Surgical approach to orbital tumour

By- Dr. Kawshik Nag,
Resident,
Ophthalmology, Phase-A
Chittagong Medical College

1. Surgical Approach To Orbital Tumour And Optic nerve Fenestration By- Dr. Kawshik Nag Resident, Ophthalmology, Phase-A Chittagong Medical College.

2. Orbital Tumours Orbital tumours are rare. They have a wide histological variance. Benign tumours are far more common in children. Difficult surgical challenge despite advances. Safe access to the orbit via the cranium.

3. Orbital Tumours

4. Orbital Tumours Pediatric Orbital tumours Benign Dermoids Capillary Hemangioma Lymphangioma Optic nerve glioma Adult Orbital Tumours BENIGN Meningioma Cavernous Hemangioma MALIGNANT Rahbdomyosarcoma Metastatic diseases MALIGNANT Lymphoma Metastatic diseases

5. Orbital tumours Intraconal tumours Extracoanl tumours Cavernous hemangioma Neurofibroma Schwannoma Lymphoma Fibrous histiocytoma Lymphoma Lymphangioma Metastesis : Adults – breast (up to 70%), bronchus, prostate, skin (melanoma), gastrointestinal tract and kidney. Children – Neuroblastoma , Ewing sarcoma, leukaemia Rhabdomyosarcoma Desmoids

6. Orbital tumours

7. Surgical Approach To Orbital tumour Principles in the Treatment of Orbital Tumour : • The essence is to achieve safe “total” excision of benign tumours . • “En bloc” excision in malignant tumours . • Use “safe” orbital spaces to access the tumour . • Attack the tumour from the base of the cone. • Avoid bipolar coagulation . • Gentle handling of the intraorbital structures . • No fat to be sacrificed . • Reconstruction of the walls of the orbit.

8. Surgical Approach To Orbital tumour Orbitotomy: Orbitotomy operation refers to surgical approach for an orbital mass lesion . Types: Anterior Orbitotomy i. Superior approach used for the lesions located in the superoanterior part of the orbit. It can be performed through: • Transcutaneous route or • Transconjunctival route .

9. Surgical Approach To Orbital tumour ii . Inferior approach is suitable for the lesions located in the inferoanterior part of the orbit. It can be performed through: Transcutaneous route or Transconjunctival route . iii. Medial approach can be performed through: Transcutaneous route Transconjunctival route or Transcaruncular route . iv. Lateral approach is performed through a lateral canthotomy incision

10. Surgical Approach To Orbital tumour Lateral orbitotomy : The preferred incisions are: Upper eyelid crease incision or Lateral canthotomy incision. Transfrontal orbitotomy Temporofrontal orbitotomy .

11. Anterior Orbitotomy It is indicated only when the lesion is readily palpable through the eyelids and is judged to be mainly in front of the equator of eyeball. Fig. Anterior orbitotomy ( A , superior approach, upper eyelid crease incision ; B , inferior approach, subciliary incision; C , medial i.e. frontoethmoidal approach; D , lateral approach by lateral canthotomy )

12. Superior Approach

13. Superior Approach

14. Superior Approach

15. Superior Approach

16. Inferior Approach

17. Inferior Approach

18. Inferior Approach

19. Inferior Approach

20. Medial Approach FIG.1 . Place a speculum beneath the eyelids to expose the medial canthus.  Grasp the caruncle with a toothed forceps and transect it along its mid-vertical line . FIG.2 . With a Westcott scissors, extend the wound several millimeters superiorly and inferiorly .

21. Medial Approach FIG.3 . With a Steven scissors, spread the wound and continue the dissection behind Horner’s muscle to the posterior lacrimal crest. FIG.4 . With a narrow malleable retractor, pull the orbital tissues laterally to expose the medial orbital wall for a distance of about 2 cm behind the posterior lacrimal crest.

22. Medial Approach FIG.5 . Using a scalpel or periosteal elevator, make a 2-cm cut just behind the posterior lacrimal crest to expose the lamina papyracea .   FIG 6 . With the Freer elevator, fracture the lamina papyracea outward.  

23. Medial Approach FIG. 7 . Once hemostasis has been achieved, open medial periorbita with slits above and below the medial rectus muscle. FIG.8 .  Reapproximate the caruncle with an interrupted suture of 6-0 fast-absorbing plain gut, and repair the conjunctival incision above and below with a running or several interrupted sutures of the same material.

24. Lateral Approach

25. Lateral Approach

26. Lateral Approach

27. Lateral Approach

28. Lateral Approach

29. Lateral Approach

30. Lateral Orbitotomy Indictions : Laterally placed extraconal tumours . Intraconal tumours lateral or inferior to the optic nerve. It is useful for lacrimal gland tumours , retrobulbar lesions , such as cavernomas and can be extended for posterior lesions. Advantages: Good exposure, W ell-tolerated procedure. Disadvantages: Visible but minimal scar.

31. Lateral Orbitotomy FIGURE- Skin incisions for eyebrow, lid crease, and lateral canthal approach. FIG- Schematic drawing demonstrating the surgical area accessible by the lateral orbitotomy .

32. Lateral Orbitotomy FIG.1.  Mark an S-shaped incision line from the inferior lateral brow, along the lateral orbital rim, and inferolater -ally along a laugh line at the upper border of the zygomatic arch. FIG.2 . With a scalpel blade, cut the skin along the marked line.With scissors, complete the cut through orbicularis muscle and deep fascia to the periosteum of the orbital rim.

