Ординатура / Офтальмология / Английские материалы / Surgical Atlas of Orbital Diseases_Mallajosyula_2009
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Decision Making 273
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Figures 19.4A and B: This patent presented with painful proptosis |
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of 1 month duration.He had exposure Keratitis and his vision was 20/ |
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400. Note the severe swelling, tarsorrhaphy for exposure keratitis, |
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and chemosed conjunctiva. The CT scan shows a heterogenous |
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lesion surrounding the optic nerve. Radiologist reported it as |
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meningioma. The past history was significant that he had discontinued |
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treatment for tuberculosis.Since this type of acute/subacute |
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presentation is unusual for meningioma, I thought of infective pathology |
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( tuberculosis) and wanted to confirm the diagnosis by a biopsy |
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Figures 19.4C to E: When lateral orbitotomy was performed (C) a pinkish mass was found around the optic nerve, which was biopsied. The histopathology showed it to be non-Hodgkins B-cell lymphoma (D) He was referred to an oncologist and he responded very well to radiotherapy (E)
to emphasize that usually there are more than one option, and the procedure chosen varies from one surgeon to other, depending upon the individual's preference.
Intraconal Lesion: Lateral orbitotomy is indicated for intraconal lesions and lacrimal gland lesions. There are different approaches; the most commonly performed are Stallard-Wright's procedure, Reese-Berke's procedure and superior lidcrease incision (Figures 19.5A and B). Each has its own merits. I will outline these approaches, before I discuss my preferences.
Stallard-Wright's incision starts at the lateral third to half, beneath the eyebrow, up to the lateral end of the brow, and then descends vertically along the lateral border of the orbit, and extends horizontally along the crow's feet .Thus it has two horizontal incisions, one at the level of sub-brow, and the other
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Figures 19.5A and B: Lateral Orbitotomy incisions in frontal (A) and lateral (B) views. Stallard-Wright (yellow), ReeseBerke (White) and superior lid crease incision (pink)'
at crow's feet, which are well hidden. But the vertical component of the incision leaves a visible scar. The advantages of the incision include a very large and adequate area of surgical exposure to deal with huge tumors. The other advantage is that the lateral canthus is not disturbed.
Reese-Berke’s incision (Figures 19.6A to 19.9B) is a horizontal incision that starts from the lateral canthus and extends 4-5 cm horizontally along the crow's feet. This incision gives a very good exposure to deal with most of the tumors. The scar is very well hidden in the crow's feet and surgical scar is never an issue. The only disadvantage is that the lateral canthus is disturbed and needs to be reconstructed at the end of the surgery. For those of you who are routinely doing oculoplastic procedures, this is neither difficult, nor time consuming. In those situations where the patient had a long standing and prominent proptosis, you may even do lateral tarsal strip at the time of reconstruction of the lateral canthus and correct horizontal laxicity of the lid.
Superior lid crease incision (Figures 19.10A to 19.11C) is another excellent approach, where in the incision is along the lid crease, and then extends along the crow's feet. The entire incision is very well hidden, so that the scar is not visible. It also gives a very adequate exposure. The lateral canthus is not disturbed. However, damage to Levator Palpebrae Superioris leading to ptosis is a known complication.
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Steps of Reese-Berke Approach
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Figures 19.6A and B: Steps of lateral orbitotomy Reese-Berke's incision. Traction suture was applied to lateral rectus (A). Horizontal incision made from the lateral canthus (B)
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Figures 19.7A and B: Zygoma was exposed (A), cuts were made above and below and the zygoma was being removed with a rounger (B)
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Figures 19.8A and B: Periosteum was incised, and reflected (A). Lateral Rectus was identified. Traction suture applied earlier helps in its identification. Lateral rectus was retracted away from the tumor (B)
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Figures 19.9A and B: The tumor was removed with the help of cryo (A). After securing hemostasis, the Zygoma was replaced in its place and secured. Drain is placed in a separate stab incision and not in the original incision. This gives a better scar. The wound is closed in layers
Steps of Superior Lidcrease Incision
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Figures 19.10A to C: The incision is along the lid crease and extends horizontally along the crow's foot (A and B).
Carefully dissect up to the septum, and approach the lateral wall (C)
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Figures 19.11A to C: The lateral wall is exposed (A), which has been removed. Periosteum was incised. The tumor was exposed (B), dissected, and removed with the help of a cryo (C)
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I believe that a scar on the face is a cosmetic blemish. I wish to perform the orbitotomy leaving as minimal scar as possible. The scar induced by the vertical component of Stallard-Wright's incision is of concern, and I wish to avoid it. Hence it was more than 2 decades since I performed Stallard-Wrights incision. My routine is Reese-Berke's approach. It gives adequate exposure to deal with most of the tumors (Figures 19.12A to 19.13C). If the tumor is too big, then I perform superior lid crease incision. The scar induced in these two procedures is very well hidden and patient's satisfaction is very high.
However it is very important to remember that intraconal tumor can be excised by lateral orbitotomy
approach, only if it is lateral to optic nerve. If the tumor is medial to optic nerve, it cannot be excised through lateral orbitotomy as the optic nerve can get damaged. In these situations, antero-lateral orbitotomy is preferred (Figures 19.14A to 19.21B). Hence the importance of assessing the relationship of the tumor with optic nerve in coronal sections of CT scan cannot be over-emphasized.
In antero-lateral orbitotomy, lateral orbitotomy is performed to get space and better surgical exposure. 180° peritomy is performed, the medial rectus is disinserted, the globe is retracted laterally and the tumor is removed between the globe and the retracted medial rectus. Then the medial rectus is reattached.
