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Objective: To evaluate the indications, operative skills and effects of transsubperiosteal approach for excision of orbital cavernous hemangiomas (OCH)., Methods: In a retrospective study, the records of 42 cases with OCH confirmed by pathologic examination between June 2004 and June 2010 were analyzed. Preoperative diagnoses were based on clinical signs, CT and MRI examinations. According to the locations of the tumor, patients were assigned to 4 groups: group I: tumors located in the superotemporal quadrant in 18 cases; group II: tumors located in or near the superior orbital fissure in 15 cases; group III: tumors in the inferior peripheral space extending to the orbital apex in 4 cases; group IV: tumors in the inferonasal quadrant in 5 cases. In all 4 groups the periorbital skin was incised and then the periosteum of orbital rim was exposed. Tumors were removed from subperiosteal space. The complications and follow-up results were recorded., Results: The rate of preoperative correct diagnosis was 100%. All cases were cured by once surgical procedures for average 20-30 min. Thirty-eight (90.5%) tumors were removed intact. The deblocking removal was recorded in 4 (9.5%) cases. In order to improve the surgical exposure of orbital apex in group II, superolateral orbital rim was removed in 6 (14.3%) cases and the walls were drilled in 3 (7.1%) cases. Follow-up periods ranged 1 to 7 years. No recurrent or remnant was recorded on imaging reviews. The visual acuity was improved in 6 (14.3%) cases. The temporary complications included chemosis in 9 (21.4%) cases, limited ocular movement in 4 (9.5%) cases and ptosis in 3 (7.1%) cases. The permanent complications included limited ocular extreme movement and dilated pupil, both in 2 cases (4.7%)., Conclusions: Transsubperiosteal approach is eligible for the removal of OCH in the superotemporal, inferonasal quadrant and the floor of the orbit and is recommended for the tumors near the superior orbital fissure. This approach is safe and effective for removal of OCH with less surgical complication.

Objective: To present a new technique for orbital decompression that minimizes surgical approaches while maximizing the removed areas of orbital walls and to evaluate the efficacy and safety of it for patients with severe thyroid associated ophthalmopathy (TAO)., Methods: A retrospective review of 40 cases (66 eyes) with severe TAO undergoing the modified decompression between January 2009 and January 2011 was conducted. All patients were assigned to three groups, which were group CON: compressive optic neuropathy in 30 eyes, group MP: marked proptosis in 30 eyes, and group EK: exposure keratopathy in 6 eyes. The deep lateral, medial walls and orbital floor decompressions were underwent via an eyelid crease or a lateral sub-brow S-shape approach with a transcaruncular approach. Clinical outcomes were recorded including visual acuity, exophthalmometry, diplopia, clinical activity score (CAS) and CT scans before and 6 months after surgery. Intra- and postoperative complications were recorded., Results: The postoperative visual acuity was improved in 17 eyes (56.7%, P < 0.05) of group CON. The mean proptosis reduction was (8.1 ± 2.7) mm (t = 11.73, P < 0.01) and (11.4 ± 3.1) mm (t = 15.52, P < 0.01) in group CON and group MP, respectively. The CAS was decreased in group CON (P < 0.01). Compared with preoperative records, the degree of diplopia was not significantly different in group CON (U = 131.0, P = 0.309) and group MP (U = 157.5, P = 0.881). Diplopia resolved in 7 cases (39%) of group CON, 5 cases (28%) of group MP. New-onset diplopia or its aggravation was recorded in 3 cases (17%) of group CON, 4 cases (22%) of group MP. The other postoperative improvement included recovered color vision, reduced intraocular pressure, and healing keratopathy. The important complications were intraoperative dural tears, new-onset diplopia and ocular inferior displacement., Conclusions: The modified orbital decompression offers wide exposure to the three orbital walls, marked proptosis reduction, and no apparent scar. It is efficacious and safety for the treatment of CON and inflammatory activity of TAO without serious complications, meanwhile, has little risk of induced diplopia.

