This lecture reviews orbital surgical techniques.
Lecturer: Dr. Yasser Khan
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DR YASSER KHAN: Okay. There we go. Okay. Good. Okay. Am I on, then, Lawrence? Good. Perfect. Hey, good morning, everybody. Actually, good morning my time. It’s probably about 8:00 a.m.. I’m actually in Toronto, Ontario, Canada, speaking to you. I’m sure you are from everywhere around the world. Welcome. And we had spoken last time about orbital disease. And today we’ll continue that talk on the second part of the series, called orbital surgical techniques. For those of you joining in, who were not able to make it last time, don’t worry. The lectures are separate. So this is basically talking about orbital surgical techniques. As always, we’ll try to keep it as interactive as possible, and you’re welcome to ask questions and things like that. So my name is Yasser Khan. I work in ophthalmic plastic and reconstructive surgery at McMaster University and the University of Toronto in the greater Toronto area in Canada. So we’ll begin now. And I’ll look for your questions and answers, and I’ll try and see if I can stop at different points in the lecture to answer any questions you may have or any clarifications you may need. So when it comes to orbital surgery, orbital surgery is — often a lot of people are very anxious about orbital surgery. It doesn’t have to be very anxiety-provoking. It can be actually — if you follow an organized approach, it can actually be very interesting and enjoyable to do, so to speak. So what we’re gonna talk about is that orbital surgery has changed a lot over the last several years, and new techniques have been combined with older, well known surgical approaches. There are many trends and advantages towards doing more aesthetic incisions. The old days of you doing these large incisions that left a lot of scarring are not favored now. Orbital imaging is much better now, at finding out exactly where the neoplasm or where the lesion is. And a lot of deep, deep orbital lesions can be approached by more anterior approaches. So basically, there’s really — when it comes it approaching any patient that needs orbital surgery, there’s really four things that I want you to keep in mind, for every single patient that comes in to your clinic, to your office. And these four things — if you keep them in mind, as basic principles, you will never lose track of what to do, and how to encounter things. So number one, always try and figure out whether the tumor or the neoplasm or the pathology you’re facing is anterior or deep. Second is: always try and determine by imaging or even clinical examination which direction the globe has been pushed. Is what the relationship of the lesion is to the optic nerve. Always try and find out exactly or try and estimate which surgical space the lesion or the tumor is in, and of course, always know what the goal of the biopsy is. Whether it’s going to be an excisional biopsy, or an incisional biopsy. And always, like I said, keep your incisions as aesthetic or as cosmetic as possible. You can see here — these are different approaches. But if you even memorize this slide, and basically take note of it, you will be able to encounter and deal with most surgical problems. So you can see — many anterior approaches use the traditional eyelid crease approach, which is excellent at camouflaging scar, the lateral approach here, which is excellent at hiding or camouflaging scars, there’s the incision where you’re making it in the line that you already have, and the dotted line implies transconjunctival. Even lateral orbitotomy that are lateral to the optic nerve — where the position of the lesion to the optic nerve is important — you can see there’s multiple incisions you can make. An eyelid crease extending into the lateral canthus, this is the lateral canthus, and the more wider, classic orbitotomy incision. And finally, for any anterior orbitotomy with lesions that are deep but medial to the optic nerve, you can always use the vertical lid split, J here, a transconjunctival, or transcaruncular approach. So the first thing I always ask when I see someone with an orbital tumor, I always ask: Is the mass anterior, or deep, or very, very posterior? So the anterior position of the mass in the orbit, to me, is probably the most important thing to determine. And the key thing is: what differentiates — whether it’s anterior or deep — is the position of the mass, with respect to the equator of the globe. Okay? So anything in front of the equator or the halfway point of the globe of the eyeball — that’s considered anterior. And with anterior masses, I always use the front door. So you always use anterior approaches. Okay? With posterior masses, you basically go deep. And for that, you need more advanced techniques. So always look at the equator. And the next slide will basically explain that to you in a second. A few slides down. What about the optic nerve? So always choose the approach that does not cross the optic nerve. Of course, this is common sense, but sometimes common sense is lacking, and we don’t approach it properly. And we refuse to change approach. So remember, always, always, always do not cross the optic nerve. And if you go in there and you realize the lesion is more medial or more lateral than you thought, then change your approach. And if you started a transcaruncular, medial approach, change it and start doing the lateral orbitotomy. But do not cross the optic nerve. There’s a huge risk that you can damage the optic nerve and cause visual loss. For example, any deep tumors lateral to the optic nerve, do lateral orbitotomy. Medial to the optic nerve, do medial orbitotomy, via the eyelid or the conjunctiva, as mentioned before. Is everybody okay with this so far? Good. Let me just