This live webinar will cover different surgical approaches for the management of orbital tumors, imaging diagnostics, and recommendations for day-to-day practice, even for centers with limited resources.
Lecturer: Dr. Marisol Iñiguez Soto, Ophthalmologist, Zapopan, Mexico
[Marisol] Good morning, all of you, I’m Dr. Marisol Iñiguez from Guadalajara, Mexico. First of all, I want to say thank you to Cybersight for the invitation and giving me the opportunity to be with you this day in this hour of the morning here in Mexico, 8am.
I’m going to talk to you about some orbital tumors surgical approach in real patients, in real cases, that I have had the opportunity to treat in my hospital, Hospital Civil de Guadalajara, here in Guadalajara, Mexico.
We’re going to begin with a little boy. Our first patient is two-years-old little boy. Which his main problem is history of two months and his mom says that the eye is going out. The left eye is going out, the little boy says too. And in this picture we can see in the first vision of situation patient doctor. On the first visit we can see the proptosis of left eye. Pseudoptosis. He had limitation in the abduction movement of the left eye and red eye in the intermittent form. The first thing that we have to do in all kind of patients, even if they are pediatric or adult, if they are hospitalized or they are come in for consultation, is to see what the visual acuity.
In the right eye, we have central fixation and 20/20. For the left eye we have central fixation and 20/60. Even though he’s a two year old boy, he has a very good attitude and we could take the visual acuity as an older person. You don’t have to be with the idea that if it’s a pediatric patient it’s going to be difficult. All kinds of patients must have the visual acuity at the beginning.
In the esquiascopy we can see astigmatism in the left eye that could be, maybe provoked by the proptosis and the pseudoptosis. For the eyelids, eyebrows, and eyelashes I would like to see the picture again. We can see that the conjunctiva in the right eye is normal. In the left eye, in the temporal zone, we have redness.
And we do show these little marks in different colors for the students of the fellowships that are studying in my hospital. And with these marks we can see that it’s not an illusion, it’s not like the mom is making out a history, it’s a real situation where the eyelid is coming down. You see that these stands between within the visual reflex in the corneal and the distance that goes to the whirl of the eyelid, we can see a difference in which the left eye is a real proptosis. Always we can see the sulcus line of the eyelid. In this moment we could think in a panorama proptosis that we have to be sure of the movement and the quality of the elevator muscle.
We can see, too, that the eyeball, the left eyeball is distended, is down and we have a big volume in the interior eyelid too. We continue with the exploration. The intraocular pressure it’s about 12 millimeters in the right eye, 16 millimeters in the left. Taken with I Care. In the exophthalmometry we have 16 millimeters right eye, 19 millimeters in the left. We have an important difference here.
This picture is very useful because sometimes maybe we can think it’s the position of the head during the picture or maybe the patient moved during the exploration. But with this position of the head in one position like this, we can see that actually there is a proptosis. Even if you don’t have the exophthalmometer, you can see with that position of the head that’s it’s a really proptosis in the left eye. And in the axial vision, we can see the photographs that we have the proptosis in the left eye as the mom said.
What is going to be our approach? For the beginner ophthalmologists, it could be heavy, scary. But if you continue with a protocol of always make a complete clinical history and follow step by step the diagnosis, you are going to be fine. And your patient is going to be fine too.
In this tomography in the current slide in the current projection, we can see here the tumor is embulbing and is touching the eyeball and the temporal wall is eroded. We have to be very carefully, because we have a really short story. We have a two month story and now with two months we have the temporal wall eroded. We must hurry up with this patient. In these other projections like more intracorneal, we can see that the walls in the frontal temporal zygomatic is totally eroded. And in the actual projection, we can see even a little communication between brain and orbital tissues. Our mass is not well-limited bordered mass, so we have here a few points that calls maybe it’s a malignancy mass and we must be very fast with the surgery to make diagnosis and treatment. Thinking about he’s a three-years-old patient.
