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The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical techniques, to report preliminary outcomes and to discuss advantages, indications and limitations of this approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The extent of surgical resection was tailored to the size and location of tumor and was classified into four subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in 7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive without evidence of disease. The preliminary data emerging from this case-series support the feasibility and safety of endoscopic-assisted orbital exenteration.

Summary Purpose To evaluate our patients with rhino-orbito-cerebral mucormycosis according to a new scoring system and to compare those who underwent orbital exenteration persuant to a new threshhold. Methods Mucormycosis is a fungal disease that can be of acute onset, aggressive, and angioinvasive. Aggressive surgical debridement, long-term systemic antifungal therapy, and treatment of underlying predisposing factors are essential to the treatment. However, orbital exenteration is a very difficult decision to make, particularly in patients with orbital involvement, because there is little information in the literature, resulting in limited support for making this aggressive surgical decision. In this study, our 43 cases of mucormycosis were evaluated in terms of orbital exenteration using a scoring system (including clinical signs and symptoms, ophthalmoscopic findings, and radiologic results) developed by Shah et al., which establishes indications for orbital exenteration in mucormycosis. Results According to our study, if the threshold score for exenteration is 19.0, the sensitivity was 100% and specificity was 97%, providing better results than the 23.0 threshold score determined by the reference study for exenteration. When these two score thresholds were compared, there was a statistically significant difference. Conclusion We believe that this scoring system may be beneficial to use for orbital exenteration in patients with mucormycosis. Prospective studies in large case series are required to determine the most appropriate threshold score.

Purpose: We report the clinical outcomes of Korean patients who were diagnosed with orbital malignancies and underwent orbital exenteration.Methods: We retrospectively reviewed the tumor origins, histopathological diagnoses, local/regional recurrences, distant metastases, surgical margin clearances, overall and event-free survivals, and adjuvant chemotherapy or radiation therapy statuses of 14 patients who underwent orbital exenteration in our center from February 2009 to March 2020.Results: We enrolled seven men and seven women of mean age at the time of exenteration of 68 years (range, 37 to 80 years). The mean follow-up period was 44.6 months (range, 10 to 133 months). Most tumors had arisen in the eyelid (seven cases, 50.0%). The most common pathological diagnosis was malignant melanoma (five cases, 35.7%). We observed no local or regional recurrence after exenteration, but distant metastases developed in seven cases, of which four were malignant melanomas (80% of all melanomas). Positive surgical margins were observed in six cases (42.9%). The distant metastasis rate was 42.9%; the overall survival rate was 60%. The 1-year overall survival rate was 100%, the 2-year survival rate was 81.8%, and the 5-year survival rate was 56.1%. The 1-year event-free survival (EFS) rate was 100%, the 2-year EFS rate was 72.7%, and the 5-year EFS rate was 49.9%. Nine patients received adjuvant radiation or chemotherapy and six patients received combined chemoradiation.Conclusions: Patients underwent orbital exenteration to treat orbital malignancies and received postoperative chemotherapy and/or radiation exhibited differences in clinical outcomes and survival rates depending on the tumor type.

The standard of care for treatment of sino-orbital mucormycosis involves aggressive surgical debridement and liposomal amphotericin, and the roles of adjunctive and topical therapies are less clear. Here we describe a case of severe refractory sino-orbital mucormycosis in an immunocompetent patient who responded to combination therapy with liposomal amphotericin, isavuconazole, micafungin, and topical amphotericin deoxycholate after failing to achieve negative surgical margins.

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino‐orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

Here, we report a case of an orbital solitary fibrous tumor (SFT) with multiple local recurrences, even after orbital exenteration, and lung metastases after 41 years. The report discusses the clinical and histopathological findings of this case. A 34-year-old female patient with an orbital SFT was treated with orbital exenteration after local resection failed to prevent a recurrence. Ten years later, the patient underwent radiation therapy, followed by two rounds of gamma knife treatment, leading to remission. Forty-one years after the first treatment, the patient, at the age of 75 years, was found to have lung metastases along with orbital recurrence for the eighth time. The patient underwent radiation therapy but died from radiation pneumonitis. Our case emphasizes the need for long-term follow-up of patients with orbital tumors, even after orbital exenteration, to monitor for metastasis.

Lacrimal gland adenoid cystic carcinomas are rare, aggressive orbital tumors characterized by poor overall prognosis, tendency for local recurrence and metastasis despite aggressive treatment. Treatment continues to be controversial. Many authorities today will often initiate surgery (orbital exenteration with or without bone removal vs. globe-sparing resection) and adjuvant radiotherapy (external beam or proton beam therapy). We introduce a case of lacrimal gland adenoid cystic carcinoma treated with orbital exenteration and adjuvant volumetric modulated arc therapy, and discuss the related literature.

