Orbital Tumors Excision without Bony Marginotomy under Local and General Anesthesia

A swinging upper eyelid approach for excision of lacrimal gland masses

PURPOSE

To describe a novel transconjunctival technique for excision of well-defined masses of the orbital lobe of the lacrimal gland.

METHODS

Case series of three patients undergoing excision of a well-defined mass of the orbital lobe of lacrimal gland using a swinging upper eyelid flap. This technique entails a supratarsal conjunctival incision combined with lateral canthotomy and superior cantholysis.

RESULTS

Complete removal of the mass without visible scars was achieved in all cases. There were no complications related to this approach.

CONCLUSION

The swinging upper eyelid approach produces a wide exposure of the superolateral orbit. It allows safe removal of large lacrimal gland masses without the need for bone removal, while affording acceptable cosmesis.

A review of solitary fibrous tumours of the orbit and ocular adnexa

Solitary fibrous tumour (SFT) is an uncommon spindle cell tumour of mesenchymal origin characterised by NAB2-STAT6 gene fusion. Although it was first described in the pleura, it can occur in connective tissue in any part of the body, but rarely presents in the orbit and ocular adnexa. SFT, which is part of the same disease spectrum as other fibroblastic tumours such as giant cell angiofibroma, haemangiopericytoma and fibrous histiocytoma, usually presents as a painless, slow-growing mass in any age group and generally follows a benign course, with a good prognosis after complete excision. However, malignant forms rarely occur. Even for benign tumours a more aggressive clinical behaviour is possible, with relentless infiltrative local growth, frequent recurrence following surgery, and malignant transformation with the potential for metastatic spread. Careful long-term follow-up is essential. The published literature on SFTs of the orbit and ocular adnexa is reviewed, and the aetiology, clinical presentation, epidemiology, radiological features, histopathology, immunohistochemistry, risk stratification, clinical management, and prognosis are discussed, reflecting on our own experience.

The transconjunctival orbitotomy: A versatile approach to the orbit and beyond

In the management of orbital disorders and defects, minimally invasive surgical approaches have become increasingly efficient for their reduction of operative trauma and access without compromise of therapeutic benefit or diagnostic yield. Various approaches have focused on bone- and canthal-sparing techniques and concealed and small skin incisions. We review the current state of knowledge of procedures to enter the orbit via the conjunctiva. Any quadrant of the orbit can be accessed via the conjunctiva. Surgical incisions involve the orbital palpebral, forniceal, and bulbar conjunctiva. According to the location, nature, and size of the lesion, the transconjunctival orbitotomy can be used as a single procedure, in combination with a caruncular approach or as an adjunct in a multidisciplinary procedure for lesions extending deep into or outside the orbit. The working space and field of operating view can be expanded by releasing the horizontal tension of the eyelid with a lateral cantholysis, lateral paracanthal blepharotomy, or medial lid split procedure. Complications related to the conjunctival incision are reduced to dry eye disease.

Anesthesia for ophthalmic surgery: an educational review

PURPOSE

Selecting an anesthetic agent for ophthalmic surgery has crucial implications for the surgeon, anesthesiologist, and patient. This educational review explores the common classes of anesthesia used in ophthalmology. Additionally, we discuss the considerations unique to cataract, glaucoma, strabismus, orbital, oculoplastic, and ocular trauma surgeries.

METHODS

A comprehensive Embase search was performed using combinations of the subject headings "anesthesia", "eye surgery", "ophthalmology" and "cataract extraction", "glaucoma", "strabismus", "vitreoretinal surgery", "retina surgery", "eye injury", and "eyelid reconstruction".

RESULTS

Topical anesthetics are the most commonly used form of ocular anesthesia, used in both an office and surgical setting, and carry a minimal side effect profile. Notably, topical anesthetics offer analgesia, but do not provide akinesia or amnesia. Regional blocks, such as are sub-Tenon's, peribulbar, and retrobulbar blocks, are used when akinesia is required in addition to analgesia. Recently, sub-Tenon's blocks have recently gained popularity due to their improved safety profile compared to other regional blocks. General anesthesia is considered for long, complex surgery, surgery in patients with multiple comorbidities, surgery in young pediatric patients, or surgery in patients intolerant to local or regional anesthetic.

