Endoscopic medial orbital fat decompression for proptosis in type 1 graves orbitopathy

PURPOSE

To describe the surgical technique for endoscopic medial orbital fat decompression in type 1 (lipogenic) Graves orbitopathy and report outcomes.

DESIGN

Retrospective interventional case review.

METHODS

We reviewed 108 patients (206 orbits) with inactive, type 1 Graves orbitopathy without diplopia, who underwent endoscopic medial orbital fat decompression solely for proptosis reduction. Following endoscopic transethmoid medial orbital wall decompression, extraconal and intraconal orbital fat was removed with a low-suction cutting instrument. All patients were followed up for at least 12 months. Surgical time, preoperative and postoperative Hertel exophthalmometry, incidence of postoperative diplopia within 30-degree visual field in the primary gaze, and other complications were analyzed.

RESULTS

The mean surgical time was 97.7 ± 16.7 minutes (67-136 minutes). The mean follow-up was 16.0 ± 4.2 months (12-24 months). Preoperative and postoperative proptosis values at final review were 21.1 ± 2.3 mm (17-26 mm) and 13.0 ± 0.9 mm (12-15 mm), respectively (P < .001). Median reduction in proptosis was 8.0 mm with mean of 8.2 ± 1.8 mm (4-11 mm). Symmetry to within 2 mm was achieved in 106 of 108 patients (98.1%). Twenty-five of 108 patients (23.1%) had diplopia within 30-degree visual field of the gaze, and 23 of these had complete resolution within 3 months, while the remaining 2 patients required squint surgery.

CONCLUSIONS

Endoscopic medial orbital fat decompression may be an effective technique for proptosis in selected patients with type 1 Graves orbitopathy and is associated with a low rate of surgically induced diplopia.

Horizontal eye position in thyroid eye disease: a retrospective comparison with normal individuals and changes after orbital decompression surgery

Objective

To compare horizontal eye positions between proptotic thyroid eye disease patients and normal individuals, and to examine positional changes after orbital decompression surgery in thyroid eye disease patients.

Methods

The present case-controlled and retrospective comparative study included 78 proptotic thyroid eye disease patients who underwent bilateral orbital decompression surgery [lateral orbital wall decompression (Group L), 47 patients; medial orbital wall decompression (Group M), 9 patients; and balanced orbital decompression (Group B), 22 patients] and 143 age-matched healthy volunteers as controls. The interpupillary distance was measured to determine horizontal eye positions before and 3 months after surgery in thyroid eye disease patients and was also examined in control eyes. Horizontal eye shifts were calculated by subtracting postoperative from preoperative interpupillary distances.

Results

Preoperative interpupillary distances in thyroid eye disease patients were significantly larger than in controls. The interpupillary distances were significantly decreased postoperatively in Groups M and B, but were significantly increased in Group L. The order of the magnitude of the horizontal shifts was Groups M>B>L.

Conclusions

Proptotic thyroid eye disease patients preoperatively showed laterally displaced eyes in comparison with controls. However, the eyes shifted medially after the medial orbital wall decompression and the balanced orbital decompression, although the former showed more shift. Medial orbital wall or balanced orbital decompression can be used to correct both lateral and anterior displacement of the eyes.

Frontal epidural empyema (Pott's puffy tumor) associated with Mycoplasma and depression

A 37-year-old male has left exophthalmia, which gradually evolved in the last two years, finally with a deviation of left eye (LE), down side and out, with gradually decrease of visual acuity (VA). These symptoms are accompanied with headache and psychiatric manifestations with irritability, decreased attention, anxiety, insomnia, depressed mood. Brain Computed Tomography (CT) shows a tumor mass in air leakage sinus, bilateral frontal and bilateral ethmoidal, with left orbital invasion. This tumor mass lysis by pressure the supero-posterior wall of the left orbit, with the delimitation of a frontal epidural process with a capsule and calcifications. Additionally, it has been shown there is a bilateral maxillary sinusitis. The surgical intervention removed the infection focal spots rearranging the left eyeball, recovering the VA. The sinuses were drained. The psychiatric symptoms in the post operatory phase disappeared. Histopathological examination of the excised tissue revealed sinus ciliated respiratory mucosa with mixed acute and chronic inflammatory infiltrate and focal squamous metaplasia. The lamina propria is edematous and contains large numbers of neutrophils, lymphocytes and plasma cells. Histopathological diagnosis is acute and chronic sinusitis.

CONCLUSIONS

An untreated infection of the aerial sinuses can lead to a complication like Pott's puffy tumor. When signs such as ophthalmologic, psychiatric and intense headaches appear, it suggests the presence of the Pott's puffy tumor (PPT). The clinical signs are reversible once the tumor has been removed.

A rare case of a solitary intraocular neurofibroma

BACKGROUND

Solitary neurofibroma in the absence of neurofibromatosis is of rare occurrence and very few cases have been reported till date.

OBJECTIVE

To report a case of a solitary intra-ocular neurofibroma.

CASE

A 65-year-old man presented to us with a large swelling appearing to arise from right pthisical eye for the past one and a half years. After knowing the extent and origin of mass lesion, right eyeball was enucleated and subjected to histopathological examination which revealed intraocular neurofibroma in the absence of neurofibromatosis which is of very rare occurrence.

