Optic nerve decompression via the lateral facial approach

Two cases of visual loss after lateral orbital wall fracture are presented: one with retrobulbar hematoma and evidence of optic nerve compression who failed to respond to lateral canthotomy and high-dose corticosteroid administration, and the second with immediate, total blindness associated with fracture of the bony optic canal. In both, extradural decompression of the orbit and optic nerve was achieved through the lateral facial approach with partial return of visual acuity and without surgical complications. The role of orbital and optic nerve decompression in the management of patients with blindness following orbital trauma is controversial. Orbital decompression may be of value for cases of post-traumatic visual loss unresponsive to medical management. If optic nerve injury is suspected as the cause, the additional step of decompression of the optic nerve is a logical but unproven procedure. The indications for optic nerve decompression are not established and should be considered only within the context of the specific needs of the individual patient.     

Endoscopic orbital and optic nerve decompression

The endoscopic transnasal approach is well suited for decompression of both the orbit and optic canal. High-resolution nasal endoscopes provide excellent visualization for bone removal along the orbital apex and skull base. Endoscopic orbital decompression has proved to be safe and effective for the treatment of patients with Graves' orbitopathy; however, the indications and outcomes for endoscopic decompression of the optic nerve remain controversial.     

Orbital decompression in Graves' orbitopathy: a combined endoscopic and external lateral approach

AIMS: First, to assess the outcomes of endoscopic and external lateral orbital decompression in patients with dysthyroid orbitopathy. Second, to establish a correlation between the percentage of postoperative diplopia and the technique used. METHODS: A retrospective review of 40 patients (73 eyes) who underwent endoscopic medial orbital decompression and external lateral orbital decompression between 1997 and 2003 at the H?pital Enfant-Jesus in Quebec City. Some of these patients also had an inferior endoscopic decompression. All patients had exophthalmos. The principal indications for surgery were 42 eyes with compressive optic neuropathy, 13 eyes with other ocular disorders, and 18 eyes with exophthalmos only. All patients with neuropathy underwent endoscopic decompression of the optic canal. RESULTS: All patients had satisfactory improvement of their ocular pathology. Optic neuropathy was completely resolved in 92.85% (39 of 42 eyes). In patients who did not have preoperative diplopia (26), diplopia developed in 70% (14 of 20) of those who underwent medial and inferior decompression compared with 16.6% (1 of 6) of patients who underwent medial decompression only. CONCLUSION: Endoscopic medial orbital decompression is very effective in resolving compressive optic neuropathy. Preservation of the orbital floor, when the degree of exophthalmos allows, reduces the incidence of postoperative diplopia.     

Selection of patients and choice of operation for orbital decompression in graves ophthalmopathy

Until the fundamental cause of the orbital problem associated with Graves' disease is better understood and can be prevented or reversed, some patients will need palliative orbital decompression. Of the available methods of orbital enlargement, the transantral ethmoidal decompression and the transfrontal operation seem most useful because of the amount of bone that can be removed by either approach. Transantral decompression is an appropriate operation for those patients with serious bilateral disease who would otherwise be treated systemically with corticosteroids. It also is of value as a preliminary step to extraocular muscle surgery after the orbital process has stabilized in those patients with exophthalmos and extraocular muscle myopathy and diplopia. Cosmetic decompression by this route is practical but total rehabilitation may also require upper lid and rectus muscle surgery. Forty patients with Graves' ophthalmopathy were treated by transantral decompression in the period July, 1969, to July, 1972. Seventeen of these had optic nerve dysfunction and visual field defects, papilledema, or choroidal folding. Fourteen patients had proptosis without optic neuropathy and six of these had corneal ulceration. Five patients had decompression specifically as a preliminary to eye muscle surgery and four patients had decompression for purely cosmetic reasons. The transfrontal decompression is ideal for patients with unilateral exophthalmos and when orbital exploration is needed. The transfrontal operation can salvage vision in the occasional patient with serious disease that is not palliated by transantral decompression. Orbital decompression is a more conservative approach to palliation than is high-dose long-term systemic steroid therapy. Orbital decompression has effectively controlled the optic neuropathy of Graves' disease without serious complications from the operation and without risking the potential side-effects of long-term high-dose steroid therapy.     

