New Tools for Orbital Surgery

“Thanks to cross-pollination with other fields, we can now introduce some wonderful new technologies to give our patients a much more pristine, precise surgical experience,” said Edward Wladis, MD. In his Oculofacial Plastic Surgery Subspeciality Day presentation on Saturday, he shared a few tools that have improved surgical procedures for him and his patients. Many of these tools have been used in other fields, including otorhinolaryngology and neurosurgery.

Medial intraconal lesions. Accessing these tumors can be challenging, and techniques such as lateral orbitotomy and craniotomy are not always appropriate and can lead to serious complications. Instead, Dr. Wladis prefers to use an endoscopic approach inspired by colleagues in otorhinolaryngology as well as piezoelectric saws:

• The transethmoidal approach is an endoscopic method to reach and excise lesions without external incisions. Using this technique under minimal general anesthesia, surgeons can open the medial wall of the orbit, dissect periorbita, retract the medial rectus, and dissect the tumor, all via the patient’s nose. This approach avoids the dangers of crossing the optic nerve and facilitates faster recovery.
• Piezoelectric saws are useful when osteotomies are necessary. Oscillating between 20 and 30 kHz, they are designed to target mineralized tissues but leave soft tissues unscathed. Because these saws self-irrigate, surgeons can have a free hand for dissection or retraction. Overall, use of this tool is less traumatic for soft tissues, allows for rapid healing, and reduces risk of postoperative complications. Dr. Wladis began using this device about eight years ago and now considers it a workhorse for lateral orbitotomies.

Intra-orbital dissections. These procedures should be very delicate and precise, explained Dr. Wladis, but conventional cutting tools can lead to bleeding and transection of orbital structures. Using ultrasonic devices can overcome some of these problems.

• The cavitron ultrasonic surgical aspirator selects tissues with high water and low collagen content, thus sparing the vasculature. Comparable to a phaco tip for the orbit, it is easy to integrate into clinical practice and provides constant aspiration, dissection, and irrigation. In Dr. Wladis’ experience, this device can speed up surgery and mitigate intraoperative blood loss.

Intravenous ketorolac for pain. Medication for pain control is an important component of overall management, said Dr. Wladis, but unfortunately, narcotic analgesics are often used even though they are not the most effective solution and carry the risk of addiction. The nonsteroidal anti-inflammatory drug ketorolac may be a safer alternative. Despite concerns that it may increase risk of hemorrhage, a closer look at the literature shows that it has been safely used in a variety of surgical settings. In a 100-person clinical trial, patients randomized to ketorolac before orbital surgery had significantly lower pain scores immediately after surgery compared with the placebo arm and maintained low pain scores on postoperative day 1. The study group also experienced a reduced need for opioid analgesics.—Kanaga Rajan

Financial disclosures: Dr. Wladis: FuzeHub: S; Horizon Therapeutics: C,L; Johnson & Johnson: C; Lions Eye Foundation: S; Patent 62/332,690: P; Praxis Biotechnology: O

Disclosure key. C = Consultant/Advisor; E = Employee; L = Lecture Fees; O = Equity Owner; P = Patents/Royalty; S = Grant Support