Transcranial superior orbitotomy for the treatment of intraorbital intraconal tumors: surgical technique and long-term results in single institute

Sino-orbital foreign body caused by a slingshot injury in a young boy

Slingshots or hand catapults, historically used as a military or hunting weapon, are common toys among children and young teenagers. Their use can be dangerous as a strike to the eye or orbit can result in significant injuries including blindness. We describe a rare case of a sino-orbital foreign body caused by a slingshot injury in a young boy. The case was managed by a multidisciplinary team involving ear, nose and throat, ophthalmology and paediatrics, and the foreign body of a metal ball bearing was removed using an endoscopic transnasal approach. Although the patient made a good recovery, the case highlights the danger of slingshot devices misused by children.

Endoscopic diagnostic and surgical orbital approach in canines

The aim of this study is to describe new diagnostic and surgical orbital approaches using video endoscopy in canines. Four different endoscopic approaches were investigated in this study of video endoscopy in cadavers: dorsal transorbital ligament approach via incision of the orbital ligament (DTOLA), dorsal subpalpebral transconjunctival approach (DSTA), ventral subpalpebral transconjunctival approach (VSTA), and transoral orbital approach (TOA). Two additional approaches, the ventral transpalpebral approach (VTA) and dorsal caudal transmuscular approach (DCTA) along with the DTOLA and DSTA were used in clinical patients. The most technically demanding approach was DTOLA; however, it provided the best visualisation of different anterior and posterior orbital structures. Visualisation of primarily the dorsal orbital wall, dorsal portion of the eye globe, and dorsal extraconal space also was achieved by DSTA. The VSTA enabled good visualisation of the ventral orbital floor and the ventral extraconal and intraconal space. In contrast, the TOA provided relatively poor visualisation of orbital structures, limited to the ventral orbital quadrant. Meanwhile, the VTA provided visualisation similar to the VSTA, while DCTA visualisation was limited to the dorsal and caudal orbital space. Orbital endoscopy is an effective and minimally invasive procedure that can be used for diagnostic and surgical orbital procedures.

Personalized multidisciplinary approach of orbital apex foreign body: A case report and literature review

Foreign bodies in the intraconal space are unusual, and lodgment at the orbital apex was even more unusual. High-velocity object injuries, such as gunshots or industrial accidents, are the common causes of intraorbital foreign bodies. It is difficult for surgeons to retrieve foreign bodies from the orbital apex as it is a deep, narrow space with critical surrounding structures. The use of an image-guided navigation system improves the accuracy of transnasal endoscopic surgery and causes less damage. We present a case in which a bullet became lodged in the orbital apex and was successfully removed using transnasal endoscopic surgery with the collaboration of otolaryngologists and ophthalmologists. To summarize, orbital apex foreign bodies are harmful, and prompt removal with a personalized multidisciplinary approach is critical.

Primary and Secondary Optic Nerve Sheath Meningioma

Objective  This study was aimed to review issues relating to the recognition, radiographic diagnosis, monitoring, and management of primary and secondary optic nerve sheath meningioma (ONSM). Design  This study is a review of peer-reviewed literature combined with illustrative case studies. Participants and Methods  A literature search was conducted via the PubMed database using pertinent search terms. Selected articles were limited to those written or translated into English. Additional works cited within articles were also included. Individual cases were drawn from the experience of a tertiary academic neuroophthalmic and orbital practice. Tables summarize radiotherapeutic and surgical studies, excluding single case reports and studies focusing on meningioma of intracranial origin. Main Outcome Measurements  Review of reported surgical and radiotherapeutic series is the primary measurement. Results  The natural history of optic nerve sheath meningiomas is primarily characterized by progressive ipsilateral vision loss. Diagnosis is typically based on radiographic imaging findings, with biopsy remaining indicated in some patients. Management strategies may include observation, radiation, and/or surgical intervention, or a combination of these approaches. The role of surgery, especially with respect to primary ONSM (pONSM), remains controversial. Advancement of radiotherapy techniques has shifted modern treatment paradigms in pONSM toward radiation as primary treatment, as surgical outcomes are inferior in major studies. Although radiation remains the treatment of choice in many cases, selected patients may benefit from surgery, especially in the setting of secondary ONSM (sONSM). Conclusion  A wide variety of radiotherapeutic and surgical treatment modalities for ONSM exist. The specific indications for each management strategy continue to be redefined.

