Ossifying fibroma of the lateral orbital wall in an adult

Orbital ossifying fibroma is an extremely rare condition, especially in adults. This rare tumor mostly develops at the medial wall of the orbit. We report a histopathologically confirmed ossifying fibroma involving the lateral orbital wall in an adult. This case suggests that orbital ossifying fibroma should be considered in the differential diagnosis of orbital bony lesions in adults and that unusual presentations may occur.     

Review of lateral orbital wall ossifying fibroma

Significant histological overlap exists between fibro-osseous lesions and diagnosis is made on a clinicopathological basis. Ossifying fibroma is a benign fibro-osseous neoplasm of the jaw and craniofacial complex that has generated a degree of controversy regarding diagnosis and classification, especially with respect to the psammomatoid variant. Orbital lesions mainly arise from the paranasal sinuses affecting the medial or inferior orbital wall. Lateral orbital wall ossifying fibroma is, therefore, a rare condition with only a single previous case report. We present a second case of lateral orbital wall ossifying fibroma and a review of the associated literature.     

Ossifying fibroma: a rare cause of orbital inflammation

PURPOSE: To describe the clinical and radiologic features of 4 cases of ossifying fibroma affecting the orbit and to review the literature on orbital involvement by the tumor. METHODS: Small case series. RESULTS: Four patients (3 children and 1 adult) with ossifying fibromas invading the orbit were examined. Two of the 3 children were examined for ossifying fibromas on the orbital roof. One had the psammomatoid form of the disease and the other the trabecular variant. Despite striking differences in the histologic pattern and in the radiologic appearance of the lesions, both children displayed a significant degree of orbital inflammation mimicking orbital cellulitis. The third child and the adult patient had the orbit involved by trabecular ossifying fibromas invading the orbital floor. The tumor of the adult clearly originated in the maxilla, filled the maxillary sinus, and eroded the orbital floor. The tumor of the third child occupied the maxillary, ethmoid, and sphenoid sinuses. In both cases, the clinical presentation was painless eye dystopia and proptosis. CONCLUSIONS: Regardless of the histologic pattern (trabecular or psammomatoid), ossifying fibromas can induce a substantial degree of orbital inflammation in children and must be included in the differential diagnosis of acute orbital inflammation during childhood.     

Intraosseous hemangioma of the lateral orbital wall

PURPOSE: To report the clinical and radiologic features of two patients with intraosseous orbital hemangiomas of the lateral wall. METHODS: Case reports and literature review. RESULTS: The first patient presented with an indolent mass over the lateral orbital rim. Intraosseous hemangioma was not considered in the differential diagnosis. A biopsy specimen was taken from the tumor, which caused significant bleeding. After biopsy, an orbital CT scan revealed a lesion involving the left lateral orbital rim and soft tissue of the temporal fossa. The rim was grossly enlarged, with several cavities of different sizes. The tumor of the second patient was located more posteriorly and extended into the roof. The patient complained of parietal headache, epiphora, and local pain. A CT scan revealed a round, lytic lesion involving the greater sphenoid wing and frontal bone. The tumor was approached through a coronal flap and resected en bloc without problems. CONCLUSIONS: The diagnosis of intraosseous hemangioma can be difficult, especially when tumors are located in the anterior part of the lateral wall. In this location, intraosseous hemangiomas tend to induce few symptoms and thus have a higher likelihood of biopsy being performed before a correct diagnosis. A CT scan with bone windows can play a beneficial role in the evaluation of lytic bone lesions in intraosseous hemangioma.     

Solitary eosinophilic granuloma of the lateral orbital wall

Two children (aged 18 and 23 months at the initial examinations) were each ultimately found at surgery to have a solitary eosinophilic granuloma of the lateral orbital wall. Both patients had a symptomatic period of six weeks during which time other diagnoses were considered: bacterial preseptal cellulitis and mumps dacryoadenitis in the first case and traumatic recurrent orbital hematoma in the second. Diagnostic difficulties stemmed from confusing features in their histories, as well as the location of the lesion and the deceptively minimal swelling relative to the actual size of the lesion. Follow-up ten and 18 months after curettage of the two lesions showed no recurrence or evidence of systemic involvement. Although most reported cases describe the orbital frontal bone as the site of origin in the orbit, our cases demonstrated that unifocal eosinophilic granuloma may occur in the lateral wall of the orbit.     

