FP205 : Lid Sparing Orbital Exenteration Without Removing Periosteum is Effective for Socket and Lid Reconstruction

Dr. Salil Kumar Mandal, M12531, Dr. Tamojit Chatterjee, Dr. Madhumita Banerjee

Dr.Salil Kumarc Mandal. Dr.Tamojit Chatterjee. Dr.Madhumita Banerjee

Abstract

Purpose; To evaluate the  surgical and cosmetic  outcomes and recurrence rates of the ocular malignancies with metastatic potentialafter lid/periosteum sparing orbital exenteration .

Methods; Prospective interventional  case series of ten eyes and  patients  over a period of three years. All the patient had biopsy proved ocular malignancy with spreading tendency. Lid sparing orbital exenteration without removing periosteum was done in all the cases. Sockets and lid reconstruction were performed   simultaneously. Patients were  followed up for one year.

Results; All the ten patients had  satisfactory  post surgical, cosmetic and functional outcomes. Preserving  periosteum in the orbit is very effective for split thickness skin graft to accept on host    and helps in successful lid reconstruction  from forehead  rotational flap.

Conclusion; Lid sparing orbital exenteration without removing periosteum is effective for socket reconstruction with split thickness skin graft. No recurrence of malignancy was noted in one year follow up period.

Introduction: Orbital exenteration is commonly done in cases of malignant neoplasm of the orbital content either primary or secondary spread from adjacent structure which are not treatablewith simple excision and radiotherapy. Orbital exenteration is classified as total,subtotal and super exenteration. According to Levin et.al indications for orbital exenteration are as follows-

1. Life threatening malignancy

2.Life threatening infection

3.Intractable pain and deformity

In this study all the ten cases were done for malignancy with life threatening situation. Lid sparing orbital exenteration with retention the  of orbital periosteum along withSplit thickness skin grafting to  cover orbital periosteum and  fore head rotational flap was performed for lid reconstruction followed by fitting of prosthesis to bring an  acceptable cosmetic outcome

AIMS AND OBJECTIVES

To evaluate the  surgical and cosmetic  out come

To evaluate the  recurrence of the ocular malignancy with spreading tendency after lid sparing orbital exenteration .

To evaluate effectiveness of   socket and lid reconstruction without removing periosteum and prosthetic fittings

Methods;

Prospective interventional   case series of ten eyes and  patients  over a period of three years. All the patient had biopsy proved ocular malignancy with spreading tendency.In this study 5 patient were female and 3 patient were male . Lid sparing orbital exenteration without removing periosteum done in all the cases. Split thickness skin grafting done to cover the orbital bone. Sockets and lid reconstruction performed   simultaneously followed by prosthetic fitting.  Patients were  followed up for one year.

Inclusion criteria

1.Malignancy strictly confined to orbital content without invading the periosteum

2.Malignancy invading the lid margin upto 2-3 mm.

3.No h/o chemotherapy and radiotherapy

4.Regional lymph node biopsy negative

Exclusion criteria

1.Malignancy spreading to adjacent structures invading the periosteum

2.Distant metastasis

3.Regional lymph node biopsy positive cases.

4.H/o chemotherapy and radiotherapy.

In this study males were 4 and females were 6 in number.In this study age ranges from 45 to 80.In this study squamous cell ca were 6 basal cell ca 2  orbital meningeal  mesothelial tumor 2.

Surgical procedure: Incision line is marked first. Surgical incision made  8-9 mm away  from lid margin directly reach to the orbital margin. Orbital septum exposed but  not disturbed .Over the periosteum all the soft tissue including optic nerve with eye ball is removed. Spit thickness skin grafting made over periosteum of the orbital bone.Fore head rotation flap made with eye palpebral aperture fixed with cut margin of the sparing lid. Follow up ranges from one years  to 2years

Clinical Data of the Seven Cases

 

No	Age	Sex	Tissue of orgin	H.P	Type of Operation	Post Of Rt	Post of CT	Live/Death
1	70	f	Conjunctiva Cornea Lid	Squamous cell Ca	LidSparing Exenteration with lid reconstruction	no	NO	Live 3yrs
2.	74	f	Ocular surface + lid	Squamous cell Ca	LidSparing Exenteration with lid reconstruction	no	no	Live 2yrs
3	45	f	Optic nerve sheath	Meningeal mesothelioma	LidSparing Exenteration	no	no	Live2.5yrs
4	60	M	Optic nerve sheath	Meningeal mesothelioma	LidSparing Exenteration	NO	NO	Live3yrs
5.	78	f	Conjunctiva Cornea Lid	Squamous cell Ca	LidSparing Exenteration	no	no	Live2yrs
6	64	M	Conjunctiva Cornea Lid	Sebeceous cell ca	LidSparing Exenteration with lid reconstruction	no	no	Live 1.5yrs
7.	65	M	Conjuctiva involving lid	Squamous cell ca	LidSparing Exenteration with lid reconstruction	no	no	live2yrs
8.	68	M	Lid	BCC	LidSparing Exenteration with lid reconstruction	no	no	Live 2.5
9	56	F	Lid conjunctiva	BCC	LidSparing Exenteration with lid reconstruction	no	no	Live 3yrs