Primary Orbital Dedifferentiated Liposarcoma

BACKGROUND

Primary dedifferentiated liposarcoma of the orbit is a rare condition.

CASE DESCRIPTION

A 41-year-old man presented with a history of right ophthalmalgia with eye movement and exophthalmos that had developed 2 months earlier. Neuroimages revealed a right orbital mass located above the superior rectus muscle. Tumor resection through the right frontal craniotomy was performed. Histopathologic findings showed the dedifferentiated liposarcoma.

CONCLUSIONS

Primary orbital dedifferentiated liposarcomas remain challenging for their diagnosis and standard treatment. Clinicians should keep in mind the possibility of liposarcoma with orbital tumors.

An Anatomical Feasibility Study for Revascularization of the Ophthalmic Artery. Part II: Intraorbital Segment

INTRODUCTION

Distal ophthalmic artery (OpA) aneurysms are a rare subset of vascular lesions with lack of optimal treatment. The management of these aneurysms may require complete occlusion of the parent vessel, carrying a risk of permanent visual impairment due to individual variations of extracranial collateral flow to the intraorbital ophthalmic artery (iOpA).

OBJECTIVE

To test the feasibility of a superficial temporal artery (STA) to iOpA bypass to prevent acute ischemic retinal injury. Two different transorbital corridors (superomedial and posterolateral approaches) for this bypass were evaluated.

METHODS

Each approach was carried out in 10 specimens each (n = 20). The corridors were compared to achieve the optimal exposure of the iOpA until the central retinal artery origin was visualized. An end-to-end anastomosis was performed from STA-to-iOpA. The arterial caliber and length at the anastomotic sites, required donor artery length, and intraorbital surgical area were measured.

RESULTS

STA-iOpA bypasses were performed in all specimens. For the posterolateral transorbital approach, the mean caliber of STA was 1.8 ± 0.2 mm, and that of iOpA was 1.7 ± 0.5 mm. The required STA graft length was 78.3 ± 1 mm with lateral iOpA transposition of 8.2 ± 1.1 mm. For the superomedial approach, the average STA length required for an intraorbital bypass was 130.8 ± 14.0 mm. The mean calibers of iOpA and STA were 1.5 ± 0.1 mm and 1.5 ± 0.1 mm, respectively.

CONCLUSIONS

This study demonstrates the feasibility of a novel revascularization technique of the iOpA using 2 different transorbital approaches. These techniques can be used in the management of intraorbital lesions such as OpA aneurysms, tumoral infiltrations, or intraoperative injuries.

Intra-Orbital Meningioma Causing Loss of Vision in Neurofibromatosis Type 2: Case Series and Management Considerations

Objectives: Little evidence exists regarding the management of orbital meningioma causing vision loss in the setting of neurofibromatosis Type 2 (NF2). We review here our experience with patients at risk for blindness due to intra-orbital meningioma. Design/Setting/Participants/Main Outcome Measures: The charts of patients with NF2 presenting for evaluation of intra-orbital meningioma and vision impairment between 2008 and 2013 were retrospectively reviewed in accordance with institutional IRB policies. Patients with primarily extra-orbital tumors and minimal intra-orbital extension were excluded. Charts were analyzed for the presence and/or imaging progression of intra-orbital tumor, presence of other optic apparatus pathology, presence and/ or progression of vision impairment, and intervention performed (if any). Results: Seven patients with intra-orbital meningioma on MRI and bilateral vision loss and/or unilateral visual impairment due to tumor and contralateral blindness of any etiology were identified. Patients without salvageable vision in either eye were excluded (n = 3). Diagnosis of meningioma was obtained either by biopsy or based on imaging assessment. Conclusion: Conservative management of orbital tumors in NF2 may be preferred in asymptomatic patients but may not be acceptable in patients with progressive visual decline. Radiation is a reasonable option for meningiomas of the orbit and optic nerve sheath. Finally, although the benefit of cranial nerve decompression in NF2 for preservation of facial nerve and hearing has previously been established, the role of optic nerve decompression for preservation of vision in NF2 remains poorly defined.

