2019-2020 BCSC (Basic and Clinical Science Course), Section 07: Oculofacial Plastic and Orbital Surgery (MAJOR REVISION)

377 Pages·2019·138.117 MB·English

by  American Academy of Ophthalmology, Bobby S. Korn MD PhD (editor)

77
Oculofacial Plastic and
Orbital Surgery
2019–2020
(cid:2)BCSC
Basic and Clinical
Science Course™
Published after collaborative
review with the European Board
of Ophthalmology subcommittee
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The American Academy of Ophthalmology is accredited by the Accreditation Council for Con-
tinuing Medical Education (ACCME) to provide continuing medical education for physicians.
The American Academy of Ophthalmology designates this enduring material for a maximum of
10 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with
the extent of their participation in the activity.
CME expiration date: June 1, 2022. AMA PRA Category 1 Credits™ may be claimed only once be-
tween June 1, 2019, and the expiration date.
BCSC® volumes are designed to increase the physician’s ophthalmic knowledge through study and
review. Users of this activity are encouraged to read the text and then answer the study questions
provided at the back of the book.
To claim AMA PRA Category 1 Credits™ upon completion of this activity, learners must demon-
strate appropriate knowledge and participation in the activity by taking the posttest for Section 7
and achieving a score of 80% or higher. For further details, please see the instructions for requesting
CME credit at the back of the book.
The Academy provides this material for educational purposes only. It is not intended to represent the
only or best method or procedure in every case, nor to replace a physician’s own judgment or give
specific advice for case management. Including all indications, contraindications, side effects, and
alternative agents for each drug or treatment is beyond the scope of this material. All information and
recommendations should be verified, prior to use, with current information included in the manufac-
turers’ package inserts or other independent sources, and considered in light of the patient’s condition
and history. Reference to certain drugs, instruments, and other products in this course is made for
illustrative purposes only and is not intended to constitute an endorsement of such. Some material
may include information on applications that are not considered community standard, that reflect
indications not included in approved FDA labeling, or that are approved for use only in restricted
research settings. The FDA has stated that it is the responsibility of the physician to determine
the FDA status of each drug or device he or she wishes to use, and to use them with appropriate,
informed patient consent in compliance with applicable law. The Academy specifically disclaims
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all claims that may arise from the use of any recommendations or other information contained herein.
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Cover image: From BCSC Section 9, Uveitis and Ocular Inflammation. Large mutton-fat keratic precipi-
tates in a patient with sarcoidosis. (Courtesy of Debra Goldstein, MD.)
Copyright © 2019 American Academy of Ophthalmology. All rights reserved. No part of
this publication may be reproduced without written permission.
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Basic and Clinical Science Course
Louis B. Cantor, MD, Indianapolis, Indiana, Se nior Secretary for Clinical
Education
Christopher J. Rapuano, MD, Philadelphia, Pennsylvania, Secretary for
Lifelong Learning and Assessment
Colin A. McCannel, MD, Los Angeles, California, BCSC Course Chair
Section 7
Faculty for the Major Revision
Bobby S. Korn, MD, PhD, Chair, La Jolla, California
Cat N. Burkat, MD, Madison, Wisconsin
Keith D. Car ter, MD, Iowa City, Iowa
Julian D. Perry, MD, Cleveland, Ohio
Pete Setabutr, MD, Chicago, Illinois
Eric A. Steele, MD, Portland, Oregon
M. Reza Vagefi, MD, San Francisco, California
The Acad emy wishes to acknowledge the American Society of Ophthalmic Plastic and Re-
constructive Surgery (ASOPRS) for recommending faculty members to the BCSC Section 7
committee.
