Efficacy of lateral orbital rim decompression in patients with prior rim-sparing, three-wall orbital decompression.

PURPOSE: The purpose was to study the effects of removal of the lateral orbital rim in patients with prior three-wall decompression for thyroid eye disease (TED). MATERIALS AND METHODS: This was a single-institution retrospective case series of patients presenting with symptoms and signs of residual symptomatic proptosis that had previously undergone three-wall decompression for TED. Data collected included patient age, gender, presenting symptoms, ocular history, proptosis reduction, and complications. RESULTS: Eleven orbits were identified. The mean preoperative exophthalmometry for the operative eye was 24.0 mm with 2.7 mm of relative proptosis. Removal of the lateral orbital rim resulted in a mean reduction in proptosis of 2.5 mm (range: 0.5-5.0 mm, P < 0.001). There was no significant change in diplopia, lagophthalmos, margin reflex distance (MRD) 1, MRD2, or exposure keratopathy. No canthal deformities were noted. All subjects reported satisfaction with functional and cosmetic outcomes of lateral orbital rim removal, and none reported problems with external contour irregularities of the lateral canthal region. CONCLUSION: Removal of the lateral orbital rim as part of a maximal orbital bony decompression adds to the decompressive effect of proptosis reduction with minimal side effects.

Randomised, masked study of local anaesthesia administered prior to external dacryocystorhinostomy under general anaesthesia.

OBJECTIVES: To determine whether administration of local anaesthetic at the site of skin incision during open lacrimal drainage surgery under general anaesthesia alters the total dosage of anaesthetic drugs required during total intravenous anaesthesia (TIVA), and whether it alters postoperative pain and recovery. STUDY DESIGN: Masked comparison of a randomized, two-group interventional study. PATIENTS AND METHODS: Patients undergoing unilateral external dacryocystorhinostomy under total intravenous general anaesthesia were recruited from the lacrimal service at Moorfields Eye Hospital between September 2012 and February 2014. The patients were randomised to receive, after induction and stabilisation of general anaesthesia, infiltration of the ipsilateral paranasal tissues with 2.5 ml of 0.5% bupivacaine with 1:100000 epinephrine ("treatment" group), or a sham injection ("control" group); the infiltration was performed about 7 min prior to the skin incision. The infusion rates for propofol and remifentanil were adjusted to maintain a steady intra-operative mean blood pressure of 55-70 mmHg and BIS score of 40-60%. The time taken for extubation of the patient after cessation of TIVA was recorded, and postoperative pain scores (on a Likert scale from 0-10) were taken at regular intervals after extubation. The average intra-operative mean blood pressures, total drug usage, extubation time and pain scores for each of the two groups were compared using two-tail Student's t-testing and Wilcoxon rank sum testing. RESULTS: There were 12 patients (7 female; 58%) in the treatment group and 11 (7 female; 64%) in the control group, with similar average age at surgery (59 years treatment, 53 years control; p = 0.38) The average operative time was 45 min in the treatment group (median 42, range 30-55) and 47 min (median 45; range 37-61) in the control group (p = 0.52). The mean dosage of propofol required to maintain satisfactory GA was significantly less in the "treatment" group (89.8 mcg/kg/min) as compared to the "control" group (mean 126 mcg/kg/min) (p = 0.0007). Likewise, remifentanil dosage was significantly less in the "treatment" group (100 ng/kg/min) as compared to controls (259 ng/kg/min) (p = 0.00007). The mean non-invasive blood pressure was consistently lower during surgery in the "treated" group, and showed less intra-operative variation. After surgery, the patients receiving LA had a significantly shorter extubation time (mean time 6.0 min in "treated" group, 12.1 min in "controls"; P < 0.0002) and also significantly lower pain scores at 10, 30, 60, 120 and 180 min after extubation (p < 0.01, p < 0.01, p < 0.01, p < 0.01 and p < 0.05, respectively). CONCLUSIONS: Ipsilateral infiltration of local anaesthesia containing epinephrine in the paranasal tissues just prior to open dacryocystorhinostomy under total intravenous anaesthesia is associated with a 28% reduction in mean propofol usage, and a 61% reduction in remifentanil usage. LA usage during GA also produces improved and less variable intra-operative mean blood pressures, a significantly shorter extubation time and significantly lower postoperative pain scores.

Using fixed anatomical landmarks to avoid medial rectus injury: a radiographic analysis in patients with and without Graves' disease.

