ORBIT POSTERS
Anatomic Relationships of the Ethmoidal Arteries in the Orbit: A
Cadaveric Study
Michael J. Henry, MD, Maziar Bidar, MD, Louise A. Mawn, MD.
Vanderbilt University, Nashville, TN.
Abstract Body:
Introductory Sentence: The purpose of this study was to describe the anatomical relationships of the anterior and
posterior ethmoidal arteries with respect to the anterior lacrimal crest and optic foramen in cadaveric orbits.
Methods: A cadaveric study based on the dissection of 12 human orbits. Orbits were accessed via a cranial approach
with careful removal of the frontal lobe and the bony roof. Measurements were made from the anterior lacrimal crest
to the anterior eithmoidal artery as it entered the medial orbital wall. The distance between the anterior and
posterior ethmoidal arteries (graphic 1), as well as the distance from the posterior ethmoidal artery to the optic
foramen were also measured.
Results: The mean distance found from the anterior lacrimal crest to the anterior ethmoidal artery was 25.5mm
(range 21-30mm). Mean distance between the anterior and posterior ethmoidal arteries was 12.75mm (range 618mm), and mean distance from the posterior ethmoidal artery to the optic foramen was 6mm (range 4-10mm).
One orbit was found to have an accessory ethmoidal artery that was found 10mm posterior to the anterior eithmoidal
artery and 5mm anterior to the posterior ethmoidal artery.
Conclusions: This cadaveric study was conducted in attempt to describe the surgical anatomical relationships of the
ethmoidal arteries within the orbit. The 24-12-6mm estimation is often used to describe the anterior to posterior
landmark distances of the ethmoidal arteries with respect to the orbital rim, anterior to posterior eithmoidal
foramina, and optic foramen, respectively. On average, our findings agree with this estimation within 1.5mm. We
were unable to locate cadaveric studies specifically describing these surgical landmarks in the modern English
literature.
Bibliography: 1. Kirchner JA, Yana Disawae, Crelin ES: Surgical anatomy of the ethmoidal arteries. A laboratory
study of 150 orbits. Arch Otolanryngol 74 : 382-386, 1961.
2. Ducasse A, et al.: Anatomical basis of the surgical approach to the medial wall of the orbit. Anatomia Clinica 7 :
15-21, 1985.
Author Disclosure Block:
M.J. Henry, None; M. Bidar, None; L.A. Mawn, None.
Zebrafish as a Model for Orbital Development
Alon Kahana, MD, PhD, Mark J. Lucarelli, MD, Mary C. Halloran, PhD.
University of Wisconsin, Madison, WI.
Introductory Sentence:
The zebrafish Danio rerio is a small freshwater teleost that has been used to study vertebrate development. Its
strength as a model organism is based on several properties: (1) during early development, the embryo is
transparent, allowing for excellent visualization of developing cells, tissues and organs, and (2) it is small, has a
short lifespan, and is externally fertilized, allowing for studies employing both forward and reverse genetics. The
ocular and craniofacial structures of zebrafish share remarkable similarities with humans. They have the same
extraocular muscles and general muscle orientation (e.g. anterior rectus instead of medial rectus, etc.), the same
cranial nerves, which follow the same anatomic path, and a similar bony orbit of neural crest origins.
Methods: In order to establish the utility of zebrafish as a model for orbital development, we have investigated the
development of cranial nerves and the contribution of the neural crest to the zebrafish orbit using fluorescence and
confocal microscopy techniques. Results: We show that the developing lens placode and primordial eye are required
for proper targeting of neural crest cells to the developing orbit. Unilateral enucleation at 20 hours post fertilization
dramatically delays recruitment of FoxD3-expressing neural crest cells to the orbit. In addition, laser-ablation of
developing cranial nerves result in asymmetric development.
Conclusions: Zebrafish can be a useful model for studying the genetics and cell biology of vertebrate orbital
development.
Bibliography:
1. Yelick, P.C., Schilling, T.F. Molecular dissection of craniofacial development using
zebrafish. Critical Reviews in Oral Biology and Medicine. 2002, 13(4):308-322.
2. Patton, E.E., Zon, L.I. The art and design of genetic screens: zebrafish. Nature Reviews
Genetics. 2001, 2:956-966.
3. Moens, C.B., Prince, V.E. Constructing the hindbrain: insights from the zebrafish.
Developmental Dynamics. 2002, 224:1-17.