check and see if you have any questions. None so far. Good. So we’ll keep on going. Okay. Good. So this is also a very, very important slide. Okay? It kind of summarizes the surgical approaches to the orbit. So you can see here, this line here is the equator. So anything in front of this line is the equator, meaning it’s the halfway point of the eyeball. Anything in front of the equator is basically an anterior orbitotomy, and anything behind is a posterior orbitotomy. So you can see here in the guide — it says anything anterior to the equator, you would do anterior orbitotomy, anything posterior to the globe and lateral to the optic nerve, behind the eyeball, so deep — lateral to the optic nerve, you would do a lateral orbitotomy in this area there. So anything that’s posterior to the globe but medial to the optic nerve — so in this area right there — then you would do a deep medial approach, of some kind, and basically if it’s the — anything that’s a posterior one third of the orbit, in the optic canal or chiasm, then you can do more transcranial approaches. Anything that’s at the apex needs a transcranial approach. And you need to work with a neurosurgeon to lift the brain up, so you can go into the apex. I think that anything that is in this grey area is approachable with a lateral — with a deep lateral or deep medial approach. But anything that gets to be at the apex, you’ve got to use a neurosurgeon to help you get there. Okay? This is another very, very important diagram that basically shows most of the anatomy knowledge that you will need to do orbital surgery. Yes, there’s fine details that you need to know, like vessels and nerves and whatever, but I think in general, if you know this and understand what is in each area, I think you’ll be fine. So, for example, the orbit exists — the eyeball and the orbit exist together in rooms for surgical spaces. So the first space that hugs the globe, which we’re all familiar with, is called the sub-Tenon’s, or the Tenon’s space. And that basically hugs the globe, and goes to the optic nerve. Okay? And you can see all these spaces are differentiated by the eyeball, the extraocular muscles, and the optic nerve. So anything that’s outside of the cone which is formed by, as you know, the extraocular muscles and the optic nerve, is considered extraconal space. Right there you can see in this grey area and in the coronal section, that’s the extraconal space. It’s outside of the cone and outside of the Tenon’s space. Anything that is in the cone… Sorry, that’s in the cone, close to the optic nerve, or surrounded by the extraocular muscles, is the intraconal space. Again, it’s very important, because that guides where you will make your incision and how you will approach something. Anything that is basically outside of the whole orbit area, of course, is the extraorbital space. So brain, nose, skin, tissues. And of course, there’s a subperiosteal space, which is basically just beneath the periosteum, and that’s where you get the hemorrhage and the infections. So next question I always consider is the type of biopsy to do. Excisional versus incisional. When a mass is very circumscribed, meaning it’s very isolated, it’s got nice margins on CAT scan or MRI scan, it’s got a capsule, it’s easily accessible, and you know for a fact or you’re fairly confident that it is not malignant, or something malignant, then excisional biopsy is always preferred. And you can use a cryoprobe, you can use sutures to try and get a deep mass out. Okay? So things that would need that would be like a cavernous hemangioma, maybe a capillary hemangioma, any kind of dermoid cyst, maybe a lymphangioma, all these things you would want to excise completely. Other things you would want to excise completely would be a pleomorphic adenoma, in particular — why? Because a pleomorphic adenoma if you do an incisional biopsy, it’s got about a 15% chance of malignant transformation. So that’s one tumor that is sort of premalignant, that you do not want to do an incisional biopsy. You want to do an excisional biopsy on, and take the whole thing out. For incisional biopsies, I think mostly what you want to do with incisional biopsies is things that are deep. Things that you know are malignant. And the treatment is either chemotherapy or radiation, and you just want a piece of tissue to find out exactly what’s going on. Things that are diffuse, are not localized, do not have a capsule, things that are infiltrative. Those all would require incisional biopsy. Obviously if it’s a really deep lesion, and you can’t get access to it, and it’s not circumscribed, then go for an incisional biopsy. And always, always, always be flexible. Especially when it comes to orbital surgery. It’s a very small space. You may not be successful the first time. You may not be able to get to the mass. It may be too deep. It may be hidden with fat. Don’t forget, the orbital space is a very small space. And you don’t have complete access. You’re looking through a very tiny hole. Very tiny spaces. Your visual exposure is very minimal. And so, you know, sometimes there’s bleeding. And you have to go through the bleeding. And there’s fat. The fat is definitely not your friend. It always comes in the way. You have to push the fat aside. So you may not be able to find it, find the lesion or find the neoplasm. And so you have to be able to modify your approach, use other approaches, have more than one — what we say — one trick in your bag. So everybody clear on this? Good. I’m not getting any questions and answers, so I think everybody should be clear on this, and I’ll keep going. So let’s talk about anterior orbital approaches. Okay? So anterior orbital approaches are basically any surgical approach that is in this grey zone here. Okay? Notice, that is the equator or the halfway