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Orbital Exenteration

  • Elad Ben Artsi
  • Suresh Sagili
  • Raman Malhotra
Chapter

Abstract

Orbital exenteration is the removal of all the orbital contents including the periorbita and eyelids. The aim of exenteration is to achieve local control of disease extending to the orbit while preserving normal tissues whenever possible to optimize surgical rehabilitation. Subtotal exenteration (eyelid sparing, conjunctiva sparing) is a modification of exenteration to aid healing and cosmetic rehabilitation. If the bone of the orbit is invaded, an “extended” exenteration is required that includes resection of the diseased bone. The ethmoids, maxillary wall, and zygomatic bone are commonly resected in extended orbital exenteration. Orbital invasion by periocular cutaneous malignant tumors (basal cell carcinoma, sebaceous gland carcinoma, squamous cell carcinoma, and melanoma) remains the most common indication for orbital exenteration. Other indications include tumors arising in the conjunctiva, orbit, globe, or paranasal sinuses. Orbital reconstruction, an integral component of the procedure, can be achieved by local methods (healing by secondary intention [laissez-faire], split-thickness skin graft, or dermis fat graft), locoregional advancement flaps (pedicle flaps, temporalis muscle transfer, frontalis rotational flap, or temporoparietal fascial flap), or microvascular free flaps.

Keywords

Orbital exenteration Subtotal exenteration Eyelid sparing Conjunctiva sparing Extended exenteration Laissez-faire Split-thickness skin graft Dermis fat graft Advancement flaps Pedicle flaps Temporalis muscle transfer Frontalis rotational flap Temporoparietal fascial flap Microvascular free flaps 

References

  1. 1.
    Zhang Z, Ho S, Yin V, et al. Multicentred international review of orbital exenteration and reconstruction in oculoplastic and orbit practice. Br J Ophthalmol. 2018;102(5):654–8.  https://doi.org/10.1136/bjophthalmol-2017-310681.CrossRefPubMedGoogle Scholar
  2. 2.
    Goldberg RA, Kim JW, Shorr N. Orbital exenteration: results of an individualized approach. Ophthal Plast Reconstr Surg. 2003;19:229–36.CrossRefGoogle Scholar
  3. 3.
    Ben Simon GJ, Schwartz RM, Douglas R, et al. Orbital exenteration: one size does not fit all. Am J Ophthalmol. 2005;139:11–7.CrossRefGoogle Scholar
  4. 4.
    Tyers AG. Orbital exenteration for invasive skin tumors. Eye. 2006;20:1165–70.CrossRefGoogle Scholar
  5. 5.
    Howard GR, Nerad JA, Carter KD, et al. Clinical characteristics associated with orbital invasion of cutaneous basal cell and squamous cell tumors of the eyelid. Am J Ophthalmol. 1992;113:123–33.CrossRefGoogle Scholar
  6. 6.
    Madge SN, Khine AA, Thaller VT, et al. Globe-sparing surgery for medial canthal basal cell carcinoma with anterior orbital invasion. Ophthalmology. 2010;117:2222–8.CrossRefGoogle Scholar
  7. 7.
    Donaldson MJ, Sullivan TJ, Whitehead KJ, et al. Squamous cell carcinoma of the eyelids. Br J Ophthalmol. 2002;86:1161–5.CrossRefGoogle Scholar
  8. 8.
    Gerring RC, Ott CT, Curry JM, et al. Orbital exenteration for advanced periorbital non-melanoma skin cancer: prognostic factors and survival. Eye. 2017;31(3):379–88.  https://doi.org/10.1038/eye.2016.218.CrossRefPubMedGoogle Scholar
  9. 9.
    Sagiv O, Nagarajan P, Ferrarotto R, et al. Ocular preservation with neoadjuvant vismodegib in patients with locally advanced periocular basal cell carcinoma. Br J Ophthalmol. 2018.  https://doi.org/10.1136/bjophthalmol-2018-312277CrossRefGoogle Scholar
  10. 10.
