PRESENTED BY : DR ALOK

MODERATED BY : DR SOURABHA

 Indications
Thyroid Associated Orbitopathy ( M/c).
Vasculitis

.
Lesions of posterior orbit & apex with compressive
optic neuropathy .
large myopic globes.
Problems

associated with Orbitopathy

Exposure keratopathy.
Diplopia.
Optic Nerve Compression.
2

 In

1911, Dollinger = Kronlein's approach lateral wall decompression.

In 1920, Moore = Intra orbital decompression.
In 1931, Naffziger = superior decompression
In 1936, Sewall = external ethmoidectomy
approach-medial orbital wall.
In 1950, Hirsch = orbital floor.( caldwell-luc)
In 1957, Walsh and Ogura = infero medial
decompression
In 1990, Kennedy = Endoscopic transnasal

Proptosis
Corneal problems
Diplopia
Eyelid retraction
Optic nerve compression
Most common cause of unilateral or bilateral
proptosis in adult.
multisystem. autoimmune disorder
hyperthyroid, hypothyroid, euthyroid
inflammation and enlargement EOM (MR>IR)
4

 Werners

Classification: NOSPECS

Class 0 (No Signs)

Class I (Only Signs)
Class II (Soft tissue Swelling)
Class III (Proptosis)
Class IV (Extraocular muscle)
Class V (Corneal Exposure)
Class VI (Sight Loss)

For initial CAS, score only 7 items (1 for each)

1. Spontaneous orbital pain
2. Gaze evoked orbital pain
3. Eyelid swelling that is considered to be due to
active phase
4. Eyelid erythema
5. Conjunctival redness that is considered to be
due to active phase
6. Chemosis
7. Inflammation of caruncle or plica
At follow up total score all 10 items
8. Increase of 2mm in proptosis
9. Decrease in ocular excursion in any one
direction 8o
10.Decrease of acuity equivalent to 1 snellen line
6

CT scan classical
coca cola bottle
sign on axial view
( Hypertrophy of
muscle sparing the
tendon )
MRI Hypertrophy
of Inferior Rectus.

Treatment
Medical

Management :

Medications

targeting euthyroid

state
Cessation of Smoking (thiocyanate)
Ophthalmic Management: Local
measures
Corticosteroids
Radiation therapy
8

 Surgical

Management :

Indications

: optic neuropathy, diplopia,

corneal exposure, and cosmesis
Surgical Procedures
Orbital Decompression
Strabismus repair
Correction of eyelid malpositions

 Strabismus
Extraocular

Repair:
muscle recessions

preferred
Alternative marginal myotomies
Eyelid

Surgery :

lateral

tarsorrhaphy
lengthening of Mullers and levator
muscles
lower lid elevation
blepharoplasty with orbital fat removal
10

Approaches :
External

SUPERIOR
LATERAL
MEDIAL

Transantral

Open sublabial
Microscopic
Endoscopic

Endoscopic

transnasal

11

12

13

14

Shell

of bone which surrounds

and protects the eye
Relations
Sup Ant cranial fossa
Med Nasal cavity & ethmoidal
labyrinth
Inf
Maxillary sinus
Lat Infra temporal fossa & Middle
cranial fossa
Apex Middle cranial fossa
15

 Shape

quadrilateral
pyramid with base
facing forwards,
laterally and slightly
inferiorly.
Height of orbital
margin 35 mm
Width of orbital
margin 40 mm
Depth of orbit - 45-55
mm
Volume of orbit - 30
ml

16

Seven

bones form
the bony orbit
Frontal
Sphenoid

(greater &
lesser wing)
Maxilla
Zygoma
Lacrimal
Ethmoid
Palantine
17

Formed by (from anterior to posterior):

Lacrimal bone
Frontal process of maxilla
Ethmoid (Lamina papyracea)
Sphenoid (Body)

Extremely thin
Anteromedially lacrimal fossa b/w ant
& post lacrimal crest
Foramina for ant & post Ethmoidal
arteries & nerves in frontoethmoid
suture line.
Rule of 24-12-6 is suggested.

