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ABSTRACT: The position of the globe relative to the orbital rim plays a significant role in the relationship between the eyelids and the cornea. A prominent globe (relative proptosis) may cause eyelid retraction and exposure keratopathy. Simple horizontal lower eyelid tightening exacerbates eyelid retraction. Optimal correction with an orbital decompression or advancement of the orbital rim entails considerable risk. A technically simpler alternative, placement of an orbital rim onlay implant, was evaluated.
Fourteen patients with symptomatic relative proptosis underwent placement of a porous polyethylene orbital rim onlay implant.
Lower eyelid position, exposure keratopathy, and ocular discomfort were improved in all patients. Two patients required minor surgical revisions.
Porous polyethylene orbital rim onlay implants are a satisfactory option to treat the sequelae of relative proptosis.
Ophthalmic Plastic and Reconstructive Surgery 02/1999; 15(1):67-73. · 0.69 Impact Factor
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ABSTRACT: To calculate the volume of bone in 3 areas of the deep lateral orbit that are available for removal in decompression surgery and to demonstrate these 3 areas within a 3-dimensional computed tomographic reconstruction of the orbit.
The 3 areas of bone in the deep lateral orbit were designated the lacrimal keyhole, the sphenoid door jamb, and the basin of the inferior orbital fissure. By means of digitized computed tomographic scans, these 3 areas of bone were analyzed by measuring preoperative and postoperative orbital volumes and predicted bony expansion volumes in 9 patients (17 orbits) who underwent deep lateral orbital decompression surgery. We also calculated the volume of bone that could be removed from 11 normal orbits. A 3-dimensional computer reconstruction of an orbital computed tomographic scan was created, and the 3 areas of potential bone were delineated within it.
The average volumes of the basin of the inferior orbital fissure, the sphenoid door jamb, the lacrimal keyhole, and the total of the 3 regions were 1.2, 2.9, 1.5, and 5.6 cm3, respectively. The 3 areas of bone contributed variably to the total, with the door jamb contributing the most volume of the 3, nearly twice the value of the other 2. There was, however, a significant amount of interpatient variability, especially for the door jamb region.
Orbital decompression surgery of the deep lateral wall can provide adequate volume expansion because of the amount and location of potential space that exists in the 3 areas of deep bone.
Archives of Ophthalmology 01/1999; 116(12):1618-24. · 3.71 Impact Factor
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ABSTRACT: Cosmetic lower eyelid surgery is not about removing excess skin, muscle, and fat. Rather, it is about restoring eyelid/midface contour. By the third decade of life, the suborbital orbicularis oculi fat begins to descend and the orbital septum weakens and bows forward creating the classic "double convexity deformity." The removal of eyelid fat simply converts this deformity to a "concavity/convexity deformity." The lower eyelid fat redistribution procedure, as described herein, can be used to address this problem.
Seminars in Ophthalmology 10/1998; 13(3):103-6. · 0.90 Impact Factor
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ABSTRACT: To report a case of unilateral blindness after ipsilateral prophylactic transcranial optic canal decompression for fibrous dysplasia.
Case report. A 37-year-old woman with fibrous dysplasia underwent a prophylactic left optic canal decompression. Preoperatively, the left eye had a visual acuity of 20/20.
Four days after apparently uncomplicated left optic canal decompression, the left eye lost all light perception. Blindness in the left eye persisted despite surgical exploration and transcranial optic nerve sheath fenestration.
Although prophylactic optic canal decompression warrants consideration in selected patients with fibrous dysplasia, notable risks are associated with this surgery.
American Journal of Ophthalmology 10/1998; 126(3):469-71. · 4.22 Impact Factor
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ABSTRACT: Tumors of the orbital apex are difficult to approach through a standard lateral orbitotomy exposure. The transcranial approach has been described, but it requires an open craniotomy as well as dissection through the annulus of Zinn in its tight superior segment to reach intraconal and inferior lateral tumors. It is well recognized that the transcranial approach is optimal only for tumors of the superomedial orbital apex. Our study demonstrates that by enlarging the bony incision of a classic lateral orbitotomy to include a generous marginotomy and removing the deep sphenoid wing up to the superior orbital fissure, good exposure of the lateral orbital apex can be obtained. Tumors of the apex, including those that extend slightly into the cavernous sinus, can be removed from the cranial nerves and extraocular muscle origins in en face fashion, providing optimal ability to identify the delicate neurovascular structures of the orbital apex and avoid damage to them. The operating microscope is extremely useful for bony and soft tissue dissection. We report four benign tumors of the orbital apex removed using this approach. Two tumors encroached slightly into the cavernous sinus. Three of four patients were told that they had inoperable tumors. By use of the deep orbital apex approach described, all four tumors were successfully exposed and removed. Visual and motor function was unchanged or improved in all four patients, with the exception of one tumor that incorporated the inferior division of the third cranial nerve; in that patient, the transected nerve was anastomosed microscopically, and partial return of function was noted. The transorbital ophthalmic approach to tumors of the inferolateral orbital apex has significant potential advantages in comparison with a frontal craniotomy approach.
