Hatem Krema - Ocular Oncology Surgeries

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

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Hatem Krema - Ocular Oncology Surgeries

  1. 1. Surgical Procedures in Ocular Oncology Hatem Krema, MD, MSc, FRCS
  2. 2. Eyelid Tumours
  3. 3. Excision of a subcutaneous circumscribed mass (Dermoid cyst)
  4. 4. Pentagon Excision of lower eyelid margin tumour + Reese lateral canthotomy (For up to 40% eyelid margin defect)
  5. 5. Excision of BCC from the middle of lower eyelid Reconstruction with Tenzel rotational flap (for > 40% eyelid defect)
  6. 6. Total Lower Eyelid Excision and Lamellar reconstruction of the eyelid
  7. 7. Lymphangioma of the eyelid and conjunctiva Hatem Krema, FRCSEd
  8. 8. Excision and Reconstruction Plan Hatem Krema, FRCSEd
  9. 9. Anterior lamella: Mustardé rotational cheek flap Posterior lamella: Modified Hughes tarso-conjunctival flap Hatem Krema, FRCSEd
  10. 10. Undermining the involved conjunctival quadrant Hatem Krema, FRCSEd
  11. 11. Full thickness eyelid excision Hatem Krema, FRCSEd
  12. 12. Complete excision of the involved conjunctiva and eyelid with hemostasis Hatem Krema, FRCSEd
  13. 13. Hatem Krema, FRCSEd
  14. 14. Dissection of Mustardé rotational cheek flap Hatem Krema, FRCSEd
  15. 15. Mustardé rotational cheek flap and contour sutures Hatem Krema, FRCSEd
  16. 16. Modified Hughes tarso-conjunctival flap Hatem Krema, FRCSEd Conjunctiva Tarsus
  17. 17. Appearance at the conclusion of surgery Hatem Krema, FRCSEd
  18. 18. One day after surgery Hatem Krema, FRCSEd
  19. 19. One week after surgery Hatem Krema, FRCSEd
  20. 20. Four weeks after surgery (Separation of the eyelids) Hatem Krema, FRCSEd
  21. 21. Preoperative and post operative compared Hatem Krema, FRCSEd
  22. 22. Large medial canthal Basal Cell Carcinoma: Excision and lamellar Reconstruction
  23. 23. Extensive Medial Canthal Basal Cell Carcinoma Hatem Krema, FRCSEd
  24. 24. Excision and Reconstruction plan Hatem Krema, FRCSEd
  25. 25. Excision of the tumor with margin control Hatem Krema, FRCSEd
  26. 26. Dissection of Mustardé rotational flap Hatem Krema, FRCSEd
  27. 27. Hatem Krema, FRCSEd Glabellar flap and trans-nasal wiring
  28. 28. Reconstruction of posterior lamella with free tarso-conjunctival graft Hatem Krema, FRCSEd
  29. 29. Hatem Krema, FRCSEd Appearance at the conclusion of surgery
  30. 30. Hatem Krema, FRCSEd Functional eyelids one week after surgery
  31. 31. Orbital Tumours
  32. 32. Excision of a lacrimal gland mass Hatem Krema, FRCSEd
  33. 33. CT images Bilateral lacrimal gland masses Hatem Krema, FRCSEd
  34. 34. Marking skin incision Hatem Krema, FRCSEd
  35. 35. Skin crease incision Hatem Krema, FRCSEd
  36. 36. Orbital lobe is exposed beneath the septum Hatem Krema, FRCSEd
  37. 37. Trans-septal orbital lobe delivery Hatem Krema, FRCSEd
  38. 38. Trans-septal orbital lobe excision Hatem Krema, FRCSEd
  39. 39. Closure of the wound Hatem Krema, FRCSEd
  40. 40. Histopathology: Lacrimal gland lymphoma Hatem Krema, FRCSEd
  41. 41. 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
  42. 42. Excision of Circumscribed Extraconal Mass
  43. 43. Clinical Presentation Hatem Krema, FRCSEd
  44. 44. MRI images Extraconal inferolateral orbital tumour Hatem Krema, FRCSEd
  45. 45. Subciliary skin incision + Trans-septal inferior orbitotomy Hatem Krema, FRCSEd
  46. 46. Histopathology: Cavernous Hemangioma Hatem Krema, FRCSEd
  47. 47. Before surgery One week after surgery Hatem Krema, FRCSEd
  48. 48. Orbital Extraconal circumscribed tumors can be delivered through: Subciliary/ eyelid crease skin incision + Trans-septal approach Hatem Krema, FRCSEd
  49. 49. Excision of a Circumscribed Intraconal Mass
  50. 50. Clinical Presentation Hatem Krema, FRCSEd
  51. 51. CT images Left intraconal inferolateral circumscribed orbital mass Hatem Krema, FRCSEd
