Surgery for Orbital Tumors. Part II: Transorbital Approaches

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Surgery for orbital tumors. Part II: transorbital approaches

KIMBERLEY P. COCKERHAM, M.D., GHASSAN K. BEJJANI, M.D., JOHN S. KENNERDELL, M.D., AND JOSEPH C. MAROON, M.D. Department of Ophthalmology, Allegheny General Hospital; and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Orbital tumors can be excised or biopsy samples obtained via transorbital approaches, especially those located in the anterior two thirds of the orbit. The indications and various surgical steps will be reviewed for the anterior, the anteromedial, and the lateral approaches. Some of these approaches can be combined or extended to accommodate large or deep-seated tumors.

KEY WORDS ¥ orbital tumor ¥ transorbital approach ¥ orbitotomy ¥ anteromedial approach ¥ tumor excision

Tumors may occur in all parts of the orbit. The key to edict.2 The anterior orbitotomy is a misnomer because appropriate surgical management is to obtain good-quali- bone removal is often not required. A biopsy sample of ty preoperative imaging studies because even anteriorly infiltrating anterior orbital lesions is usually easily ob- located lesions may have posterior extensions that are not tained by fine needle aspiration. If this technique fails or appreciated on clinical examination. Dermoid cysts, for is unavailable, an anterior approach with incisional biop- example, may have a dumbbell shape and intracranial ex- sy sampling can be performed. The place of incision is de- tension. The safest yet most direct approach should be termined by the tumor location (Fig. 1). A superior mass, used to reach orbital tumors or inflammatory processes. A for instance, can be approached through an eyelid crease multidisciplinary approach with extraorbital approaches is incision or a supraorbital or subbrow incision. essential in complex tumors that involve multiple regions Eyelid Crease Approach for Incisional Biopsy Sam- or deep-seated orbital tumors that cannot be reached by pling of the Lacrimal Gland. A biopsy sample of lacrimal orbitotomy alone.10,16 gland lesions, such as lymphoma, sarcoidosis, or nonspe- cific orbital inflammation, can be obtained through an eyelid crease incision (Fig. 2). The procedure may be per- TYPES OF TRANSORBITAL APPROACHES formed after the patient has received a local anesthetic and There are four primary routes by which transorbital le- intravenous sedation in some cases, although general an- sions can be reached: 1) the anterior orbitotomy without esthesia is usually preferred because the lacrimal gland is osteotomy (superior [eyelid, supraorbital or subbrow inci- typically not easily anesthetized. The eyelid crease on the sion] or inferior [transconjunctival, subciliary, or lower affected side is marked and injected with a local anesthet- eyelid incision]), or with osteotomy of the superior orbital ic. The skin and orbicularis fibers lateral to the region of rim (for large lesions); 2) lateral orbitotomy; 3) medial or- the levator are incised. Hemostasis is achieved using cau- bitotomy; and 4) a combination of the lateral and medial terization. Blunt dissection is carried down to the level of orbitotomies. the lacrimal gland. A biopsy specimen is then obtained using an Ellman radiofrequency unit with the loop attach- ment, a No. 15 blade, or blunt-tipped Westcott scissors. ORBITAL APPROACHES Because the inflamed lacrimal gland can bleed briskly, Anterior Orbitotomy care must be taken to achieve complete hemostasis prior to skin closure. A pressure patch is placed on the wound. The anterior approach to the orbit is useful for lesions Biopsy samples of superior extraconal lesions are ac- of the anterior two thirds of the orbit.5,7,8,12,14 This approach quired in a similar fashion, usually through a supraorbital was devised by Knapp11 in 1874 and popularized by Ben- incision or subbrow incision.

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Fig. 1. Diagram showing incisions for orbital approaches. Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001.

