Eli L. Chang

Transcaruncular orbital decompression for management of compressive optic neuropathy in thyroid-related orbitopathy.

This study was conducted to assess the outcome of transcaruncular orbital decompression to treat compressive optic neuropathy in thyroid-related orbitopathy. It involved a retrospective, noncomparative case series of 18 eyes of 10 consecutive patients with documented vision loss secondary to thyroid-related orbitopathy. Bony decompression of the orbital apex was performed via a transcaruncular approach. Main outcome measures were visual acuity, color vision, presence of diplopia, and reduction of exophthalmos. Of 18 eyes, 16 (89 percent) had improved visual acuity after the operation. One eye had no improvement and one had worsening of vision in the setting of diabetic retinopathy. Color vision was improved in 12 eyes (67 percent). Five of the patients did not have diplopia before the operation; none of these patients developed double vision after intervention. Exophthalmos was decreased by an average of 2.6 mm. The authors conclude that transcaruncular orbital decompression for compressive optic neuropathy in thyroid-related orbitopathy is successful in restoring visual function. Compared with other approaches used for decompression surgery, the transcaruncular approach offers direct access to the medial wall and orbital apex without a cutaneous incision or disruption of the medial canthus. In addition, this approach allows a controlled, graded removal of the ethmoidal air cells and reduced recovery time.

Bilateral multifocal hemangiomas of the orbit in the blue rubber bleb nevus syndrome

PURPOSE To report the clinical findings and surgical treatment of multifocal, bilateral orbital hemangiomas in a patient with the blue rubber bleb nevus syndrome, a rare vascular disorder characterized by distinctive cutaneous and visceral hemangiomas. DESIGN Interventional case report. METHODS Review of clinical findings, radiologic studies, and treatment of the patient. RESULTS A 36-year-old female with multifocal, bilateral orbital lesions was seen with severe proptosis and decreased visual acuity of the left eye. Surgical debulking of multiple cavernous hemangiomas of the orbit resulted in decreased proptosis and an improvement in visual acuity. Subsequent histopathologic analysis and the results of a systemic workup revealing multiple, distinctive, cutaneous and visceral lesions were found to be consistent with the blue rubber bleb nevus syndrome. CONCLUSIONS Although hemangiomas of the orbit are relatively common occurrences, multifocal, bilateral lesions may exist in the setting of underlying systemic hemangiomatosis. Bilateral or multifocal hemangiomas associated with cutaneous or visceral lesions should alert the clinician to the possibility of a number of syndromes that may have life-threatening consequences.

Temporal Fossa Orbital Decompression for Treatment of Disfiguring Thyroid-Related Orbitopathy

OBJECTIVE To describe a technique for treating disfiguring thyroid-related orbitopathy by bony decompression into the temporal fossa and to analyze results. DESIGN Retrospective, noncomparative case series with description of a surgical technique. PARTICIPANTS Thirty-three consecutive patients with disfiguring thyroid-related orbitopathy undergoing decompression into the temporal fossa with the described technique. INTERVENTION Reduction in exophthalmos by removal of the lateral orbital wall and the greater sphenoid wing using an eyelid crease approach. MAIN OUTCOME MEASURES Amount of reduction in exophthalmos after surgery and incidence of induced postoperative diplopia. RESULTS The average reduction in exophthalmos was 4.51 mm (range, 3-6 mm; standard deviation, +/-0.95 mm). New-onset postoperative diplopia was observed in 1 patient. CONCLUSIONS Bony decompression of the orbit into the temporal fossa via an eyelid crease approach is an effective treatment for disfigurement in patients with thyroid-related orbitopathy and no preoperative diplopia.

