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Objective: To present a versatile approach to the medial orbit and orbital apex through the caruncle., Design: Retrospective, noncomparative, case series with description of surgical technique., Participants: Twenty-five consecutive patients underwent orbital surgery by use of a transcaruncular approach., Intervention: Inferior and medial wall fracture repair or orbital decompression by means of a transcaruncular or combined transfornix-transcaruncular approach., Main Outcome Measures: The surgical indications and complications were recorded for each patient., Results: Ten patients (10 orbits) underwent combined inferior and medial orbital wall fracture repair through a combined transfornix-transcaruncular approach. In 8 of 10 (80%) orbits, the inferior oblique muscle was disinserted during surgery. Fifteen patients (24 orbits) underwent orbital decompression surgery for dysthyroid orbitopathy. An isolated transcaruncular approach was used in 5 of 24 orbits, and a combined transfornix-transcaruncular approach was used in 19 of 24 orbits. There were no complications related to either approach., Conclusions: Orbital bone removal and fracture reduction may be safely completed through a combined transfornix-transcaruncular approach. The transcaruncular approach provides excellent and safe exposure of the medial orbital wall, and it avoids scarring associated with the Lynch approach.

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.

Purpose: To describe the uses and determine the safety of a commercially available acellular dermal allograft in ophthalmic plastic and reconstructive surgery. The existing literature regarding current applications and results using acellular dermal allograft is reviewed., Methods: The study design was a retrospective, noncomparative case series. Participants consisted of 63 consecutive patients undergoing ophthalmic plastic and reconstructive surgery using an acellular dermal matrix graft. The main intervention was placement of a dermal allograft. Outcome measures included the degree of clinical improvement and complications for each patient., Results: We used AlloDerm (LifeCell Corporation, The Woodlands, TX, U.S.A.) as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and an orbital implant wrapping material. Clinical improvement was noted in all cases. There were no complications attributable to the acellular dermal matrix material., Conclusions: We describe several novel ophthalmic plastic and reconstructive surgical applications using acellular dermal allograft tissue. This material may be used safely as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and a wrapping material. Clinically, the allograft appears to be biocompatible, nontoxic, and nonallergenic in the orbit, eyelid, and midfacial tissues. Long-term data and studies comparing the efficacy of acellular dermal allograft with conventional materials are necessary.

Objective: To evaluate the technique of using an intact autogenous periosteal flap for tethering of the globe in patients with severe paretic strabismus., Methods: We performed a periosteal flap procedure on 5 patients and followed their postoperative course. The flap was created from the medial, lateral, or superior orbital walls. A description of the harvesting and manipulation of the flap and the initial postoperative findings are presented., Results: All patients showed marked reduction in their postoperative strabismic deviation compared with preoperative measurements. Greater early postoperative swelling was noted after this procedure than with the standard strabismus surgery. No complications were experienced during or after surgery. Two patients required a second operation for adjustment of the periosteal flap for adequate alignment., Conclusions: The vascularized periosteal flap technique provides an excellent tether for the globe. Early and late stability has been favorable.

Purpose: To examine normal anatomic relationship of the globe to the bony orbit, and relate variations in this relationship to clinical parameters., Methods: Seventy-nine axial and sagittal magnetic resonance imaging (MRI) scans of the globe and orbit were studied. Any patients with pathology, as reported by the radiologists' findings, were excluded. Measurements were made on the images to determine the position of the globe relative to the bony orbit and to describe the configuration of the anterior face of the maxillary sinus. Clinical measurements were performed on photographs of 36 patients who underwent MRI scans. An independent observer rated these photographs for two clinical findings: inferior scleral show and tear trough deformity., Results: Correlations were found in the following sets of variables. (i) Corneal projection from infraorbital rim and corneal projection from lateral rim; (ii) corneal projection from supraorbital rim and corneal projection from lateral rim; (iii) scleral show and corneal projection from lateral orbital rim; and (iv) tear trough deformity rating and angle of anterior face of maxillary sinus. There were no significant correlations found in the other data variables., Conclusions: The data show that abnormal relationships between the globe and the bony orbit can have clinical consequences. Inferior scleral show is shown to be related to relative globe prominence, measured from either the lateral or the inferior orbital rims. The tear trough deformity is correlated with a sloping maxillary face. The results provide a rational basis for surgeries designed to normalize these relationships.