point of the eyeball. Anything in front of it would be an anterior orbital approach. And you can see here, most of these approaches are either superior or even inferior, just not past the equator. But most of the approaches will be superior. Okay? So I personally prefer an anterior orbitotomy whenever I possibly can do it. Okay? Obviously… So I will approach even very posterior lesions that are behind the equator with an anterior orbitotomy approach, or like an eyelid crease approach. And usually you can get there from the front, as long as your dissection is clean, you have good assistants, who are retracting the fat and the tissues away, you can actually get to many lesions and do an incisional biopsy, for example, or even if it’s a cavernous hemangioma, you can basically remove that as well. You avoid bone removal. It is much faster. And there’s less healing time involved. Or less morbidity. This is an example of a 50-something-year-old man, that came in with an anterior orbital mass. You can see he has diffuse fullness and swelling here, and basically a globe ptosis, as well as an eyelid ptosis. On CAT scan, you can see basically there’s a poorly circumscribed mass that’s basically hugging the globe. And molding and involving the lacrimal gland. Okay? And it’s also quite diffuse, as it does extend anteriorly. So this is something which you can see — you have access to the lesion, anterior to the equator. And of course, you can use an anterior approach for this. So what I did was an anterior orbitotomy. A classic anterior orbitotomy involves making an eyelid crease incision, going through skin, orbicularis, orbital septum. You’ll often encounter postseptal orbital fat, you get the fat aside, you basically through blunt dissection — and with a good assistant and retraction, you can get the fat aside, and then right away identify any lesions. In this case, we took the fat aside, we entered the orbital septum, and basically saw a pinkish lesion that actually clinically looked very similar to a lymphoma, which it ended up being. I’ve got a little video that shows you exactly what we’re doing here. Okay. So you can see here… Basically I make my skin incision. And that’s orbicularis. And I use a high temperature battery operated cautery a lot for my surgery. Because it’s low power enough, I’ve got enough control, where I can do a lot of my dissections in a really nice way, using the high temperature cautery. You can see I went through the orbicularis. I use Q-Tips a lot in my blunt dissection, because the orbit is all about the layers, and you can peel the layers off very nicely using Q-Tips and high temp. I’ve hardly used any Westcott scissors or anything to cut. I’m using Q-Tips and high temperature. Now I’m using Westcotts to open the septum. Always careful that, you know, we see fat — as soon as we see fat, I know I’m safe. And right away, actually, this pinkish mass was present right underneath the septum. So it actually had expanded. Sometimes you see fat and you’ve got to move fat aside. That looks like lymphoma clinically, and indeed ended up being lymphoma. Lymphoma has a salmon-like appearance. Because it’s very infiltrative, it goes all the way back, and because the treatment is radiation, I didn’t feel the need to do an excisional biopsy, so I did an incisional biopsy, and sent it for flow cytometry and analysis. With lymphoma, pathologists always like a fresh specimen, as opposed to putting in formalin, but if you don’t have access to pathology and it will take a few days to get a specimen to a pathologist, I would put it in formalin. The pathologist can still work on it, even though it is preserved in formalin. Another example of an anterior orbital tumor that basically is taken out medially and anteriorly. You can see it starts anterior to the orbit. We did a biopsy through a very tiny eyelid crease incision, and was able to get actually the entire tumor out. Ended up being a benign lesion. A really good cosmetic postoperative result, as you can see. So what do you do for lower anterior orbitotomy lesions? Which by the way are less common than superior? That’s the area right here. So for that, I basically will use more subciliary or transconjunctival approaches. You can see here… Is a patient with a bit of fullness on the right lower eyelid. On CAT scan, she had a tumor that was located in the inferior orbital space, but it was anterior. So in this case what I did was I did a canthotomy cantholysis. You swing the eyelid over, and then you approach the inferior orbit through a transconjunctival approach. And you can see the tumor was clearly visible there. And I’ll show an example of this in a bit. You can see again… After surgery is done, you don’t even have to suture the conjunctiva. You can put one suture in, but you don’t have to, and you can put the lateral canthus back where it belongs, and she has a really good cosmetic result. I’ll come back to this approach in a bit. Later on. So that’s the anterior approach. And there really isn’t much — there’s the eyelid crease approach. And then for superior lesions, which is most of the lesions, for the less common inferior lesions, you use a trans-conj approach. What about when something is deep? When something is behind the equator, what are the deep surgical approaches? The deep surgical approaches can be divided into two. Lateral and medial. And they’re both very, very separate. You can’t use lateral approaches for medial lesions. You can’t use medial approaches for lateral lesions. Because don’t forget, you don’t want to cross the optic nerve, as a basic rule. So when it comes to medial deep lesions, there’s actually — that’s probably the most challenging part of original surgery. Is really taking on those deep medial lesions. And really for that, you have to be flexible. And your