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Figures 19.12A to D: Note the gross proptosis of right eye in this female, due to a very large cavernous hemangioma occupying most of the orbit, as shown in the CT scan imaging. Such a large tumor could be excised through Reese-Berke's incision excised tumor (C) and postoperative recovery (D)
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Figures 19.13A to C: Another patient with a prominent proptosis of right eye due to a large neurofibroma, excised through Reese-Berke's incision. Note that the incisional scar is very well hidden in the crow's feet
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Figures 19.14A and B: Diagrammatic representation of anterolateral orbitotomy for a case of axial proptosis (A) due to intraconal tumor located medial to optic nerve (B)
Figures 19.15A and B: Lateral orbitotomy was performed with the lateral wall removed. The medial rectus muscle was disinserted, with double armed 6-0 vicryl sutures attached to the tendon
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Figures 19.16A and B: The eyeball and the medial rectus were retracted to get adequate space for dissection of the tumor. The tumor was excised through this space with the help of a cryo (A). The medial rectus was reinserted, conjunctiva was sutured. The lateral orbitotomy incision was closed
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Figures 19.17A to C: Female 45 years presented with painless, progressive proptosis of left eye of 3 years duration and progressive blurring of vision since 6 months. She had RAPD with optic disc edema (A). Her BCVA was 20/200. CT scan (B and C) revealed a homogenous, hyperdense tumor with very well defined borders in the intraconal space and medial to the optic nerve (red arrow …B). There was no enhancement on contrast. Since the tumor was intraconal and medial to optic nerve, anterolateral orbitotomy was planned
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Figures 19.18A to C: Lateral orbitotomy was performed with Reese-Berke's incision. The Zygoma was removed, and periorbita incised to facilitate moving the globe laterally (A). 180° peritomy was performed medially from12 to 6 o'clock position. Medial Rectus muscle was identified
(B), and disinserted after applying 6-O vicryl sutures (C)
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Figures 19.19A and B: The globe is retracted laterally, and the disinserted medial rectus medially to get adequate surgical space (S…A). By careful dissection in this space, the tumor was identified (T…B)
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Figures 19.20A and B: The tumor was dissected carefully from the surrounding structures and was removed carefully with the help of a cryo (A and B)
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Figures 19.21A and B: The medial rectus muscle was anchored to its original incision (A). The conjunctiva was sutured into its place (B). The lateral orbitotomy wound was closed as usual
Apical conal lesions are better approached through transcranial approach with the help of a neurosurgeon. This was discussed in the concerned chapter.
Imaging studies tell us if we are dealing with optic nerve glioma or meningioma of optic nerve sheath. I prefer to follow closely a case of optic nerve glioma with imaging every 6 months and perform surgery only if the eye has become blind or the tumor is nearing the orbital apex. For meningioma, I do lateral orbitotomy and take a biopsy for histopathological confirmation (which is mandatory here) before referring for radiotherapy.
Lesions of Superior Peripheral Space: Anterior orbitotomy approaches are normally used for these lesions, the exception being lateral orbitotomy for lacrimal gland tumors. However I am excising lacrimal gland tumors, up to moderate size through anterior orbitotomy approaches.
For tumors of the superior peripheral and subperiosteal spaces, both subciliary and superior lidcrease incisions give very good surgical exposure (Figures 19.22A and B). However the surgical scar is better camouflaged in the lid crease and hence is my preferred procedure (Figures 19.23A to 19.31C).
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Figures 19.22A and B: Superior Anterior orbitotomy incisions, subciliary (white) and Lid-crease (yellow) incisions
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Figures 19.23A to C: Female 38 years, presented with proptosis of left eye of 2 years duration. Note that the globe is pushed down and in, with fullness of superior sulcus (A). CT scan of the orbit revealed lacrimal gland tumor pushing the globe down and in (B) Excavation of the lateral wall of orbit could be seen (C)
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Figures 19.24A and B: Lid-crease incision was made (A), the septum was identified and reflected from the orbital rim (B)
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Figures 19.25A and B: The lacrimal gland mass was removed with the help of cryo (A). The excised tumor is shown in B
Decision Making 281
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Figures 19.26A and B: Female 18 years, presented with progressive, painless proptosis of right eye since 8 years. Note the severe proptosis of right eye with the eyeball pushed down and out. Note also the bluish mass lesion in the right upper lid (A and B)
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Figures 19.27A and B: CT scan of the orbit shows multilobulated lesion, occupying most of the intraconal space, pushing the optic nerve infero-laterally, and extending from the apex to the upper eyelid
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Figures 19.28A and B: Superior lid-crease incision was chosen, since if needed, it could be converted to lateral orbitotomy also. Note the tumor (T) on either side of the superior oblique (S.O) tendon. The tendon of superior oblique was outlined yellow to facilitate recognition
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Figures 19.29A and B: The tumor was excised carefully, without damaging the superior oblique, with the help of cryo (A). Note that the superior oblique tendon is intact (B), and also the cavity formed after the excision of the tumor
Figure 19.30: The excised tumor (Cavernous hemangioma)
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Figures 19.31A to C: A patient with cavernous hemangioma located in the anterior part of superior peripheral space being excised in toto through superior lid crease incision. The incision in this situation can be smaller (A) The tumor is seen in B. Look how well the incision is camouflaged in the lid crease (C) in the figure taken immediately after completion of surgery. The surgery was performed under local anesthesia
For lesions of medial peripheral space, the approaches can be percutaneous Lynch incision or transconjunctival incisions (Figures 19.32A and B).
Subcaruncular incision is popular for thyroid decompression of medial wall, since it gives access to ethmoid sinus. The scar is never an issue with transconjunctival approaches.
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Figures 19.32A and B: Lynch Incision (white line) and transconjunctival approaches (subcaruncular incision blue line and subconjunctival peritomy incision redline)