Deep Lateral Wall Partial Rim-Sparing Orbital Decompression with Ultrasonic Bone Removal for Treatment of Thyroid-Related Orbitopathy

Abstract

Purpose To describe the results of thyroid-related orbitopathy (TRO) treated by ultrasonic deep lateral wall bony decompression with partial rim sparing (DLW-PRS). Methods A review was carried out, from January 2015 to September 2017, of all patients treated with ultrasonic DLW-PRS decompression using a SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator, using a lateral, small triangle flap incision for access. The primary outcome was the change in proptosis (measured by the difference in Hertel exophthalmometry measurements). Other secondary outcomes were changes in visual acuity (VA) (using Snellen scale, decimal fraction), presence of lagophthalmos, eyelid retraction (measured by upper eyelid margin distance to the corneal reflex (MRD1) and lower eyelid margin distance to the corneal reflex (MRD2), and presence of exposure keratopathy). Results A total of 58 orbital decompressions in 35 patients were reviewed, with 23 patients (65.7%) having bilateral decompressions. There was a female preponderance with 26 patients (74.2%), and the mean age ± standard deviation was 52.6 ± 13.9 years. Mean proptosis was 24.51 ± 1.76 mm preoperatively, reduced to 19.61 ± 1.27 mm in final follow-up. The mean reduction was 4.9 ± 1.54 mm. VA improved from 0.8 ± 0.14 to 0.9 ± 0.12, p=0.039. 5 of 13 patients (38.4%) with preoperative diplopia reported improvement or complete resolution after surgery. MRD1 was reduced from 5.25 ± 0.88 mm to 4.49 ± 0.7 mm. MRD2 was also reduced from 6.3 ± 0.88 mm to 5.0 ± 0.17 mm. Presence of lagophthalmos was reduced from 35 eyes (60.3%) to five (8.6%); the presence of epiphora was also reduced from 20 patients (57.1%) to 3 (8.5%) following decompression. Complications of the surgery included zygomatic hypoaesthesia in 14 (40%) patients in the early postoperative period and chewing alterations in 10 (28.5%) of the patients. All of these complications were resolved at the 6-month follow-up visit. We noted no surgical complications such as ocular or soft tissue damage, infection, inflammation, or visual loss. Conclusions The SONOPET® ultrasonic bone curette can be used safely and effectively for DLW orbital decompression surgery. The main benefits were good visualization and handling of tissues and speed and ease of use of the equipment. This trial is registered with ClinicalTrials.gov identifier: NCT04025034.

Orbital Solitary Fibrous Tumor: Four Case Reports—Clinical and Histopathological Features

“…All of our cases were adult patients (range: 25 to 78 years, mean: 55). In our study, all cases of SFT were in female patients, but the literature shows that there is no gender-based predilection [ 8 , 12 ]. The most common form of clinical presentation is with unilateral painless proptosis, with slow growth; it may be associated with eyelid edema, visual alterations, the presence of a palpable mass, tearing, and ipsilateral ptosis [ 1 , 11 ].…”

“…This tumor appears mainly in the fifth decade of life, but it can appear any time from age 15 to over 89 [ 8 ]. All of our cases were adult patients (range: 25 to 78 years, mean: 55).…”

“…The classic histopathological features of SFT are cells which are described as spindle shaped with a small cytoplasm and indistinct nucleoli, and the tumor matrix contains a distinctive thick “ropy” type of collagen between tumor cells [ 8 , 14 ]. SFT should be differentiated from other spindle-shaped cell orbital tumors, such as fibrous histiocytoma, HPC, meningioma, and schwannoma [ 14 ].…”

“…SFTs show strong and diffuse positivity with CD34 (90–100%) [ 8 – 10 , 13 ], vimentin, BCL2, and CD99 [ 15 , 16 ] and negativity with keratin, cytokeratin, EMA, S100, SMA, and desmin [ 14 ]. The CD34 protein is a transmembrane protein that is expressed in vascular and hematopoietic tissue.…”

“…In one case, we also describe the use of SONOPET® (Stryker, Kalamazoo, MI, USA) ultrasonic aspirator system for the tumor excision postincisional biopsy. It is a surgical tool that uses low-frequency ultrasonic vibrations to fragment tissue while simultaneously irrigating and aspirating the surgical field [ 8 ].…”