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Orbital decompression, optic n decompression and EndoDCR

Jun 02, 2018

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    Indications

    Thyroid Associated Orbitopathy ( M/c).Vasculitis .Lesions of posterior orbit & apex with compressiveoptic neuropathy .large myopic globes.

    Problems associated with OrbitopathyExposure keratopathy.Diplopia.Optic Nerve Compression.

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    In 1911, Dollinger = Kronlein's approach -

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

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    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)

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    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)

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    For initial CAS, score only 7 items (1 for each)1. Spontaneous orbital pain2. Gaze evoked orbital pain3. Eyelid swelling that is considered to be due to

    active phase4. Eyelid erythema5. Conjunctival redness that is considered to be

    due to active phase6. Chemosis7. Inflammation of caruncle or plica

    At follow up total score all 10 items8. Increase of 2mm in proptosis9. Decrease in ocular excursion in any one

    direction 8 o

    10.Decrease of acuity equivalent to 1 snellen line6

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    CT scan classicalcoca cola bottlesign on axial view

    ( Hypertrophy ofmuscle sparing thetendon )

    MRI Hypertrophyof Inferior Rectus.

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    TreatmentMedical Management :

    Medications targeting euthyroidstateCessation of Smoking (thiocyanate)Ophthalmic Management: LocalmeasuresCorticosteroidsRadiation therapy

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    Surgical Management :

    Indications : optic neuropathy, diplopia,corneal exposure, and cosmesisSurgical Procedures

    Orbital DecompressionStrabismus repairCorrection of eyelid malpositions

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    Strabismus Repair:

    Extraocular muscle recessions preferredAlternative marginal myotomies

    Eyelid Surgery :lateral tarsorrhaphylengthening of Mullers and levatormuscleslower lid elevationblepharoplasty with orbital fat removal

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    Approaches :External

    SUPERIORLATERALMEDIAL

    TransantralOpen sublabialMicroscopicEndoscopic

    Endoscopictransnasal

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    Shell of bone which surroundsand protects the eyeRelations

    Sup Ant cranial fossaMed Nasal cavity & ethmoidallabyrinthInf Maxillary sinusLat Infra temporal fossa & Middlecranial fossaApex Middle cranial fossa

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    Shape quadrilateralpyramid with basefacing forwards,laterally and slightlyinferiorly. Height of orbitalmargin 35 mmWidth of orbitalmargin 40 mmDepth of orbit - 45-55mm

    Volume of orbit - 30ml

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    Seven bones formthe bony orbit

    FrontalSphenoid (greater &lesser wing)MaxillaZygomaLacrimalEthmoidPalantine

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    Formed by (from anterior to posterior):

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

    Extremely thinAnteromedially lacrimal fossa b/w ant& post lacrimal crestForamina for ant & post Ethmoidal

    arteries & nerves in frontoethmoidsuture line. Rule of 24-12-6 is suggested.

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    Formed by:

    orbital plate of maxillaOrbital process of palatineZygomatic orbital plate

    Infraorbital grooveLocation of infraorbital nerve

    which supplies sensation to skin overmalar prominence, alveolus and teethThin (0.5 1 mm), dehiscent in 29%.Encountered in - orbital decompression

    - orbital floor fracturerepair- maxillectomy

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    Formed by:Orbital plate of frontal boneLesser wing of sphenoid

    Supraorbital notch transmits the nerve &vesselsTrochlea = connective tissue sling anchors thetendinous part of the superior oblique muscleto the orbital wall.

    Encountered in - orbital decompression- orbital fracture repair- frontal sinus trephination- ext frontoethmoidectomy

    - orbital exenteration20

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    Formed by Zygomatic process of frontal bone Greater wing of sphenoid Orbital surface of zygoma

    Whitnall`s tubercle deep to rim & abovemid point. Attachment of lateral canthaltendonEncountered in - orbital decompression

    - Infratemporal fossa surgery- orbital fracture repair- lateral craniotomy- modified craniofacial

    resection 21

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    Optic canal lesser

    wing of sphenoidThickest part orbitaltubercle(4.8 mm wide)Isthmus (4.6 mm)Posterior ( 7.07 mm)Length 8 16mm (avg11,m>f)

    Thickness of bone :0.79 mm avg (sphenoid)

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    Optic foramenSuperior orbital

    fissureInferior orbitalfissure

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    Transmits :

    - Optic nerve Ophthalmic artery

    Medial & superior to geometric apex

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    Separates lateral wall from roofTransmits the followingstructures:

    Frontal NerveLacrimal nerveTrochlear nerve (CN IV)

    Ophthalmic vein suf Oculomotor nerve (CN III)Abducens nerve (CN VI)Nasociliary nerve

    Ophthalmic vein infOrbital branch of middlemeningeal arteryRecurrent branch oflacrimal artery

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    Connects to orbit to infratemporal fossa andto pterygopalatine fossa in the medial mostpart

    Located between floor and lateral wallTransmits:Infraorbital arteryMaxillary div of Trigeminal

    Br of sphenopalatine ganglionBr of inferior ophthalmic V to pterygoid plexusOrbitalis muscle

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    ORBITAL FASCIA

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    Anesthesia : General Anesthesia orLocal Anesthesia 1 Position : Reverse Trendelenberg

    positionHypotensive anaesthesia and topical1:1000 adrenaline ribbon gauze asroutinely used in ESS is used.

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

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    Which eye --?More severe eye first ( as there will befurther 1-2mm recession in first 3 months

    post sx ).

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    UNCINECTOMY INFUNDIBULOTOMY

    ANTERIOR AND POSTERIOR ETHMOIDECTOMY

    SKELETONIZATION OF LAMINA PAPYRACEA

    LARGEST POSSIBLE MIDDLE MEATAL ANTROSTOMY

    REMOVING BONE OF LAMINA PAPYRACEA

    +/- MEDIAL ORBIT FLOOR

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    middle turbinate

    Lamina papyracea

    Maxillary sinus roof

    Maxillary line

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    Endoscopic orbital Decompression

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    INCISING PERIORBITA FAT PROLAPSE

    HEMOSTASIS /NASAL PACKING

    POST OP CARE

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