Chapter 39 - Orbital exenteration

Introduction Total Knee Arthroplasty (TKA) is the gold standard treatment for advanced gonarthrosis, but its availability remains limited in low-resource settings. This study presents preliminary outcomes of TKA performed in Lubumbashi. Methods A retrospective, single-center study was conducted on patients who underwent TKA between August 2017 and August 2024. Data collected included demographic, clinical, radiological, and functional variables. Pre and postoperative assessments were based on the International Knee Society (IKS) score. All surgeries were performed using posterior-stabilized prostheses. Postoperative follow-up averaged 24 months. Results A total of 27 patients were included in this series. The mean age was 63.3 years, with a female predominance (sex ratio 0,7). Gonarthrosis was primary in 82% of cases, with advanced radiographic stages Ahlbäck IV-V in 89%. The average preoperative IKS score was 104, improving to 172 postoperatively. Complications included one hematoma, one deep vein thrombosis, two superficial infections, and two cases of late-onset medial laxity. Two patients experienced persistent severe pain, and two cases of prosthetic loosening were detected after two years. Overall, 82.5% of patients achieved good to excellent outcomes. Discussion This study confirms that total knee arthroplasty is feasible and effective in a resource-limited environment when surgical technique and perioperative management are adapted to local constraints. Despite infrastructural and economic barriers, functional outcomes and complication rates were comparable to other African series. The progressive improvement observed reflects the institutional learning curve, strengthened by international collaboration and protocol standardization. Persistent challenges include limited implant supply, inadequate rehabilitation infrastructure, and lack of health insurance coverage. Expanding training programs, improving logistics, and developing regional arthroplasty registries remain essential for sustainable progress. Conclusion TKA can be successfully implemented in sub-Saharan provided that surgical indications are appropriate and perioperative protocols are rigorously applied

Objective Periacetabular osteotomy (PAO) is widely used in the treatment of young and middle-aged patients with developmental dysplasia of the hip (DDH) as a reconstruction surgery of the pelvis. This article proves that PAO is a suitable method for young and middle-aged patients through discussing the selection criteria of patients, operation results and troubles in the operation. Methods literatures from January 1988 to May 2014 in PubMed with the key words periacetabular osteotomy or PAO and DDH. Literatures about patients' selection criteria, operation results and the troubles in the surgery were selected from all the literatures. Based on the review of them, we analyzed the prognosis caused by selection criteria of patients, operation results and troubles in the surgery. Results Before the operation, the articular cartilage conditions and the hip joint deformity were evaluated by radiographic images, the hip joint function was evaluated by physical examination. The reasonable position of the bone fragment and additional operations were chosen in the surgery. The reasonable postoperative exercise was selected. The satisfactory results can be obtained in DDH patients by treating with PAO. Conclusions PAO is one of the effective means to treat young and middle-aged DDH patients. Key words: Acetabulum; Hip dislocation, congenital; Developmental dysplasia of the hip; Osteotomy

Orbital exenteration is a surgical procedure that removes varying degrees of the orbital contents and periorbital soft tissue, including periorbital skin, the globe, extraocular muscles, optic nerve, the periorbita, and the orbital fat. In some instances, the disease process may necessitate removal of the bony orbital walls as well. Orbital exenteration is reserved for highly malignant and potentially fatal neoplasms originating from the ocular adnexal structures; ocular tumors with extension to the orbital soft tissue; orbital extension of tumors of the paranasal sinuses or nasal cavity; and orbital extension from intracranial processes. Tumors necessitating orbital exenteration may include squamous cell carcinoma, basal cell carcinoma, sebaceous carcinoma, melanoma of the conjunctiva, uveal melanoma with extrascleral or orbital extension, epithelial cancers such as adenoid cystic carcinoma of the lacrimal gland, rhabdomyosarcoma, and other rare tumors. The indications for orbital exenteration in a number of previously published series are summarized in Table 23-1. In addition to cancers, nonmalignant neoplasms—such as neurofibromatosis causing severe orbital displacement, immobility, and blindness or extensive lymphangioma compromising function and cosmesis—may also lead to orbital exenteration. Nonneoplastic diseases of rapidly infiltrative nature, either inflammatory or infectious, and nonneoplastic diseases associated with refractory orbital pain may also be indications for orbital exenteration. Examples include invasive fungal infections of the orbit such as mucormycosis; orbital socket contracture after enucleation causing severe pain; and extreme cases of Graves orbitopathy unresponsive to other treatment modalities. Orbital exenteration results in complete loss of vision in the affected eye as well as significant disfigurement of the upper face; thus, counseling of the patient prior to surgery and understanding of the patient’s expectations are important to minimize the patient’s distress. During the preoperative interview, the patient’s past medical and surgical history, current medications, coagulation status, and allergies should be ascertained; there should also be a review of systems, with a focus on symptoms of cancer and metastasis. The physical examination should include careful inspection for signs of local or regional extension of disease. Regional lymph node and distant-organ metastasis must be ruled out prior to the decision to proceed with an orbital exenteration.

