Subarachnoid hemorrhage following uneventful thyroid orbital decompression

A 24-year-old woman developed subarachnoid hemorrhage and left frontal lobe ischemia following uneventful right transconjunctival orbital decompression for thyroid-related immune orbitopathy. CT, MRI, CT angiography, and carotid angiography confirmed subarachnoid hemorrhage and brain ischemia on the left side without any cerebral vascular abnormalities on either side. All tests were unremarkable. She fully recovered at last follow-up, 4 months after surgery. We did not find any reason for the subarachnoid hemorrhage and left frontal lobe ischemia. This complication should be considered after orbital surgery for patients with thyroid-related immune orbitopathy.     

Intracranial penetrating orbital injury

The authors report a case of double-penetrating injury of the globe with intracranial involvement from a pellet gun. A 16-year-old boy had a visual acuity of bare light perception in the left eye after being hit by a pellet. There was an inferior limbal entry site, dense hyphema, and no view of the fundus. Computed tomographic scan showed the pellet intracranially close to the left cavernous sinus. After neurosurgical clearance, the patient underwent primary closure of the corneoscleral entry site followed 3 weeks later by pars plana vitrectomy, lensectomy, and repair of a rhegmatogenous retinal detachment. At 12 months postoperatively, visual acuity was 20/300 and the retina was attached. Our case demonstrates the potential for significant visual recovery in some patients with a penetrating orbital injury and intracranial involvement. Complete radiographic evaluation with neurosurgical consultation is important in the management of these patients prior to ophthalmologic intervention with possible foreign body removal. There is a need for more public awareness regarding the potentially harmful effects of pellet guns.     

Current trends in orbital decompression

A questionnaire was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and the Orbital Society in regard to indications, surgical techniques and results of orbital decompression for Graves' disease. It was found that more than 60% of orbital decompressions were performed for mild to severe exophthalmos to correct corneal exposure or disfigurement. A total of 3.9% of these procedures were performed to relieve visual loss in compressive neuropathy. The large majority of decompressions were performed using antral-ethmoidal decompression via a translid or fornix approach. The amount of retrodisplacement was greatest with Kennerdell-Maroon or four-wall decompression and the least with lateral wall decompression. The antral-ethmoidal and three-wall decompression techniques gave an average of 4 to 6 mm of retrodisplacement. It was determined from the survey that antral-ethmoidal decompressions performed through the transantral approach were more likely to relieve the pressure in compressive neuropathy and also more likely to induce a worsening of muscle balance. In contrast, antral-ethmoidal decompressions performed via the translid approach were not as effective in relieving compressive neuropathy but had a much lower incidence of worsened muscle balance, and in fact, resulted in a higher incidence of improved muscle balance. The same trends were confirmed in the author's surgical practice, and an anatomic explanation is offered. The importance of creating nasoantral windows following decompression is emphasized. The risks of cerebrospinal fluid leakage and changes in eyelid positioning following decompression are described.     

Nontraumatic orbital hemorrhage

Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, “encysted” hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome.     

Large meningoencephalocele after orbital decompression

A 71-year-old woman with a history of thyroid eye disease was seen for evaluation of a skull-base mass noted on neuroimaging. She had previously under-gone bilateral orbital decompressions and strabismus surgery and had no neurologic symptoms. Bony defects along the skull base and cerebrospinal fluid leaks are known risks of orbital surgery. This is the first report of a large, asymptomatic meningoencephalocele after orbital decompression surgery.     

Combined endoscopic medial and inferior orbital decompression with transcutaneous lateral orbital decompression in Graves' orbitopathy

PURPOSE: To determine the clinical efficacy and morbidity of combined endoscopic transnasal medial and inferior wall orbital decompression performed in conjunction with transcutaneous lateral orbital decompression. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty-four subjects (64 orbits) underwent combined orbital decompression procedures for treatment of Graves' orbitopathy. INTERVENTION: Transnasal endoscopic medial wall and floor with simultaneous transcutaneous lateral orbital decompression. MAIN OUTCOME MEASUREMENTS: Ocular motility, visual acuity, and exophthalmometry. RESULTS: No new ocular motility disturbances occurred. There was a mean gain of 0.7 Snellen lines in acuity (range +9 to -10 lines). A mean proptosis reduction of 4.2 mm was observed (range 1-9 mm). CONCLUSIONS: Combined endoscopic transnasal medial and inferior orbital wall decompression done in conjunction with transcutaneous lateral orbital decompression carries a low risk of morbidity, including new onset motility disorders, and yields anatomic retropulsion of the globe that is comparable to other methods.     

