Orbit, 2014; 33(6): 456–458 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.950282
C ASE REPORT
Minimal Invasive Transcaruncular Optic Canal Decompression for Traumatic Optic Neuropathy Krishna Vaitheeswaran, Preetinder Kaur, and Shalini Garg
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
St. Stephens Hospital, Tis Hazari, Delhi, India
ABSTRACT Traumatic optic neuropathy is a cause of loss of vision associated with head injuries. Treatment options include observation, steroids and decompression of the optic canal. We report a case where the optic canal decompression was performed using a transcaruncular approach under a regional block. The incision was made through the caruncle and the dissection was carried down to the periosteum down to the orbital apex where the optic nerve was seen exiting through the optic canal posterior to the posterior ethmoidal artery. The optic nerve was decompressed with good visualization. Hemostasis and wound closure was achieved using fibrin glue. Postoperatively visual acuity improved with minimal inflammation enabling early rehabilitation. Keywords: Medial orbitotomy, optic canal decompression, optic nerve decompression, orbital apex, transcaruncular orbitotomy, Traumatic optic neuropathy
CASE REPORT Traumatic optic neuropathy is a devastating cause of sudden loss of vision. The treatment of the condition includes observation, the use of corticosteroids and surgical decompression of the optic nerve1. Currently, surgical decompression is limited to the cases with the most profound impairment of visual function2,3. The routes of decompression include transcranial and endoscopic approaches and are associated with considerable patient morbidity and complications4. The present case report describes a modified orbital/ethmoidal approach to the orbital nerve through an incision placed in the caruncle. Previously described for orbital decompression for thyroid eye disease5, this approach provides a rapid access to the orbital apex and was performed under regional block. No sutures were used and local hemostasis and wound closure was achieved using fibrin glue.
A 22-year old man of Indian origin, presented with sudden loss of vision following a road traffic accident. There were injuries on the forehead and upper face with complaints of total loss of vision in the left eye immediately following the accident.There was no history of loss of consciousness. Visual acuity was no perception of light in the left eye and 20/20 in the right eye. There was a relative afferent pupillary defect of 3 log units in the left eye. Ocular movements were normal in both the eyes as was the visual field of the right eye. A CT Scan revealed fractures of the medial wall of orbit and roof with blood in the posterior ethmoids (Figure 1). A diagnosis of traumatic optic neuropathy was made. An orbital exploration and decompression of the optic nerve was performed. The procedure was
Received 7 July 2013; Revised 5 March 2014; Accepted 28 July 2014; Published online 10 September 2014 Correspondence: Dr. Krishna Vaitheeswaran, 71, Vijaylakshmi Apartments, IP Extension, Patparganj, Delhi, India 110092, Tel: 91-9868579651, E-mail: [email protected]
456
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Transcaruncular Optic Canal Decompression
457
FIGURE 1. (a) CT Scan of the orbits showing fracture medial wall of orbit on the left side with blood in the ethmoids. (b) CT Scan of the orbits showing fracture of the roof of orbit on the left side.
performed through a transcaruncular incision. The incision was made and deepened to the periosteum, which was incised to gain access to the sub-periosteal space in the medial orbit. The dissection was carried down to the orbital apex through the sub-periosteal space, where the optic nerve was seen exiting through the optic canal, just posterior to the posterior ethmoidal vessels. Fracture fragments were seen in this area compressing the optic nerve. The fracture fragments were removed and the optic canal was decompressed. A hematoma around the optic nerve and in the surrounding superior rectus muscle was seen. This was drained by incision the sheath of the optic nerve and making an incision into the muscle hematoma. The sheath fenestration was continued into the orbit transecting the tight ring of Zinn. Hemostasis was achieved and the caruncular incision opposed and sealed using fibrin glue. Postoperatively, the visual acuity improved to hand movements close to face, on day 1 and stabilized at 20/32 at last follow up at 6 months. The wound remained healthy with no cosmetic blemishes or complaints (Figure 2).