Author Disclosure Block:
A. Kahana, None; M.J. Lucarelli, None; M.C. Halloran, None.
Orbital Reconstruction After Sphenoid Wing Meningioma Resection
Using the Medpor Orbitozygomatic Implant
Cat N. Burkat, M.D.1, Noel Palmero, M.D.1, Todd Trier, M.D.2, John G. Rose, Jr., M.D.3.
1
Oculoplastics Service, University of Wisconsin, Madison, WI, 2Department of Neurosurgery, Dean Health Systems,
Madison, WI, 3Oculoplastics & Facial Cosmetic Surgery Service, Dean Health Systems, Madison, WI.
Abstract Body:
Introductory Sentence: The purpose of this study is to determine the efficacy of the Medpor Orbitozygomatic (OZ)
implant for Reconstruction of the superolateral orbital wall after skullbase dissection for resection of sphenoid wing
meningioma.
Methods: A retrospective case study was carried out on patients who underwent skull base dissection and
transcranial orbitotomy followed by reconstruction with the OZ implant from 2004-2005.
Results: In the 4 patients treated with this approach, all had excellent cosmesis, with no facial temporal “hourglass”
deformity. Cosmesis was much improved, compared to a lack of orbital reconstruction. No patients had oscillopsia.
One had postoperative diplopia, but it was unclear whether this was due to the implant. Operative time was
markedly reduced, compared to other techniques of orbital reconstruction.
Conclusions: The OZ implant allows excellent cosmetic results and reduces operative time for orbital reconstruction
following transcranial resection of sphenoid wing meningioma.
Bibliography:
1. Brusati R. Biglioli F. Mortini P. Raffaini M. Goisis M. Reconstruction of the orbital
walls in surgery of the skull base for benign neoplasms. International Journal of Oral &
Maxillofacial Surgery. 29(5):325-30, 2000.
2. Papay FA. Zins JE. Hahn JF. Split calvarial bone graft in cranio-orbital sphenoid wing
reconstruction. Journal of Craniofacial Surgery. 7(2):133-9, 1996.
3. Evans BT. Neil-Dwyer G. Lang D. Reconstruction following extensive removal of
meningioma from around the orbit. British Journal of Neurosurgery. 8(2):147-55, 1994.
4. Maroon JC. Kennerdell JS. Vidovich DV. Abla A. Sternau L. Recurrent spheno-orbital
meningioma. Journal of Neurosurgery. 80(2):202-8, 1994.
Author Disclosure Block:
C.N. Burkat, None; N. Palmero, None; T. Trier, None; J.G. Rose, None.
Repair of Internal Orbital Wall Fractures Using Porous Polyethylene/
Titanium (TITAN) Orbital Implants
David E. Holck, M.D..
Wilford Hall Medical Center, San Antonio, TX.
Introductory Sentence:
Multiple alloplastic materials exist in the repair of internal orbital wall fractures. Each is associated with complications
unique to that material. Materials combining the benefits of stability from fibrovascular ingrowth with the rigidity of a
metal would offer benefits that exceed each individual substance alone. We evaluated a modified design of the
porous polyethylene/ titanium implant (TITAN, POREX Surgical, Newnan, GA) on large orbital floor and combined
floor/ medial wall fractures.
Methods: Nineteen orbital fractures in 17 patients were treated using a TITAN orbital implant. Twelve fractures
involved large orbital floor areas without adequate posterior support, and seven were combined orbital floor and
medial wall fractures. For combined floor and medial wall fractures, a custom designed plate was used to conform to
the floor and medial wall. Footplates were cut for rigid fixation over the orbital rim. Postoperative evalution included
computed tomography, and clinical evaluation at (at least) postoperative day one, week one, months one, three and
six.
Results: In all cases, adequate reduction of the orbital fracture was obtained. No cases of clinical motillity restriction
from incarceration of orbital soft tissue to the implant surface have been observed. One patient was noted to have
1.5mm of hyperglobus postoperatively. Three fractures were noted to have the orbital plate impinging on the rectus
muscles at the posterior aspect of the implant, but these did not have clinical sequelae. No cases of bleeding,
infection, migration, extrusion, exposure, or need for explantation were encountered.