18

Formed by:
orbital plate of maxilla
Orbital process of palatine
Zygomatic orbital plate

Infraorbital

groove
Location of infraorbital nerve
which supplies sensation to skin over
malar prominence, alveolus and teeth
Thin (0.5 1 mm), dehiscent in 29%.
Encountered in - orbital decompression
- orbital floor fracture
repair
- maxillectomy
19

 Formed

by:

Orbital plate of frontal bone

Lesser wing of sphenoid

Supraorbital

notch transmits the nerve &

vessels
Trochlea = connective tissue sling anchors the
tendinous part of the superior oblique muscle
to the orbital wall.
Encountered in
- orbital decompression
-

orbital fracture repair

frontal sinus trephination
ext frontoethmoidectomy
orbital exenteration
20

 Formed

by

Zygomatic process of frontal bone

Greater wing of sphenoid
Orbital surface of zygoma

Whitnall`s

tubercle deep to rim & above

mid point. Attachment of lateral canthal
tendon
Encountered in - orbital decompression
- Infratemporal fossa surgery

- orbital fracture repair

- lateral craniotomy
- modified craniofacial
resection
21

 Optic

canal lesser
wing of sphenoid
Thickest part orbital
tubercle(4.8 mm wide)
Isthmus (4.6 mm)
Posterior ( 7.07 mm)
Length 8 16mm (avg
11,m>f)
Thickness of bone :
0.79 mm avg (sphenoid)

22

 Optic

foramen
Superior orbital
fissure
Inferior orbital
fissure

23

 Transmits

Optic nerve
Ophthalmic artery

Medial

& superior to geometric apex

24

Separates lateral wall from roof

Transmits the following
structures:

Frontal Nerve
Lacrimal nerve
Trochlear nerve (CN IV)
Ophthalmic vein suf

Oculomotor nerve (CN III)

Abducens nerve (CN VI)
Nasociliary nerve

Ophthalmic vein inf

Orbital branch of middle
meningeal artery
Recurrent branch of
lacrimal artery

25

 Connects

to orbit to infratemporal fossa and

to pterygopalatine fossa in the medial most
part
Located between floor and lateral wall
Transmits:

Infraorbital artery
Maxillary div of Trigeminal
Br of sphenopalatine ganglion
Br of inferior ophthalmic V to pterygoid plexus
Orbitalis muscle

26

ORBITAL FASCIA

27

 Anesthesia

: General Anesthesia or
Local Anesthesia 1
Position : Reverse Trendelenberg
position
Hypotensive anaesthesia and topical
1:1000 adrenaline ribbon gauze as
routinely used in ESS is used.

1 Metson et al.Laryngoscope;1994:104:904-908

28

 Which

eye --?
More severe eye first ( as there will be
further 1-2mm recession in first 3 months
post sx ).

29

 UNCINECTOMY
ANTERIOR

AND POSTERIOR ETHMOIDECTOMY

SKELETONIZATION
LARGEST

INFUNDIBULOTOMY

OF LAMINA PAPYRACEA

POSSIBLE MIDDLE MEATAL ANTROSTOMY

REMOVING

BONE OF LAMINA PAPYRACEA

+/- MEDIAL ORBIT FLOOR

30

middle turbinate
Lamina papyracea

Maxillary line

Maxillary sinus roof

31

Endoscopic orbital Decompression

32

33

 INCISING

PERIORBITA

FAT PROLAPSE

HEMOSTASIS

/NASAL PACKING
POST OP CARE

34

 Modified

blepharoplasty incision /
transconjunctival / anterior orbitotomy /
bicoronal forehead flap
Horizontal canthotomy Incision(1.5 cm)
Inferior cantholysis
Division of the conjunctiva, inferior
retractors and orbital septum
Periosteal incision placed about 78mm on
lateral orbit outside the orbital

35

 osteotomy

is made 3mm behind the lateral

orbital rim
lateral wall periosteum is opened
Fat made free ,anterior pole of the gland
made free and allowed to float into the
bone lateral wall defect.
Medial and floor decompression.
Preserve ant2/3rd of maxilloethmoidal bone
strut -> prevents block of max sinus aeration
with fat prolapse.