  52. 52. Transconjunctival fornix approach - Inferolateral orbitotomy Hatem Krema, FRCSEd
  53. 53. Transconjunctival fornix approach - Inferolateral orbitotomy Hatem Krema, FRCSEd
  54. 54. Before surgery Two weeks after surgery Hatem Krema, FRCSEd
  55. 55. Shortest route to anterior intraconal masses is by Transconjunctival approach. Hatem Krema, FRCSEd
  56. 56. Excision of a large Circumscribed Intraconal Mass
  57. 57. Clinical Presentation Hatem Krema, FRCSEd
  58. 58. Imaging Previous CT (Axial view) MRI Hatem Krema, FRCSEd
  59. 59. Transconjunctival Superolateral Orbitotomy Hatem Krema, FRCSEd
  60. 60. Transconjunctival Superolateral Orbitotomy Hatem Krema, FRCSEd
  61. 61. Histopathology: Neurofibroma with myxoid degeneration Hatem Krema, FRCSEd
  62. 62. Three Weeks After Surgery Hatem Krema, FRCSEd
  63. 63. Large encapsulated intraconal tumours can still be delivered through Transconjunctival approach.. Hatem Krema, FRCSEd
  64. 64. Cryoextraction of a large Intraconal Circumscribed Mass
  65. 65. Clinical Presentation
  66. 66. Lateral Canthotomy Hatem Krema, FRCSEd
  67. 67. Limbal based Periotomy and hooking of muscles Hatem Krema, FRCSEd
  68. 68. Disinsertion of two recti muscles Hatem Krema, FRCSEd
  69. 69. Retraction of the globe and orbital fat Hatem Krema, FRCSEd
  70. 70. Cryoextraction of the tumor out of orbit Hatem Krema, FRCSEd
  71. 71. Tumor is delivered completely out of orbit Hatem Krema, FRCSEd
  72. 72. Recti muscles are sutured in place Hatem Krema, FRCSEd
  73. 73. Lateral canthotomy is resutured Hatem Krema, FRCSEd
  74. 74. Conjunctiva is resutured Hatem Krema, FRCSEd
  75. 75. Resolution of proptosis one week after surgery Hatem Krema, FRCSEd
  76. 76. Incision Biopsy of a Diffuse Orbital Mass
  77. 77. Clinical presentation and imaging Rapid proptosis in a patient with history of breast cancer Hatem Krema, FRCSEd
  78. 78. 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
  79. 79. Stepwise Approach in Management of a Diffuse Orbital Tumour
  80. 80. Clinical Presentation Right slow proptosis after orbital biopsy 9 years before Histopathology: Angiolymphoid Hyperplasia Hatem Krema, FRCSEd
  81. 81. 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
  82. 82. Imaging at initial visit Diffuse orbital mass encompassing lateral rectus muscle Hatem Krema, FRCSEd
  83. 83. Management: Step 1= medical “down-staging” 3 months course of combination of Prednisolone 30 mg/day + Azathioprine 50 mg/ day Hatem Krema, FRCSEd
  84. 84. After 3 months of medical treatment No further regression of proptosis after 8 weeks of treatment Before medical treatment Hatem Krema, FRCSEd
  85. 85. MRI repeated after medical therapy MRI T1 (Contrast enhancement + fat suppression) MRI T1 (Axial View) Hatem Krema, FRCSEd
  86. 86. Management: Step 2 : Surgical excision of tumor remnants from the lateral and medial aspects of the lateral rectus Hatem Krema, FRCSEd
  87. 87. 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
  88. 88. Lid-Sparing Orbital Exenteration
  89. 89. Initial Presentation Hatem Krema, FRCSEd
  90. 90. Previous Biopsy: Conjunctival Mucoepidermoid Carcinoma
  91. 91. En- block Excision of all orbital contents Hatem Krema, FRCSEd
  92. 92. Dissecting the eyelids into anterior and posterior lamellae Hatem Krema, FRCSEd
  93. 93. En- block Excision of all orbital contents Hatem Krema, FRCSEd
  94. 94. Sparing of the anterior lamellae of both eyelids Hatem Krema, FRCSEd
  95. 95. Suturing anterior lamellae of both eyelids Hatem Krema, FRCSEd
  96. 96. Orbital socket is formed 2 weeks after exenteration Hatem Krema, FRCSEd
  97. 97. Patient is fitted with orbital prosthesis Hatem Krema, FRCSEd
  98. 98. “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
  99. 99. Primary Surgical Excision of Orbital Capillary Haemangioma
  100. 100. Case 1: Inferior Orbital Hemangioma (Inducing Right Hypertropia) Hatem Krema, FRCSEd
  101. 101. MRI Hatem Krema, FRCSEd