Here is another projection where we can see totally eroded that temporal wall. More eroded. And here we can see the approach that we did with this little patient. Oh, sorry. It’s a video. Here we have our patient, we are going to make a temporal osteotomy, we open the periosteum and we take a piece of temporal bone. And we arrive to the mass. If you see the mass, you have no capsule, so we have to take out in little pieces. But certainly we take off all the tumor. After that, we close the periosteum with vicryl 6.0, separate points. And because it’s a little guy, we use to put this for not have retrobulbar emeresh. We finish the procedure.
After one day of evolution, the boy is well. Eight days. 15 days of evolution we can see that the movement of the eyes are conserved. The pupil reflex is good, the movement is really good. He’s well. Now we have the piece complete to make the histopathologies examination and he’s a very good boy.
Histopathology result talks about it’s just histiocytosis of Langerhans cells. Fortunately completely removed. And these kinds of patients, it will envelope them and very quickly form. They have a very good prognosis and now he’s three years old. He’s well, he’s going to school in a popular kindergarten, so we could have a very good diagnosis and treatment in a very good way and in a good time. We don’t have to estimate these kinds of patients even if you don’t have the resources, you can do a lot if you have a very good clinical history, a good expiration, and if you can’t do that you have to refer the patient.
Our next patient is an adult. She’s a 52-years-old woman. And if you can see, I’m going to come back a little bit. The limitation of the movement of the left eye, we’re going to see again. Limitation in the left eye. For the left and right movement it’s okay, and she has a proptosis that is evident and she has also a history of diplopia.
Here we have, I’m going to make a pause in the tomography. Here we have the axial projection and we can see a very huge mass behind the eyeball, intracoronal, but certainly it has very good limited borders so it talks about a benign lesion. Also, if you can see the temporal wall, the wall is not eroded as the other case, the three-year-old boy. This wall is related.It talks about coronicity, it talks about maybe the patient noted it’s like one year before, this curious mass that has been there for a long, long time, so it provokes the revelation of the temporal wall.
Now we’re going to have the coronal projection. Here we have the tumor, it’s behind the eyeball. And it’s located more up than down or down temporal. In this tomography, we can see where is going to be the most effective way to arrive to the mass. Maybe you are going to have combined approaches and is well done. But always before going to the surgery, always you have to be sure and have radiology images. (coughs) Sorry.
And in another coronal projection, we can see that the mass is almost in the nuclear apex, the orbital apex, inside the cone, surrounded by the muscles. We have to be very careful and even if you see these kinds of tumors that are big, that are for difficult approaches that it’s difficult to get inside, don’t be afraid. Just follow the protocol and always try to do the simple thing.
We’re going to arrive another time in temporal way. Okay. But always we have to mark the eyelid sulcus just in case to be prepared. If you notice, we mark it in the natural sulcus, not to make another heal. And we’re going to approach in temporal wall so we’re going to mark our italic S down the eyebrow. And here again, we have separated the tissue until we arrive to the periosteum that we opened with the scalpel. After that we remove the periosteum to arrive to the bone, very carefully, because remember that you have an eyeball, a functional eyeball there. After that with a lot of care, we use an element to break the bone. This piece of bone, we have to very carefully keep a watch on it because we are going to replace after the surgery that cut of bone to complete the orbit.
Here you can see the mass, it was not too difficult, even if it’s so big. And we are going to remove very carefully. After that we make some measures for the histopathology service. And the ball is almost 25 millimeters for each side. Now to incorporate that piece of bone and we like to suture the bone with a little hose that we make with the motor. And here we have our patient in the eight days after surgery.
This is our land here in Tequila, where tequila is made for all the world.
You can see it’s another temporal way to arrive. It’s a different patient, different age, but the technique is more or less the same. Here we have another patient with, the last patient was a stronoma, this patient is a hemangioma. And he’s a 45-years-old man that arrives with a proptosis history of one year, diplopia, and the cosmetic aspect is important too. One more time, we make some marks in the photographs to evidence for the patient and for the doctors that are studying with us, that the right eyeball is down compared with the left. And this image in the superior photograph, we can see the limitation for the up movement, even for the right movement the position of the rapider muscle. And, well, we have to do something. One more time it looks like so different, so difficult, but remember, if you follow the instruction, if you follow the protocol, you are going to do just fine.