36

 Combined

endoscopic and open approach

Transconjunctival-endoscopic = allow dissection of

medial wall beyond posterior ethmoid neurovascular
bundle upto optic canal.
Lateral wall decompression + endoscopic (avg
decompression 6.9mm)

Balanced

orbital decompression = medial and

lateral wall without floor ( reduce new onset
diplopia)
Two wall = superior + lateral wall.

37

 Mean

reduction in axial proptosis = 3.25.1mm2

(endoscopic approach)
Endoscopic approach with a modified
CaldwellLuc = 4.83mm1
Conventional transantral approach = 4.8mm(3.45.3)2
Three wall decompression = 7.2mm1-7.52

Lateral wall decompression + endoscopic (avg

decompression 6.9mm) 2

38

 Orbital

bruising (minor and temporary)

Diplopia (pre-existing or de novo, improves post
operatively)

Particularly associated with inferomedial

decompressions
Pts with restricted motility and diplopia within 200 of
the primary position preoperatively are most likely to
require subsequent muscle surgery

Preservation

of an inferomedial bony strut at

junction of medial wall and floor will
minimize this complication.

39

 Epiphora

( de novo or exacerbated after

surgery, improves except in NLD injury)
Paraesthesia (in territory of infraorbital
nerve)
Others

Secondary bacterial sinusitis

imploding maxillary antrum
mucocoele

40

 Tumors

/Fracture repair /Foreign body

removal /Orbital
decompression/exenteration
Lateral / Inferior / Medial / Superior
Orbitotomy/ Endoscopic
Endoscopic =>

Orbital hematoma
Fronto-ethmoid mucocele
Orbital decompression
Benign orbital lesions especially of medial orbit

41

 Given

by Kronlein in 1889. Modified by Berke in

1953, Maroon (1976)

Useful for retrobulbar lesions, and it can be

extended for more posterior lesions.

Involves temporary removal of the lateral wall

of the orbit to gain access to the entire
lacrimal gland and lateral, superolateral, and
inferolateral tumors eg; pleomorphic adenomas
of lacrimal gland and some cavernous
hemangiomas.
42

 Modified

stallard-Wright
incision (Lazy S )
Incision is deepened and
the periosteum exposed
and incised 2 mm above
zygomatic
frontal
suture.
Temporalis
muscle is
dissected and retracted
posteriorly.
Lateral
orbital rim divided.
Periorbita
is incised
parallel to lateral rectus

43

Indications:
Orbital decompression,
orbital biopsy &
excision of orbital lesions.
Subciliary incision through skin and
orbicularis muscle with direction along orbital
septum
Orbital periosteum is incised approximately
2mm inferior to orbital rim.
Orbital floor is exposed, identification of intra
orbital N vessels
44

Given by Dandy 1921

Compound trauma of orbit
Decompression of optic
canal
Removal of apical and
combined apical intracranial
lesion.
Infra brow incision
Deepend
till periosteum.
Which is incised 2-3 mm
superior to the orbital rim.
periorbita is separated from
the orbital roof periorbita
incised if required

45

Described in 1973 by Galbraith

and Sullivan
Effective in the management of
small, medial orbital tumors
such as cavernous
hemangiomas, schwannomas,
hemangiopericytomas, and
isolated neurofibromas.
1800 conjunctival peritomy at
corneoscleral limbus from 120
to 60 clock
Medial rectus retracted &
disinserted from globe ,with
careful blunt dissection &
retraction, orbital mass is
identified

46

 Bleeding

Orbital

hematoma
Infection of globe
Diplopia
Loss of vision excess pressure on globe,
compression of Central Retinal Artery
Inadvertant Intracranial injury
Direct perforation of globe

47

Indications
Trauma;
Thyroid

eye disease;
Neoplastic compression e.g. meningioma;
Fibrosis due to chronic inflammation e.g.
Wegeners granulomatosis.