Objective Orbital invasion is associated with a poor prognosis in cases of sinonasal malignancy. This study aimed to analyze the oncological outcomes of sinonasal malignancies involving the orbit. Patients and Methods We reviewed the medical records of 116 patients with a sinonasal malignancy who had orbital invasion at initial diagnosis and followed up at least 6 months between June 1991 and October 2017 at a single institute. The overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS) rates according to the clinicopathological factors, extent to orbit, and treatment modality were compared. Results Patients were mainly treated with surgery and postoperative radiation (n = 39, 33.6%) and concurrent chemoradiation (n = 72, 62.1%). Only five patients (5.1%) underwent orbital exenteration. The OS, DSS, and PFS rates significantly decreased in patients older than 60 years of age and in patients with a higher Charlson Comorbidity Index Score (each p Conclusion Orbit preservation and relatively successful oncological outcome could be obtained with surgery and adjuvant radiation or concurrent chemoradiation.

Approcci multidisciplinari per la gestione dei tumori nasosinusali con invasione orbitaria: revisione critica della letteratura.La vicinanza anatomica dell’orbita con il compartimento nasosinusale e la base cranica giustifica il fatto che un’invasione orbitaria possa essere frequentemente osservata nei tumori che originano dall’etmoide, dal seno mascellare e dal seno frontale. L’obiettivo principale di questa review è quello di analizzare le evidenze scientifiche a oggi disponibili in letteratura circa la frequenza, le strategie di trattamento e i risultati ottenuti nella gestione dei tumori nasosinusali benigni e maligni con invasione orbitaria. È stata condotta una revisione sistematica della letteratura scientifica pubblicata dal 1995 al 2020. Un’invasione dell’orbita è stata osservata nel 2-4% dei papillomi invertiti, nel 12-15% delle lesioni fibro-ossee, nel 27-32% degli angiofibromi giovanili, nel 35-45% dei tumori maligni ben differenziati, e nel 50-80% delle neoplasie maligne scarsamente differenziate. L’asportazione chirurgica radicale con margini di resezione negativi rappresenta il caposaldo per il trattamento delle neoplasie benigne e maligne a basso grado. Schemi di chemioterapia di induzione specifici per ogni sottotipo istologico rappresentano invece il trattamento di scelta per i tumori maligni scarsamente differenziati, nel tentativo di ridurre il volume di malattia e aumentare le possibilità di preservazione del contenuto orbitario. Nei casi in cui si osservi una risposta significativa alla chemioterapia di induzione, un trattamento radio-chemioterapico esclusivo con intento radicale è in grado di migliorare i risultati di sopravvivenza oncologica, lasciando alla chirurgia solo un ruolo di salvataggio in caso di persistenza o recidiva di malattia. In caso di preservazione dell’orbita, appropriate strategie di ricostruzione devono essere pianificate durante l’intervento chirurgico al fine di minimizzare possibili complicanze post-operatorie e per ottimizzare i risultati estetici e funzionali a lungo termine. L’infiltrazione dell’apice orbitario rappresenta il fattore prognostico negativo principale nel trattamento di queste neoplasie. Un lavoro di squadra all’interno di un gruppo multidisciplinare è indispensabile per ottimizzare il controllo locale di malattia, ridurre la morbilità per il paziente e aumentare le possibilità di preservazione dell’orbita.Orbital invasion is frequently observed in tumors involving the maxillary, ethmoid and frontal sinuses given the proximity of the orbit to the sinonasal tract and ventral skull base. The main objective of the present review is to determine the existing evidences on the frequency, treatment, and outcomes of orbital invasion in benign and malignant sinonasal tumors

BACKGROUND Orbital exenteration (OE) is an ablative procedure used in the management of malignancies of the orbit of either primary or secondary origin. Publications evaluating this procedure have suffered from small patient numbers, heterogeneity of pathologies, and poor patient follow-up. The purpose of this study was to assess patient outcomes in a large cohort of patients undergoing OE at a tertiary cancer center. METHODS A retrospective review was conducted of 180 consecutive patients who underwent OE at the authors' institution. Overall survival (OS) was the primary end point measured in the study. Time to locoregional recurrence (progression-free survival [PFS]) and disease-free survival were secondary end points. RESULTS Between the years 1993 and 2011, 180 consecutive patients received OE for craniofacial malignancy at the authors' institution. The median follow-up for the cohort was 9.7 years (116 months). The median OS was 73 months, and the median PFS was 96 months. The presence of perineural invasion was associated with shorter OS (P = .01) and PFS (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter PFS than negative margins (P < .01) but with no change in OS (P = .15). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5), and there was 1 death observed (0.6%). CONCLUSIONS Used judiciously in the setting of a multidisciplinary management plan, OE for tumor control is a safe therapy. LAY SUMMARY Between the years 1993 and 2011, 180 consecutive patients received orbital exenteration for craniofacial malignancy at the MD Anderson Cancer Center. The median follow-up for the cohort was 9.7 years. The presence of perineural invasion was associated with shorter overall survival (P = .01) and progression-free survival (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter progression-free survival than negative margins (P < .01). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5).

