Ocular Surface Squamous Neoplasia (OSSN) is a spectrum of pre-cancerous and cancerous lesions of the conjunctival epithelium (transparent coat covering the surface of the eye).
Dermoid cyst (also known as choristoma) is a benign tumor growing out of a embryonic suture line. The tumour consists of normal cells occurring in an abnormal location. It is usually diagnosed in children when it is first visible but it is not uncommon to have adults coming to the clinic to know if it can be removed.
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. Surgery can take care of many of these after effects.
Hering’s Law for the eyelids: There is reflexive descent of the contralateral upper eyelid after the ipsilateral surgical correction of unilateral ptosis. Hering’s law is explained by considering the two eyes as paired organs and it follows that the muscles moving it will work in co-ordination.
Coloboma can present with eyelid coloboma, iris coloboma or choroidal coloboma, a combination of the three or all three. Eyelid colobomas part of goldenhar syndrome is usually in the upper eyelid, resulting incomplete closure resulting in exposure keratopathy which can then turn into a corneal ulcer as in our case.
The MRI scan showed a large intraconal well defined mass sitting right next to the optic nerve causing mass effect which in turn was causing diminution of vision. My working differentials going into surgery- based on location and imaging was Cavernous Hemangioma, Fibrous Histiocytoma, Dermoid cyst, Schwannoma among others.
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.
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. 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.
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.
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.