Transcranial orbital decompression for progressive compressive optic neuropathy after 3-wall decompression in severe graves' orbitopathy.

PURPOSE: To determine surgical outcomes after transcranial decompression of the superior orbit in patients with progressive compressive optic neuropathy (CON) secondary to Graves' orbitopathy (GO) who had previously been treated with 3-wall decompression. METHODS: Approval from the West Virginia University Institution Review Board was obtained. A retrospective review of 4 patients with GO who received bilateral transcranial decompression of the orbits for progressive compressive optic neuropathy after bilateral maximal extracranial 3-wall decompression was performed. The patients were treated by the Multidisciplinary Orbit and Skull Base Services at West Virginia University and the University of Michigan. RESULTS: Bilateral transcranial decompression of the orbit for GO was performed on 8 orbits in 4 patients. All 8 orbits had radiographic evidence of compression of the orbital apex, and all patients had been treated with steroids, orbital radiation, and bilateral 3-wall decompression. Preoperative vision ranged from 20/25 to 20/100, which improved to 20/25 or better in all eyes. The visual field mean deviation improved from a mean of -13.05 to -1.67 dB. Hertel measurements improved from a mean of 19.25 to 15.25 mm. Extraocular motility was essentially unchanged. Two patients were noted to have asymptomatic ocular pulsations. There were no other complications, and all patients remained stable during a follow-up period of 5 years (range 2-8 years). CONCLUSIONS: Transcranial decompression is an effective and safe method of salvaging vision when standard treatments fail. This is only the second report of transcranial decompression for refractory compressive optic neuropathy after decompression from a standard approach.

Amniotic membrane in medial canthal reconstruction.

PURPOSE: To describe the use of amniotic membrane for reconstruction of large medial canthal defects. METHODS: Four cases of medial canthus resection of cutaneous malignancies were reconstructed using amniotic membrane to cover exposed sclera and orbital fat, combined with other reconstructive techniques including titanium plating and myocutaneous flaps. RESULTS: Complete epithelialization of the scleral defect covered with amniotic membrane was seen within 6 weeks in all 4 patients. CONCLUSIONS: Amniotic membrane is useful for complex reconstructions of the medial canthus, and can be combined with other techniques such as myocutaneous flaps. This technique results in good functional and cosmetic results.

Intraoperative fluoroscopy-guided removal of orbital foreign bodies.

PURPOSE: To describe the use of intraoperative fluoroscopy as an aid in the removal of radio-opaque orbital foreign bodies. METHODS: A retrospective interventional case series of 12 patients with orbital foreign bodies that required removal for various indications. All patients underwent orbitotomy and removal of the foreign bodies with the aid of real-time intraoperative fluoroscopic localization. RESULTS: The orbital foreign body was successfully removed without complication in all 12 patients. One patient with ethmoid sinusitis preoperatively had resolution of the infection after surgery. Two patients with extraocular motility deficits preoperatively experienced significant improvement in motility after surgery. Three patients who required MRI studies for unrelated conditions were able to undergo scanning postoperatively without complications. Two patients were combat casualties treated by US medical personnel during Operation Iraqi Freedom. There were no cases of visual or ocular morbidity directly attributable to foreign body removal. CONCLUSION: Intraoperative fluoroscopy is a valuable tool that can aid in the removal of radio-opaque orbital foreign bodies.

North American blastomycosis of the eyelid.

A 26-year-old diabetic man presented with a papillomatous eyelid lesion. Histopathology was consistent with Blastomyces dermatitidis. A 1-year course of itraconazole led to resolution in this case. Although skin is the most common extrapulmonary site of blastomycosis, eyelid involvement is rare. Prompt diagnosis and treatment improve morbidity and mortality.

Chordoma of the anterior cranial fossa and ethmoids with orbital involvement.

PURPOSE: To report a case of orbital chordoma, emphasizing the clinical, operative, and histopathologic findings, and to review similar English-language reports. METHODS: This is a single case report with histopathologic correlation. Search of the English-language literature and review of referenced citations was performed. RESULTS: After treatment with resection and proton beam radiation, our patient is alive, without recurrence at 3-year follow-up. Biopsy of the recurrent tumor was consistent with chordoma. The original biopsy had S100 and pancytokeratin-positive tumor cells, with abundant clear to eosinophilic cytoplasm. Focal EMA positivity was present. Literature review identified 14 additional cases. CONCLUSION: Orbital chordoma is rare. Extraocular motility disturbances occur solely with intracranial lesions as well as those extending into the orbit, but globe displacement is the most common sign of orbital involvement. This tumor often recurs in the path of previous resection. Diagnosis is confirmed by distinctive histopathologic features and positive staining for S100, pancytokeratin, and EMA. Treatment and outcome analysis of orbital chordoma is difficult due to its rarity and lack of reported follow-up and may need to be extrapolated from reported skull base cases.