Romanian Journal of Ophthalmology, Volume 61, Issue 3 , July-September 2017 . pp:192- 195 [608227]

Romanian Journal of Ophthalmology, Volume 61, Issue 3 , July-September 2017 . pp:192- 195

GENERAL ARTICLE

192 Romanian Society of Ophthalmology
© 2017
doi:10.22336/rjo.2017.3 5

Transnasal endoscopic orbital decompression

Hainăroșie Răzvan* **, Ioniță Irina* **, Pietroșanu Cătălina* **, Pițuru Silviu*, Hainăroșie Mura* **,
Zainea Viorel* **
*”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
**“Prof. Dr. Dorin Hociotă” Institute of Phonoaudiology and Functional ENT surgery, Bucharest, Romania

Correspondence to : Silviu Pițuru,
”Carol Davila” University of Medicine and Pharmacy, Buchare st,
8 Eroii Sanitari Blvd., Code 050474, District 5, Bucharest, Romania,
Mobile phone: +40722 488 675, E -mail: [anonimizat]

Accepted: September 8th, 2017

Abstract
Transnasal endoscopic orbital decompression is a viable alternative for external orbital
decompression. Today, it can be performed due to the great development of endoscopic
technology and specific endoscopic surgical instruments. It requires strong anatomic
knowled ge and skilled hands.
We present our experience with endoscopic orbital decompression focusing on the
s u r g i c a l t e c h n i q u e u s e d i n o u r d e p a r t m e n t . T h e s u r g i c a l m a n e u v e r s m u s t b e f i r m a n d
gentle protecting the local risk elements and respecting the orbital co ntent.
Keywords: orbit, decompression, endoscopy

Introduction
Orbital decompression was first reported
in 1911 by Dollinger, a lateral decompression
technique being proposed. Naffziger proposed an
orbital roof decompression in 1931. This type of
approach was used when managing bilateral
disease, and when neurosurgical assistance
needed it. Still, the orbit communication with the
intracranial content leads to pulsating proptosis.
Sewall described the medial decompression of
the orbit in 1936. He described the entire
removal of the medial wall of the orbit. The
orbital content prolabated into the ethmoid
cavity. In 1950, Hirsch used the technique
described by Lewkowitz and performed an
inferior orbitotomy using the transantral
Caldwell -Luc approach, removing the inferior
orbital wall. The orbital content prolabated into
the maxillary sinus. Using a transantral Caldwell-
Luc approach, Walsh and Ogura decompressed both the medial and the infer ior wall of the orbit
in the same surgery.
Using the endoscope, Kennedy imagined
the endoscopic approach of the medial wall of
the orbit. Michel popularized the technique later
in 2001.
The development of the optical technology
used in rigid endoscopes and the advancement in
optical video chip will provide the surgeon with
the right tools to perform the orbital
decompression under endoscopic guidance.
Levine proposed special instruments
designed for orbital decompression.
The indications for orbital decomp ression
are the following [ 1,2]:
– ethmoiditis with orbital complications
– ethmoidal mucoceles
– orbital hematoma – trauma or endoscopic
sinus surgery
– Graves orbitopathy
– exophthalmos

Romanian Journal of Ophthalmology 2017; 61( 3): 192-195

193 Romanian Society of Ophthalmology
© 2017 – exposure keratopathy
– diplopia
– optic neuropathy
– tumors located medial to the optic nerve
– sinonasal or skull base tumors with
orbital compartment extension
From an ethical point of view, there are two
ways to obtain the informed consent depending
on the patients’ general health status. When
dealing with a sc heduled surgery, the patient
needs to be thoroughly presented the surgical
plan with its advantages, disadvantages, risks,
benefits, possible complications and prognostic,
and afterwards the informed consent can be
obtained. When facing an emergency situat ion,
the informed consent is not a priority, the
surgical and medical gestures have to be
performed to save the patient’s life or prevent
permanent damages. After the surgery, an
emergency report will be written to justify the
absence of the informed conse nt.
Materials and method
We analyzed the cases that underwent
endoscopic orbital decompression in the IIIrd
ENT and Head and Neck Surgery Department of
“Prof. Dr. Dorin Hociota” Institute of
Phonoaudiology and Functional ENT Surgery in
the period 2007 -2010. The patients who
underwent purely endoscopic orbital
decompression were included in the study. In
one case, inferior wall orbital decompression
was associated to the medial decompression of
the orbit.