visual exposure is actually the least. But there’s many approaches. So there’s a transconjunctival medial anterior orbitotomy, there’s my favorite for deep lesions, which is the vertical upper eyelid split, orbitotomy, there’s the upper eyelid skin crease medial anterior orbitotomy, the transcaruncular approach, the transcutaneous frontoethmoidal anterior orbitotomy, also known as the Lynch incision, classically, and of course the transnasal endoscopic access to the apex, which I don’t do, but I have done it before in the past, with my ENT colleagues, who are just much better at endoscopic surgery. Especially at the apex. Than I am. But the two most common techniques that I use for medial deep lesions are transconjunctival orbitotomy or the vertical lid split orbitotomy. And I’ll talk about these in a second. So the transconjunctival approach is very useful for doing optic nerve sheath fenestrations, for doing any kind of optic nerve incisional biopsies, for doing any kind of medial intraconal biopsies, and also it’s great for an inferomedial orbital decompression, and in fact, the transconjunctival or transcaruncular is how I do my inferomedial orbital decompressions now. It’s a 15-minute procedure where I take the medial wall out, and it gives the patient a nice decompression. Here is a medial intraconal tumor. We took the medial rectus off the globe, and did a transcaruncular approach, and was able to access the lesion. This is an example of a patient that had that medial intraconal tumor. I basically went in there and detached the medial rectus, gave me a direct access to the medial intraconal space. Was able to retract the globe and get access to the tumor. And obviously put the muscle back, of course. This is also a useful way of doing an optic nerve sheath fenestration. It’s actually my favorite preferred way. You can see this patient — with the medial rectus taken care of, and avoiding any fat. Because fat will cover your site. I was able to get access to the medial part of the optic nerve, which in my opinion is easier and safer. And had a nice view of the gyri, and I was able to use my knife. So here is a picture with a camera, which means I had good sight going in there. So this is a nice approach that I like to use for my optic nerve sheath fenestrations as well. Okay. This is another example of a transconjunctival approach. I use a transconjunctival approach for all my inferior tumors, and also for repairing orbital fractures. I don’t make any anterior incisions, like the plastic surgeons do, when fixing my orbital floor fractures. I’ll do a lateral canthotomy, cantholysis. This is my swing approach. I’ll make a trans-conj incision halfway between the fornix and the base of tarsus right there, and basically reflect the inferior conjunctiva and inferior eyelid retractors, and basically using retraction, I basically enter the inferior orbital space, in front of the orbital septum. You can see here the septum has not been violated. I’m actually in front of the septum. And then I can enter the inferior orbit. By incising periosteum, and entering below the periorbital. So basically the dissection occurs in this space right there. This is a gentleman with an orbital floor fracture. And — I’m sorry. Why is it not coming? This shows you — let me try and — hold on. Sorry about that. I’m gonna quiet the volume down, because you don’t want to listen to all the conversations we had in the OR with both my fellows. Some of them are not very nice. So anyways… That’s a lateral canthotomy and cantholysis. So there I’m doing the cantholysis now. Remember, it’s a swinging technique. I’ve got the forceps for retraction. See there? And I’ve done the canthotomy, cantholysis. This is my forced duction testing to make sure there’s no entrapment. I always compare with the other eye. This patient had inferior rectus entrapment. So now I’m doing a transconjunctival approach. And you can see I’m working halfway between the inferior fornix and basically the base of tarsal plate. And basically making incisions halfway. I’m cutting the conjunctiva and retractors, and through sharp and blunt resection, I’m releasing the conjunctiva and the retractors. So like I said, I use this approach for my fractures, as well as any inferior orbital tumors. I take a 5-0 vicryl suture, and I’m using it for retraction of my conjunctiva and retractors, and I basically carry my dissection to the inferior orbital rim. A Desmarres retractor helps. You want to do a suborbicularis approach. You can see here I’ve not violated the orbital septum. I’m above the orbital septum, but underneath the orbicularis. This is the inferior orbital rim. I’m actually incising the periosteum. And then what I’ll do is, once the periosteum is incised, then I’ll take my inferior elevator and basically enter the floor of the orbit. So I’m incising the periosteum now. Okay? So that’s the inferior orbital rim right there. I use Q-Tips a lot to blunt dissect tissues. And now I’m cutting the periosteum. So that’s the inferior orbital rim. And now I’m using a free elevator to reflect my periosteum, so that I can enter the inferior orbit, underneath the periorbita. And there you go. So now I’ve entered my orbital cavity. So now from this point here, I can basically fix any orbital fracture. I can do a decompression, I can go into the medial orbit, and do a medial decompression and a floor decompression, any tumors I can basically have a really nice view and access to any tumors as well. So it’s a really nice approach. And it’s basically cosmetically — it’s a very good result. And there’s no scars in the skin or anything like that. The surgeon always carries the suction. And a retractor to reflect. And you can see here — is the fracture right there. And this is the… I use Medpor for my floor implants. And I’m just