Ophthalmic Plastic and Reconstructive Surgery 10/1998; 14(5):336-41. · 0.69 Impact Factor
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ABSTRACT: The unhappy postblepharoplasty patient with lateral canthal dystopia, round eye, and scleral show presents perhaps the single greatest challenge to the aesthetic reconstructive surgeon. The problem may be as simple as a lax eyelid, which is inferiorly displaced by gravity or as complex as an eyelid, which has full thickness vertical inadequacy in each of the three eyelid lamellae. The transeyelid subperiosteal midface-lift with lower eyelid reconstruction is a reliable procedure for addressing full thickness lower eyelid vertical tissue inadequacy by totally reconstructing the lower eyelid by the classic three individual layer reconstructive technique. Vertical and horizontal adequacy or inadequacy for each of the three eyelid layers is determined and then individually addressed in the total eyelid reconstruction. This procedure has the potential to fully reconstruct and reposition the lower eyelid and lateral canthus such that the final position, function, and appearance is as good or better than it was before the changes caused by time, gravity, and previous surgery.
Seminars in Ophthalmology 10/1998; 13(3):107-14. · 0.90 Impact Factor
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ABSTRACT: Endoscopic techniques are being successfully applied to address eyebrow and forehead ptosis. The methods rely on extensive subperiosteal and subgaleal release of the forehead and scalp flap, allowing the elevation of soft tissues. Ablation of the depressor supercilli and procerus can be performed to address skin folding in the glabellar region. The mobilized frontotemporal flap is then elevated to the desired level and fixated with microscrews to the outer table of the skull. Laterally, the flap is fixed to the deep temporalis fascia. The technique relies upon a solid knowledge of the regional anatomy and the use of specialized instruments now available for dissecting under the flap. The endoscopic forehead lift can achieve results comparable to those obtained by the open coronal forehead lift while minimizing the incidence and extent of postoperative cutaneous anesthesia and telogenic hair loss, which frequently follows open coronal forehead surgery. In addition, the endoscopic technique is able to address eyebrow ptosis in the balding male without causing disfiguring scarring.
Ophthalmic Plastic and Reconstructive Surgery 04/1998; 14(2):107-18. · 0.69 Impact Factor
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ABSTRACT: We report the case of a 43-year-old man who presented with painless proptosis of the right eye of 6 weeks' duration. Examination demonstrated a tense right orbit and decreased vision and extraocular motility bilaterally. Diagnostic evaluation included computed tomographic imaging of the head and orbits, a therapeutic trial of high-dose systemic corticosteroids, and orbital biopsy, which revealed the presence of metastatic adenocarcinoma. The primary tumor was found to be an estrogen-receptor-positive, infiltrating ductal adenocarcinoma of the right breast. Therapy included lumpectomy of the breast mass, orbital irradiation, and hormonal therapy. Metastatic carcinoma of the breast should be considered in the differential diagnosis of orbital neoplastic disease in the male patient.
Ophthalmic Plastic and Reconstructive Surgery 04/1998; 14(2):130-3. · 0.69 Impact Factor
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ABSTRACT: The use of a transcaruncular approach to the medial orbit provides excellent exposure of the medial wall and avoids a cutaneous scar. This article presents the clinical procedure in a retrospective study of 8 patients. An incision through the caruncle, combined with an incision along the inferior conjunctival fornix, provides wide exposure of the medial and inferior orbit. Traumatic fractures of the orbit typically involve the thin bone of the medial and inferior walls. The clinical history and findings in 8 patients with bony orbital fractures are presented. In each case, surgical repair was based on the transcaruncular approach. Results of postoperative evaluation (range of 24 days to 32.5 months) are described, with a mean follow-up period of 8.5 months. The authors conclude that the transcaruncular approach is well suited to surgical repair of blow-out fractures to the medial orbit, in combination with an inferior transconjunctival incision.