48

Intraocular disk, 1 mm length

Intraorbital, 25 mm length

Intracanalicular, 9 mm length
Intracranial, 16 mm length

49

 Visual

impairment following trauma with

evidence of Afferent Pupillary defect with out
evidence of any injury to eye.
Diagnosis = RAPD supported by disc edema,
congestion of vessels
+ CT/MRI scan
+ VEP

50

51

 Primary

Direct contusion on optic canal/Nerve or

Deformation of Sphenoid with transfer of force into
intracanalicular nerve

Secondary

compression of nerve

Bony fragments
Hemorrhage nerve swells with in canal
compression of blood supply Ischemia

52

SURGERY IF
# of optic canal on CT with vision
<6/60
# of optic canal with vision >6/60 but
vision deteriorates on steroid
Vision deterioration (or<6/60) after
48hrs of steroid with probable canal
injury
CONTRAINDICATIONS
Complete disruption of optic nerve
Direct TON (intraorbital portion
injured)
53

Uncinectomy
Anterior and Posterior Ethmoidecotmy
Sphenoidotomy
Identify Lamina Papyracea, Fovea Ethmoidalis,
Posterior Ethmoids
Anterior face of sphenoid widely opened [ until
roof of sphenoid and post.ethmoids is
continuous]
Identify Optic Nerve,Carotid artery, Orbital apex

54

 Blunt

Freer elevator pushed through lamina

papyracea (1.5 cm ) ant to junction of
post.ethmoid & Sphenoid.
Carefully keep orbital periosteum intact.
Bone over posterior orbital apex flaked off.
Bone of optic canal flaked off.
Incise optic sheath ( use sharp sickle knife )
in upper medial quadrant.

55

56

 Optic

tubercle thick bone overlying

junction of orbital apex and sphenoid sinus.
Incision continued over orbital periosteum of
posterior orbital apex
No pack placed on nerve or in sinuses.
Length of decompression = Orbital apex 1cm posterior to face of sphenoid sinus

Cranio facial approach (upto optic chiasm)

57

 Transorbital

Pringle (1916)
Extranasal transethmoid Sewall
Transantral Kennerdell
Intranasal microscopic
Craniotomy Dandy
Endoscopic Endonasal Kountakis (1993)

58

VA > 6/60 ; no posterior orbit/optic canal

#
2 VA 6/60 ; no posterior orbit/optic canal
#
3 VA >PL - ve & # post.orbit/optic canal
(or)
VA PL - ve but no #
4 VA PL - ve with # displaced

59

GOOD PROGNOSIS

BAD PROGNOSIS

Blunt injury

Sharp injury

PL +ve

PL ve

Early presentation & Sx Late presentation & late Sx

Acute injury (trauma )

Progressive vision loss

Compressive diseases of
orbital apex/canal
60

 To

be done by Experienced surgeon.

Injury to skull base with CSF leak, meningitis.
Injury to internal carotid artery.
Injudicious manipulation of bony fragments can
have catastrophic consequences.
Optic nerve injury with permanent vision loss

61

62

63

64

65

 Good

landmark is the anterior portion of

middle turbinate, sac lies just lateral to
it.
The maxillary line is a mucosal projection
along the lateral nasal wall .

66

 Lacrimal

pump
=> Movements of the lids cause the puncta
to close against each other.
=> Tears pushed into the lacrimal sac.