basically sizing the floor implant. And I basically place the floor implant in the floor. To give you an idea… That’s the inferior orbital rim. That’s the orbit. And I’m basically putting it right in the floor, to prevent prolapse of any orbital tissues into the sinus. Okay? So that’s a trans-conj approach. It’s a useful approach for many lesions. The advantage of this is there’s minimal intraorbital dissection, you avoid large skin scars, you can directly approach a lesion, and it’s safer. You avoid sort of medial nerve fibers. The disadvantages is that it is a tight oblique view of the nerve, and you have to disinsert the medial rectus, when it comes to these trans-conj approaches. The vertical upper eyelid split orbitotomy is actually my favorite procedure for doing medial deep lesions. And it’s basically deeper areas of the extraconal and intraconal space. You can nicely approach the intraconal space deep, right behind the eyeball, with this surgical approach. And the healing time is excellent. And the scar camouflage is excellent as well. It’s a nice approach to reach beyond the equator. So basically this area here, in grey, which is the anterior and the posterior areas. Especially lesions right behind the globe. This is a patient that came to me with a one-year history of severe headaches, and a gradual proptosis on the left side. Okay? You can see by just looking at her that the proptosis is quite obvious. I did a CAT scan, and on CAT scan, you can see a very, very large, almost the size of the globe — a very large superior intraconal orbital tumor. It was well circumscribed, and my suspicion was that it was most likely a cavernous hemangioma. At the 1/3 junction of the eyelid, I make a straight incision. You’re not cutting the levator horizontally. You’re basically making a vertical incision. So basically the levator is cut vertically, which avoids ptosis postoperatively, and it’s basically like making a wedge or eyelid laceration. Which then I repair after. So you can see here — I take my 15-degree blade, I make a skin incision, and then I take a Stevens scissors and cut the eyelid in half. So then you can use your retraction sutures to split the eyelid, and enter the sub-Tenon’s space. So first you enter the sub-Tenon’s space, and from that, you enter right behind the globe into the intraconal space, where the tumor is. So you can see I’ve used 4-0 silk sutures for my retraction. It gives me a nice approach right to the conjunctiva, into the sub-Tenon’s space. You can see I’m entering right behind the eyeball, and into the space. You can see I’m using Stevens scissors and entering the intraconal space, reflected the conjunctiva and sub-Tenon’s down. I put a retraction suture in the sclera, a trans-scleral fixation suture, so I rotate the globe inferiorly, so it gives me better access into the intraconal space right there. And with good retraction, good assistance, you can actually enter the space, and especially for benign lesions — this is a cavernous hemangioma, you can either use a cryoprobe to get the tumor out, or you can actually put a 4-0 silk suture through the tumor and get that out that way as well. The other option is that, especially in cavernous hemangiomas that are vascular and benign, you can actually just drain it, so it becomes smaller, and take that out. Preferably if you can take the whole thing out intact, with a cryoprobe, that’s much better. And then it’s closed. This is an example of a different patient with a vertical lid split approach. I’ll walk you guys through it. So you can see here I’m taking a Stevens scissors and basically making a vertical cut in the eyelid. Make sure you have good cautery. So that you can cauterize the margins. I use a 4-0 silk suture for retraction, to split the eyelid. So it gives me good access. Okay. So you can see here… Let me pull this up a bit. Okay. So I basically — both ends. And so now you have this here, and what I’ll do is now, with my Westcott scissors, I will basically come and make a conjunctival incision to the globe, and then basically — when I hit the globe, then I go sub-Tenon’s, and basically enter the intraconal space. It’s a relatively bloodless field. You can see there’s not a lot of — I’m controlling hemostasis carefully with bipolar cautery. You have to have bipolar cautery. But it’s a relatively bloodless field, and there’s not much fat. And you get really… Conjunctival scarring is hidden. So I’m just basically — I’ve incised the conjunctiva, and now I’m entering the sub-Tenon’s space, through some sharp and blunt dissection. I do a partial conjunctival peritomy, so I can reflect the conjunctiva back, and it gives me more exposure, and this way I can put the conjunctiva back at the end of the procedure. Okay? You can see I’m reflecting the globe down. And just carrying on my dissection. Going in there. Okay. So basically, at this point, once everything is excised, once everything is prepared, then I enter the intraconal space, and this is at the very end of the procedure. Coming up right now. I kind of skipped the video. So the tumor has been removed. And basically now we’re closing up. Okay? So I often don’t even close the conjunctiva up, because the conjunctiva tends to heal by itself very nicely. And sometimes by closing it artificially, you can cause symblepharon and things like that. So this is basically just a standard closure, off a vertical eyelid laceration, basically. Okay? So tarsus to tarsus — basically closing in layers, right? You have tarsus to tarsus eyelid — lash line to lash line, muscle to muscle, and you close it in layers, and it gives you a really nice aesthetic result afterwards. Initially, patients will have ptosis. But in my experience, almost 95% have no ptosis. Sometimes you have to go back in there and do a ptosis repair, but usually