Kazim, Michael

Purpose: To determine the clinical utility of the assessment of preoperative orbital compliance in predicting the amount of postoperative proptosis reduction in patients with stable-phase thyroid eye disease who undergo orbital fat decompression surgery. Methods: A retrospective chart review was conducted of stable-phase thyroid eye disease patients who underwent orbital fat decompression by a single surgeon. Orbital compliance was measured preoperatively as axial globe displacement (in millimeters) using a Hertel exophthalmometer. Displacement ≥2.5 mm was classified as high compliance and <2.5 mm as low compliance. Radiographic thyroid eye disease type, preoperative proptosis, and intraoperative fat volume removed were recorded. Linear regression analysis determined whether orbital compliance independently predicted postoperative proptosis reduction. Levene’s test assessed variability between groups. Results: Forty-six orbits from 24 patients were included, 15 orbits with low compliance and 31 with high orbital compliance. Patients with high orbital compliance had a mean postoperative proptosis reduction of 3.19 mm (range 0.5–6.0 mm) while patients with low orbital compliance had a mean proptosis reduction of 2.67 mm (range 2.0–3.5 mm). On average, higher preoperative orbital compliance led to 0.959 mm greater proptosis reduction compared with low orbital compliance, when accounting for radiographic thyroid eye disease type and volume of fat removed intraoperatively ( p = 0.048). Variability in proptosis reduction was higher among the high orbital compliance group ( p = 0.00085). Conclusions: Higher preoperative orbital compliance results in greater proptosis reduction. However, patients with high orbital compliance have greater variability in proptosis reduction, suggesting that surgical outcomes are less predictable among these patients.

Purpose: This study assesses intersurgeon variability in proptosis reduction after orbital decompression for thyroid eye disease. Methods: This multicenter retrospective study included patients with thyroid eye disease who underwent orbital decompression from 1 of 7 surgeons at 7 different institutions between January 2002 and December 2018. Data were included if a single decompression technique was performed on ≥10 patients by ≥2 surgeons. The primary outcome was postoperative change in proptosis with emphasis on comparison among surgeons utilizing similar surgical techniques. Statistical analysis was performed with χ 2 and ANOVA testing, and a multivariable logistic regression model was generated. Results: Six hundred thirty-three orbits that underwent orbital decompression were included. Five different decompression techniques were analyzed: medial wall (n = 29), fat + lateral wall (n = 113), medial wall + floor (n = 123), fat + lateral wall + medial wall (n = 140), and fat + lateral wall + medial wall + floor (n = 228), without significant difference in proptosis reduction among surgeons. Surgeons did not demonstrate significant differences in outcomes at different time points compared with each other or themselves. Outcomes when comparing endoscopic versus open medial wall decompression varied among surgery types. Multivariate modeling revealed a statistically significant association between postoperative change in proptosis with preoperative proptosis ( p < 0.001). Conclusions: Postoperative change in proptosis did not differ significantly between surgeons utilizing similar orbital decompression techniques for patients with thyroid eye disease. This study may strengthen the statistical validity of multicenter clinical trials assessing orbital decompression outcomes performed by surgeons employing uniform surgical techniques, thereby advancing our understanding of optimal surgical management strategies for thyroid eye disease.

Purpose: To determine treatment outcomes, recurrence rates, and predictors of recurrence, to inform future therapeutic approaches for spheno-orbital meningiomas (SOM). Methods: A retrospective single-center study of SOM treated from 1990 to 2021 was conducted with comprehensive neuro-ophthalmologic follow-up at Columbia University Medical Center (CUMC). Recurrence requiring reintervention was defined clinically as worsening of visual acuity, visual field defect, or ocular motility after an initial period of stabilization or 6 months of improvement following treatment, or radiologically as either a regrowth with an increase in tumor size by 20% at the site of previous growth or a new region of tumor growth. Results: In total 46 patients met the inclusion criteria. The mean follow-up was 106 months (range 1–303). Dictated by the phenotype of the disease, patients underwent either gross- (50%), near- (17%), or subtotal resection (26%). Removal of the anterior clinoid process (ACP) was performed in 52% of patients. Nine patients (20%) required an enucleation or exenteration. Radiotherapy was employed at some point of treatment in 50% of cases. Inherited cases (24%) were referred to CUMC for treatment following 1 or more recurrences. The total recurrence rate, including inherited cases, was 54%, occurring at a mean interval of 43 months. The recurrence rate of patients treated solely at CUMC was 40%, occurring at a mean interval of 41 months. A subset of patients (32%) had 2 or more recurrences. Histopathology at the first surgery was WHO grade I (87%) and II (13%) and at the final surgery was WHO grade I (74%), II (21%), and III (4%). A subset of grade I tumors that received radiotherapy (35%) evolved to a higher grade or developed multiple recurrences without a change in histologic grade I. Grade II tumors and treatment with radiotherapy increased the odds of recurrence. Removal of the ACP and gross total resection decreased the odds of recurrence. Conclusion: Due to the routinely long interval to tumor recurrence, lifelong surveillance of patients with SOM is prudent. ACP resection and gross total resection, where possible, reduce tumor recurrence and the need for further treatment. Radiotherapy should be reserved for higher-grade meningiomas and select grade I tumors.