An ocular prosthesis is an artificial eye that replaces the natural eye following an enucleation, evisceration, or orbital exenteration. This maxillofacial prosthesis also boosts the lost social and mental well being of a patient. But, the success of any prosthesis depends upon various factors mainly on the functional recording of the tissue bed the anophthalmus eye. In this case report, a combination of impression technique and procedure is followed to achieve a stable and retentive ocular prosthesis.

Purpose: This study aims to analyse disease-free survival, overall survival and risk factors after orbital exenteration in patients with conjunctival and uveal melanoma. Methods: Patients who underwent orbital exenteration due to conjunctival and uveal melanoma were included in this retrospective study (March 2000 to March 2018). Results: A total of 76 patients were enrolled in this study: 60 patients had a conjunctival melanoma and 16 had a uveal melanoma. In conjunctival melanoma, the mean age was 68.4 years. The overall survival rate was 82% after 1 year and 52% after 5 years. Univariate analysis of overall survival found that the following parameters were predictive of a worse prognosis: gender, extent of the primary tumour, lymph node metastases, distant metastases, adjuvant chemotherapy or radiotherapy and relapse. In multivariate analysis, relapse and adjuvant radiotherapy appeared to contribute to a significantly worse prognosis. In uveal melanoma, the mean age was 63.6 years. Eleven patients died during follow-up (mean follow up 30.7 months). The overall survival and disease-free survival rates after 1 year were 62% and 57%, respectively. An analysis of risk factors was not possible due to the small number of cases. Conclusion: Orbital exenterations in conjunctival and uveal melanoma are rarely necessary, but can be performed as an ultima ratio treatment with curative intent. Disease-free survival and overall survival are significantly lower for both groups due to the advanced stage of the disease compared to patients treated without exenteration in the literature. If a recurrence occurs after exenteration, the prognosis is poor in both groups.

Maxillary sinus carcinoma is a rare neoplasm, with incidence of 0.2 to 0.8% of all systemic malignancies. Patients are diagnosed in the advanced stage when there is orbital invasion with abnormal ocular signs and symptoms. The standard treatment of maxillary sinus carcinoma is en bloc radical maxillectomy along with orbital exenteration, followed by postoperative adjuvant therapy. Orbital exenteration is used when the malignancy extends to the orbit in case of squamous/basal cell carcinoma. The aim of the current review is to provide an insight into the management of advanced maxillary carcinoma with orbital involvement in a 42-year-old male.

Background: Face is the index of the mind, through which we express our various emotions. Defect of eyes can be congenital or acquired, due to carcinoma or trauma, which can lead to severe facial asymmetry and disfigurement. It results in several functional, esthetic and psychological disturbances to the patient. Restoring form and function in such patients is a very challenging task and requires an individualized design and technique for each patient. Case Report: This case report showcases rehabilitation of a patient who was diagnosed with exenterated left eye secondary to squamous cell carcinoma and maxillary sinus. Various steps for fabrication of a custom silicone orbital prosthesis have been elaborated in this article which improved the patient’s psychological, social and emotional well-being. Conclusion: The customized silicone orbital prosthesis does not only provide a life like-appearance but also has the advantage of being light in weight. Apart from being comfortable, economical and non-invasive use of the orbital prosthesis for a disfigured face undoubtedly improves the quality of life and the overall well-being of the patient. Keywords: Custom silicone orbital prosthesis, Exenteration, Squamous cell carcinoma.

BACKGROUND Sinonasal malignancies are rare but demanding due to complex anatomy, usually late diagnosis, and inconsistent therapy strategy based on multimodality approaches. Squamous cell carcinoma (SCC) is the most common histology, with poorer prognosis. In the setting of orbital invasion, an orbital exenteration may be required. However, in case of primary rejection of disfiguring surgery or unresectable disease, proton beam therapy (PBT) should be largely considered, allowing for better sparing of neighboring critical structures and improved outcomes by dose escalation. CASE SUMMARY A 62-year-old male presented with a recurrent SCC in the nasal septum abutting frontal skull base and bilateral orbits at 7 mo after primary partial nasal amputation. Because of refusal of face-deforming surgery and considerable adverse effects of conventional radiotherapy, the patient underwent a PBT by hyperfractionated accelerated scheme, resulting in complete response and moderate toxicities. After 2 years, a nasal reconstruction was implemented with satisfactory appearance and recurrence-freedom to date. Another patient with an initially extended sinonasal SCC, invading right orbit and facial soft tissue, declined an orbital exenteration and was treated with a normofractionated PBT to the gross tumor and elective cervical lymphatics. The follow-up showed a continuous tumor remission with reasonable late toxicities, such as cataract and telangiectasia on the right. Despite T4a stage and disapproval of concurrent chemotherapy owing to individual choice, both patients still achieved outstanding treatment outcomes with PBT alone. CONCLUSION PBT enabled orbit preservation and excellent tumor control without severe adverse effects on both presented patients with locally advanced sinonasal SCC.

