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Background Orbital aspergillosis is a rare sight- and life-threatening fungal infection affecting immunocompromised or otherwise healthy patients. It is often misdiagnosed due to its unspecific clinical and radiologic appearance. Therapeutic delay can have dramatic consequences. However, progress in microbiological diagnostic techniques and therapeutic experience from case series help improve the management of this disease. Case presentation A 78-year-old immunocompetent woman presented at an eye clinic for subacute swelling, reddening, and ptosis of her left upper eyelid. Based on radiologic and histologic considerations, she was treated for idiopathic orbital inflammation, but her condition worsened. After a second biopsy of the orbital mass, aspergillosis was diagnosed. Her condition improved promptly after initiation of an oral voriconazole treatment. Additionally, using a polymerase chain reaction (PCR) assay, A. fumigatus was identified on tissue of both biopsies and its azole susceptibility was examined simultaneously. Conclusions In the case described here, oral antifungal treatment was sufficient for the therapy of invasive orbital aspergillosis. Performing fungal PCR on orbital tissue can accelerate the diagnostic process and should be performed in ambiguous cases of slowly growing orbital mass. Finally, interdisciplinary management is the key to optimal treatment of orbital tumours and infections.

This study aims to analyse the various modifications of orbital exenteration. Patients undergoing orbital exenteration from March 1978 to October 2019 were included in this retrospective study. The patients were evaluated on the basis of the indication, type of exenteration, reconstruction technique, overall survival (OS), and disease-free survival (DFS). In total, 300 patients were enrolled in this study. As many as 24 patients had lid and conjunctiva sparing anterior exenteration, 16 had lid sparing anterior exenteration, 83 had anterior exenteration, 14 had lid and conjunctiva sparing total exenteration, seven had lid sparing total exenteration, 44 had total exenteration, one had lid and conjunctiva sparing extended exenteration, 23 had lid sparing extended exenteration, and 88 had extended exenteration. As many as 39 patients had a primary wound closure. Six patients underwent reconstruction with a split-thickness skin graft, 177 patients with a local or regional flap, and 40 patients with a microvascular flap. A total of 38 patients did not undergo reconstruction. The mean follow-up was 40 months (range 6–216 months). The OS rate was 82.2% after 1 year, 58.5% after 5 years, and 49% after 10 years for all patients with malignant tumours. The DFS rate was 67.7% after 1 year, 45.6% after 5 years, and 31.7% after 10 years. Individual types of orbital exenteration allow patient-adapted therapies. The preservation of uninvolved orbital tissue facilitates orbital reconstruction. The type of exenteration did not have any influence on overall survival.

A 56-year-old man presented with a periorbital subcutaneous mass and ipsilateral visually significant orbital inflammation that was refractory to broad-spectrum antibiotics. Orbitotomy with biopsy revealed the diagnosis of metastatic lung cancer, and the patient was initiated on systemic chemotherapy and adjuvant radiation. This is the first report of pulmonary adenocarcinoma metastatic simultaneously to the periocular cutaneous and intraorbital soft tissues. Atypical periorbital and orbital inflammation may be the initial presentation of occult malignancy and require a high index of suspicion and tissue biopsy for diagnosis and life-saving management.

The goal of orbital reconstruction is to repair wound injuries, anatomically correct the eye location, prevent enophthalmos and restore ocular function. Many surgeons recommend materials for the reconstruction of (trauma) defects which can be bent into an anatomical shape and which possess the properties of radio pacificity and long-term stability. However the ideal material for orbital reconstruction remains controversial apart from these desired properties. Autologous bone is often referred to as the' gold standard,' probably due to its mechanical properties, the potential for revascularisation and its adaptation to the orbital tissue with minimal acute and chronic immune reactivity. The aim of this analysis is to provide a comprehensive overview of the benefits and disadvantages of materials used to repair traumatic orbital defects and to provide a realistic set of guidelines based on evidence and complexity.

Objective: To describe the dissection protocol for the pig head to obtain the orbital tissue, as well as a simple setup for ophthalmic surgical wetlabs. Methods and Analysis: A descriptive study. The pig head dissection was performed at the abattoir for convenience. The orbital tissue thus obtained was used to set up the wetlab workstation. Results: A cost-effective, low technology, affordable set-up for ophthalmic surgical wetlab protocol was developed. High resolution photographs of the procedure were taken and were presented for ease of description. The dissection protocol was test-run at an ophthalmic surgical training workshop. Conclusions: The porcine orbit and the wetlab setup were available and affordable. The dissection in the abattoir is easy and reproducible. The orbit was used instead of the enucleated globe and this ensures stability throughout surgical practice sessions.

