经结膜入路眼眶海绵状血管瘤切除术的研究

目的：：探讨经结膜入路眼眶海绵状血管瘤切除术的手术方式和注意事项,并观察其疗效及并发症。方法：采用回顾性方法分析2007-01/2013-11的74例眼眶海绵状血管瘤患者。术前经CT或MRI联合彩色多普勒检查确诊。手术全部采用结膜入路,鼻下、颞下及正下方肿瘤采用下穹窿结膜切口,颞上象限的肿瘤采用颞侧结膜入路,鼻上及上方肿瘤采用内上方穹窿结膜入路,暴露后钳夹肿瘤,轻轻挽出瘤体;如肿瘤与周围组织粘连紧密,则采用分步切除的方法：先切除部分瘤体,然后直视下再切除残留的肿瘤。结果：74例海绵状血管瘤的术前确诊率达到100％。肌锥内58例(78％),肌锥外16例(22％),其中颞上方12例(16％),上方16例(22％),鼻下、颞下方及正下方46例(62％),肿瘤直径8~59mm,手术全都采用结膜入路,其中下穹窿结膜入路46例,颞侧结膜入路12例,鼻上方结膜入路16例,有9例患者采取先摘除1/3瘤体,瘤体缩小后,再摘除剩下的肿瘤。8例患者术后视力下降,其中6例术后半年视力恢复。5例患者术后视力提高,术后无眼球突出,球结膜充血水肿10例,1例患者术后瞳孔不等大,复视6例。结论：经结膜入路手术切除肿瘤适用于除眶尖部以外的所有眼眶海绵状血管瘤,结合直视下分步切除肿瘤法,可有效降低手术风险,提高手术安全性。     

Transconjunctival orbitotomy for orbital cavernous hemangiomas

BACKGROUND: Orbital cavernous hemangiomas, particularly those within the retrobulbar space, are approached by neurosurgeons as well as by ophthalmic surgeons. Several surgical techniques have been applied over the past decades. Less traumatic approaches in this functionally and cosmetically important region are desirable. We describe a transconjunctival approach in 39 patients with orbital cavernous hemangiomas. METHODS: Thirty-nine patients with orbital cavernous hemangiomas were treated with transconjunctival orbitotomy. The clinical and radiologic characteristics of orbital cavernous hemangiomas were analyzed in the course of their appropriate treatment. RESULTS: In all patients, cavernous hemangiomas were just behind the globe or were compressing it. Computed tomography and magnetic resonance imaging showed orbital cavernous hemangiomas as round, well-defined intraconal masses. In 37 cases, the tumors were removed intact, and only 1 patient suffered permanent vision loss as a result of intraoperative hemorrhage. In the other 2 cases, the tumor fragments were incompletely removed. Visual acuity increased in 6 of the 9 cases with primary visual impairment. Thirty-two patients with primary proptosis were resolved completely. Six patients with visual field defect were also improved. INTERPRETATION: Retrobulbar intraconal cavernous hemangiomas can be removed successfully through a transconjunctival approach. However, if the tumor is close to, or touching, the orbital apex, adhering tightly to retrobulbar tissue, or combined with large draining veins, operation through other approaches must be considered.     

经结膜入路摘除眼眶海绵状血管瘤临床分析

目的探讨经结膜入路摘除眼眶海绵状血管瘤的适应证。方法回顾性分析17例(17眼)经结膜入路手术摘除的眼眶海绵状血管瘤患者,对所有患者主要症状、体征(如视力、眼球突出度、眼球运动异常和眼底异常等)以及影像学特点进行分析。术后随访视力、眼球突出度及眼球的运动等情况,随诊时间为6个月～48个月。结果 17例患者均为单眼发病。14例术前主诉为无痛性、渐进性眼球突出。眼球运动受限或复视6例,视力下降4例、眼睑肿胀3例、视盘水肿和黄斑异常各2例、角膜上皮点状混浊1例。影像学表现为类圆形、边界清楚、密度均匀球后肌锥内肿物,CT平均值为59Hu,所有患者肿瘤与眶尖组织无粘连,无眶骨质改变。肿瘤最大者30mm×20mm×16mm,最小15mm×10mm×6mm、18mm×10mm×5mm。随访期间无复发,无视力丧失、眼球固定等并发症。结论经结膜入路摘除影像学显示与周围组织无明显粘连、眶尖透明三角区存在的眼眶海绵状血管瘤是安全的手术方式。     