Objective: To analyze the etiology and related factors of destructive ophthalmic surgeries, including enucleation of the eyeball, evisceration and orbital exenteration. Methods: The medical records of 676 patients (676 eyes) who underwent ophthalmic destructive procedures were reviewed retrospectively from July 2011 to September 2017 at the Eye Hospital, Wenzhou Medical University. There were 437 males and 239 females; aged from 7 months to 90 years old, and the causes of the operation and its distribution were analyzed. Results: In 676 cases, 230 cases were enucleation, accounting for 34.0%; 426 cases were evisceration, accounting for 63.0%; 20 cases were orbital exenteration, accounting for 3.0%. There were 31 children younger than 12 years old, among them, 18 cases of enucleation and 2 cases of orbital exenteration due to retinoblastoma. There were 430 cases of adults aged from 19 to 60 years old. Ocular trauma related diseases were the first cause, about 219 cases. There were 191 elderly patients over the age of 60. Keratitis and cornea related diseases (57 cases) and glaucoma (51 cases) were the main causes. And in older patients, removal of orbital contents was a common cause of eyelid malignancy. Conclusions: In different age groups, the main causes of unilateral blindness are different. Therefore, the emphases of the promotion of preventive health care knowledges and treatment priorities should be different among different age groups. Key words: enucleation; evisceration; orbital exenteration; ocular trauma; retinoblastoma; eyelid malignant tumor

To determine the course of reconstructive treatment and outcomes with use of the rectus abdominis free flap after orbital exenteration with or without total maxillectomy. Retrospective chart review of treatment and outcomes of patients who had rectus abdominis free-tissue transfer for orbital exenteration with or without total maxillectomy at the Mayo Clinic between 1994 and 2004. Charts of patients who had rectus abdominis free flap reconstruction after orbital exenteration were retrospectively reviewed and the surgical technique evaluated. An explanation of the surgical technique for rectus abdominis free-tissue transfer to the orbital cavity is provided, along with a discussion of the advantages and disadvantages of this reconstructive method. Twelve of 13 patients who underwent reconstruction with rectus abdominis free-tissue transfer had a successful outcome (flap viability 92%). Cosmetic results were acceptable both to patients and to surgeons. Rectus abdominis microvascular free-tissue transfer for repair of orbital exenteration defects is a safe and reliable alternative to the use of the temporalis or the pectoralis major muscle as a pedicle flap; it provides a larger volume of well-vascularized tissue and greater placement flexibility without associated orientation problems; and the long vascular pedicle facilitates the use of multiple donor vessels within the head and neck, which is an advantage in previously irradiated patients. Postoperative care and the donor site defect are well tolerated. The flap allows reliable obturation of the oral maxillectomy defect, and it negates the need for cavity care in these patients.

Deep Brain Stimulation (DBS) has emerged as a promising therapeutic approach for various neurological disorders. This video article elucidates the intricacies of DBS surgery and patient selection criteria. The article comprehensively discusses the indications for DBS across diverse conditions including Parkinson’s disease, primary generalized dystonia, essential tremor, obsessive-compulsive disorder, Tourette’s syndrome, drug-resistant major depression, drug-resistant epilepsy, minimally conscious state, and certain addictive disorders. The article ensure optimal outcomes and patient safety. The surgical procedure is meticulously detailed, encompassing the pre-operative planning phase involving Magnetic Resonance Imaging (MRI) and stereotactic coordinates determination. The step-by-step surgical process is elucidated, from frame application and Computed Tomography (CT) fusion to electrode implantation and confirmation of placement. Post-operative management, including programming of the Implantable Pulse Generator (IPG) and addressing complications, is also discussed. By providing insights into the surgical nuances of DBS and patient selection criteria, this video article serves as a valuable resource for neurosurgeons and healthcare professionals involved in the management of neurological disorders amenable to DBS therapy.