Sekundäre Erblindung nach orbitaler Holzfremdkörperverletzung

We report a 68-year-old male who had orbital trauma from a bicycle accident. His vision was initially normal but deteriorated over 8 days to complete blindness. After 13 days, when he first consulted a physician, clinical investigation revealed total ophthalmoplegia, ptosis, and chemosis. Computed tomographic scan showed fractures of the medial orbital wall, orbital floor, and posterior ethmoid with dislocation into the orbital apex near the optic nerve. The patient was sent to our department for optic nerve decompression. Clinical examination showed induration and an already healed infraorbital entry wound suggesting an orbital foreign body, which was confirmed by ultrasound. Renewed analysis of CT scans in different window settings could clearly demonstrate a wooden foreign body in the lower eyelid. Additionally, a diffuse inflammation in the orbital apex was diagnosed. The foreign body was removed and decompression of the orbita and optic nerve was performed. Antibiotics and corticosteroids were administered i.v. Unfortunately, no visual improvement could be achieved.     

Endoscopic orbital decompression for Graves' ophthalmopathy

BACKGROUND: Graves' ophthalmopathy generates a volume excess for the orbital cavity, which may produce proptosis, pain, exposure keratitis, diplopia, and optic neuropathy. Endoscopic orbital decompression expands the orbital cavity into the ethmoid cavity and medial maxillary sinus. This retrospective study documents the outcomes after endoscopic orbital decompression for patients with Graves' ophthalmopathy. METHODS: Data collected included demographic information, symptom resolution, complications related to the surgery, reduction in proptosis, subsequent need for eye muscle surgery, and hospital length of stay. Between July 1989 and April 2003, 62 patients were referred for endoscopic orbital decompression (often unilateral). RESULTS: Three patients refused use of their medical records for research purposes. Seventy percent were women; the average age of the study group was 49 years. Preoperatively, 63% of the patients had diplopia and optic neuropathy was noted in 27%. Two patients had a cerebrospinal fluid leak identified and managed during the decompression. No postoperative leaks occurred. Twenty-five percent of patients did not require eye muscle surgery. Forty-eight percent of the patients underwent one procedure to manage diplopia. The average reduction in proptosis was 2.5 mm. Fifty-four percent were managed as an outpatient and 27% underwent a 23-hour observation period. CONCLUSION: This data supports the safety, efficiency, and efficacy of endoscopic orbital decompression for unilateral and bilateral Graves' ophthalmopathy. Eye muscle surgery frequently will be required to manage diplopia after decompression.     

Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression

OBJECTIVE: To evaluate the efficacy and safety of a combined endoscopic and transconjunctival orbital decompression in patients with thyroid-related orbitopathy with orbital apex compression. STUDY DESIGN: Retrospective review. METHODS: A sequential series of patients with thyroid-related orbitopathy presenting with orbital apex compressive myopathy with and without optic neuropathy who were undergoing combined endoscopic and transconjunctival decompression by the same surgeons from 1992 to 2001 was reviewed. Patients were regularly evaluated preoperatively and postoperatively over a 3- to 55-month period to record the effects of this approach on visual acuity, Hertel exophthalmometry, and diplopia. Complications and secondary ophthalmological procedures were reviewed. RESULTS: Between 1992 and 2001, 72 combined endoscopic and transconjunctival decompressions were performed on 41 patients with orbital apex compression. Visual acuity improved in 89.3% of the patients with compressive optic neuropathy (P <.0005) and in 34.1% of those without neuropathy. Proptosis was reduced by 3.65 mm, on average. There was one case of transient intraoperative cerebrospinal fluid extravasation at the site of the optic nerve decompression, and one patient developed epistaxis. CONCLUSIONS: The study supports the treatment of thyroid-related orbital apex compression with and without compressive optic neuropathy by a combined transconjunctival and endoscopic approach. This approach offers short hospital stays, excellent visual recovery, and minimal complications in patients with thyroid-related orbital apex compressive myopathy and related compressive optic neuropathy. The beneficial effects observed in the patients with visual loss continued to improve over time and were significant (P <.001).     

Combined Transconjunctival/Intranasal Endoscopic Approach to the Optic Canal in Traumatic Optic Neuropathy

Surgical decompression of the optic canal is indicated in patients with traumatic optic neuropathy who fail to respond to corticosteroids. Traditional surgical approaches to the orbital apex have been effective in achieving optic nerve decompression but require either a craniotomy, provide limited exposure with late identification and protection of the optic nerve, or require external incisions. The combined transconjunctival/intranasal endoscopic approach to the optic canal offers sufficient exposure, allows early identification and protection of the optic nerve, provides space for the use of multiple surgical instruments, obviates a craniotomy and external incisions, and can be performed quickly with minimal morbidity. The technique of combined transconjunctival/intranasal endoscopic optic nerve decompression will be described and the experience with nine cases will be presented.     