Multiple cavernous hemangiomas presenting as orbital apex syndrome

A 41-year-old man presented with a 7-year history of gradually increasing right proptosis and a 2-year history of decreased vision and limited eye movements. Right proptosis (11 mm), limitation of movement in all gazes, anisocoria, and visual impairment implied orbital apex compression. Computed tomography showed several distinct lesions with mild delayed enhancement extending to the orbital apex. Through a lateral orbitotomy, 10 discrete hemangiomas were removed uneventfully. Histopathologic findings were consistent with cavernous hemangioma in all tumors removed. Proptosis resolved after surgery at 3 to 4 weeks. Visual acuity was unchanged (20/25), and eye movement significantly improved at last follow-up, 15 months after surgery.     

Orbital cavernous hemangioma with bone erosion

Purpose To report a rare computed tomography (CT) feature in one case of orbital cavernous hemangioma (OCH). Methods Case report. The clinical features, CT findings, and pathological examination are presented. Results A 43-year-old Chinese man developed slowly progressive proptosis and decreased vision in his left eye over 13 years. The best-corrected visual acuity was 20/400 OS. Fundus examination showed moderate disc pallor in the left eye. CT scan revealed a 3.7×3.5-cm homogeneous soft tissue mass occupying nearly the whole retrobulbar space. There was focal bone erosion of both the deep lateral orbital wall and deep superior wall. At surgery, a 3.5×3.0×3.3-cm purplish, well-defined, round mass was removed intact without complication. The histopathologic examination proved it to be OCH. One year later, the visual acuity recovered to 20/15. Conclusion Patients with OCH may show bone erosion on CT scan, so the presence of bone defect on CT scan should consider the possibility of OCH. The paper was sponsored by the Natural Science Foundation of Guangdong Province, China (036651)     

眼眶海绵状血管瘤的手术入路选择

目的 探讨眼眶海绵状血管瘤经不同入路手术摘除的效果及其与影像学定位的关系.方法 回顾性病例研究.分析164例经手术摘除的眼眶海绵状血管瘤患者资料,并对这些患者的手术入路、影像学特征、手术效果及其选择标准进行总结.结果 经结膜入路者101例(占61.6％),位于肌锥内间隙,边界清楚且无明显黏连.经皮肤入路前路开眶者25例(占15.2％),位于肌锥外间隙,位置浅在.外侧开眶者32例(占19.5％),位于肌锥内间隙,均有较多黏连.内外侧联合开眶者5例(占3.0％),位于肌锥内间隙,形态不规则或者有较多黏连.内侧开眶者1例(占0.6％)、位于内直肌内侧.156例患者肿瘤完整摘除,仅有2例视力丧失.另8例患者患者大部分切除.结论 眼眶海绵状血管瘤可以通过选择合适的手术入路成功摘除.眼眶手术入路选择应根据病变性质、位置、范围而定,尽可能采取术野暴露清楚,损伤小、易于切除病变和外观良好的手术入路.     

不同手术入路摘除眼眶内海绵状血管瘤23例分析

目的:探讨眼眶海绵状血管瘤的临床特点、术前定性诊断与手术进路的适应证选择、手术方法及技巧。方法:回顾性分析2002-03/2006-03荆州市中心医院眼科手术治疗的海绵状血管瘤23例,其中,男10例,女13例;右眼9例,左眼14例;年龄18～63(平均41.2)岁;以渐进性眼球突出和视力下降为主要临床表现。10例采用前路结膜切口开眶入路,6例采用前路皮肤切口开眶入路,7例采用外侧开眶入路。结果:96%(22/23)根据超声波和CT可作出术前准确诊断。70%(16/23)采用前路开眶,30%(7/23)采用外侧开眶顺利摘除肿物。结论:眼眶海绵状血管瘤术前基本上可作出诊断,安全、有效地摘除海绵状血管瘤选择手术进路很重要,关键在于术前对肿瘤性质、位置、粘连程度的正确判断和手术操作的技巧,大部分的病例不需外侧开眶即可顺利摘除肿物。     