Here we have our tomography. In these projections we can see that there is a contrast tomography and the lesion has more reflex so it seems to be a vascular tumor. And we can see that it’s pushing down the eyeball in the left image. But another time we can see that the wall is not eroded, that it’s a good sign, a good situation. It speaks to us about something that it’s not malignancy. In the actual position, we can see the tumor that is near the temporal wall but it’s touching the muscles and maybe the optic nerve.
We have to be very careful here, speak very well with the patient, have a lot of confidence, and a lot of communications with the patient. Because, yes, he’s has a long story of proptosis and diplopia, but after the surgery he can still with the diplopia, he can lose a little bit of visual acuity, and he has to be conscious of this and about the the risk of the surgery.
It’s the same approach with an italic S in the temporal wall of the skin. Mark the sulcus of the eyelid if it’s necessary to arrive an approach by two sides. And then we operate where the periosteum and we have to be very carefully with the external muscle. Because if you don’t have very good equipment of the strabismus in your team, you are going to have a little problems with the movement of the eyeball after the surgery if you are not very carefully or maybe if the mass is too big. Always have a good friend of strabismus surgery.
And here we have the mass, it’s a little bit bigger than the other. And here’s the patient eight days before surgery. If you can see the eyeball is not completely in parallel, but it’s better than before and we have a little bit of edema and ecchymosis. But they’re doing very well, the diplopia is not more on his life. He recovered two lines of vision so it’s a good result.
Here we have another different case, it’s a little girl, three-years-old too, that arrives from the oncology service. She has leukemia but also the mom begins to see the proptosis of right eye. She arrives to the service with a magnetic resonance and it’s very evident that we have a mass in the temporal region near to the muscle pushing the eyeball that it’s eroding the temporal wall. So we have a different diagnosis but the approach is the same. And fortunately with this early diagnosis, the patient received the chemotherapy in time as well and now she’s with a regular life. She’s taking my class, so she’s really good.
For the eyelid surgery approach, obviously this approach is going to be when the mass, we can see it in the studies, up of the eyeball. That is going to be the easiest form for not making another scar and to make a really good fast and efficient approach.
This is a very good case. You’ll see in the moment because in a way because this is a 14-year-old girl. The mass is not provoking limitation of the movement, it’s not provoking limitation of the visual acuity, but cosmetic is a huge situation that we must solve. Most of the time in public hospitals, like mine, they don’t prioritize cosmetic situations. But here, in this patient, 14-years-old, I think that the emotional situation is going to be very, very huge if we don’t do something. The tumor is not so aggressive, the tumor is not malignancy, but emotion, she is going to be provoked. She has a very good way to access. Here we have the tomography, sorry. And in a coronal projection you can see the tumor is well independent, it is not pushing the eyeball. So maybe functional is not a surgical patient, but cosmetic it has all the chance to improve.
We get inside of the sulcus and very carefully remove the tumor, even if it’s benign, we don’t want to push up around the tumor. Because if the tumor grows out, there is going to be a lot of inflammation because it’s a dermoid case. Here’s the eight days post surgical. And here she is at 14 days after surgery. And after that, she had her party, her 15-years-old party. Here in Mexico, a big party for the girls is at 15-years-old. So I get invited, it was a really good party.
Our next patient, I can see a lot of questions here. Okay, the diagnosis is the pathology, I send it, right? Okay.
This patient, the main problem is our third opinion because he has been treated in Tamaulipas, it’s another state here in Mexico of the north. “Does my eye could be saved” versus observation versus enucleation. In his town, they just tell him that they could enucleate the eyeball or just observation. He wants to improve his physical appearance, to improve the visual acuity, and also he has a story of itching, burning, and abnormal discharge of the right eye.
In the pathologic history, he has a lot of allergies: penicillin, Trimethoprim, Trimethoprim-sulfamethoxazole, wheat, cockroach, and cats. This is important because of the final diagnosis, you’re going to see why. And his ophthalmology, his story of this little boy. The right eye has had mechanical ptosis since he was one. But if you can see the evolution of the photographs, he always had the visual axis free. It means that he has not amblyopia of the right eye. And in the other hospital they want to make enucleation. We have to put the diagnosis here. At nine-years-old, after all the development of the visual acuity, the tumor covers the visual acuity, and they cannot move the eyelid. And in Tamaulipas they have neurofibromatosis. But it not make sense if they have neurofibromatosis, maybe, how they want to remove the eyeball.