The Acad emy also wishes to acknowledge the following committees for review of this
edition:
Committee on Aging: Claudia M. Prospero Ponce, MD, Houston, Texas
Vision Rehabilitation Committee: Terry L. Schwartz, MD, Cincinnati, Ohio
Practicing Ophthalmologists Advisory Committee for Education: Stephen R. Klapper, MD,
Primary Reviewer, Carmel, Indiana; Bradley D. Fouraker, MD, Chair, Tampa, Florida;
Alice Bashinsky, MD, Asheville, North Carolina; David J. Browning, MD, PhD, Charlotte,
North Carolina; Cynthia S. Chiu, MD, Oakland, California; Steven J. Grosser, MD, Golden
Valley, Minnesota; Troy M. Tanji, MD, Waipahu, Hawaii; Michelle S. Ying, MD, MSPH,
Ladson, South Carolina
The Acad emy also wishes to acknowledge the following committee for assistance in devel-
oping Study Questions and Answers for this BCSC Section:
Self- Assessment Committee: Jurij R. Bilyk, MD, Philadelphia, Pennsylvania; Todd A. Good-
glick, MD, Chevy Chase, Mary land; Renzo A. Zaldivar, MD, Morrisville, North Carolina
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Eu ro pean Board of Ophthalmology: Peter J. Ringens, MD, PhD, EBO-B CSC Program Liai-
son, Maastricht, Netherlands; Peter P. M. Raus, MD, EBO Chair for BCSC Section 7, Geel,
Belgium; Lelio Baldeschi MD, PhD, Bruxelles, Belgium; Maria Borrelli, MD, Naples, Italy;
Paul M. Jonckheere, MD, Antwerp, Belgium; Ilse Mombaerts, Prof. Dr, Leuven, Belgium
Financial Disclosures
Acad emy staff members who contributed to the development of this product state that
within the 12 months prior to their contributions to this CME activity and for the dura-
tion of development, they have had no financial interest in or other relationship with any
entity discussed in this course that produces, markets, resells, or distributes ophthalmic
health care goods or ser vices consumed by or used in patients, or with any competing
commercial product or ser vice.
The authors and reviewers state that within the 12 months prior to their contributions
to this CME activity and for the duration of development, they have had the following
financial relationships:*
Dr Burkat: Horizon Pharma (C)
Dr Browning: Aerpio Therapeutics (S), Alcon Laboratories (S), Alimera Sciences (C),
Emmes (S), Genentech (S), Novartis Phar ma ceu ti cals (S), Ohr Phar ma ceu ti cal (S), Pfizer
(S), Regeneron Phar ma ceu ti cals (S), Springer (P), ZEISS (O)
Dr Fouraker: Addition Technology (C, L), Alcon Laboratories (C, L), OASIS Medical
(C, L)
Dr Grosser: InjectSense (O), Ivantis (O)
Dr Klapper: AdOM Advanced Optical Technologies (O)
Dr Korn: Elsevier (P), Horizon Pharma (C), Kaneka Pharma (C), Mallinckrodt Pharm a-
ceu ti cals (C)
Dr Perry: Elsevier (P), US FDA Ophthalmic Devices Panel (C), Lacrimal Drainage Ma-
nometer Patent (P)
The other authors and reviewers state that within the past 12 months prior to their contri-
butions to this CME activity and for the duration of development, they have had no finan-
cial interest in or other relationship with any entity discussed in this course that produces,
markets, resells, or distributes ophthalmic health care goods or ser vices consumed by or
used in patients, or with any competing commercial product or ser vice.
*C = con sul tant fees, paid advisory boards, or fees for attending a meeting; L = lecture fees (honoraria),
travel fees, or reimbursements when speaking at the invitation of a commercial sponsor; O = equity own-
ership/stock options of publicly or privately traded firms (excluding mutual funds) with manufacturers
of commercial ophthalmic products or commercial ophthalmic ser vices; P = patents and/or royalties that
might be viewed as creating a potential conflict of interest; S = grant support for the past year (all sources)
and all sources used for a specific talk or manuscript with no time limitation
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Recent Past Faculty
Vikram D. Durairaj, MD
Jill Annette Foster, MD
Morris E. Hartstein, MD
Marsha C. Kavanagh, MD
Christine C. Nelson, MD
In addition, the Acad emy gratefully acknowledges the contributions of numerous past
faculty and advisory committee members who have played an impor tant role in the devel-
opment of previous editions of the Basic and Clinical Science Course.