Results of orbital decompression in Taiwan

Orbital decompression was performed on 116 orbits with Graves' ophthalmopathy. The indications for decompression were dysthyroid optic neuropathy (DON), recalcitrant corneal exposure (EXP) and disfiguring exophthalmos (COS). All cases but one (in the DON group) had improved or unchanged vision. The average retinal sensitivity improvement in the DON group was 6.7 +/- 6.1 dB and 85% had a significant retinal sensitivity improvement (>5 dB). The average retroplacement effect was 4.4 +/- 2.1 mm and only five cases (7%) had postoperative asymmetry of more than 2 mm by Hertel's exophthalmometry. The most frequent sequela was diplopia, which tended to occur in more severely myopathic eyes. In our series, 21% (10/48 cases without preoperative diplopia) developed diplopia after decompressive surgery. Hypoglobus is another complication, noted in two cases, which was successfully repositioned. In conclusion, decompressive surgery is a safe and effective procedure to restore vision and reduce exophthalmos in Graves' ophthalmopathy. Careful evaluation of clinical parameters, individualization of surgical goals and intraoperative titration of the retroplacement effect are the key to optimal results.     

Modified orbital decompression for dysthyroid orbitopathy

PURPOSE: The transantral approach to orbital decompression remains useful for the management of exophthalmos associated with dysthyroid orbitopathy. However, the risk of postoperative diplopia is a concern. Preservation of the anterior periorbita may help support the orbital contents and decrease the incidence of diplopia. METHODS: The medical records were reviewed of 15 consecutive patients who underwent 30 transantral orbital decompressions for proptosis associated with dysthyroid orbitopathy. The procedures were completed in standard fashion, including removal of the inferomedial bony strut between the medial orbital wall and the floor. However, stripping of the periorbita was only done posteriorly; the anterior 10 to 15 mm of periorbita were left intact. RESULTS: Six patients had preoperative diplopia that persisted after decompression. Of the nine patients without diplopia preoperatively, none developed diplopia. Proptosis was reduced a mean of 3.5 +/- 2.6 mm. CONCLUSIONS: Preservation of the anterior periorbita during transantral orbital decompression reduces the risk of postoperative diplopia. An adequate reduction in proptosis is also achieved.     

Abducens nerve palsy after orbital decompression

Introduction: Double vision after decompression surgery for Thyroid Eye Disease (TED) is well described in the literature and the incidence ranges from 0 to 64%. The Mechanisms for new onset diplopia after orbital decompression are poorly understood. Common theories include: Fibrosis of muscles, displacement of the muscle cone, and reactivation of the TED.

Aim: We present two cases with Abducens nerve palsy after uncomplicated secondary orbital decompression surgery.

Results: Two patients with inactive TED, who were followed for an average of 2 years prior to uneventful secondary decompression surgery, presented at the first postoperative visit with double vision and limitation of abduction in the recently operated eye. Magnetic resonance imaging(MRI) was done in both cases and revealed no abnormal bleeding or scaring.

Discussion: Our two cases of Abducens palsy following reoperative orbital decompression may be due to ischemic neuropathy caused by postoperative hemorrhage or inflammation.     

Lateral wall advancement in orbital decompression

Treatment of dysthyroid orbitopathy can be enhanced with a modified craniofacial approach using a lateral wall osteotomy, and anterolateral advancement and osteosynthesis in conjunction with medial and inferior wall orbital decompression. The technique of lateral wall advancement is described, and the results are discussed. While the authors advocate orbital decompression for dysthyroid optic neuropathy, advancement of the lateral orbital wall can easily be performed as an adjunct to the two- or three-wall decompression procedure. Advancement appears to increase the overall decompressive effect by providing a potential space where lateral expansion can occur and by enlarging the bony orbital volume. It also appears to lessen lid retraction and facilitates (and in some cases, obviates) the need for further lid retraction surgery.     

Pressure-volume orbital measurement comparing decompression approaches

Commonly used orbital decompressions are lateral wall, antral-ethmoidal, "three-wall," and "four-wall" decompressions. Bladders filled with saline were placed in intact bony orbits before and after decompression for comparison of compliance curves by these four methods. The lateral wall decompressions produced the least volume change, while the four-wall produced the most. The three-wall decompression provided next best pressure reduction.     