Here we have the patient. If you can see the expression, he’s mad. After seeing all of the doctors he doesn’t want to cooperate. But we can see the right eye that the eyelid is very big, it’s bigger than the other, it’s so big that they cannot move their eyelid, they cannot open it.
And these measurements are very important for us in plastic surgery, because in all these marks we can see that there is several numbers of elevator function muscle. He doesn’t have the natural surface of the eyelid, and he has a lot of secretion in the eyelashes. With these kind of tumors, the history of the patient, we must make the transillumination and with this proof we can see that maybe it’s a vascular tumor. If we are thinking in a vascular tumor, we must have to ask for ultrasonography. And we can see in this study that it’s a high flush lesion. After that we ask for a contrast tomography and we can see a mass that is hyper-reflected in the totally part of the eyelid.
In the actual projection we can see that the mass is covered the totally part of the portion in the eyeball, but the eyeball is respected. And we have to decide the therapy, we ask for arteriography and this arteriography, sorry, we can see that the principal vessel is from the ophthalmic artery. It means that we cannot use sclerotherapy because if we use that we are going to lose the 20/20 visual acuity that he has. We must arrive and take out the tumor with an open biopsy. He is not a good candidate for sclerotherapy. With the images and the history, we can talk, we can think that the lesion is a hemangiolymphangioma.
We have the approach by the sulcus eyelid, we mark it in the upper sulcus. We separate the tissues very carefully, because remember that it is a vascular lesion. But with all the studies that we asked before, we can see where is the principal vessel to avoid the bleeding. And here we are separating the mass, it is almost removed, but we are going to arrive to the principal vessel. We close it, we use the cautery and then we remove the complete mass. After that, we have to search the aponeurosis to attach it to the tarsals, not go up through the tarsal conjunctiva to protect the cornea. And then we close the skin with separate points.
Eight days before, 15 days after, and in 15 days we can see the visual axis free. It’s a good result. He needed a cosmetic surgery after that, oculoplastic surgery. But the important situation here is that now he can use the right eye. Anybody who had removed the eyeball in the way that they informed in the other hospital in Tamaulipas, and now he’s in the high school and he has a regular life.
Here we have the sample, based on the histopathology result, talks about the hemangiolymphangioma, as we thought. Thoroughly removed and negative for malignancy. And here we have a very beautiful photograph of the histopathologies because we have a very representative vessel with erythrocytes and another vessel with lympha. In these type of patients, you see we use the same approach as the dermal case, but even if we approach the same way in the sulcus eyelid, we use a very different way to diagnose this. The important thing here is a very good, I insist, in a very good clinical history. Remember the allergies of this boy, that’s why every time he had a period of allergies or some situations with nose-throat problems, the mass get bigger. That point it’s very important to make the diagnosis. And if you don’t have the time and you don’t give the regular time to your patients, you are going to lose these little details. It’s very important to have a very good communication with the patient, with the moms, to have a very good diagnosis.
This is another patient in which we arrive by the sulcus eyelid too, but even the approach is the same. The history is different. This tumor is pushing the eyeball and this patient has neurofibromatosis. If you see there’s a lot of variety of presentations in these kinds of tumors and I insist, even if you see that so big, so aggressive, don’t be afraid, just follow the instructions, follow the protocol, and you’re going to be fine and your patients are going to be just excellent.
Here we have another type of approach for floor or transconjunctival. Here we have, oh, sorry. Here we have a little five-year-old boy with a tumor, history of tumor at two years, so the tumor begins at three-years-old. Sorry.
Yes, the tumor is in the inferior eyelid. He had a violet color. He’s bigger when he makes efforts and now we have another probably vascular tumor. And here we have the tomography. Fortunately the wall is not eroded, the inferior wall. And if you can see, it’s more reflective tissue this contrast tomography and the eyeball is fine. It’s another case that the functional situation is not involved but the cosmetic problems that it provokes in the school is higher than the visual acuity that he could lost. Even the visual acuity is fine, we are going to make the surgery because the improvement of the emotional situation of this patient is going to change in 180 degrees.
