Orbital cholesterol granuloma: a retrospective case series

Background To review the clinical features, radiographic features, therapy, pathological features and prognosis of orbital cholesterol granuloma(CG). Methods Twelve patients with orbital CG who were referred to Tianjin Eye Hospital between January 2002 and December 2020 were include in this retrospective case series study. Data collected included patient ophthalmic manifestations, imaging finding, treatment strategies, pathological features and prognosis were retrospectively reviewed. Results The patients comprised 10 males and 2 females. The mean age was 34.5±8.9 years(range 16 to 45 years). Four patients had a history of orbital trauma. The clinical manifestations at first visit were proptosis ( 7/12, 58.3%), periorbital or eyelids swelling (6/12,50%), limitation of eye displacement (4/12,33.3%), ptosis(2/12,16.7%), decreased visual acuity (1/12,8.3%).CT showed a non-enhancing,well-circumscribed lesion in the orbit with extensive erosion of the adjacent frontal bone and temporal bone.MRI showed a non-enhancing mass with intermediate to high signal intensity on T1- and T2-weighted imaging. Ten patients underwent lateral orbitotomy, and two patient underwent supraorbital orbitotomy,.All patients had aggressive bone erosion. Histopathologic evaluation of the cyst contents and wall revealed cholesterol clefts,multinucleated giant cells,histiocytes, foamy macrophages,and altered blood pigments. The median recurrence time of 79.6±49.8 months (range 19 month to 193 months). Three patients were lost to follow-up. No postoperative diminution of vision was noted,and no recurrence was observed. Conclusions Cholesterol granulomas can present as superiotemporal or temporal orbital lesions. The diagnosis can be established based on CT and MRI. Most of patients can have no history of orbital trauma.

Extended surgical interventions in children with retinoblastoma invasion into the optic nerve

Introduction. Standard eye enucleation (EE) may not always guarantee a sufficient length of resection of the optic nerve (ON) so that the tumor cells do not spread along the optic nerve at the intersection line. Surgical access and the scope of surgical intervention are determined by the spread and localization of the tumor, as well as the qualification of the operating team.Purpose — to evaluate the role of extended surgical interventions in the spread of extraocular tumors on the ON.Materials and methods. The study included 9 patients with retinoblastoma (RB) and macroinvasion of the ON during primary magnetic resonance imaging (MRI) and/or micromorphological invasion of the ON resection line after EE. 4 of the 9 patients were treated with primary/secondary EE, induction chemotherapy (CT) and high-dose CT (HDCT), radiation therapy (RT). 5 out of 9 patients underwent secondary extended surgical interventions: exenteration of the orbit (n = 1), osteoplastic lateral orbitotomy with precanal resection of the ON (n = 2) in combination with EE in one case, subfrontal craniotomy (n = 1) and orbitozygomatic craniotomy (n = 1) with prechiasmal resection of the ON and EE with adjuvant RT (excluding the latter case) and CT, without HDCT.Results. It should be noted that the overall survival (OS) of 5 patients with complete microscopic resection (R0) after extended secondary operations was 75 ± 0.217 % with an average follow-up period of 77.25 ± 18.8 months, while in 4 patients with R1 (n = 4) without secondary extended operations with HDCT reached only 50 ± 0.25 % with an average follow-up period of 57 ± 24.8 months.Conclusion. MRI is mandatory for the primary diagnosis of RB, especially when there is a risk of the tumor spreading through the ON. Secondary surgery with R0-resection has a positive effect on survival. The need for adjuvant RT and CT after surgery should be discussed.

Orbitozygomatic approach for large orbital cavernous hemangioma

Background: Cavernous hemangiomas, more accurately defined as cavernous venous malformations, constitute the most common primary intraorbital tumors of adults comprising 4–9% of all tumors,[4] and the second most frequent cause of unilateral proptosis after thyroid-related orbitopathy.[3] Over 80% are located within the intraconal compartment, most commonly in the lateral aspect.[1] Surgical treatment for orbital cavernous hemangioma is generally required in symptomatic cases, optic nerve compression, and cosmetically disfiguring proptosis.[2] Transcranial approaches, the most familiar approaches for neurosurgeons, provide wide access to the entire superior and lateral orbit. They usually offer direct visualization, allowing for a safer dissection, while minimizing significant injury to the native neural and vascular anatomy of the orbit.[5] Although transcranial approaches continue to evolve, in many cases, they have been supplanted by endoscopic skull base approaches and modifications to deep lateral orbitotomy approaches.[5] Case Description: A 62-year-old male patient presented with slowly expanding left proptosis, which he had first noticed 3 years before presentation. He was already blind in his right eye due to a history of traumatic amaurosis in childhood. The left eye examination revealed severe proptosis with restricted eye movement in all directions and significant visual impairment (visual acuity of 20/300, expressed by Snellen test, with no improvement on correction). MRI of the orbit showed a large left superolateral intraconal cavernous hemangioma compressing and displacing the optic nerve, with the typical feature of slow gradual irregular enhancement with delayed washout on contrast-enhanced image. A one-piece modified orbitozygomatic approach was performed and a total en block resection was achieved. The bone flap was fixed with titanium miniplates and screws, the temporal muscle and the skin were closed in a standard fashion. The patient did not present any new deficit in the postoperative period. The patient had good functional and cosmetic outcomes with resolution of proptosis, restoration of eye movements, and improvement of visual acuity in the 3-month follow-up. Postoperative MRI showed total resection. Conclusion: The orbitozygomatic approach for large orbital cavernous hemangioma provides satisfactory orbital decompression and large working space, reduces traction, and increases visualization and freedom to dissect small vessels and nerves that may be tightly attached to the tumor pseudocapsule.