Surgical anatomy of the deep lateral orbital wall

PURPOSE: To determine the exact anatomic location and volume of the thickest section of the greater wing of the sphenoid bone (trigone), which is removed during deep lateral orbital wall decompression. METHODS: Eighteen dried skulls were used to determine the exact anatomic location and computed tomography (CT) images of 20 patients (10 male, 10 female) were used for volumetric calculations. RESULTS: Mean values were 14.5 mm for the orbital rim to inferior orbital fissure distance, 23.3 mm for rim to trigone distance, 13.0 mm for width of the trigone base, 5.8 mm for trigone to orbital apex distance, and 12.3 mm for trigone height. The width of the narrowest section of the trigone was 5.2 mm. The trigone was found to have a lower segment (0.92 cc) neighboring the inferior orbital fissure, and an upper segment (0.32 cc) adjoining the thick substance of frontal bone. The narrowest part between these two segments was located just at the superior border of the lateral rectus muscle. CONCLUSIONS: The authors recommend avoiding the thin rectangular portion located in the inter-fissural area adjacent to the superior orbital fissure. A high intersubject variability underscores the need for individualized preoperative analysis by imaging studies.     

Advantageous surgeon's position in deep lateral orbital wall decompression

The deep lateral orbital wall decompression is now the first surgical approach in orbital decompression ( Leone et al., 1989 ). Although it is a popular procedure with few complications and satisfactory results, tips for bone removal depend on each surgeon's experience. Here, I present differences of surgical effects, depending on the surgeon's standing positions.     

Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy

PURPOSE: This study aimed to determine the relative incidence and time course of new-onset strabismus after balanced medial plus lateral wall orbital decompression versus decompression of the lateral wall alone for dysthyroid orbitopathy. METHODS: The study design was a retrospective nonrandomized comparative case series. Thirty-two consecutive patients underwent balanced medial plus lateral wall orbital decompression or lateral wall orbital decompression for dysthyroid orbitopathy. The incidence, duration, and treatment of postoperative strabismus was recorded for each patient. RESULTS: Significant preoperative strabismus was present in 31% (4/13 patients) of the balanced decompression group and in 26% (5/19 patients) of the lateral wall decompression group. Only 25% (1/4) of cases of preexisting strabismus in the balanced decompression group resolved postoperatively without muscle surgery, whereas 60% (3/5) of cases in the lateral wall decompression group resolved postoperatively without surgery. Preoperative strabismus was absent in 69% (9/13) of patients in the balanced decompression group and in 74% (14/19) of patients in the lateral wall decompression group. New-onset, persistent postoperative strabismus developed in 33% (3/9) of patients in the balanced decompression group and in 7% (1/14) of patients in the lateral wall decompression group. CONCLUSION: Lateral wall orbital decompression may produce less new-onset, persistent postoperative strabismus than balanced medial plus lateral wall orbital decompression for dysthyroid orbitopathy.     

Foreign bodies in the orbit misdiagnosed as fracture of the orbital lateral wall

54 years old male presented with an injury to the face. As a result of this incident, some pieces of glass were penetrating into the left orbit. Total ophthalmoplegia and hematoma with exophthalmus in the left orbit were observed. The difficulties of radiology and clinical diagnosis was described. The circumstances of accident were wrong reported by the patient. Radiograms and computed tomography (CT) were misdiagnosed. As a result of theses, it was necessary to perform two times operation. The best useful but not ideally in diagnostic was NMR. Consultation and collaboration with oculist, radiologist, neurologist and maxillofacial surgeon is often useful.     

