Faculty Bibliography

PURPOSE: To examine the role of transnasal and transantral endoscopic surgical approaches in the management of apical orbital lesions. METHODS: Retrospective case series. RESULTS: Three patients underwent combined orbital and endoscopic surgery for treatment of apical orbital lesions. In two of these patients, the orbital apex was decompressed, which resulted in visual recovery. Using endoscopic approaches to the posterior orbit and orbital apex allowed better visualization, with minimal manipulation of tissues in an area where surgical access is limited. CONCLUSIONS: Apical orbital lesion management benefits from a multidisciplinary and individualized plan. Endoscopic approaches can be used to improve visualization and access to a difficult surgical area. They also allow extra instrumentation to be used through the relatively capacious paranasal sinuses. These advantages may obviate lateral orbitotomy in some situations. Although endoscopic techniques are useful for biopsy, debulking, and removal of orbital apex lesions, they may be more difficult to apply to an intraconal lesion at the orbital apex

A 79-year-old man with myelodysplastic syndrome developed a right optic neuropathy with optic disc edema and intractable periocular pain, one month after undergoing removal of a gangrenous gallbladder. Although results of a temporal artery biopsy were negative, he was treated with prednisone for presumed temporal arteritis. Attempts at tapering the prednisone dose led to recurrence of periocular pain. On neuro-ophthalmologic evaluation six months after the prednisone treatment was begun, he had developed right fourth and sixth cranial nerve palsies, and magnetic resonance imaging demonstrated a right orbital apex mass. Trans-sphenoidal biopsy revealed Aspergillus fumigatus. During treatment of aspergillosis, the patient developed a left hemiparesis. Magnetic resonance imaging disclosed multiple ring-enhancing cerebral masses. Biopsy revealed Nocardia asteroides. The patient was successfully treated for both infections with recovery of neurologic function except for the right optic neuropathy. Although immunocompromised patients are known to be subject to multiple infections, this may be the first reported case of concurrent sino-orbital aspergillosis and cerebral nocardiosis

BACKGROUND: Graves' orbitopathy can produce proptosis, compressive optic neuropathy, and extraocular motility abnormalities; symptoms result from an increase in orbital volume due to expansion of intraorbital fat, with or without extraocular muscle involvement. STUDY DESIGN: We conducted a chart review of patients who underwent orbital decompression to treat Graves' orbitopathy. Twenty-two orbits (13 patients) underwent orbital bone decompression, of which 17 orbits (9 patients) underwent the combined medial and lateral 'balanced' decompression. RESULTS: All patients had significant improvement with an average decrease in proptosis of 5.9 mm in the balanced decompression group. Restoration of normal optic nerve function was achieved in all patients with compressive optic neuropathy. Diplopia was noted in 4 patients (30.7%) preoperatively. Two patients had new postoperative diplopia (15.35%). CONCLUSION: In our experience, 'balanced' decompression results in a reduction of proptosis and improved optic nerve function and has a low incidence of complications

We report an effective alternative treatment of profound chronic exposure keratopathy in a proptotic eye due to intraorbital extension of basal cell carcinoma. The corneal surface gradually reepithelialized in a 6-week period after the first application of Tegaderm transparent dressing (3M, St. Paul, MN, U.S.A.) with instillation of antibiotic ointment on the ocular surface. The patient has been comfortable with an intact epithelial surface, a vascularized cornea, and nonirritated surrounding skin after changing the Tegaderm dressing daily for 15 months. There was no evidence of recurrent corneal ulceration or infiltrations. We conclude that Tegaderm represents a useful treatment of exposure keratopathy due to chronic proptosis

The orbit in Graves disease undergoes expansion in soft tissue content as a result of the infiltration of orbital fat, extraocular muscles, and the lacrimal gland. Compression of the intraorbital contents leads to disorders of the lid-corneal interface, keratopathy, motility disturbances, exophthalmos, and optic neuropathy. Orbital decompression has traditionally been reserved for those patients with unremitting optic neuropathy. This article provides a historical review of orbital decompression, as well as a review of the evolution of surgical approaches toward both soft tissue and bony decompression. Recent trends in surgical management include fat decompression, more extensive posterior sculpting of the lateral wall, and direct approaches to the medial wall. Preoperative predictors of diplopia and hypoglobus are addressed, as are the various techniques that are employed to limit new postoperative strabismus. The roles of endoscopy and combined surgical techniques are also reviewed. Expanded indications for decompression and its effect on increased intraocular pressure are discussed as well

PURPOSE: To determine the utility of CT imaging in identifying patients with dysthyroid optic neuropathy. METHODS: Orbital CT scans of 12 randomly selected patients with dysthyroid optic neuropathy and 15 control subjects with Graves orbitopathy were retrospectively reviewed by two investigators blinded to the clinical data. The clinical diagnosis of optic neuropathy was made by one author before obtaining CT images and was based on clinical features. RESULTS: Optic nerve crowding (P<0.001) and intracranial fat prolapse (P<0.05) were the imaging features independently related to optic neuropathy. A muscle index greater than 50% had excellent sensitivity (100%) but did not have high specificity (47%) for dysthyroid optic neuropathy. Superior ophthalmic vein dilation and proptosis did not show significant relations with optic neuropathy. CONCLUSIONS: This study suggests that patients with Graves orbitopathy who have severe optic nerve crowding, intracranial fat prolapse, and/or muscle index greater than 50% present on orbital CT scans are more likely to have coexisting optic neuropathy

BACKGROUND: Orbital signs and symptoms occur in approximately one half of children with Graves disease, but the symptoms are usually minor and limited to the eyelids. Prominent proptosis is uncommon in children with this disorder. METHODS: Review of eight children with prominent proptosis associated with thyroid eye disease. Four patients were treated at the Children's Hospital of Philadelphia, the other four at the Columbia Presbyterian Medical Center. RESULTS: At initial presentation, children ranged in age from 3 to 16 years. There were five girls and three boys. Seven of eight children had hyperthyroidism at ophthalmic presentation. Four patients had restrictive myopathy, and all of the seven patients who underwent neuroimaging had extraocular muscle enlargement. Five patients were treated with lubrication. Two underwent orbital fat decompression. One patient had thyroid eye disease and myasthenia gravis. CONCLUSIONS: Proptosis in childhood thyroid eye disease usually is associated with a hyperthyroid state. The proptosis may be dramatic, but corneal exposure and restrictive myopathy are seen in only some of the patients. Neuroimaging shows enlarged extraocular muscles. Most children with this complication can be treated conservatively with topical lubrication, but orbital fat decompression may be considered in patients with more advanced conditions.