    Xu Y, Li F, Jia R, et al. Updates on the clinical diagnosis and management of ocular sebaceous carcinoma: a brief review of the literature. Onco Targets Ther. 2018;11:3713–20.  https://doi.org/10.2147/OTT.S162073.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Bartley GB, Garrity JA, Waller RR, et al. Orbital exenteration at the Mayo Clinic 1967–1986. Ophthalmology. 1989;96:468–73.CrossRefGoogle Scholar
  12. 12.
    Cook BE Jr, Bartley GB. Treatment options and future prospects for the management of eyelid malignancies: an evidence-based update. Ophthalmology. 2001;108:2088–98.CrossRefGoogle Scholar
  13. 13.
    Chao AN, Shields CL, Krema H, et al. Outcome of patients with periocular sebaceous gland carcinoma with and without intraepithelial invasion. Ophthalmology. 2001;108:1877–83.CrossRefGoogle Scholar
  14. 14.
    McKelvie PA, Daniell M, McNab A, et al. Squamous cell carcinoma of the conjunctiva: a series of 26 cases. Br J Ophthalmol. 2002;86:168–73.CrossRefGoogle Scholar
  15. 15.
    Shields JA, Shields CL, Demirci H, et al. Experience with eyelid-sparing orbital exenteration: the 2000 Tullos O. Coston lecture. Ophthalmic Plast Reconstr Surg. 2001;17:355–61.CrossRefGoogle Scholar
  16. 16.
    Miller CV, Wolf A, Klingenstein A, et al. Clinical outcome of advanced squamous cell carcinoma of the conjunctiva. Eye (Lond). 2014;28(8):962–7.  https://doi.org/10.1038/eye.2014.79.CrossRefGoogle Scholar
  17. 17.
    Shields JA, Shields CL. Massive orbital extension of posterior uveal melanoma. Ophthal Plast Reconstr Surg. 1991;7:238–51.CrossRefGoogle Scholar
  18. 18.
    Damato B, Coupland SE. An audit of conjunctival melanoma treatment in Liverpool. Eye (Lond). 2009;23:801–9.CrossRefGoogle Scholar
  19. 19.
    Kersten RC, Tse DT, Anderson RL, et al. The role of orbital exenteration in choroidal melanoma with extrascleral extension. Ophthalmology. 1985;92:436–43.CrossRefGoogle Scholar
  20. 20.
    Rahman I, Maino A, Cook AE, et al. Mortality following exenteration for malignant tumors of the orbit. Br J Ophthalmol. 2005;89:1445–8.CrossRefGoogle Scholar
  21. 21.
    Lin KL, Tena LB, Finger PT. Orbital brachytherapy for extrascleral extension of choroidal melanoma. Br J Ophthalmol. 2006;90:1438–9.CrossRefGoogle Scholar
  22. 22.
    Meel R, Radhakrishnan V, Bakhshi S. Current therapy and recent advances in the management of retinoblastoma. Indian J Med Paediatr Oncol. 2012;33:80–8.CrossRefGoogle Scholar
  23. 23.
    Honavar SG, Manjandavida FP, Reddy VAP. Orbital retinoblastoma: An update. Indian J Ophthalmol. 2017;65(6):435–42.  https://doi.org/10.4103/ijo.IJO_352_15.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Raney B, Huh W, Hawkins D, et al., for the Soft Tissue Sarcoma Committee of the Children’s Oncology Group, Arcadia, CA. Outcome of patients with localized orbital sarcoma who relapsed following treatment on Intergroup Rhabdomyosarcoma Study Group (IRSG) Protocols-III and -IV, 1984–1997: a report from the Children’s Oncology Group. Pediatr Blood Cancer. 2013;60(3):371–6.  https://doi.org/10.1002/pbc.24289.CrossRefGoogle Scholar
  25. 25.