DISCUSSION The management of traumatic optic neuropathy is limited by the lack of conclusive evidence for any form of therapy due to the absence of randomized controlled trials evaluating the disorder and its management4. !
2014 Informa Healthcare USA, Inc.
FIGURE 2. Postoperative picture of the caruncle showing a good healthy wound with little postoperative inflammation.
Various intracranial and extracranial surgical techniques have been used in the past, primarily for patients with the worst baseline acuities or those who failed to improve with steroids1. Though being increasingly used, the efficacy of endoscopic optic nerve decompression is not satisfactory for universal use6. Previous studies have shown a poor visual result in patients with no light perception and hemorrhage within the ethmoid sinus6. The use of the technique described would enable rapid and safe access to the optic nerve providing an opportunity for visual salvage in poor prognosis cases. Performed under regional block, this allows a direct approach to the optic nerve with minimal dissection providing advantages of early rehabilitation. The surgical and
458 K. Vaitheeswaran et al. visual result associated with this procedure needs to be evaluated in a large series of patients.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES
3.
4.
5.
6.
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
1. Levin LA, Beck RW, Joseph MP, et al. The treatment of traumatic optic neuropathy: the International
2.
Optic Nerve Trauma Study. Ophthalmology 1999;106: 1268–1277. Acheson JF. Optic nerve disorders: role of canal and nerve sheath decompression surgery. Eye 2004;18:169–174. Steinsapir KD, Goldberg RA. Traumatic optic neuropathy: an evolving understanding. Am J Ophthalmol 2011;15: 928–933. Yu-Wai-Man P, Griffiths PG. Surgery for traumatic optic neuropathy. Cochrane Database Syst Rev 2013; June18 Doi: 10.1002/14651858.CD005024.pub. Shorr N, Baylis HI, Goldberg RA, Perry JD. Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 2000;107:1459–1463. Yang QT, Zhang GH, Liu X, et al. The therapeutic efficacy of endoscopic optic nerve decompression and its effects on the prognosis of 96 cases of traumatic optic neuropathy. J Trauma Acute Care Surg 2012;72:1350–1355.
Orbit
C ASE REPORT
Minimal Invasive Transcaruncular Optic Canal Decompression for Traumatic Optic Neuropathy Krishna Vaitheeswaran, Preetinder Kaur, and Shalini Garg
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
St. Stephens Hospital, Tis Hazari, Delhi, India
ABSTRACT Traumatic optic neuropathy is a cause of loss of vision associated with head injuries. Treatment options include observation, steroids and decompression of the optic canal. We report a case where the optic canal decompression was performed using a transcaruncular approach under a regional block. The incision was made through the caruncle and the dissection was carried down to the periosteum down to the orbital apex where the optic nerve was seen exiting through the optic canal posterior to the posterior ethmoidal artery. The optic nerve was decompressed with good visualization. Hemostasis and wound closure was achieved using fibrin glue. Postoperatively visual acuity improved with minimal inflammation enabling early rehabilitation. Keywords: Medial orbitotomy, optic canal decompression, optic nerve decompression, orbital apex, transcaruncular orbitotomy, Traumatic optic neuropathy
CASE REPORT Traumatic optic neuropathy is a devastating cause of sudden loss of vision. The treatment of the condition includes observation, the use of corticosteroids and surgical decompression of the optic nerve1. Currently, surgical decompression is limited to the cases with the most profound impairment of visual function2,3. The routes of decompression include transcranial and endoscopic approaches and are associated with considerable patient morbidity and complications4. The present case report describes a modified orbital/ethmoidal approach to the orbital nerve through an incision placed in the caruncle. Previously described for orbital decompression for thyroid eye disease5, this approach provides a rapid access to the orbital apex and was performed under regional block. No sutures were used and local hemostasis and wound closure was achieved using fibrin glue.