THE PATIENT having a total orbital exenteration with or without skin grafts to the orbit usually has an extended period of convalescence requiring considerable care of the wound, followed by a permanent cavitary cosmetic defect on one side of the face. A number of modifications of this procedure have been advocated to shorten the period of convalescence and to improve the cosmetic appearance. 1-5 The purpose of this report is to describe a technique of orbital exenteration which replaces the orbital defect with methyl methacrylate and utilizes the skin of the lids to close the orbital wound. The technique is applicable only in patients with a primary malignant orbital tumor which is confined to the intraorbital space posterior to the orbital septum and which does not involve the bony wall of the orbit. Technique The procedure is done under general anesthesia. The eyelashes are trimmed. Two units of blood are

Invited Commentary

The authors report and evaluate their experience with an individualized approach to orbital exenteration. Retrospective chart review was performed on a consecutive series of 25 orbital exenteration patients at a tertiary care center. The cases were classified into two groups for the retrospective analysis: Total exenteration procedures involved the removal of the entire orbital contents including the periorbita (13 cases), and subtotal procedures preserved at least a quadrant of the orbit or the orbital tissues posterior to the globe (12 cases). The total exenteration group had a lower rate of clear surgical margins and a higher rate of systemic metastasis, whereas patients in the subtotal exenteration group had fewer surgical complications and better functional and aesthetic results. The surgical planning for orbital exenteration should take into account the location, extent, and biological behavior of the orbital disease process and the reconstructive and prosthetic options for the exenterated socket. When an individualized approach to orbital exenteration is used, subtotal procedures can offer improved functional and aesthetic results while still maximizing the chances for a surgical cure.

Potentially dangerous interactions between psychotropic medications and medicines frequently used in anesthesia pose substantial risks regarding perioperative care. We aimed to review the recommendations of perioperative psychotropic medication management and to discuss potential interactions of the frequently used psychotropic drugs with anesthetic agents. PubMed/MEDLINE and Scopus databases were searched for the review articles reporting data on the perioperative management of psychotropic medications. Considering the heterogeneity of the included studies, a narrative approach to synthesis was conducted. The recommendations were summarized in the final selection of studies and categorized according to the main side effects, drug interactions, and anesthetic implications for perioperative management for each psychotropic drug category: antidepressants, antipsychotics, mood stabilizers, anxiolytics, and stimulants. Of the 12,569 identified citations, 11 articles were included in the narrative review. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, atypical antidepressants, antipsychotics, antiepileptic mood stabilizers, and benzodiazepines are generally recommended to be continued perioperatively. The decision to maintain or adjust monoamine oxidase inhibitors or psychostimulants should be carefully individualized, considering the patient's overall health status and the potential for drug interactions with specific anesthetic agents. Discontinuation of lithium 72 hours before major surgery is recommended. For the effective management of psychotropic medications perioperatively, a multidisciplinary case-based evaluation is recommended to provide adequate care. Close collaboration of anesthesiology and surgical teams with mental health professionals is vital to ensure patient safety and optimal outcomes.

The primary objective was to investigate the trends in orbital exenteration rates at a large tertiary care center, particularly in the context of recent advancements in immunotherapy, targeted agents, and globe-sparing surgical techniques, which have significantly impacted patient management. The authors conducted a retrospective cohort study at the University of Miami. Patients who underwent orbital exenterations from 2011 to 2024 were identified by obtaining surgical coding data via institutional data brokers and validated through a rigorous surgical chart review. The authors used Poisson regression with robust standard errors to compare incidence trends, using the Florida state population as an offset. The analyses compared 2011 to 2017 with 2018 to 2024 and examined year-by-year variation, ensuring a robust and reliable study. A total of 179 exenteration cases were identified. Compared with 2011 to 2017, total exenterations decreased by 39% in 2018 to 2024 (incidence rate ratio [IRR] = 0.61; p = 0.004). Significant declines were also observed from 2018 to 2024 for cutaneous squamous cell carcinoma (IRR = 0.49; p = 0.023) and ocular surface squamous neoplasia (IRR = 0.17; p = 0.002), while sebaceous gland carcinoma increased (IRR = 2.94; p = 0.015). Year-over-year analysis estimated a 3.9% annual decrease in total exenterations. This study revealed a significant decline in total orbital exenterations from 2018 to 2024 and diagnosis-specific declines in exenterations for cutaneous squamous cell carcinoma and ocular surface squamous neoplasia compared with 2011 to 2017. This trend coincides with the introduction of Programmed Cell Death Protein 1 (PD-1) inhibitors and other immunotherapies, first approved by the United States Food & Drug Administration in 2018, and suggests they may have contributed to the observed decline. These findings reflect shifting oncologic treatment paradigms and underscore important implications for surgical training and resource planning.