Conclusions: For large orbital floor fractures without adequate posterior support or combined orbital floor and medial
wall fractures, the TITAN orbital implant provides appropriate fracture reduction. Footplates cut from the material
may be rigidly screwed to the orbital rim providing fixation. The material is available with a barrier surface that
prevents adhesions from othe orbital soft tissue to the implant, while having a porous side that facilitaes
fibrovascular adhesions for additional stability. The same benefits of rigidity and minimal implant memory must be
taken into consideration when placing the implant to avoid the complication of orbital soft tissue incarceration.
Bibliography: 1. Sugar AW, Kuriakose M, Walshaw ND. Titanium mesh in orbital wall reconstruction. Int J Oral
Maxillofac Surg. 1992; 21: 140-144.
2. Choi JC, Fleming JC, Aitken PA, Shore JW. Porous polyethylene channel implants: a modified porous polyethylene
sheet implant designed for repairs of large and complex orbital fractures. OPRS. 1999;15(1):56-66.
Author Disclosure Block:
D.E. Holck, None.
Porous Polyethylene Implants With Embedded Titanium Mesh: Use in
Orbital Fracture Repair and Computed Tomography Visualization
Charles V. Duss, M.D., Paul D. Langer, M.D..
New Jersey Medical School, Newark, NJ.
Introductory Sentence:
Over the past fifteen years, porous polyethylene implants have been successfully used in the surgical repair of orbital
fractures with excellent cosmetic and functional results; however, radiographic visualization of these implants
postoperatively is difficult. A newer version of the implant (Medpor TITANTM) combines the biologically integrative
property of the traditional porous polyethylene implant with a radiographically visible titanium core. We report our
early experience with this implant in the repair of orbital fractures.
Methods: The charts of all patients since November 2004 presenting with new orbital wall fractures, from the
practice of one surgeon (PDL), were reviewed. Patients undergoing surgical correction with placement of a
polethylene implant with embedded titanium were included in the study. Clinical outcome, patient tolerance, and
visibility of the implant on postoperative computed tomography (CT) scans were assessed.
Results: Of thirty-eight new patients with orbital wall fractures, eighteen required surgical repair to address
significant enophthalmos and/or persistent diplopia. Each patient underwent the transconjunctival placement of a
porous polyethylene implant containing embedded titanium mesh following the surgical repositioning of herniated
orbital tissue. After an average follow up of six months, all eighteen patients achieved satisfactory clinical outcomes
based on reduction of enophthalmos and/or diplopia, with no significant adverse reactions to the implants. No cases
of postoperative infection or implant extrusion were observed during the study period. Fifteen of the eighteen
patients underwent postoperative orbital CT scans, and in each case the implant was well visualized.
Conclusions: Porous polyethylene implants containing embedded titatium mesh combine the advantage of traditional
porous polyethylene implants (the capacity for fibrovascular ingrowth) with the additional feature of radiographic
density. In this early retrospective study, patients tolerated the implant well, and most importantly, precise
radiologic localization of the implant was achieved postoperatively due to the visibility of the titanium mesh on CT
scan. The Medpor TITANTM implant may be an excellent alternative to a traditional porous polyethylene implant when
postoperative imaging of the implant is critical.
Bibliography: 1. Rubin P.A., et al. Orbital reconstruction using porous polyethylene sheets. Ophthalmology.
101(10):1697-708, 1994.
2. Choi JC, Sims CD, Casanova R, Shore JW, Yaremchuk MJ. Porous polyethylene implant for orbital wall
reconstruction. J Craniomaxillofac Trauma. 1995 Fall;1(3):42-9.
Author Disclosure Block:
C.V. Duss, None; P.D. Langer, None.
The Use of Lone Star Elastic Stay Hooks in Orbital Surgery
Orin M. Zwick, M.D., M. Reza Vagefi, M.D., Kimberly P. Cockerham, M.D., F.A.C.S..
University of California San Francisco, San Francisco, CA.
Introductory Sentence:
The Lone Star Elastic Stay Hooks are an extremely useful tool during orbital surgery and
provide consistent exposure and retraction.
Methods:
Lone Star Elastic Stay Hooks (Lone Star Medical Products,Inc., Stafford, TX)have been utilized in neurosurgical,
urologic and colorectal cases (1,2), but have not been described in ophthalmic plastic literature. We describe the use
of this retractor system during dacryocystorhinostomy, temporal artery biopsy and orbitotomy for excision of tumors,
fracture repairs and decompression. After the skin incision is performed, the stay hooks are secured to the sterile
drape with any small clamp (Fig 1 and 2). Results: Exposure is of utmost importance when performing orbital or
plastic reconstructive surgery. When removing an orbital tumor through an anterior or lateral orbitotomy, clear
visualization and careful dissection help to prevent damage to the vital structures confined to this small area. The
Lone Star Elastic Stay Hooks are a useful tool that are easy to use and placement can be modified throughout the
surgical procedure. They are atraumatic to the skin and are insulated except the actual skin hook portion. By
retracting tissues with the elastic stay hooks, more attention can be directed toward the manipulation of the delicate
orbital tissues.
