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Advances in endoscopy benefit patients requiring orbital surgery
Surgeons are now able to access areas that they were unable to reach adequately in the past.
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As optics and instrumentation have improved for our colleagues in otolaryngology and neurosurgery, we, as ophthalmologists, especially orbital surgeons, have been able to take advantage of these advances and improve our patients’ experiences. We have all become accustomed to endoscopic brow lifts, endoscopic dacryocystorhinostomy and the more recent intraocular endoscopy. But orbital surgeons have been fortunate to enjoy the benefits of collaborations with our colleagues in other fields to minimize our patients’ morbidities and hospital stays.
Likely the most familiar use of endoscopy in orbital surgery is in decompression of the orbit for thyroid disease. Ideally, doctor and patient have waited until the active disease has run its course. At our institution, the medial wall is decompressed in conjunction with the lateral wall in a “balanced decompression.” This gives the patient a low likelihood of new diplopia, thought to be because the eye is moved very little in vertical space (the incidence is about 15% in patients without any preoperative diplopia). Rarely, it is necessary to do this when the disease is active and the patient is failing medical treatment, due to corneal decompensation or severe compressive optic neuropathy. In these cases, it is even more critical that the endoscopic portion of the procedure is performed because a posterior decompression is the most effective and, in the right hands, safest way of quickly relieving the severe pressure on the optic nerve in the orbital apex.
Another common use of endoscopy in orbital surgery is drainage of abscesses related to sinus disease. Medial abscesses against the lamina papyracea, in particular, almost invariably associated with infectious sinus disease, are often drained when the sinuses are drained in functional endoscopic sinus surgery. A rigid endoscope is extremely useful as an adjunct when addressing abscesses in other locations in the orbit, as well, allowing exploration and direct illumination deep into areas that otherwise are quite difficult to visualize.
For masses originating in the lateral parts of the orbit, from about the 7 o’clock to the 12 o’clock positions on a right orbit, lateral or superior approaches will better suit the pathology. For lesions situated mainly in other orbital meridians, however, an endoscopic-assisted or fully endoscopic surgical approach is indicated and, in the hands of an experienced team, causes less tissue trauma and gives more direct access to the pathology. For some slow-growing pathology, a decompression of the medial and/or inferior orbit via endoscopy may be sufficient long term. In other cases, this may be a temporizing measure, and later resection of the mass must be undertaken.
S. Tonya Stefko
Both intraconal and extraconal pathology may be addressed with a team of surgeons. Our groups have removed foreign bodies, gliomas and other intraconal tumors (hemangiomas are particularly well-suited to this approach), drained intraconal abscesses, and performed optic nerve biopsies in this manner. It is imperative to have excellent image guidance for these cases. Many of us were taught that metal projectiles near the orbital apex, in the setting of good vision, were to be left in place permanently. In this era of ubiquitous MRI, however, it often makes sense to remove the foreign body after a fibrotic response has had time to occur, and endoscopic assistance frequently renders this safer.
Endoscopy is useful also for retrieval of slipped extraocular muscles, whether from trauma or strabismus surgery. Traumatic optic neuropathy is an area that still incites much controversy, perhaps because there exists no reliable treatment for this. There is no series supporting decompression of the optic canal, but in cases in which there is clear compression of the optic nerve by a bone fragment, and the patient is awake and able to give clear exam and consent, we may offer a removal of the bony fragment via transnasal endoscopy, as this procedure is safe in the hands of an experienced endoscopist.
Recent reports in the neurosurgical literature of using the orbit as a corridor to the anterior and middle crania fossae abound. Eyebrow craniotomies with endoscopic assistance for approach to the anterior fossa and sellar region are relatively commonplace, and approaches to the cavernous sinus are possible via a lateral canthal or eyelid approach, as well. These all have dual advantages of minimal to no brain retraction and excellent camouflage of scar.
Overall, patients requiring orbital surgery have benefited greatly from advances in endoscopic surgery over the past 10 to 20 years. This is true especially for pathology located in areas we were unable to reach adequately in the past, such as the orbital apex near the optic nerve.
Visit UPMCPhysicianResources.com/Ocular to learn more about endoscopic orbital surgery. You can also submit clinical questions or read the most recent questions asked of the UPMC Eye Center’s ophthalmology experts.