Objective: To evaluate the clinical features, diagnostic methods and treatment of intraorbital nonmetallic foreign body injuries., Methods: In a retrospective study, the records of 25 consecutive cases with nonmetallic foreign bodies in the orbit confirmed by surgery were analyzed with special attention to the types of injury, history, clinical manifestations, imaging findings, treatment and follow-up results., Results: Among 25 cases with nonmetallic foreign bodies, 23 cases were caused by trauma, including 11 cases with wooden bodies, 3 cases with glass, grease, or stone, 2 cases with plastic pen point, and one case with fire crackers. The remaining two cases had iatrogenic foreign bodies. The distinctive clinical manifestation was the periorbital fistula recorded in 11 (44%) cases, mostly in patients with wooden foreign bodies. The CT findings were different in various foreign bodies. The wooden foreign bodies showed low density in the acute stage and the density increased gradually from the acute to the chronic stage. CT images with lower windows could distinguish a wooden foreign body better. The grease was seen as low density mimicking orbital fat on CT. The stone or glass showed as masses with high density. Wooden foreign bodies displayed low signals on both MRI T1- and T2-weighted images. The surrounding pus was seen as a ring with high signal on T2-weighted images. The inflammatory infiltration showed marked enhancement. The grease displayed high signal on both T1- and T2-weighted images and showed lower signal than that of the fat. All patients underwent surgical removal of retained foreign bodies and the surrounding decomposed tissues. The infected wounds were not sutured at one stage operation. After follow-up for 6 months, all wounds healed normally and all patients recovered well. No complications were encountered., Conclusions: There are various types of intraorbital nonmetallic foreign bodies. The clinical manifestations of these different foreign bodies are complex. CT is the preferred examination for this condition. With the combination of correct diagnosis, proper surgical skills, and complete removal of foreign bodies and surrounding decomposed tissues, nonmetallic foreign bodies can be treated efficiently.

Objective: To evaluate the clinical features, diagnostic methods and treatment of extraocular extension of choroidal melanoma., Methods: It was a retrospective case series study. The records of 12 consecutive cases with extraocular extension of choroidal melanoma confirmed by pathologic examination were analyzed with special attention to the case histories, clinical manifestations, imaging findings, treatment and follow up results., Results: Four patients were misdiagnosed as glaucoma. Another 4 patients were confirmed the diagnosis of melanoma and 3 of them received the operations of transscleral local resection. The common clinical manifestations included: impaired vision, exophthalmos, blepharoptosis, limited ocular motility, conjunctival hyperemia, and increased ocular or orbital pressure, etc. Characteristic sign was raised mass on the surface of sclera. All cases underwent orbital MRI preoperatively, 6 underwent ocular B-scan echography, and 6 underwent orbital CT scanning to evaluate for extraocular extension of tumor. Typical ultrasonography revealed the discontinued ocular wall and an intraocular mass with a continuous hypoechoic extraocular mass. In some cases the extraocular mass showed hypoechoic with medium echo area. CT scan showed a well-defined homogeneous intraconal mass connecting with intraocular lesion in 6 cases, which could infiltrate eye or optic nerve. The MR signal features of intraocular tumors with extraocular extension showed 4 patterns in all patients. The typical pattern was the tumor showed hyperintensity on T(1) and hypointensity on T(2)-weighted image. The maximum diameter of extraocular tumor was measured over 4 mm in 9 cases. MRI was useful for demonstrating multiple extraocular lesions, remote metastatic lesion or micro extraocular tumor, of which minimal diameter was 3 mm in our cases. Orbital exenteration was performed in 11 cases and ocular enucleation with excision of extraocular tumor was in 1 cases. Microscopic examination showed the epithelioid-cell-type tumors were the most common. The tumor extended out of the eye by three types of way in our cases. Follow-up ranged from 1 to 5 years in 8 cases, who underwent chemotherapy, radiotherapy or interferon. Six cases had no recurrences and general health. Death and metastasis was respectively recorded in one case., Conclusions: Delayed treatment could induce the growth of choroidal melanoma to the stage of extraocular extension, which has few specific clinical manifestations. The combination of multiple imaging examinations was helpful for the correct diagnosis. Surgical operation with adjunctive therapies could partly reduce recurrence and metastasis of melanoma.

