Thyroid Eye Disease (TED) is one of the commonest conditions we encounter in an #oculoplastics clinic. It presents in various forms- acute, sub-acute, chronic, smoldering inflammation and sometimes quite silent. About 1/3rd of patients with TED are known to a have a sub-clinical silent course. While acute symptoms have debilitating morbidity with sight threatening features, the after effects of TED can have long lasting eye abnormalities like protruding eyeballs👀, squint👁️, staring look 😳and inability to close eyes causing eye dryness.
This lady first presented with Right upper eyelid retraction with normal thyroid profile values. However, clinically she had all the signs of the after effects of TED and was in the inactive stage of the disease. She was very upset by the abnormal lid position of her right eye.
The staring look of eyelid retraction in TED can be very awkward for patients while meeting people and in photos of themselves. This eyelid malposition can be easily corrected with a 30 minute procedure done under local anaesthesia with very predictable outcomes. This lady was very pleased with the outcome of the surgery as she’s back to her beautiful Pre-TED self.
⏲Surgery time: 30 mins 💉Anaesthesia: Done under Local 🗓️Downtime: 3-4 weeks 📈Duration of effect: Permanent 📠 Phone: +91 80 2502 3257 📩 E-mail:dr.raghuraj.hegde@gmail.com 🖥️ Website: www.drraghurajhegde.com
There is a mystical hole in the wall – of the orbit. An ancient myth among oculoplastic and maxillofacial surgeons alike-that once an Orbito- zygomatico-maxillary complex (OZM) fracture or commonly known as ZMC fracture is reduced, the orbital floor fracture automatically gets reduced and there is no need to repair the floor of the orbit. This was classic textbook teaching. However, this is true of only a small percentage of ZMC fractures.
But with modern roads, high speed traffic- high impact injuries are getting quite frequent, more complex fractures are presenting to hospitals. The myth has been busted by experienced surgeons over the years. However, the myth still persists.
Pic 1
We see in Pic 1 that there is a medium sized orbital floor defect extending all the way to the inferior orbital fissure despite excellent reduction of the OZM fracture with the help of our maxillofacial team lead by @prashanth.rajaram . The orbital floor then was repaired with a porous polyethylene sheet to prevent both post operative entrapment and late enophthalmos.
Pic 2
Surgery- We see in Pic 2 intra-operatively that there were additional fractures to fix that were not visible on the Pre-op scans. We can achieve complete exposure of the fractures using a Trans-conjunctival as well as a trans-oral incisions thus avoiding a skin incision altogether. If we need fix the fronto-zygomatic part of the fracture an eyelid crease incision would be used (we didn’t need it in this case). Eyelid crease incision is well hidden in the fold of the upper eyelid crease. Fracture repairs do not require ugly skin scars and can be achieved with hidden incisions.
Pic 3
The Pre and post surgery CT 3D reconstructions shows the excellent reduction of the OZM fracture. In this case a 2 point fixation was enough to reduce the fracture.
Pic 4
In Pic 4 we see the coronal, axial and saggital cuts showing good open reduction and internal fixation (ORIF). The “empty” space seen in the sagittal section in the post op image is occupied by the radio-lucent porous polyethylene sheet (Omnipore) but is holding the orbital contents from prolapsing into the maxilla.
I hope that this busted myth becomes a thing of the past and there is more collaborative work among Oculoplastic, cranio-maxillo-facial, Oto-rhino-laryngologists, Plastic Surgeons and Neurosurgeons in the multi-disciplinary field of facial trauma.
This beautiful lady underwent Ptosis correction surgery in the right eye. She had an uneventful post surgery course. As is obvious from the before and after photos, she was thrilled at the result. It was like opening a window to a world which was hidden from her for many years because of the acquired Ptosis.
Droopy Eyelid Surgery or Ptosis correction surgery is more art than science. I’m sure all Oculoplastic Surgeons agree it is a challenge to treat patients with ptosis. Each case is so different that it is almost feels like you are starting from scratch. While challenging, it is also among the most satisfying Oculoplastic conditions to treat.