American Acade my of Ophthalmology Staff
Dale E. Fajardo, EdD, MBA, Vice President, Education
Beth Wilson, Director, Continuing Professional Development
Ann McGuire, Acquisitions and Development Man ag er
Stephanie Tanaka, Publications Man ag er
Susan Malloy, Acquisitions Editor and Program Man ag er
Jasmine Chen, Man ag er of E- Learning
Beth Collins, Medical Editor
Eric Gerdes, Interactive Designer
Naomi Ruiz, Publications Specialist
Debra Marchi, Permissions Assistant
American Acad emy of Ophthalmology
655 Beach Street
Box 7424
San Francisco, CA 94120-7424
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Contents
General Introduction . . . . . . . . . . . . . . . . . . . . . . . . xv
Introduction to Section 7 . . . . . . . . . . . . . . . . . . . . . . xvii
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PART I Orbit 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 Orbital Anatomy . . . . . . . . . . . . . . . . . . . . . . . . 5
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Dimensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Topographic Relationships. . . . . . . . . . . . . . . . . . . . . . . 6
Roof of the Orbit . . . . . . . . . . . . . . . . . . . . . . . . . 6
Lateral Wall of the Orbit . . . . . . . . . . . . . . . . . . . . . . 6
Medial Wall of the Orbit . . . . . . . . . . . . . . . . . . . . . . 7
Floor of the Orbit . . . . . . . . . . . . . . . . . . . . . . . . . 8
Apertures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Ethmoidal Foramina . . . . . . . . . . . . . . . . . . . . . . . 9
Superior Orbital Fissure . . . . . . . . . . . . . . . . . . . . . . 9
Inferior Orbital Fissure . . . . . . . . . . . . . . . . . . . . . . 9
Zygomaticofacial and Zygomaticotemporal Canals . . . . . . . . . 10
Nasolacrimal Canal . . . . . . . . . . . . . . . . . . . . . . . 11
Optic Canal . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Periorbita . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Intraorbital Optic Nerve . . . . . . . . . . . . . . . . . . . . . 11
Extraocular Muscles and Orbital Fat . . . . . . . . . . . . . . . . 11
Annulus of Zinn . . . . . . . . . . . . . . . . . . . . . . . . 13
Vasculature of the Orbit . . . . . . . . . . . . . . . . . . . . . 14
Lymphatic System of the Orbit . . . . . . . . . . . . . . . . . . 14
Nerves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Lacrimal Gland . . . . . . . . . . . . . . . . . . . . . . . . . 17
Periorbital Structures . . . . . . . . . . . . . . . . . . . . . . . . 19
Nose and Paranasal Sinuses . . . . . . . . . . . . . . . . . . . 19
2 Evaluation of Orbital Disorders . . . . . . . . . . . . . . . 21
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Progression . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Periorbital Changes . . . . . . . . . . . . . . . . . . . . . . . 22
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . 22
Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
vii
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viii (cid:2) Contents
Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Primary Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Computed Tomography . . . . . . . . . . . . . . . . . . . . . 26
Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . 27
Comparison of CT and MRI . . . . . . . . . . . . . . . . . . . 29
Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . 31
Secondary Studies . . . . . . . . . . . . . . . . . . . . . . . . . 31
Venography . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Arteriography . . . . . . . . . . . . . . . . . . . . . . . . . 32
CT and MR Angiography . . . . . . . . . . . . . . . . . . . . 32
Stereotactic Navigation . . . . . . . . . . . . . . . . . . . . . 32
Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Laboratory Studies . . . . . . . . . . . . . . . . . . . . . . . . . 34
3 Congenital Orbital Anomalies . . . . . . . . . . . . . . . 35
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Anophthalmia . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Microphthalmia . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Treatment of Anophthalmia/Microphthalmia . . . . . . . . . . . . . 36
Craniofacial Clefting and Syndromic Congenital
Craniofacial Anomalies . . . . . . . . . . . . . . . . . . . . . . 38
Congenital Orbital Tumors . . . . . . . . . . . . . . . . . . . . . 40
Hamartomas and Choristomas . . . . . . . . . . . . . . . . . . 40
4 Orbital Inflammatory and Infectious Disorders . . . . . 43