眼眶外侧壁击人性骨折的临床特征及手术治疗

目的 探讨眼眶外侧壁击人性骨折的临床特征及手术治疗要点。方法 回顾性系列病例研究。分析2007年1月至2010年1月在上海交通大学医学院附属第九人民医院眼科住院诊治的12例眼眶外侧壁击人性骨折患者的临床资料,结合术后复查结果,分析此类型骨折的临床特点及治疗预后。结果 12例眼眶外侧壁击人性骨折病例均表现为颧骨额突楔入眶内,其中1例眼球破裂行一期眼球摘除手术,4例发生外伤性视神经病变。1例表现为眼球突出,8例眼球内陷。复视5例,眼球运动障碍5例。眼部合并损伤有：上睑畸形3例,上睑下垂1例,内眦间距增宽合并泪道损伤3例。合并骨折有：眶底骨折11例,颧弓骨折9例,眶内壁骨折6例,鼻眶筛骨折3例。手术治疗根据损伤范围采用下睑缘睫毛下切口、口内切口、冠状切口、眉下外侧眶缘切口或原有伤口,完全复位骨折片,钛钉钛板固定,多孔聚乙烯或钛网修复合并的眶内壁或底壁骨折,伤后骨折已畸形愈合的病例,采用截骨复位术修复骨折。11例行眶壁整复手术的病例,眶壁骨折均得到准确复位。结论 眼眶外侧壁击人性骨折对眼部损伤严重,应提高对此类骨折的认识,及时采取有效的治疗。     

Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall

BACKGROUND/AIMS: Surgical correction of ocular alignment in patients with third cranial nerve paralysis is challenging, as the unopposed lateral rectus muscle often pulls the eye back to exotropia following surgery. The authors present a simple surgical approach to overcome this difficulty. This approach is also applicable to removal of unwanted overactivity of the lateral rectus in Duane syndrome. METHODS: A review was made of the records of four patients with third cranial nerve paralysis and one with Duane syndrome with exotropia in which the lateral rectus muscle was removed from its scleral insertion and reattached to the orbital wall. Additional surgery to bring the eye to the midline included medial rectus resection, medial transposition of the vertical recti, and passive suturing of the eye to the medial orbit wall. RESULTS: All patients achieved satisfactory ocular alignment following surgery. Ocular ductions were limited. These results were stable for 1.5-4 years of follow up. No major complications occurred. CONCLUSION: Lateral rectus muscle disinsertion and reattachment to the orbital wall to absorb its force and thus remove abduction torque was a simple and safe surgical procedure for restoring ocular alignment in four patients with third cranial nerve paralysis and in one patient with Duane syndrome with severe exotropia.     

Primary orbital rhabdomyosarcoma in an adult

PURPOSE. Rhabdomyosarcoma is the most common primary orbital malignant tumor in children. Though rare above the age of twenty, the authors present a case of primary orbital rhabdomyosarcoma in an adult and review the literature. DESIGN. Clinico-pathologic case report. METHODS. A 34-year-old man presented with a recurrent orbital tumor four years after initial excision. This tumor was initially misdiagnosed elsewhere as Merkel cell tumor on the basis of spurious immunohistochemical studies. Excision biopsy of the recurrent orbital mass was performed. MAIN OUTCOME MEASURES. MRI of the orbit and brain was done as well as histopathologic examination and immunohistochemistry of the excised mass. RESULTS. Histopathologic study of the excised orbital tumor revealed rhabdomyosarcoma. CONCLUSION. Careful microscopic evaluation and immunohistochemical stains are important in confirming the diagnosis of atypical cases of orbital tumors.     

Primary orbital rhabdomyosarcoma in an adult

PURPOSE . Rhabdomyosarcoma is the most common primary orbital malignant tumor in children. Though rare above the age of twenty, the authors present a case of primary orbital rhabdomyosarcoma in an adult and review the literature. DESIGN. Clinico-pathologic case report. METHODS . A 34-year-old man presented with a recurrent orbital tumor four years after initial excision. This tumor was initially misdiagnosed elsewhere as Merkel cell tumor on the basis of spurious immunohistochemical studies. Excision biopsy of the recurrent orbital mass was performed. MAIN OUTCOME MEASURES . MRI of the orbit and brain was done as well as histopathologic examination and immunohistochemistry of the excised mass. RESULTS . Histopathologic study of the excised orbital tumor revealed rhabdomyosarcoma. CONCLUSION . Careful microscopic evaluation and immunohistochemical stains are important in confirming the diagnosis of atypical cases of orbital tumors.     

