This video demonstrates the eyelid-sparing orbital exenteration in a 55-year-old patient with ocular surface squamous neoplasia. This procedure enables early wound healing and cosmetic rehabilitation thus minimizing patient morbidity.
Presentation: Dr. Raksha Rao, Centre for Sight, Hyderabad, India
Surgeon: Dr. Santosh G. Honavar, Centre for Sight, Hyderabad, India
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Orbital exenteration is the surgical removal of the orbital contents, including the eyeball. Exenteration may be subtotal, total, extended exenteration, or radical exenteration, depending on the amount of orbital contents excised. Exenteration is generally considered to be a radical procedure that should be performed only when there is a valid indication. It is indicated in primary orbital malignancies, eyelid tumors with orbital extension, ocular surface tumors with orbital extension, intraocular tumors with orbital extension, and for uncontrolled orbital mucormycosis. Following orbital exenteration, the challenge lies in providing a customized orbital prosthesis. A good surgical technique is essential to provide a concave, smooth, and stable skin cover, over which an orbital prosthesis can be glued on. Exenteration can be performed by either an eyelid-sacrificing or eyelid-sparing technique. With an eyelid-sacrificing method, the orbital cavity can be lined by temporalis muscle, forehead flaps, or graphs. Some surgeons advocate spontaneous granulation, and this offers comparable cosmetic results. However, healing by granulation takes longer, and requires intensive postoperative care. To circumvent this problem, an eyelid-sparing technique may be used when possible. This method, popularized by Coston and Small, is a modification of the total exenteration technique, which spares parts of both the eyelids with transverse blepharorrhaphy to cover the orbit, thus ensuring better cosmesis and early rehabilitation. In addition, sparing of the orbicularis muscle provides an excellent vascular supply to the skin flap, enabling early wound healing. This video demonstrates the eyelid-sparing orbital exenteration in a 55-year-old patient with orbital extension of the conjunctival squamous cell carcinoma, also known as ocular surface squamous neoplasia. Exenteration should be performed under general anesthesia. After the patient has been prepped and draped, the incision marking is placed 2 millimeters behind the lash line, and joining them at the medial and lateral commissures. A sterile piece of gauze is placed in the conjunctival cul-de-sac, in conjunctival tumors, as in our case, to avoid maceration of the tumor. Three traction sutures with 4-0 silk are placed through the upper and lower tarsi to provide traction on the orbital contents. Incision is then made with a radio frequency probe along the skin marking. Dissection is carried in the preseptal plane, which decreases the likelihood of violating the orbital septum, which is especially important in our case, where the tumor is present in the anterior orbit. Also, it spares the orbicularis muscle, which provides an excellent vascular supply to the skin flap. Dissection is done ’til the orbital rim is reached, and the periosteum just outside the arcus marginalis is incised. Periosteal elevators are used to dissect the periosteum off the bony orbit, beginning at the orbital rim and continuing all the way back to the orbital apex. Along the superior rim, dissection is gently carried around the supraorbital notch. The supraorbital and supratrochlear neurovascular bundles are identified and cauterized. Subperiosteal dissection is then carried from anterior to posterior lacrimal crest and beyond. Dissection should be performed carefully along the medial wall, so as to not fracture the thin lamina papyracea. Most of the periosteum is loosely adherent to the bone, with tight adhesions seen at several anatomic locations, including the bony sutures and orbital fissures. At these points, gentle dissection is done to prevent any tear in the periosteum. After negotiating the frontozygomatic suture with gentle dissection, zygomaticofacial and zygomaticotemporal neurovascular bundles are identified and cauterized. Dissection should be performed carefully along the orbital floor, so as to not fracture the thin bone and create a communication with the maxillary sinus. The sac is approached by dissecting medial to it and dividing the common canaliculus and orbicularis attachments. It is then dissected from the lacrimal sac fossa and divided from the nasolacrimal duct with cautery. The exposed nasolacrimal duct is obliterated by cautery to decrease the risk of postoperative fistula formation. In the infratemporal orbit, the inferior orbital fissure is encountered and penetrating vessels divided with cautery. Next, the infraorbital nerve is identified and cauterized. A pair of curved enucleation scissors are then introduced into the posterior orbit. The optic nerve, superior orbital fissure contents, and posterior orbital tissues are cut. Hemostasis can be obtained with ice cold wet gauze, pressure, and cautery. If necessary, additional hemostasis is achieved with Surgicel or bone wax. The socket is carefully inspected for any residual tumor tissue, and the adequacy of resection may be judged with the aid of frozen section control. The resection of additional orbital apical tissue may be required. The eyelid flaps are reapproximated in two layers. Orbicularis is closed with 4-0 vicryl and the skin using 6-0 silk. Aspiration of the socket for any blood or serum is done using a 10-CC syringe every day, ’til a dry aspiration is obtained, followed by dressing of the wound. The socket usually heals quickly over the course of 3 to 6 weeks, and is ready for a prosthesis at the end of 6 to 8 weeks. Eyelid-sparing orbital exenteration enables early wound healing and cosmetic rehabilitation, thus minimizing patient morbidity. Our patient did very well and had an excellent cosmetic outcome.
March 8, 2018