The Journal of cranio-maxillofacial trauma 02/1998; 4(1):7-12.
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ABSTRACT: Only limited volume expansion is offered by traditional lateral orbital decompressions in which the anterior segment of the lateral wall is removed to allow lateral soft tissue prolapse. A great deal of additional soft tissue expansion can be obtained, not only laterally, but also posteriorly by removing the deep portion of the sphenoid wing. The authors report their experience in removing this bone through a coronal approach.
The authors performed maximal, three-wall, orbital decompressions through a coronal approach for 20 patients with thyroid-related orbitopathy. A disfiguring proptosis resulting from stable Graves' disease orbitopathy was the indication for surgery in all cases. Through a coronal approach, the lateral rim was left in place and thinned, augmented with specialized orbital rim onlay implants, or repositioned with osteosynthesis systems. The bone over the lacrimal fossa was sculpted to form a "keyhole" for the lacrimal gland, thereby providing additional orbital expansion. Once the medial canthal tendon and lacrimal sac had been elevated from their periosteal attachment, excellent exposure was obtained for medial and inferior orbital decompression.
The authors report the results of 20 coronal orbital decompressions during a period of 44 months. Seven cases included lateral rim advancement. Up to 6 mm of retrodisplacement was achieved without rim augmentation, 9 mm with rim augmentation.
The deep lateral orbital wall can provide significant room for volume expansion. The authors found that up to 6 mm of proptosis reduction can be obtained using the lateral wall alone. The coronal approach provides access to all four orbital walls for deep orbital decompression. The authors' philosophy of treatment in cases without compressive optic neuropathy is evolving toward the use of the lateral wall as the first approach with the incorporation of additional walls as needed.
Ophthalmic surgery and lasers 11/1997; 28(10):832-43.
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ABSTRACT: Blepharoplasty is one of the most successful aesthetic surgical procedures. Careful preoperative planning and conservative tissue resections can help to minimize complications and optimize results. Although some young patients request blepharoplasty specifically because of age-related changes in the eyelid skin, the surgery is that of sculpture and contouring of the entire aesthetic unit. The aging process in the eyelid complex is characterized by skin texture changes with loss of elasticity and formation of wrinkles, fat redistribution, enophthalmos, and anterior displacement of fat with a lower eyelid orbital fat prolapse. Once the etiology of the deformity and the associated periorbital anatomy are recognized, a local assessment and surgical treatment plan can produce optimal results.
Dermatologic Clinics 11/1997; 15(4):635-47. · 2.16 Impact Factor
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ABSTRACT: To present the results of our treatment of dural cavernous sinus fistulas with surgical exposure of the superior ophthalmic vein (SOV), retrograde venous catheterization, and coil embolization of the cavernous sinus.
Twelve patients with dural cavernous sinus fistulas were treated via a retrograde transvenous SOV approach in our hospital during a 3-year period. All patients had been referred by ophthalmologists because of secondary glaucoma and decreased visual acuity. Angiography showed preferential venous drainage of the dural cavernous sinus fistulas to an enlarged ipsilateral SOV. A total of 13 SOV exposures were performed, one patient with bilateral fistulas required bilateral treatment. The vein was surgically exposed by an ophthalmologist and then catheterized. Platinum coils were delivered through a microcatheter at the fistula site and into the root of the SOV, until there was complete angiographic closure.
Catheterization and embolization were successful in 12 of the 13 patients, with complete angiographic occlusion of the fistula. Two patients with bilateral fistulas had transient worsening of symptoms on the contralateral side. Three patients required follow-up angiography. No early complications occurred, and late complications were minor in two cases. All patients except one with long-standing symptoms recovered premorbid visual acuity. At follow-up, 11 (92%) of the 12 embolized fistulas remained occluded.
Retrograde catheterization of the SOV and embolization of the cavernous sinus with coils is a direct, safe, and efficient way to occlude dural cavernous sinus fistulas.