视神经管局部解剖与鼻内镜下解剖的结合研究

目的:为鼻内镜下视神经管减压术的临床运用提供解剖学依据。方法:10具(20侧)成人湿性尸头,从正中矢状位锯开,以直尺、量角器等测量工具测量视神经管与前鼻棘间的距离和角度;5具(10侧)(含儿童尸头2具)湿性尸头经鼻腔行鼻内镜下视神经管眶口至颅口段解剖,观察视神经管及其相关解剖标志。结果:大体标本观察,均可见到视神经管与颈内动脉呈“八”字形关系,测得视神经管内侧壁长度平均(9.12±1.89)mm,视神经管眶口直径平均(4.12±0.53)mm,前鼻棘到视神经管眶口内壁中点距离平均(61.22±6.23)mm,前鼻棘到视神经管眶口内壁中点的角度平均(45.3±4.5)°。鼻内镜下观察,沿视神经管眶口向后,可见到不同程度的一条反光带,即视神经管,7侧(70%)可见到明显的隆起,3侧(30%)无明显隆起,无法按照隆起形状判断视神经管。结论:结合大体解剖观察与鼻内镜下解剖观察,有助于准确识别鼻内镜下的视神经管,从而提高鼻内镜下视神经管手术的准确性。     

Orbit and orbital apex

Pathology affecting the orbit and orbital apex is diverse and heterogeneous. Many of the differential pathologies require management in a multidisciplinary team involving both otolaryngology and ophthalmology. This article discusses the differential pathologies. Emphasis has been placed on Graves orbitopathy, traumatic optic neuropathy, and the indications for decompression in each. The differential diagnosis for a lesion within the orbit and orbital apex is diverse. The presentation, investigation, and appropriate management of these conditions is discussed with emphasis on traumatic optic neuropathy and Graves orbitopathy.     

Combined-approach orbital decompression for thyroid-related orbitopathy

Surgical treatment of thyroid-related orbitopathy can be accomplished by transorbital or endoscopic techniques. Transorbital surgery has advantages in the orbital floor and lateral wall, and endoscopic decompression is best suited to the medial orbital wall. We describe a retrospective review of 16 orbits (10 patients) treated with surgery, combining endoscopic decompression of the medial wall and a transorbital approach to the floor and lateral wall. Follow-up averaged 20.8 months. Vision and field defects improved dramatically in compressive optic neuropathy cases. Hertel measurements improved, on average, 4.9 mm. Two patients with severe preoperative diplopia required strabismus surgery after decompression. Combined-approach decompression is a safe and efficacious operation with conceptual advantages over current surgical techniques.     

Combined-approach orbital decompresion for thyroid-related orbitopathy

Surgical treatment of thyroid-related orbitopathy can be accomplished by transorbital or endoscopic techniques. Transorbital surgery has advantages in the orbital floor and lateral wall, and endoscopic decompression is best suited to the medial orbital wall. We describe a retrospective review of 16 orbits (10 patients) treated with surgery, combining endoscopic decompression of the medial wall and a transorbital approach to the floor and lateral wall. Follow-up averaged 20.8 months. Vision and field defects improved dramatically in compressive optic neuropathy cases. Hertel measurements improved, on average, 4.9 mm. Two patients with severe preoperative diplopia required strabismus surgery after decompression. Combined-approach decompression is a safe and efficacious operation with conceptual advantages over current surgical techniques.     

Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves’ orbitopathy

Background: To determine the clinical outcomes and morbidity of endoscopic medial wall combined with transcutaneous lateral orbital wall decompression in Graves’ orbitopathy.

Methodology: A retrospective noncomparative case series of patients who underwent surgical decompression for Graves’ orbitopathy at Hospital Universitario de Fuenlabrada between 2004 and 2014 was performed. We reviewed the patients’ charts and analyzed before and after the decompression, the visual acuity (Snellen chart), optic nerve compression (fundoscopy and optic coherence tomography), exophthalmometry (Hertel measurement), ocular motility, diplopia, eyelid surgery needed after decompression and its possible complications.