Table 1 . Endoscopic orbital decompression
Orbital decompression Number of patients
Ethmoiditis with orbital
complications 19
Ethmoidal mucoceles 14
Orbital hematoma –
trauma/ endoscopic sinus
surgery 5/ 12
Optic neuropathy 4
Graves orbitopathy 3
Tumors located medial to
the optic nerve 2
Sinonasal tumors with
orbital compartment
extension 27
The technique used was performed under
general anesthesia with orotracheal intubation.
Pieces of cotton moisturized in adrenaline
solution were mounted along the inferior
turbinate and into the medial meatus.
If a major septal deviation was
encountered, septoplasty was performed to
achieve a good exposure of the ethmoidal bulla.
After 5 minutes, we gently medialized the
medial turbinate. The uncinate process and the
bulla ethmoidalis were exposed. Inferior
uncinectomy was performed. The surgeon had to
assess the insertion of the uncinate process
preoperatively to avoid harming the orbital
contents when uncinectomy was performed.

Medial meatotomy was performed; if
needed meatotomy orifice could be enlarged,
and inferior wall decompression could be
conducted.
Anterior ethmoidectomy was done by
removing the ethmoidal cells until the lamina
papy racea was reached. Lamina papyracea
represents the insertion of the medial turbinate
on the lateral wall of the nasal cavity. It separates
the anterior ethmoid from the posterior one.
Posterior ethmoidectomy was continued
until the skull base was reached. The procedure
can be completed when sphenoidotomy is
Fig. 1 Inspecting the middle meatus. UP –
uncinate process; BE – bulla ethmoidalis; MT –
middle turbinate

Romanian Journal of Ophthalmology 2017 ; 61(3): 192-195

194 Romanian Society of Ophthalmology
© 2017 needed, in addition, a total
sphenoethmoidectomy wa s achieved.

T h e m e d i a l w a l l o f t h e o r b i t a l c a v i t y w a s
exposed widely. The medial wall of the orbit was
penetrated with a particular pyramidal tip
instrument. The lamina papyracea was removed
by using special dissectors with aspiration.

The periorbit was exposed and two or
three horizontal incision lines were performed
with a blunt tip endoscopic knife. One or two
sliding of fascia had to be preserved in patients
without optic neuropathy to protect the medial
rectus muscle to minimize postoperative
diplopia.

Fig. 2 Ethmoidal cavity inspection after
anteroposterior ethmoidectomy; LP – lamina
papyracea; SB – skull -base

Fig. 3 Exposing the medi al orbital wall
Fig. 4 E l e v a t i n g t h e b o n e o f t h e m e d i a l o r b i t a l
wall; LP – lamina papyracea; PO -periorbit

Fig. 5 Incising the periorbit with OF (orbital fat)
protruding into the ethmoidal cavity

Romanian Journal of Ophthalmology 2017; 61( 3): 192-195

195 Romanian Society of Ophthalmology
© 2017 Result and discussion
Medial orbital decompression was
performed successfully. Still, in Graves
orbitopathy, we considered that a 360 -degree
decom pression is the gold standard [ 6,7].
T h e o r b i t i s a c o n e -shaped compartment
made up of bony walls circumferentially and the
orbital septum anteriorly. The intact orbital
septum can manage pressures up to 50 mmHg.
The term “orbital compartment syndrome” was
presented in 1990 by Kratky. Increas ed pressure
in the intraorbital compartment may
compromise the vascularisation of the optic
nerve that will lead to irreversible blindness
[3,4].
If the blood flow in the posterior ciliary
arteries, central retinal artery, or vasa nervorum
of the optic ne rve is obstructed, optic
neuropathy may appear due to ischemia. In
orbital abscesses or orbital hematoma, the orbit
must be decompressed in the first 8 hours [ 5].
Conclusions
Endoscopic medial orbital decompression
is a safe and reliable technique. Advan ced
anatomic knowledge is necessary to perform the
decompression safely. If needed, it can
completed with inferior decompression, which
can also be performed endoscopically.
The procedure must be performed by
surgeons who can also perform medial
canthotom y or decompress the orbit externally.
The endoscopic approach offers an excellent
visualization and control of the skull base area
and orbital apex.

Acknowledgement
All the authors have equally contributed to
this paper.
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