Orbital tumor removal is a procedure employed to remove tumors in the orbital region. The orbital region comprises extraocular muscles, nerves, blood vessels, and surrounding bone. Tumors and inflammation can grow around and behind the eye, pushing the eye forward such that a bulge called proptosis develops. A corneal breakdown can result if the orbital tumor does not allow eyelid closure. Proptosis can be caused by lymphoid tumors, thyroid eye disease, vascular tumors, lacrimal gland tumors, and growths in the orbit originating from the sinus. Other causes of orbital tumors include inflammation, infection, and metastatic cancer elsewhere in the body settling in orbit.
Orbital tumors can also arise from Schwann cells, and they are usually benign. Other benign tumors come from glial cells, which are found in the optic nerve. Benign tumors, especially if they come with symptoms or are cosmetically disfiguring, can affect the eye.
Removal of orbital tumors is complicated due to the delicate location of the tumor. The goal of surgery is to:
- Preserve the eye and vision
- Alleviate orbital tumor symptoms and restore good health
- Avoid having to remove the eye altogether. However, if this is not possible, the eye must be removed to save a life in case of a malignant tumor
- Stop a malignant tumor from progressing to a life-threatening phase
Preparation & Expectation Before Surgery
Before surgery, the doctor must understand a patient’s history of orbital surgery if applicable. One of the challenges in orbital tumor removal is determining which approach to take to reach the tumor. It involves both the neurosurgeon and ophthalmologists working together. Hence, the patient should expect extensive tests and examinations, including a physical exam, detailed history, and imaging tests.
Types, Purpose & Procedure
The size and location of the tumor will determine the choice of surgical approach. Usually, the surgeon approaches the tumor from a lateral (side) direction, from below the eye (incisions will be made along the lid or eyebrow), or from above. The tumor removal procedure may take four to eight hours, depending on tumor size and complexity of the procedure. In some cases, the patient may require reconstruction. Some defects may be acquired in surgery, such as Graves' disease, which will also need reconstructive surgery. All surgical procedures involving orbital tumor removal use local or general anesthesia. Some cases, like in the soft-tissue approaches, go further to use orbital and regional nerve blocks together with local or general anesthesia.
Lateral Bone Flap (Traditional Lateral Orbitotomy)
When an orbital tumor is too big or involves sinus, extensive surgery with bone flaps is required. This procedure is considered traditional and involves removing the lateral orbital wall, which is replaced after the tumor has been removed. Due to the position of lesions in the middle to posterior orbit, the surgeon makes soft-tissue incisions that incorporate a bony marginotomy. The bony flap further exposes the deep orbit to provide the surgeon room to maneuver and access the tumor for removal.
In these approaches, the surgeon chooses the most appropriate incision, depending on the lesion’s location within the orbit. If the tumor lies inferior to the optic nerve, the surgeon makes an incision 4 mm on the conjunctiva beneath the inferior tarsal margin. The incision is made through the lower eyelid retractors and into orbital fat. If the surgeon finds it appropriate, s/he may extend the incision laterally or medially. A lateral incision involves slightly loosening the lateral canthal tendon using scissors, to avoid complete release from the rim of the orbit.
If the lesion is situated superiorly, the surgeon makes an incision through the upper eyelid crease 8-10 mm above the lid's margin. The surgeon may customize the incisions medially or laterally, depending on tumor location.
Blunt dissection follows, and the surgeon has several options. For instance, the surgeon dissects soft fatty tissue from the tumor’s face using Stevens scissors and cotton-tipped applicators. S/he passes a half-circle needle via the tumor’s face to cause a decrease in the size of the lesion. A whip suture is then used, and if there are cavernous malformations, it can aid in decreasing the lesion’s size anteriorly. The surgeon can use a tiny anterior incision into the tumor to suction the contents of dermoid cysts or schwannomas. The surgeon then uses a blunt dissection to remove the tumor.
Risks, Side Effects & Complications
The traditional lateral orbitotomy has recorded more complications than the soft-tissue approach, such as:
- External scar
- Longer operation time
- Temporalis muscle wasting
- Increased pain postoperatively
- Longer recovery time after surgery
The soft tissue approach often has less intraoperative or postoperative surgical complications with fewer recurrences compared to the traditional method. It also has less recovery time, mild decrease in visual acuity, and almost no damage to the optic nerve.
After Care, Recovery & Results
Soft tissue approach patients can go home the same day of the procedure. However, those who undergo traditional lateral orbitotomy may need to stay in the hospital for three to seven days with recovery expected to range from two to six weeks following surgery. The small incisions made on the conjunctiva and eyelid crease in the soft tissue approach register relatively quicker recovery with a minimally visible scar and minimal ecchymosis (skin discoloration).
Patients show improved visual acuity and ocular motility, especially in those who undergo the soft tissue approach. Some of the patients with Graves’ disease may need additional reconstructive surgery to reposition the lids. If Graves’ disease is severe, the patient may require the optic nerve and/or the eye to be decompressed or repositioned.