Alternative Path for Optic Nerve Decompression in Pseudotumor Cerebri With Full Endoscopic Lateral Transorbital Approach

Abstract

Endonasal endoscopic approaches are the most preferred surgical methods in patients with pseudotumor cerebri because of easy access to the optic nerve, but the choice of this technique may not apply to all endoscopic endonasal cases. Moreover, there may be difficulties in practice in some cases, including the coronavirus disease 2019 pandemic. This study aimed to suggest an alternative endoscopic approach by lateral orbitotomy for optic nerve decompression in patients with pseudotumor cerebri. The study was performed using 5 fresh-frozen cadaver heads (bilaterally, total of 10 sides) injected intravenously with colored silicone preserved in the cold chain. An average of 2.5 cm skin incision was made to fit the lateral orbitotomy. The lengths of the recurrent meningeal artery (mm), the meningo-orbital band (mm), and the optic nerve (mm) to the orbital margin were measured. After these morphometric measurements, optic nerve decompression was performed endoscopically, and the length of the decompression was measured (mm). The average length (mm) between the orbital rim and meningeal recurrent artery (or meningolacrimal branch) was 16.2 mm, between the orbital rim and the meningo-orbital band was 18.5 mm, and between the orbital rim and optic nerve was 44.1 mm. The average optic nerve decompression length was 4.4 mm. The endoscopic lateral orbitotomy approach provides easy access to the optic nerve by anatomically following the recurrent meningeal artery and the meningo-orbital band. It can be a safe second-line approach after endonasal approaches for optic nerve decompression in pseudotumor cerebri.

The Transorbital Approach, A Game-Changer in Neurosurgery: A Guide to Safe and Reliable Surgery Based on Anatomical Principles

“…Actually, the transorbital approach is employed for a variety of procedures, including optic nerve decompression [28], biopsy [29], and removal of orbital tumors [30,31], as well as lesions in the anterior and middle skull bases [32] and repair of meningoencephaloceles [33]. It has been shown to be effective and safe in many studies, with low rates of complications and high rates of success [34].…”

Ophthalmology and oculoplastics for the rhinologist

“…Recently, the advent of transorbital neuroendoscopic surgery (TONES) has provided pathways to intraorbital, sinonasal, and intracranial regions previously inaccessible through external, or even endonasal endoscopic routes [18]. These have facilitated minimally invasive approaches to the lateral orbit (inaccessible via the endoscopic endonasal approach) and spheno-orbital pathologies [19]. In cases of deep-seated disease such as rhino-orbital mucormycosis, endoscopic intervention can be sight-saving compared to traditional surgical approaches [14 ▪▪ ].…”