    Woo KI, Sagiv O, Han J, et al. Eye-preserving surgery followed by adjuvant radiotherapy for lacrimal gland carcinoma. Ophthal Plast Reconstr Surg. 2018;1:570.  https://doi.org/10.1097/IOP.0000000000001106.CrossRefGoogle Scholar
  26. 26.
    Nazar G, Rodrigo JP, Llorente JL, et al. Prognostic factors of maxillary sinus malignancies. Am J Rhinol. 2004, 18(4):233–8. http://www.ncbi.nlm.nih.gov/pubmed/15490570. Accessed 30 July 2018.CrossRefGoogle Scholar
  27. 27.
    Safi A-F, Behn L, Rothamel D, et al. Therapy of sinonasal malignancies invading the orbit-orbital exenteration versus preservation of the orbit plus radiotherapy. J Craniomaxillofac Surg. 2017;45(2):258–61.  https://doi.org/10.1016/j.jcms.2016.11.013.CrossRefPubMedGoogle Scholar
  28. 28.
    Rose GE, Wright JE. Exenteration for benign orbital disease. Br J Ophthalmol. 1994;78:14–8.CrossRefGoogle Scholar
  29. 29.
    Gonzalez LF, Bilyk JR. Intracranial arterial avulsion during orbital exenteration. Orbit. 2012;31:190–3.CrossRefGoogle Scholar
  30. 30.
    Looi A, Kazim M, Cortes M, et al. Orbital reconstruction after eyelid- and conjunctiva-sparing orbital exenteration. Ophthal Plast Reconstr Surg. 2006;22:1–6.CrossRefGoogle Scholar
  31. 31.
    Levin PS, Ellis DS, Stewart WB, et al. Orbital exenteration. The reconstructive ladder. Ophthal Plast Reconstr Surg. 1991;7:84–92.CrossRefGoogle Scholar
  32. 32.
    Cooper J. Wound management following orbital exenteration surgery. Br J Nurs. 2009;18(6):S4.CrossRefGoogle Scholar
  33. 33.
    Stanley D, Emerson DJ, Daley JC. Whitehead’s varnish and Jelonet–a better dressing for skin graft donor sites than Jelonet alone. Ann R Coll Surg Engl. 1988;70:369–71.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Lim M, Lew-Gor S, Sandhu G, et al. Whitehead’s varnish nasal pack. J Laryngol Otol. 2007;121:592–4.CrossRefGoogle Scholar
  35. 35.
    Cooper J. The MOEWAT as a proposed method of evaluating orbital exenteration wounds. J Wound Care. 2011;20(478):480–3.Google Scholar
  36. 36.
    Cooper J, Dharmasena A, Malik R, et al. Reliability and effectiveness of the manchester orbital exenteration wound assessment tool: inter-observer agreement. Orbit. 2015;34(3):127–31.  https://doi.org/10.3109/01676830.2015.1014506.CrossRefPubMedGoogle Scholar
  37. 37.
    Cameron M, Gilbert PM, Mulhern MG, et al. Synchronous reconstruction of the exenterated orbit with a pericranial flap, skin graft and osseointegrated implants. Orbit. 2005;24:153–8.CrossRefGoogle Scholar
  38. 38.
    Shore JW, Burks R, Leone CR Jr, et al. Dermis-fat graft for orbital reconstruction after subtotal exenteration. Am J Ophthalmol. 1986;102:228–36.CrossRefGoogle Scholar
  39. 39.
    Sira M, Malhotra R. Reconstruction of orbital exenteration defects by primary closure using cheek advancement. Br J Ophthalmol. 2013;97(2):201–5.CrossRefGoogle Scholar
  40. 40.
    Beare R. Flap repair following exenteration of the orbit. Proc R Soc Med. 1969;62:1087–90.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Mercer DM. The cervicofacial flap. Br J Plast Surg. 1988;41:470–4.CrossRefGoogle Scholar
  42. 42.
