Orbit and Orbital Apex

Navigation-assisted, endonasal, endoscopic optic nerve decompression for the treatment of nontraumatic optic neuropathy

BACKGROUND

Many authors have reported on therapeutic strategies for traumatic optic neuropathy and their experience with endonasal endoscopic optic nerve decompression for traumatic optic neuropathy. However, to our knowledge, few have described the therapeutic strategies for nontraumatic optic neuropathy and navigation-assisted endoscopic optic nerve decompression as a treatment for nontraumatic, compressive optic neuropathy. The aim of this study was to examine the advantages in treating nontraumatic optic neuropathy with the minimally invasive, image-guided, navigation-assisted, endonasal endoscopic optic nerve decompression.

METHODS

This was a retrospective study of 20 patients (21 eyes) diagnosed with nontraumatic optic neuropathy, undergoing an endonasal endoscopic approach to relieve space-occupying lesions and decompress the optic nerve under image-guided navigation. This article describes our research on the therapeutic strategies for nontraumatic optic neuropathy patients, with special focus on the advantages of navigation-assisted, endonasal, endoscopic optic nerve decompression for the treatment of nontraumatic optic neuropathy. Medical photographs were used to estimate the status of the patients.

RESULTS

In 18 of the 20 cases, space-occupying lesions were completely resected. In two cases, they were partially resected. All 20 cases (21 eyes) underwent image-guided, navigation-assisted, endonasal endoscopic optic nerve decompression. Visual acuity improved in 20 eyes (95.2%) and remained stable in one eye. There were no intraoperative or postoperative complications.

CONCLUSIONS

Optic nerve decompression is the main treatment strategy for nontraumatic optic neuropathy, to relieve space-occupying lesions and decompress the optic nerve, and to retain and/or improve visual acuity. Image-guided navigation can help doctors pinpoint the optic nerve when facing anatomical deformation caused by a space-occupying lesion. Navigation-assisted, endonasal endoscopic optic nerve decompression is a feasible, safe, practical, and minimally invasive approach.

Guidelines for radiographic imaging of cranial neuropathies

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Approach to a Patient with Diplopia in the Emergency Department

BACKGROUND

Diplopia can be the result of benign or life-threatening etiologies. It is imperative for the emergency physician to be proficient at assessing diplopia and recognize when urgent referral or neuroimaging is required.

OBJECTIVE

The first part of this review highlights a simple framework to arrive at the appropriate disposition of diplopic patients presenting to the emergency department (ED). The second part of this review provides more detail and further management strategies.

DISCUSSION

ED strategies for assessment of diplopia are discussed. Management strategies, such as when to image, what modality of imaging to use, and urgency of referral, are discussed in detail.

CONCLUSIONS

Unenhanced plain computed tomography (CT) of the head or orbits is largely not useful in the work-up of diplopia. Magnetic resonance imaging is preferred for ocular motor nerve palsies. Due to limited resources in the ED, patients with isolated fourth and sixth nerve palsies with the absence of other neurological signs on examination should be referred to Neurology or Ophthalmology for further work-up. All patients presenting with an acute isolated third nerve palsy should be imaged with CT and CT angiography of the brain to rule out a compressive aneurysm. Contrast-enhanced CT imaging of the brain and orbits would be indicated in suspected orbital apex syndrome or a retro-orbital mass, thyroid eye disease, or ocular trauma. CT and CT venogram should be considered in cases of suspected cavernous sinus thrombosis. In any patient over the age of 60 years presenting with recent (1 month) history of diplopia, inflammatory markers should be obtained to rule out giant cell arteritis.

Orbital apex disorders: Imaging findings and management

Orbital apex disorders include orbital apex syndrome, superior orbital fissure syndrome and cavernous sinus syndrome. These disorders result from various etiologies, including trauma, neoplastic, developmental, infectious, inflammatory as well as vascular causes. In the past, these have been described separately based on anatomical locations of disease process; however, these three disorders share similar causes, diagnostic evaluation and management strategies. The etiology is diverse and management is directed to the causative process. This imaging review summarizes the pertinent anatomy of the orbital apex and illustrates representative pathological processes that may affect this region. The purpose of this review is to provide an update on the current status of diagnostic imaging and management of patients with orbital apex disorders.

Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa: A Retrospective Review of Thirteen Patients

BACKGROUND: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa.

OBJECTIVE: To present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa.

METHODS: Twenty-five patients underwent lateral orbitotomies from April 2012 to July 2015. Excluding patients with solely intraorbital pathologies, 13 patients’ clinical and radiographic records were retrospectively reviewed.

