Contents

Part One :: Basic Concepts

1.Applied Anatomy of Orbit03

Mark J Lucarelli, Nancy Kim

2.Clinical Approach to Proptosis23

Subrahmanyam Mallajosyula

Pain 23; Progression 25; Proptosis 28; Axial proptosis 29; Measurement of proptosis 35; Pulsations 37; Pupil 41; Perception of color vision 41; Prism bar-cover test (PBCT) 42; Periorbital changes 45; Lid changes 46; Conjunctival changes 48; Palpation 51; Auscultation 51; Evaluation of a case of proptosis 53

3.Imaging a Case of Proptosis:: CT and MRI56

Subrahmanyam Mallajosyula, Ravi Varma

Evaluation of a CT scan of orbit 58; Common mistakes 59; Bony orbit 60; Eyeball 65; Enlarged extraocular muscle 69; Soft-tissue lesions 72; Lacrimal gland tumors 76; Cystic lesions of the orbit 78; Metastatic lesions 81; Contrast enhancement 83; 3-D reconstruction of the orbit 84

4.Role of Cytology in Orbital Lesions85

Geeta K Vemuganti, Anirban Bhaduri

Fine needle aspiration/sampling techniques 85; Intraoperative-operative diagnosis by squash and imprint cytology 85; Squash/imprint cytology 85; Case illustrations 86

5.Pathology of the Orbital Diseases 97

KS Ratnakar

Classification 97; Diagnosis of orbital tumors 98; Developmental lesions 98; Inflammatory lesions 100; Orbital infections 101; Cysticercosis 102; Neoplastic lesions 102; Benign tumors 103; Malignant tumors 104; Metastasis 105; Graves disease 106; Mucocele 106

Part Two :: Disease Patterns of Proptosis

6.Thyroid-Associated Orbitopathy111

Peter J Dolman

Incidence and epidemiology 112; Risk factors and predictive variables 112; Pathogenesis 112; Course of disease 114; Clinical classification 114; The VISA classification 114; Vision/optic neuropathy 114; Inflammation/congestion 116; Strabismus/motility restriction 117; Appearance/exposure 117; General management guidelines 118

7.Orbital Infections120

Shome debraj, Walinjkar Jaydeep, Mukherjee Angshuman

Risk factors 121; Etiological causes of orbital infections 121; Bacterial infections 121; Fungal infections 121; Parasitic infections 121; Protozoal infections 121; Diagnosis 121; Imaging studies 121; Emergency department care 122; Further inpatient care 122; Case illustrations 123

8.Orbital Inflammatory Disease128

E Ravindra Mohan, Moupia Goswami, Vinathi Mutyala

Orbital amyloidosis 129; Sarcoidosis 130; Nonspecific orbital inflammatory syndrome (NSOIS) 131; Kimuras disease 132; Wegeners granulomatosis 132; Langerhans histiocytosis 133; Rosai-Dorfman disease 133; Orbital xanthogranuloma 134; Case illustrations 134

9.Orbital Lymphoma146

Christopher Knapp, Ram Vaidhyanath, Laurence Brown, Raghavan Sampath

REAL classification 146; WHO classification of NHL 146; Modified Ryes classification of Hodgkins lymphoma 147; When to suspect lymphoma 147; When to suspect idiopathic orbital inflammatory disease 148; Case illustrations 148

10.Vascular Lesions of Orbit151

Subrahmanyam Mallajosyula, Mohd Javed Ali

Malformations 151; Lymphangioma 151; Orbital varices 152; Cavernous hemangioma 152; Other congenital malformations 152; Sturge-Weber syndrome 152; Wyburn-Mason syndrome 153; Klippel-Trenaunay syndrome 153; Shunts 153; Carotid-Cavernous fistula 153; New growths 154; Capillary hemangioma 154; Hemangiopericytoma 155; Angiosarcoma 155; Kaposis sarcoma 155; Hemangioendothelioma 155; Hemangioblastoma 155; Case illustrations 157

11.Orbital Tumors of Neurological Origin162

Christopher M Knapp, Ram Vaidhyanath, Laurence Brown, Raghavan Sampath

Optic nerve glioma 162; Optic nerve meningioma 163; Orbital schwannoma (neurilemmoma) and neurofibroma 165; Case illustrations 166