This article reviews the most common locations and natural history of sinonasal carcinomas. It also reviews surgical indications and current evidence regarding adjuvant and neoadjuvant therapies. In the past, orbital clearance was generally done for ethmoid and maxillary cancers, even without a marked neoplastic infiltration; however, such indications have changed in the recent years due to advances in our understanding of the disease, as well as new chemotherapeutic and radiotherapy protocols. Surgical resection of tumors close to the orbit exhibits the challenging task of balancing treatment goals and patient's desires.

This study aims to analyse the various modifications of orbital exenteration. Patients undergoing orbital exenteration from March 1978 to October 2019 were included in this retrospective study. The patients were evaluated on the basis of the indication, type of exenteration, reconstruction technique, overall survival (OS), and disease-free survival (DFS). In total, 300 patients were enrolled in this study. As many as 24 patients had lid and conjunctiva sparing anterior exenteration, 16 had lid sparing anterior exenteration, 83 had anterior exenteration, 14 had lid and conjunctiva sparing total exenteration, seven had lid sparing total exenteration, 44 had total exenteration, one had lid and conjunctiva sparing extended exenteration, 23 had lid sparing extended exenteration, and 88 had extended exenteration. As many as 39 patients had a primary wound closure. Six patients underwent reconstruction with a split-thickness skin graft, 177 patients with a local or regional flap, and 40 patients with a microvascular flap. A total of 38 patients did not undergo reconstruction. The mean follow-up was 40 months (range 6–216 months). The OS rate was 82.2% after 1 year, 58.5% after 5 years, and 49% after 10 years for all patients with malignant tumours. The DFS rate was 67.7% after 1 year, 45.6% after 5 years, and 31.7% after 10 years. Individual types of orbital exenteration allow patient-adapted therapies. The preservation of uninvolved orbital tissue facilitates orbital reconstruction. The type of exenteration did not have any influence on overall survival.

PurposeOrbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach.MethodsWe performed a clinicopathological review of patients referred to Guy's and St Thomas' NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed.Results27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects.ConclusionsA multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.

Objective. The current paper presents an interesting case of facial reconstruction after the excision of a giant basal cell carcinoma located in the orbitofrontal region. Methods. Performing the excision while securing the appropriate oncologic safety margin has determined the appearance of a soft tissue defect that required a complex reconstruction using three regional flaps: frontal, temporal fascial and temporal muscle flaps. Results. After the excision and reconstruction in a single surgical stage, the postoperative result was favorable, the 12 months assessment showing that the patient was satisfied with the aesthetic aspect. Conclusion. Including the orbital exenterations in the excisional treatment of giant neoplasms located in the facial region requires a complex reconstructive plan. The surgical team has to consider the relief of the anatomical structures that are targeted, as well as the necessity of achieving satisfactory aesthetic results while ensuring oncological radicality.

Os tumores conjuntivais representam um amplo espectro de lesoes benignas e malignas, algumas capazes de acarretar nao somente a perda da visao como, tambem, da vida. Este trabalho tem como objetivo relatar o caso de paciente com carcinoma espinocelular de conjuntiva com desfecho incomum, revisar o quadro clinico tipico e as opcoes terapeuticas e ressaltar a importância do diagnostico precoce. A demora em procurar atendimento especializado contribuiu para a progressao da lesao, de modo a inviabilizar o tratamento conservador. O paciente foi submetido a exenteracao total com retirada do globo ocular e anexos.

The authors report the case of an 80-year-old male patient who had a modified left orbit exenteration with preservation of myocutaneus eyelid flap. The radical surgical treatment was performed due to high-grade recurrent pleomorphic conjunctival sarcoma with extension to the sclera and medial orbit. Five previous resection surgeries were performed, until the exenteration was considered. Prosthetic rehabilitation was planned integrating interdisciplinary biomedical knowledge, to create a new hybrid osteointegrated method with costume-made titanium miniplates and magnetic retention. During the second-year follow up, the system appeared osteointegrated. No failures from the retention mechanism have been reported. The patient reported to have a functional role inside and outside his house. Social interactions have not been limited by the anatomical facial defect. This new hybrid system is a feasible option to rehabilitate patients with orbital or facial defects, even for the elderly.