In the axial position, sagittal position, and we arrive very carefully for not lesion the skin, we separate the retractor muscles from tarsals to arrive to the floor of the orbit. Very carefully, because remember, it’s a vascular tumor. Here we have the tumor. We are going to separate the bad spots. But remember that we are forming medical students, (laughs) so this chocolate seeds have been pushed up and all this comes out. We are going to remove the capsule. And this is the boy after 15 days.
This is another patient, I have to say that it’s not a tumor but the approach is the same, and it’s important to see the difference between these cases. Even if it’s not a tumor, you can help these kind of patients in the same way. It’s a little girl, 12-years-old and she said that something get inside my eye and after that I have double vision.
Here is the photographs of the movement of the left eye. We can see very important limitation for the up and down movement. Another kind we can see the one position for the photograph. And yes, she has a little proptosis. We ask for tomography and we can see a mass, excellent and very well-defined, that appears in the same position in the actual projection and here is pushing the eyeball. But the medial wall is not altered and in the sagittal projection, it continues the same form of the mass. It’s not a tumor. We know that. But it’s a foreign body that we should remove.
We are going to arrive making a suture in the grey line of the eyelid. After that, we separate the tissues onto the floor of the orbit. Very carefully, to not make another incision in the skin. And with a lot of care, because remember, we have an eyeball there, we have a foreign body. And we have it, finally. It’s a marble. I don’t know how the marble gets in, but we must believe the girl that something got inside the eye. And after that we close the retractors to both of the tarsals with vicryl 6.0. And it’s a good result. We have here the photograph, she arrives in this condition and at 15 days after surgery she’s recovering the position of the eyeball and eyelid.
For the roof approach or intracameral approach, we have to ask some help from neurosurgery service because here we have an astrocytoma. We have a resonance that shows that a mass is getting inside the orbit and it’s a little boy of three-years-old. In this situation, the ophthalmologist cannot get inside alone. We must have a multidisciplinary team that help us. Most of the time we go together with neurosurgery. Here other doctors, dermatologists, because it’s a very different approach, it’s not for ophthalmologists. In this photograph, we have the craniotomy and it’s a very good way to arrive to the orbit. Obviously, it’s a bigger surgery, more time, more risks, but somebody has to do it. And the ophthalmologist can’t do it alone. It’s very important to always note that you can ask for some help to be sure that your patients are going to be in excellent conditions.
And finally the transcaruncular approach for masses that are in the medial wall. Oh, sorry for the audio. Here we are putting some epinephrine in the conjunctiva. After that, very carefully, we’re going to arrive to the caruncle. Very carefully, because remember we have there a major muscle and we don’t have to ask for the attention of the strabismus service.
For example, this little baby of two days old, I mean, it’s a newborn baby. She arrives with this cellulitis problem, proptosis, ptosis, chemosis, limitation of the movement of the right eye. And in the tomography we can see a mass that is occupating the orbital wall in the medial wall of the right orbit. It’s pushing the eyeball, it’s touching the medial rectus and if you see in the other orbit, there is an abscess too. It’s not an abscess, it’s the lacrimal sac. So this little guy has congenital obstruction of the lacrimal system but in a severe way, severe presentation. It’s not a tumor, a real tumor, but it’s a mass that is located in the medial wall. We must arrive in a way that is not to make healing or a scar in a guy so young. It’s a very good moment to arrive transconjunctival.
Here’s the video. With the tomography we know that the brain is safe and in a transcaruncular way, we arrive to the abscess, it’s a lot of secretion. It was four millimeters of secretion. And just one day before surgery, you can see this little baby in an excellent condition, just one day before. It’s not a tumor, but it’s a very good way to use the transcaruncular approach.
This is an another regular case that we have. Another time I insist this tumor is not affecting the movement and the visual acuity of this little girl. But imagine this little girl in the school. Obviously, in an emotional form, this tumor is affecting a lot. So that’s why we accept to treat them even if it’s cosmetic.