Introduction5 billion people around the world do not have access to safe, affordable, timely surgical care. This series of qualitative interviews was launched by The Lancet Commission on Global Surgery...

To evaluate the features and outcome of management of malignant conjunctival squamous tumors in King Hussein Cancer Center (a referral tertiary cancer center in the Middle East). Retrospective case series of 31 eyes for 31 patients with conjunctival squamous neoplasia. Main outcome measures included: age, gender, laterality, tumor location, pathological features, tumor stage, treatment modality, and outcome. Twenty (65%) patients were males and median age was 58y. Twenty-two (71%) eyes had the tumor in the nasal quadrant. Tumor invasion to nearby structures was seen in 19 (61%) eyes, including the cornea, fornix, eyelid, and orbit in 17 (55%), 1 (3%), 2 (6%), and 3 (10%) eyes, respectively. Eye salvage was achieved by surgical excision with cryotherapy followed by topical chemotherapy in 28 (90%) eyes, and orbital exenteration was necessary in 3 (10%) eyes due to orbital tumor invasion. Tumor recurrence was seen in 7 (23%) eyes, and the significant predictive factors for recurrence were tumor extension onto the nearby structures (P=0.04), tumor invasiveness (P=0.038), and tumor TNM stage (P=0.031). No significant change in visual acuity was seen, and disease related mortality was 6% (2 patients, both had orbital invasion by invasive squamous carcinoma). Conjunctival squamous carcinoma is more common in males. Advanced American Joint Committee on Cancer (AJCC) T-stage, tumor local invasion, more pathologically aggressive tumors, and surgical treatment alone (without adjuvant therapy) are associated with higher risk for recurrence, and orbital invasion is the most important poor prognostic factor for metastasis and death. Treatment strategies should be affected by tumor characteristics at presentation.

BackgroundPatients with acquired hemophilia A (AHA) who require open heart surgery have a life-threatening risk of hemorrhage. Limited data exist to guide perioperative management of these patients.Case presentationA 53-year-old female with rheumatoid arthritis, concomitant aortic valve endocarditis, and severe aortic regurgitation presented to our hospital. Bleeding and abnormal coagulation tests were noted during the initial workup, and she was diagnosed with AHA. The perioperative management plan included the use of pharmaceuticals, porcine recombinant factor VIII, and blood products. Extensive preoperative coagulation data were obtained, and factor VIII levels were continuously monitored to mitigate bleeding complications. The aortic valve replacement and root repair were uneventful.ConclusionCardiac surgery in patients with AHA is possible as long as complex perioperative hemostatic and hematology management is used.

Controversy exists regarding many aspects of decision making pertaining to same-day versus staged bilateral TKA (BTKAs), including patient selection, perioperative management decisions, and other important choices. In the absence of suitable randomized trials, we sought to determine areas of consensus among national experts on the following questions: (1) What are the comparative risks of same-day BTKAs compared with unilateral TKA (UTKA) and staged BTKAs? (2) Who should be considered an appropriate candidate for same-day BTKAs? (3) What constitutes appropriate workup and perioperative management for BTKAs? (4) What is the optimal time between procedures if same-day BTKAs are not deemed appropriate? (5) Are there orthopaedic or rehabilitation considerations for BTKAs that might outweigh medical contraindications? In the setting of a consensus conference of national experts in orthopaedic surgery, anesthesiology, perioperative medicine, and epidemiology, the major questions surrounding same-day BTKAs were addressed by using an extensive literature review and the modified Delphi process. The process concluded with a meeting of participants and formulation of consensus statements. Eighty-one percent of participants agreed that BTKAs are more invasive and complex procedures associated with increased risk for perioperative adverse events compared with UTKA in an unselected group of patients. The consensus group agreed that physicians and hospitals should consider using more restrictive patient selection criteria and exclude those with a modified cardiac risk index greater than 3 to mitigate the potentially increased risk. The majority of the group agreed that perioperative assessment and management should reflect the higher level of acuity of same-day BTKAs. Eighty-one percent of participants agreed that if a patient is not deemed a candidate for same-day BTKAs, a second TKA should be scheduled no sooner than 3 months after the first. The entire group agreed that when there is a conflict between the orthopaedic need and the medical adequacy of same-day BTKAs, the medical concern for the patient's safety should prevail over the orthopaedic need. Experts perceived that same-day BTKAs increase medical risk, and thus a systematic approach to the management of patients should be taken to minimize complications.