Purpose: To describe a technique to secure a mucous membrane graft to a custom conformer during reconstruction of the conjunctival fornices and socket., Methods: A cyanoacrylate-based tissue glue was used instead of sutures to secure the mucous membrane graft to the conformer., Results: The adhesion between the graft and the conformer weakens over time, permitting easy removal of the conformer from the socket 6 to 12 weeks postoperatively. No complications were encountered in six patients in whom this technique was used., Conclusion: Using a cyanoacrylate-based tissue glue is simpler and quicker than suturing a mucous membrane graft.

Purpose: The position of the globe relative to the orbital rim plays a significant role in the relationship between the eyelids and the cornea. A prominent globe (relative proptosis) may cause eyelid retraction and exposure keratopathy. Simple horizontal lower eyelid tightening exacerbates eyelid retraction. Optimal correction with an orbital decompression or advancement of the orbital rim entails considerable risk. A technically simpler alternative, placement of an orbital rim onlay implant, was evaluated., Methods: Fourteen patients with symptomatic relative proptosis underwent placement of a porous polyethylene orbital rim onlay implant., Results: Lower eyelid position, exposure keratopathy, and ocular discomfort were improved in all patients. Two patients required minor surgical revisions., Conclusions: Porous polyethylene orbital rim onlay implants are a satisfactory option to treat the sequelae of relative proptosis.

Objectives: To calculate the volume of bone in 3 areas of the deep lateral orbit that are available for removal in decompression surgery and to demonstrate these 3 areas within a 3-dimensional computed tomographic reconstruction of the orbit., Design: The 3 areas of bone in the deep lateral orbit were designated the lacrimal keyhole, the sphenoid door jamb, and the basin of the inferior orbital fissure. By means of digitized computed tomographic scans, these 3 areas of bone were analyzed by measuring preoperative and postoperative orbital volumes and predicted bony expansion volumes in 9 patients (17 orbits) who underwent deep lateral orbital decompression surgery. We also calculated the volume of bone that could be removed from 11 normal orbits. A 3-dimensional computer reconstruction of an orbital computed tomographic scan was created, and the 3 areas of potential bone were delineated within it., Results: The average volumes of the basin of the inferior orbital fissure, the sphenoid door jamb, the lacrimal keyhole, and the total of the 3 regions were 1.2, 2.9, 1.5, and 5.6 cm3, respectively. The 3 areas of bone contributed variably to the total, with the door jamb contributing the most volume of the 3, nearly twice the value of the other 2. There was, however, a significant amount of interpatient variability, especially for the door jamb region., Conclusion: Orbital decompression surgery of the deep lateral wall can provide adequate volume expansion because of the amount and location of potential space that exists in the 3 areas of deep bone.

Tumors of the orbital apex are difficult to approach through a standard lateral orbitotomy exposure. The transcranial approach has been described, but it requires an open craniotomy as well as dissection through the annulus of Zinn in its tight superior segment to reach intraconal and inferior lateral tumors. It is well recognized that the transcranial approach is optimal only for tumors of the superomedial orbital apex. Our study demonstrates that by enlarging the bony incision of a classic lateral orbitotomy to include a generous marginotomy and removing the deep sphenoid wing up to the superior orbital fissure, good exposure of the lateral orbital apex can be obtained. Tumors of the apex, including those that extend slightly into the cavernous sinus, can be removed from the cranial nerves and extraocular muscle origins in en face fashion, providing optimal ability to identify the delicate neurovascular structures of the orbital apex and avoid damage to them. The operating microscope is extremely useful for bony and soft tissue dissection. We report four benign tumors of the orbital apex removed using this approach. Two tumors encroached slightly into the cavernous sinus. Three of four patients were told that they had inoperable tumors. By use of the deep orbital apex approach described, all four tumors were successfully exposed and removed. Visual and motor function was unchanged or improved in all four patients, with the exception of one tumor that incorporated the inferior division of the third cranial nerve; in that patient, the transected nerve was anastomosed microscopically, and partial return of function was noted. The transorbital ophthalmic approach to tumors of the inferolateral orbital apex has significant potential advantages in comparison with a frontal craniotomy approach.