Purpose To describe the details of a unique case of cannibalistic orbital trauma and the oculoplastic reconstruction approach. Observations A 65-year-old homeless man survived a disfiguring cannibalistic facial and bilateral orbital injury that included bilateral loss of all adnexal structures, partial exenteration of the left orbit, and severe damage to the right globe and anterior orbital structures. The patient's extensive facial and orbital tissue damage required emergent surgery, which included left exenteration and right eyelid reconstruction. Conclusions This is the first report of cannibalistic evisceration in a live victim who survived the attack, posing a unique reconstructive challenge. Bilateral globe removal was avoided to provide time for the patient's emotional recovery. Although this was an exceptional surgical scenario, traditional oculoplastic principles remained crucial to achieving a successful outcome. The patient survived and was pleased with his surgical outcome, refusing further reconstruction or prosthesis fitting.

Secondary orbital implant surgery refers to the introduction of a new implant in an anophthalmic socket or the replacement of an existing orbital implant. Secondary orbital implantation may be considered in the following cases: a socket with no implant, a socket with a very small implant, an exposed implant, a migrated implant, prosthetic eye fitting problems or discomfort, or to improve prosthesis motility. Primary implant placement can be delayed in cases of severe ocular or orbital infection or when an adequately sized implant cannot be placed. An orbital implant exchange may be needed to address complications of primary implants. Secondary orbital implant surgery is more challenging than primary implantation, primarily owing to the disruption of anatomic planes, rearrangement of orbital tissue, and varying degrees of orbital scarring from the primary surgery. Not only are the results of the surgery less predictable, but the complication rate is also higher. Several surgical techniques have been developed to improve efficacy, attain successful outcomes, and minimize complications. Preoperative strategic planning, adept surgical techniques, and vigilant monitoring for postoperative complications are essential. This chapter describes surgical techniques for the placement of secondary orbital implants.

Background: Orbital floor fractures always represent achallenge for reconstruction. Various techniques for treatmenthad evolved over the past years, each with their strengths andweaknesses. The main aim of surgical repair is to relocateherniated orbital tissue and fat back into the orbit restoringboth the function and aesthetic aspect. Reconstruction oforbital floor can be performed using various types of materials,either autologous as rib grafts or cartilage grafts or alloplasticas titanium mesh.Aim of the Study: The aim of this study is to compare theresults of using autologous cartilage grafts with those of splitrib graft in small posttraumatic orbital floor defects reconstruction.Patients and Methods: 30 patients with orbital floordefects due to maxillofacial trauma. They were divided into2 groups according to the technique of reconstruction: Group1: 15 patients who had reconstruction by onlay split rib graftsGroup 2: 15 patients who had reconstruction by conchalcartilage grafts, using either unilateral or sutured bilateralconchal cartilage grafts in large defects. Both methods wereanalyzed clinically and radiologically and were compared asregards, their advantages and disadvantages Postoperativeassessment using CT scan were used.Results: With the conchal cartilage grafts, the results weremore favorable with statistically significant decrease incomplications.Conclusion: Reconstruction of orbital floor fracturesusing conchal cartilage grafts represents a safe and reliablemethod of reconstruction with less complications.

Eyelid trauma is commonly encountered by ophthalmologists and spans a spectrum from easily managed abrasions to complex injuries that involve the deeper orbital tissue and globe. This chapter reviews the epidemiology, evaluation, and management of eyelid trauma, focusing on eyelid lacerations. It includes information about the identification and treatment of periorbital foreign bodies. It details instructions for laceration repair, both simple and complex, such as margin-involving and levator complex-involving lacerations. This chapter also addresses key components of the acute management of eyelid burns. Of note, canalicular trauma and injuries involving the lateral canthal tendon are not discussed in this chapter as they are addressed in other chapters. In summary, this chapter provides a comprehensive overview of the assessment and management of non-canalicular eyelid trauma.

Purpose To retrospectively evaluate the risk factors for the development of late enophthalmos in pure blowout fractures. Methods We reviewed 49 cases of pure blowout fractures diagnosed in Ajou University Hospital, South Korea, from January 2005 to June 2015. We assumed that several factors influence the development of late enophthalmos, including bony defect size, volume of displaced soft tissue, number of fracture sites, involvement of floor, soft tissue incarceration through the bony defect, and patient age. Results Twenty-one patients were diagnosed with late enophthalmos (group 1) while 28 patients were not (group 2). Soft tissue incarceration, presumably causing the soft tissue injury, was the only factor that increased the risk for late enophthalmos in this study (p = 0.04, odds ratio 4.5). In contrast with previous studies, there were no meaningful correlation between bony defect size or volume of displaced soft tissue and development of late enophthalmos. Number of fracture sites, involvement of floor, and patient age did not increase the risk for late enophthalmos. Conclusions We suggest that the delayed orbital tissue atrophy due to soft tissue injury plays a more important role than other hypotheses in the development of late enophthalmos. It is necessary to overcorrect to some extent if there is soft tissue incarceration through the bony defect in the initial computed tomography, and clinicians should warn patients about the development of late enophthalmos despite orbital reconstructive surgery.

