ENDONASAL ENDOSCOPIC ORBITAL DECOMPRESSION

Introduction:
Today, there is a growing trend towards the use of minimally invasive techniques in surgery as
well as day-care surgery. This is a result of trying to achieve a better cosmetic outcome
combined with reducing the morbidity associated with extensive tissue dissection. Endoscopic
surgery exemplifies these attempts and has been enthusiastically adopted by general surgeons,
gynecologists and ENT surgeons. Endoscopic orbital surgery, is performed primarily via
sinonasal approaches by ENT surgeons. Endonasal endoscopic approaches are well established
for orbital decompression, orbital medial wall fracture repair and optic nervedecompression.
The widespread use of endoscopes in medicine followed the development of fiberoptic
transmission of light by van der Heel, Harold Hopkins and Narinder Kapany [(who coined the
term fiberoptics) (Prabhakaran and Selva, 2008)] . This allowed vastly superior illumination at
the surgical site, thus overcoming the main limiting factor of endoscopes until that time. The first
endoscope using fiberoptic transmission was a gastroscope built by Hirschowitz in 1958 (Gow,
1998). Rigid endoscopy became popular with the invention of rod lenses by Harold Hopkins in
1960 (Gow, 1998). They were first used in rigid cystoscopes and later in other endoscopes.

The use of endoscopes in orbital surgery was first described by Norris and Cleasby (1981). The
initial reports by Norris and Stewart (1985) detailed the use of the endoscope in obtaining biopsy
from orbital tumors and in removing foreign bodies from the orbit.
Endoscopic sinus surgery for the treatment of acute andchronic sinusitis was well established by
the first third of this century (Hajek, 1962). It was based on the commendable anatomical studies
of Zuckerkandl (1892), Onodi (1911) and Grnwald. Transnasal endoscopic sinus surgery was
introduced in the mid 1980s. The term FESSwas coined by Kennedy (1985). Endoscopic orbital
decompression wasfirst described by Kennedy(1990) and Michel (1991) in the early 1990s.
Overthe years, enhanced visualization of key anatomic landmarkssuch as the region of the orbital
apex, which is a critical area of decompression in optic neuropathy, has made endoscopic surgery
a versatile tool (Al-Mujaini et al, 2009).




Indications:
1. Orbital Abscess in the medial, supero-medial or infero-medial compartment of the orbit.

Fig. Axial view of a Contrast Enhanced CT Scan showing a left subperiosteal orbital
abscess with the characteristic peripheral ring enhancement (red arrow).
2. Orbital Cellulitis (Fig. ).


Fig. CT Scan of the Paranasal Sinuses, coronal cut showing right orbital cellulitis
secondary to fungal sinusitis.





3. Orbital Haematoma (Fig. ) in the medial, supero-medial or infero-medial compartment of
the orbit.




Fig. A clinical photograph showing an orbital haematoma affecting the right eye
following a fall resulting in proptosis.



Fig: Clinical photograph showing an orbital haematoma affecting the right eye following
trauma











4. Dysthyroid Orbitopathy / Thyroid-associated Orbitopathy.


Fig: Coronal CT scan showing bulky extraocular muscles, within the orbits, in the region
of the orbital apices




Fig: Axial MRI scan showing bulky extraocular muscles bilaterally, the classical cola
bottle sign












5. Orbital Tumors occupying the medial compartment of the orbit (Fig. ).

Fig. Clinical photograph of a patient with right proptosis due to a nasal mass.



Fig. CT Scan of the Paranasal Sinuses (axial view) showing the tumour resulting in right
proptosis in the same patient as in Fig. .
6. Orbital Fractures confined to the medial wall or the floor (Fig. ).


Fig. A CT Scan (axial view) showing a fracture of the medial wall of the orbit with the
orbital contents prolapsed into the ethmoids.
7. Foreign bodies embedded in the orbit require decompression of the orbit to facilitate their
removal

Fig. A foreign body embedded in the left orbit

Fig. Endoscopic view of the foreign body prior to removal endoscopically. After
performing an ethmoidectomy, the splintered lamina papyracea was gently removed
piecemeal, following which the metallic foreign body was gently teased out.

Fig. The foreign body after endoscopic removal
8. Fractures of the medial orbital wall with muscle entrapment.



Fig. Axial CT scan of a patient with post traumatic medial orbital wall fracture, showing
left medial rectus entrapment. Note the fracture fragment embedded within the left
medial rectus muscle. The lamina papyracea had to be removed, and the fracture
fragment gently teased off the underlying muscle, which had also developed an
intramuscular haematoma.


Fig. The intraoperative endoscopic image showing the fracture fragment being teased
off the prolapsed orbital contents.


The sequelae of the proptosis that results due to the above-mentioned indications 1-5, include
exposure keratopathy, diplopia and eventually visual loss if not treated rapidly. Timely orbital
decompression decreases intra-ocular pressure and increases the effective volume of the orbit,
thus preventing these sequelae.

Anaesthetic Considerations:
This surgery is performed under general anaesthesia and there are no local considerations, unless
the general condition of the patient or any medical problem (such as thyrotoxicosis) may pose a
risk to anaesthesia.

Specific Investigations:
1. CT Scan of the Paranasal Sinuses with orbital cuts is anessential pre-requisite since it not
only helps to detect the site and extent of thelesion, but also serves as a road-map to guide
the surgeon during surgery (Fig. ).

Fig. A Contrast enhanced CT Scan(Coronal view) of the same patient as in Fig.
showing the haematoma occupying the superomedial compartment of the orbit thus,
rendering itself amenable to endoscopic evacuation.


Fig. A Contrast enhanced CT Scan (Coronal view) showing the presence of an apical
root abscess with acute maxillary and ethmoid sinusitis with cheek cellulitis on the left
side and an orbital abscess in the infero-medial compartment of the left orbit. This orbital
abscess was the complication of a dental procedure.