Purpose: To report a case of unilateral blindness after ipsilateral prophylactic transcranial optic canal decompression for fibrous dysplasia., Methods: Case report. A 37-year-old woman with fibrous dysplasia underwent a prophylactic left optic canal decompression. Preoperatively, the left eye had a visual acuity of 20/20., Results: Four days after apparently uncomplicated left optic canal decompression, the left eye lost all light perception. Blindness in the left eye persisted despite surgical exploration and transcranial optic nerve sheath fenestration., Conclusion: Although prophylactic optic canal decompression warrants consideration in selected patients with fibrous dysplasia, notable risks are associated with this surgery.

Background and Objective: Only limited volume expansion is offered by traditional lateral orbital decompressions in which the anterior segment of the lateral wall is removed to allow lateral soft tissue prolapse. A great deal of additional soft tissue expansion can be obtained, not only laterally, but also posteriorly by removing the deep portion of the sphenoid wing. The authors report their experience in removing this bone through a coronal approach., Patients and Methods: The authors performed maximal, three-wall, orbital decompressions through a coronal approach for 20 patients with thyroid-related orbitopathy. A disfiguring proptosis resulting from stable Graves' disease orbitopathy was the indication for surgery in all cases. Through a coronal approach, the lateral rim was left in place and thinned, augmented with specialized orbital rim onlay implants, or repositioned with osteosynthesis systems. The bone over the lacrimal fossa was sculpted to form a "keyhole" for the lacrimal gland, thereby providing additional orbital expansion. Once the medial canthal tendon and lacrimal sac had been elevated from their periosteal attachment, excellent exposure was obtained for medial and inferior orbital decompression., Results: The authors report the results of 20 coronal orbital decompressions during a period of 44 months. Seven cases included lateral rim advancement. Up to 6 mm of retrodisplacement was achieved without rim augmentation, 9 mm with rim augmentation., Discussion: The deep lateral orbital wall can provide significant room for volume expansion. The authors found that up to 6 mm of proptosis reduction can be obtained using the lateral wall alone. The coronal approach provides access to all four orbital walls for deep orbital decompression. The authors' philosophy of treatment in cases without compressive optic neuropathy is evolving toward the use of the lateral wall as the first approach with the incorporation of additional walls as needed.

This study reviewed the nature and severity of ocular and orbital air bag-related injuries at a large tertiary care referral center. The records of all patients treated by the ophthalmology trauma service for air bag-related ocular injuries between 1993 and 1995 were reviewed. Five patients were identified who had air bag-related ocular trauma. All of the patients who were referred to the ophthalmology trauma service for air bag-related ocular injuries had significant ocular or orbital injury. The extent and severity of the injuries were variable, ranging from orbital contusion to ruptured globe and retinal detachment. Although air bags substantially reduce the overall rates of mortality and morbidity associated with motor vehicle accidents, they also cause a variety of ocular injuries.

Optic canal decompression may be beneficial in cases of indirect optic nerve trauma, with or without canal fracture. Although no definitive data exist to clarify its role, several clinical series have reported on optic canal decompression for the treatment of intracanalicular optic nerve trauma, providing only limited information of the details of the procedure. We describe extradural optic canal decompression using a transethmoidal/transorbital approach. Removal of > 180 degrees of the bony canal is possible with this method. The technique can be accomplished by orbital surgeons familiar with orbital apical anatomy and orbital microsurgery. Experience with cadaver dissection of the orbital apex and cadaver surgery may be useful in that it provides confidence for the surgeon operating in this critical region. Careful exposure, microscopic visualization, delicate technique, and thorough anatomic knowledge minimize the risk of complications such as carotid artery penetration or dural laceration.

The implantation of an orbital hydroxyapatite implant was complicated by conjunctival dehiscence, cutaneous fistula formation, and infection with Staphylococcus aureus. Pathologic examination of the sphere 2 years after its implantation revealed reduction in the size of the implant, peripheral lamellar bone formation and central necrosis. This is the first report of this constellation of complications with hydroxyapatite spheres positioned in the orbit. The 2-year interval between implantation and removal of the sphere is the longest reported in a case with histopathologic analysis.