    Moretti E, Ortiz S, Gómez García F, et al. Complete mobilization of the cheek zone for orbit exenteration. J Craniofac Surg. 2005;16:823–8.CrossRefGoogle Scholar
  43. 43.
    Zwahlen RA, Grätz KW, Obwegeser JA. The galea fascia flap in orbital reconstruction: innovative harvest technique. Eur J Surg Oncol. 2006;32:804–7.CrossRefGoogle Scholar
  44. 44.
    Reese AB, Jones IS. Exenteration of the orbit and repair by transplantation of the temporalis muscle. Am J Ophthalmol. 1961;51:217–27.CrossRefGoogle Scholar
  45. 45.
    Pryor SG, Moore EJ, Kasperbauer JL. Orbital exenteration reconstruction with rectus abdominis microvascular free flap. Laryngoscope. 2005;115:1912–6.CrossRefGoogle Scholar
  46. 46.
    Patel SY, Tamboli DA, Mancini R. Two-stage rapid exenteration reconstruction to allow early radiation therapy for an aggressive orbital cancer. Int Ophthalmol. 2018;38(2):833–6.  https://doi.org/10.1007/s10792-017-0525-3.CrossRefPubMedGoogle Scholar
  47. 47.
    Sia DIT, Chalmers A, Singh V, et al. General anaesthetic considerations for haemostasis in orbital surgery. Orbit. 2014;33(1):5–12.  https://doi.org/10.3109/01676830.2013.842250.CrossRefPubMedGoogle Scholar
  48. 48.
    Hansen TB. Hot water irrigation to obtain haemostasis [Danish]. Bull Midwifes (Copenh). 1890;3:8–10.Google Scholar
  49. 49.
    Novoa E, Schlegel-Wagner C. Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting. J Laryngol Otol. 2012;126:58–60.CrossRefGoogle Scholar
  50. 50.
    Stangerup S, Dommerby H, Siim C, et al. New modification of hot-water irrigation in the treatment of posterior epistaxis. Arch Otolaryngol Head Neck Surg. 1999;125:686–90.CrossRefGoogle Scholar
  51. 51.
    Stangerup SE, Thomsen HK. Histological changes in the nasal mucosa after “hot-water-irrigation”: an animal experimental study. Rhinology. 1996;34:14–7.PubMedGoogle Scholar
  52. 52.
    Limawararut V, Valenzuela AA, Sullivan TJ, et al. Cerebrospinal fluid leaks in orbital and lacrimal surgery. Surv Ophthalmol. 2008;53:274–84.CrossRefGoogle Scholar
  53. 53.
    de Conciliis C, Bonavolonta G. Incidence and treatment of dural exposure and CSF leak during orbital exenteration. Ophthal Plast Reconstr Surg. 1987;3:61–4.CrossRefGoogle Scholar
  54. 54.
    Ebersold MJ. Five things oculoplastic surgeons should know about neurosurgery. Ophthal Plast Reconstr Surg. 2000;16:247–9.CrossRefGoogle Scholar
  55. 55.
    Massoud VA, Fay A, Yoon MK. Cerebrospinal fluid leak as a complication of oculoplastic surgery. Semin Ophthalmol. 2014;29(5–6):440–9.  https://doi.org/10.3109/08820538.2014.959187.CrossRefPubMedGoogle Scholar
  56. 56.
    Goldberg RA, Weinberg DA, Shorr N, et al. Maximal, threewall, orbital decompression through a coronal approach. Ophthalmic Surg Lasers. 1997;28:832–43.PubMedGoogle Scholar
  57. 57.
    Graham SM, Brown CL, Carter KD, et al. Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease. Laryngoscope. 2003;113:1206–9.CrossRefGoogle Scholar
  58. 58.
