ORBIT/OPTIC NERVE DECOMPRESSION HISTORICAL PERSPECTIVE

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1 ORBIT AND OPTIC NERVE DECOMPRESSION Steven D. Schaefer, MD, FACS Professor and Chair Department of Otolaryngology New York Eye and Ear Infirmary New York Medical College HISTORICAL PERSPECTIVE

2 NORMAL AND PATHOLOGIC OPTIC NERVE FUNCTION Retinal Ganglion Cells Glutamate-and and ATP-mediated signalling at optic nerve nodes of Ranvier. Process involves axons or astrocytes. Glutamate activates perinodal astrocytes which support axon activity (Butt, Eye, 2004). ATP-Ca+-signalling in nerve injury NORMAL AND PATHOLOGIC VASCULAR FUNCTION

3 PATHOGENESIS Orbitopathy Increased Intra-orbital Pressure Hemorrhage Infection Mass Lesion Optic Neuropathy Neuropathy Secondary to ICP PATHOGENESIS Orbitopathy Autoimmune Increased Intra-orbital Pressure Hemorrhage Infection Mass Lesion Cosmetic deformity, Corneal Ulceration, Lid Retraction Optic Nerve Compression, Mixed Orbitopathy Results Optic Neuropathy Neuropathy Secondary to ICP

4 SURGICAL INDICATIONS Failure of Medical Management and Disease Course(chemosis, diplopia, motility, lid retraction, proptosis, vision ) Increased Intra-orbital Pressure Hemorrhage Infection Mass Lesion Cosmetic deformity, Corneal Ulceration, Lid Retraction Optic Nerve Compression, Mixed Orbitopathy SURGICAL INDICATIONS Failure of Medical Management Cosmetic deformity, Corneal Ulceration, Lid Retraction Optic Nerve Compression, Mixed Orbitopathy Results

5 SURGICAL INDICATIONS Optic Nerve Decompression Neuropathy Secondary to ICP Orbital Apex, Annulus of Zinn, Optic Canal Timing, Failure of Medical Therapy, Controversial Results SURGICAL APPROACH Superior Approach (Naffziger) Lateral Approach (Kronlein) Infero-medial (transantral) Medial/inferior (Lynch, Endoscopic combined) Transorbital (transcaruncular, orbital debulking) Cosmetic deformity, Corneal Ulceration, Lid Retraction Optic Nerve Compression, Mixed Orbitopathy

6 SURGICAL APPROACH SELECTION Indications/Evaluation Failure of Medical Management Time Course of Disease Corneal Ulceration Diplopia Hertel Exophthalmometry Red Vision Visual Acuity Pupillary Response (afferent pupillary defect) Cosmetic deformity, Corneal Ulceration, Lid Retraction Optic Nerve Compression, Mixed Orbitopathy 1 Antrostomy Complete Uncinectomy Large Antrostomy 2 Ethmoidectomy Total Ethmoidectomy Avoid Frontal Recess Avoid herniation of orbit obstructing maxillary ostium

7 3 Removal of Orbital Plate Play With and Without Preservation of Inferomedial Strut 4 Incision Periorbita Performed After Optic Nerve Decompression

8 5 Decompression Orbit Play Play 6 Combined Endoscopic And Transconjunctival Orbital Decompression

9 SURGICAL CONSIDERATIONS Optic Nerve Decompression ObitlA A l Orbital Apex, Annulus of Zinn, Optic Canal Timing, Failure of Medical Therapy, Controversial 1 Identification Orbital Apex Optic Nerve Decompression 2 Removal of Medial Optic Canal with Burr Play

10 Optic Nerve Decompression 3 Removal of Medial Optic Canal with Curette Play RESULTS +/- Cosmetic deformity Mixed Orbitopathy Hertel Visual Acuity mm Garrity, N=428 65% of < 20/20 Michel, N= to 0.75 lines Metson, N=13/24* 5.1/5.0* *without periorbita fascial sling 29.3% diplopia

11 RESULTS N = 72 eyes, 41 patients from , 3-55 mos f/u, Laryngoscope /- Cosmetic deformity Mixed Orbitopathy Optic Nerve Compression RESULTS +/- Cosmetic deformity Mixed Orbitopathy Optic Nerve Compression Results Visual Acuity 89.3% with compressive neuropathy (p>.0005), 34.1% without Proptosis mm 20 pt. preop diplopia, 1 pt. diplopia p, 4 pt. diplopia p 0 pt. sunseting

12 RESULTS Optic Nerve Decompression Sofferman, Warner, Kountakis, Guyer, Knox, Luxenberg Multiple approaches and timing, variable ibl results Levin, Int. Optic Nerve 32% surgery, 57% untreated, 52% Trauma Study Group, N=133, Multiple Variables steroids visual acuity, p=0.22 within 7 days of injury Rajiniganth, N=44 when vision unchanged or after 70% visual acuity with surgery < 7 days, y, 24% with surgery steroid, compression by CT > 7 days CONCLUSIONS Orbitopathy Increased Intra-orbital Pressure Hemorrhage Infection Mass Lesion Optic Neuropathy Neuropathy Secondary to ICP