Outcome of modified keyhole craniotomy for orbital tumors: Technical note for retrospective case series

Objectives: Keyhole craniotomy has evolved as a minimally invasive alternative for accessing orbital and orbital apex lesions. This study evaluates a modified keyhole approach performed through a lateral orbitotomy, aiming to minimize tissue disruption while achieving adequate exposure for tumor resection. Materials and Methods: A retrospective review was conducted on 10 patients with benign or malignant orbital or orbital apex tumors who underwent excision using the modified keyhole craniotomy between June 2023 and December 2023 at Cairo University Hospitals. Clinical and radiological follow-up was performed at 3 months, 1 year, and 3 years. Primary outcomes included anatomical exposure, extent of resection, and optic nerve decompression. Secondary outcomes included cosmetic results, visual function, and recurrence. Results: The cohort included 6 females and 4 males (mean age 31.6 years). Tumor types included meningioma ( n = 3), glioma ( n = 2), dermoid cyst ( n = 1), cavernous hemangioma ( n = 1), and nonspecific inflammatory lesions ( n = 3). Total excision was achieved in 7 cases; subtotal excision in 3. Proptosis improved in all patients, with mean Hertel measurements decreasing from 4.5 mm preoperatively to 1.75 mm postoperatively. Visual acuity improved in 4 patients and remained stable in 4; one patient experienced postoperative visual deterioration due to tumor extension into the posterior medial orbit. Complications included one cerebrospinal fluid leak and two transient lateral rectus pareses. No cases developed enophthalmos. One meningioma recurred at 1-year followup. Cosmetic outcomes were uniformly favorable. Conclusion: The modified keyhole craniotomy via lateral orbitotomy provides effective exposure for orbital and orbital apex tumors with minimal tissue disruption, excellent cosmetic outcomes, and low complication rates. This technique has applicability to neurosurgeons in rural or remote locations because it is a minimally invasive approach and does not need any special instruments or equipment, and may serve as a standardized option for selected intraorbital and spheno-orbital lesions.