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Infectious Inflammation. . . . . . . . . . . . . . . . . . . . . . . 43
Cellulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Necrotizing Fasciitis . . . . . . . . . . . . . . . . . . . . . . . 48
Mycobacterial Infection . . . . . . . . . . . . . . . . . . . . . 50
Zygomycosis . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Aspergillosis . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Parasitic Diseases . . . . . . . . . . . . . . . . . . . . . . . . 53
Noninfectious Inflammation . . . . . . . . . . . . . . . . . . . . . 53
Thyroid Eye Disease. . . . . . . . . . . . . . . . . . . . . . . 53
Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Immunoglobulin G4– Related Disease . . . . . . . . . . . . . . . 66
Nonspecific Orbital Inflammation. . . . . . . . . . . . . . . . . 67
5 Orbital Neoplasms and Malformations . . . . . . . . . . 71
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Vascular Tumors, Malformations, and Fistulas . . . . . . . . . . . . . 71
Infantile (Capillary) Hemangioma. . . . . . . . . . . . . . . . . 71
Lymphatic Malformation. . . . . . . . . . . . . . . . . . . . . 73
Distensible Venous Malformation . . . . . . . . . . . . . . . . . 74
Cavernous Venous Malformation . . . . . . . . . . . . . . . . . 75
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Contents (cid:2) ix
Arteriovenous Malformation . . . . . . . . . . . . . . . . . . . 77
Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . 78
Orbital Hemorrhage. . . . . . . . . . . . . . . . . . . . . . . 80
Neural Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Optic Nerve Glioma . . . . . . . . . . . . . . . . . . . . . . . 80
Neurofibroma . . . . . . . . . . . . . . . . . . . . . . . . . 83
Meningioma . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Schwannoma . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Mesenchymal Tumors. . . . . . . . . . . . . . . . . . . . . . . . 87
Rhabdomyosarcoma. . . . . . . . . . . . . . . . . . . . . . . 87
Miscellaneous Mesenchymal Tumors . . . . . . . . . . . . . . . 89
Lymphoproliferative Disorders . . . . . . . . . . . . . . . . . . . . 91
Lymphoid Hyperplasia and Lymphoma . . . . . . . . . . . . . . 91
Plasma Cell Tumors . . . . . . . . . . . . . . . . . . . . . . . 95
Histiocytic Disorders . . . . . . . . . . . . . . . . . . . . . . 95
Xanthogranuloma. . . . . . . . . . . . . . . . . . . . . . . . 97
Lacrimal Gland Tumors . . . . . . . . . . . . . . . . . . . . . . . 98
Epithelial Tumors of the Lacrimal Gland . . . . . . . . . . . . . . 98
Nonepithelial Tumors of the Lacrimal Gland . . . . . . . . . . . . 101
Secondary Orbital Conditions . . . . . . . . . . . . . . . . . . . . 101
Globe and Eyelid Origin . . . . . . . . . . . . . . . . . . . . . 101
Sinus Disease Affecting the Orbit . . . . . . . . . . . . . . . . . 101
Metastatic Tumors . . . . . . . . . . . . . . . . . . . . . . . . . 104
Metastatic Tumors in Children . . . . . . . . . . . . . . . . . . 104
Metastatic Tumors in Adults . . . . . . . . . . . . . . . . . . . 105
Management of Orbital Metastases . . . . . . . . . . . . . . . . 107
6 Orbital Trauma . . . . . . . . . . . . . . . . . . . . . . . 109
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Midfacial (Le Fort) Fractures . . . . . . . . . . . . . . . . . . . . . 109
Orbital Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Zygomatic Fractures. . . . . . . . . . . . . . . . . . . . . . . 110
Orbital Apex Fractures. . . . . . . . . . . . . . . . . . . . . . 111
Orbital Roof Fractures . . . . . . . . . . . . . . . . . . . . . . 112
Medial Orbital Fractures . . . . . . . . . . . . . . . . . . . . . 112
Orbital Floor Fractures . . . . . . . . . . . . . . . . . . . . . 114
Intraorbital Foreign Bodies . . . . . . . . . . . . . . . . . . . . . 117
Orbital Compartment Syndrome . . . . . . . . . . . . . . . . . . . 118
Traumatic Vision Loss With Clear Media . . . . . . . . . . . . . . . 119
Mass Casualty Incidents . . . . . . . . . . . . . . . . . . . . . . . 122
7 Orbital Surgery . . . . . . . . . . . . . . . . . . . . . . . 123
Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Surgical Spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Orbitotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Superior Approach . . . . . . . . . . . . . . . . . . . . . . . 124
Inferior Approach. . . . . . . . . . . . . . . . . . . . . . . . 126
Medial Approach . . . . . . . . . . . . . . . . . . . . . . . . 127
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