=> Tears accumulating in the sac (lacrimal

lake)
=> Tears pushed down into the NLD when
eyes open
because of the relative
negative pressure caused in the lacrimal
lake.
67

1.
2.
3.
4.
5.

Unilateral or bilateral .
Nature of the discharge (clear / purulent )
H/o Allergy
H/o Medication / Trauma / Surgery.
History to rule out infective/Non-infective
granulomatous conditions.
6. On physical examination
Palpate the region of the naso-lacrimal sac and
see for any reflex from the puncta.
7. Eyelids to look for excessive laxity, punctum
for evidence of obstruction or inflammation.

68

 Syringing

= through the inferior canaliculus.

Inability to flush = obstruction at the site of the
punctum or inferior canaliculus while reflux of
saline = obstruction is more distal.
Gentle skilled Probing with a 0 Bowmans probe
Hard obstruction = bone or calculi
Soft obstruction = soft tissue.
Massaging of the sac = discharge from the puncti
=consistent with chronic dacrocystitis.
Swelling inferolateral to the medial canthus
Jones test
69

70

 Dye

(Fluorescein ) disappearance test

Primary Jones dye test (type I and II )
Lacrimal Irrigation ( syringing )
Dacryocystography( for stricture,
obstruction,diverticuli, fistulae, dacryoliths,
tumors)
Radionuclide Dacryoscintigraphy ( for functional
obstruction)
USG/CT/MRI
CT/MR Dacryocystography
Lacrimal Endoscopy ( 0.8 mm )

71

72

 Low

Howarths incision
Lacrimal sac with its attached periosteum is
dissected free from the lacrimal fossa and is
retracted laterally
Rhinostomy of 1.5 cm is created taking care not
to damage the nasal mucosa.
A vertical slit is made in the exposed nasal
mucosa and, similarly, a corresponding vertical
slit is made in the lacrimal sac
Flaps created are sutured together.
Epithelium lined rhinostomy created.
73

 Advantages.
Consistently

high success rates

Biopsy of the lacrimal sac possible if it looks
abnormal.
Disadvantages
Might require general anaesthesia with an
overnight stay.
Facial scar.
Injury to normal lacrimal pump function.
Risk of haemorrhage.
Revision surgery by the same approach
difficult.
74

 Common

causes of failure of external DCR

(EXTDCR).
Intranasal synechiae
Improper placement of the rhinostomy site
[eg, into an agger nasi cell(8 percent of
cases) or the superolateral aspect of the
middle turbinate]

75

 Indications

for Primary endoscopic DCR :

1. In the management of tearing associated with
primary acquired NLDO
2. Infection of lacrimal sac associated with
primary acquired NLDO
3. NLDO secondary to specific inflammatory or
infiltrative disorders
4. The level of obstruction should be distal to
the junction of the lacrimal sac and the duct.
5. In the management of lacrimal duct injuries
associated with sinus surgeries

76

77

 An

incision is made in the mucosa overlying

the anterior lacrimal crest.
Posteriorly based muco-perichondrial flap is
raised.
Anterior lacrimal crest is removed using a
punch.
Just lateral to Uncinate process is the thin
lacrimal bone that forms the remainder of
the medial aspect of the lacrimal fossa.

78

79

80

81

82

 Sac

is exposed (Dark red colour and firm )

Sac is divided vertically using sickle knife /450
beaver scalpel.
A probe placed within the sac, tenting it
medially, facilitates incision.
Micro-scissors are then used both inferiorly and
superiorly to create anterior and posterior flaps.
These flaps of sac mucosa are then placed in
continuity with the mucosa of the nasal wall.
A stent may then be inserted.