    Bolger WE, Tadros M, Ellenbogen RG, et al. Endoscopic management of cerebrospinal leak associated with the use of bone wax in skull-base surgery. Otolaryngol Head Neck Surg. 2005;132:418–20.CrossRefGoogle Scholar
  59. 59.
    Schaefer SD, Soliemanzadeh P, Della Rocca DA, et al. Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression. Laryngoscope. 2003;113:508–13.CrossRefGoogle Scholar
  60. 60.
    Rahman I, Cook AE, Leatherbarrow B. Orbital exenteration: a 13 year Manchester experience. Br J Ophthalmol. 2005;89:1335–40.CrossRefGoogle Scholar
  61. 61.
    Mehta V, Alon EE, Buchbinder D, et al. Novel use of unilateral galeopericranial flaps for closure of sino-orbital cutaneous fistulas. Laryngoscope. 2011;121:777–81.CrossRefGoogle Scholar
  62. 62.
    Limawararut V, Leibovitch I, Davis G, et al. Sino-orbital fistula: a complication of exenteration. Ophthalmology. 2007;114:355–61.CrossRefGoogle Scholar
  63. 63.
    Al-Hity A, Gregory ME, Kemp EG. The intraoperative use of polydioxanone foil to reduce the risk of sino-orbital fistula formation in orbital exenteration. Orbit. 2018;37(2):140–4.  https://doi.org/10.1080/01676830.2017.1383463.CrossRefPubMedGoogle Scholar
  64. 64.
    Yassur I, Hirschbein MJ, Karesh JW. Clinicopathologic reports, case reports, and small case series: 0.01% becaplermin gel for the treatment of a chronic orbital ulcer after exenteration. Arch Ophthalmol. 2001;119:1858–9.PubMedGoogle Scholar
  65. 65.
    Kuiper JJ, Zimmerman MB, Pagedar NA, et al. Perception of patient appearance following various methods of reconstruction after orbital exenteration. Orbit. 2016;35(4):187–92.  https://doi.org/10.1080/01676830.2016.1176207.CrossRefPubMedGoogle Scholar
  66. 66.
    Nerad J, Carter KD, LaVelle WE, et al. The osseointegration technique for the rehabilitation of the exenterated orbit. Arch Ophthalmol. 1991;109:1032–8.CrossRefGoogle Scholar
  67. 67.
    Greig AV, Jones S, Haylock C, et al. Reconstruction of the exenterated orbit with osseointegrated implants. J Plast Reconstr Aesthet Surg. 2010;63:1656–65.CrossRefGoogle Scholar
  68. 68.
    Wong JCL, Thampy R, Cook A. Life expectancy following orbital exenteration. Br J Ophthalmol. 2015;99(1):1–4.  https://doi.org/10.1136/bjophthalmol-2013-304436.CrossRefPubMedGoogle Scholar
  69. 69.
    Weiss GJ, Korn RL. Metastatic basal cell carcinoma in the era of hedgehog signaling pathway inhibitors. Cancer. 2012;118(21):5310–9.  https://doi.org/10.1002/cncr.27532.CrossRefPubMedGoogle Scholar
  70. 70.
    Wu A, Sun MT, Huilgol SC, et al. Histological subtypes of periocular basal cell carcinoma. Clin Exp Ophthalmol. 2014;42(7):603–7.  https://doi.org/10.1111/ceo.12298.CrossRefPubMedGoogle Scholar
  71. 71.
    Williams LS, Mancuso AA, Mendenhall WM. Perineural spread of cutaneous squamous and basal cell carcinoma: CT and MR detection and its impact on patient management and prognosis. Int J Radiat Oncol Biol Phys. 2001;49:1061–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Elad Ben Artsi
    • 1
  • Suresh Sagili
    • 2
  • Raman Malhotra
    • 1
  1. 1.Corneo-Plastic Unit, Queen Victoria HospitalEast GrinsteadUK
  2. 2.Ophthalmology DepartmentThe Royal Shrewsbury HospitalShropshireUK

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