Cryo-assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases

Ophthalmological and Interdisciplinary Surgical Approaches to the Orbit

The treatment of orbital masses often requires an interdisciplinary approach. Ophthalmological surgical approaches include the anterior transcutaneous approach for removal of dermoids or taking biopsies. Anterior transconjunctival orbitotomy is suitable for masses of the inferior orbit or the intraconal compartment, but is inappropriate for masses of the orbital apex. The lateral transosseous orbitotomy often fits for masses of the lateral or intraconal compartment, especially for neoplasms of the lacrimal gland e.g. pleomorphic adenoma. Cryoextraction is often the technique of first choice for cavernous haemangiomas of all localisations. Transfrontal approaches are suitable for the resection of tumours of the optic nerve and of the orbital apex.

Clinical Outcome and Technical Nuances After Resection of Orbital Cavernous Venous Malformations-A Single-Center Experience

BACKGROUND

Cavernous venous malformations (CVMs) represent the most common benign intraorbital lesions. Enlarging or symptomatic CVMs (progressive proptosis or visual disturbances) are treated by surgical resection. For this, a variety of different surgical approaches have been described. The aim of this study was to present a contemporary series of orbital CVMs treated via open microsurgical approaches.

METHODS

In this study, patients who underwent resection of orbital CVMs between 2002 and 2019 were included. Presenting symptoms were noted and neuro-ophthalmologic examinations performed pre- and postoperatively. For surgical resection, the location of the orbital CVM and its relation to the orbital anatomy led to decision-making for appropriate approaches. A comparison between anatomical location and surgical outcome was performed.

RESULTS

Overall, 35 patients with orbital CVMs were included. Most common presenting symptoms were progressive proptosis (43%) and visual disturbances (34%). Most common location was the lateral quadrant (37%) followed by the superior quadrant (20%). A subfrontal craniotomy was performed in 40% of cases followed by a supraorbital craniotomy including the orbital rim in 34% of cases. For surgical excision, a cryo-probe was used in 30 patients, and complete resection was feasible in all cases. Location of a CVM within the superior quadrant was associated with improved postoperative recovery of visual acuity. No differences for clinical outcomes were observed depending on the surgical approach.

CONCLUSIONS

Resection of orbital CVMs is indicated in patients with visual disturbances or progressive proptosis. In these, microsurgical approaches can be used with minimal morbidity for complete removal of these well-circumscribed lesions.

Surgery around the Orbit: How to Select an Approach

Orbital region pathologies may be safely and effectively treated through a various number of approaches. As the concept of "outcome" and minimally invasive surgery keeps gaining popularity in neurosurgery, these approaches-each with specific indications and limitations-together provide the best surgical options.

Surgical Outcomes of Intraconal Cavernous Venous Malformation According to Their Location in Four Right-Angled Sectors

The present study evaluated the surgical outcomes of intraconal cavernous venous malformation according to their location in 4 right-angled sectors. Data regarding the surgical method and approach, surgical outcome, and postoperative complications were retrospectively analyzed for 18 patients with intraconal cavernous venous malformations that were surgically treated at the authors' center between March 2006 and May 2017. The lesion location was defined using 2 perpendicular lines connecting the optic disc and the 4 surrounding rectus muscles in the coronal plane, which resulted in the formation of 4 right-angled sectors (upper-outer quadrant, upper-inner quadrant, lower-inner quadrant, and lower-outer quadrant). Accordingly, there were 3, 3, 8, and 4 lesions in the upper-outer, upper-inner, lower-outer, and lower-inner quadrants, respectively. Ten patients received anterior orbitotomy and 8 received lateral orbitotomy. There were no recurrences during the follow-up period. All patients exhibited reduced proptosis after surgery. Vision improved in 4 patients and remained unchanged in 14. Five patients experienced ocular movement limitation (1 permanent and 4 temporary), 1 developed an inferomedial blowout fracture, 2 developed a temporary sensory deficit, and 1 developed temporary ptosis. The authors' findings suggest that intraconal cavernous venous malformations most frequently occur in the lower-outer quadrant. Although most lesions can be removed via anterior orbitotomy, large lesions located near the orbital apex or on the orbital wall require lateral orbitotomy. Ocular movement limitation is a common complication and can become permanent in rare cases, necessitating close monitoring. Lesion location and surgical approach do not seem to influence the postoperative complication rate.

Trans-septal suture retraction for endoscopic orbital surgery

PURPOSE

We describe a novel technique for endonasal endoscopic orbital surgery. Previously described strategies for minimally invasive orbital surgery include mobilization of the medial rectus muscle and cryosurgical retraction of the pathologic lesion. Herein we describe endoscopic trans-septal suture retraction of an orbital cavernous hemangioma to facilitate intra-orbital dissection from an external approach.

