Ординатура / Офтальмология / Английские материалы / Surgical Atlas of Orbital Diseases_Mallajosyula_2009

Preface

When I was a student, I often heard from my teachers saying "Proptosis is a Pandora's box". Surprisingly I continue to hear it even today! Many a time I am asked to speak on the topic titled "Proptosis is a Pandora's box", and I always change it to "Is Proptosis still a Pandora's box?" It was so, in the past, when the only imaging available was orbital venography. The information of the orbital disease process obtained with it was very meager. I salute my professor Dr. Vengala Rao, who used to perform orbitotomies in those days. It is the challenges he used to encounter, that stimulated me to take up this branch. Fortunately, advances in imaging techniques have made an immense contribution in the assessment of a case of proptosis, so that today, we know what we are dealing with. With careful clinical assessment, and knowledge in reading of CT/MRI, we can even arrive at the histopathological diagnosis of majority of cases. Hence, surprises are very few and far in between. Similarly, advances in histopathology and immunohistochemistry, anesthesia, chemo and radio therapy have made immense contributions in understanding and management of proptosis. The best example is Rhabdomyosarcoma. Today, nearly half the cases of proptosis can be managed by nonsurgical methods or with very minor surgical procedures. I thankfully acknowledge the roles of Dr Vengala Rao, my first teacher, Jack Rootman, Peter J Dolman, Brad Lemke and Mark J Lucarelli in furthering my understanding of orbital diseases.

The specialty of orbital diseases is very well advanced in North America and Europe, but not so in most other countries. Availability of ophthalmic literatures authored by orbital surgeons from the developing countries are very few. The idea of bringing this color atlas is to share two decades of my experience in orbital diseases. Though it is an atlas in principle, enough information is provided to understand the conditions and plan treatment strategies. It covers most of the common and some of the rare causes of proptosis. With color illustrations, and case presentations, I tried to make this book interesting to read and also to provide practical knowledge in clinical situations.

I thank all my contributing authors, who are internationally reputed, for their co-operation. The chapters they contributed were those in which they have a wealth of experience, viz. Jack Rootman on mesenchymal tumors, Peter J Dolman on thyroid associated orbitopathy (We rarely see such severe TAO in India ), Mark J Lucarelli on anatomy and fractures of orbit.

I hope my efforts help shatter the myth that "proptosis is a Pandora's box". If this book inspires at least some ophthalmologists to pursue this specialty with more interest and vigor and blossom into efficient orbital surgeons, the purpose of this book is served. I truly believe that "What I do, you can also do" and who knows you may do even better.

Subrahmanyam Mallajosyula

15-05-2008 Hyderabad

Acknowledgements

At the outset, I wish to acknowledge the significant roles played initially by my parents and then by my wife Rama, in my professional pursuits, which took a lot of time from my family and children Harsha and Aahlad. I greatly appreciate their cooperation.

My teacher Dr. Kotagiri Vengala Rao was the first to introduce me to orbital surgery during my postgraduation. I still relish those memories. I thank Dr. Jeffrey Nerad for introducing me to Dr. Jack Rootman. I acknowledge the role of Dr. Jack Rootman, Peter J Dolman in fine tuning my skills—both clinical and surgical. They are not only great teachers, but also wonderful human beings. My fellowship with them was made possible due to the financial assistance I received from them. I also thank the Orbis Inc. for awarding me the Ziegler's International Fellowship, which has part financed my fellowship at University of British Columbia, Vancouver. Similarly I thank the Association of Asian Indians in Ophthalmology for awarding the competitive fellowship, which financed my training with Mark J Lucarelli, Brad Lemke and Richard K Dortzbach at the University of Wisconsin, Madison. It was a great learning experience.

I thank all my contributing authors (and their supporting staff), who are all very eminent and highly reputed, for sparing their time to make this book wonderful. I thank my fellow Dr. Mohd Javed Ali, for all his assistance in proofreading. He is ever ready to help.

I wish to acknowledge the support and encouragement I received from Shri Jitendar P Vij, Chairman and Managing Director, Mr Tarun Duneja, Director (Publishing) and Mr PS Ghuman, Sr Production Manager of M/s Jaypee Brothers Medical Publishers (P) Ltd. I also thank Mr Upinder, Mr Pankaj, Mr Ram Murti and Mrs Seema Dogra of the same family (Jaypee) for their technical support.

Contents

Orbital osteology 3; The periorbita 6; The orbital apex 6; The cavernous sinus 8; The globe 8; The extraocular muscles 9; Lids 10; The lacrimal system 13; The nerves of the orbit 14; Vascular anatomy of the orbit: Arterial supply 17; Vascular anatomy of the orbit: Venous outflow 19; Paranasal sinuses 20; Conclusion 20

Pain 23; Progression 25; Proptosis 28; Axial proptosis 29; Measurement of proptosis 35; Pulsations 37; Pupil 41; Perception of color vision 41; Prism bar-cover test (PBCT) 42; Periorbital changes 45; Lid changes 46; Conjunctival changes 48; Palpation 51; Auscultation 51; Evaluation of a case of proptosis 53

Evaluation of a CT scan of orbit 58; Common mistakes 59; Bony orbit 60; Eyeball 65; Enlarged extraocular muscle 69; Soft-tissue lesions 72; Lacrimal gland tumors 76; Cystic lesions of the orbit 78; Metastatic lesions 81; Contrast enhancement 83; 3-D reconstruction of the orbit 84