深外侧壁联合内侧壁眼眶减压术治疗甲状腺相关性眼病

目的：探究深外侧壁联合内侧壁眼眶减压术治疗甲状腺相关性眼病的临床治疗效果及安全性。

方法：分析我科既往住院患者病历,纳入2019-01/2020-05在我科住院的符合纳入标准的甲状腺相关性眼病患者17例。所有患者均在全身麻醉下行深外侧壁联合内侧壁眼眶减压术,比较患者术前术后的视力、暴露性角膜炎恢复情况、突眼度、眼压以及并发症情况。

结果：所纳入研究的对象中,有甲状腺相关眼病视神经病变(DON)8例9眼,术前的最佳矫正视力0.78±0.15,术后1mo 0.36±0.12,与术前视力相比有差异(P<0.01),术后6mo 0.38±0.12,与术后1mo无差异(P=0.594)。术前眼球突出度23.75±2.55mm,术后1mo为14.85±1.53mm,与术前突眼度相比有差异(P<0.01),术后6mo为14.60±1.64mm,与术后1mo基本保持稳定(P=0.658)。术前眼压25.56±3.23mmHg,术后1mo为18.42±2.35mmHg,与术前相比有差异(P<0.01),术后6mo眼压降至15.82±2.57mmHg,与术后1mo眼压相比有差异(P<0.01)。术前有暴露性角膜炎6例6眼,术后1mo有4眼好转,2眼治愈,术后6mo 6眼全部治愈。术后患者复视情况均有不同程度减轻,并有部分患者复视症状在此后6mo持续好转,未出现其他严重并发症。

结论：深外侧壁联合内侧壁眼眶减压术可以有效地改善眼突,对DON及暴露性角膜炎等严重并发症也有良好的疗效,并发症少,是治疗严重甲状腺相关性眼病的有效手术方案。     

Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno

AIMS: A modified surgical technique is described to perform a one, two, or three wall orbital decompression in patients with Graves' ophthalmopathy. METHODS: The lateral wall was approached ab interno through a "swinging eyelid" approach (lateral canthotomy and lower fornix incision) and an extended periosteum incision along the inferior and lateral orbital margin. In addition, the orbital floor and medial wall were removed when indicated. To minimise the incidence of iatrogenic diplopia, the lateral and medial walls were used as the first surfaces of decompression, leaving the "medial orbital strut" intact. During 1998, this technique was used in a consecutive series of 19 patients (35 orbits) with compressive optic neuropathy (six patients), severe exposure keratopathy (one patient), or disfiguring/congestive Graves' ophthalmopathy (12 patients). RESULTS: The preoperative Hertel value (35 eyes) was on average 25 mm (range 19-31 mm). The mean proptosis reduction at 2 months after surgery was 5.5 mm (range 3-7 mm). Of the total group of 19 patients, iatrogenic diplopia occurred in two (12.5%) of 16 patients who had no preoperative diplopia or only when tired. The three other patients with continuous preoperative diplopia showed no improvement of double vision after orbital decompression, even when the ocular motility (ductions) had improved. In the total group, there was no significant change of ductions in any direction at 2 months after surgery. All six patients with recent onset compressive optic neuropathy showed improvement of visual acuity after surgery. No visual deterioration related to surgery was observed in this study. A high satisfaction score (mean 8.2 on a scale of 1 to 10) was noted following the operation. CONCLUSION: This versatile procedure is safe and efficacious, patient and cost friendly. Advantages are the low incidence of induced diplopia and periorbital hypaesthesia, the hidden and small incision, the minimal surgical trauma to the temporalis muscle, and fast patient recovery. The main disadvantage is the limited exposure of the posterior medial and lateral wall.     

眶壁爆裂性骨折手术治疗的临床疗效观察

目的 评价眶壁修补术治疗眶壁爆裂性骨折的疗效。方法 采用眶壁修补术治疗30例眶壁爆裂性骨折。术后随访3～6月，平均4．5月。观察术后视力、眼球突出度、眼球活动度及其并发症。结果 视力：3例因伴有眼部有它病变，严重影响视力，治疗的视力有提高；余27例手术前后视力基本不变。跟球突出度：术后增加1mm者4例；增加2mm者9例；增加3mm者9例；增加4mm者8例。眼球活动度：术前上转或外转完全受限或部分受限者，术后均得到了不同程度的改善。结论 眶壁修补术是治疗眶壁爆裂性骨折的有效方法。