  102. 102. Sub-ciliary skin incision and tumour exposure Hatem Krema, FRCSEd
  103. 103. Trans-septal inferior orbitotomy Hatem Krema, FRCSEd
  104. 104. Total excision with blunt dissection through subciliary skin incision + trans-septal inferior orbitotomy Hatem Krema, FRCSEd
  105. 105. Wound closure Hatem Krema, FRCSEd
  106. 106. Histopathology: Capillary Hemangioma Hatem Krema, FRCSEd
  107. 107. Two weeks after surgery: Resolution of the hypertropia Pre-operative Post operative Hatem Krema, FRCSEd
  108. 108. Case 2: Diffuse Periocular Capillary Hemangioma (Involving Eyelids, Conjunctiva & Orbit) Hatem Krema, FRCSEd
  109. 109. MRI Hatem Krema, FRCSEd
  110. 110. Skin incisions and tumor extension Hatem Krema, FRCSEd
  111. 111. Delivery of the subcutaneous component of the hemangioma Hatem Krema, FRCSEd
  112. 112. Delivery of the orbital component of the tumor Hatem Krema, FRCSEd
  113. 113. Total excision by sliding the tumor out under the medial canthal tendon Hatem Krema, FRCSEd
  114. 114. Wound Closure Hatem Krema, FRCSEd
  115. 115. Histopathology: Capillary Hemangioma Hatem Krema, FRCSEd
  116. 116. Pre-operative Post operative Two weeks after surgery Hatem Krema, FRCSEd
  117. 117. Pediatric orbital capillary hemangioma can be surgically excised, when indicated, with intact tumor wall to prevent amblyopia. Hatem Krema, FRCSEd
  118. 118. Management of limbal squamous cell carcinoma
  119. 119. Surgical Excision 1. Alcohol (absolute 70%) corneal epitheliectomy 2. + Lamellar keratosclerectomy 3. Triple freeze- thaw of the conjunctival margins Hatem Krema, FRCSEd
  120. 120. Reconstruction If less than one quadrant involved  Primary conjunctival closure. Alternatives: - Free Conjunctival graft from the other eye - Amniotic membrane Hatem Krema, FRCSEd
  121. 121. Intraocular Tumours
  122. 122. Surgical Resection of an iridociliary melanoma Hatem Krema, FRCSEd
  123. 123. Radioactive Plaque Insertion
  124. 124. Hatem Krema, FRCSEd
  125. 125. Hatem Krema, FRCSEd
  126. 126. Radioactive Plaque Insertion (Example 2)
  127. 127. Dosimetry Hatem Krema, FRCSEd
  128. 128. Periotomy at the involved quadrant Hatem Krema, FRCSEd
  129. 129. Muscle bridle sutures Hatem Krema, FRCSEd
  130. 130. Transillumination Hatem Krema, FRCSEd
  131. 131. Dummy plaque application + repeating transillumination Hatem Krema, FRCSEd
  132. 132. Preplacing scleral sutures Hatem Krema, FRCSEd
  133. 133. Inserting the radioactive plaque in position Hatem Krema, FRCSEd
  134. 134. Fixing the radioactive plaque in position Hatem Krema, FRCSEd
  135. 135. Resuturing the conjunctiva Hatem Krema, FRCSEd
  136. 136. Before Treatment After Treatment Treatment Outcome Hatem Krema, FRCSEd
  137. 137. Enucleation
  138. 138. 360 degree Periotomy Hatem Krema, FRCSEd
  139. 139. Subtenon blunt dissection Hatem Krema, FRCSEd
  140. 140. Hanging sutures of the four recti muscles Hatem Krema, FRCSEd
  141. 141. Cauterization and myotomy of the two oblique muscles Hatem Krema, FRCSEd
  142. 142. Isolation of the globe from all extraocular muscle attachments Hatem Krema, FRCSEd
  143. 143. Delivering the globe out of the orbit and section of the optic nerve Hatem Krema, FRCSEd
  144. 144. The globe is delivered by outward traction on the muscle stumps Hatem Krema, FRCSEd
  145. 145. Securing haemostasis of the orbital socket Hatem Krema, FRCSEd
  146. 146. Insertion of a medpore implant Hatem Krema, FRCSEd
  147. 147. Implant is secured within the orbital socket Hatem Krema, FRCSEd
  148. 148. Suturing the recti muscles by imbrication over the orbital implant Hatem Krema, FRCSEd
  149. 149. Closure of the Tenon’s capsule with interrupted sutures and conjunctiva with continuous suture Hatem Krema, FRCSEd
  150. 150. Satisfactory Cosmetic Outcome Enucleation OSEnucleation OSEnucleation OD
  151. 151. Surgical Procedures in Ocular Oncology Hatem Krema, MD, MSc, FRCS

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