Subbrow Approach to Superior Orbital Lesions. The retractors is used to improve visualization of the mass. steps highlighting this approach are shown in Fig. 3. An The supratrochlear and supraorbital neurovascular bun- incision is made through the lower-brow follicles, parallel dles are visualized and preserved. The superior orbital rim to the orientation of the brow hair, to preserve as many fol- is removed using a sagittal saw. A cryoprobe or Alice licles as possible. The incision is continued to the level of clamp is then used to remove the tumor, and the bone is the orbital bone. The skin and subdermal tissues are re- replaced and secured with titanium miniplates. In cases tracted. The periosteum (periorbita) is incised and dissect- of posterior superior orbital lesions, a craniotomy is nec- ed from the orbital bone, and the lesion is usually imme- essary. diately visible. A transconjunctival route may be used to approach infe- A pediatric Alice clamp or cryoprobe can be used to rior orbital lesions, through a skin incision (subciliary or pull the lesion forward as the blunt Westcott scissors and lower eyelid) or via an extraorbital approach. The cryo- long cotton-tipped applicators are used to release all adhe- probe is useful for extraction of deeper orbital masses. sions. Hemostasis is achieved with cauterization. The periorbital incision may be closed with interrupted No. 5-0 Lateral Orbitotomy vicryl sutures before closing the dura. A pressure patch is The lateral approach was first proposed by Kronlein13 in placed on the wound. 1889, and it was later modified by Berke.3 In 1976 we Superior Approach With Superior Osteotomy. The described our modification of the Berke technique, advo- steps of this approach are illustrated in Fig. 4. Larger ex- cated the use of the surgical microscope, and designed traconal superior orbital lesions cannot be removed by the special microinstrumentation and a self-retaining orbital more simple approach. A superior osteotomy is needed. retractor.15 The incision is made in a subbrow or in a supraorbital The lateral orbitotomy is useful for retrobulbar lesions, position, and its horizontal extent should be generous (at and it can be extended for more posterior lesions. The pro- least 3 cm). A combination of No. 4-0 silk sutures and cedure involves temporary removal of the lateral wall of

Fig. 2. Diagrams illustrating an anterior orbitotomy performed via an eyelid crease approach. The skin and orbicularis fibers are incised lateral to the region of the levator (A). The lesion is exposed and a biopsy sample is obtained (B) before skin closure (C). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001.

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terior wall is completed using a combination of rongeurs and drills. The extent of resection depends on the location of the lesion. The exposure can be extended posteriorly all the way to the orbital apex.1,4 The lateral orbital periosteum is identified. A traction suture is then placed under the lateral rectus muscle dis- tally so that by pulling the traction suture the movement of the muscle can be identified under the periorbita. A periorbital incision is made, avoiding the lateral rectus muscle (Fig. 5). The microscope is used if desired. The lateral rectus is retracted inferiorly or superiorly, depend- ing on the tumor location. Handheld retraction is used to retract the globe anteriorly and to retract the orbital soft tissues. When the tumor is identified, it is dissected using sharp and blunt techniques with cotton-tipped applicators, microdissection instruments, or blunt-tipped scissors. A cryoprobe with special elongated orbital tip is placed on the lesion to provide traction. The tip freezes to the tumor, but the sides of the probe do not freeze, thus allowing the probe to be placed against other tissues in the orbit without freezing them. The cryoprobe is sequentially replaced as the tumor is rolled out. It is advisable to avoid pulling the tumor with a great deal of force because this can dam- age the tissues around it and lead to subsequent bleeding. The process continues until the tumor is freed up entirely and can be removed. After achieving complete hemostasis, closure is begun by smoothing the periorbita into position and verifying that the lateral rectus is intact. The periorbita need not be closed with sutures. The bone is replaced and held in posi- Fig. 3. Diagrams showing an anterior orbitotomy performed via a subbrow approach. Anterior orbitotomy approach to a subpe- riosteal mass (A) via a subbrow approach. An incision is made through the lower brow and parallel to the follicles to preserve them (B). The periosteum is exposed and incised, exposing the lesion (C). The tumor is then excised (D), and the periorbital incision closed with interrupted No. 5-0 vicryl sutures (E). The skin is then closed with interrupted sutures (F). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001. the orbit to gain access to the entire lacrimal gland and lateral, superolateral, and inferolateral tumors. Examples of lesions suited to this approach include pleomorphic ad- enomas and some cavernous hemangiomas. The patient is placed in the supine position with the head turned to side opposite the lesion. A lateral orbitotomy is performed after induction of general anesthesia. A curvilinear incision is made, beginning in the lateral upper brow, extending to the midlateral orbit, and then straight back for 3 cm from the lateral canthus. The periorbita of the lateral orbital wall is dissected from the bone with blunt periosteal elevation. The lateral canthus is tightly attached and is removed using the sharp end of the periosteal elevator, sweeping from above or be- Fig. 4. Diagrams depicting an anterior orbitotomy and superior low the canthus. The lateral periorbita is dissected poste- osteotomy. A generous subbrow incision is made (A). Retraction riorly to the posterior one fourth of the orbit, exposing the facilitates tumoral exposure (B). The area of bone to be removed is marked (C). The bone is removed using a sagittal saw (D), widen- lateral orbital wall (Fig. 5). ing the exposure to the lesion. This approach is more suited to large Angled cuts are made in the inferior and superior orbital extraconal lesions in which added exposure is needed. Reprinted rims, angled slightly toward each other to remove a key- with permission from Kennerdell, et al. Practical Diagnosis and stone portion of bone from the lateral orbital wall. After Management of Orbital Diseases. Boston: Butterworth-Heineman, excising the anterolateral orbital wall, removal of the pos- 2001.

