 9.6), which improved to 100.3% postoperatively (range 92 to 110%, SD 5.7). The average decrease in orbital volume was 22.5% (range 10 to 54%, SD 11.4, p < 0.001). Conclusions With careful preoperative planning and meticulous surgical technique, combined orbital floor and medial wall fractures involving the inferomedial strut can be successfully repaired with a preshaped porous polyethylene/titanium implant through a transconjunctival/transcaruncular approach with inferior oblique disinsertion.

Subtotal excision with adjunctive sclerosing therapy for the treatment of severe symptomatic orbital lymphangiomas.

Orbital lymphangiomas are congenital malformations with abnormal and dead-end lymphatic channels and present management challenges to ophthalmologists and orbital surgeons. Recurrent hemorrhage and expansion can lead to vision loss and disfigurement. We report our technique that uses adjunctive intraoperative injection of sodium morrhuate, 5%, under direct visualization into lymphangioma channels prior to excision. We believe that in the hands of experienced orbital surgeons, and with appropriate preoperative evaluation and careful surgical technique, this procedure is useful in saving vision and avoiding complications from orbital lymphangiomas.

The effect of orbital decompression surgery on lid retraction in thyroid eye disease.

PURPOSE: To determine the effect of orbital decompression surgery on lid retraction as a function of proptosis reduction in the setting of thyroid eye disease. METHODS: Retrospective interventional case series of all consecutive medial and lateral orbital decompressions performed by the authors for thyroid eye disease from 1999 to 2008. Primary outcome measures included postoperative proptosis and lid retraction. RESULTS: One hundred sixty-five eyes of 89 patients were included. The average amount of proptosis reduction at final follow up (average 30 months) was 4.6 mm. The average improvement in upper lid retraction was 0.9 mm, and the average improvement in lower lid retraction was 0.8 mm. There was a statistically significant correlation (0.12, p = 0.005) between the amount of proptosis reduction and lower lid elevation. No such correlation (-0.010, p = 0.90) was seen for upper lid position. In cases where inferior rectus recession was performed subsequent to decompression surgery (n = 20), the effect of proptosis reduction on lower lid position was negated (correlation -0.01, p = 0.980). CONCLUSION: A statistically significant correlation exists between the amount of proptosis reduction from orbital decompression surgery and improvement in lower lid retraction. No such correlation exists between proptosis reduction and upper lid retraction. Inferior rectus recession negates the positive effect of orbital decompression on lower lid position.

Comparison of lateral and medial orbital decompression for the treatment of compressive optic neuropathy in thyroid eye disease.

PURPOSE: To compare the efficacy of lateral orbital decompression with medial orbital decompression for the treatment of compressive optic neuropathy (CON) caused by thyroid eye disease (TED). METHODS: A retrospective review of all patients undergoing orbital decompression for TED-associated CON between 2003 and 2008 was conducted. Clinical outcome measures included visual acuity, mean deviation on Humphrey visual field, Ishihara color plate testing, afferent pupillary defect, and Hertel exophthalmometry. A composite CON score was also calculated for each patient based on the 3 visual outcome measures, with a higher CON score reflecting greater disease severity. RESULTS: Twenty-eight eyes of 17 patients were included in the study. Ten orbits underwent lateral wall decompression, and 18 orbits underwent medial decompression. Both groups showed a significant postoperative improvement in visual acuity, Humphrey visual field testing, and color testing at 3 months following the initial surgery. The composite CON score improved 9.04 ± 9.97 points after lateral decompression (p = 0.02) and 9.03 ± 10.84 points after medial decompression (p = 0.003). There was no significant difference in the degree of improvement in any of the visual outcome measures between the lateral and medial groups. There was a statistically significant difference in the amount of proptosis reduction resulting from lateral decompression compared with medial decompression (6.3 versus 3.1 mm, respectively, p < 0.0001). CONCLUSIONS: Lateral orbital decompression and medial orbital decompression are both efficacious for the treatment of TED-associated CON. Lateral decompression also results in a greater proptosis reduction than medial decompression.

Closure of mid-posterior Tenon's capsule in enucleation.