In this report, we discussed the progression from the initial presentation until surgical intervention, clinical course, and devastating outcome of a neglected giant sebaceous gland carcinoma of the eyelid in a poorly compliant elderly patient. A 79-year-old woman was referred for treatment of a giant ulcero-nodular lesion in the right upper eyelid. Nine months before, an orange lesion arising from the tarsal conjunctiva in the upper eyelid was observed in her examination undergone in the healthcare center where she initially presented, and the cornea appeared transparent. Surgical excision was recommended, which she declined. The examination three months before in the same center revealed that the lesion invaded the globe and anterior segment architecture could not be visualized. She was then recommended surgical removal of the eyeball, which she also refused. Radiological imaging demonstrated a 33x35 mm mass lesion in the superior lateral of orbit with exophytic growth and invasion of the globe and no systemic metastases were found. Total orbital exenteration surgery was immediately planned and performed. Histopathological examination revealed sebaceous gland carcinoma. Elderly patients with poor compliance should discuss their condition with a psychiatrist and should be managed by a multidisciplinary approach. This way, patients with eyelid malignancies can be encouraged to undergo surgery and receive early treatment, decreasing the need for exenteration, improving clinical outcomes, and reducing the risk of morbidity and mortality.

A 45-year-old female presented with a gradually enlarging painless mass for 8 years associated with diminution of vision, arising from the right orbit. It measured 10 x 8 x 6 centimetres (Figure 1A...

Aim: The aim was to study the correlates of depression, anxiety, self-esteem, and suicidal ideas in patients of COVID-associated mucormycosis (CAM) and effects of treatment. Materials and Methods: A cross-sectional, analytical study was performed in a tertiary care center in Western Maharashtra. By purposive sampling, 34 patients of CAM were included in the study with their informed consent and after obtaining ethical clearance. A self-made questionnaire to include demographic and clinical details was filled. Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale (RSES), and Suicidal Ideation Attributes Scale (SIDAS) were applied after initial diagnosis. The HADS, RSES, and SIDAS were reapplied after their operative treatment. Results: A significant reduction in anxiety and depression scores postoperatively was seen. No significant difference was found in self-esteem or suicidal ideas postoperatively in the study population. However, patients who underwent orbital exenteration showed a significant reduction in level of self-esteem with anxiety and depression postoperatively. No specific correlation was found between the computed tomography score, family history, intensive care unit admission, or orbital exenteration with anxiety, depression, self-esteem, and suicidal ideas. Conclusion: Levels of anxiety and depression in patients of CAM reduced significantly after treatment, but self-esteem worsened in males more than females owing to disfigurement. There is a need of psychological counseling in patients of mucormycosis undergoing a debilitating surgery both pre- and postoperatively for a better outcome and recovery.

A 38-year-old woman presented with sudden-onset painful lid swelling, proptosis and external ophthalmoplegia on the right side for 20 days, associated with loss of vision for nine days. On contrast-enhanced computed tomography (CECT), a retrobulbar mass was noted involving intraconal and extraconal spaces, extending up to the orbital foramina with enhancement and thickening of meninges. CT arteriography further revealed multiple feeding vessels from the maxillary artery. Embolization of feeding vessels followed by right orbital exenteration with primary reconstruction using forehead flap was done. This is an unusual case of orbital cavernous hemangioma (OCH) which emphasizes the importance of CT arteriography in specific cases of OCH, where routine neuroimaging may be inconclusive.

Sinonasal squamous cell carcinoma (SNSCC) is a rare and aggressive malignancy which often presents at an advanced stage. The gold-standard treatment includes negative-margin surgical resection plus adjuvant therapy. In cases of orbital invasion, surgery requires orbital exenteration which can carry significant morbidity and result in decreased quality of life. In selected patients, induction chemotherapy (IC) can allow for orbit preservation without compromising oncologic outcomes. The available literature will be briefly discussed.

Purpose To evaluate the surgical outcome and safety of acellular human dermal allograft as a new lining material to the exposed orbit after exenteration. Methods Retrospective case series of patients who underwent orbital exenteration followed by reconstruction with meshed-type acellular dermal allograft from 2009 to 2018 in a single tertiary institution. Results There were 14 eyes (2 right, 12 left) of 14 patients (6 men, 8 women). Mean age at operation was 69.1 ± 16.5 years. Indication for surgery was malignancy in all patients. One patient underwent subtotal exenteration, while the rest underwent total exenteration. SureDerm Meshed was used in 12 patients, AlloDerm Meshed in 1, and CGDerm Meshed in 1. Mean follow-up period was 12.1 months. Full or nearly full epithelialization occurred in 10 of 14 patients (71.4%) at 1 month and 9 of 12 patients (75.0%) at 3 months. There was delayed epithelialization in 3 patients due to poor wound care (n = 1), adjuvant radiotherapy (n = 1), and adjuvant radiotherapy followed by cerebrospinal fluid leak (n = 1). Conclusions Meshed acellular human dermal allograft showed good success in reconstruction after orbital exenteration and may be considered as an alternative lining material to split-thickness skin graft after orbital exenteration.

A 78-year-old Caucasian woman presented with pain in her right and only eye that was worse on abduction. Her history was significant for a choroidal melanoma affecting her left eye for which she underwent an orbital exenteration 12 years previously. Computed tomography and magnetic resonance imaging of the right orbit identified a mass lesion affecting the medial rectus, suspicious for metastatic melanoma. A histopathological diagnosis of metastatic melanoma was subsequently made following biopsy of the right medial rectus.