83

1. There is no external scar.

2. The lacrimal pump system is preserved.
3. Any concomittant intranasal pathology causing
epiphora can be addressed
4. Lacrimal sac mucosa is preserved
5. The risk for cutaneous fistulas, of concern in
patients who had previous radiation therapy or
certain granulomatous disorders, also may be
reduced, as there is no external incision

84

1. Presence of a firm indurated mass at the

level of medial canthus.
2. Any swelling near medial canthus where
malignancy is yet not excluded.
3. Bloody epiphora
4. Presence of bony destruction as seen in
radiological films
5. Pseudoepiphora( hyperlacrimation) : is
essentially reflux tearing: the main gland over
secretes because of lack of secretion from
minor glands along the lid margin.

85

 The

canaliculus is dilated to allow passage of

a vitreoretinal light probe, (ideally through
the superior canaliculus) which is advanced
into lacrimal sac.
Point of light seen endoscopically acting as a
guide to fashion the rhinostomy.
Use optimum power to ablate tissue.(???)
Once the sac is exposed, the light probe is
withdrawn, replaced by lacrimal probe.

86

 Rhinostomy

is enlarged to 58mm diameter.

A silicone stent may then be passed through
both superior and inferior canaliculi and be
retrieved from the nose.
The loop should not be excessively tight as it
can cause granulations at the rhinostomy site
and can cheese-wire through the canaliculi.

87

 Ability

to vaporize soft tissue and bone.

Good haemostatic properties.
Deliverable through a flexible laser fibre.
Co2,

Argon,Nd:YAG not suitable.

Ho:YAG, KTP/532 and diode laser are
suitable.

88

 Ho:YAG

laser - Vaporizes bone /good haemostatic

properties
Disadvantage -- tendency to spatter
requiring repeated cleansing of the
endoscope lens.
The KTP/532 star pulse laser has similar
advantages but avoids this problem.
The diode laser has a single-use fibre -Expensive
The erbium:YAG laser--ideal for this surgery,
but as yet no suitable delivery system exists.
89

Advantages of endonasal laser DCR

No external scar
Outpatient procedure
Can be done under Local anesthesia
Minimal bleeding
Short operating time
Less disruption of medial canthal anatomy and
lacrimal pump function.
Disadvantages
Laser precautions
Expense of the laser
Overall higher failure rates due to stenosis and
scarring at the rhinostomy site.
90

 Small/Improper

placement of
rhinostomy.(Bony/Membranous)
Sump syndrome/small cicatrized sac
Scar ( at rhinostomy/ canaliculi-sac Junction)
Granuloma
Bony spicules/Incomplete periosteum removal
Pump insufficiency/persistent sac diverticulum
Previuos Sx, RT, Chemo for PNS tumor

91

 Microscope

with a 300-mm lens may be used

Stent - Some do not insert a stent while
others leave a stent in for several months.
Size of the ostium -- affect success rates.
Transcanalicular DCR -- laser fibre through
canaliculus (600 micron optical fibre).
Balloon dacryocystoplasty -- Dilates stenosis.

92

 Mitomycin

C and 5-Fluorouracil have been

tried.

93

 Epiphora

in newborns - incidence 20 percent .

Congenital NLDO usually happens at the distal
end of the nasolacrimal duct and is
membranous.
>95 percent = spontaneous resolution in the
first 12 months.
Further 60 percent in the succeeding 12
months.
Therefore No treatment should be considered
until 12 months of age.
Thereafter, the standard treatment is
syringing and probing, under general
anaesthesia, under visual guidance.
94

 Most

common cause of proximal

obstruction
Due to a thin membrane which can be
treated with DCR and stenting.
If dense fibrous membrane or stenosis
=>two approaches
1.Insertion of Lester-Jones tube
2.Canaliculodacryocystorhinostomy

95

 Insertion

of Lester-Jones tube=a permanent

indwelling ceramic tube between the nasal
cavity and the conjunctival sac to drain tears
and completely bypass the lacrimal drainage
system.
Canaliculo DCR = resection of the stenosed
region of the common canaliculus with
primary anastomosis over a stent in
conjunction with a DCR.

96

THANK YOU
97