METHODS

A 36-year-old male presented with blurred vision in his left eye for several years, along with several months of progressive left proptosis and decreasing visual acuity. Imaging revealed a 2.5 cm orbital mass consistent with a cavernous hemangioma. The patient underwent a combined transconjunctival and endoscopic approach for resection.

RESULTS

Following left medial orbital wall and floor decompression, endoscopic trans-septal suture retraction facilitated dissection of the lesion from intraorbital structures. A complete extracapsular resection of the lesion was achieved. The inferomedial orbit was reconstructed with a synthetic implant.

CONCLUSION

Trans-septal suture retraction is an effective adjunctive technique for endonasal endoscopic orbital tumor surgery. This technique facilitates safe retraction and dissection of soft tissue lesions from critical intraorbital structures.

[The transpalpebral keyhole approach in surgery of orbital cavernomas: a case report and literature review]

AIM

Currently, there are many different surgical approaches to orbital pathology. This pathology rarely occurs in neurosurgical practice, and neurosurgeons have often used approaches that can be accompanied by negative cosmetic and functional outcomes.

MATERIAL AND METHODS

We present a case report of orbital cavernoma removal via a minimally invasive approach.

RESULTS

The presented case demonstrates successful removal of orbital cavernoma using the transpalpebral approach: a skin incision along a natural fold of the upper eyelid and orbitofrontal keyhole craniotomy. In the postoperative period, existing symptoms regressed; the patient assessed the cosmetic effect as excellent.

CONCLUSION

The transpalpebral keyhole approach can be an excellent alternative to traditional approaches to orbital cavernomas. This approach demonstrated its efficacy and safety in skull base surgery and provided excellent functional and cosmetic outcomes.

Endoscopic Transnasal Cryo-Assisted Removal of Orbital Cavernous Hemangiomas: Case Report and Technical Hints

BACKGROUND

Cryoprobe devices are used by ophthalmic and orbital surgeons for extraction of fluid-filled intraorbital lesions. No series has described cryodissection via an exclusively transnasal approach. We describe 2 cases of purely endoscopic transnasal removal of intraconal orbital hemangiomas with the aid of a dedicated cryoprobe.

METHODS

All transnasal endoscopic intraorbital procedures were collected and analyzed. In cases in which intraorbital dissection was performed with the use of an Optikon Cryo-line probe, clinical features, histology, size and location of the lesion, early and late complications, surgical procedure time, and hospital length of stay were analyzed. Patient follow-up included endoscopic endonasal evaluations performed at 2, 4, and 8 weeks after surgery and ophthalmologic and orthoptic evaluations performed 2 days and 2 months after surgery.

RESULTS

Two transnasal intraorbital endoscopic procedures with the aid of the dedicated Cryo-line probe were collected. Lesions were located in the intraconal space, medial to the optic nerve. In both patients, the histologic evaluation was compatible with cavernous hemangioma, and complete resection was obtained. Mean hospital stay was 5.5 days. Postoperative ophthalmologic and orthoptic evaluations performed 2 months postoperatively revealed complete resolution of preoperative symptoms.

CONCLUSIONS

Cryoprobes represent an adjunctive tool in the orbital surgeon's armamentarium useful in the extraction of fluid-filled intraorbital lesions. This preliminary experience suggests that their use can ease the removal of intraconal hemangiomas with an exclusively transnasal approach. The analysis of further cases is necessary to confirm safety and efficacy.

Cavernous venous malformation (cavernous hemangioma) of the orbit: Current concepts and a review of the literature

The cavernous venous malformation of the orbit, previously called cavernous hemangioma, is the most common primary orbital lesion of adults. Cavernous venous malformation occurs more often in women and typically presents in the fourth and fifth decades of life. It is a benign vascular malformation characterized by a well-defined capsule and numerous large vascular channels. The most common sign of cavernous venous malformation is progressive axial proptosis from the preferential involvement of the intraconal orbital space. Optic nerve damage and other signs of orbital pathology may be present, with a variable degree of visual impairment. The combination of ultrasound, computed tomography, and magnetic resonance imaging leads to an accurate diagnosis in the vast majority of cases. Surgical and nonsurgical treatments are required in case of symptomatic lesions, with a characteristic multidisciplinary management influencing optimal outcome. Orbitotomy represents the traditional surgical approach. Recently, the endoscopic transnasal approach to the orbital cavity has gained interest, representing a feasible and safe, less-invasive surgical technique for the management of cavernous venous malformation.