Analyses on the misdiagnoses of 25 patients with unilateral optic nerve sheath meningioma

AIM

To investigate clinical features of optic nerve sheath meningioma (ONSM) that was misdiagnosed, and to find methods to reduce the misdiagnoses.

METHODS

Retrospective series study. Twenty-five misdisgnosed patients with unilateral ONSM were collected from Jan. 2008 to Jan. 2015 and the clinical records reviewed.

RESULTS

Patients were misdiagnosed with acute papillitis most frequently (n=17), immediately followed by optic atrophy (n=8), ischemic optic neuropathy (n=5), acute retrobulbar optic neuritis (n=5), optic disc vasculitis (n=3). For each patient, the minimum frequency of misdiagnoses was once and the maximum was 4 times. As for the lasting time of being misdiagnosed, the shortest was 1.5mo and the longest was 45mo. Twenty-one cases (84%) were once treated with glucocorticoids, and its side effects was found in seventeen patients. Twenty patients (80%) complained with varying degree of vision loss. When a definite diagnosis was made, sixteen cases (64%) showed slight exophthalmos and eighteen cases (72%) had the tubular ONSM.

CONCLUSION

ONSM without loss obvious exophthalmos is easily misdiagnosed in clinic, and for most of these ONSMs are tubular.

Superolateral Orbitotomy for Intraorbital Tumors: Comparison with the Conventional Approach

Objectives This study aims to compare the surgical and functional outcomes of superolateral orbitotomy (group A) and conventional superior orbitotomy (group B) for benign orbital tumors. Design A retrospective review of 31 consecutive orbital tumor surgeries with the fronto-orbital approach was conducted. Setting Procedures were performed at two institutions by a single surgeon. Participants A total of 31 orbital tumor patients participated in this study. Overall, 11 intraconal and 2 extraconal tumors in group A and 11 intraconal and 7 extraconal tumors in group B were resected by superolateral orbitotomy, respectively. Main Outcome Measures Demographic information, pre- and postoperative neurological findings and neuroimaging data, and pathological data were collected. Surgical and functional outcomes were compared and statistically analyzed between the two different surgical procedures. Results The surgical outcomes were not significantly different between the two groups. In patients with intraconal tumors, the functional outcome was significantly better in group A than in group B. Conclusion Superolateral orbitotomy provides better functional outcomes.

[Surgical approaches of tumors of the posterior cone of the orbit]

The surgical management of posterior orbital tumors is complex because it is an anatomical area located at the borders between the face and the skull base. The goal of the procedures carried-out in this area is to resect the tumor while preserving vision by using the safest possible approach. The aim of our work was to determine, in the light of our experience and of a review of the literature, the advantages and drawbacks of the numerous approaches described.

Endoscopic transnasal approach for resection of locally aggressive tumors in the orbit

OBJECT

In recent years, application of endoscopic transnasal surgery (ETS) has been expanded to orbital lesions, and preliminary results have started to be published for medially located soft mass lesions. However, reports on experience with endoscopic intraorbital surgery aimed at resection of invasive skull base tumors remains quite limited. This report presents the authors' experience with ETS for locally aggressive tumors involving the orbit.

METHODS

ETS was performed for 15 cases of aggressive tumors involving the orbit: 5 meningiomas (meningothelial, n = 3; atypical, n = 1; anaplastic, n = 1), 4 chordomas, 2 chondrosarcomas, and 4 others (metastasis from systemic myxofibrosarcoma, schwannoma, inverted papilloma, and acinic cell carcinoma, n = 1 each). Among these, 9 tumors were located outside the periorbita and 6 inside the periorbita. In 6 intraperiosteal tumors, 5 were intraconal lesions, of which 3 arose in the muscle cone (anaplastic meningioma, optic sheath meningioma, and metastatic myxofibrosarcoma), and 2 meningothelial meningioma had invaded from the sphenoid ridge or the cavernous sinus into the muscle cone through the optic canal and the superior orbital fissure. A case of schwannoma originated around the cavernous sinus and pterygopalatine fossa and extended extraconally into the periorbita. Intraoperatively, ethmoid air cells and the lamina papyracea were removed, and extraperiosteal tumors were safely approached. For intraperiosteal tumors, the periorbita was widely opened, and the tumors were approached through the surgical window between the rectus and oblique muscles.