Objective This study was aimed to evaluate health-related quality of life in patients undergoing anterolateral craniofacial resection (AL-CFR) with orbital exenteration (OE) for malignant skull base tumors and to investigate the effects of early psychiatric intervention.Design Present study is a prospective, observational study.Setting The study took place at the hospital department.Participants Twenty-six consecutive patients were selected who underwent AL-CFR with OE at our hospital between 2005 and 2015.Main Outcome Measures Health-related quality of life was assessed preoperatively and 3, 6, 12, and 24 months after surgery using the Hospital Anxiety and Depression Scale (HADS) and medical outcomes study 8-items Short Form health survey (SF-8). In all cases, psychiatric intervention was organized by the consultation liaison psychiatry team preoperatively and postoperatively.Results Ten (38.0%) of the 26 patients died and 16 (62.0%) were alive and disease-free at the end of the study. The 3-year overall and disease-free survival rates were 64.9% and 53.3%, respectively. Twenty-one patients (80.8%) developed psychiatric complications after surgery and needed treatment with psychotropic medication. Before surgery, 28% of patients had HADS scores ≥8 for anxiety and 20% had scores ≥8 for depression. Seven of the eight items in the SF-8 were significantly lower than those for the general Japanese population. However, scores for all the SF-8 items gradually improved during postoperative follow-up, reaching approximately 50 points, which is the national standard value, at 2 years after surgery.Conclusions Craniofacial resection with OE was feasible and well tolerated in patients with malignant skull base tumors who received early psychiatric intervention to decrease the considerable psychological impact of this procedure.

This study aimed to assess the indications for destructive eye surgeries (DES) among children and ascertain the proportion avoidable. The Eye theatre register was retrospectively reviewed. Data on children who had DES from 1st January 2008-31st December 2017 was retrieved. These included biodata; clinical presentation, diagnosis, indication and type of surgery, and outcome of management. The total number of paediatric ophthalmic surgeries within the study period was computed. The data were entered into Epi Info statistical software, version 3.4 for analysis. Descriptive and analytical statistics were applied, p-values < 0.05 were considered statistically significant. A total of 634 ophthalmic surgeries were performed on children within the study period, 50(7.9%) eyes of 49 children had destructive eye surgeries. Thirty-three (67.3%) were males and 16(32.7%) were females; M:F ratio was 2.1:1. The mean age was 6.7±5.0 years with a range of 1.7-11.7years (Mean±SD). Most, 27(55.1%) of the participants had evisceration, 15(30.6%) had enucleation while 7(14.3%) had exenteration. More males, 24(72.7%) had evisceration while more females 10(62.5%) had enucleation (Fisher’s exact test=13.8, p=0.001). The main indications for DES included tumour in 22(44%) eyes, trauma to eyes in 13(26%) and intractable infections in 8(16%) eyes. All the 15 eyes enucleated were confirmed cases of retinoblastoma. Seven (14.3%) persons had orbital exenteration of which 6(85.7%) were retinoblastoma. In all, 42(84%) destructive eye surgeries in this study were avoidable. There is a need for improved enforcement of the “Child’s Right Act” in our environment.

Background Orbital reconstruction following oncologic midface resection is uniquely challenging, and makes critical contributions to patient aesthetics, function, and identity. Approach is largely dependent on surgeon and patient preferences, and there exists no consensus on defect characterization. Objective The goal of the study is to provide a mental framework for the reconstructive oncologic surgeon to use as a foundation during his or her approach to the orbit. Design The design of the study is based on the review of current literature and expert opinion. Conclusions Critical versus optimal objectives must be set in orbital reconstruction, and a systematic approach should be followed. We approach orbital reconstruction by first deciding whether globe-sparing surgery is possible, or if orbital exenteration will be necessary. We then set critical and optimal objectives for our chosen pathway. Critical goals in globe-sparing reconstruction include maintaining orbital volume and preserving visual function, and an optimal goal includes preservation of the nasolacrimal system. Critical goals in orbital exenteration include obliterating the defect, sealing the skull base and nasal cavities, and allowing eye protection to be worn over the contralateral eye postoperatively. Optimal goals in exenteration include preparation for prosthetics, volume and bony replacement, eyelid-sparing technique, and consideration of postoperative radiation.

The main goal of head and neck reconstruction is the restoration of form and function. Oncologic surgery makes this process more complex, as the preplanned defect can be very different from its intraoperative counterpart. This emphasizes the role of preoperative planning and a diverse reconstructive “tool box” that can accommodate a variety of complicated defects. The other reconstructive goals are determined by the patient with the aid of an interdisciplinary team. While multiple local and regional reconstructive options are available, free tissue transfer provides a versatile and reliable option for reconstruction—especially for complex orbital defects. Here the authors discuss free soft tissue transfer options for orbital exenteration. This review will catalog the advantages and disadvantages of the radial forearm, rectus abdominis, latissimus, and anterolateral thigh.