33. Lateral Orbitotomy FIG.3 . Incise the periosteum 2 mm outside the bony rim around the lateral orbit from the superior to the inferior corners of the wound. Separate periosteum from bone with a periosteal elevator . FIG.4- Elevate periorbita from the lateral orbital wall for a distance of 3 to 4 cm.  If bleeding is encountered from vessels penetrating the lateral wall, insert a small sponge and apply gentle pressure for several minutes.

34. Lateral Orbitotomy FIG.5. Place six half-length 4-0 silk sutures around the wound edges and clamp the sutures to the drapes for better exposure. FIG.6. At the level of the frontozygomatic suture line, place wide malleable retractors on either side of the bony orbital rim to protect the soft tissues.

35. Lateral Orbitotomy FIG.7. Move the malleable retractors inferiorly to the upper surface of the zygomatic arch. Make a cut 1.5 cm deep through the orbital rim just above the arch. Angle the cut slightly upward. FIG.8. Drill a hole 1 mm in diameter near the rim on either side of each cut .

36. Lateral Orbitotomy FIG.9 . With a sturdy rongeur , grasp the bony rim and fracture the bone outward.  Cut any adherent tissue from the bone with scissors. Wrap the bone in saline-soaked gauze and place it aside FIG.10 . Remove the thin bone of the greater sphenoid wing from the lateral orbital wall with rongeurs .

37. Lateral Orbitotomy FIG.11 . Identify the lateral rectus muscle by grasping its insertion at the globe and rotating the eye medially. With scissors, open the periorbita by making a vertical cut just inferior or superior to the muscle. FIG.12 . Dissect through the orbital fat by bluntly separating the interlobular capsules with a Freer elevator or dissectors.

38. Lateral Orbitotomy FIG.13 . Carefully dissect around the lesion, staying close to its capsule, and bluntly separate it from adjacent orbital tissues. FIG.14 . After biopsy or removal of the lesion, close periorbita with inter- rupted 6-0 Vicryl sutures.

39. Lateral Orbitotomy FIG.15 . Replace the lateral orbital rim and secure it with 4-0 prolene or nylon sutures passed through the predrilled holes.   FIG.16 . Close periosteum over the orbital rim with interrupted 4-0 Vicryl stitches.  Repair the orbicularis muscle with 6-0 Vicryl and the skin with 6-0 fast-absorbing plain gut or prolene sutures.

40. Lateral Orbitotomy . FIGURE- Skull showing the lateral orbitotomy with screw fixation, removed lateral rim and wall

41. Transfrontal Orbtitotomy Indications: Superiorly and medially placed moderate and small-sized tumours Intraconal tumours medial to optic nerve. In this technique, orbit is opened through its roof. In this procedure supratrochlear nerve is preserved. The approach to the tumour should be preferably between the superior rectus and medial rectus muscles,to avoid any injury to the branches of the oculomotor nerve. This procedure is particularly useful for tumour to the optic nerve.

42. Transfrontal Orbtitotomy A B Figs A and B: (A) Superior orbitotomy for the transfrontal approach. (B) How to preserve the supratrochlear nerve by breaking the bony strut which anchors the nerve using a fine osteotome .

43. Temporofrontal Orbitotomy Indications : All tumours with middle fossa extension. All tumours with infratemporal extension. This approach provides an access to the orbit (through its roof) and anterior and middle cranial fossa simultaneously . Advantages: Minimally invasive, particularly for retention cysts. Disadvantages: Visible scar, R isk of infection , L imited indications.

44. Temporofrontal Orbitotomy A B C Fig. A : Bony exposure on a cadaveric skull. Figs B and C: Intra-operative images of the temporofrontal craniotomy.

45. Optic Nerve Sheath Fenestration It is a surgical procedure where incision are made into the meninges surrounding the optic nerve in order to relieve elevated intracranial pressure. Indication : Idiopathic intracranial hypertension. Papilledema. Elevated intracranial pressure secondary to disease with progressive vision loss.

46. Optic Nerve Sheath Fenestration

47. Optic Nerve Sheath Fenestration

48. Optic Nerve Sheath Fenestration

49. Optic Nerve Sheath Fenestration

50. Optic Nerve Sheath Fenestration

51. Optic Nerve Sheath Fenestration

52. Optic Nerve Sheath Fenestration

53. Optic Nerve Sheath Fenestration

54. References Aadil S C. Orbital tumours in : Prakash N T, Ravi R, editors. Ramamurthi and Tandon’s Textbook of Neurosurgery, Third Edition . New Delhi, Jaypee Brothers Medical Publishers; 2012 : Vol 3: 2026-2043, Kenneth W L, Ian B, Geraint F. tumours of the orbit in: Kenneth W L, Ian B, Geraint F, Editors . Neurology and Neurosurgery Illustrated, Fifth Edition. Elsevier, 2010;352-353. Brad B. Orbit in: Brad B, Editors. Kanski’s Clinical Ophthalmology a systemic approach, Eighth Edition. Elsevier, 2016; 78-117, Ramanjit S, Radhika T. Diseases of the orbit in: Ramanjit S, Radhika T, Editors. Parsons’ Diseases of the Eye, Twenty two Edition. Elsevier, 2015; 483-501, Khurana AK, Indu K. The skull, Orbit and Paranasal Sinuses in: Khurana AK, Indu K, Editors. Anatomy and Physiology of Eye, Third Edition. CBS publishers & Distributors Pvt Ltd,2017;569-591