Fig. Coronal cut of the Contrast Enhanced CT Scan of the same patient as in Fig.

Fig. The axial cut of the Contrast enhanced CT Scan of the same patient as in Fig.

2. MR Imaging of the Orbit and the Para Nasal Sinuses is useful for detecting the accurate
site of the lesionwithin the globe (extraconal or intraconal)



Fig.MR Image (coronal view) of the same patient as in Fig. showing the globe sinking
into the maxillary antrum following fracture of the orbital floor.

3. Thyroid Function Tests in patients with thyroid pathology.
4. Testing Visual acquity, Colour vision, Intra ocular pressure and retinoscopy are of great
importance to document pre-operative vision and integrity of the visual pathway.


Surgery of Orbital Decompression:
Other approaches used for orbital decompression :
In 1911 Dollinger performed a lateral walldecompression, nevertheless with minimal
extent.Naffsinger (1931) developed a superior decompression of thecontents into the anterior
cranial fossa.Consequently, Sewall (1936) described a medial walldecompression through an
external ethmoidectomyapproach. Hirsch (1950) was the pioneer to employ a Caldwell-Luc
approach to obtain result by removal of the orbitalfloor. Walsh & Ogura in 1957, extended this
approachto include a medial wall decompression. Since then,this approach is widely accepted as
the standard approachfor orbital decompression. In 1990 Kennedy describedthe first approach
using nasal endoscopes. To maximizethe degree of decompression obtained, he used a
WalshOgura approach with a lateral orbitotomy.


Steps of Endoscopic Orbital Decompression:
1. Performing an uncinectomy
2. Performing an endoscopic spheno-ethmoidectomy

3. Exposing the lamina papyracea (a) upto the orbital apex where one encounters the hard
optic tubercle, which seperates the posterior ethmoids from the sphenoid (b) and even to
visualize the optic nerve (c)
(a)

(b)

(c)



4. Gentle removal of the thin bone of the medial orbital wall (lamina papyracea) taking care
not to injure the underlying orbital periosteum


One must be very careful to ensure that the orbital periosteum does not get injured in this
process, as it will obscure the removal of bone behind it. Even if the orbital periosteum
needs to be split, it must be done after the entire lamina has been exposed.





5. Slitting the orbital periosteum, if indicated.


Advantages:
There are several advantages of an endoscopic orbital decompression over the external
approaches:
Minimal Access Surgery
Decreased morbidity
No external scar
Easy access to the orbital apex
Improved access to the inferior and medial walls of the orbit
Simultaneous treatment of sinusitis



Contraindication:
The endonasal endoscopic route for orbital decompression can be used only in pathologies
localized to the medial, supero-medial and infero-medial regions of the bony orbit. Lesions
situated laterally are not accessible endoscopically and hence not amenable to treatment using
this approach.
Not all proptosed orbits need to be surgically decompressed.
1) In patients of Graves ophthalmopathy, decompression should only be considered if
maximal medical therapy has failed to control the proptosis, and there is clinical evidence
of non-improvement or progressive visual loss
2) In some patients with post-traumatic proptosis, a carotico-cavernous fistula may develop,
this diagnosis can be made by an MRI Angiogram, and more specifically with a DSA.
The presence of an early draining vein during the arterial phase, coupled with a dilated
superior ophthalmic vein on Magnetic Resonance Angiography may help in arriving at
the diagnosis. The management is by an Interventional Neuro Radiologist using the
technique of embolisation of the feeding vessel with steel coils to occlude the fistula,
with dramatic results.


Fig: Clinical photograph of a patient with a post traumatic carotico-cavernous fistula
affecting the left eye and presenting as proptosis, chemosis and visual loss, mimicking
symptoms of an orbital haematoma


Fig: the T2 weighted MRI Scan showing the dilated superior ophthalmic vein on the left
side



Fig. MR Angiogram showing evidence of an early draining vein in the arterial phase, on
the left side, suggestive of a carotico-cavernous fistula.




Fig. Digital Subtraction Angiogram confirming the MRA findings in Fig.



Fig. The successful occlusion of the abnormal communication after embolisation using
steel coils.




Fig. Clinical photograph of the same patient post-embolisation showing a dramatic
reduction in the proptosis.

Complications:
Sun-setting of the orbit- This occurs, if during the decompression, too much of the
orbital floor is removed.
Injury to optic nerve- The optic nerve is most likely to be injured in the region of the
orbital apex while performing an over-enthusiastic orbital decompression.
Injury to medial rectus resulting in diplopia can occur if care is not taken while slitting
the orbital periosteum. The medial rectus runs close to the medial orbital wall in its
medial one thirds and hence care should be taken not to slit the periosteum here.
Meticulous surgery yields good results in experienced hands (Fig. ).



Fig. The clinical photograph of the same patient as in Fig. showing complete recovery of
the proptosis and eye-movements after right orbital decompression for an orbital
haematoma. However, since the patient came late to us, exposure keratopathy had set in
prior to surgery which was eventually managed by the ophthalmologists.


CSF leak is likely to occur if the skull base is traumatised.
Obstruction of the Frontal Recess may occur if there is an over zealous removal of bone
in the antero-superior portion of the medial orbital wall. The orbital periosteum prolapses
into the frontal recess resulting in obstruction and subsequent iatrogenic sinusitis.














Hence, if the above is kept in mind during an orbital decompression, the results are good(Fig. ).



Fig. The Coronal view of the CT Scan of the same patient as in Fig. 7 days after left
orbital decompression and evacuation of pus, showing the orbital periosteum intact with the
orbital contents bulging into the ethmoidectomy cavity.




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