This girl, eight-years-old, another situation of proptosis. It was a hemangiolymphangioma. After surgery, 15 days after, this little girl she has 20/20 of visual acuity with no problems of movement of the eyes. The eyelid is in good position, a little edema, inflammation of the inferior eye. But for 15 days after surgery, I think it’s a good result.
In this image, this patient has 10-years-old, this little girl. If you can see the image, the left, see the expression, the expression says a lot. Another time, the visual acuity is well but see the picture in the right hand, see how the expression, how this might be different, their confidence is different. This little girl she had a hemangiolymphangioma, they treated with sclerosant therapy with no image study. They provoked a telecanthus, they provoked ptosis, and they provoked strabismus. With the scar, we are going to ask for dermatology service help. But in the right image we can see that we fixed the telecanthus, the ptosis, and the strabismus. And now she’s happier than before.
Sorry about this case, but it’s important to mention that not most of the times, in few cases, in a few very sad cases, we have this situation. This girl, 12-years-old, arrived to the service with a history of two weeks of proptosis in right eye and loss of vision. We proposed to the family to make a biopsy to get inside with general anesthesia. The family didn’t want to accept the general anesthesia even not local anesthesia for biopsy and they only goes out of the hospital. After that, two weeks after that first visit, the girl arrives with this huge proptosis, chemosis, no vision at all, corneal ulceration. And here we have the first resonance that we saw and why we proposed to get inside and get a biopsy. The biopsy was Ewing sarcoma and we should make an mutilation and make some variations to enucleation surgery, a thorough exenteration because the tumor was so, so big and arriving to the brain.
These cases, they don’t have to be present in 2021. But unfortunately we are going to see it in communities with no health access or in communities with different cultural ways to see the light. This girl arrived in a good moment and the family didn’t accept the treatment. At the end we have to do this mutilate surgery, we don’t want to do that, we don’t like to do that, but you have to be prepared because it could arise.
At the end, it’s very important, most for the beginners, always take pictures. Take pictures, always. For two reasons, you’re going to have a very good file and very good material for future conferences. You are going to have your gallery of good prognosis and good cases. But you have to take pictures because most of the time you can have later problems and you have that file, you have the photographs before, during and after surgeries, you’re going to be protected. Always, always, please everybody have an intake form so that you can take the pictures and be safe.
Another very important point is to have radiology before surgery, always. Even if you have that idea that it’s a common dermoid cyst, that it’s very common, it’s benign, it’s not a big deal. Always ask for radiology images. And, another point is everything must go to histopathology examination. Maybe it’s obvious, but even if you’re tired, I know, altered vision, a little mass in the eyelid, a little mass in skin, always, even if it looks very simple, very not offensive, always send everything to histopathology examination.
Very important to have a multidisciplinary approach. Imagine this little girl with Ewing sarcoma, or the other girl with leukemia, or Langerhans cells histopathology. We are ophthalmologists, we have to be sure that the eyes are perfect, that the visual acuity is fine. But remember that we are not only eyes with legs, we are a complete body, we have to be with very huge equipment of good doctors like oncology, histology service, pediatrics, endocrinology, to get the attention that the patient should have.
And remember that every patient is unique, as you saw, most of the tumors could be similar and you can say, “Oh, it’s easy, it’s the same approach.” It’s not a cuisine recipe, you have to be very ethic to think that every patient is a unique and special case that you have to treat in a very important way as the patient was your family member. And do not forget that Hippocrates said, “Primum non nocere.” If you can do that something always you can ask for help. This is the end of my presentation and now I’m going to answer a few questions.
You have some questions. Approach to the posterior intracranial orbit apex tumors? Well, I think I said it. Usually we get the mass through a combination of temporal, maybe eyelid sulcus and floor approaches. If these options or combined approaches aren’t enough, we must ask some help of neurosurgery service, as we did in the astrocytoma case.
What’s the diagnosis and management of an intraocular tumor originating from the optic disc? Well, for intraocular tumors in Mexico City, Mexico City, they use brachytherapy therapy and intraocular chemotherapy. But here in Guadalajara, we don’t have that options. Most of the time these patients with intraocular malignant tumors we have to send it to Mexico City to the National Pediatric Institute. Because here, unfortunately, we don’t have that options.