Fine needle aspiration/sampling techniques 85; Intraoperative-operative diagnosis by squash and imprint cytology 85; Squash/imprint cytology 85; Case illustrations 86

Classification 97; Diagnosis of orbital tumors 98; Developmental lesions 98; Inflammatory lesions 100; Orbital infections 101; Cysticercosis 102; Neoplastic lesions 102; Benign tumors 103; Malignant tumors 104; Metastasis 105; Grave's disease 106; Mucocele 106

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Incidence and epidemiology 112; Risk factors and predictive variables 112; Pathogenesis 112; Course of disease 114; Clinical classification 114; The VISA classification 114; Vision/optic neuropathy 114; Inflammation/congestion 116; Strabismus/motility restriction 117; Appearance/exposure 117; General management guidelines 118

Risk factors 121; Etiological causes of orbital infections 121; Bacterial infections 121; Fungal infections 121; Parasitic infections 121; Protozoal infections 121; Diagnosis 121; Imaging studies 121; Emergency department care 122; Further inpatient care 122; Case illustrations 123

Orbital amyloidosis 129; Sarcoidosis 130; Nonspecific orbital inflammatory syndrome (NSOIS) 131; Kimura’s disease 132; Wegener’s granulomatosis 132; Langerhan’s histiocytosis 133; Rosai-Dorfman disease 133; Orbital xanthogranuloma 134; Case illustrations 134

REAL classification 146; WHO classification of NHL 146; Modified Rye’s classification of Hodgkin’s lymphoma 147; When to suspect lymphoma 147; When to suspect idiopathic orbital inflammatory disease 148; Case illustrations 148

Malformations 151; Lymphangioma 151; Orbital varices 152; Cavernous hemangioma 152; Other congenital malformations 152; Sturge-Weber syndrome 152; Wyburn-Mason syndrome 153; KlippelTrenaunay syndrome 153; Shunts 153; Carotid-Cavernous fistula 153; New growths 154; Capillary hemangioma 154; Hemangiopericytoma 155; Angiosarcoma 155; Kaposi’s sarcoma 155; Hemangioendothelioma 155; Hemangioblastoma 155; Case illustrations 157

Optic nerve glioma 162; Optic nerve meningioma 163; Orbital schwannoma (neurilemmoma) and neurofibroma 165; Case illustrations 166

Mesenchymal soft tissue tumors 170; Rhabdomyosarcoma 170; Rhabdomyoma 172; Leiomyoma 172; Leiomyosarcomas 172; Adipose tumors 172; Liposarcoma 174; Fibrous tissue tumors 174; Histiocytic tumors 175; Fibrous histiocytoma 175; Malignant tumors of uncertain type 175; Rhabdoid tumor 175

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Intraconal lesion 273; Reese-Berke’s incision 273; Steps of Reese-Berke approach 274; Steps of superior lidcrease incision 275; Apical conal lesions 279; Lesions of superior peripheral space 279; Thyroid associated orbitopathy 285

General principles 288; Approaches 289; Anterior orbitotomy 289; Swinging lower eyelid flap 289; Lateral orbitotomy 290; Stallard-Wright lateral orbitotomy 290; Transfrontal orbitotomy 291; Complications 291; Postoperative management 291; Case illustrations 291

Surgical anatomy 299; ENT approach to proptosis 300; Various etiological factors of proptosis in ENT 300; Sinus diseases causing proptosis 301; Purulent infections 301; Extensive nasal polyposis 301; Mucormycosis 301; Allergic fungal sinusitis 301; Frontoethmoidal mucocele 302; Tumors of paranasal sinuses causing proptosis 302; Fibrous dysplasia 302; Hemangiopericytoma 302; Juvenile nasopharyngeal angiofibroma 303; Squamous cell carcinoma 303; Rhabdomyosarcoma 303; Non-Hodgkin’s lymphoma 303; Esthesio-neuroblastoma 304; Caldwell-Luc operation 304; Lateral rhinotomy/medial maxillectomy 305; Total maxillectomy 306; Patterson’s operation 305; FESS 309; Neurosurgical approaches of proptosis 309; Transcranial approach 311; Extracranial approach 309; Case illustrations 313

Indications 318; Patient preparation 318; Surgical procedure 318; Types 319; Management of the exenterated socket 320; Prosthesis 320; Complications of exenteration 320; Case illustrations 321

Types of prosthesis 327; Complete prosthesis 327; Factors that affect the fit of an orbital prosthesis 328; Preparation of the patient 328; Impression of the orbital defect 328; Casting 329; Sculpting 329; Moulding 330; Using the desired material 331; Fabrications of ocular prosthesis 331; Assemble of prosthesis 331; Care of your prosthesis 331; Storing the prosthesis 332; Preventing mishaps 333

Nonspecific inflammations of the orbit (NSOIS) 337; Specific inflammations of the orbit 338; Orbital cellulitis 338; Rhino-orbital mucormycosis 338; Chronic granulomatous infections 338; Parasitic infestations 338; TolosaHunt syndrome 339; Capillary hemangioma 339; Acute intraorbital hemorrhage and emphysema 340; lymphoprolifarative and other neoplastic lesions 340; Case illustrations 340