Results and observation;Total no of patients were ten of which males were 4 and females were 6.Lid sparing orbital exenteration  with retaining the  orbital periosteum simultaneously performing forehead  rotational flap for lid reconstruction was done   in all the cases. All the patient were followed up for one year .No recurrence of the disease was observed during the followup period.All the patients had moderate to good cosmetic outcomes with adequate prosthetic fittings . Most cases were categorized as orbital, ocular, and adnexal malignancy, with squamous cell ca (6) and basal cell carcinoma(2) being the most common.Complications occurred in some of the cases. Infection and partial graft rejection was the commonest .It was treated conservatively with systemic antibiotic  and anti inflammatory drugs. In this study all patient retained  prosthesis for good cosmesis throughout the post operative  period .H.P.E  report of all patients had margin free tumor margins .None  of the case had involvement of the optic nerve. During  the follow up period none of the patients died due to recurrence of the disease.

Fig -1 Preoperative and post operative image of  lid sparing orbital exenteration.with forehead rotational flap for lid reconstruction

Discussion ; Orbital exenteration is highly disfiguring surgery. It is to be done as life saving, desperate procedure. It may cause complete removal with success in cases of locally invasive tumor e.g squamus cell  ca. basal cell ca  and  meningeal mesothelioma. Orbital exenteration with tumor free margin helps in long term follow up with no recurrence and no such death results in this study. Squamous cell carcinoma was the most prevalent in our series. This is slightly different than the series described by Rathbun and associates. In contrast they found 30% of the cases (14/48) to be basal cell carcinoma, and only 12.5% (6/48) to be Squamous cell carcinoma. Squamous cell ca is more aggressive than the basal cell ca and it requires more extensive surgery  because of perineural involvement. Several authors thought about disfiguring effect of the surgery that is why lid sparing orbital exenteration is chosen for this study.It may cause rapid healing with good cosmetic outcomes.  Shields and associates report that eyelid sparing technique can be used in most of the cases of malignant tumors and in more than half of the cases originating in the eyelids In this study all the cases underwent lid sparing orbital exenteration with preserving periosteum for split thickness skin graft

In this study we preserved the orbital tissue  as much as possible. After removal of the tumor routine map biopsies were taken from various parts of the orbit . One must take into consideration the biological behavior of the tumor. In cases of highly malignant infiltrative tumors such as adenoid cystic carcinoma of the lacrimal gland or conjunctival malignant melanoma, which are potentially surgically curable we prefer a wider surgical margin and additional separate intraorbital map biopsies after removing the tumor en-bloc. If surgical cure is not possible

then limited debulking is performed. Most important part of the patient rehabilitation is the lid reconstruction in exenterated eye. In this study we prefer exenteration with  preserving orbital periosteum for split thickness graft. In bare bone split thickness skin  graft is not accepted properly .That is why we prefer periosteum to be retained in all the cases. thehead rotational flap is mounted over the lid sparing part for lid reconstruction .This will help in retaining the prosthesis  with proper support for a longer period.    Subtotal exenteration with preservation of orbital tissue volume, eyelids, or conjunctiva may facilitate the use of orbital and ocular prosthesis and improve esthetic and functional out come. Regarding the complication in  this series infection and partial graft rejection were the most common. One case had fistulae formation another two cases had displacement of  the prosthesis .This is  treated with simple tract excision and conservative management by systemic antibiotics. Interestingly, Yassur and associates report the efficacy of becaplermin gel (recombinant human platelet derived growth factor) for the treatment of chronic orbital ulcer after exenteration. Orbital exenteration is successful in the surgical treatment of squamous cell ca and basal cell ca. Success rate of the surgery depends upon the tumor free margin before metastasis to the distant organs. In this study all case done with wider tumor free margin with no optic nerve involvement .If the tumor margin is very close chemotherapy and radiotherapy increases the life span of the patient. Aesthetic reconstruction of the exenterated orbit is complicated but may be associated with good cosmetic results. It is more likely to be successful in cases of subtotal exenteration . The best functional and cosmetic outcome are judged by the ability to wear a prosthetic device, the absence of a patch, and the lack of postoperative complications such as sino-orbital fistula.

Conclusion; Lid sparing orbital exenteration with preservation the orbital  periosteum for split thickness skin graft followed by forehead rotational flap for lid reconstruction is effective for prosthetic fit without patch .It  is functionally, anatomically and cosmetically more effective  in long term follow up period. Patients psychological status is also much more satisfactory.

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