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move anterior and medial tumors within the muscle cone. We have also designed a special retractor for this approach.16 The medial orbitotomy is effective in the management of small, medial orbital tumors such as cavernous hemangiomas, schwannomas, hemangiopericytomas, and isolat- ed neurofibromas. This procedure may be used in conjunction with a sinus procedure in cases in which both regions are involved. The medial orbitotomy is performed after induction of general anesthesia. A medial peritomy in which relaxing incisions are angled superiorly and inferiorly is used to expose the medial rectus muscle insertion (Fig. 7). The medial rectus is freed from its intramuscular sep- tum and check ligaments and imbricated with No. 6-0 vicryl suture, doubly locked at both borders, and severed from the insertion site with blunt Westcott scissors. The medial rectus is then gently retracted medially. The medial orbital retractor is introduced, and the malleable retractor or modified enucleation spoon is used to retract the globe laterally. These can be attached to a bar of the Leyla system. Dissection is then performed using the microscope. The microsurgical instruments, in conjunction with long cotton-tipped applicators, are used to dissect the fat deeper and deeper until the tumor is identified. Bipolar cautery is used to coagulate the the sources of blood in the medial orbital compartment and to remove the fat until the tumor is identified. When a sufficient surface area is exposed, a specially designed cryoprobe is applied to the tumor to facilitate its manipulation. Using the cryoprobe to lift the tumor, the posterior portions are progressively dissected and the tumor is finally removed. If the tumor is such that it cannot be resected intact, then it is often removed piece- meal by using a pituitary cupped forceps. Occasionally bi-