Pleomorphic adenoma of a deep orbital ectopic lacrimal gland

Ectopic lacrimal gland, being one of the choristomas, is comprised of lacrimal gland tissue outside the lacrimal gland fossa in the fronto-lateral part of the orbital roof. Ectopic lacrimal gland is a rare condition where the gland may be found in the orbit, eyelids, ocular adnexa or within the globe. Neoplastic transformation of such tissue may occur. A sixty-two-year old male patient presented with right eye proptosis and slight nasal displacement of the globe. Computerized tomography scan revealed a well-defined hypodense lesion of size 19 x 18 x 20 mm supero-lateral to lateral rectus muscle, with mild proptosis and thinning of the right lateral orbital wall. Excisional biopsy was performed through a lateral orbitotomy approach. A well circumscribed globular mass was removed from the right orbit, well behind the fossa for the lacrimal gland in the retrobulbar space. Histopathology was suggestive of pleomorphic adenoma of lacrimal gland. Pleomorphic adenoma is an epithelial tumor of the lacrimal gland which is extremely rare from an ectopic lacrimal gland and only few cases have been reported in literature till date.     

Glaucoma Management in Carotid Cavernous Fistula

Carotid cavernous fistulas (CCF) are vascular communications between the carotid artery and the cavernous sinus. Ophthalmologists are called to diagnose and manage the condition in cases that present with ocular features. A 73-year-old female was referred to our glaucoma center clinic. Eight years before, she had started receiving medication for glaucoma and had undergone laser iridotomy, but a satisfactory management of intraocular pressure (IOP) had not been achieved. The patient was complaining of intermittent diplopia, bilateral proptosis, and conjunctival chemosis over the past 6 months. Best-corrected visual acuity in the right (OD) and left eye (OS) was 9/10 and 10/10, respectively. Visual field testing showed slight paracentral field defects mostly in OS. IOP was 20 mm Hg in OD and 34 mm Hg in OS. We referred the patient to neuroradiology, and MRI angiography revealed a CCF with angiographic classification of Cognard grade 2. Closure of the CCF by transarterial embolization was performed in the neuroradiology department. One week following the procedure, the clinical signs of diplopia, proptosis, and conjunctival chemosis had greatly improved, and IOP was reduced to 12 mm Hg OD and 19 mm Hg in OS. Glaucoma treatment was maintained with topical brimatoprost, brinzolamide, and timolol. Owing to the risk of vision loss associated with vascular stasis, retinal ischemia, and high IOP, ophthalmologists must be aware of the clinical features of CCF and should request appropriate imaging studies such as MRI angiography in order to confirm the diagnosis and plan multidisciplinary treatment.     

眼眶静脉性蔓状血管瘤手术体会

目的 探讨眼眶静脉性蔓状血管瘤的手术方法及疗效。方法 对我院2例眼眶静脉性蔓状血管瘤患者,采用外眦延长联合结膜切口进行手术摘除。结果 肿瘤范围广,粘连紧密而大部分切除。术后眼球突出改善,轻度上睑下垂,3月后恢复。无复发。结论 眼眶静脉性蔓状血管瘤采用外眦延长联合结膜切口进行手术摘除,创伤小、外观影响及并发症少,可取得较满意的临床效果。     

Endoscopic and trans-fornix removal of a giant orbital-ethmoidal osteoma

A 39-year old female was referred with a 2 year history of slowly progressive headache, exophthalmos, diplopia and restricted eye movements with exotropia of the right eye. Orthoptic examination revealed restricted elevation and mildly restricted adduction of the right eye. CT and MRI demonstrated a large (35 x 20 x 23 mm) calcified infraorbital lesion extending into the ethmoidal sinus. Because the visual field defects were progressive and the acuity OD dropped to 20/80 surgical intervention was necessary. The osteoma was successfully removed using an inferior and medial orbitotomy with swinging eyelid combined with an endoscopic approach. In a second procedure the orbital floor was reconstructed with a porous polyethylene (Medpor) implant. A final procedure consisted of a 3 mm recession of the left superior rectus muscle and infundibulotomy by the sinus surgeon to open the blocked maxillary sinus. After 6 months visual acuity OD had returned to 20/20. Orthoptic examination showed normal binocular function.     