American Journal of Neuroradiology 06/1997; 18(5):921-8. · 2.93 Impact Factor
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ABSTRACT: Injection of corticosteroids is a well-documented and successful mode of treatment for periorbital capillary hemangiomas. Because of the greater potential risk involved with retrobulbar injections, no prior study has described this treatment for tumors located behind the orbital septum. Although retroseptal intraorbital capillary hemangiomas comprise only 7% of all adnexal capillary hemangiomas, complications such as optic nerve compression or astigmatism may necessitate treatment.
Three patients with deep orbital hemangiomas that caused vision-threatening complications were treated with intralesional injections of triamcinolone and betamethasone. Orbital injection was performed with use of real-time ultrasonographic guidance of the needle. This technique was valuable in providing continuous, accurate, and safe advancement of the needletip in the orbit to avoid the globe and orbital walls. Ultrasonography also permitted precise placement of the needle tip within the tumor and visualization of the injected material.
Significant improvement was demonstrated in all cases on the basis of both ultrasonographic measurements and regression of clinical manifestations such as astigmatism, chemosis, proptosis, and optic nerve pallor. No complications were noted.
Intralesional injection of corticosteroids to treat retroseptal and retrobulbar capillary hemangiomas was found to be a safe and effective treatment modality in our patients. Positioning of the injecting needle was guided by ultrasonography.
Journal of American Association for Pediatric Ophthalmology and Strabismus 04/1997; 1(1):34-40. · 1.03 Impact Factor
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International Ophthalmology Clinics 02/1997; 37(3):97-122.
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Archives of Ophthalmology 10/1996; 114(9):1156-7. · 3.71 Impact Factor
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ABSTRACT: Optic canal decompression may be beneficial in cases of indirect optic nerve trauma, with or without canal fracture. Although no definitive data exist to clarify its role, several clinical series have reported on optic canal decompression for the treatment of intracanalicular optic nerve trauma, providing only limited information of the details of the procedure. We describe extradural optic canal decompression using a transethmoidal/transorbital approach. Removal of > 180 degrees of the bony canal is possible with this method. The technique can be accomplished by orbital surgeons familiar with orbital apical anatomy and orbital microsurgery. Experience with cadaver dissection of the orbital apex and cadaver surgery may be useful in that it provides confidence for the surgeon operating in this critical region. Careful exposure, microscopic visualization, delicate technique, and thorough anatomic knowledge minimize the risk of complications such as carotid artery penetration or dural laceration.
Ophthalmic Plastic and Reconstructive Surgery 10/1996; 12(3):163-70. · 0.69 Impact Factor
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ABSTRACT: To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience.
Retrospective clinical review.
University tertiary referral hospital and eye institute.
Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings.
Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization.
Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar.
All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein.
When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.
Archives of Ophthalmology 07/1996; 114(6):707-14. · 3.71 Impact Factor
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ABSTRACT: The implantation of an orbital hydroxyapatite implant was complicated by conjunctival dehiscence, cutaneous fistula formation, and infection with Staphylococcus aureus. Pathologic examination of the sphere 2 years after its implantation revealed reduction in the size of the implant, peripheral lamellar bone formation and central necrosis. This is the first report of this constellation of complications with hydroxyapatite spheres positioned in the orbit. The 2-year interval between implantation and removal of the sphere is the longest reported in a case with histopathologic analysis.
Ophthalmic Plastic and Reconstructive Surgery 07/1996; 12(2):131-5. · 0.69 Impact Factor
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ABSTRACT: Orbital decompression is typically indicated for Graves' orbitopathy. Other causes of proptosis can also be safely and effectively addressed surgically with orbital decompression. Patients with prominent globes can have significant discomfort related to exposure keratopathy, lagophthalmos, and inefficient function of the globe-eyelid interface. We present six cases of non-Graves' proptosis that were addressed with orbital decompression. Indications for surgery included hypoplastic malar eminence with scleral show, enlarged globes, and congenital shallow orbits. Successful reduction of proptosis was achieved by orbital decompression with subsequent relief of presenting symptoms. Graded balanced orbital decompression was used to minimize shifts of the muscle cone. In some cases osteotomies and advancement of the lateral wall and malar region were also employed. Complications included transient esotropia, esotropia requiring surgery, and microplate granuloma. Orbital decompression should be considered for patients with relative proptosis and related eyelid malpositions regardless of the underlying etiology.
Ophthalmic Plastic and Reconstructive Surgery 01/1996; 11(4):245-52; discussion 253. · 0.69 Impact Factor
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Ophthalmology 03/1995; 102(2):173-4. · 5.45 Impact Factor
