Hatem Krema - Ocular Oncology Surgeries
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Hatem Krema - Ocular Oncology Surgeries

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Examples of Ocular Oncology Surgeries performed by Hatem Krema, MD, MSc, FRCS

Examples of Ocular Oncology Surgeries performed by Hatem Krema, MD, MSc, FRCS

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Hatem Krema - Ocular Oncology Surgeries Hatem Krema - Ocular Oncology Surgeries Presentation Transcript

  • Surgical Procedures in Ocular Oncology Hatem Krema, MD, MSc, FRCS
  • Eyelid Tumours
  • Excision of a subcutaneous circumscribed mass (Dermoid cyst)
  • Pentagon Excision of lower eyelid margin tumour + Reese lateral canthotomy (For up to 40% eyelid margin defect)
  • Excision of BCC from the middle of lower eyelid Reconstruction with Tenzel rotational flap (for > 40% eyelid defect)
  • Total Lower Eyelid Excision and Lamellar reconstruction of the eyelid
  • Lymphangioma of the eyelid and conjunctiva Hatem Krema, FRCSEd
  • Excision and Reconstruction Plan Hatem Krema, FRCSEd
  • Anterior lamella: Mustardé rotational cheek flap Posterior lamella: Modified Hughes tarso-conjunctival flap Hatem Krema, FRCSEd
  • Undermining the involved conjunctival quadrant Hatem Krema, FRCSEd
  • Full thickness eyelid excision Hatem Krema, FRCSEd
  • Complete excision of the involved conjunctiva and eyelid with hemostasis Hatem Krema, FRCSEd
  • Hatem Krema, FRCSEd
  • Dissection of Mustardé rotational cheek flap Hatem Krema, FRCSEd
  • Mustardé rotational cheek flap and contour sutures Hatem Krema, FRCSEd
  • Modified Hughes tarso-conjunctival flap Hatem Krema, FRCSEd Conjunctiva Tarsus
  • Appearance at the conclusion of surgery Hatem Krema, FRCSEd
  • One day after surgery Hatem Krema, FRCSEd
  • One week after surgery Hatem Krema, FRCSEd
  • Four weeks after surgery (Separation of the eyelids) Hatem Krema, FRCSEd
  • Preoperative and post operative compared Hatem Krema, FRCSEd
  • Large medial canthal Basal Cell Carcinoma: Excision and lamellar Reconstruction
  • Extensive Medial Canthal Basal Cell Carcinoma Hatem Krema, FRCSEd
  • Excision and Reconstruction plan Hatem Krema, FRCSEd
  • Excision of the tumor with margin control Hatem Krema, FRCSEd
  • Dissection of Mustardé rotational flap Hatem Krema, FRCSEd
  • Hatem Krema, FRCSEd Glabellar flap and trans-nasal wiring
  • Reconstruction of posterior lamella with free tarso-conjunctival graft Hatem Krema, FRCSEd
  • Hatem Krema, FRCSEd Appearance at the conclusion of surgery
  • Hatem Krema, FRCSEd Functional eyelids one week after surgery
  • Orbital Tumours
  • Excision of a lacrimal gland mass Hatem Krema, FRCSEd
  • CT images Bilateral lacrimal gland masses Hatem Krema, FRCSEd
  • Marking skin incision Hatem Krema, FRCSEd
  • Skin crease incision Hatem Krema, FRCSEd
  • Orbital lobe is exposed beneath the septum Hatem Krema, FRCSEd
  • Trans-septal orbital lobe delivery Hatem Krema, FRCSEd
  • Trans-septal orbital lobe excision Hatem Krema, FRCSEd
  • Closure of the wound Hatem Krema, FRCSEd
  • Histopathology: Lacrimal gland lymphoma Hatem Krema, FRCSEd
  • Eyelid crease incision + Trans-septal approach for excision of pleomorphic adenoma of the lacrimal gland Sub-brow skin incision + Trans periosteal approach For excision of adenocarcinoma of the lacrimal gland Hatem Krema, FRCSEd
  • Excision of Circumscribed Extraconal Mass
  • Clinical Presentation Hatem Krema, FRCSEd
  • MRI images Extraconal inferolateral orbital tumour Hatem Krema, FRCSEd
  • Subciliary skin incision + Trans-septal inferior orbitotomy Hatem Krema, FRCSEd
  • Histopathology: Cavernous Hemangioma Hatem Krema, FRCSEd
  • Before surgery One week after surgery Hatem Krema, FRCSEd
  • Orbital Extraconal circumscribed tumors can be delivered through: Subciliary/ eyelid crease skin incision + Trans-septal approach Hatem Krema, FRCSEd
  • Excision of a Circumscribed Intraconal Mass
  • Clinical Presentation Hatem Krema, FRCSEd