Conclusions: Lone Star Elastic Stay Hooks are efficacious, readily available and provide excellent exposure during a
wide variety of ophthalmic plastic and orbital procedures. They are superior to clumsy metal retractor systems of the
past and are less traumatic than fish hooks and traction sutures. These elastic stay hooks facilitate challenging
dissection especially when experienced hands to retract tissues are not available. Previous reports have described
retractor systems that provide adequate exposure (3,4), but our experience highlights the simplicity and usefulness
of a new technique.
Bibliography: 1. Carriero A, Dal Borgo P, Pucciani F. Stapled mucosal prolapsectomy for haemorrhoidal prolapse with
Lone Star Retractor System. Tech Coloproctol. 2001 Apr;5(1):41-6.
2. Zimmerman DD, Briel JW, Gosselink MP, Schouten WR. Anocutaneous advancement flap repair of transsphincteric
fistulas. Dis Colon Rectum. 2001 Oct;44(10):1474-80.
3. Putterman A. Orbitotomy facilitated by a mechanical retraction system. Ophthalmic Sur Lasers. 1996;27:638-9.
4. Maroon J, Kennerdell J. Microsurgical approach to orbital tumors. Clin Neurosurg. 1979;26:479-89.
Author Disclosure Block:
O.M. Zwick, None; M. Vagefi, None; K.P. Cockerham, None.
Findings of Magnetic Resonance Imaging After Optic Nerve Sheath
Fenestration
BULENT YAZICI, MD1, ZEYNEP YAZICI, M.D.2, ERCAN TUNCEL, M.D.2.
1
Uludag University Dept. of Ophthalmology, BURSA, 2Uludag University Dept. of Radiology, BURSA.
Abstract Body:
Introductory Sentence: To study the morphological changes in the retrobulbar optic nerve following optic nerve
sheath fenestration (ONSF).
Methods: Nineteen eyes of 12 patients who underwent ONSF between September 2001 and February 2005 were
enrolled in the study. The surgery was performed through the transconjunctival medial orbitotomy. Mitomycin C
solution was used intraoperatively in 7 eyes to reduce the postoperative scarring. We used T2*-weighted threedimensional CISS magnetic resonance (MR) sequence which is the best MR technique for the demonstration of the
optic nerve and optic nerve sheath. Postoperative follow-up time ranged from 8 to 29 months.
Results: The study included 16 eyes of 10 patients (8 women and 2 men; age range, 9-45 years). After unilateral or
bilateral ONSF, papilledema completely resolved in 15 eyes and partially resolved in 1 eye. Papilledema recurred in 1
eye in the late postoperative period. MR imaging was performed in the early postoperative period (between 1 and 4
months) in 7 eyes and in the late postoperative period (between 6 and 29 months) in all eyes. Early MR studies
showed that perineural cerebrospinal fluid (CSF) space at the fenestration site was closed with soft tissue in 2 eyes
(Fig 1) and there was a fluid collection adjacent to the fenestration site in 5 eyes (Fig 2). In 4 of these eyes,
mitomycin C had been used during surgery. On late MR imaging, perineural CSF space was obliterated with the soft
tissue in all eyes, except one. In the eye in which papilledema recurred, the perineural CSF space was obliterated
with soft tissue on both early and late MR imaging.
Conclusions: According to the MR imaging findings, in the early
postoperative period after a successful ONSF, a fluid collection
or obliteration of the CSF space with soft tissue takes place at
the fenestration site. In the late period, major finding is the
obliteration of the CSF space with soft tissue in most eyes.
Bibliography: 1. Seitz J, Held P, Strotzer M, et al. Magnetic
resonance imaging in patients diagnosed with papilledema: a
comparison of 6 different high-resolution T1- and T2*-weighted
3-dimensional and 2-dimensional sequences. J Neuroimaging
2002; 12:164-171. 2. Hamed LM, Tse DT, Glaser JS, et al.