Delayed orbital infection after endoscopic orbital decompression for dysthyroid orbitopathy

OBJECTIVE: To present a delayed complication of endoscopic orbital decompression that has not been reported previously in the literature. DESIGN: Retrospective non-comparative small case series. PARTICIPANTS: Three patients with dysthyroid orbitopathy. INTERVENTION: The medical records of patients with dysthyroid orbitopathy who underwent endoscopic orbital decompression and subsequently developed orbital infection were reviewed. RESULTS: Three patients with dysthyroid orbitopathy developed orbital infection (cellulitis or abscess) originating from the frontal sinus more than 2 years after their endoscopic orbital decompression surgery. Management required drainage of the abscess, administration of antibiotics, and creation of adequate frontal sinus drainage. CONCLUSIONS: Delayed orbital infection can occur after endoscopic orbital decompression for dysthyroid orbitopathy when the frontal sinus ostium is obstructed by orbital fat or scar tissue. Infection within the frontal sinus can cause secondary orbital cellulitis or abscess. Early signs and symptoms of a frontal sinus infection can be easily misdiagnosed as progression of the patient's thyroid eye disease. Awareness of this possible complication followed by appropriate early intervention will prevent a potentially blinding condition. Furthermore, ever since this complication was observed, the authors' surgical technique of endoscopic decompression has been modified to leave the most anterosuperior portion of the lamina papyracea to prevent fat prolapse and scar formation into the region of the frontal recess.     

眼眶平衡减压术治疗甲状腺相关眼病

目的 探讨平衡眼眶减压术治疗甲状腺相关眼病的疗效和手术方法。方法 采用内外壁眼眶减压术治疗20例35眼甲状腺相关眼病患者。术后随访平均14个月。观察术后视力、眼球突出度和眼球运动等情况。结果 20例35眼中除1例行眶外壁减压外，其余均行内外壁平衡眼眶减压术。眼球突出度缓解3～11mm，其中3～4mm者5眼，5～9mm者28眼，10～11mm者2眼，平均6．32mm。视力从术前数指提高至0．1者6眼，提高2行以上者8眼，无变化21眼。术后眼球运动明显好转者9眼，运动障碍加重2眼。无视力丧失及术后感染。结论 平衡眼眶减压术是治疗甲状腺相关眼病的有效方法。     

Fronto-ethmoidal mucocele after coronal orbital decompression

A patient who underwent coronal orbital decompression for Graves' orbitopathy eight years earlier presented with left-sided proptosis without signs of periorbital inflammation. Computed tomography imaging showed a fronto-ethmoidal mucocele. It is suggested that this mucocele may be a late complication of decompression surgery.     

Nontraumatic subperiosteal orbital hemorrhage

PURPOSE: Nontraumatic subperiosteal orbital hemorrhage (NTSOH) has been reported rarely in association with sudden elevation of cranial venous pressure, generalized diseases with bleeding diatheses, and paranasal sinusitis. To define more clearly the clinical and imaging characteristics of NTSOH, we evaluated nine cases seen by the authors and reviewed previous case reports. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Nine patients (10 eyes) with NTSOH. INTERVENTION: All patients underwent computed tomography scans of the orbits. Patients with typical clinical and imaging features and normal visual function were observed. Those with an uncertain diagnosis or visual compromise underwent surgical drainage of the hematoma. MAIN OUTCOME MEASURES: Resolution of proptosis, diplopia, lid swelling, and ptosis. RESULTS: Nine patients ranging from birth to 73 years of age were identified. All were females. The lesions were located superiorly in eight patients (one patient had bilateral lesions) and medially in one patient. Most were associated with sudden elevation in venous pressure (vomiting, strangulation, straining), and most required no surgical intervention. The bilateral case occurred in the setting of disseminated intravascular coagulation and was the only case associated with visual loss possibly resulting from ischemic optic neuropathy. CONCLUSIONS: Nontraumatic subperiosteal orbital hemorrhage may occur at any age, usually secondary to sudden elevation in venous pressure. It is nearly always superior. The clinical and radiologic features are sufficiently characteristic to allow conservative treatment in the absence of visual compromise.     

Intracranial arterial avulsion during orbital exenteration

Intracranial injury secondary to orbital surgery is a rare event. We report a case of intracranial arterial avulsion secondary to exenteration which resulted in intracranial hemorrhage and neurologic injury.