CONCLUSION

Anesthetizing the eye has rapidly evolved in recent years, supporting the safety, efficacy and comfort of ocular surgery. Since there are many viable options of anesthetics available for ophthalmic surgery, a robust understanding of the patients needs, the skill of the surgical team, and surgery-specific factors ought to be considered when creating an anesthetic plan for surgery.

Endoscopic endonasal resection of orbital schwannoma assisted with small-incision medial orbitotomy: case series and surgical technique

PURPOSE

To describe a surgical approach for the resection of schwannomas occurring in the medial aspect of the orbit and to review a series of patients who underwent this novel technique.

METHODS

This retrospective, non-comparative case series presents the surgical technique and outcomes of patients who underwent removal of a medial orbital schwannoma via an endoscopic endonasal approach combined with a small-incision medial orbitotomy by a team of two surgeons (BSB and SKF). Patient demographics, pre- and post-operative clinical examination findings, visual field testing, and radiographic studies were reviewed. Operative reports were reviewed for technical details and complications.

RESULTS

The patients included a 12 year-old male, 73 year-old female and 8 year-old male. Indications for surgery included: decreased visual acuity, diplopia, proptosis and Humphrey visual field (HVF) deficit, in the presence of a medial orbital biopsy-proven schwannoma. The surgical approach in all three patients was primarily endoscopic endonasal. Additionally, two had transcaruncular orbitotomies and one had a small-incision medial lid crease orbitotomy to assist with lateral tumor dissection. Tumor resection was complete in one case and near-total in two cases. There were no intra-operative surgical complications. Average resected specimen volume was 3.41 cm³ ± 2.20. All patients had post-operative improvement in visual acuity (VA) and proptosis. Post-operative follow-up intervals were 27.5 months, 12.3 months and 3.5 months, respectively.

CONCLUSION

Resection of orbital schwannomas using an endoscopic endonasal approach with small-incision medial transorbital assistance is a safe and effective option for a multidisciplinary surgical team.

Fate and Management of Incompletely Excised Solitary Fibrous Tumor of the Orbit: A Case Series and Literature Review

PURPOSE

There is an imperfect correlation between the histology and behavior of solitary fibrous tumor (SFT). In addition, recurrence is common, and dedifferentiation may occur over time. Preferred primary treatment is intact excision, but friable pseudocapsules and tenacious attachments can thwart this goal in the crowded, visually sensitive orbit. This study addresses the fate and appropriate management of incompletely excised orbital SFT.

METHODS

Among a single surgeon's 7-case experience with orbital SFT, 3 cases involved incomplete primary excision, either before (2 cases) or after (1 case) referral. We reviewed the clinicopathologic data in these 3 cases, with follow-up intervals of 18, 21, and 52 years after initial presentation. We reviewed the English-language literature on SFT, with special attention to evolving nomenclature, orbital involvement, recurrence, malignant transformation, and management options.

RESULTS

Benign versus malignant designations of SFT vary with histological and behavioral criteria. Approximately 150 orbital cases have been reported. Published rates of primary malignancy and recurrence across all histologic categories are 6% to 12% and 30% to 37%, respectively. We identified 43 well-documented recurrences (range, 6 months-33 years; median, 3 years) and 10 cases of histological dedifferentiation (range, 14 months-33 years). Because of SFT's rarity and needed follow-up intervals, the value of adjuvant therapy is not yet proven. In follow up of 18, 21, and 52 years after initial presentation, our 3 cases with incomplete excision showed either no recurrence (Case 1) or no morphological dedifferentiation (Cases 2, 3).

CONCLUSION

A treatment algorithm is predicated on the completeness of surgical excision and histological features. However, we recommend case-by-case multidisciplinary decisions in a tumor-board setting.

Expanded use of transconjunctival orbitotomy in management of different orbital tumors at different locations

PURPOSE

To assess the surgical outcomes of transconjunctival approach in management of different orbital tumors at different locations.

