Endoscopic surgery of the orbital apex: Outcomes and emerging techniques

OBJECTIVES/HYPOTHESIS: To review our experience with endoscopic orbital apex surgery. STUDY DESIGN: Retrospective review. METHODS: All cases with Current Procedural Terminology codes for endoscopic orbital decompression between 2002 and 2011 at two institutions were reviewed. Patients with a diagnosis of Graves orbitopathy or an orbital complication of sinusitis were excluded. Presenting symptoms, lesion location, pathology, surgical outcomes, and complications were examined. RESULTS: A total of 27 patients were identified. Seventeen (63%) of the patients were men, and the average age was 56 (range = 14-82) years. Eighteen patients had primary orbital apex lesions, and nine patients had sinonasal lesions that predominantly involved the medial orbital apex. The lesions were found to be on the right in 59% of cases. The etiologies include benign (40.7%), malignant (44%), infectious (7.4%), and metastatic (7.4%) lesions. Obtaining a pathologic diagnosis was successful endoscopically in all but two (7.4%) patients, both with lateral lesions. The two-surgeon, four-handed technique and intraoperative image guidance employing fused computed tomography/magnetic resonance imaging were used in the majority of intraconal cases. Complications occurred in three patients (11%) and included myocardial infarction, deep venous thrombosis, and vision loss. There were no cerebrospinal fluid leaks or postoperative hemorrhages. Notably, vision remained stable or improved in all but one patient (3.7% risk of vision decline). Average follow-up was 4 years (range = 1 month-8 years). CONCLUSIONS: The endoscopic approach to the orbit apex offers significant advantages over traditional external approaches, and should be the preferred approach for all medial and inferior lesions. A two-surgeon multihanded technique can help facilitate difficult cases.