it’s very minor. And to get a medial tumor out with this approach and only having to do a ptosis repair postoperatively is pretty good. So this is the patient 6 months postoperatively. I did not do a ptosis repair on her at all. Pretty good scar camouflage. There actually is no scar. And she has no ptosis. Another example of a patient with a vertical eyelid split approach. You can see she has a medial deep orbital tumor. And we did a vertical lid crease approach. And the tumor, which was a cavernous hemangioma, was easily visible, was removed, this is the end result, and you can see 6 or 7 months postoperatively, she looks pretty good. So the advantages are that this procedure has an excellent scar camouflage. It maintains good lid height and contour. You can really access the superior orbit, and lesions medial to the optic nerve, that are either peripheral or intraconal. The disadvantages of the procedure is that it can sometimes be difficult to reach the lesion located in the medial posterior one third of the orbit. So if it’s really far back, it is actually more difficult to get. And obviously this is not for inferior lesions, because then you’re crossing the optic nerve. And also potential ptosis. Which, to be honest, has happened to me maybe once or twice, and I’ve had to fix them, but that’s a minor thing, to fix a ptosis. What about deeper lateral lesions? There’s really one surgical procedure that I have in my bag of tricks. Is, you know, basically the classic lateral orbitotomy. With or without bone removal. Over the years, I’ve gotten less and less removing bone. So I hardly ever remove bone. Sometimes you have to. But I can basically get all lesions in this grey area, basically, in the posterior lateral orbital space, both extraconal and intraconal, in a lateral orbitotomy, without bone removal. You have a nice opportunity to have excellent scar camouflage with this procedure. You can remove bone or not. Like I said. And really — access to large, deep lesions. And you can really see quite well. My preferred is either the canthotomy, or the lid incision. I hardly ever use this incision anymore. These are the traditional incisions that were quite large. And were very disfiguring, and also endangered the optic nerve. I don’t do these anymore. Okay? Again, an example of the old way of doing things. We had these large incisions. And again, this scar would probably heal, but you know what? If you can make an incision in the eyelid crease or canthotomy? Much, much better. So here’s a patient with a lateral intraconal large tumor. How would you approach that? It’s well surrounded and encapsulated or circumscribed. And most likely it’s benign. And so most likely it’s a cavernous hemangioma, common things being common. And it’s an adult. So I basically approach it through an eyelid crease approach. In this case, this was basically posterior. Although, to be honest, in this day and age, if I did this now, I probably would not remove bone. But at that point it was quite large, and I didn’t think we could remove it without removing bone. So we basically made two incisions in the lateral orbital rim, removed the bone, and had clear access. Now, removing the bone is actually something that you can learn on your own. What I recommend doing is, if you have an orthopedic surgeon, or even better, if you have an oral maxillofacial surgeon friend or colleague, I would book my first case of an orbital tumor with them. Bring them in. See how they remove the bone. Learn from them, and then when you’re faced with this yourself, then basically you can… You can basically remove the bone yourself. But I think that if you have not seen this procedure before, it helps to bring an oral surgeon or oral maxillofacial surgeon or plastic surgeon with you to help you, and learn from them, so that you can do this yourself after. Once I’ve made two cuts in the bone, in the rim, I basically remove it with a rongeur, and the bone is, by the way, put back. You have nice access to this tumor. You can use a cryoprobe to remove the tumor. And this looks like a cavernous hemangioma. Okay? And you can see — the orbital rim — the lateral orbital rim is, of course, put back with sutures. And you can see the holes here. That’s for putting the bone back. Fixating it back to the orbit. Okay? And with excellent scar camouflage. You can see the patient did very well. The large tumor was removed, and you can’t even tell that the surgery was done. This is a patient that came to me many years ago. And she sat in my examination room with sunglasses on. I asked her to take the sunglasses off. She had this huge proptosis, and she lived like this for about five, six years. You can see — quite disfiguring. She did have vision in this eye, surprisingly, and her cornea was clear. Why was it clear? Because she actually could close the eyelid on top of the cornea. So her cornea was actually clear, and was not opacified with scarring or ulcers. I was really surprised. And she had vision. Basically I did an MRI scan. She had a huge orbital mass. That was right behind the globe. It was pressing the globe. This is really huge. So… What I did was… I basically decided to do a lateral orbitotomy. And basically did a canthotomy. In this case, we had to take bone off. Obviously, because it’s a huge lesion. So I removed the lateral orbital rim. Okay? And basically here it is. Removing the rim. Okay? And you can see this tumor is quite large. Right beneath the eyeball. And it was removed — it was an excisional biopsy. It was removed in its entirety right there. It was about almost 4 centimeters. So you can see the globe is about 2.5 centimeters. So it was quite large. And then we put the bone back. And we closed the incision. It ended up being a grade I schwannoma, by the way. And you can see — I actually put