It is one of the surgeries where the easiest part of the procedure is the surgery itself. The pre and post surgery counselling of what to expect after surgery as well some acceptable trade offs are an important aspect of this wonderful surgery. Surgeons often have to hand hold the patient during the entire process till the patient completely recovers from the procedure.
The surgery itself is a day care procedure done using an eyelid crease approach which hides the thin incision mark within the eyelid fold. In some cases ptosis surgery can be undertaken using a posterior approach without an external incision or resulting mark. If you or someone you know are suffering from this easily correctable condition, consult your nearest Oculoplastic Surgeon.
⏲Surgery time: 30-45 mins 💉Anaesthesia: Done under Local 🗓️Downtime: 3-4 weeks 📈Duration of effect: Long term 📠 Phone: +91 80 2502 3257 📩 E-mail:dr.raghuraj.hegde@gmail.com 🖥️ Website: www.drraghurajhegde.com
Nothing beats the feeling of being able to remove a skull base tumour through a small incision in the upper eyelid crease. This here is after the tumour has been completely excised. This picture shows the amount of exposure we can achieve by just the orbital route and also that’s me admiring the orbital anatomy for a few seconds before closing up.
This below are the CT and MRI collages showing the tumour occupying the supero-lateral part of the right orbit causing lytic bone destruction of the lateral orbital wall up to the lateral skull base. It is present in the extra-conal space of the orbit extending to the epidural space and infiltrating the right temporalis muscle. It is important to note here that there is no infiltration into the peri-orbita as well as the dura. This was confirmed intra-operatively.
The following picture shows the surgical steps performed using the eyelid crease incision approach. Periosteal incision, lateral orbital rim window, debulking of the tumour with frozen section margin control and finally closure. Needless to say my Neurosurgical colleague was assisting me during the procedure and fortunately he didn’t have to take over the case. We could avoid both a craniotomy and need for any dural repair in this patient. A win-win for everyone.
Histopathology of the clinical specimen turned out to be Plasmacytoma. The ImmunoHistoChemistry (IHC) of the specimen revealed CD138 being positive with kappa chain restriction. A systemic work up which included among other things a PET-CT, Bone Marrow Aspiration (BMA) and Bone Marrow Biopsy (BMB) revealed no evidence of Multiple myeloma. Plasma cells were less than 4% and were all well differentiated. So the final diagnosis was Extra-medulary Primary Orbital Plasmacytoma. It is very rare to find isolated extra-medulary plasmacytoma in the orbit.
This case was taken up by the tumour board. In view of the complete excision of the tumour with margins and no systemic involvement, it was decided to observe the patient with close follow up.
Facial Trauma can be damaging with tissue loss. Despite accurate and meticulous reconstruction, the scarring can be severe in the face. Scar modulation is an essential part of post trauma care and I often advise patients as much when they come with traumatic injuries of the face.
Pic 1 shows the photos at presentation compared with one taken 8 weeks out from surgery.
In this case, a 25year old man fell down from his motorcycle, scraped the road and cut his eyebrow at several places with some tissue loss. Despite careful reconstruction and suturing (Pic 2), the patient started developing a thick scar on the wound site at 4 weeks post surgery.
In such cases my go to #ScarCocktail is F5U (an anti-metabolite) : Triamsolone Acetonide (a long acting steroid) in the ratio of 9:1. This gives excellent results as can be see in Pic 3. it is both safe and effective in the treatment of scars.
2020 has been an incredible year. For sure it has been a tough year but in all the difficult periods there are the big life lessons. The paranoia of the early days of the pandemic has given way to a little breathing space now. This pandemic has been a pause button on our lives and it was a time to take stock. It made us realise how privileged we were to have the things we had taken for for granted. It showed us what was truly important in our lives and what was the fluff in it.
Personally even in the middle of a raging pandemic, there were some silver linings-the biggest of which was the family time we were able to manage- which would have been impossible if we had our regular office commutes and schedules. The joy of seeing our daughter growing up and watching her cross various milestones can’t be expressed in mere words. Of course, there was nothing called free time for both of us even though we were at home for long stretches of time- Iksha made sure of it!
