Look again – Transorbital surgery innovation

Posted on 28 March 2017

With a groundbreaking new technique, certain brain tumours can now be removed through the eye socket, radically speeding up recovery. These two women experienced it.

An innovative surgical technique called endoscopic transorbital surgery means surgeons no longer need to go through the skull to remove certain brain tumours. Pioneered in South Africa by ENT surgeon Prof Darlene Lubbe of Mediclinic Cape Town, the procedure is done through a small incision in the corner of the eye – which is far less invasive and shortens recovery times by months. For Caroline Murray and Wasela Ross, it has made all the difference.

CAROLINE MURRAY’S STORY

‘I’m a keen swimmer so I kept thinking the discomfort in my ear was caused by water,’ says Caroline. ‘When I started hearing strange noises in my ear and felt my eyesight in one eye deteriorating, I went to see my GP, who referred me to an ENT surgeon. My symptoms just became worse, and I developed a very low tolerance for noise and tinnitus in my one ear,’ says Caroline.

It was shortly after her 50th birthday in February 2016 that an MRI showed she had a sphenoid wing meningioma, a benign brain tumour prevalent in women over 50. A craniotomy was performed to debulk the tumour, but it wasn’t removed completely as some of the mass was difficult to reach.

Prof Lubbe has been developing endo-orbital surgery at Groote Schuur Hospital together with neurosurgeon Prof Allan Taylor and ophthalmologist Dr Hamzah Mustak. The surgery entails using an endoscope (camera) to guide instruments between the eyeball and the bony 
eye socket in order to get to the brain or optic nerve.

‘I’m a registered nurse and I’d already heard about the groundbreaking work Prof Lubbe was doing,’ Caroline recalls. She underwent endo-orbital surgery in August 2016, during which more of the tumour around the optic nerve was removed, helping to relieve many 
of her symptoms.

Caroline adds that within weeks she was recovering well. ‘I got back on my motorbike and back to working full time. I now spend many happy hours on the beach without discomfort. I hugely appreciate the amazing medical staff who have made this possible.’

WASELA ROSS’S STORY

During a checkup in January 2016, Wasela Ross was told that the brain tumour which had previously wreaked havoc with her vision had returned. She’d had cranial surgery to remove it the first time, and she recalled how long it took to recover because it involved a surgical incision into her skull and partial removal of her skull cap.

This time her ophthalmologist, Dr Kendrew Suttle, had other plans for her. Together with Prof Lubbe, they performed the less invasive endo-orbital surgery.

Prof Lubbe and her team first operated through Wasela’s nostrils, using their delicate instruments to remove the bone around the optic nerve and relieve the pressure on the nerve.

They then made a small incision in her eyelid and slid the camera and instruments along the walls of the eye to reach the tumour and remove it.

‘After my first brain operation, it took nearly three months before I could see properly again, but this time my vision improved almost immediately,’ says Wasela.

The stitches were removed after a week and now, three months later, only tiny scars remain. Wasela was able to return to work within two weeks of having the procedure.

What is transorbital surgery?

Endoscopic transorbital or endo-orbital surgery is not only less invasive than cranial surgery, but the recovery time is also shorter and many patients have reported improved vision.

Prof Lubbe explains, ‘By using endo-orbital surgery, we make a tiny incision in the corner of the eye – so small that we don’t even need to stitch it up. If, for example, someone sustains an injury to the nose during a rugby match, it can rupture the anterior ethmoid artery at the top of the nose. We find the artery, cauterise it, and we’re done within a matter of minutes.’

Visionaries

South Africa and Italy were the first countries outside the US where endo-orbital surgery was successfully performed. The procedure was pioneered by US plastic surgeon Prof Kris Moe at the University of Washington. Prof Lubbe saw him demonstrate it at a conference in Vienna when it was still in its early development. She started practising the technique in South Africa, adapting it together with neurosurgeon Prof Allan Taylor and ophthalmologist Dr Hamzah Mustak.

This interdisciplinary team now performs the surgery at Mediclinic Cape Town and Mediclinic Panorama, and have established a fellowship programme for ophthalmologists, ENT surgeons and neurosurgeons to learn the technique and work with specially trained radiologists.

When is it used?

Endo-orbital surgery can be used for a broad range of diseases, tumours and injuries in the front part of the head. In the past, surgery to deal with this would result in an ugly scar and involve a complex operation. Prof Lubbe and her team are using endo-orbital surgery more frequently for brain tumours as well, in lieu of craniotomies, because patients recover so much faster – as Wasela experienced.

What are the benefits?

‘With a craniotomy, the patient will spend about a week in ICU, but with our endo-orbital surgery, we discharge them after just four days in a general ward,’ says Prof Lubbe.

What are the risks?

‘The main risks of this surgery would be similar to those of traditional surgery,’ says Prof Lubbe. ‘The only added risk would be potential loss of vision, but in all cases where we’ve performed this surgery we have managed either to improve a patient’s vision or it remained unchanged. As long as the surgeon is sufficiently skilled in the technique, the risks are minimal or at least lower than those associated with traditional brain, eye and sinus procedures.’

What’s next?

The biggest area of growth for Prof Lubbe’s team is orbital operations specifically for the eye. An ophthalmic procedure that they regularly perform with the technique is to treat thyroid eye disease. ‘We remove the bone on both sides of the eye and release some of the fat so that the eye can sink back into the socket. This prevents future vision loss. The alternative therapy for this is radiation – which we don’t really want to give to someone with a benign disease, or a very high dose of steroids – with all the unpleasant side effects,’ says Prof Lubbe.

See more articles from the Mediclinic Family magazine here.

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