Results: A total of 20 patients (36 orbits) were operated. The mean follow-up was 44 months (range 18–84). Vision improved dramatically in all compressive optic neuropathy cases (5 cases). Hertel measurements improved on average 3.5?mm (range 1.5–4.5). Diplopia was cured in eight patients (40%) and nine patients with severe preoperative diplopia required strabismus surgery after decompression. Eyelid surgery was further needed in 13 patients. Hyaluronic acid injection was the most used technique for the treatment of eyelid retraction (6 out of 13 patients). Only two major complications were observed: one case had a major post-operative epistaxis and another a cerebrospinal fluid leak. Both were resolved without further sequelae.

Conclusions: These results suggest that endoscopic medial wall combined with transcutaneous lateral wall orbital decompression is an effective and safe treatment for the symptomatic dysthyroid eye disease with important proptosis or compressive optic neuropathy.     

Endoscopic transnasal orbital decompression

Orbital decompression for dysthyroid orbitopathy has traditionally been performed through either an external or a transantral approach. The advent of intranasal endoscopes allowed for the development of a transnasal approach for medial and inferior orbital wall decompression. Using this approach, orbital decompressions were performed on 13 orbits in eight patients with severe complicated dysthyroid orbitopathy. Simultaneous bilateral lateral orbitotomies were performed on five patients. Walsh-Ogura decompressions and lateral orbitotomies were performed on two orbits. When combined with lateral orbitotomy, Hertel measurements improved an average of 5.7 mm in orbits decompressed transnasally and 4.5 mm in orbits decompressed with a Walsh-Ogura approach. Transnasal decompression alone improved Hertel measurements an average of 4.7 mm. Visual acuity improved in three of four patients with optic neuropathy, and in all patients with exposure keratopathy. We conclude that the endoscopic transnasal approach provides comparable decompression to traditional methods while avoiding the morbidity of an external ethmoidectomy or Caldwell-Luc antrotomy.     

Antral-ethmoidal decompression of the orbit in Graves' disease: ten-year experience

The orbital manifestations of Graves' disease usually comprise the most distressing component of this inadequately understood disease entity. Patients with optic neuropathy, exposure keratopathy, or disfiguring proptosis can be helped considerably by decompression of the swollen orbital tissues into the maxillary and sinus cavities. Experience with 104 patients personally operated by the senior author and analyzed by chart review and patient questionnaire indicates that antral-ethmoidal decompression is a successful form of therapy, generally free of serious complications. It is now employed earlier in the course of Graves' ophtholmopathy than in the past.     

Visual loss due to orbital fracture. The role of early reduction

Serious injury to the optic nerve is an uncommon, usually permanent, complication of orbital fractures. Occasionally it is due to reversible changes, such as edema, contusion, or compression of the optic nerve. The early management of visual loss due to orbital fracture is controversial. Some authors advocate emergency optic nerve decompression; others recommend steroid therapy alone. We present a case of nearly complete unilateral loss of vision after a lateral orbital fracture with compression of the optic nerve by bony fragments. Computed tomographic scanning of the orbit helped us to pinpoint the cause of visual compromise and also served as a guide in planning surgery. Large dosages of steroids, combined with early reduction of the fracture, resulted in substantial recovery of vision. This case illustrates the importance of precisely determining the nature of the injury and the cause of visual compromise. A protocol for management of these injuries is presented.     

Computer-aided three-dimensional reconstruction and measurement of the optic canal and intracanalicular structures.

OBJECTIVE: To reconstruct the human optic canal and its inner structures and to provide detailed knowledge of this region for optic nerve decompression. METHODS: Six optic canals and their inner structures were reconstructed using a computer-aided three-dimensional reconstruction system. Quantitative measurement of the canal wall thickness, bony canal transverse area, optic nerve transverse area, dural sheath transverse area, subarachnoid space transverse area, and subarachnoid space volume was done using the computer morphometric analysis system. The detailed spatial relationship among intracanalicular structures was also carefully identified on the three-dimensional models. RESULTS: The thinnest portion of the canal was the middle part of the medial wall (0.45 +/- 0.14 mm) and the narrowest space was in the middle part of the optic canal (the transverse area was 18.21 +/- 1.20 mm2). The volume of subarachnoid space that can be considered the compensatory space for distention incurred by the hemorrhage, optic nerve edema, or hematoma was 21.16 +/- 4.31 mm3. At the cranial opening, the middle part, and the orbital opening, its transverse area was 4.45 +/- 0.46 mm2, 2.68 +/- 0.54 mm2, and 1.23 +/- 0.34 mm2 respectively. CONCLUSIONS: Because the compensatory space was limited, even a tiny amount of blood or swelling of the nerve may cause optic nerve compression. Because the compensatory space for distention gradually decreases from cranial end to orbital end, the middle part and the anterior part of the optic canal and dural sheath are critical in optic nerve decompression.     