复杂眼眶良性肿瘤手术方法探讨

目的：复杂眼眶良性肿瘤手术方法的探讨。方法：对我院2001年11月至2002年6月7例复杂眼眶良性肿瘤病人，视神经鞘瘤1例，脑膜瘤2例，泪腺混合瘤1例。广泛静脉蔓状血管瘤1例，眶顶巨大血管瘤1例，眶尖肌锥内侧海绵状血管瘤1例，采用外眦延长切口、结膜切口或二者联合切口进行手术切除，并观察其临床疗效。结果：肿瘤完全切除6例，1例肌锥内血管瘤紧密包绕视神经为保存视力而大部分切除。术后眼球突出均消失，部分有短暂性复视、上脸下垂、眼球运动受限．3～6月恢复，6例视力不变，1例因脑膜瘤包绕视神经与神经一并切除而视力丧失。结论：复杂眼眶良性肿瘤采用外眦延长切口、结膜切口或二者联合切口进行手术切除，创伤小、外观影响少、并发症少、成功率高，可取的满意的临缶床效果。     

Temporary blindness after cosmetic blepharoplasty.

A patient who underwent a cosmetic blepharoplasty suffered a retrobulbar hemorrhage with no light perception deception detected when the dressing was removed two hours postoperatively. Opening the incision site led to the complete return of visual acuity and ocular motility and relief of the proptosis. The rebleeding of cauterized blood vessels may have caused the retrobulbar hemorrhage and seems to be a potential problem in all cosmetic blepharoplasties. Eliminating the use of postoperative bandages may prevent blindness after cosmetic blepharoplasty since it allows early detection of a retrobulbar hemmorrhage. This allows the nurse to check the patient for loss of vision and proptosis at ten-minute intervals for the first two hours after surgery so immediate treatment can be implemented if retrobulbar hemorrhage and central retinal artery occlusion occur.     

Acute spontaneous extraconal hematic cyst of the orbit

A 49 year old man presented with one day history of mild right eye pain and proptosis. There was no definite history of trauma. On examination there was limitation of movement in all directions of gaze and 6 mm proptosis of his right eye. CT scan showed extraconal lesion compressing the optic nerve and inferior rectus muscle. Right inferior conjunctival fornix based approach was performed with lateral canthotomy and inferior cantholysis and exploration revealed a cyst containing blood which was removed.     

A Patient with Keratoconus,Nanophthalmos, Lipodermoids,and Pigmentary Retinopathy

A 44-year-old male with no pertinent history other than poor vision for more than 25 years was examined. Best corrected visual acuity was 20/80 OD [MR: +14.25 +1.00?×?15°] and 20/200 OS [MR: +15.00 +1.50?×?175°]. Significant limitation in ocular movements and the presence of an orbital lipodermoid in the infero-temporal aspect of each eye were noted. Forced duction test was positive for the same directions of limitation indicating possible extraocular muscle fibrosis. Ophthalmoscopy was remarkable for the presence of peripheral bony spicules. Corneal topography was compatible with keratoconus (K_max?=?55.04D OD and 52.87D OS). A-scan revealed axial lengths of 16.96?mm OD and 16.32?mm OS, compatible with a diagnosis of nanophthalmos. OCT revealed diffuse macular thickening for both eyes with foveal thickness of 350?µm OD and 353?µm OS. Over the next 12 years the patient had stable visual acuity, manifest refractions and anterior segment examination. Ophthalmoscopy revealed only minimal progression of pigmentary changes. We report the first case of these simultaneous multiple findings which may refer to a possible syndromic association of congenital or early childhood onset.     

Wavefront-guided treatment for previous laser in situ keratomileusis and photorefractive keratectomy: case reports

PURPOSE: To describe the off-label use of the Alcon LADARVision System for CustomCornea (LADARWave and LADARVision4000) in two patients, one for retreatment after laser in situ keratomileusis (LASIK) and one for retreatment after photorefractive keratectomy (PRK). METHODS AND RESULTS: Both patients were unhappy with the quality of their vision after initial refractive surgery. The first patient initially had LASIK to correct -4.75 D of myopia in each eye, and then had retreatment with CustomCornea. Before retreatment, manifest refraction was OD 0.50 -0.50 x 180 degrees (20/25 uncorrected) and OS -0.50 -0.75 x 180 degrees (20/40 uncorrected). Two months after retreatment with CustomCornea, his uncorrected visual acuity OD was 20/15, and 1 month after retreatment in his left eye, uncorrected visual acuity was 20/15. The second patient had PRK OD, with a postoperative uncorrected visual acuity of 20/25 and cycloplegic refraction of +1.00 -0.75 x 84 degrees. After CustomCornea retreatment, his 3.5-month postoperative uncorrected visual acuity was 20/15 and manifest refraction was +0.50 -0.50 x 180 degrees. CONCLUSION: The Alcon LADARVision System for CustomCornea was used effectively to retreat both a myopic LASIK and myopic PRK patient, primarily for subjective quality of night vision complaints.     