Professionally, despite the trying times, managed to try some new ideas in my surgeries and was part of some challenging surgeries-taking my work to a different level. I finally designed and launched my own professional website and Instagram channel-which I had been procrastinating for a long time. I have been sharing my patient stories, blogs, articles and surgical outcomes for more than 6 months now.
Research and publications-Managed to complete a few manuscripts, published a few of them/many on the way and some more ongoing work. I want to be publishing a lot more in the following year.
I don’t think I have read as much in any year as I have done this year- about everything from covid to history to politics. I used all my dishwashing time and later driving time to listen to podcasts and audio books. So hopefully I know a little more about the complicated world around me.
The thing I missed most this last year was my reduced contact with my patients. I also realised how important doing surgeries were to who I was. I was extremely grateful to restart surgeries later in the year and things are all looking better now.
A year is what it is made to be. Our attitude matters rather than what happens to us. 2021 will be similarly challenging but we’ve got put our best foot forward. Like this picture below where Iksha had her first taste of the beach. She was scared of the waves but I’m sure will learn to enjoy the tides very soon.
I was part of something new last week. It is perhaps the first time this was done in India.
A 4 year old girl was referred to me after she recovered from a fall from the second floor on to a cement road. She came to me with a strange complaint from her parents. Whenever the child cried, the left side of the face would swell up. She had Rhinorrhoea (running nose) and frequent headaches.
Her CT Scan showed why it was so.
She had crack in her skull starting from her Left ethmoid sinus passing through her left orbit superiorly into the frontal bone- a huge ugly crack. There was a direct tract from the sinuses to the subcutaneous space. Whenever she cried the increased sinus pressure would force air into the orbit and then into the skin which would be seen as a swelling. It was the cause of subcutaneous emphysema. The coronal, saggital and axial cuts confirmed the course of the orbito-frontal- cranial fracture line.
However on examination something didn’t make sense- the hypoglobus- pushing the left eye down. I carefully scouring the CT scan DICOM data in my computer from which I couldn’t pin-point a reason despite a left orbital roof defect.
To rule out a CSF leak, I ordered an MRI scan with contrast. On the scans it was imediately made clear that there was a meningoencephalocele into the left orbit. There was possibly a dural tear and CSF leak from that tear itself.
MRI Images
Correlating the CT scans with the MRI showed that the meningocele was through the left orbital roof defect.
Leaving it well alone would risk a future ascending infection. Even 6 months earlier, I would have referred this case to a neurosurgeon who would repair this with an open sky craniotomy and a bad scalp wound. That was the conventional treatment for such conditions.
I discussed this case with my colleague and skull base surgeon- Dr. Gaurav Medikeri. We have been collaborating with each other for a few cases in the last few months. As a team, we are exploring the possibility to approach the Anterior Cranial Fossa (ACF) using an orbital access- Trans-Orbital Neuro-Endoscopic Surgery (TONES). With this technique we can operate on skull base lesions with minimally invasive approach. This has the benefit of reduced morbidity, complications as well as hospital stay. I wanted to explore if there was a less invasive way to resolve the problem for this girl.
Since the patient was poor we managed to arrange for some funds from the charitable foundation of the hospitals we work in. Given the complexity of the case, we did a thorough planning for the surgery.
The surgery Trans-Orbital Neuro-Endoscopic Surgery (TONES)
We managed to fix this post-traumatic meningoencephalocele via TONES. I accessed the superior orbit and roof fracture through the upper eyelid crease incision dissecting in the sub-orbicularis pre-septal plane followed by a periosteal incision on the superior orbital rim. A gush of Cerebro-Spinal Fluid (CSF) burst through when I tried to separate the edges of the rood fracture from the prolapsed menigocele. The dural tear was larger than we had anticipated and dura was stuck to the peri-orbita. The arachanoid layer of the meninges was intact. The encephalocele had retracted from the orbital roof defect once the separation was done. My colleague then repaired the dural tear and CSF leak with a dural substitute. I then repaired the orbital roof fracture with osteomesh- an osteo-integrating mesh implant. New bone formation should occur in 1-2 years.