polar cauterization or a CO2 laser is needed to reduce the tumor. Because direct visualization is difficult, direct pal- Fig. 5. Diagrams illustrating the lateral orbitotomy: AÐF: In- pation is often essential to confirm that the tumor is com- itial exposure. G and H: Periorbita opening and tumor resection. pletely excised. The medial rectus is then reattached to its The anatomical relationship of the temporalis, globe, sphenoid insertion site, and the conjunctiva is closed. A pressure bone, lacrimal gland, and globe are detailed (A). The skin incision patch is placed until the next morning. is outlined (B). The incision is deepened and the periosteum exposed and incised (C). The temporalis muscle is dissected and retracted posteriorly (D). The orbital rim is removed (E) and the Medial Lateral Orbitotomy lateral orbital wall drilled down (F). The periorbita is opened (G) and tumor exposed (H). m = muscle. Reprinted with permission Large or posteriorly located medial orbital tumors may from Kennerdell, et al., Practical Diagnosis and Management of be resected via transorbital approaches, but they require a Orbital Diseases. Boston: Butterworth-Heineman, 2001. combined lateralÐmedial orbital approach. Large, primar- ily medial intraconal tumors are ideally suited for this approach, particularly large neurofibromas or hemangiomas located deep in the medial orbital compartment. The later- tion by nonabsorbable No. 4-0 nylon sutures. The perior- al approach is identical to the previously described ap- bita and the slip of temporalis and periosteum are attached proach except the lateral incision is made directly through at the lateral orbital margin with No. 5-0 nondyed vicryl the canthus, 3 cm posteriorly, in the fashion of Berke.3 sutures (Fig. 6). Vertical mattress sutures are used to close This is done to allow the globe to be prolapsed into the the subcutaneous tissue to approximate the wound edges, bone defect laterally so that more room can be obtained and the skin is closed with a running suture. A pressure medially to extract the tumor (Fig. 8). patch is applied until the next morning. Intraoperatively, 10 mg of Decadron and 1 gram of An- Transconjunctival Medial Orbitotomy cef are administered in all cases in which orbitotomy is performed. A combination of antibiotic and steroid drops The medial approach was described in 1973 by Gal- is prescribed twice daily for at least the 1st week postop- braith and Sullivan6 to decompress the optic nerve and re- eratively. Patients in whom large tumors were resected are lieve papilledema. We have used the same approach to replaced on a 5-day course of prednisone postoperatively.

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Fig. 6. Diagrams showing closure of the lateral orbitotomy. The orbital osteotomy is secured in place by using the predrilled holes and nonabsorbable sutures (A). The temporalis fascia and periosteum/periorbita complex are closed (B). The skin is then closed (C). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001.

CONCLUSIONS Most orbital tumors can be safely approached via the transorbital routes. They require instruments and skills that are atypical for the general ophthalmologist. The presence of important neurovascular structures within the

Fig. 7. Diagrams depicting stages in a medial orbitotomy. The medial orbitomy is used for well-circumscribed lesions in the intraconal medial region (A). A medial peritomy with relaxing incisions exposes the medial rectus muscle insertion (B). The latter is freed and imbricated (C). The medial orbital retractor is placed with the Fig. 8. Diagrams illustrating step in the mediolateral orbitoto- enucleation spoon used to retract the globe laterally (D). The mi- my. The medial lateral orbitotomy is ideal for large medial intra- croscope is brought in and dissection performed to isolate the tu- conal tumors (A). The skin incision is straight or slightly curved to mor. The ophthalmic cryoprobe is useful to hold the tumor (E). follow a dominant laugh line (B). A lateral canthotomyÐcantholy- After excision of the tumor, direct palpation is often essential to sis is performed. The lateral rim and wall are removed, as already confirm complete excision because direct visualization is difficult. described in Fig. 5 (C). A medial transconjunctival orgitomy is per- The medial rectus is then reattached to its insertion site and the con- formed, as outlined in Fig. 7 (D). The globe is retracted laterally junctiva is at the limbal site of the relaxing incisions (F). Reprinted into the defect created by the lateral orbitotomy by using a spoon with permission from Kennerdell, et al., Practical Diagnosis and retractor, and the tumor is exposed (E). Reprinted with permission Management of Orbital Diseases. Boston: Butterworth-Heine- from Kennerdell, et al., Practical Diagnosis and Management of man, 2001. Orbital Diseases. Boston: Butterworth-Heineman, 2001.