12.Mesenchymal Tumors170

E Weis, J Rootman

Mesenchymal soft tissue tumors 170; Rhabdomyosarcoma 170; Rhabdomyoma 172; Leiomyoma 172; Leiomyosarcomas 172; Adipose tumors 172; Liposarcoma 174; Fibrous tissue tumors 174; Histiocytic tumors 175; Fibrous histiocytoma 175; Malignant tumors of uncertain type 175; Rhabdoid tumor 175

13.Bone Tumors of Orbit180

Venkatesh C Prabhakaran, Dinesh Selva

Clinical presentation 180; Osteoma 180; Fibrous dysplasia 181; Ossifying fibroma 182; Osteoblastoma 183; Chondroma 183; Cholesterol granuloma 184; Aneurysmal bone cyst 184; Giant cell lesions 184; Osteogenic sarcoma 184; Chondrosarcoma 186; Mesenchymal chondrosarcoma 186; Ewings sarcoma 186; Langerhans cell histiocytosis (LCH) 186; Intraosseous hemangioma 186

14.Tumors of Lacrimal Gland 190

Raman Mittal

Classification 190; Epithelial cyst (Dacryops) 190; Case illustrations 191; Pleomorphic adenoma 191; Adenoid cystic carcinoma 194

15.Cystic lesions of Orbit199

Golam Haider, Subrahmanyam Mallajosyula, Mohd Javed Ali

Classification 199; Dermoid and epidermoid cysts 200; Teratomas 201; Cephalocele 201; Microphthalmos with cyst 202; Mucocele 202; Cysts of the optic nerve sheath 203; Hematic cyst 203; Simple cyst 204; Retention cyst 204; Lacrimal ductal cyst 204; Implantation cyst 205; Dacryocele 205

16.Parasitic Cysts of Orbit207

Subrahmanyam Mallajosyula, Mohd Ather, Modini Pandarpurkar

Cysticercosis 207; Case illustrations 208; Hydatid cyst of orbit 217

17.Orbital Fractures 220

Alon Kahana, Mark J Lucarelli, Cat N Burkat, Richard K Dortzbach

Introduction 220; Anatomy 220; Imaging 226; Implant materials 227; General operative considerations 229; Pediatric patients 231; Timing of surgery 231; Decision:: repair or not repair 232; Floor fractures 233; Medial wall fractures 236; Lateral wall and zygomatico maxillary fractures 238; Late and secondary fracture repair 238

18.Secondary and Metastatic Orbital Tumors244

Kasturi Bhattacharjee, Harsha Bhattacharjee, Ganesh Kuri, Shyamanga Borooah

Orbital extension of intraocular tumors 244; Orbital extension of retinoblastoma 244; Orbital extension of medulloepithelioma 246; Orbital extension of uveal melanoma 247; Orbital extension of lacrimal sac tumors 250; Orbital extension of eyelid tumors 252; Basal cell carcinoma (BCC) 252; Sebaceous carcinoma of the eyelid 253; Squamous cell carcinoma of the eyelid 255; Malignant melanoma of eyelid 256; Orbital extension of intracranial tumors 257; Orbital extension of conjunctival tumors 258; Squamous cell carcinoma of the conjunctiva 258; Malignant Melanoma of the conjunctiva 259; Orbital extension of tumors of the nasal cavity and paranasal sinus 260; Orbital extension of nasopharyngeal tumor 262; Metastatic orbital tumors 263

Part Three :: Management Strategies:: Surgical

19.Decision Making271

Subrahmanyam Mallajosyula

Intraconal lesion 273; Reese-Berkes incision 273; Steps of Reese-Berke approach 274; Steps of superior lidcrease incision 275; Apical conal lesions 279; Lesions of superior peripheral space 279; Thyroid associated orbitopathy 285

20.Orbitotomies288

Ramesh Murthy, Anirban Bhaduri, Vikas Menon, Santosh G Honavar

General principles 288; Approaches 289; Anterior orbitotomy 289; Swinging lower eyelid flap 289; Lateral orbitotomy 290; Stallard-Wright lateral orbitotomy 290; Transfrontal orbitotomy 291; Complications 291; Postoperative management 291; Case illustrations 291