Trans-Orbital Neuro-Endoscopic Surgery (TONES)
By doing this surgery using this technique, we managed to avoid a craniotomy and the accompanying scar in a 4 year old child. Her only scar from the surgery would be hidden in the eyelid crease.
With good planning and multi-disciplinary team work we can push boundaries while getting best outcomes for our patients. It is always exciting to do new things.
Update: March 2021
Wanted to update this case with post operative outcome and imaging photos.
About 8 weeks out from surgery, the child is doing well. The CSF Rhinorrhoea, headaches and hypoglobus has resolved. The sub-cutaneous emphysema has about 90% resolved and only the nasal area is getting filled up and not much of a problem. She has Left orbital residual enophthalmos resulting in left Pseudo-ptosis.
The post operative MRI imaging reveals that roof defect repair is successful and there is no proplapse of intra-cranial contents to the left orbit anymore.
As of now, we have decided not to chase after the left orbital enophthalmos and ptosis and wait for the tissues to recover from surgery. We will probably revisit the residual conditions at a later date.
This 35 year old lady approached me with an unusual complaint,
“My eyes are closing over my eyeballs.”
Though surprised at first, on examination indeed there was hooding of the Lateral canthi of both eyelids (Outer corners of the eyelids) which was well appreciated on a side profile photograph (pic 1 above right).
This was an aesthetic as well as a functional problem. Her old photo (Fig 2 ➡️ swipe), taken 10 years back at her wedding showed how with time a combination of facial/orbital fat atrophy with laxity of the lateral canthi on both sides had caused the eyelid hooding.
After ruling out any connective tissue disorder which could also cause such a condition, I performed the Lateral Canthoplasty (Reconstructing the lateral canthus) thus restoring the ideal almond shape of the palpebral (eyelid) opening. Not just a new lateral canthus needs to be reconstructed, we also have the make sure the eyelid do not stick back together by using silicone bolsters as tissue spacers. (Pic 3)
40% of the facial features is determined by the eyes and peri-ocular area. So we can see in this case that just the change in the lateral canthal position, improves the facial profile manifold. The surgery has solved the aesthetic as well as the functional problem for this beautiful lady.
I got a pleasant surprise a few days back when one of my patients who is now in another city sent me his selfie showing that he has got back to his old handsome self. He was operated by our team nearly a year back. I was very happy to know all our efforts was worthwhile.
Picture of patient One year after Surgery
Read on to know his surgical story.
This young man unfortunately got injured when he slipped while hurrying down the stairs and hit his face on the railing. He sustained what is known as Naso-Orbito-Ethmoidal (NOE) fracture. The frontal bone (forehead area) was severely fractured into multiple pieces- the force so high it caused leakage of his Cerebro-spinal fluid (fluid surrounding the brain). Both his orbits (Eye sockets) had large Blow-in fractures and his nose was flattened due to the force.
Our team consisting of a Neuro-surgeon, Oculoplastic Surgeon (Me) and Maxillofacial Surgeon operated on him for nearly 10 hours to get this young man back to his pre-accident status. The Neurosurgeon fixed his CSF leak after taking a bi-coronal flap approach and we then painstakingly fixed his frontal bone fractures piece by piece using titanium plates and mesh as a framework. I then repaired both his orbits👀 with pre-fabricated combined medial and floor titanium implants using the trans-conjunctival approach to avoid any extra skin incisions. The left anterior nasal buttress had to be fixed with a titanium mini-plate from an oral incision. The flattened nose 👃still had to be fixed which was then suspended from the frontal bone titanium frame while using internal nasal splints and external POP splint to hold the nasal bones in the desired position. This was perfect team work which reflected in the excellent post-operative outcome.
(Above) The patient’s Straight Face and Side Profile pictures on table and (Below) His Straight Face and Side Profile two weeks after surgery.
(Above) Pre-operative 3D reconstructed CT images showing severe frontal and nasal bone fractures. (Below) Post-operative 3D reconstructed CT images showing well corrected external fractures.
(Above) Pre-operative Coronal, Sagittal, Axial CT images showing Bilateral Blow-in floor and medial wall orbital fractures as a part of the NOE fracture. (Below) Post-operative Coronal, Sagittal, Axial CT images showing perfectly reconstructed orbits on both sides.