CONCLUSION

The isolated neurofibroma of intraocular origin can present as an isolated orbital mass without systemic features.

[Rationale for distinguishing the lipogenic form of thyroid orbitopathy]

Pathogenesis of lipogenic form of thyroid orbitopathy (TO) is presented. 172 patients with TO are presented, among them 47 males (93 orbits) and 125 females (250 orbits). Features of clinical manifestations of lipogenic form of TO are described. The results of CT of extraocular muscles (EOM) and orbital fat volume are studied in these patients and the density of EOM is assessed.

Long-term outcomes of unilateral orbital fat decompression for thyroid eye disease

BACKGROUND

The aim of this study was to evaluate the long-term outcomes after unilateral orbital fat decompression in patients with thyroid eye disease.

DESIGN

Retrospective, comparative, cross-sectional study

PARTICIPANTS

Thirty-three orbits of 33 patients were included in this study. Of the 33 patients, 13 underwent fat decompression (group A), and the other 20 had bony decompression (group B).

METHODS

The medical records of patients who underwent orbital decompression to reduce proptosis for thyroid eye disease were retrospectively reviewed. The degrees of proptosis were measured by Hertel exophthalmometry preoperatively and over a follow-up period of more than 3 years. We evaluated the change in proptosis after surgery.

MAIN OUTCOME MEASURES

Postoperative change in exophthalmos.

RESULTS

A recurrence in proptosis from fat decompression was seen in ten patients (76.9 %) in group A and in only two patients (10 %) in group B. The amount of regression due to surgery after 3 years was 2.3 ± 1.4 mm and 0.7 ± 0.9 mm in groups A and B respectively. The tendency of regression was more prominent in group A than in group B.

CONCLUSION

The long-term effect of unilateral orbital fat decompression for the reduction of proptosis in patients with thyroid eye disease may be weak, leading to regression. Care should be taken when determining the extent of fat decompression with consideration for this tendency.

[Spontaneous orbital hematoma: two case reports]

Although rare, spontaneous intra-orbital hematoma can quickly jeopardize vision. It usually presents with painful proptosis. It can result from multiple etiologies, and the diagnosis is based on imaging studies in the absence of known causes. We describe two cases of spontaneous intraorbital hematoma. The first, of unknown etiology, required needle drainage. The second was associated with a subperiosteal hematoma of the orbital roof complicating a periorbital bone infarction in a patient with sickle-thalassemia.

Rhino-orbital fungal infection: two cases report

Rhino-orbital fungal infections are serious and life threatening complications of immunocompromised host. The authors reported two cases of rapid progressive proptosis and eyelid necrosis of immunocompromised patients who suffered from highly malignant T-celled lymphoblastic leukemia/lymphoma and congenital heart disease with multiple anomalies. Although early diagnosis was made and prompt treatments including medical and surgical interventions were performed, both patients died.

A case of exorbitism in association with Wegener's granulomatosis with renal involvement

Wegener's granulomatosis (WG) is a necrotizing granulomatous vasculitis involving the nose, paranasal sinuses, lungs, and kidneys. Ocular involvement can occur in about 50% of cases. There are very few reports of WG with orbital inflammation and exorbitism. We report a case of a female patient who presented with exorbitism related to orbital inflammation secondary to WG, with renal involvement. A 29-year-old woman with a previous history of recurrent pan-sinusitis presented with bilateral exophthalmos and renal failure with rapidly progressive glomerulonephritis. Computed tomography showed extensive bilateral soft tissue in the retro-orbital area. Immunologic tests showed the presence of type-C anti-neutrophil cytoplasmic antibodies and renal biopsy revealed pauci immune crescentic glomerulonephritis. The patient was treated with corticosteroids and pulses of cyclophosphamide followed by azathioprine and trimethoprim-sulfamethoxazole. After a follow-up of 10 months, the renal outcome was favorable with improvement of renal function but there was persistence of exorbitism and loss of visual function. Our case suggests that WG should be considered in the differential diagnosis of persistent bilateral exophthalmos. Prompt recognition of this early manifestation is important for the institution of early treatment.

[Extraocular myositis and comparative pathology: two case reports in the dog]

Two cases of extraocular myositis in dogs are reported in a golden retriever and an Australian shepherd. This condition is characterized by sudden bilateral exophthalmos, the absence of pain and third eyelid protrusion, orbital sonography showing the enlargement of extraocular muscles, and a quick response to systemic steroids at an anti-inflammatory dose. The literature review reports a breed predisposition in the golden retriever, mainly in females. Histopathologic evaluations confirm the inflammation of one or several extraocular muscles. Chronic disease was also described. Canine extraocular myositis shows some resemblance to Graves ophthalmopathy but can better be compared to idiopathic orbital myositis. Both disorders are probably the consequence of an immune dysfunction that still has to be discovered.

Surgical management of heavy eye phenomenon

Heavy eye phenomenon can be cosmetically unaccepted due to significant pseudoproptosis and hypotropia. We highlight the salient features of this condition, and report successful cosmetic outcome following a staged procedure comprising orbital decompression and horizontal recti surgery.