Another question, do you have any experience with hydatid cyst of the orbit? With hydatid cysts, I don’t have any experience because here in Mexico it’s not an endemic zone for echinococcus granulosus. In addition, this kind of cyst, they are most common, more frequent in liver. Even the 70% of these cases are liver and 20% are in lung. So it’s not very common to find it in the orbit. But I have not had this kind of cases because here in Mexico we don’t have endemic zones of that parasite.
Another question in the nasal approach, well, I don’t have it in my hospital, unfortunately, we don’t have endoscopic equipment. My hospital is the most bigger hospital in the west zone of my country. We accept patients from the north, east and a little bit south of Mexico. It’s a public hospital for the people that doesn’t have any kind of medical insurance. If we want to make an endoscopic approach, the patient has to pay for it. And most of the time our patients don’t have that money.
Some of these questions of Graves orbitopathy surgical decompression. I didn’t touch Graves orbitopathy. But in a surgical decompression, we can make fat or bone decompression internal and extraconal fat decompression and they work very well. And we can make bone decompression of the lateral, I like to do lateral and temporal, temporal and medial wall. Because it’s going to give you even five millimeters of changing in the orbital exophthalmometry without the risk of provoking diplopia. Because remember that if you touch the floor, you can have the risk of making diplopia for the patient. In several cases we have to make far the decompression and the three walls decompression too.
Another question. How can we diagnose melanoma? Well, for choroidal melanoma we use alterialgraphy and choriography in A and B mode. But if you find the melanoma in the eyelids, so in the conjunctiva, the diagnosis is clinical. And for the treatment, remember in brachytherapy in Mexico City. And here for the decision of the lesion, we can remove the mass or the lesion with five millimeters beyond, to be sure that we’re not going to be residual. After that we send it to the oncology service.
A ha, this is a very good question. What we have four minutes. How does your management change with pediatrics? Well, if you see the cases, I have young and adult patients. For pediatrics, the technique is almost the same. But in children we must be very historic for the movement we saw and the eye position. If we have a secondary ptosis of their surgery, we must repair it as soon as possible because remember, that these pediatric patients can develop an amblyopia or lazy eye. All the post surgery patient, all the post surgery pediatric patients must have a stioscapy or visual therapy they need that, it’s necessary. Because if we don’t have to affect the visual acuity for the future in these patients.
Remember too that the children get more inflammation, so we have to be careful with a very different technique. And I like to use vicryl closing the skin because maybe it will be like redness or more edema, but I don’t like to bother the children after surgery to retie the sutures. It’s up to you, you can use Prolene, nylon, but in my personal side, I prefer to use vicryl because after that the suture is going to fall down alone and I don’t want to bother another time, put in stress, this little child.
I think we have two minutes. Okay. Orbital tumor surgery tips for beginners. Well, I said that. Always take pictures, always have a very good radiology team for the images. Multidisciplinary approach and you can do that as personal help.
Another question, rare presentation of a common tumor? I remember a dermoid cyst in a five-year-old girl. It was not the common presentation of the mass in the eyebrow. It was not like the girl in the video. The tumor was inside the orbit, attached to the temporal wall, pushing the eyeball, provoking limitation of the movement and diplopia. And when we sent the tumor to histopathology service they said that it was a dermoid cyst. But it was not the regular form, it was not well-defined. This was not a relation to see that it was not a cuisine recipe. We have to afford the patient in an individual and particular form.
Well, what else? This is important. What will we do if the tumor cannot remove all? Well, we must remember that removing a tumor is for diagnosis and treatment. If you cannot remove it completely, you are going to have at the end, based on pathology result. And with the histopathology diagnosis you can offer then other treatment options that could eliminate the rest of the tumor. Always is better to wait for a diagnosis than to damage the tissue that is surrounding the tumor or damage the eyeball or damage the muscles of the optic nerve.
I think we are in time. Thank you all for being here in this moment. If you have more questions after the presentation, you saw my Instagram direction: Oftalmologa_marisol. And I’m here to help you if you need some tips or some opinions. Thank you very much for your attention.