Lateral transorbital approach: an alternative microsurgical route for supratentorial cerebral aneurysms

OBJECTIVETransorbital approaches for neurosurgery have recently attracted attention and several anatomical studies have aimed to improve these techniques, but significant deficiencies in clinical practice remain, especially for aneurysm surgery. The authors present an alternative microsurgical route and the results of an analysis of patients with intracranial aneurysms who underwent a lateral transorbital approach (LTOA) using lateral orbito-zygoma-sphenotomy (LOZYGS).METHODSThe clinical and surgical results of a series of 54 consecutive patients with 1 or more aneurysms who underwent surgery via LTOA are reported. A lateral orbitotomy was performed after making a 3-cm skin incision parallel to the lateral orbital rim. A second bone flap, which included the zygoma and sphenoid bones that form the lateral orbital wall, was removed. The lesser sphenoid wing, including the anterior clinoid process, was fully drilled, except in cases of middle cerebral artery (MCA) aneurysms. Cisternal dissection was performed using the classic microsurgical technique starting from the proximal Sylvian fissure and carotid cistern. After the aneurysm was clipped following microsurgical principles, the dura mater was closed in a watertight fashion and 2-piece bone reconstruction was achieved.RESULTSSixty aneurysms in 54 patients were clipped using the LOZYGS route. Twenty-one aneurysms were located on the MCA, 30 on the anterior communicating artery, 8 on the internal carotid artery, and 1 at the apex of the basilar artery. The unruptured-to-ruptured aneurysm ratio was 17:43. The operative field was moved to the orbit using the LTOA to avoid interference by bone and muscle tissues. Early proximal control was achieved using a short working distance and direct exposure of the base of the cerebrum, without any requirement for retraction. Because different view angles and surgical corridors were used, no segment of the aneurysm or the parent artery remained unexposed. Therefore, the introduction of additional tools was not required.CONCLUSIONSThe LTOA allowed enhanced broad-perspective exposure of the operative field, early proximal control, and satisfactory surgical freedom. This alternative surgical approach safely exposed the target area and the operative field. The LOZYGS route is safe and effective for the LTOA and microsurgical clipping of anterior circulation aneurysms. According to the authors’ surgical experience and clinical experience, the LTOA can be considered an alternative surgical route to supratentorial aneurysm surgery.

Lateral Orbitotomy for Cavernous Malformation: A Case Report with Technical Consideration

Cavernoma is benign tumour of the orbit. It results in proptosis, visual disturbance, diplopia and ptosis of the eye. It is amenable to surgery and this results in complete after surgical removal without recurrence. We report a case of right orbital cavernoma in a female, who presented with non-pulsatile painless proptosis, slight ptosis and double vision while looking at the right side. Her MRI revealed that she had a cavernoma of the right orbit. She was operated by the lateral orbitotomy. This easily removed the tumour, cosmetically acceptable and she became symptom free. Bang. J Neurosurgery 2020; 10(1): 102-105

Removal of a retrobulbar wooden foreign body trapped in the orbital fissure by lateral orbitotomy and mandibular coronoidectomy in a French bulldog

A four-year-old dog is presented with severe ocular pain, right eye swelling and slight exophthalmos, three days after partial removal of a wooden foreign body stuck under the right eye through the canthus medialis. A CT scan showed the presence of the foreign body in the retrobulbar space, trapped into the orbital fissure medially to the right branch of the mandible. Removal of the foreign body was performed by lateral orbitotomy associated with coronoidectomy of the vertical branch of the right hemimandible. The optical nerve was entirely torn by the foreign body. After postoperative recovery, the clinical outcome was good apart from unilateral blindness. The dog lives a normal life according to the owners’ evaluation. This case is the first description of the surgical treatment by the combination of lateral orbitotomy and mandibular coronoidectomy of an identified retrobulbar foreign body, medial to the mandible, stuck into the orbital fissure.

The Lateral Orbitotomy Approach for Intraorbital Lesions

The lateral orbitotomy approach (LOA) was first described by Kronlein in 1888 and has since been subject to many modifications and variations. When considering orbital approaches, the location of the pathology is often more important in decision making than the type of pathology. The LOA is best suited for access to intraconal and extraconal lesions lateral to the optic nerve. Pathologies treated via the LOA include primary orbital tumors, extraorbital tumors with local extension into the orbit, and distantly metastatic lesions to the orbit. These all often initially manifest with vision loss, oculomotor deficits, or proptosis. The expertise of a multidisciplinary team is needed to execute safe and effective treatment. Collaboration between many specialties may be required, including ophthalmology, neurosurgery, otolaryngology, plastic surgery, oncology, and anesthesiology.The modern technique involves either a lateral canthotomy or eyelid crease incision with removal of the lateral orbital wall. It affords many advantages over a pterional craniotomy, primarily a lower approach morbidity and superior cosmetic outcomes. Reconstruction is fairly simple and the rate of complications—vision loss and extraocular muscle palsy—are low and infrequently permanent. Deep orbital apex location and intracranial extension have traditionally been considered limitations of this approach. However, with increased surgeon comfort, modern technique, and the adoption of endoscopy, these limits have expanded to even include primarily intracranial pathologies. This review details the LOA, including the general technique, its indications and limitations, reconstruction considerations, complications, and recent data from case series. The focus is on microscopic access to intraorbital lesions.