BACKGROUND: Injury to the medial rectus (MR) is a potentially devastating complication of orbital and sinus surgery. Precise knowledge of the MR relative to the lamina papyracea (LP) is important during endoscopic surgery for both Graves' ophthalmopathy and inflammatory disease. The objective of this study is to determine the location of the MR in relation to easily identified and frequently encountered intranasal landmarks in patients with and without Graves' disease. METHODS: High-resolution computed tomography scans were analyzed in 100 controls and 63 patients with Graves' disease. The MR position was recorded relative to the maxillary sinus ostium (MSO), anterior ethmoid artery (AEA), and posterior ethmoid artery (PEA)/horizontal basal lamella (BL). Clinically relevant variables recorded at each level included the Keros stage, AEA position, MR height, and distance of the MR to orbital floor, skull base, and LP. RESULTS: The mean distances between the MR and LP were statistically different for both groups. Controls at the MSO, AEA, and PEA/BL were 2.92, 1.69, and 1.06mm; for Graves' patients measurements at these sites were 2.12, 1.20, and 0.029mm. When comparing the two groups, each of these distances were statistically significant (p<0.02). There was no difference in ethmoid cavity width (p>0.05) between controls (9.66mm) and Graves' patients (9.70mm). Sex, age, and skull base depth were not statistically significant factors. CONCLUSION: This study illustrates the position of the MR from the perspective of an endoscopic surgeon utilizing fixed intranasal landmarks. Knowledge of the position of MR is critical to safely perform decompression surgery and when operating adjacent to the LP during endoscopic surgery.

Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair.

PURPOSE: To evaluate clinical characteristics, preoperative imaging findings, pre- and post-operative outcomes, and satisfaction of patients requiring secondary reconstruction after inadequate primary orbital fracture repair. METHODS: Retrospective review of 13 patients requiring secondary orbital reconstruction following unsatisfactory primary repair. Primary outcomes were postoperative changes in enophthalmos, hypo- or hyper-globus, superior sulcus deformity, and restrictive strabismus. Secondary outcomes included patient satisfaction. RESULTS: Of 13 patients, 9 patients had primary orbital implants, and 4 patients did not. Of the 9 with implants, 6 had inferior displacement posteriorly, 2 had superior displacement posteriorly, and 1 had good position but had entrapped orbital tissues beneath it. Findings from primary surgery included enophthalmos (12/13), hypoglobus (10/13), hyperglobus (1/13), superior sulcus deformity (9/13), restricted supraduction (12/13), and restricted infraduction (7/13). Mean preoperative enophthalmos and hypoglobus were 4.4 ± 2.6 mm and 2.9 ± 1.4 mm, respectively. Secondary reconstruction resulted in mean reduction of enophthalmos by 3.4 ± 1.4 mm (p < 0.001), of hypoglobus by 2.9 ± 1.5 mm (p < 0.001), and of hyperglobus by 1 mm (n = 1). All 9 patients had resolution of their superior sulcus deformity. Of 12 cases with restricted ocular motility, all had improvements in postoperative motility following secondary surgery. Mean improvement in supraduction and infraduction was 1.8 ± 1.0 points (p < 0.001) and 1.4 ± 1.3 points (p = 0.025), respectively. Twelve patients reported being very satisfied or satisfied with secondary surgery; 1 patient was neutral. CONCLUSIONS: This study demonstrates that secondary orbital reconstruction can achieve excellent functional and cosmetic results with high patient satisfaction and minimal complications. Secondary reconstruction of previously repaired orbital fractures should be considered when clinically indicated.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury.

PURPOSE: Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described. METHODS: This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded. RESULTS: Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25-80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1-5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively. CONCLUSION: Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Masquerading Orbital Sarcoidosis with Isolated Extraocular Muscle Involvement.

Two patients, previously diagnosed and treated for euthyroid, autoantibody-negative thyroid eye disease, presented with active orbitopathy. An atypical disease course and presentation prompted orbital biopsy. Extraocular muscle histopathology demonstrated noncaseating granulomatous inflammation consistent with presumed orbital sarcoidosis involving multiple extraocular muscles, including the inferior oblique in one of the cases. These two cases emphasize the importance of a broad differential diagnosis and the utility of an orbital biopsy in the context of an unusual disease presentation or poor treatment response. The patients' clinical course is discussed alongside important clinical signs, imaging findings, and biopsy results that support a diagnosis of isolated orbital sarcoidosis.

Customised 3D Printing: An Innovative Training Tool for the Next Generation of Orbital Surgeons.

Additive manufacturing or 3D printing is the process by which three dimensional data fields are translated into real-life physical representations. 3D printers create physical printouts using heated plastics in a layered fashion resulting in a three-dimensional object. We present a technique for creating customised, inexpensive 3D orbit models for use in orbital surgical training using 3D printing technology. These models allow trainee surgeons to perform 'wet-lab' orbital decompressions and simulate upcoming surgeries on orbital models that replicate a patient's bony anatomy. We believe this represents an innovative training tool for the next generation of orbital surgeons.

Mastication induced retrobulbar hemorrhage.

Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.