Squamous papillomas are squamous-derived growths commonly arising from the oral cavity and oropharynx. A 75-year-old woman presented with chronic persistent left nasal obstruction and gradual painless non-axial proptosis with loss of vision in the left eye. Computed tomography scan showed an iso-dense lesion filling the frontal, left ethmoidal and sphenoidal sinuses, and the nasal cavity, with extension into the left orbit. She underwent surgical tumor resection with orbital exenteration and histology revealed features of an aggressive hyperkeratotic squamous papilloma arising from the sino-nasal region. Although squamous papillomas have been natively associated with the oral cavity and oropharynx, they present less frequently as sino-nasal tumors with orbital invasion.

Simple Summary Managing locally advanced periocular malignant tumours, especially those invading the orbit, is challenging. Orbital exenteration has long been considered the gold standard. The development of conservative surgical techniques in the early 2000s, followed by the emergence of new targeted therapies and immunotherapies over the past decade, has led to a paradigm shift towards the use of ‘eye-sparing’ strategies. Abstract The management of periocular skin malignant tumours is challenging. Surgery remains the mainstay of treatment for localised eyelid cancers. For more locally advanced cancers, especially those invading the orbit, orbital exenteration has long been considered the gold standard; however, it is a highly disfiguring and traumatic surgery. The last two decades have been marked by the emergence of a new paradigm shift towards the use of ‘eye-sparing’ strategies. In the early 2000s, the first step consisted of performing wide conservative eyelid and orbital excisions. Multiple flaps and grafts were needed, as well as adjuvant radiotherapy in selected cases. Although being incredibly attractive, several limitations such as the inability to treat the more posteriorly located orbital lesions, as well as unbearable diplopia, eye pain and even secondary eye loss were identified. Therefore, surgeons should distinguish ‘eye-sparing’ from ‘sight-sparing’ strategies. The second step emerged over the last decade and was based on the development of targeted therapies and immunotherapies. Their advantages include their potential ability to treat almost all tumours, regardless of their locations, without performing complex surgeries. However, several limitations have been reported, including their side effects, the appearance of primary or secondary resistances, their price and the lack of consensus on treatment regimen and exact duration. The aim of this article was to review the evolution of the management of locally advanced periocular malignant tumours over the last three decades and highlight the new paradigm shift towards the use of ‘eye-sparing’ strategies.

Introduction: The aim of the study was to report our experience in the use of Gamma Knife Stereotactic Radiosurgery (GKSTRS) for conjunctival squamous cell carcinoma (SCC) invading the orbit, as an alternative to exenteration surgery. Patients and Methods: Patients who had GKSTRS for conjunctival SCC invading the orbit but sparing the bone (AJCC eighth ed. T4a) with a minimum of 1-year follow-up were included. Treatment failure was defined as no decrease in tumour size 3 months post-treatment, or further growth during the follow-up period. Patients were followed up 3-monthly for 2 years and 6-monthly afterwards with a minimum of yearly MR Imaging of orbit. Results: Six patients met the inclusion criteria. MR imaging was used to identify the extent of orbital involvement of SCC. Stereotactic radiosurgery utilizing the Leksell Gamma Knife® Perfexion was delivered in a single session in which patients received 18–20 Gy to the 45–50% isodose. The median follow-up was 29 months. Four patients responded to the treatment and had no evidence of recurrence at their most recent follow-up. The treatment failed in 2 patients, in 1 of whom the tumour was larger and extended deeper into the orbit. The other patient developed a recurrence away from the treated area at 9 months, suggesting a multifocal disease. Both patients had poorly differentiated SCC. Conclusion: GKSTRS is a potential alternative to orbital exenteration surgery for conjunctival SCC extending into the anterior orbit in a selected group of patients refusing orbital exenteration or has a second blind eye. Nevertheless, the disease is more likely to recur than with exenteration surgery, hence lifelong monitoring and low threshold for surgical intervention or retreatment is prudent.

Temporalis muscle flap is one of the most commonly used flaps in orbital reconstruction. Although multiple case series in the literature have reported elevation of the flap with an open incision and a retrograde approach from the periorbital region, to the best of the authors' knowledge, no studies have reported the use of an endoscopic method. Therefore, the authors' study presents endoscopy-assisted temporalis muscle reconstruction of a defect that occurred in the periorbital region following orbital exenteration. Minimal scarring and morbidity are some of the advantages of endoscopic methods, and healing without complications was achieved in our patient during the postoperative period. To the authors' knowledge, their study is the first to report the use of temporalis muscle flap in endoscopy-assisted periorbital reconstruction, which is a preferred method for endoscopic surgery.