Purpose: To identify risk factors for the development of new-onset, postoperative diplopia following orbital decompression surgery based on patient demographics, clinical exam characteristics, radiographic parameters, and surgical techniques. Methods: We conducted a multi-center retrospective chart review of patients who underwent orbital decompression for thyroid eye disease (TED). Patient demographics, including age, gender, smoking history, preoperative exophthalmometry, clinical activity score (CAS), use of peribulbar and/or systemic steroids, and type of orbital decompression were reviewed. Postoperative diplopia was determined at a minimum of 3 months postoperatively and before any further surgeries. Cross-sectional area ratios of each extraocular muscle to orbit and total fat to orbit were calculated from coronal imaging in a standard fashion. All measurements were carried out using PACS imaging software. Multivariable logistic regression modeling was performed using Stata 14.2 (StataCorp, College Station, TX). Results: A total of 331 patients without preoperative diplopia were identified. At 3 months postoperatively, 249 patients had no diplopia whereas 82 patients developed diplopia. The average postoperative follow-up was 22 months (range 3–156) months. Significant preoperative clinical risk factors for postoperative diplopia included older age at surgery, proptosis, use of peribulbar or systemic steroids, elevated clinical activity score, and presence of preoperative compressive optic neuropathy. Imaging findings of enlarged cross-sectional areas of each rectus muscle to the overall orbital area also conferred a significant risk of postoperative diplopia. Regarding surgical factors, postoperative diplopia was more common among those undergoing medial wall decompression, bilateral orbital surgery, and balanced decompression, whereas endoscopic medial wall decompression was found to be relatively protective. Conclusions: This study identifies risk factors associated with the development of diplopia following orbital decompression using multivariable data. This study demonstrates that several characteristics including age, clinical activity score, the cross-sectional muscle to orbit ratios, in addition to the type of orbital decompression surgery, are predictive factors for the development of new-onset postoperative diplopia.

Purpose: To morphologically describe and mathematically quantify a novel clinical feature of thyroid eye disease (TED). Methods: A retrospective study was conducted of TED patients and age-sex-matched normal controls. The arched Rainbow Brow appearance in TED patients was determined by unanimous agreement of 3 oculoplastic surgeons. Eyebrow curvature was assessed by plotting 15 points along the eyebrow in ImageJ. The fourth-degree polynomial (y = ax4 + bx3 + cx2 + dx + e) was fitted to each eyebrow. Results: Two hundred seventy-one eyes were analyzed (200 TED and 71 age-sex-matched normal controls). A Rainbow Brow was identified in 42% of TED patients. A unilateral Rainbow Brow was seen in 15% of patients. The fourth-degree polynomial coefficients yielded significant differences between Rainbow Brow patients and age-sex-matched normal controls for the coefficients a, b, c, and d. Similar analysis of TED patients with and without a Rainbow Brow showed differences in coefficients a and b. Age >50 years (p = 0.009) and the presence of brow fat expansion (p < 0.001) were associated with the presence of a Rainbow Brow. Proptosis >24 mm showed a trend toward association with the presence of a Rainbow Brow (p = 0.057). When considering the contribution of these features in a multivariable analysis, only brow fat expansion was a significant contributing factor (p = 0.009). Conclusions: The Rainbow Brow is a distinct entity in TED and is likely consequent to brow fat pad expansion. Patients with a Rainbow Brow have different eyebrow curvature as compared to both normal age-sex-matched controls and TED patients without a Rainbow Brow.