For details of such types of surgeries and for appointments
Carotid-Cavernous Fistula (CCF) is an abnormal passage of blood between the venous cavernous sinus and the internal carotid artery.
Relationship of the Eye in relation to the cavernous sinus and Internal Carotid Artery
There are two main types of CCF as per the Barrow’s Classification (see pic below) 1. Direct CCFs or Type A where a tear in the internal carotid wall causes a single high flow fistula drains directly into the cavernous sinus. 2. Indirect CCFs or Type B,C,D- which are low-flow fistulas between meningeal branches of the internal carotid artery system and the cavernous sinus
Barrow’s Classification of Carotid Cavernous Fistulas
The case we are going to be discussing in this article is a 37 year old female patient who presented to the clinic with left eye
Proptosis,
Upper eyelid Oedema
Engorged Episcleral Vessels
On examination she had
Bruit on palpation
Swooshing sounds on auscultation
Increased intra-ocular pressure in the Left eye compared to Right (LE 21mmHg, RE 15mmHg)
A clinical diagnosis of Indirect Carotid-Cavernous Fistula was made.
This usually a straightforward referral to my Endovascular neurosurgery & Interventional Radiology colleagues who do an elegant minimally invasive procedure to close the CCF through the Femoral Vein. They got a Dynamic MRI, Digital Subtraction Angiography and Orbital Colour doppler to see flow. On the MRI You can see the superior ophthalmic Vein quite prominently because it has been arterialised (Red Arrow)
The DSA confirms the clinical diagnosis as well as the possible approaches to the cavernous sinus
Digital Subtraction Angiography (DSA) confirming the Indirect Carotid-Cavernous Fistula (CCF)
My Endovascular Neurosurgeons & Interventional Neuro-radiologist colleagues usually cure this condition in an elegant way running the angio- catheter through the femoral vein and accessing the CCF through the Inferior Petrosal Vein. Although the inferior petrosal sinus is the simplest, shortest, and most commonly used venous route to the cavernous sinus, the superior ophthalmic vein (SOV), superior petrosal sinus, basilar plexus, and pterygoid plexus present other endovenous options.
The Various Approaches to the Cavernous Sinus
In rare instances, the SOV is the sole route available as in this case. Hence I was called upon to expose the SOV for my colleagues to gain access to the CCF. Hence I was called upon to expose the SOV for my colleagues to gain access to the CCF.
Exposure of Superior Ophthalmic Vein (SOV)
A medial eyelid crease incision. The Orbital Septum is then dissected and incised. Fat prolapses. Blunt dissection of the supero-medial orbital fat is done towards the supra-orbital notch till the arterialised SOV is identified (Blue Arrow). Once identified and dissected, the SOV is looped with a rubber ligature.
After SOV is identified it is followed by cannulation of the SOV and closure of the CCF using Onyx- a vascular embolic agent.
Onyx- A Vascular Embolic Agent
Six weeks post procedure there is complete disappearance of Left Eye Proptosis, Upper eyelid Oedema & engorged episcleral veins. The comparison photos at presentation and 6 weeks post embolisation of CCF.
The comparison photos at presentation (Above) and 6 weeks post embolisation of CCF (Below)
It is very rare that oculoplastic surgeons are asked to provide access to interventional neuro-radiologists. This is one such case. We have performed such interventions in 3 cases till date at our hospital with similarly successful outcomes. The important thing to remember as a surgeon while accessing the SOV is that the vein is arterialised due to the CCF and bleeding can be very severe is the vessel wall is damaged. Hence three important factors in the successful outcome of this approach is
Knowledge of Clinical Anatomy and the intimate relationship between the SOV and the other orbital tissue.
Clean dissection field and careful movements in the supero-medial orbit.
Delicate separation of orbital tissues from the SOV without damaging the vessel wall.
This case was interesting way to tackle the case. In a sense I was re-learning an old skill since this technique has been mentioned in literature for more than 30 years but due to advanced endovascular technology, this approach has run into disuse. As I found out, there may be certain candidates for this procedure.
DR. RAGHURAJ HEGDE 