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Unauthenticated | Downloaded 09/27/21 02:40 PM UTC K. P. Cockerham, et al. orbital fat contents makes dissection tedious. Many of the 8. Hassler W, Schaller C, Farghaly F, et al: Transconjunctival ap- instruments required to facilitate orbital surgery are readi- proach to a large cavernoma of the orbit. Neurosurgery 34: ly available from ophthalmological and neurosurgical in- 859Ð862, 1994 strument companies. Unlike a typical ophthalmological 9. Hurwitz JJ, Mishkin SK: The value of cryoprobe-assisted re- procedure, the surgeon’s index finger is essential to pal- moval of orbital tumors. Ophthalmic Surg 19:94Ð97, 1998 10. Kennerdell JS, Maroon JC: Microsurgical approach to intraor- pate and occasionally provide dissection for deep masses. bital tumors. Technique and instrumentation. Arch Ophthal- Cotton-tipped applicators are very helpful for performing mol 94:1333Ð1336, 1976 blunt dissection and retraction when working in the orbital 11. Knapp H: A case of carcinoma of the outer sheath of the optic fat. In addition to the standard instruments that are useful nerve, removed with preservation of the eyeball. Arch Oph- in orbital tumor surgery such as the wire lid speculum, thalmol Otol 4:323Ð354, 1874 blunt Westcott scissors, the Stevens and Green hooks, 12. Kronish JW, Dortzbach RK: Upper eyelid crease surgical ap- other specific orbital instruments are required—malleable proach to dermoid and epidermoid cysts in children. Arch retractors, curved scissors and forceps with specialized 6- Ophthalmol 106:1625Ð1627, 1998 inch length, and a cryoprobe.9,14,17 There is no fixed orbital 13. Krönlein RU: Zur Pathologie and operativen Behandlung der retractor system currently available that can be easily used Dermoidcysten der Orbita. Beitr z Klin Chir Tubing 4: 149Ð163, 1889 and that is superior to manual retraction. We are currently 14. Lazar M, Rosen N, Geyer O, et al: A transconjunctival cryosur- working to develop a newer practical and efficient retrac- gical approach for intraorbital tumours. Aust N Z J Ophthal- tor system, which combines orbital retractors with special- mol 13:417Ð420, 1985 ized shapes and the neurosurgical Leyla system. 15. Maroon JC, Kennerdell JS: Lateral microsurgical approach to intraorbital tumors. J Neurosurg 44:556Ð561, 1976 References 16. Maroon JC, Kennerdell JS: Surgical approaches to the orbit. In- dications and techniques. J Neuorsurg 60:1226Ð1235, 1984 1. Arai H, Sato K, Katsuta T, et al: Lateral approach to intraorbital 17. Maroon JC, Onik G, Quigley MR, et al: Cryosurgery re-visited lesions: anatomic and surgical considerations. Neurosurgery for the removal and destruction of brain, spinal and orbital tu- 39:1157Ð1163, 1996 mours. Neurol Res 14:294Ð302, 1992 2. Benedict WL: Surgical treatment of tumors and cysts of the orbit. Am J Ophthalmol 32:763Ð773, 1949 Acknowledgement 3. Berke RN: Modified Krönlein operation. AMA Arch Ophth 51:609Ð632, 1954 The authors would like to acknowledge Mrs. Alexis Ferencz for 4. Carta F, Siccardi D, Cossu M, et al: Removal of tumours of the her assistance in preparing this manuscript. orbital apex via a postero-lateral orbitotomy. J Neurosurg Sci 42:185Ð188, 1998 5. Carter JB: Transconjunctival resection of an orbital dermoid tumor. J Maxillofac Surg 13:239Ð242, 1985 6. Galbraith JE, Sullivan JH: Decompression of the perioptic Manuscript received April 13, 2001. meninges for relief of papilledema. Am J Ophthalmol 76: Accepted in final form May 3, 2001. 687Ð692, 1973 Address reprint requests to: Ghassan K. Bejjani, M.D., Tristate 7. Harris GJ, Logani SC: Eyelid crease incision for lateral orbito- Neurosurgical AssociatesÐUPMC, 200 Lothrop Street, Suite 5C, tomy. Ophthal Plast Reconstr Surg 15:9Ð18, 1999 Pittsburgh, Pennsylvania 15213. email: [email protected].

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