Abstract Introduction Middle turbinate resection (MTR) is commonly performed during endonasal endoscopic sinus and skull base surgery. Objective The purpose of this study was to characterize the additional orbital soft-tissue volume expansion during endoscopic medial orbital wall decompression with adjunctive MTR. Methods A retrospective review of patients who underwent endoscopic medial wall decompression with MTR was performed. The imaging software AW (GE Healthcare, Chicago, IL, USA) was used to overlay pre and postoperative orbital computed tomography (CT) images to visualize the preoperative position of the middle turbinate and the postoperative orbital soft tissue in the ethmoid bed. The imaging software Vitrea (Vital Images Inc., Minnetonka, MN, USA) was used to manually segment postoperative scans to determine the volume of orbital tissue which had filled the space previously occupied by the middle turbinate or medial to it. Results Nine orbits from 5 patients were included in this study; all patients were female with a history of hyperthyroidism. The average age was 55.6 years (range 32–74). Of the 9 orbits, 7 (78%) had orbital soft tissue within the space of the resected middle turbinate postoperatively. The average volume of orbital tissue within or medial to this space was 0.83 +/− 0.67 cc. No patients had any postoperative complications. Conclusions In this patient cohort, adjunctive middle turbinate resection for endoscopic medial orbital wall decompression added ∼ 0.83 cc of volume for orbital soft tissue after medial wall decompression. Middle turbinate resection is a useful adjunct to the orbital surgeon's armamentarium to augment the results of a medial orbital decompression for select patients.

AbstractThe aim of the study is to describe a mathematical model for analyzing eyebrow curvature that can be applied broadly to curvilinear facial features. A total of 100 digital images (50 men, 50 women) were obtained from standardized headshots of medical professionals. Images were analyzed in ImageJ by plotting either 8 or 15 points along the inferior-most row of contiguous brow cilia. A best-fit curve was automatically fit to these points in Microsoft Excel. The second derivative of the second-degree polynomial and a fourth-degree polynomial were used to evaluate brow curvature. Both techniques were subsequently compared with each other. A second-degree polynomial and fourth-degree polynomial were fit to all eyebrows. Plotting 15 points yielded greater goodness-of-fit than plotting 8 points along the inferior brow and allowed for more sensitive measurement of curvature across all images. A fourth-degree polynomial function provided a closer fit to the eyebrow than a second-degree polynomial function. This method provides a simple and reliable tool for quantitative analysis of eyebrow curvature from images. Fifteen-point plots and a fourth-degree polynomial curve provide a greater goodness-of-fit. The authors believe the described technique can be applied to other curvilinear facial features and will facilitate the analysis of standardized images.

Purpose: Well-differentiated neuroendocrine or carcinoid tumors are found most commonly in the gastrointestinal tract. When metastatic to the orbit, they tend to have a propensity for the extraocular muscles. The purpose of this study was to better understand the diversity in presentation of orbital carcinoid disease and to determine predictors for survival. Methods: In this observational cross-sectional cohort study, data from 8 tertiary orbital practices were compiled. Demographic, clinical, pathologic, American Joint Committee on Cancer stage and grade, imaging, and management data were extracted for all the patients. Descriptive statistics were calculated. Subgroups were compared utilizing analysis of variance analyses and Kaplan–Meier curves. Time to progression and disease-specific and overall mortality were calculated. Comparisons were performed for the following a priori pairs: unknown versus known primary tumor, single versus multiple extraocular muscle involvement, unilateral versus bilateral orbital disease, extraocular muscle versus other orbital involvement, and excisional versus incisional surgery. Results: A total of 28 patients with carcinoid tumors of the orbit were identified. Of these, 57.1% of patients were female, the mean age at diagnosis of the primary tumor was 58.8 years and the mean age at diagnosis of orbital disease was 62.6 years. At primary presentation, all patients were American Joint Committee on Cancer stage III or IV and 21.4% demonstrated carcinoid syndrome. Muscle involvement was noted in 78.6% of patients, and of these, 72% were noted to have single muscle disease. Eight patients had no primary tumor identified; 3 of these 8 demonstrated disseminated disease at the time of diagnosis. The overall 5-year survival rate was 81.8% from diagnosis of primary tumor and 50% from diagnosis of orbital disease. Subgroup analysis revealed that patients with unilateral orbital disease when compared with bilateral orbital disease had a longer progression-free survival and time to death from all causes ( p = 0.025). Patients with disease localized to the orbit at presentation had longer time to death than those with disseminated disease. Treatment with surgery, radiation, or octreotide did not appear to affect survival. Patients managed with systemic chemotherapy had a shorter time of survival than the rest of the group. All other subgroup comparisons were not found to be statistically significant. Conclusions: Neuroendocrine tumors of the orbit represent a wide spectrum of disease, with some cases being part of disseminated disease, while others being localized presentations. This heterogeneity may be responsible for the slightly higher overall survival in these patients than others with metastatic carcinoid tumors in other locations.