Relation of the Vector Force Needed to Lift the Upper Eyelids and the Degree of Exophthalmos.

The aim of this study was to determine the relation of the vector force needed to lift the upper eyelids and the degree of exophthalmos (EX). In the 109 magnetic resonance imaging films, the degree of EX (the shortest distance from the cornea to the line connecting both lateral orbital rims), the anterior angle (θ, an angle formed from the lower margin of the upper eyelid-superior transverse ligament (STL)--with a parallel line connecting the supraorbital rim and the infraorbital rim in the sagittal film), the length from the STL to the upper eyelid margin (levator length [LL]), the thickness of the STL (WT), and the thickness the of levator palpebrae (LT) were measured.The average EX was 14.5 ±â€Š2.35  mm. The average θ was 33.84 ±â€Š2.15 degrees. The vector force needed to lift the upper eyelids (cos θ) was 0.83. The average LL was 21.0 ±â€Š1.54  mm. The average WT was 1.07 ±â€Š0.22  mm. The average LT was 1.69 ±â€Š0.30  mm. There was a significant positive relationship between the EX and age (P = 0.022). The EX in those younger than 20 years (12.8 ±â€Š2.06) was significantly lesser than that of the other age groups. There was no significant relationship between the EX and cos θ. However, there was a significant positive relationship between the EX and the LL. There was a significant positive relationship between LL and LT, and between LL and WT.The farther the eyeball protrudes, the longer the LL is needed. The longer the LL is, the thicker the levator muscle and STL.

Surgical effects of various orbital decompression methods in thyroid-associated orbitopathy: computed tomography-based comparative analysis.

OBJECTIVES: To evaluate the surgical effects of orbital fat decompression and bony decompression in each orbital wall using computed tomography (CT) in thyroid-associated orbitopathy (TAO). METHODS: In 27 TAO patients (48 orbits) with exophthalmos who underwent orbital wall decompression combined with fatty decompression, we recorded the resected orbital fat volume intraoperatively and estimated the decompression volume of the orbital wall in the deep lateral, medial and inferior walls using postoperative orbit CT images. Then, the correlation between exophthalmos reduction by Hertel reading and decompression volume in each area was analyzed to validate the surgical predictability, surgical efficiency and contribution level to total exophthalmos reduction. RESULTS: The decompression volume in orbital fat and the deep lateral wall showed relatively high correlation with exophthalmos reduction (surgical predictability) compared to medial and inferior wall. The surgical efficiency was highest at deep lateral wall (2.704 ± 0.835 mm/cm(3)), followed by medial wall (0.892 ± 0.527 mm/cm(3)), orbital fat (0.638 ± 0.178 mm/cm(3)) and inferior wall (0.405 ± 0.996 mm/cm(3)). The actual contribution level to total exophthalmos reduction was highest in fatty decompression, followed by deep lateral decompression. CONCLUSION: In TAO patients with exophthalmos, orbital fat and deep lateral orbital wall are more predictable and contributory surgical targets for postsurgical exophthalmos reduction.

Ophthalmic manifestations of paranasal sinus disease: a clinical grading system.

BACKGROUND: Ophthalmic complications are common manifestations of paranasal sinus disease. We propose a clinical grading system to standardize the category, treatment, and outcome of these complications. METHODS: Forty-two patients with paranasal sinus disease-induced ophthalmic complications were included in the study. The patients were categorized according to their clinical presentation: Grade I, patients with anatomical disturbance; Grade II, patients with ophthalmic functional involvement; Grade III, patients with orbital infection; and Grade IV, patients with visual impairment. RESULTS: The age of the patients ranged from 8 to 65 years (mean = 30 years). Overall, 36% patients had ophthalmologic manifestations with anatomical disturbance (Grade I), 26% had functional disturbance (Grade II), 26% had orbital infections (Grade III), and 12% had visual loss (Grade IV). The cause of the ophthalmic manifestations was allergic fungal sinusitis in 50%, chronic rhinosinusitis in 36%, acute sinusitis in 10%, and mucocele in 4%. The most common ophthalmic manifestation was proptosis (36%), followed by orbital infection (26%), functional involvement (26%), and visual impairment (12%). The patients underwent functional endoscopic sinus surgery and medical treatment when indicated. The outcome in Grades I, II, and III was favorable; the outcome in Grade IV was not favorable. CONCLUSION: This simple clinical grading system provides a useful tool for assessing the overall status of ophthalmic complications of Acute and chronic paranasal sinus disease at the initial clinical assessment and for subsequent management of these complications.

