Trigeminal Ophthalmic Branch Schwannoma: Case Report and Literature Review

Schwannomas are the fourth most common primary neoplasms affecting the brain and cranial nerves. Central lesions commonly arise from sensory nerve roots, and a common intracranial site is the vestibular branch of the 8th nerve (>85%). We present the case report of a patient who has a schwannoma extending from the pterygopalatine fossa to the orbit, complaining about facial pain in the trajectory of the trigeminal ophthalmic branch. Schwannomas represent 1 to 2% of all neoplasms of the orbit, and trigeminal schwannomas are extremely rare, accounting for less than 0.5% of all intracranial tumors.

Abordaje transconjuntival en comparación con abordaje subciliar para el tratamiento de fracturas orbitarias / Transconjunctival versus subciliary approach for the treatment of orbital fractures

RESUMEN: Introducción: Los abordajes transconjuntival preseptal y subciliar han sido ampliamente utilizados para el manejo quirúrgico de las fracturas orbitarias. Sin embargo, aún existe incertidumbre sobre las complicaciones asociadas a cada uno de estos abordajes. Métodos: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios. Realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Resultados y conclusiones: Identificamos seis revisiones sistemáticas que en conjunto incluyeron 21 estudios primarios, de los cuales cuatro corresponden a ensayos aleatorizados. Concluimos que el abordaje transconjuntival preseptal podría disminuir tanto la incidencia de ectropión como de un resultado estético insatisfactorio, pero la certeza de la evidencia es baja. Además, este abordaje probablemente disminuye el riesgo de complicaciones intra y postoperatorias, tales como diplopía, parestesia transitoria, equimosis, exposición escleral, laceración del plato tarsal y laceración palpebral inferior. Por otro lado, el abordaje transconjuntival podría aumentar el riesgo de entropión, pero la certeza de la evidencia también es baja.

ABSTRACT: Introduction: The preseptal transconjunctival and subciliary approach have been widely used for the surgical management of orbital fractures. However, there is still uncertainty about the complications associated with each of these approaches. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified six systematic reviews that included 21 primary studies, four of which correspond to randomized trials. We conclude that the preseptal transconjunctival approach could decrease the incidence of ectropion and an unsatisfactory aesthetic result, but the certainty of the evidence is low. Furthermore, this approach probably decreases the risk of intra and postoperative complications, such as diplopia, transient paresthesia, ecchymosis, scleral show, tarsal plate laceration and lower palpebral laceration. On the other hand, the transconjunctival approach could increase the risk of entropion, but the certainty of the evidence is also low.

A Meta-analysis of complications of orbital blowout fracture by surgical approaches / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To investigate the effect of conjunctival approach and skin approach on postoperative complications in orbital blowout fracture through Meta-analysis.<p>METHODS: Search literatures in PubMed, Web of Science, Cochrane library, OVID, Chinese biomedical literature database, Weipu, Wanfang and CNKI database from the establishment of the database to May 30, 2018. The main contents included randomized controlled trials and cohort studies about comparing the postoperative complications of orbital blowout fracture through the transconjunctival approach and subciliary approach. Meta-analysis of the incidence of complications was performed using Review Manager 5.3 statistical software.<p>RESULTS: A total of 7 cohort studies were included. The Newcastle Ottawa Scale(NOS)score showed that the quality of the included literature was above 6 points. Meta-analysis showed no significant difference in odds ratio(OR)between the transconjunctival approach group and subciliary approach group \〖<i>OR</i>=0.74, 95% <i>CI </i>(0.44-1.24),<i> P=</i>0.25\〗. Sensitivity analysis showed that the results of the Meta-analysis were stable and reliable. Funnel plot analysis showed that there might be publication bias in the included literature.<p>CONCLUSION: The effect of skin approach and conjunctival approach on the incidence of postoperative complications of orbital blowout fractures is not significant. The two approaches have their own advantages and disadvantages. It is necessary to combine the clinical practical considerations to select the most suitable surgical approach.

O acesso subciliar como opção para o tratamento de fratura do complexo zigomático-orbitário: relato de caso / The subciliary approach as an option for the treatment of zigomatic-orbital complex fractures: case report

A escolha do tipo de acesso para exploração do complexo zigomático-orbitário depende da localização e tipo de fratura, da experiência do cirurgião e do sucesso dos resultados obtidos. São vários os tipos de acesso para essa região, dentre eles, podem ser citados o acesso subciliar, o subtarsal e o transconjuntival. O acesso subciliar além de promover uma excelente exposição do rebordo infra-orbitário, da parede lateral da órbita e do assoalho orbital, mostra um resultado estético aceitável com cicatriz imperceptível. No entanto, alguns problemas estão relacionados a esta abordagem como o aumento da exposição da esclera e o ectrópio. O propósito deste trabalho é apresentar um caso clínico e discutir seu protocolo de tratamento, bem como suas vantagens e desvantagens e as possíveis complicações.