METHODS

This prospective, non-comparative, clinical interventional study was conducted in the period between March 2017 and January 2020 and included 61 patients with histologically proved orbital tumors. In all cases, a conjunctival incision near the fornix was made depending on the tumor location as revealed by CT or MRI. A traction suture was applied to one or two relevant recti muscles to guide the globe toward the desired direction. Blunt orbital dissection was made toward the tumor until exposing its anterior surface. The procedure was considered successful if the predetermined decision (total excision with improved clinical manifestations for benign and biopsy for diagnosis in malignant tumors) was achieved without causing permanent complications. The procedure was considered a failure if the predetermined decision was not achieved or if permanent complications developed.

RESULTS

The patients were divided into: Group A of 47 patients (77.05%) with benign tumors and Group B of 14 patients (22.95%) with malignant tumors. The overall success rate of the approach was 98.36% (60 out of 61 patients), while failure occurred in one case (1.64%).

CONCLUSIONS

The transconjunctival orbitotomy is an excellent approach to manage different tumors at different orbital locations with rapid recovery and maximum cosmetic results. It is the only approach that can access intra-conal, mid-orbital tumors whatever their relation to the optic nerve without crossing it.

A prospective randomized double-blinded study of dexmedetomidine versus propofol infusion for orbital surgeries

PURPOSE

Orbital surgeries are traditionally taken up under general anesthesia. Local anesthesia combined with moderate sedation can also be considered as an alternative option. This study was performed to compare the safety and efficacy of dexmedetomidine and propofol infusion for orbital surgeries under local anesthesia.

METHODS

Twenty patients undergoing orbital surgery by a single surgeon were enrolled in this prospective randomized study. Selected patients were randomly administered dexmedetomidine (Group D) or propofol (Group P). Hemodynamic and respiratory effects, sedation levels, recovery profile, analgesic properties, and satisfaction levels of the patients and the surgeon were assessed.

RESULTS

There was a significant decrease in mean arterial pressures following drug administration compared to initial measurements in both the groups. However, a statistically significant decrease in heart rate was observed only in Group P. The sedation score at the end of loading dose was 3.3 ± 0.82 in Group D and 2.5 ± 0.52 in Group P and this difference was also statistically significant (P value-0.027). The surgeon's satisfaction score was 6.5 ± 0.71 in Group D and 5.6 ± 1.07 in Group P (P value - 0.045). There were no statistically significant differences observed in patients' satisfaction, pain, and anxiety scores in either group. No major hemodynamic changes or complications were noted in either of the groups.

CONCLUSION

Dexmedetomidine, in comparison to propofol, provides better sedation levels with good hemodynamic stability. It also offers better surgeon satisfaction, thus providing a useful alternative for general anesthesia in selective patients undergoing orbital surgery.

Clinicopathological Features and Outcomes in Lymphoma of Extraocular Muscles

PURPOSE

To describe the clinicopathological features and report the outcomes of treatment in lymphoma involving the extraocular muscles (EOM), the largest reported case-series.

METHODS

A retrospective case series of patients with lymphoma involving the EOM from a single tertiary referral orbital center, between March 1992 and March 2018. Patients with other histopathologic diagnoses or who did not have an EOM biopsy were excluded. The main outcome measures were histologic evaluation and clinical follow-up including tumor response, recurrence, and survival.

RESULTS

Twenty-five patients were included, 16 female; 9 male; median age 64.7 years (range 33.8-92.6 years). Unilateral involvement was present in 23 cases (92%). Lymphoma was found to be primary in 15 patients (60%), and any EOM could be affected by disease. Fourteen patients (56%) displayed impaired duction in the direction of the affected muscle. The commonest histologic type was extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue in 16 cases (64%) followed by follicular lymphoma in 3 cases (12%), diffuse large B-cell lymphoma in 2 cases (8%), gamma delta T-cell lymphoma in 2 cases (8%), small lymphocytic lymphom and lymphoplasmacytic lymphoma in 1 case each (4%). All 4 patients with high-grade lymphomas (diffuse large B-cell or T cell lymphoma) were found to have systemic disease. Patients were treated with combinations of radiotherapy, chemotherapy, or immunotherapy, with low toxicity. Two patients developed treatment-related complications. With a median follow-up of 26 months (range 3-108 months), there was only 1 recurrence, which was successfully salvaged with Rituximab, and no deaths due to lymphoma.