Fractured orbital wall reconstruction with an auricular cartilage graft or absorbable polyacid copolymer.

OBJECTIVE: The objective of the study was to compare the functional and aesthetic results of fractured orbital wall reconstruction with an auricular cartilage graft or absorbable polyacid copolymer. MATERIALS AND METHODS: Twenty patients with blow-out orbital fracture/orbital floor associated or not with the medial wall were assessed by the same craniofacial surgical group. All were evaluated preoperatively and postoperatively by an ophthalmologist for diplopia, enophthalmos, exophthalmos, sensitivity, ophthalmic reflexes, intraocular pressure, and visual field.The patients were subjected to a preoperative facial multislice computed tomographic scan, repeated 6 months after surgery. Eight patients underwent reconstruction with an auricular cartilage graft, and 12 patients, with blade absorbable polyacid copolymer. Subtarsal access was used for all patients. RESULTS: Two patients showed temporary ectropion, 1 in each group. All patients presented satisfactory ocular function, and all tests revealed good orbital delineation, orbital symmetry, periorbital sinus individualization, and reduction of blow-out. CONCLUSIONS: The blow-out orbital wall reconstruction can be performed with the use of an auricular cartilage or with a blade absorbable copolymer without differences regarding functional or aesthetic complications and sequelae.

Surgical correction of orbital and periorbital deformities using lamella and complex osteotomies in both orbital rim and wall.

PURPOSE: For dealing with the problems in orbital and periorbital deformities. METHODS: In orbital deformities such as hypertelorism, orbital dystopia, radiated orbit, and secondary deformities of traumatic orbit, the authors used lamella osteotomies of either orbital rim and wall or complex osteotomies in both adjacent orbital rims and walls with bicoronal incision and galea aponeurotica dissection. In most of the cases, the fragments of complex osteotomies were repositioned with rigid fixation. RESULTS: Best results with nearly normal orbital volumes, better contour of orbit and midface, and improved eyelids and vision were achieved in 44 cases. There were 5 cases of supraorbital osteotomy (intracranial routine), 8 cases of medial orbital osteotomy, 3 cases of inferior orbital osteotomy, and 28 cases of both lateral and inferior orbital osteotomy in the series. No complications occurred. Clinical measurement was achieved in both pre- and postoperative osteotomies. According to comparative recordings, such as cephalometric measurement of the interorbital distance, exophthalmic measurement with Hertel exophthalmometer, the angle between orbital horizontal level and bilateral tragus linkage, and the linear distance between lateral canthus and tragus, the gap difference between pre- and postoperative data were achieved. The orbital and midface appearance has improved significantly. CONCLUSIONS: Lamella and complex osteotomies of orbital rim and wall were proved to be save and effective for correction of most deformities of the orbital and periorbital region.

[How to investigate a patient with exophthalmos?]. / Comment explorer une exophtalmie?

Exophthalmos is the main symptom revealing orbital masses. This sign needs to be imaged mainly by MRI and/or CT. As Graves disease is the main etiology of exophthalmos, CT scan should be performed as the initial imaging modality. Indications for US and Doppler are mostly limited to the study of ocular masses, and eventually may help the characterization of extra-ocular lesions. In all cases, imaging is useful to characterize: the precise location of the lesion which can be the intra-conal space (including muscles), the extra-conal space (associated or not to an extra-orbital lesion), or the eyeball; the features of the lesion (density, signal, enhancement.). These findings are used to generate a differential diagnosis. Imaging is also useful to precise the extension of the mass, and in some cases to select the appropriate surgical approach, and for follow-up.

Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system.

The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.

Orbitopatía tiroidea. Primera parte / Thyroid orbitopathy. First part

Se hace una revisión bibliográfica de las principales características de la orbitopatía tiroidea y se menciona la experiencia de nuestro servicio

[The current role of radiotherapy in immunogenic exophthalmos]. / Il ruolo attuale della radioterapia nell'esoftalmo immunogenico.

In this study, the value of radiation therapy was investigated in 41 patients with Graves' ophthalmopathy treated with orbital irradiation at the Radiotherapy Department of Mauriziano Hospital in Turin, 1986 through 1993. Our series consisted of 41 patients (32 women and 9 men), whose mean age was 53.6 years (range: 26-72 years). All patients had a high index of endocrine ophthalmopathy, based on the American Thyroid Association classification-NOSPECS classes III and IV. Irradiation was administered with two opposed convergent beams tilted posteriorly 5-10 degrees with 20 Gy/12 fractions/2 weeks. The total dose delivered to the lens was than 5%. The follow-up consisted of endocrinologic and ophthalmologic tests and, if possible, of pre/post-irradiation orbital US. A positive result was obtained in 31 patients, which was very good in 22 of them. Severe complications, i.e., 1 corneal ulceration and 3 cataracts, were observed in the patients with associated ocular conditions and were treated simultaneously with high-dose corticosteroids so that no direct and unquestionable correlation can be made between irradiation and complications. To conclude, our data show that radiation therapy can improve the signs and symptoms of Graves' disease, as many authors report.

[A method of evaluating the clinical course of edematous exophthalmos and pseudotumor of the orbit]. / O metodike otsenki klinicheskogo techeniia otechnogo ekzoftel'ma i psevdotumora orbity.

Study of the combinations of symptoms and signs contributing to the clinical picture of edematous exophthalmos (EE) and orbital pseudotumor (OP) has helped single out 14 classes, each of them reflecting the subjective or objective status of a patient. An 0 to 4 score rating inside each class permits ruling out this or that symptom (0 score) or assess its severity (1-2; 3-4 scores). These classes comprise patients' complaints, the status of the periorbital tissues, upper lid and bulbar conjunctiva, the degree of the eyeball protrusion, eye mobility and strabismus angle, and changes in the intraocular pressure and fundus oculi. Analysis of the symptoms markedness in scores for each of the 14 classes, carried out with due consideration for the process stage separately for EE and OP, has shown that the total score is under 6 in the initial stage of the disease and 17 in the decompensation stage. The score drastically rises in the far progressed stages of both EE and OP, being 23-29 in EE and 22-27 in OP. The authors emphasize that the suggested rating helps objectively assess the process stage in each case and thus choose the treatment strategy.

Dynamic proptosis.

Dynamic proptosis can be defined as exophthalmos occurring when a variable force is applied to the orbital contents. In a series of 26 patients (13 males and 13 females, 1 to 82 years old), the causes of dynamic proptosis included neurofibromatosis (nine cases), fistulas (three cases), malignancies (three cases), meningoencephaloceles (two cases), mucoceles (two cases), surgery (two cases), orbital varix (two cases), dermoid cysts (two cases), and aneurysm (one case). Dynamic proptosis can be either spontaneous or induced, and can occur either with an intact or an incompetent bony orbit.

Orbital Graves' disease. A modification of the "NO SPECS" classification.

This paper reviews the original American Thyroid Association (ATA) classification of the orbital changes in Graves' disease, analyzes the subsequent modification of the classification made by the ATA in 1977, and, finally, suggests a second modification. This consists of the addition of six specific soft-tissue signs to Class II of the original classification.