Tomoaki Higashiyama, Masahito Ohji Department of Ophthalmology, Shiga University of Medical Science, Otsu, Japan Purpose: This study was performed to observe changes prospectively in exophthalmos and orbital fat in patients with inactive thyroid-associated ophthalmopathy (TAO) treated with bimatoprost. Methods: In this 12-month single-treatment pilot observational study, 13 patients with inactive-phase TAO were administered bimatoprost to treat exophthalmos due to TAO. Exophthalmos values and orbital tissue volumes were measured on MRI by technicians in a masked fashion. Results: Nine orbits of nine patients (eight women, one man) were treated with bimatoprost for 12 months. Mean exophthalmos values before and after treatment were 21.7±2.2 and 21.7±2.0 mm, respectively. The mean value after 12 months of treatment was not significantly different from before treatment (P=0.82). Mean orbital fat volume before and after 12 months of treatment was 17.2±2.5 and 17.0±3.0 cm3, respectively. The corresponding total extraocular muscle volume was 4.0±0.7 and 3.8±0.9 cm3, respectively. Mean volume in each tissue type after 12 months of treatment was not significantly different from before treatment (orbital fat, P=0.70; extraocular muscles, P=0.32). Conclusion: Topical bimatoprost treatment did not reduce exophthalmos or orbital fat in this cohort of patients with inactive TAO. Keywords: bimatoprost, thyroid-associated ophthalmopathy, exophthalmos, orbital fat

Aim The aim of the study is to determine the effect of orbital tissue herniation, as determined by computed tomography (CT) scan, on diplopia and ocular motility scores in blowout fracture patients. Materials and methods Patients who sustained pure orbital blowout fractures in the period 2000–2010, and for whom CT scan reports were available, were included in the study. Three levels of tissue herniation were reported: none, fat only, and fat and muscle. Orthoptic assessment included binocular single vision (BSV) and uniocular fields of fixation (UFOF) scores. Results One hundred and twenty-three patients were included in the study. Although mean BSV and UFOF scores decreased with increasing amounts of tissue prolapse, there was no significant difference between the BSV, UFOF scores of injuries with no tissue prolapse and those with only fat herniation (P > 0.05). A significant difference was noted between the BSV and UFOF scores of no/fat herniation and injuries with fat and muscle prolapse groups. Patients with muscle herniation had a tendency for an unfavourable outcome following surgical intervention. Conclusion We suggest that orbital fat herniation alone may not be an adequate indication for surgical intervention for correction of diplopia in orbital blowout fractures. Cases with orbital muscle herniation are more likely to have an unfavourable outcome in relation to diplopia.

1. There are some patients seeking additional improvement after reduction malarplasty. Major reasons are as follows: One is suboptimal reduction of zygomatic body, and another is prominence being located at or close to the orbital rim that cannot be improved by conventional reduction malarplasty. 2. Conventional reduction malarplasty focuses mainly on reduction of the anterolateral zygomatic body and zygomatic arch and offers limited improvement at the orbital rim. 3. In selected patients with malar prominence located close to the orbital rim, reduction malarplasty with a modified tripod osteotomy and burring of the orbital rim provides aesthetically satisfying and reliable results. 4. Both burring of the orbital rim and modified tripod osteotomy can be done through subciliary or transconjunctival approach, not through bicoronal approach. 5. The orbito-malar complex is osteotomized at the zygomatic arch, zygomaticomaxillary suture, and inferior to the usual zygomaticofrontal suture by a reciprocating saw and osteotome. The movable bony segment is repositioned and fixed at the lateral orbital rim, inferior orbital rim, and zygomatic arch. For minimizing bony step around the osteotome line and additional reduction of partial bony protrusion, burring also can be applied. 6. Care should be taken to protect the orbital tissue during the burring and tripod osteotomy by adequated retractors and good knowledge of three-dimensional anatomy.

We compared histological structure of the orbital and subcutaneous adipose tissue. Quantitative morphometry showed that the mean diameter of adipocytes and their volume density in the orbital adipose tissue were significantly lower than in the subcutaneous fat, while volume density of vessels and elements of the connective tissue in the orbital adipose tissue was higher. Previously known and revealed here differences in the structure of orbital and subcutaneous adipose tissue do not answer the question, whether subcutaneous adipose tissue can be used for replacement of the orbital tissue deficit.