the rim back, using titanium plates. You can also use sutures, 3-0 prolene suture. This was right after the surgery, after closure. And so this was her, about a month postoperatively, and this was her about a year postop. And this is how she presented. Now, she did lose — her vision was count-fingers. To light perception. But at least she could live a normal life and be able to contribute to society. So she was happy. This is an example of a posterior orbital tumor. That I saw recently. This was well circumscribed. Most likely a cavernous hemangioma. Patient presented with severe headaches for about a year or so. You can see hardly any proptosis. This was discovered on routine MRI scan. Young patient, probably in her 30s. So what did we do? Here’s another example. I’m sorry. This is somebody else. So this is… I apologize. This is her MRI scan. You can see it’s a cavernous hemangioma. It’s located in the intraconal space. And it’s relatively small. But causing her enough symptoms. So what I did was… I basically did a lateral orbitotomy. Now, you can see… Always be prepared to change course. I sometimes will mark two incisions, because it’s hard to mark incisions, once they’re all swollen and you’ve injected the anesthetic. So I always mark more than one incision, in case I have to change course. And basically… If I need to go deeper, or I need a bigger approach. But basically, the incision I made was an eyelid crease, extending into the lateral canthus area. I was able to reflect the periosteum. Did not have to remove bone. The cavernous hemangioma was very visible. I used a cryoprobe to remove the tumor. And the patient had an excellent result. This is another example of a small lateral canthotomy. This is just the incision. You can see the patient had a — I’m sorry. This is that patient’s MRI scan. I just had it in the wrong order. So basically we… Removed the cavernous hemangioma without removing bone, using a cryoprobe, closed the canthotomy, and this is her postop. So what do you do with the orbital apex? Any lesion in the orbital apex needs a transcranial orbitotomy. And really needs a neurosurgeon. So just to conclude, when it comes to orbital techniques, I use what I call the soft approach to orbital surgery. Be systematic. Be organized. Always be flexible. Be willing to change course. And pay attention to what technique to use. And I think that’s it. We’ll stop here, guys. Let me look at the questions. Only one question. Please kindly label the incisions A to F. Okay. Maybe next time I’ll do that. Any other questions? Silent group. Any other questions? Good. Also, let me know what topics you want to see. We’re gonna try to do this on a regular basis, when it comes to oculoplastics and orbit. Whether it’s eyelid or lacrimal or anything like that. Please let me know what types of things you want to see. Or want me to talk about in the future. What is SOFT? I’m sorry. SOFT is a mnemonic. It’s my approach to orbital surgery. SOFT stands for systematic, which is S, O is organized, F is flexible, and T is technique. SOFT. Okay? Ptosis surgery — so we’ll get to that. I think the people at Cybersight are taking your feedback, as to what types of things you want me to talk about. But definitely ptosis has been suggested. Good. Any other questions? Do people see a lot of orbital surgery? Who in your regions or areas of the world is doing the orbital surgery? Is it ophthalmologists? Neurosurgeons? Plastic surgeons? The AF… So please explain the AF incision. I’m sorry. I don’t understand. The AF incisions meaning what? Can you… Elaborate on that question? I think… Please explain the A to F incisions. I don’t understand the question. Oh, sorry. That was this one right there, I think. A to F? Is this is it? That’s probably it. These are basically — A to F incisions are basically… The incisions you use when doing different orbitotomy approaches. Right? So this is probably the slide that best explains where you would make the incisions, depending on what orbital approach you want to do. So, for example, if you want to do an anterior orbital approach, because the tumor is anterior to the equator, of the globe, of the eyeball, you could do an eyelid crease approach, a canthotomy/cantholysis, subciliary, or transconjunctival approach. And this is for lateral orbitotomy, and this is more for medial lesions. That’s the eyelid split approach, transcaruncular, transconjunctival, and basically a lid incision. Okay. Any other questions? Question was asked: orbital floor fracture. Medpor is the best? Well, Medpor is not the best. It’s the most expensive. It’s what I prefer. But for a relatively small to mid-floor fracture, there’s multiple things you can use. You can use silastic sheathing, which is basically plastic. You can use PDS. You can use Supramid. There’s different materials that you can use in in your operating room that will suffice. You can even use Gore-Tex. As long as you have a barrier between the intraorbital contents and the sinus. To prevent prolapsing of materials into the sinus. Medpor is best — I like it because often for large fractures, it really keeps the orbital contents away from the sinus. But there’s other things you can use. Medpor is actually quite expensive. It’s readily available where I come from, but may not be an option where you are. I had a question — vertical incisions. Is there a risk of lid margin repositioning? You mean… No. I mean, as long as… So this is where your eyelid surgery techniques come into play. As long as you are comfortable doing a good eyelid laceration repair, where you bring all the tissues together, like you bring tarsus to tarsus, you bring the grey line of the eyelid margin together, you bring muscle and skin together, as long as you do a good vertical closure, just like you would for an eyelid laceration, you’re