Management of complex eyelid lacerations

Eyelid lacerations are a common injury faced by ophthalmologists in the emergency room setting. Prior to the evaluation of any ocular and adnexal trauma, examination for possible life-threatening injuries should be carried out to determine whether consultation from other surgical or medical services is required (Figs 1, 2). Once the determination has been made that trauma has been limited to the ocular and adnexal areas, the emphasis of the examination should be placed on preservation of the globe and its function (Fig 3). Only after evaluation of the trauma in this hierarchy has been carried out can the focus be safely placed on the assessment and repair of the eyelid laceration.

Re: "The effect of orbital decompression surgery on lid retraction in thyroid eye disease".

To the Editor: It was with great anticipation that we read “The Effect of Orbital Decompression Surgery on Lid Retraction in Thyroid Eye Disease” by Cho et al. We have been awaiting a study to either confirm or contradict our findings as published in our article entitled “Normalization of Upper Eyelid Height and Contour After Bony Decompression in Thyroid-Related Ophthalmopathy: A Digital Image Analysis” Arch Ophthalmol 2004;122(12):1882–1885. Perhaps, the authors were unaware of our publication or the aticle by van den Bosch WA et al., as neither were cited in the article despite their assertion, “To our knowledge, there no other studies that examine the effect of orbital decompression on eyelid position”. There are a number of critical points that we must respectfully illustrate to the authors. The methodology used by the authors is simply primitive. There is no mention of whether the measurements were performed by photographic analysis or by a ruler held up the patients face. If the analysis was done by photographic analysis there is no mention of the photographic technique. Small changes in head tilt and fixation point can greatly alter results in eyelid position, palpebral fissure width, and exposed area. Calculations based on retrospective review without clearly defined methodology to take consistent photographs and measure them in a reliable and reproducible fashion should be inadmissible in the modern digital age. Although we recognize that there can be a great deal of variability in the eyelid position and that a single photograph may not be representative, there should be some attempt in the methodology to minimize as many influencing factors as possible. There have been numerous publications dating back well over a decade in the literature on digital photographic analysis and its accuracy. This type of analysis should be considered the gold standard for any type of eyelid image analysis. Any type of measurement not using well defined, fixed photography, and computer generated analysis should be considered no better than order of magnitude estimates. For selection criteria, it must be noted that the authors included patients in their data set using extremely lax exclusion criteria. Patients included in the study underwent different types of decompression surgery, had subsequent strabismus surgery, eyelid surgery, and radiotherapy. All of these variables should be minimized in order to produce consistent, relevant results. If the précis of the article is that decompression surgery can potentially affect eyelid position then all other factors that could potentially alter eyelid position other than decompression surgery should be neutralized. This would include strabismus surgery, eyelid surgery, eyelid crease, or lateral canthal incisions that could alter eyelid position, radiation, and any other factors that could affect the outcome of the study. None of these variables appear to have been accounted for in their methodology further contributing to the inconsistency and unreliability of the data obtained in this study. Finally, eyelid height or eyelid retraction alone does not completely define the effect of upperor lower-eyelid position. We found a direct correlation between the amounts of decrease in axial proptosis to the amount of nasal migration of the uppereyelid peak (i.e., reduction in “lateral flare”). Decrease in axial proptosis via decompression surgery also correlates to a reduction in the average exposed surface area of the palpebral fissure. Both of these notable findings are reproducible and logical and are not addressed in Cho et al. To summarize, we believe that reductions in axial proptosis from orbital decompression surgery has many significant effects on eyelid position and contour that extend beyond the simplistic measurement of marginal reflex distance. These changes can be easily quantified and measured using digital imaging analysis. Although we welcome the contributions of the authors, we feel strongly that digital imaging analysis capable of quantifying height and contour changes of the eyelids should be the standard by which eyelid position is assessed and reported. Furthermore, all photographs taken for the purpose of analysis must be standardized in order to produce sophisticated, reproducible results. Finally, based upon our careful review of the Cho et al. study, we were unable to endorse the generation of meaningful data without proper elimination or minimization of confounding factors and other potentially relevant variables. For all these concerns, we do not find the conclusions of the authors to be valid or relevant.