Ultrasonic measurement of ocular rectus muscle thickness in patients with Graves' ophthalmopathy

The aim of this study was to evaluate changes in extraocular muscle thickness and to assess its correlation with the degree of proptosis in patients with Graves' ophthalmopathy (GO).

MATERIAL AND METHODS

A total of 242 patients (207 females and 35 males) with Graves' ophthalmopathy were enrolled into the study (GO group). Their mean age was 53.83±14.49 years. In addition, we examined an age-matched (53.51±12.79 years) control group of 40 healthy persons. All the participants underwent ophthalmological examination, including eye protrusion measurement and ultrasonographic evaluation of extraocular muscles thickness.

RESULTS

The mean exophthalmos in the GO and control groups was 17.84±2.79 mm and 16.0±1.58 mm, respectively. The enlargement of inferior rectus muscle was recorded in 92.1% of patients, lateral rectus muscle in 81.2%, and medial rectus muscle in 50.8% (P<0.001). A significant correlation between exophthalmos and muscle thickness sum was found in the GO group (Spearman correlation coefficient, 0.515; P<0.0001).

CONCLUSIONS

Graves' ophthalmopathy is more frequent in medium-aged women than men. A significant enlargement of inferior, lateral, and medial straight muscles was noticed in the GO group. With increasing proptosis, the sum of the muscle thickness was increasing, and exophthalmos moderately correlated with muscle thickness sum.

[Measurement of the globe proptosis by CT and its accuracy in patients with unilateral orbital fracture]

OBJECTIVE

To evaluate the accuracy of measurement of the globe proptosis by CT in patients with unilateral orbital fracture.

METHODS

25 patients with unilateral orbital fracture were included. CT was performed before and after operation. The globe proptosis on the unaffected side was measured before and after operation by using Hertel exophthalmometer (HE), CT images with orbital lateral rim (OLR) and the optic nerve foramen (ONF) as reference points. The accuracy was evaluated comparably by statistical analyses.

RESULTS

The preoperative and postoperative average globe proptosis were (13.9 +/- 3.1) mm and (12.5 +/- 2.2) mm in HE group, (16.1 +/- 2.6) mm and (15.7 +/- 2.3) mm in the OLR group, (45.3 +/- 4.8) mm and (46 +/- 3.9) mm in the ONF group, showing a significant difference between the pre-and post-operative results in HE group, but not in OLR and ONF groups.

CONCLUSIONS

CT measurement with the orbital lateral rim as reference point is more reliable than Hertel exophthalmometer measurement for globe proptosis.

MR imaging in aneurysmal bone cyst of the orbit

Aneurysmal bone cyst is a benign fibro-osseous lesion usually described in the long bones. Intraorbital aneurysmal bone cyst is a rare clinical entity with an entirely different outcome and prognosis as compared to the usual pediatric orbital tumors. The authors report magnetic resonance imaging (MRI) features of an orbital mass lesion in a 4-year-old child who presented with painless proptosis of right eye. Characteristic MRI findings led to a suspicion of an aneurysmal bone cyst that was totally excised via a right frontotemporal craniotomy. Appreciation of characteristic MRI features can be of extreme help for appropriate diagnosis and management of this rare entity.

[Computed tomographic anatomy of the orbit in the view of a clinician]

The paper deals with the examination of computed tomograms of 72 patients (90 orbits), including 29 males (36 orbits) and 43 females (54 orbits), who had no any orbital pathology. The patients' age ranged from 34 to 65 years. Data on the volume of the bony orbit and its soft tissue contents are given. The dimensions of the transversal opening to the orbit and its depth are shown. The volumes of all the ocular muscles (extraocular muscles, the elevator muscle of the upper eyelid), optic nerve, eyeball, and ocular fat are separately calculated. These indices may be used for both the differential diagnosis of true exophthalmos and pseudoexophthalmos and the planning of any orbital surgery.

Traumatic carotid cavernous fistula associated with a mandibular fracture

Carotid cavernous sinus fistula is an abnormal vascular interconnection between a branch of the carotid artery and the cavernous sinus. This is an uncommon complication of craniofacial injuries, as it occurs in only 0.17-0.27% of cases, according to the literature. The differential diagnosis should include superior orbital fissure syndrome, orbital apex syndrome, orbital haematoma and cavernous sinus thrombosis. The case is reported of an 18-year-old white woman who was involved in a motor vehicle accident. Clinical examination revealed only mandibular fractures, with the absence of skull-base, mid-face or any other fractures. Two days after the trauma, her condition deteriorated, and extraocular movements were totally absent. Magnetic resonance angiographic scanning was performed, and a carotid cavernous sinus fistula was found. This was treated by embolization resulting in restoration of eye movement and vision.

Exacerbation of Graves Ophthalmopathy With Interferon-α Therapy

Thyroid dysfunction, particularly hypothyroidism, following interferon-alpha therapy is not uncommon. To our knowledge, this is the first case report of exacerbation of Graves ophthalmopathy during treatment with interferon-alpha for chronic hepatitis C virus.