IgG4-related disease is an immune-mediated disorder affecting almost all major organs of the body. A 62-year-old male, who was diagnosed with an orbital tumor and a nasal-orbital communicating tumor of the left eye, underwent endoscopic endonasal removal of the orbital tumor and fenestration of the ethmoid sinus. The tumor originated in the orbital tissue and showed pathological changes associated with IgG4-positive chronic inflammation. He was diagnosed with IgG4-related orbital disease. At 4 months of follow-up after surgery, there was no recurrence.

Background The treatment of complex orbital floor fractures with extensive orbital prolapse remains a surgical challenge in craniomaxillofacial traumatology and is still controversially discussed. Reduction of orbital tissue via a transcutaneous or transconjunctival approach alone can be very difficult and lead to unsatisfying results. Methods Over a 3-year-period, we enrolled 13 patients who underwent endoscopy-assisted reconstruction of isolated orbital floor fractures via a combined subciliary and transantral approach. Patient data, imaging and ophthalmologic examination were reviewed prospectively. Results Ten patients underwent primary surgical treatment, 3 patients had secondary surgical treatment because of unsatisfactory results of primary surgical intervention. All patients had an uneventful postoperative course without ophthalmologic deterioration, no further surgical procedures were necessary. Conclusions The additional use of an endoscopy-assisted transantral approach provides a reliable treatment modality in selected cases. To our knowledge, this is the only study of patients treated with a combined subciliary and transantral approach. Special emphasis was given to postoperative functional results, a short algorithm for use of an additional transantral endoscopy-assisted approach is presented.

The objectives of this study were measure the orbital volume of healthy Koreans and analyze the differences between orbital tissue volume with respect to age and sex and to assess any correlation between body mass index (BMI), eyeball position, and orbital volume.We retrospectively evaluated the scan results of patients who had undergone orbital computed tomography scans between November 2010 and November 2011. We assessed the scan results of 184 orbits in 92 adults who had no pathology of the orbit. The individuals were classified into 3 groups with respect to age. Orbital volume, effective orbital volume (defined as the difference between orbital and eyeball volume), extraocular muscle volume, orbital fat volume, and transverse globe protrusion were recorded and analyzed. The records of the subjects were reviewed retrospectively, and BMI was calculated. A correlation analysis was performed to investigate the correlation between BMI, eyeball position, and orbital volume.Orbital tissue volume, with the exception of orbital fat volume, was larger in men compared with women. In both sexes, orbital fat volume increased with increasing age, whereas the other volumes decreased. Orbital tissue volumes increased with increasing BMI, but transverse globe protrusion was not significantly related to BMI. In addition, orbital volume and effective orbital volume were positively correlated with transverse globe protrusion.These results provide basic information about the effects of age, sex, and BMI on orbital volume and eyeball position in healthy Koreans. Furthermore, these results will be helpful in the diagnosis of orbital diseases and in planning orbital surgeries.

To define a method of quantifying axial proptosis in patients with Graves' orbitopathy (GO) and to validate a score that correlates with the orbital involvement and helps determine the degree of proptosis correction for elective orbital decompression.Retrospective, case series.The study included 50 patients (group A) and 29 control subjects who underwent orbital computed tomography (CT). The method was then validated in another group of 21 patients with GO (group B).The orbital area (OA) was measured manually on the central axial section of the CT scan at a level where the lens is visualized. The OA intersects the projection of the globe and delimitates the chord of an arch (globe chord [OC]). The area of the circular sector under the chord (CA) represents the portion of the globe within the orbit.A CA-to-OA ratio was calculated to reduce the error due to variability of the measurements and to perform correlations with some of the clinical parameters of GO.Measurement error was low (2%). We did not observe significant differences in the mean OA of patients with GO (783.6 ± 12.1 mm(2)) and controls (758.5 ± 20.4 mm(2); P = not significant). The OC value in patients with GO was 130.2 ± 11.5 mm(2), significantly lower than in controls (281.8 ± 9.7 mm(2); P0.0001). The CA-to-OA ratio also was lower in patients with GO than in controls (0.16 ± 0.01 vs. 0.38 ± 0.01; P0.0001). A significant correlation was found in patients with GO between the CA-to-OA ratio and proptosis (P0.001), lid fissure (P = 0.004), and intraocular pressure (P0.001). In group B, the CA-to-OA ratio was 0.18 ± 0.02, significantly different from that of controls (P0.0001) and inversely correlated with proptosis (P0.0001) and lid fissure (P0.045).By measuring the CA-to-OA ratio, we were able to quantify the degree of axial proptosis in patients with GO. The significant correlation of CA/OA with some orbital parameters confirms that this parameter also may be used as a measure of orbital involvement in GO.The author(s) have no proprietary or commercial interest in any materials discussed in this article.