Commentary: Clinico-demographic profile of orbital exenteration in a tertiary eye care center – A 20 years’ experience

Orbital exenteration (OE) is the removal of all the orbital contents with or without periorbita and eyelids. It results in disfigurement due to radical excision but can help in controlling lethal and progressive invasive tumors. OE is indicated for periocular malignancies involving the orbit but has also been performed for the management of infectious diseases, inflammatory diseases, trauma, and post-burn patients.[1] Though classically indicated for periocular malignancies, a changing trend and need for exenteration reflect the changes in the diagnostics and therapeutics allowing early diagnosis and conservative management of cancer and changing the etiological profile of the disease. A rising trend of OE for rhino-orbito-cerebral mucormycosis was seen in the COVID era. However, the management of orbital aspergillosis in immunocompetent patients by OE has been challenged by Pushker et al.[2] with the control of infection with antifungal agents alone. Cytologically benign teratomas, schwannomas, neurofibromas, gliomas, and meningiomas may show a progressive course with danger to vision and pain, necessitating surgery. The current study highlights the trend of OE over 20 years; however, comparison or the description of indications over the two different study periods would help understand the change in the etiologies.[3] A detailed analysis of the ocular tumor patients who needed exenteration despite neoadjuvant chemotherapy or previous surgery will help in understanding the stage and aggressiveness of the disease and a changing trend for the same. Data about the extent of resection, the type of exenteration, and the need for any additional surgical interventions such as maxillectomy, lymph node resection, craniofacial resection, and rhinectomy will help in understanding the disease stage and extent at presentation and can be analyzed according to the etiology. The sociodemographic profile and geographic spread of the patients undergoing exenteration can be indirect indicators of access to care and should be evaluated to understand the need for setting up diagnostic and specialized treatment units with adequate infrastructure and multidisciplinary settings and to train specialist ophthalmologists accordingly. The surgical and oncological outcomes of cancer treatment include recurrence-free survival. Local recurrence ranging from 8.5% to 36% and positive surgical margins from 8% to 57.5% mandating adjuvant treatment or re-surgery have been reported.[4] OE is not associated with lower recurrence rates or survival compared to eye-sparing surgery.[4,5] Other factors with poor outcome and prognosis include older age, low visual acuity on presentation, the extent of the tumor, tumor spread, and perineural invasion, which need emphasis. A better understanding of these factors might explain the changing trend for exenteration with eye-sparing surgery preferred more often in recent years. Wide excision conservative surgeries followed by adjuvant treatment have resulted in a low tumor recurrence rate and long-term vision support.[6] New targeted therapies, radiation, globe-sparing surgeries, and immunotherapies have emerged recently as promising management for ocular surface tumors, melanomas, and basal cell carcinoma invading the orbit. OE is now rarely done for rhabdomyosarcoma and orbital retinoblastoma. Recently, studies have questioned whether OE for lacrimal gland carcinomas has any benefit on overall survival compared to globe-sparing surgery.[7] Overall survival rates for 5 years and 10 years appear to be approximately similar for eye sparing and OE studies. These studies, however, do not comment on the quality of life and rehabilitation of these patients, which can be factors of refusal for surgery due to psychological and functional impact.[5,7] The decision of an OE or a globe-salvage strategy should be discussed at a multidisciplinary tumor board meeting and should consider the extent, invasiveness, histology, mutation status, visual status, psychological impact, and choice of the patient. Complete clearance of tumor margins should be the primary aim, and a temptation for globe salvage should not be allowed to compromise this aim. Need for yearly systemic surveillance is important as the presence of clear surgical margins may not always prevent micro-metastasis to lymph nodes or distant organs.