  • CT images Left intraconal inferolateral circumscribed orbital mass Hatem Krema, FRCSEd
  • Transconjunctival fornix approach - Inferolateral orbitotomy Hatem Krema, FRCSEd
  • Transconjunctival fornix approach - Inferolateral orbitotomy Hatem Krema, FRCSEd
  • Before surgery Two weeks after surgery Hatem Krema, FRCSEd
  • Shortest route to anterior intraconal masses is by Transconjunctival approach. Hatem Krema, FRCSEd
  • Excision of a large Circumscribed Intraconal Mass
  • Clinical Presentation Hatem Krema, FRCSEd
  • Imaging Previous CT (Axial view) MRI Hatem Krema, FRCSEd
  • Transconjunctival Superolateral Orbitotomy Hatem Krema, FRCSEd
  • Transconjunctival Superolateral Orbitotomy Hatem Krema, FRCSEd
  • Histopathology: Neurofibroma with myxoid degeneration Hatem Krema, FRCSEd
  • Three Weeks After Surgery Hatem Krema, FRCSEd
  • Large encapsulated intraconal tumours can still be delivered through Transconjunctival approach.. Hatem Krema, FRCSEd
  • Cryoextraction of a large Intraconal Circumscribed Mass
  • Clinical Presentation
  • Lateral Canthotomy Hatem Krema, FRCSEd
  • Limbal based Periotomy and hooking of muscles Hatem Krema, FRCSEd
  • Disinsertion of two recti muscles Hatem Krema, FRCSEd
  • Retraction of the globe and orbital fat Hatem Krema, FRCSEd
  • Cryoextraction of the tumor out of orbit Hatem Krema, FRCSEd
  • Tumor is delivered completely out of orbit Hatem Krema, FRCSEd
  • Recti muscles are sutured in place Hatem Krema, FRCSEd
  • Lateral canthotomy is resutured Hatem Krema, FRCSEd
  • Conjunctiva is resutured Hatem Krema, FRCSEd
  • Resolution of proptosis one week after surgery Hatem Krema, FRCSEd
  • Incision Biopsy of a Diffuse Orbital Mass
  • Clinical presentation and imaging Rapid proptosis in a patient with history of breast cancer Hatem Krema, FRCSEd
  • Incision Biopsy of an Orbital Metastasis 1.Crease incision, trans-septal exposure 2.Determine the appropriate biopsy site 3.Mark a block of tissue with a knife 4.Remove the tissue block with scissors Hatem Krema, FRCSEd
  • Stepwise Approach in Management of a Diffuse Orbital Tumour
  • Clinical Presentation Right slow proptosis after orbital biopsy 9 years before Histopathology: Angiolymphoid Hyperplasia Hatem Krema, FRCSEd
  • Previous Management History - Two debulking surgeries that were followed by Recurrence. - Several 2-weeks courses of full- dose systemic steroids were followed by Recurrence. - 40 Gys of fractionated stereotactic radiotherapy ended by Recurrence. Hatem Krema, FRCSEd
  • Imaging at initial visit Diffuse orbital mass encompassing lateral rectus muscle Hatem Krema, FRCSEd
  • Management: Step 1= medical “down-staging” 3 months course of combination of Prednisolone 30 mg/day + Azathioprine 50 mg/ day Hatem Krema, FRCSEd
  • After 3 months of medical treatment No further regression of proptosis after 8 weeks of treatment Before medical treatment Hatem Krema, FRCSEd
  • MRI repeated after medical therapy MRI T1 (Contrast enhancement + fat suppression) MRI T1 (Axial View) Hatem Krema, FRCSEd
  • Management: Step 2 : Surgical excision of tumor remnants from the lateral and medial aspects of the lateral rectus Hatem Krema, FRCSEd
  • Patient is maintained on 5 mg oral steroids/ every 2 days No recurrence after 4 years of follow-up Before surgical excision 3 weeks after surgical excision Hatem Krema, FRCSEd
  • Lid-Sparing Orbital Exenteration
  • Initial Presentation Hatem Krema, FRCSEd
  • Previous Biopsy: Conjunctival Mucoepidermoid Carcinoma
  • En- block Excision of all orbital contents Hatem Krema, FRCSEd
  • Dissecting the eyelids into anterior and posterior lamellae Hatem Krema, FRCSEd
  • En- block Excision of all orbital contents Hatem Krema, FRCSEd
  • Sparing of the anterior lamellae of both eyelids Hatem Krema, FRCSEd
  • Suturing anterior lamellae of both eyelids Hatem Krema, FRCSEd
  • Orbital socket is formed 2 weeks after exenteration Hatem Krema, FRCSEd