Orbital decompression is typically indicated for Graves' orbitopathy. Other causes of proptosis can also be safely and effectively addressed surgically with orbital decompression. Patients with prominent globes can have significant discomfort related to exposure keratopathy, lagophthalmos, and inefficient function of the globe-eyelid interface. We present six cases of non-Graves' proptosis that were addressed with orbital decompression. Indications for surgery included hypoplastic malar eminence with scleral show, enlarged globes, and congenital shallow orbits. Successful reduction of proptosis was achieved by orbital decompression with subsequent relief of presenting symptoms. Graded balanced orbital decompression was used to minimize shifts of the muscle cone. In some cases osteotomies and advancement of the lateral wall and malar region were also employed. Complications included transient esotropia, esotropia requiring surgery, and microplate granuloma. Orbital decompression should be considered for patients with relative proptosis and related eyelid malpositions regardless of the underlying etiology.

Background: Porous coralline hydroxyapatite orbital implants have gained significant popularity for use in anophthalmic sockets. Several reports have noted increased rates of early implant exposure., Methods: Six patients with exposure complications of primary hydroxyapatite implants after enucleation or evisceration were studied., Results: The hydroxyapatite implant exposures occurred 2 to 8 weeks after implantation. Magnetic resonance imaging scans with gadolinium enhancement obtained in two patients demonstrated a "cold" zone anteriorly with failure of fibrovascular ingrowth in the region of anterior exposure. Several different surgical procedures were used to regain implant coverage, including freshening the edge of the conjunctival defect and observing for spontaneous closure, burring away the anterior surface of the hydroxyapatite implant, and placing autogenous free tissue grafts of hard-palate mucosa or thin dermis-fat graft over the exposed hydroxyapatite. Repeated exposure after free graft was noted in several patients, and three of the six patients followed have an intact surface but very thin conjunctiva overlying hydroxyapatite spicules., Conclusion: Although small areas of hydroxyapatite exposure (< 3 mm) may close spontaneously, larger defects do not tend to close spontaneously and should be actively managed. Based on our experience, optimal results are obtained with free autogenous tissue grafts combined with burring of the anterior hydroxyapatite surface. Steps should be taken at the time of primary implantation to minimize implant exposure, including choosing appropriately sized implants and obtaining careful coverage with good vascularized tissue under minimal tension.

Ophthalmologists continue to search for the ideal orbital implant for the anophthalmic socket. The successful long-term clinical performance of an implantable prosthesis is highly dependent on the materials from which the device is fabricated. Among the materials issues are chemistry, surface texture, and porosity. Polyethylene, a polymer comprised of simple hydrocarbon chains, is highly resistant to biological degradation and possesses mass and fabrication properties that would be favorable in an orbital implant. In this report, our early experimental experience with porous polyethylene orbital enucleation implants is reported. Our findings are sufficiently encouraging to warrant further exploration and refinement of the polyethylene device examined.

We examined three patients with arteriovenous malformation of the orbit. At initial examination, all patients had a slowly progressive mass effect combined with congestive symptoms and clinical signs typical of an orbital vascular lesion. Arteriovenous malformation of the orbit was diagnosed on the basis of clinical and radiographic assessment, including the use of digital subtraction angiography and in one patient, magnetic resonance imaging. Treatment of each patient involved neuroradiologic embolization of the vascular lesion followed by surgical excision. Transient complications of endovascular management occurred. In one patient particulate emboli migrated into the central retinal artery after postembolization orbital surgical excision; consequent focal ischemic retinopathy contributed to short-term visual field deficits, which eventually resolved spontaneously. In another patient, spasm of the ophthalmic artery occurred during embolization, resulting in a transient afferent pupillary defect and loss in visual acuity to 20/60, which resolved over the subsequent week. High-flow orbital vascular lesions represent a considerable treatment challenge because of the complex anatomic and hemorrhagic characteristics of the malformation. Neuroradiologic characterization and embolization as a preoperative adjuvant is not without risk but offers an important advantage in the treatment of these formidable lesions. A combination of endovascular and surgical management may allow otherwise inoperable lesions to be treated successfully.