fine. There’s no lid margin repositioning problems. I’ve had maybe one or two ptosis, never had entropion or trichiasis, never had notching with this kind of procedure. Okay. I have done… So the question was asked about doing orbital surgery using the CT-guided or image-guided… CT-guided navigator. I have used that before. I typically, for deep lesions, I typically work with an ENT surgeon. And we use a CT-guided surgery, where you have a live CAT scan in the OR, and you basically use that to go to the orbit. I do have a whole talk on that. I’ve done it before. But we don’t have enough time today. But maybe in the future, if you guys are interested, I can talk about CT-guided surgery, and show you nice slides of how a posterior orbital tumor is pinpointed live, using CT-guided imaging. Maybe that’s a future talk. but it’s an effective procedure. But the whole setup is about $200,000. It’s an expensive setup. In my hospital, there is only one, and the ENT surgeons and neurosurgeons use it a lot. I get to use it once in a while. So what type of anesthesia is best for orbital surgeries? Basically… A lot of anterior incisional biopsies you can do under local anesthetic. And not even IV sedation. You can give them an oral sedative, if you want. But if you have good local anesthetic, in the skin, around the orbit, you can actually do a lot of anterior orbital lesions. So for sure, you don’t need general anesthetic. But anything that is posterior to the equator, any posterior deep approaches, it’s a very deep approach, and you definitely need general anesthetic for that. But for the anterior approaches, I don’t think you need it, and I’ve had pretty good success doing a lot of these anterior approaches with just local anesthetic. The question was asked: in an orbital floor fracture repair, how do you ensure that all the entrapped tissues have been freed from the fracture, especially at the posterior end? Well, what I do — basically by looking, and being very, very obsessive about making sure that everything, all orbital contents are out of the sinus, by having a good approach, so you have good visualization, by having a headlight that goes deep in, so you can see everything, by having good assistants, and I’ve got excellent fellows. All my fellows, if they’re listening, have been excellent in helping with my surgeries, my residents and my fellows, and lastly, after I have the Medpor implant in there, I do forced duction testing. After I close up the fracture — especially in instances where there’s entrapment of the inferior rectus muscle, I always do a forced duction testing to make sure there’s no tissues left behind. And I always check underneath my implant to make sure there’s nothing there, and I’m all clear. Where to place the incision for a large medial canthal dermoid? For that, I will basically make it in the — basically in the upper eyelid medial skin crease, and extend it into the medial canthus. So almost like a Lynch approach. Or what you could… Let me go back to that, actually, if I can. So for a medial orbital dermoid, I would make my incision probably halfway, like that. Where the eye is. But I wouldn’t do the entire C. I would just start over here, and basically end above the fundus of the lacrimal sac. Okay. We’ll try and work on the ptosis surgery talk next time. I’ll have to work with the Cybersight people, and we’ll determine a topic for the next talk, next month, probably. Yeah. Are there any anatomical landmarks for the vertical lid split? Yeah, it’s one third, two thirds. So you divide the eyelid into three parts. Okay? So you divide the eyelid into three parts. And so one, two… So one, two, three. And you basically do the one third — so if the eye is divided into three parts, you do the medial one third. And that’s where you make your incision. There’s no landmark. It’s just the medial one third of the eyelid. So one third, two thirds. Good. I think we’ll stop here. My email… Did you guys all get my email? I think I had it. If you have ever any questions, you’re welcome to contact the Cybersight guys. They’re actually very good. It’s an excellent team. And they will be able to get ahold of me, or answer your questions and coordinate. But worst case scenario, you can always email me at email@example.com. So that’s another way of getting ahold of me, if you have any other questions. Oh, I will answer this, because I didn’t address it. What are your indications to put drains in the orbit at the end of surgery? When I first started doing orbital surgery, I used a lot of drains. The old Jackson-Pratt suction drain. I was afraid with decompressions. But it would be a waste of time putting it in. Then I would have to have a second procedure to remove the drain and put the suture in the skin. I have not used an orbital drain for about 12 years in my surgery. I don’t use drains anymore. It’s not a problem at all. If I’m worried about a retrobulbar hemorrhage, I’ll leave the wound slightly open, I won’t close it tightly, so any blood can seep through the spaces in the wound. But I don’t put drains in anymore. I don’t use them in orbital surgery anymore, and I’ve never had an issue with that. Good. Well, listen. Thank you so much. Excellent questions. I hope this was useful. If you have any questions, email me or contact Cybersight, and they’ll definitely be able to help you. And I look forward to seeing you guys all next month. We can switch to either eyelids or lacrimal, and I’ll coordinate with the Cybersight team and pick a topic. But please provide them with suggestions of what you want to see, whether it’s eyelid or lacrimal, or even orbital surgery. And we’ll try to do this on a regular basis every month and cover an area that is useful to you. Good. Okay. Well, everybody have a wonderful day. Or night. Bye.
January 24, 2017