Tension pneumo-orbit secondary to minor blunt force trauma

IntroductionTension pneumo-orbit is a rare but eye-threatening sequelae of orbital trauma. Minimal trauma to the lamina papyracea can result in a valve effect leading to rapid-onset proptosis and optic nerve compression in the absence of a haematoma.Case reportWe describe a case of medial orbital wall fracture in a 35-year-old lady following a minor fall at home. She presented with severe proptosis of the left eye. Imaging showed marked pneumo-orbit, which was managed definitively by endoscopic orbital decompression.DiscussionTension pneumo-orbit requires prompt recognition and surgical decompression. An endonasal approach may be used to decompress the orbit via the medial wall.     

内镜下经筛径路眶内侧壁减压联合脂肪减压术治疗Graves眼病

目的 探讨内镜下经筛径路眶内侧壁减压术联合内镜下经筛径路眶肌锥内脂肪减压术治疗Graves眼病(Graves' ophthalmopathy,GO)的可行性,并分析其疗效.方法 对2006年10月至2011年5月因并发眶尖拥挤视神经病变而接受眶减压手术的29例GO患者进行回顾性分析.所有患者术前确诊为非组织活动期,均因视力下降、视野缺损或色觉障碍,同时合并眼球突出而接受内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术,术后定期随访.根据术后9个月视力、色觉改善程度,以及眼球突出度矫正度、复视等并发症判断疗效.结果 共收集资料齐全的GO患者29例(45眼).术后9个月,44眼(97.8％)视力明显改善,视力从术前((x)±s,下同)的-0.65±0.30提高至-0.24±0.22,视力平均提高达0.55 ±0.17,手术前后比较差异有统计学意义(t=- 13.012,p＜0.001);29眼术前色觉障碍者,23眼(79.3％)术后明显改善;术后双眼眼球对称度达100％,手术前后比较,平均眼球突出矫正度达(7.07±1.59) mm(4～11 mm).术后所有病例双眼眼球突出度相差＜2 mm,除1例术后复视加重外,术后无一例新发复视、视力下降、眶内出血等并发症发生.结论内镜下经筛径路眶内侧壁减压术联合肌锥内眶脂肪减压术在实现眶尖部减压的同时可以达到有效矫正眼球突出度的效果,且具有微创,无颜面部瘢痕,术后复视、眼球移位等发生率极低的优点,该术式是治疗GO并发眶尖拥挤视神经病变患者的安全有效的手段之一.     

鼻内镜鼻窦手术眼部并发症及其处理对策

目的 探讨鼻内镜鼻窦手术的眼部并发症可能的原因及处理经验,以期引起鼻内镜外科医生的重视.方法 收集作者收治的具有比较典型特征的鼻窦手术眼部并发症者22例8类.损伤类型分别为:纸样板损伤、眶内感染、额筛阻塞性囊肿、泪道损伤、眼外肌损伤、眶内出血、视神经损伤、眼底动脉栓塞等,并给予了相应处理.结果 单纯纸样板损伤9例中8例经保守治疗痊愈,眶纸样板损伤伴眶骨膜下感染1例和泪道损伤、额筛阻塞性囊肿各1例经鼻内镜手术痊愈.眼外肌损伤2例中1例经眼肌矫正术后除向健侧有轻微复视外,其他眼位无明显复视;另1例经眼肌矫正后仍有轻度复视.眶纸样板损伤致眶内出血1例痊愈,另1例眶内出血和1例眼底动脉栓塞导致的视力丧失无改善.视神经损伤6例(7侧)中1例(1侧)经视神经减压+眶尖减压视力恢复正常,另1侧及其余5例(5侧)无改善.结论 鼻内镜手术导致视神经损伤、眶内出血和眼底动脉栓塞导致的失明,治疗困难,预后极差;如果有残存视力,预后较好.