  • Patient is fitted with orbital prosthesis Hatem Krema, FRCSEd
  • “Lid sparing” exenteration provides rapid rehabilitation, but might not be indicated if the patient is to receive adjuvant radiotherapy. Socket covered by the anterior lamellae flap Socket covered by granulation tissue (Laissez-faire) Hatem Krema, FRCSEd
  • Primary Surgical Excision of Orbital Capillary Haemangioma
  • Case 1: Inferior Orbital Hemangioma (Inducing Right Hypertropia) Hatem Krema, FRCSEd
  • MRI Hatem Krema, FRCSEd
  • Sub-ciliary skin incision and tumour exposure Hatem Krema, FRCSEd
  • Trans-septal inferior orbitotomy Hatem Krema, FRCSEd
  • Total excision with blunt dissection through subciliary skin incision + trans-septal inferior orbitotomy Hatem Krema, FRCSEd
  • Wound closure Hatem Krema, FRCSEd
  • Histopathology: Capillary Hemangioma Hatem Krema, FRCSEd
  • Two weeks after surgery: Resolution of the hypertropia Pre-operative Post operative Hatem Krema, FRCSEd
  • Case 2: Diffuse Periocular Capillary Hemangioma (Involving Eyelids, Conjunctiva & Orbit) Hatem Krema, FRCSEd
  • MRI Hatem Krema, FRCSEd
  • Skin incisions and tumor extension Hatem Krema, FRCSEd
  • Delivery of the subcutaneous component of the hemangioma Hatem Krema, FRCSEd
  • Delivery of the orbital component of the tumor Hatem Krema, FRCSEd
  • Total excision by sliding the tumor out under the medial canthal tendon Hatem Krema, FRCSEd
  • Wound Closure Hatem Krema, FRCSEd
  • Histopathology: Capillary Hemangioma Hatem Krema, FRCSEd
  • Pre-operative Post operative Two weeks after surgery Hatem Krema, FRCSEd
  • Pediatric orbital capillary hemangioma can be surgically excised, when indicated, with intact tumor wall to prevent amblyopia. Hatem Krema, FRCSEd
  • Management of limbal squamous cell carcinoma
  • Surgical Excision 1. Alcohol (absolute 70%) corneal epitheliectomy 2. + Lamellar keratosclerectomy 3. Triple freeze- thaw of the conjunctival margins Hatem Krema, FRCSEd
  • Reconstruction If less than one quadrant involved  Primary conjunctival closure. Alternatives: - Free Conjunctival graft from the other eye - Amniotic membrane Hatem Krema, FRCSEd
  • Intraocular Tumours
  • Surgical Resection of an iridociliary melanoma Hatem Krema, FRCSEd
  • Radioactive Plaque Insertion
  • Hatem Krema, FRCSEd
  • Hatem Krema, FRCSEd
  • Radioactive Plaque Insertion (Example 2)
  • Dosimetry Hatem Krema, FRCSEd
  • Periotomy at the involved quadrant Hatem Krema, FRCSEd
  • Muscle bridle sutures Hatem Krema, FRCSEd
  • Transillumination Hatem Krema, FRCSEd
  • Dummy plaque application + repeating transillumination Hatem Krema, FRCSEd
  • Preplacing scleral sutures Hatem Krema, FRCSEd
  • Inserting the radioactive plaque in position Hatem Krema, FRCSEd
  • Fixing the radioactive plaque in position Hatem Krema, FRCSEd
  • Resuturing the conjunctiva Hatem Krema, FRCSEd
  • Before Treatment After Treatment Treatment Outcome Hatem Krema, FRCSEd
  • Enucleation
  • 360 degree Periotomy Hatem Krema, FRCSEd
  • Subtenon blunt dissection Hatem Krema, FRCSEd
  • Hanging sutures of the four recti muscles Hatem Krema, FRCSEd
  • Cauterization and myotomy of the two oblique muscles Hatem Krema, FRCSEd
  • Isolation of the globe from all extraocular muscle attachments Hatem Krema, FRCSEd
  • Delivering the globe out of the orbit and section of the optic nerve Hatem Krema, FRCSEd
  • The globe is delivered by outward traction on the muscle stumps Hatem Krema, FRCSEd
  • Securing haemostasis of the orbital socket Hatem Krema, FRCSEd
  • Insertion of a medpore implant Hatem Krema, FRCSEd
  • Implant is secured within the orbital socket Hatem Krema, FRCSEd
  • Suturing the recti muscles by imbrication over the orbital implant Hatem Krema, FRCSEd
  • Closure of the Tenon’s capsule with interrupted sutures and conjunctiva with continuous suture Hatem Krema, FRCSEd
  • Satisfactory Cosmetic Outcome Enucleation OSEnucleation OSEnucleation OD
  • Surgical Procedures in Ocular Oncology Hatem Krema, MD, MSc, FRCS