CONCLUSIONS

Lymphoma of the EOM is a rare tumor with good response to treatment, few treatment-related complications and low risk of recurrence or mortality.A retrospective review of 25 patients with lymphoma of the extraocular muscles demonstrates excellent prognosis with a high rate of local remission (96%), 2 treatment-related complications, one recurrence, and no disease-related deaths.

[Idiopathic orbital inflammatory syndrome: Report of 24 cases]

BACKGROUND

Idiopathic orbital inflammatory syndrome (IOIS) is an inflammatory condition of unknown etiology. The inflammation may affect all the structures within the orbit (anterior, diffuse, apical, myositic, dacryoadenitis) and corresponds to uniquely orbital inflammation without an identifiable local cause or systemic disease. The goal of this study is to describe the clinical and radiographic characteristics of IOIS and discuss the role of orbital biopsy in this condition.

PATIENTS AND METHODS

This is a retrospective review of the charts of 24 patients diagnosed with IOIS at Fattouma Bourguiba hospital, Monastir, Tunisia, from January 2007 to December 2015. This study included all patients with IOIS and a minimum follow-up of six months. All patients had a complete ophthalmological examination and orbital and head CT scan and/or MRI. A work-up was performed in all cases to rule out local causes and systemic disease. Only 11 patients underwent biopsy. The diagnosis of the clinical entity IOIS was made according to the Rootman criteria. Oral steroids were the first line therapy. A bolus of intravenous methylprednisolone was administered first in vision-threatening cases. Response to treatment was defined as disappearance of signs and symptoms of IOIS.

RESULTS

Orbital pain was the most common symptom (62.5%), followed by proptosis and decreased vision (37.5% each). Best-corrected visual acuity (BCVA) was greater than 5/10 in 70.7% of patients. Lacrimal gland enlargement was observed in 3 patients. Oculomotor disorders were present in 70% of cases and 20.8% of patients had compressive optic neuropathy. Orbital imaging showed, in most cases, oculomotor muscle inflammation (87.5%) involving particularly the superior rectus muscle (54.2%) and inflammation of orbital fat (66.7%). Fifty percent had myositic inflammation. Biopsy was performed in 11 patients, showing nonspecific inflammation (n=10) and the sclerosing form (n=1). A total of 83.3% of patients received oral corticosteroids for a mean duration of 5.5 months.

CONCLUSION

IOIS is a diagnosis of exclusion, based on history, clinical course, response to steroid therapy, laboratory tests, or even biopsy in selected cases. Orbital imaging provides valuable clues for diagnosis of IOIS and for identification of affected structures. Prolonged steroid therapy is necessary as IOIS classically responds to steroids; nevertheless, partial recovery or relapses often occur.

Review of extraocular muscle biopsies and utility of biopsy in extraocular muscle enlargement

Aims

To review the distribution of pathology in extraocular muscle (EOM) biopsies performed at a tertiary orbital centre, identify clinical and imaging features which are associated with benign or malignant diseases and indicate when biopsy is necessary for EOM enlargement.

Methods

Retrospective case series including 93 patients with EOM enlargement who underwent an EOM biopsy. Clinical, radiological and histopathological information was recorded from the medical records. Statistical analysis was used to compare variables between patients with malignant and benign biopsies.

Results

The median age of subjects was 61.1 years. Forty-eight cases (52%) were benign and 45 (48%) were malignant. Those with malignant pathology were significantly older (P<0.0001). Males were more likely affected by a benign disease and females by a malignancy (P=0.029). A history of malignancy (P<0.0001) and diplopia (P=0.029) were significant factors in predicting a malignancy. Pain (P=0.005) and eyelid erythema (P=0.001) were more likely in benign conditions. Idiopathic orbital inflammation was the most common benign diagnosis and lymphoma the most common malignancy.

Conclusions

Biopsy is warranted in those with an atypical presentation of EOM enlargement or suspected of having a malignancy. Some features such as age, gender, pain, diplopia, history of malignancy and eyelid erythema may help indicate a particular diagnosis; however, clinical features and imaging findings are often not pathognomonic of each disease.

Uveitic Macular Edema: Treatment Update

The aim of this review is to summarize recent developments in the treatment of uveitic macular edema (ME). ME represent a major cause of visual loss in uveitis and adequate management is crucial for the maintenance of useful vision in patients with chronic uveitis.