RESULTS: Signs/symptoms in the 13 patients (ages 28-81) included proptosis (69%), decreased visual acuity (31%), diplopia (54%), and afferent pupillary defect (69%). Pathologies were meningioma (8), esthesioneuroblastoma, lymphoma, chordoma, Ewing's sarcoma, and squamous cell carcinoma. Surgical goals were maximal safe resection in 8 patients, palliative debulking in 3 patients, and cavernous sinus biopsy in 2 patients. In 8 patients for whom maximal resection was the goal, 2 had gross total resection, while 6 had near-total resection. All patients (3) for whom palliation was the goal had symptomatic improvement. Both cavernous sinus biopsies obtained diagnostic tissue without complications. All patients with proptosis (n = 9) and diplopia (n = 7), and 2 of 4 patients with decreased visual acuity had improvement in their symptoms. No patient reported worsening of their symptoms. Mean follow-up was 12 mo (2-30 mo). Complications included oculorrhea (1), pseudomeningocele (2), transient ptosis (2), and forehead numbness (1).

CONCLUSION: The lateral orbitotomy is a promising approach for carefully selected lesions with involvement of both the lateral orbit and middle cranial fossa. It provides minimally invasive access for biopsy, decompression, or resection.

Endoscopic Endonasal Optic Nerve Decompression for Fibrous Dysplasia

Objective To evaluate visual outcomes and potential complications for optic nerve decompression using an endoscopic endonasal approach (EEA) for fibrous dysplasia. Design Retrospective chart review of patients with fibrous dysplasia causing extrinsic compression of the canalicular segment of the optic nerve that underwent an endoscopic endonasal optic nerve decompression at the University of Pittsburgh Medical Center from 2010 to 2013. Main Outcome Measures The primary outcome measure assessed was best-corrected visual acuity (BCVA) with secondary outcomes, including visual field testing, color vision, and complications associated with the intervention. Results A total of four patients and five optic nerves were decompressed via an EEA. All patients were symptomatic preoperatively and had objective findings compatible with compressive optic neuropathy: decreased visual acuity was noted preoperatively in three patients while the remaining patient demonstrated an afferent pupillary defect. BCVA improved in all patients postoperatively. No major complications were identified. Conclusion EEA for optic nerve decompression appears to be a safe and effective treatment for patients with compressive optic neuropathy secondary to fibrous dysplasia. Further studies are required to identify selection criteria for an open versus an endoscopic approach.

Orbital apex disorders: a case series

Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.

Traumatic optic neuropathy: a review

The aim of this article is to evaluate current literature on investigation and management of traumatic optic neuropathy (TON), propose recommendations for diagnosis and management, and explore novel future treatments. TON, though uncommon, causes substantial visual loss. Without clear guidelines, there is much ambiguity regarding its diagnosis and management. Investigation and treatment (conservative, medical, surgical, and combined) vary widely between centers. Electronic databases PubMed, MEDLINE, PROSPERO, CENTRAL, and EMBASE were searched for content that matched "Traumatic optic neuropathy." Articles with abstracts and full text available, published in the past 10 years, written English and limited to human adults, were selected. All study designs were acceptable except case reports and case series with fewer 10 patients. All abstracts were then evaluated for relevance. References of these studies were evaluated and if also relevant, included. A total of 2,686 articles were retrieved and 43 examined for relevance. Of these, 23 articles were included. TON is a clinical diagnosis. Visual-evoked potential is useful in diagnosis and prognosis. Computed tomography demonstrates canal fractures and concomitant injuries. Magnetic resonance images should be reserved for select and stable patients. Conservative treatment is appropriate in mild TON. Steroids are of questionable benefit and may be harmful. Surgery should be reserved for patients with radiological evidence of compression and individualized.

No light perception vision from compressive thyroid orbitopathy

Thyroid eye disease (TED) is an autoimmune inflammatory disorder that affects the extraocular soft tissues and causes eyelid retraction, proptosis and restrictive extraocular myopathy. Compressive optic neuropathy from extraocular muscle enlargement occurs in less than 5% of patients, in the majority of whom it develops within 18 months of the diagnosis of hyperthyroidism. Vision loss from compressive optic neuropathy in patients with thyroid eye disease is usually bilateral and insidious in onset and progression and is associated with diplopia and elevated intraocular pressure. To our knowledge, there have been no reported cases of acute vision loss to the level of no light perception secondary to thyroid orbitopathy. The authors report a 66-year-old Caucasian male with history of long-standing thyroid eye disease and massive proptosis who progressed from mild compressive symptoms to no light perception within days, despite being clinically stable for over 10 years.