A 22-year old man of Indian origin, presented with sudden loss of vision following a road traffic accident. There were injuries on the forehead and upper face with complaints of total loss of vision in the left eye immediately following the accident.There was no history of loss of consciousness. Visual acuity was no perception of light in the left eye and 20/20 in the right eye. There was a relative afferent pupillary defect of 3 log units in the left eye. Ocular movements were normal in both the eyes as was the visual field of the right eye. A CT Scan revealed fractures of the medial wall of orbit and roof with blood in the posterior ethmoids (Figure 1). A diagnosis of traumatic optic neuropathy was made. An orbital exploration and decompression of the optic nerve was performed. The procedure was
Received 7 July 2013; Revised 5 March 2014; Accepted 28 July 2014; Published online 10 September 2014 Correspondence: Dr. Krishna Vaitheeswaran, 71, Vijaylakshmi Apartments, IP Extension, Patparganj, Delhi, India 110092, Tel: 91-9868579651, E-mail: [email protected]
456
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
Transcaruncular Optic Canal Decompression
457
FIGURE 1. (a) CT Scan of the orbits showing fracture medial wall of orbit on the left side with blood in the ethmoids. (b) CT Scan of the orbits showing fracture of the roof of orbit on the left side.
performed through a transcaruncular incision. The incision was made and deepened to the periosteum, which was incised to gain access to the sub-periosteal space in the medial orbit. The dissection was carried down to the orbital apex through the sub-periosteal space, where the optic nerve was seen exiting through the optic canal, just posterior to the posterior ethmoidal vessels. Fracture fragments were seen in this area compressing the optic nerve. The fracture fragments were removed and the optic canal was decompressed. A hematoma around the optic nerve and in the surrounding superior rectus muscle was seen. This was drained by incision the sheath of the optic nerve and making an incision into the muscle hematoma. The sheath fenestration was continued into the orbit transecting the tight ring of Zinn. Hemostasis was achieved and the caruncular incision opposed and sealed using fibrin glue. Postoperatively, the visual acuity improved to hand movements close to face, on day 1 and stabilized at 20/32 at last follow up at 6 months. The wound remained healthy with no cosmetic blemishes or complaints (Figure 2).
DISCUSSION The management of traumatic optic neuropathy is limited by the lack of conclusive evidence for any form of therapy due to the absence of randomized controlled trials evaluating the disorder and its management4. !
2014 Informa Healthcare USA, Inc.
FIGURE 2. Postoperative picture of the caruncle showing a good healthy wound with little postoperative inflammation.
Various intracranial and extracranial surgical techniques have been used in the past, primarily for patients with the worst baseline acuities or those who failed to improve with steroids1. Though being increasingly used, the efficacy of endoscopic optic nerve decompression is not satisfactory for universal use6. Previous studies have shown a poor visual result in patients with no light perception and hemorrhage within the ethmoid sinus6. The use of the technique described would enable rapid and safe access to the optic nerve providing an opportunity for visual salvage in poor prognosis cases. Performed under regional block, this allows a direct approach to the optic nerve with minimal dissection providing advantages of early rehabilitation. The surgical and
458 K. Vaitheeswaran et al. visual result associated with this procedure needs to be evaluated in a large series of patients.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES
3.
4.
5.
6.
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 05/28/15 For personal use only.
1. Levin LA, Beck RW, Joseph MP, et al. The treatment of traumatic optic neuropathy: the International
2.
Optic Nerve Trauma Study. Ophthalmology 1999;106: 1268–1277. Acheson JF. Optic nerve disorders: role of canal and nerve sheath decompression surgery. Eye 2004;18:169–174. Steinsapir KD, Goldberg RA. Traumatic optic neuropathy: an evolving understanding. Am J Ophthalmol 2011;15: 928–933. Yu-Wai-Man P, Griffiths PG. Surgery for traumatic optic neuropathy. Cochrane Database Syst Rev 2013; June18 Doi: 10.1002/14651858.CD005024.pub. Shorr N, Baylis HI, Goldberg RA, Perry JD. Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 2000;107:1459–1463. Yang QT, Zhang GH, Liu X, et al. The therapeutic efficacy of endoscopic optic nerve decompression and its effects on the prognosis of 96 cases of traumatic optic neuropathy. J Trauma Acute Care Surg 2012;72:1350–1355.
Orbit
