Vertical Diplopia and Ptosis from Removal of the Orbital Roof in Pterional Craniotomy

Overview

Journal Ophthalmology

Publisher Elsevier

Specialty Ophthalmology

Date 2014 Dec 3

PMID 25439610

Citations 4

Authors

Shilpa J Desai

Michael T Lawton

Michael W McDermott

Jonathan C Horton

Affiliations

Soon will be listed here.

Abstract

Purpose: To describe a newly recognized clinical syndrome consisting of ptosis, diplopia, vertical gaze limitation, and abduction weakness that can occur after orbital roof removal during orbito-zygomatic-pterional craniotomy.

Design: Case series.

Participants: Eight study patients (7 women), 44 to 80 years of age, with neuro-ophthalmic symptoms after pterional craniotomy.

Methods: Case description of 8 study patients.

Main Outcome Measures: Presence of ptosis, diplopia, and gaze limitation.

Results: Eight patients had neuro-ophthalmic findings after pterional craniotomy for meningioma removal or aneurysm clipping. The cardinal features were ptosis, limited elevation, and hypotropia. Three patients also had limitation of downgaze and 2 patients had limitation of abduction. Imaging showed loss of the fat layers that normally envelop the superior rectus and levator palpebrae superioris. The muscles appeared attached to the defect in the orbital roof. Ptosis and diplopia developed in 2 patients despite Medpor titanium mesh implants. Deficits in all patients showed spontaneous improvement. In 2 patients, a levator advancement was required to repair ptosis. In 3 patients, an inferior rectus recession using an adjustable suture was performed to treat vertical diplopia. Follow-up a mean of 6.5 years later revealed that all patients had a slight residual upgaze deficit, but alignment was orthotropic in primary gaze.

Conclusions: After pterional craniotomy, ptosis, diplopia, and vertical gaze limitation can result from tethering of the superior rectus-levator palpebrae superioris complex to the surgical defect in the orbital roof. Lateral rectus function sometimes is compromised by muscle attachment to the lateral orbital osteotomy. This syndrome occurs in approximately 1% of patients after removal of the orbital roof and can be treated, if necessary, by prism glasses or surgery.

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References

Kaeser P, Klainguti G . Management of diplopia secondary to neurosurgical injury of the orbital roof. Klin Monbl Augenheilkd. 2008; 225(5):507-9. DOI: 10.1055/s-2008-1027312. View

Roberts C, Murphy M, Adams G, Lund V . Strabismus following endoscopic orbital decompression for thyroid eye disease. Strabismus. 2004; 11(3):163-71. DOI: 10.1076/stra.11.3.163.16652. View

McDermott M, Durity F, Rootman J, Woodhurst W . Combined frontotemporal-orbitozygomatic approach for tumors of the sphenoid wing and orbit. Neurosurgery. 1990; 26(1):107-16. DOI: 10.1097/00006123-199001000-00015. View

Inci S, Ozgen T . Multiple aneurysms of the anterior communicating artery: radiological and surgical difficulties. J Neurosurg. 2005; 102(3):495-502. DOI: 10.3171/jns.2005.102.3.0495. View

Bartley J, Eagleton N, Rosser P, Al-Ali S . Superior oblique muscle palsy after frontal sinus mini-trephine. Am J Otolaryngol. 2011; 33(1):181-3. DOI: 10.1016/j.amjoto.2011.04.008. View

Kerr N . Fat adherence syndrome: an animal model. J AAPOS. 2004; 8(4):349-56. DOI: 10.1016/j.jaapos.2004.04.005. View

Paridaens D, Hans K, van Buitenen S, Mourits M . The incidence of diplopia following coronal and translid orbital decompression in Graves' orbitopathy. Eye (Lond). 1999; 12 ( Pt 5):800-5. DOI: 10.1038/eye.1998.207. View

Horikoshi T, Nukui H, Mitsuka S, Kaneko M . Partial resection of the gyrus rectus in pterional approach to anterior communicating artery aneurysms. Neurol Med Chir (Tokyo). 1992; 32(3):136-9. DOI: 10.2176/nmc.32.136. View

Bhatti M, Schmalfuss I, Mancuso A . Orbital complications of functional endoscopic sinus surgery: MR and CT findings. Clin Radiol. 2005; 60(8):894-904. DOI: 10.1016/j.crad.2005.03.005. View

10.

YASARGIL M, Fox J . The microsurgical approach to intracranial aneurysms. Surg Neurol. 1975; 3(1):7-14. View

11.

Kashimura H, Kubo Y, Ogasawara K, Kakino S, Yoshida K, Ogawa A . Easy dissection of the interhemispheric fissure for treatment of the anterior communicating artery aneurysm by the pterional approach. World Neurosurg. 2010; 73(6):688-90. DOI: 10.1016/j.wneu.2010.02.064. View

12.

AlDekhayel S, Aljaaly H, Fouda-Neel O, Shararah A, Zaid W, Gilardino M . Evolving trends in the management of orbital floor fractures. J Craniofac Surg. 2014; 25(1):258-61. DOI: 10.1097/SCS.0000000000000441. View

13.

Madhugiri V, Ambekar S, Pandey P, Guthikonda B, Bollam P, Brown B . The pterional and suprabrow approaches for aneurysm surgery: a systematic review of intraoperative rupture rates in 9488 aneurysms. World Neurosurg. 2013; 80(6):836-44. DOI: 10.1016/j.wneu.2013.02.072. View

14.

Moore A, Buncic J, Munro I . Fibrous dysplasia of the orbit in childhood. Clinical features and management. Ophthalmology. 1985; 92(1):12-20. DOI: 10.1016/s0161-6420(85)34071-x. View

15.

Altay T, Couldwell W . The frontotemporal (pterional) approach: an historical perspective. Neurosurgery. 2012; 71(2):481-91. DOI: 10.1227/NEU.0b013e318256c25a. View

16.

Mehta P, Durrani O . Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated orbitopathy: a new technique and results of a case series. Orbit. 2011; 30(6):265-8. DOI: 10.3109/01676830.2011.603456. View

17.

Siracuse-Lee D, Kazim M . Orbital decompression: current concepts. Curr Opin Ophthalmol. 2002; 13(5):310-6. DOI: 10.1097/00055735-200210000-00004. View

18.

Goisis M, Biglioli F, Guareschi M, Frigerio A, Mortini P . Fibrous dysplasia of the orbital region: current clinical perspectives in ophthalmology and cranio-maxillofacial surgery. Ophthalmic Plast Reconstr Surg. 2006; 22(5):383-7. DOI: 10.1097/01.iop.0000229761.37416.3e. View

19.

Hyun S, Hong S, Kim J . Side selection of the pterional approach for superiorly projecting anterior communicating artery aneurysms. J Clin Neurosci. 2010; 17(5):592-6. DOI: 10.1016/j.jocn.2009.09.024. View

20.

Brooks S, Yu J, Preston D, Johnson M . Restricted ocular motility after orbital trauma--studies with an animal model. J AAPOS. 1999; 2(4):246-52. DOI: 10.1016/s1091-8531(98)90060-x. View