Purpose: The anatomy of the orbital apex is characterized by a complex interplay between critical bony and neural structures. Traditional methods used to study this region include dissection, static sections, and computed tomography (CT). Tomographic techniques are very useful in understanding these complex relationships, but the resolution of conventional CT and magnetic resonance imaging (MRI) is not sufficient to recognize the intricate details of the optic nerve canal and associated structures. The purpose of this study is to determine the value of microcryoplaning and computer reconstruction in visualizing the orbital apex in detail not previously possible, at any orientation in three-dimensional space., Methods: Microcryotomy of the orbital apex area was performed on cadaver specimens, and images of each cryosection were digitized. Subsequently, the lesser wing of sphenoid bone and optic nerve were outlined to allow for spatial manipulation and three-dimensional visualization of the orbital apex., Results: The authors present reconstructed computer images of the orbital apex in coronal and axial planes with CT correlation. Clinically important anatomic points and landmarks as well as potential pitfalls are demonstrated., Conclusion: Microcryoplaning and computer reconstruction are useful techniques in viewing the detailed anatomy of the orbital apex. Although microcryoplaning has the limitation of poor soft tissue detail, the resolution of captured images is much greater than those obtained from CT or MRI scans; the improved resolution allows for accurate CT correlations. The technique has utility in education, surgical planning, and quantitative analysis of orbital apical anatomy.

An 8-year-old girl had an orbital-adnexal lymphangioma and ipsilateral orbital and middle cranial fossa arteriovenous malformations. High-resolution magnetic resonance image scanning, orbital ultrasonography, and digital subtraction angiography were used for diagnosis and preoperative assessment. Complications related to this vascular neoplasm included amblyopia, acute hemorrhage with proptosis, exposure keratitis, cosmetic deformity, and recurrent preseptal cellulitis. The girl was treated with both embolization and orbital surgery for recurrent hemorrhage and proptosis. We postulated that the coexistence of a lymphangioma and arteriovenous malformation represents an unusual and extensive maldevelopment of vascular embryogenesis.

The transconjunctival approach to the inferior orbit and orbital fat offers the potential advantage of avoidance of scar creation in the lower eyelid skin and anterior lamellae. Complications of this approach, including conjunctival fornix shortening and eyelid margin malposition, have been occasionally reported. We prospectively observed 25 patients undergoing transconjunctival blepharoplasty and orbital floor surgery. Fornix depth, eyelid margin position, and the presence or absence of eyelid retraction were measured preoperatively and at each postoperative visit. No significant permanent change in these parameters was observed. Temporary entropion was observed in two patients; this resolved with conservative treatment. On self-limited suture granuloma was observed. In a subgroup of six patients, the conjunctival incision was closed on one side and left unclosed on the other. No adverse healing was noted on the unclosed side. We conclude that the transconjunctival approach is associated with a low incidence of complications, and that it does not significantly alter the fornix depth or eyelid margin position. A skin incision is avoided. The inferior orbital septum is not violated, greatly reducing the risk of development of lower eyelid retraction.

We found medial entropion of the lower eyelid to be common following orbital decompression for dysthyroid opthalmopathy. In our series significant postoperative medial entropion was noted in 14 of 69 patients, an incidence of 20%. Only four of these patients had entropion severe enough to require surgery (6%). Before orbital decompression, only one patient was found to have significant medial entropion (1.4%). Analysis of associated factors disclosed a positive relation between the amount of operative proptosis reduction and the degree of postoperative medial entropion. A strong correlation was also observed with the type of approach; transantral surgery was much more likely to be associated with significant postoperative medial entropion than was transconjunctival surgery. We suggest that the inferomedial displacement of the muscle cone that follows orbital decompression results in a force vector, transmitted through the lower eyelid retractors and capsulopalpebral ligament, that intorts the medial lower eyelid. Medial entropion in this setting often coexists with lower eyelid retraction, and if a "spacer" of sclera or ear cartilage is to be inserted into the lower eyelid, it should be carried into the medialmost portion of the eyelid to recess the posterior lamellae, including the medial retractors, and allow the eyelid margin to return to its normal anatomic position.