21.Multidisciplinary Approach to Proptosis299

Subrahmanyam Mallajosyula, B Ranganadha Reddy, M Chandrasekhar Reddy

Surgical anatomy 299; ENT approach to proptosis 300; Various etiological factors of proptosis in ENT 300; Sinus diseases causing proptosis 301; Purulent infections 301; Extensive nasal polyposis 301; Mucormycosis 301; Allergic fungal sinusitis 301; Fronto- ethmoidal mucocele 302; Tumors of paranasal sinuses causing proptosis 302; Fibrous dysplasia 302; Hemangiopericytoma 302; Juvenile nasopharyngeal angiofibroma 303; Squamous cell carcinoma 303; Rhabdomyosarcoma 303; Non-Hodgkins lymphoma 303; Esthesio-neuroblastoma 304; Caldwell-Luc operation 304; Lateral rhinotomy/medial maxillectomy 305; Total maxillectomy 306; Pattersons operation 305; FESS 309; Neurosurgical approaches of proptosis 309; Transcranial approach 311; Extracranial approach 309; Case illustrations 313

22.Orbital Exenteration318

Ramesh Murthy, Anirban Bhaduri, Sima Das, Santosh G Honavar

Indications 318; Patient preparation 318; Surgical procedure 318; Types 319; Management of the exenterated socket 320; Prosthesis 320; Complications of exenteration 320; Case illustrations 321

23.Orbital Prosthesis327

Kuldeep Raizada

Types of prosthesis 327; Complete prosthesis 327; Factors that affect the fit of an orbital prosthesis 328; Preparation of the patient 328; Impression of the orbital defect 328; Casting 329; Sculpting 329; Moulding 330; Using the desired material 331; Fabrications of ocular prosthesis 331; Assemble of prosthesis 331; Care of your prosthesis 331; Storing the prosthesis 332; Preventing mishaps 333

Part Four :: Management Strategies:: Nonsurgical

24.Medical Management of Proptosis337

Subrahmanyam Mallajosyula, Mohd Javed Ali

Nonspecific inflammations of the orbit (NSOIS) 337; Specific inflammations of the orbit 338; Orbital cellulitis 338; Rhino-orbital mucormycosis 338; Chronic granulomatous infections 338; Parasitic infestations 338; Tolosa- Hunt syndrome 339; Capillary hemangioma 339; Acute intraorbital hemorrhage and emphysema 340; lymphoprolifarative and other neoplastic lesions 340; Case illustrations 340

25.Management of Ophthalmic Tumors:: Role of Chemotherapy and Radiation Therapy344

Vijay Anand P Reddy, Nitin More, Ramesh Murthy, Anirban Bhaduri, Santosh G Honavar

Introduction 344; Ionizing radiation 344; Radiation therapy delivery methods 344; External beam radiation (teletherapy) 344; Internal radiation therapy (brachy therapy) 345; Plaque radiotherapy 346; Principles of anti-neoplastic therapy 347; Capillary hemangioma 348; Basal cell and squamous cell carcinoma 348; Tumors of lacrimal gland 348; Malignant conjunctival tumors 349; Intraocular lymphoma 349; Retinoblastoma 349; Choroidal melanomas 349; Chemoreduction regimen 350; Oculor metastasis 352; Rhabdomyosarcoma 352; Orbital lymphoma 352; Graves ophthalmopathy 353; Optic nerve glioma 353; Optic nerve meningioma 353; Sequelae of radiation therapy 353

26.Carotid-Cavernous Fistulae:: Role of Interventional Radiologist356

D Ravi Varma, D Radhika Varma

Pathophysiology 357; Clinical features 357; When to suspect CCF 359; Radiological investigations 359; Management of CCF 360; Direct CCF 360; Indirect CCF 363; Prognosis 363

27.Ocular and Systemic Associations of Proptosis366

Subrahmanyam Mallajosyula, Mohd Javed Ali

Capillary hemangiomas 366; Neurofibromatosis 366; Craniofacial dysostosis 367; Encephalocele 367; Wegeners granulomatosis 367; Wyburn-Mason syndrome 367; Hurlers syndrome 368; Nonspecific orbital inflammation syndrome 368; Sclerosing inflammation of the orbit 368; Osteoma 368; Orbital hamartoma (tuberous sclerosis) 368; Hemangioblastom 368

Index 369