Neuroimaging of the optic nerve after fenestration for
management of pseudotumor cerebri. Arch Ophthalmol 1992;
110:636-639. 3. Keltner JL, Albert DM, Lubow M, Fritsch E,
Davey LM. Optic nerve decompression: a clinical pathologic
study.Arch Ophthalmol 1977; 95:97-104
Author Disclosure Block:
B. Yazici, None; Z. Yazici, None; E. Tuncel, None.
Rethinking orbital imaging - Imaging features of orbital tumors at the
Jules Stein Eye Institute
Guy J. Ben Simon, MD1, James Fink, MD2, Christine C. Annuziata, MD1, Paul Villablanka, MD2, John D. McCann, MD,
PhD1, Robert A. Goldberg, MD1.
1
Jules Stein Eye Institute, Los Angeles, CA, 2Neuro-radiology - UCLA, Los Angeles, CA.
Abstract Body:
Introductory Sentence: To establish guidelines for orbital imaging by magnetic resonance imaging and / or
computerized tomography. To apply these guidelines for biopsy proven orbital tumors at the Jules Stein Eye Institute
in a four-year period.
Methods: Guidelines for reviewing orbital imaging studies (MRI and / or CT) were established based upon five major
characteristics: anatomic location (orbit and vicinity), bone and paranasal sinuses involvement, content, shape and
associated features. In total 85 features were established by an experienced orbital surgeon and a neuroradiologist.
Applying these criteria, imaging studies of 100 biopsy-proven orbital tumors were evaluated by three physicians: a
fellow in orbital surgery, a fellow in neuroradiology and an ophthalmology resident. Results: One hundred cases of
orbital tumors were evaluated. Common diagnoses included cystic lesions, benign tumors, inflammatory processes,
neuronal processes, and fibrous processes; malignant processes were less common. Several distinct imaging
features were typical of certain diagnoses or groups. Atypical features could be assigned in other cases. Tumor
shape, size, relations to orbital vicinity and paranasal sinuses, as well as bony erosion were predictive of a malignant
process. Benign lesions were more likely to be smaller in size, circumscribed and not associated with destructive
bone changes. Conclusions: Guidelines for analysis of orbital imaging studies, have been established and easily
implemented for evaluating orbital tumors. They provide a common language for the various specialists,
neuroradiologists, ophthalmologists and others who interpret these studies. A framework for evaluation of orbital
imaging studies is useful for teaching, research and for practical evaluation of patients. We found these guidelines to
be reproducible and clinically pertinent. We found good diagnostic accuracy when the typical features that
characterize various processes were present, but atypical presentations do occur, therefore a careful diagnostic
approach is warranted considering the benefit of imaging studies. Bibliography:
1.
2.
3.
4.
5.
6.
Selva D, White VA, O'Connell JX, Rootman J. Primary bone tumors of the orbit. Surv Ophthalmol.
2004;49:328-42.
Rootman J. Vascular malformations of the orbit: hemodynamic concepts. Orbit. 2003;22:103-20.
O'Sullivan RM, Nugent RA, Satorre J, Rootman J. Granulomatous orbital lesions: computed tomographic
features. Can Assoc Radiol J. 1992;43:349-58.
Goldberg RA, Rootman J, Cline RA. Tumors metastatic to the orbit: a changing picture. Surv Ophthalmol.
1990;35:1-24..
Graeb DA, Rootman J, Robertson WD, Lapointe JS, Nugent RA, Hay EJ. Orbital lymphangiomas: clinical,
radiologic, and pathologic characteristics. Radiology. 1990;175:417-21.
Nugent RA, Lapointe JS, Rootman J, Robertson WD, Graeb DA. Orbital dermoids: features on CT.
Radiology. 1987;165:475-8.
Author Disclosure:
G.J. Ben Simon, None; J. Fink, None; C.C. Annuziata, None; P. Villablanka, None; J.D. McCann, None; R.A.
Goldberg, None.
Relevance of US and Color Doppler Imaging in Lacrimal Gland Tumors
Florian Mann, Patricia Koskas, Olivier Berges, Serge Morax.
Fondation ophtalmologique Adolphe de Rothschild, Paris.
Introductory Sentence:
To estimate the utility of ultrasonography (US) and color Doppler imaging (CDI) for characterizing lacrimal gland
tumors.