RESULTS

Gross-total resection was achieved for 12 of the 15 tumors, including 2 intraconal lesions. After surgery, exophthalmos resolved in all 8 patients with this symptom, and diplopia resolved in 5 of 6 patients. Improvement of visual symptoms was reported by 4 of 5 patients with loss of visual acuity or constriction of the visual field. Postoperatively, 1 patient showed mild, transient worsening of existing facial dysesthesia, and another showed transient ptosis and mild hypesthesia of the forehead on the affected side. All those symptoms resolved within 3 months. No patients showed enophthalmos, worsening of diplopia or visual function, or impairment of olfaction after surgery.

CONCLUSIONS

ETS appears acceptable as a less-invasive alternative for treating aggressive tumors involving the orbit. For extraperiosteal tumors, gross-total removal can generally be achieved without neurological complications. For intraperiosteal tumors, surgical indications should be carefully discussed, considering the relationship between the tumor and normal anatomy. Wide opening of the periorbital window is advocated to create a sufficient surgical pathway between the extraocular muscles, allowing a balance between functional preservation and successful tumor resection.

[Apropos of 5 cases of optic nerve tumors diagnosed during a 6-year-period]

INTRODUCTION

Optic nerve tumors are uncommon and rarely described. By way of five patients treated at the University Hospital of Clermont-Ferrand, France, over a six-year-period, we discuss their clinical and radiological characteristics, their treatment and their course.

OBSERVATIONS

We report two cases of optic nerve glioma in small children, two cases of optic nerve sheath meningioma and a 57-year-old patient treated for lung cancer with an optic nerve metastasis and choroidal and brain metastases. The diagnosis was confirmed by imaging in all patients and histologically for the cases of optic nerve glioma.

RESULTS

The children with glioma were exclusively treated with chemotherapy, the two women with meningioma exclusively with radiation therapy, and the man with the optic nerve metastasis by chemotherapy and radiotherapy. The tumors were stabilized in all cases except for a progression in one case of glioma, one year after treatment.

DISCUSSION

Gliomas and meningiomas are the most frequent tumors; other tumors are rare. Through a literature review and many illustrations, we discuss epidemiologic, clinical and radiologic characteristics, treatment and course of these uncommon tumors.

CONCLUSION

The diagnosis of optic nerve tumors must be considered in cases of anterior or posterior progressive optic neuropathy. Treatment must be a compromise between effective treatment of the tumor and preservation of visual function. Decisions are made through multidisciplinary consultations, in which the role of the ophthalmologist is crucial for the diagnosis and success of the treatment.

Pre-chiasmatic transection of the optic nerve can save contralateral vision in patients with optic nerve sheath meningioms

OBJECTIVES

With respect to its characteristic pattern of growth from the orbit into the intracranial space toward the chiasm, patients with optic nerve sheath meningiomas (ONSM) are threatened to loose function of both optic nerves. Fortunately, in less than 5% both optic nerves are involved initially. Hence, prevention of vision of the contralateral eye is the foremost aim of any therapy. Performing pre-chiasmatic transection might offer a further treatment option to avoid further tumor growth toward the chiasm.

PATIENTS AND METHODS

In this retrospective study 12 patients with ONSM and blindness of the affected eye were included. The surgical approach was performed either from pterional intradural or as a combined approach from pterional extra- and intradural.

RESULTS

Without any exceptions, vision of the contralateral eye could be preserved and did not show any deterioration after surgery or during the follow-up time of 50.6 months. Furthermore in 58.3% of patients gross total tumor resection could be achieved. During follow up observation in 67% of patients no further tumor progress or recurrences could be observed. 4 patients, however, showed delayed tumor progress or recurrences that were treated by radiotherapy.

CONCLUSION

Pre-chiasmatic transection of the optic nerve might offer a surgical treatment option to control tumor growth and to preserve vision of the contralateral eye.