Objective: To evaluate the clinical features, diagnostic methods and treatment of recurrent orbital dermoid cysts., Methods: In a retrospective study, the records of 30 consecutive cases with recurrent orbital dermoid cyst confirmed by pathologic examination were analyzed with special attention to the case histories, recurrent factors, clinical manifestations, imaging findings, treatment and prognosis., Results: In the present series, the interval from first appearance in our institute to the operation ranged from 1 month to 36 years, with a median of 2.5 years. Once, twice and three times of operation history were noted in 20 cases, 9 cases and 1 case, respectively. The clinical characteristics included: periorbital masses with red swelling and tenderness in 16 cases, cutaneous fistulas in 4 cases, ectropion and adherence of upper lid in 4 cases. The risk factors for the recurrence included the incomplete excision the cyst or residual of the cyst wall in the bone sutures in 16 cases, misdiagnosis as subcutaneous mass leading to inappropriate operations in 11 cases, operation without imaging examinations in 8 cases, etc. CT scan was performed in all cases, which showed dermoid cysts with hypodensity or isodensity. The common imaging signs included dumbbell dermoid cysts located near the zygomaticofrontal suture in 8 cases, slender and circuitous tunnel within the orbital wall in 6 cases, and extensive and wavy impression of the bony walls in 6 cases. Surgical excision was performed in 28 cases and conservation therapy was used in 2 cases. Cystic content and wall were removed thoroughly during the operation. Follow-up ranged from 1 to 9 years and no recurrence or serious complications were noted., Conclusions: The recurrence of orbital dermoid cysts is correlated with various factors. The importance of recognition of clinical features and imaging findings of this tumor should be emphasized. With the guide of imaging examinations and the combination of various surgical skills, the recurrence of dermoid cysts could be prevented efficiently.

Objective: To evaluate the type, clinical features and diagnostic methods of orbital metastatic tumors., Methods: In a retrospective study, the records of 30 consecutive cases with orbital metastatic tumors as confirmed by pathologic examination were analyzed with special attention to the epidemiology, clinical manifestations and imaging findings., Results: Most orbital metastatic tumors in China originated from the breast, followed, in order, by the lung and liver. The metastatic tumors of the orbit most frequently originated from the liver and lung in males, and from the breast and lung in females. The male or female ratio of patients with orbital metastasis was 1:1. The orbital metastases were more common in the children and the elderly. In 50% of patients, the orbital symptoms were the first signs of the disease. The longest course was seen in metastasis from the breast and the shortest from various types of blastomas. Orbital metastases could occur unilaterally or bilaterally. The most common symptoms of orbital metastatic tumors included diplopia and orbital pain. The signs included proptosis, limited ocular movement and increased intraorbital pressure. Based on the images of computed tomography or magnetic resonance imaging, orbital metastatic tumors could be divided into four different types according to the location and morphology of the tumors. Follow-up results revealed that 60% of orbital metastasis had poor prognosis., Conclusions: The spectrum of orbital metastatic tumors in China is different from that in western countries. Familiarity with the clinical manifestation and diagnostic methods of orbital metastatic tumors can be helpful to relief the ocular symptoms and prolong the life of patients.

Objective: To study the morphological representation of the orbital tissue in thyroid associated ophthalmopathy., Methods: It was a retrospective case series. 138 specimens of TAO (include 77 specimens of orbital fat, 41 specimens of orbital periosteum and 20 specimens of lacrimal gland tissue) were analyzed by light microscopy and immunohistochemical staining., Results: The notable hyperplasia of fat was found in orbital tissue from 73 of 77 and in lacrimal gland tissue from 12 of 20. The hyperplasia of fibrous tissue and muscular metaplasia were observed in orbital periosteum., Conclusions: The hyperplasia of fat in TAO orbital and lacrimal gland tissue is a very important and ubiquitous pathological changes. Study on the orbital fat and prevent against the hyperplasia of fat maybe have a significance of effective to hold back proptosis.