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Vertical lid split approach for optic nerve sheath decompression.

Prabhakaran VC, Selva D - Indian J Ophthalmol (2009 Jul-Aug)

Bottom Line: A vertical lid split incision was used to enter the superomedial orbit and approach the optic nerve sheath.This approach resulted in a successful nerve sheath fenestration, with improvement in the patient's symptoms.The vertical lid split incision provides access to the optic nerve sheath with minimal morbidity and may be an option for optic nerve sheath decompression.

View Article: PubMed Central - PubMed

Affiliation: Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia. eye@health.sa.gov.au

ABSTRACT
We describe a vertical lid split orbitotomy approach to perform optic nerve sheath fenestration which was done in a patient with idiopathic intracranial hypertension. A vertical lid split incision was used to enter the superomedial orbit and approach the optic nerve sheath. This approach resulted in a successful nerve sheath fenestration, with improvement in the patient's symptoms. The vertical lid split incision provides access to the optic nerve sheath with minimal morbidity and may be an option for optic nerve sheath decompression.

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Intraoperative photograph demonstrating approach to the intraconal space via the vertical lid split incision
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Figure 0002: Intraoperative photograph demonstrating approach to the intraconal space via the vertical lid split incision

Mentions: The patient then underwent a left optic nerve sheath fenestration via a superomedial lid split approach. Under general anesthesia, the left upper lid was infiltrated with local anesthetic with 1:200,000 epinephrine to enhance hemostasis. The medial and superior rectus muscles were secured with 4-0 silk traction sutures to permit globe positioning during surgery. A full-thickness vertical incision was made at the junction of the medial and central thirds of the upper lid. Care was taken to remain exactly perpendicular to the lid margin. Straight iris scissors were used to transect the skin, orbicularis and tarsal plate [Fig. 1]. The incision was extended superiorly through the levator aponeurosis and palpebral conjunctiva up to the superior fornix. The incision was then extended through the conjunctival fornix continuing down to the bulbar conjunctiva lateral to the plica. Blunt dissection was then used to enter the superomedial orbit. The tendon of the superior oblique was identified and retracted medially. The intraconal space was entered between the superior rectus and medial rectus muscles [Fig. 2]. The globe was retracted laterally to enhance exposure. The optic nerve sheath was identified and neurosurgical forceps and scissors were used to open a rectangular window in the dural sheath. Hemostasis was obtained. The bulbar and forniceal conjunctiva were reapproximated with 8-0 polyglactin sutures. The lid incision was repaired in a manner identical to a full-thickness lid margin laceration with 6-0 absorbable polyglactin sutures. The recovery was uncomplicated. Vision in the left eye improved to 20/25; right eye retained 20/20 vision. Visual field changes resolved and papilledema improved markedly in the left eye. The patient remained on medical management and at the last follow-up at 28 months the findings were unchanged. Fig. 3 is the postoperative photograph.


Vertical lid split approach for optic nerve sheath decompression.

Prabhakaran VC, Selva D - Indian J Ophthalmol (2009 Jul-Aug)

Intraoperative photograph demonstrating approach to the intraconal space via the vertical lid split incision
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2712701&req=5

Figure 0002: Intraoperative photograph demonstrating approach to the intraconal space via the vertical lid split incision
Mentions: The patient then underwent a left optic nerve sheath fenestration via a superomedial lid split approach. Under general anesthesia, the left upper lid was infiltrated with local anesthetic with 1:200,000 epinephrine to enhance hemostasis. The medial and superior rectus muscles were secured with 4-0 silk traction sutures to permit globe positioning during surgery. A full-thickness vertical incision was made at the junction of the medial and central thirds of the upper lid. Care was taken to remain exactly perpendicular to the lid margin. Straight iris scissors were used to transect the skin, orbicularis and tarsal plate [Fig. 1]. The incision was extended superiorly through the levator aponeurosis and palpebral conjunctiva up to the superior fornix. The incision was then extended through the conjunctival fornix continuing down to the bulbar conjunctiva lateral to the plica. Blunt dissection was then used to enter the superomedial orbit. The tendon of the superior oblique was identified and retracted medially. The intraconal space was entered between the superior rectus and medial rectus muscles [Fig. 2]. The globe was retracted laterally to enhance exposure. The optic nerve sheath was identified and neurosurgical forceps and scissors were used to open a rectangular window in the dural sheath. Hemostasis was obtained. The bulbar and forniceal conjunctiva were reapproximated with 8-0 polyglactin sutures. The lid incision was repaired in a manner identical to a full-thickness lid margin laceration with 6-0 absorbable polyglactin sutures. The recovery was uncomplicated. Vision in the left eye improved to 20/25; right eye retained 20/20 vision. Visual field changes resolved and papilledema improved markedly in the left eye. The patient remained on medical management and at the last follow-up at 28 months the findings were unchanged. Fig. 3 is the postoperative photograph.

Bottom Line: A vertical lid split incision was used to enter the superomedial orbit and approach the optic nerve sheath.This approach resulted in a successful nerve sheath fenestration, with improvement in the patient's symptoms.The vertical lid split incision provides access to the optic nerve sheath with minimal morbidity and may be an option for optic nerve sheath decompression.

View Article: PubMed Central - PubMed

Affiliation: Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, University of Adelaide and the South Australian Institute of Ophthalmology, Adelaide, Australia. eye@health.sa.gov.au

ABSTRACT
We describe a vertical lid split orbitotomy approach to perform optic nerve sheath fenestration which was done in a patient with idiopathic intracranial hypertension. A vertical lid split incision was used to enter the superomedial orbit and approach the optic nerve sheath. This approach resulted in a successful nerve sheath fenestration, with improvement in the patient's symptoms. The vertical lid split incision provides access to the optic nerve sheath with minimal morbidity and may be an option for optic nerve sheath decompression.

Show MeSH
Related in: MedlinePlus