The type of access for treatment of the zygomatic-orbital complex fractures depends on the fracture type and localization, the surgeon's experience and the good outcomes obtained. There are several types of approach to this place, like the subciliary, the subtarsal and transconjunctival approach. The subciliary approach in addition to promoting an excellent exposure of the infra-orbital rim, the side wall of the orbit and the orbital floor it can end with an acceptable aesthetic result and imperceptible scar. However, some problems are related to this approach as increasing the exposure of the sclera and ectropion. The purpose of this paper is to present a clinical case and discuss the protocol of treatment and their advantages and disadvantages and possible complications.

Forniceal Reconstruction through Subciliary Approach in a Patient with Shallow Inferior Fornix

PURPOSE: To evaluate the usefulness of a new technique for the subciliary approach to the surgical management of anophthalmic, shallow inferior fornices. METHODS: Six patients with difficulty retaining an ocular prosthesis, due to anophthalmic, shallow inferior fornices with sufficient conjunctiva, underwent this operation from October 2003 to April 2005. Surgery consisted of the fixation of the conjunctival fornix to the periosteum immediately posterior to the inferior orbital rim through the subciliary approach. This study was prospective. RESULTS: The mean age of the patients was 40.1+/-14.7 years (range, 21~62 years). Three of six patients were male, and three were female. The mean duration of surgical anophthalmos was 16.8+/-13.2 years (range, 0.6~40 years), and the mean follow-up period was 9.3+/-8.4 months (range, 3~25 months). All 6 patients who could not wear prostheses because of shallow fornices could wear ocular prostheses successfully after the operation. An ocular prosthesis could be fitted at a mean duration of 1.83+/-0.75 weeks (range, 1~3 weeks), postoperatively. Only one patient had mild entropion, but there were no conjunctival contractures or loss of fornices postoperatively. CONCLUSIONS: The authors believe that this new technique through the subciliary approach is simple and easy to perform and enables the patient to wear an ocular prosthesis earlier than does forniceal reconstruction through the transconjunctival approach. This technique is very useful in patients with anophthalmic, shallow inferior fornices who have sufficient conjunctiva but loose attachments of the fornix to the underlying tissue, causing shallow fornices.

Lower Eyelid Retraction and Scleral Show induced by Subciliary Approach in Inferior Orbital Rim Fracture

PURPOSE: The objective of this study is to prevent postoperative lower eyelid retraction and scleral show. There are several approaches for orbital rim reconstruction. But these techniques are sometimes difficult to perform, and have some merits and faults. Maybe most common unwanted and unpleasant result that we have experienced by subciliary incision preseptal approach is the lower eyelid retraction and the scleral show. Therefore, I want to find out the causes and the solutions for such complication. We must know the mechanics for those unpleasant result first of all. METHODS: We conducted a comparison of postoperative photographs between retroseptal approach group and preseptal approach group, both with subciliary incision. In experimental retroseptal group, incision was applied at subciliary region. After elevating skin flap to preserve pretarsal muscle, not with muscle flap elevation, but direct oblique incision through the muscle, retroseptal dissection was applied to the ROOF and the septum. Fixating fracture line, periosteal and septal repair was followed by skin repair. The light compressive dressings and protection were kept in place for 7 days. The effectiveness of this operative method was made comparison with control group which the preseptal approach was applied to, by postoperative 2nd week and 2nd month. RESULTS: Author's technique had been used in 20 patients and control group was composed of 50 patients over 19months period. There were better results in experimental group than in control group and all of experimental group had no complaint about the lower eyelid retraction and the scleral show. CONCLUSION: It must be known about the reason of the lower eyelid retraction and the scleral show induced by subciliary and preseptal approach. Mechanically it can be easily proved. And the solution maybe will be easier if we get more information about the mechanics. I recommend the retroseptal subciliary approach

Prevention of Lower Eyelid Complications Caused by a Subciliary Approach : Temporary Lower Eyelid Suspension

PURPOSE: Subciliary approaches to orbitozygomatic fractures have high incidence of complications such as scleral show and ectropion. Abnormal rearrangement of eyelid flaps may be a very important factor to induce abnormal cicatrical and consequent contracture. To prevent this problem, we used temporary lower eyelid suspension. METHODS: A total of two hundred five patients were investigated for lower eyelid complication of orbitozygomatic fractures that underwent reconstruction with subciliary approach. The lower eyelid margin was pulled up toward the forehead using lower eyelid suspension suture to stretch the lower lid flaps. The lid suspension was maintained for one day after surgery. RESULTS: The complications of the lower eyelid were in 15 cases(7.3%); seven cases(3.4%) of visible depressed scar, three cases(1.4%) of scleral show, two cases(1%) of ectropion, two cases(1%) of conjunctival swelling and one case(0.5%) of hematoma. CONCLUSIONS: The lower eyelid suspension seems to allow adhering lid flap in proper anatomical position and in the status of the maximal stretch and consequently preventing the severe complications such as scleral show and ectropion caused by scar contraction after subciliary approach.