Case of cancer-associated retinopathy in which immediate treatment succeeded

PURPOSE: Cancer-associated retinopathy (CAR) leads to progressive loss of visual functions and a small number of reports have described effective treatment for the disease. We herein report a case of a CAR patient whose visual acuity improved with corticosteroid and a radical treatment of the tumor. CASE: A 70-year-old man with rapidly progressive loss of visual acuity and visual field was referred to our clinic. The visual acuity of the patient had decreased to finger count OD and 20/30 OS at the initial visit, though visual acuity three weeks before the initial visit was 20/16 in both eyes. The patient suffered from night blindness, Goldmann perimetry revealed ring-like scotoma, and the electroretinogram was negative. Fundus examination showed only attenuation of the vessels but no apparent sign of retinal degeneration. Chest computed tomography (CT) revealed a small cell carcinoma in the lung of 1.2 cm diameter. One week after the initial visit, as the visual acuity in both eyes decreased to hand motion, the patient was treated with chemotherapy, radiation, and corticosteroid pulse therapy. After the treatment, the visual acuity of the patient improved to 20/50 OD and 20/67 OS, but the visual field of the patient did not improve. The tumor in the lung was disappeared on CT. CONCLUSION: Corticosteroid treatment for CAR patients may be effective when performed rapidly after clinical symptoms appear.     

Grease-gun injury of the orbit: Computed tomography and magnetic resonance imaging in diagnosis and treatment

A 19-year-old male was referred because of a grease-gun injury of the left orbit, resulting in a 25 mm proptosis and marked decrease in vision. The clinical diagnosis of penetration of the retrobulbar fat space by the grease and the subsequent accurate drainage of the grease was made possible on the basis of high resolution computed tomography (CT) and magnetic resonance imaging (MRI). As a result, lateral orbitotomy could be avoided. Eight months after the injury the visual acuity was fully recovered and the proptosis reduced to 2 mm. The visual field was relatively undisturbed. The specific value of CT and MRI for the management of this unusual trauma is briefly discussed.     

Retinal and choroidal vascular occlusion after posterior sub-tenon triamcinolone injection

PURPOSE: To report a case of retinal and choroidal vascular occlusion occurring as a complication after posterior sub-Tenon triamcinolone injection for treatment of uveitic cystoid macular edema. DESIGN: Interventional case report. METHODS: Retrospective study. A 32-year-old woman with uveitis and cystoid macular edema underwent a right posterior sub-Tenon injection of triamcinolone (40 mg/ml, 1 ml total) through a superotemporal approach after topical anesthesia. After the procedure, the patient experienced severe eye pain, orbital ecchymosis, and globe proptosis consistent with retrobulbar hemorrhage. RESULTS: Dilated fundus examination of the right eye (OD) demonstrated multiple intraretinal hemorrhages with particulate white emboli occluding the retinal and choroidal vessels. Visual acuity was no light perception. Ocular massage and hypotensive therapy was initiated for an intraocular pressure of 50 mm Hg. Canthotomy and cantholysis were performed. A total of 39 months post-incident, her visual acuity improved to 20/100. CONCLUSION: Posterior sub-Tenon triamcinolone injection can rarely result in retinal and choroidal occlusion. Immediate intervention may preserve limited visual acuity.     

Exophthalmos in myelodysplastic syndrome

A case of myelodysplastic syndrome (MDS) who suffered alternating proptosis was reported. A 57-year-old Japanese man with MDS developed acute painful left proptosis with eyelid edema, conjunctival injection, visual disturbance, and restriction of eye movements. This lasted for 3 weeks. Computerized tomography (CT) showed swelling of the lateral and medial rectus muscles and the optic nerve, as well as a retrobulbar mass. Later, a similar painful right proptosis with severe conjunctival chemosis developed. CT showed only bilateral mild optic nerve swelling. The visual acuity of the right eye decreased to null even after remission of the proptosis. The patient died due to myocardial infarction and underwent autopsy. The right optic nerve stroma was found to be increased over that of the left. Cellular infiltration was noted in the left optic nerve and the retrobulbar connective tissue. This self-limiting and relapsing proptosis was apparently related to MDS. This is only the second MDS case with such severe ophthalmological symptoms reported in the literature.