Methods:
This is a prospective interventional case series. Medical records of 21 patients with lacrimal gland tumor were
analyzed. We assessed size, reflectivity, internal structure, flow distribution, flow velocity (high or low), vascular
pattern and resistive index . The preoperative findings were correlated with the pathology results.
Results:
Of the 21 patients, 5 had lymphoma, 1 had lymphoid hyperplasia, 1 hydrops, 2 had chronic dacryoadenitis, 6 had
pleomorphic adenoma, 2 had adenoid cystic carcinoma, 3 had pleomorphic adenocarcinoma.and 1 had meningioma
of the lacrimal fossa. Non epithelial tumors (lymphoid tumors and dacryoadenitis) appear hyporeflective with high
vascularity and a low RI (RI< 0.7). Epithelial tumors tend to have less vascularity with a higher RI (RI> 0.7).
Peripherical vascularization with calcifications and cyst inside a lesion is suspective of pleomorphic adenoma.
Conclusions:
Ultrasonography (US) coupled with color Doppler imaging has the advantage of providing a rapid, relatively
inexpensive, and noninvasive assessment of lesion morphology and vascular components. Although US has proven
useful in the analysis of lacrimal gland tumors, CDI can provide more critical information on the etiology for
subsequent management.
Bibliography: 1 Cosgrove DO, Kedar RP, Bamber JC, al-Murrani B, Davey JB, Fisher C, McKinna
JA, Svensson WE, Tohno E, Vagios E, et al.
Breast diseases: color Doppler US in differential diagnosis.
Radiology. 1993 Oct;189(1):99-104.
2. Bialek EJ, Jakubowski W, Karpinska G.
Role of ultrasonography in diagnosis and differentiation of pleomorphic
adenomas: work in progress.
Arch Otolaryngol Head Neck Surg. 2003 Sep;129(9):929-33.
3 Rose GE, Wright JE. Pleomorphic adenoma of the lacrimal gland.
Br J Ophthalmol. 1992 Jul;76(7):395-400.
4 Gunduz K, Shields CL, Gunalp I, Shields JA. Magnetic resonance imaging of unilateral lacrimal gland lesions.
Graefes Arch Clin Exp Ophthalmol. 2003 Nov;241(11):907-13.
5 Hatton MP, Remulla HD, Tolentino MJ, Rubin PA. Clinical applications of color Doppler imaging in the management
of orbitallesions.
Ophthal Plast Reconstr Surg. 2002 Nov;18(6):462-5.
6. Martinoli C, Derchi LE, Solbiati L, Rizzatto G, Silvestri E, Giannoni M. Color Doppler sonography of salivary glands.
AJR Am J Roentgenol 1994; 163:933-941
7. Shields JA, Shields CL, Epstein JA, Scartozzi R, Eagle RC Jr.
Review: primary epithelial malignancies of the lacrimal gland: the 2003 Ramon
L. Font lecture.Ophthal Plast Reconstr Surg. 2004 Jan;20(1):10-21. Review
Author Disclosure Block:
F. Mann, None; P. Koskas, None; O. Berges, None; S. Morax, None.
Necrotising Fascitis: A Case Series Of 11 Patients Presenting To An
Oculoplastic Service.
Ajay Tripathi, MBBS, MS. FRCS (Glas), FRCS (Edin), Waheeda Rahman, MRCOphth, Joyce Burns, FRCOphth,
Raghavan Sampath, MD, FRCS, FRCOphth.
University Hospitals Leicester, Leicester.
Introductory Sentence:
To discuss clinical presentation, diagnosis and management of necrotising fascitis.
Methods: A case series of 11 patients with literature review.
Results:
We present a series of 11 patients of necrotising fascitis managed by us during last five years. Out of 11
patients presented in this series, 3 were diabetic and one had co-existing sinusitis. All these patients underwent
prompt surgical intervention after diagnosis of necrotising fascitis. 2 of these 11 patients had extensive disease and
died. 9 patients made good recovery. These patients demonstrate wide ranging clinical presentation and variable
prognosis in this condition. The importance of prompt diagnosis, early intervention and multidisciplinary input is
emphasised.
Conclusions: Necrotising fascitis can be a fatal condition. It is important to maintain high index of suspicion and a
very prompt intervention is mandatory while managing these patients. As the condition can have a varied
presentation, a multidisciplinary approach is required.
Bibliography: Wong CH, Wang YS. The diagnosis of necrotizing fasciitis.
Curr Opin Infect Dis. 2005 Apr;18(2):101-6.
Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)
score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.
Crit Care Med. 2004 Jul;32(7):1535-41.
Wong CH, Chang HC, Pasupaty S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology,
and determinants of mortality.
J Bone Joint Surg Am. 2003 Aug;85-A(8):1454-60.
Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis.
BMJ. 2005 Apr 9;330(7495):830-3.
Author Disclosure Block:
A. Tripathi, None; W. Rahman, None; J. Burns, None; R. Sampath, None.
Periorbital Necrotizing Fasciitis: The Relationship between Disease
Outcome and Timing of Intervention
Gloria Wang, James Egbert, Timothy J. McCulley, MD.
Stanford University School of Medicine, Stanford, CA.
Background: Necrotizing fasciitis is a life threatening infection characterized by spread along fascial planes with
necrosis of involved and adjacent tissue. Our intension is to evaluate the relationship between disease duration and
outcome in periocular necrotizing fasciitis.
Methods: Interventional case series.
Results: We retrospectively reviewed four cases of periocular necrotizing fasciitis with particular attention to timing
of intervention. Case 1: Initial debridement was performed 3 days after onset. He was a 55 yo healthy male who
developed erythema of the left upper eyelid that following injury with a woodchip. Examination demonstrated
marked swelling of the entire upper eyelid and adjacent brow. Urgent aggressive debridement of subcutaneous
necrotic tissue which remained anterior to the orbital septum was performed. Culture grew S. aureus. Following one
week of daily debridement and antibiotic therapy, remaining skin was closed primarily and the patient continued to
do well. Case 2: Initial debridement was performed one week after onset. He was a 37 yo male suspected to be HIV
positive who presented with a one week history of left upper eyelid swelling and proptosis. Visual acuity was 20/100
with an RAPD and limited extraocular motility. CT demonstrated involvement of the superior orbital. Immediate
aggressive debridement of diffusely necrotic tissue of the upper eyelid and superior orbit was performed. Culture
grew S. aureus. Following 48 hours of broad spectum antibiotic therapy, minimal additional necrotic tissue was
excised. The patient continued to recover with improved vision and ocular motility. Case 3: Initial debridement was
performed 2 weeks following onset. She was a 43 yo female with prednisone treated autoimmune hepatitis who
developed right facial erythema and purulent orbital inflamation. On presentation she had NLP, anterior segment
ischemia and a frozen globe. Cultures grew strep pyogenes. Despite initial debridement and IV antibiotic therapy,
disease progression necessitated orbital exenteration. Case 4: Presentation was over 2 weeks after onset. She was a
77 yo female recently started on chemotherapy who developed erythema of the left periorbital area. Cultures grew
strep pyogenes. Disease progression despite antibiotics prompted referral to our service over 2 weeks following
onset. The superior half of the left side of the patient’s facial soft tissue including the orbit was necrotic. Imaging
demonstrated dural enhancement suggesting intracranial extension. Per family wishes supportive care was provided
and the patient succumbed to her disease.
Conclusions: Necrotizing fasciitis severity ranges from complete recovery to fatality. Outcome is intimately
connected with timely management.
Author Disclosure Block:
G. Wang, None; J. Egbert, None; T.J. McCulley, None.
Prominent Premalar Swelling a Sign of Thyroid Associated
Orbitopathy(TAO)
Byoung Jin Kim, M.D., Ph.D.1, Michael Kazim, M.D., F.A.C.S.2.
1
Dept. of Ophthalmology, Kangdong Sacred Heart Hospital, Medical School of Hallym University, Seoul, 2Edward S.
Harkness Eye Institute, NY Presbyterian Hospital, Columbia University, New York, NY.
Introductory Sentence:
We describe a series of patients who presented with prominent premalar swelling and thyroid associated orbitopathy
(TAO). The demographics of this group of patients are examined and postulated mechanisms for the observed
findings are discussed.
Methods: A retrospective case review was undertaken. All patients presenting with complaints of premalar swelling in
thyroid associated orbitopathy (TAO) were analysed. Patients presented from March 2002 to February 2005.