PURPOSE: To evaluate the potential advantages of closing mid-posterior Tenon's capsule during enucleation surgery by comparing its thickness and relative tissue strength with anterior Tenon's capsule. To evaluate surgical outcomes of enucleation using mid-posterior Tenon's capsule closure. METHODS: This is an experimental laboratory study and retrospective surgical case series. Histologic examination of Tenon's capsule was performed on permanently fixated human orbital specimens. Suture pull-out testing as a measure of tissue strength was performed on anterior and mid-posterior Tenon's capsule in nonfixated human cadaver orbits. A retrospective review of enucleations with primary orbital implant placement performed by the authors between 1998 and 2008 was conducted to determine the surgical outcomes of enucleation using closure of mid-posterior Tenon's capsule. RESULTS: Histologic analysis showed the average thickness of mid-posterior Tenon's capsule to be 121% greater than that of the anterior portion (518 vs. 234 µ, p < 0.001). Suture pull-out strength was 84% higher in mid-posterior versus anterior Tenon's capsule (741 vs. 1298 g, p = 0.016). Of the 103 enucleations performed by the authors (54 with unwrapped silicone implants and 49 with unwrapped porous polyethylene), there were 2 cases (1.9%) of implant extrusion and 1 case (1%) of implant exposure. CONCLUSION: From a structural and biomechanical standpoint, mid-posterior Tenon's capsule is significantly thicker and stronger than anterior Tenon's capsule, theoretically providing a superior barrier to orbital implant exposure and extrusion after enucleation.

Ultrasonic bone removal versus high-speed burring for lateral orbital decompression: comparison of surgical outcomes for the treatment of thyroid eye disease.

PURPOSE: To evaluate the efficacy of ultrasonic bone removal during lateral orbital decompression for thyroid eye disease. METHODS: Retrospective, comparative, interventional case series of lateral orbital decompressions performed by the senior author for thyroid eye disease between July 2005 and July 2008. Patients were excluded if they had other coexisting orbital conditions or concurrent decompression of other orbital walls. Primary outcome measures included visual acuity, proptosis, lagophthalmos, eyelid retraction, and exposure keratopathy. RESULTS: Thirty-six consecutive lateral orbital decompressions performed by the senior author were reviewed. The Sonopet Omni ultrasonic surgical aspirator was used to remove the lateral wall in 18 cases, and a high-speed drill with a cutting burr was used in the other 18 cases. There was no significant difference between the groups in postoperative visual acuity, proptosis reduction, lagophthalmos, eyelid retraction, exposure keratopathy, or surgical complications. The average reduction in proptosis was 3.9 mm (range, 1-6.5 mm) in the Sonopet group and 4.0 mm (range, 1-6 mm) in the drill group (p = 0.86). In our series, the average surgical case time was slightly shorter in the Sonopet group than in the drill group (104 vs. 118 minutes, p = 0.032). CONCLUSIONS: Ultrasonic bone removal is a safe and effective alternative to high-speed burring during lateral orbital decompression for thyroid eye disease.

Concomitant cranial and ocular combat injuries during Operation Iraqi Freedom.

BACKGROUND: Concomitant cranial and ocular injuries were frequently seen in combat casualties during Operation Iraqi Freedom. The incidence of these injuries is reported along with an interventional case series. METHODS: A retrospective review was conducted of all surgical patients treated by U.S. Army neurosurgeons and ophthalmologists in Iraq from December 2005 to April 2006. RESULTS: Out of 104 patients with cranial trauma and 158 patients with ocular trauma, 34 had both cranial and ocular injuries (32.7 and 21.5% of patients with cranial and ocular injuries, respectively). Neurosurgical procedures included exploratory craniotomy, decompressive craniectomy, and frontal sinus surgery. Ophthalmologic surgical procedures included globe exploration, open globe repair, primary enucleation, orbital fracture repair, lateral canthotomy and cantholysis, and repair of lid and periocular lacerations. Patients with cranial trauma had a higher incidence of orbital fracture, orbital compartment syndrome, and multiple ocular injuries compared with patients without cranial trauma (odds ratio 6.4, 3.9, and 3.3, respectively). CONCLUSION: A strong association exists between cranial and ocular trauma in combat casualties treated during Operation Iraqi Freedom. Combat health support personnel should maintain a high level of suspicion for one of these injuries when the other is present. Co-locating neurosurgeons and ophthalmologists in support of combat operations facilitates the optimal treatment of patients with these combined injuries.