Results: Six patients suffering with thyroid associated orbitopathy (TAO), complained of premalar swelling, among
326 new patients (incidence: 1.84 %). All were female with an average age of 44.2 years (range: 28-66 years). Five
of six suffered with Graves’ hyperthyroidism. One at first had Hashimoto’s thyroiditis which converted to Graves’
hyperthyroidism. In all cases thyroid associated orbitopathy (TAO) preceded the thyroid disease or developed
simultaneously (average time from thyroid associated orbitopathy (TAO) to thyroid disease: 3.0 months). The
premalar swelling was bilateral in all cases, but 2 of 6 were asymmetric. Brow, eyelid and orbital fat hypertrophy was
coincidentally noted radiolographically in 5 of 6 cases. Pretibial myxedema was noted in one case.
Conclusions: Prominent premalar swelling should be considered among the clinical features of thyroid associated
orbitopathy (TAO). The incidence will likely to increase as we examine and question patients regarding this entity.
Bibliography:
1. Rootman J, Dolman PJ. Thyroid Orbitopathy. In: Rootman J. Disease of the orbit. 2nd ed.
Philadelphia: Lippincott Williams & Wilkins; 2003:169-212.
2. Cawood T, Moriatry P, O’Shea D. Recent developments in thyroid eye disease. BMJ
2004;329:385-90.
3. Bartley GB, Fatourechi V, Kadrmas EF, et al. Clinical features of Graves' ophthalmopathy
in an incidence cohort. Am J Ophthalmol 1996;121:284-90.
4. Prabhakar BS, Bahn RS, Smith TJ.Current perspective on the pathogenesis of Graves’
disease and opthalmopathy. Endocr Rev 2003;24:802-35.
5. Smith TJ. Novel aspect of orbital fibroblast pathology. J Endocrinol Invest 2004;27:24653.
6. Kazim M, Goldberg RA, Smith TJ. Insights into the pathogenesis of Thyroid-associated
Orbitopathy. Archives Ophthalmol 2002;120:380-6.
7. Miralles JC, Soriano J, Negro JM. Facial edema associated with thyroid autoimmunity.
Allergol Immunopathol (Madr) 2002;30:47-50.
8. Goldberger S, Sarraf D, Hurwitz JJ, et al. Involvement of the eyebrow fat pad in Graves’
orbitopathy. Ophthal Plast Reconstr Surg 1994;10:80-6.
9. Hornstein OP. Differential diagnosis of facial skin swellings (author's transl.)
HNO 1979;27:129-37.
Author Disclosure Block:
B. Kim, None; M. Kazim, None.
A Novel Mechanism for Traumatic Optic Neuropathy
Thomas N. Hwang, MD, Woo-Tae Park, BS, Thomas W. Kenny, PhD, Timothy J. McCulley.
Stanford, Stanford, CA.
Introduction:
The study investigates a possible mechanism of traumatic optic neuropathy by asking whether the soft tissue wave
generated by blunt force trauma to the front of a skull is focused within the orbit as it moves toward the orbital apex.
This is the same mechanism by which a simple cone can collect and amplify sound waves. When a wave travels
through a cone from the larger opening towards the smaller opening, the wave reflects off the walls of the cone as
the diameter gets progressively smaller, generating additional waveform components and turbulence.
Methods:
A model was designed that involved striking a human cadaver head with a rubber mallet to simulate blunt trauma.
Accelerometers, placed in the orbit and on the superior scalp, recorded movement during a series of impacts directed
both to the forehead and to the back of the skull. Average waveforms for the acceleration measured at the different
locations were generated and compared. To detect the presence of any reflected wave components created by the
impact, Fourier transformation methods were used to compare the frequency profile of the acceleration waveforms
measured under the different conditions.
Results:
The acceleration waveform within the orbit during front impact had additional oscillations that were not observed
during rear impacts or during measurements on the scalp. Fourier analysis of the data showed that the frequency
spectrum of the acceleration waveform measured within the orbit had much more power in the higher frequency
components greater than 400 Hz during anterior blunt trauma compared to the acceleration measured either in the
orbit during posterior blunt trauma or on the scalp during both anterior and posterior blunt trauma.
Conclusions:
Our results suggest that the orbit can act as a collecting cone to funnel the soft tissue wave created during anterior
blunt force trauma. This might explain why traumatic optic neuropathy is seen primarily with frontal as opposed to
posterior impact.
Bibliography:
Warwar RE et al. Mechanisms of Orbital Floor Fractures A Clinical, Experimental, and Theoretical Study. Ophthalmic
Plastic and Reconstructive Surgery. 2000 May. 16(3):188-200.
Author Disclosure Block:
T.N. Hwang, None; W. Park, None; T.W. Kenny, None; T.J. McCulley, None.