The objective of this study was to examine the role of cheek rotation flaps in the reconstruction of orbital defects after exenteration. From January 2000 to August 2018, patients undergoing orbital exenteration and reconstruction with cheek rotation flaps were enrolled in this retrospective study. All patients were evaluated for wound complications, orbital rehabilitation, tumor relapse, and survival. Thirty patients completed the study. Fourteen complications allocated to 11 patients were assessed. The most common complications were seroma (13%), temporary facial nerve weakness (13%), and partial necrosis of the flap (10%). A major complication occurred in a total of two patients (7%), so that surgical correction was necessary. Eleven patients had a relapse; 15 patients died as part of the follow-up. Fifteen patients were treated with facial prostheses. The overall survival rate was 61% after 1 year and 42% after 5 years. Follow-up periods ranged from 6 to 95 months. Cheek rotation flap reconstruction after exenteration is a reliable method with a low rate of major complications. It is indicated when an approach to the parotid gland or the neck region is necessary because of suspected lymph node metastasis and in elderly patients because of their skin's laxity. It can be performed as primary or secondary reconstruction. Good esthetic results can be achieved, especially after endosseous implantation.

Endoscopic-assisted orbital exenteration (EAOE) has found a place in our surgical armamentarium in selected patients to treat sinus malignancy invading the orbit and acute fungal infection, but it may also evolve to be useful in other disorders affecting the orbit. EAOE offers four advantages: (1) a superb view of the orbital contents, (2) facilitating direct control of the ophthalmic artery, (3) permitting preservation of the superior and lateral periosteum, which facilitates wound healing, and (4) sparing of uninvolved tissues, thereby improving the fitting of external orbital/facial prosthesis. Caution is advised, especially for less experienced surgeons, in managing bulky tumors or highly vascular neoplasms with EAOE. Diffuse bleeding in such cases may be more difficult to control endoscopically. Regardless of the approach, patients should be counseled on the risks of monocular vision. With the consequent loss of depth perception, there is an increased risk of subsequent trauma, which requires strategies and patient education. Whenever orbital exenteration is used, assembling a multidisciplinary team is strongly advised to serve the individual needs of each patient.

Background:. Orbital exenteration, the removal of the entire globe, eyelids, and orbital content, is indicated in extensive neoplastic disease involving the orbital region. Although a functional reconstruction of orbital exenteration defects is mandatory, aesthetic concerns need to be considered. Facial disfigurement following reconstructive surgery often leads to great discomfort and social retirement, which can limit social interaction. The aim of this study was to explore how the society perceives the aspect of patients who underwent orbital exenteration and subsequent reconstruction, comparing two different types of reconstruction: standard anterolateral thigh (ALT) or “sandwich” fascial ALT (SALT) free flap. Methods:. An online survey was created based on four questions regarding the perception of reconstruction (discomfort at looking at that patient, perception of unhealthiness, hypothesis of social life impairment, etc); five possible answers were provided, ranging from “completely” to “not at all.” The survey was administered to the general population and to medical students. Results:. In total, 255 people participated to the survey (130 medical students and 125 people of the general population); a total of 245 surveys were considered eligible (10 were incomplete and then discharged). Statistical significance was found (P < 0.001) regarding the better overall appearance of the SALT group over the ALT one. Conclusions:. After analysis, the surgical outcome after SALT reconstruction has been found to be less disruptive in both groups, due to a reduced scar burden and a more pleasant orbital pocket. Our results encourage more research in the field of postexenteration reconstruction to achieve more aesthetic and social acceptability.

The junction of the bones of the orbit, caudal maxilla and zygoma intersect to form an anatomically intricate region known as the orbitozygomaticomaxillary complex (OZMC). Given the critical role of the OZMC in the structure, function and esthetics of the skull and midface, tumors in this region present unique challenges to the oromaxillofacial surgeon. Attempts to achieve histologically clean tumor margins in a cosmetically pleasing manner requires excellent intra-operative visualization. Additionally, minimized intra-operative and post-opertive complications is of paramount importance. In this manuscript we describe a combined intra- and extraoral approach to extensive tumors of the OZMC that incorporates orbital exenteration as a technique, which allows for excellent intra-operative visualization and mitigate intra- and post-operative complications. In addition, we describe our experience utilizing the technique in five clinical cases.

Purpose: To describe a combinatory technique made of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option after orbital exenteration. Methods: We retrospectively reviewed all patients who underwent orbital exenteration and subsequent reconstruction with this technique at our Head and Neck Department, Divisions of Ophthalmology and Otolaryngology, at San Raffaele Hospital, Milan, Italy. Results: Three patients were treated with the aforementioned technique, following orbital exenteration due to malignancies. All of them were affected by recurrent diseases arising from the ocular components or periorbital structures: one basal cell carcinoma and two squamous cell carcinomas. Excellent result was achieved considering skin texture and colour match, aesthetic results and intra and post-operative complications (only minor, surgically controlled haemorrhage and minimal dehiscence subsequent to defective healing occurred). Conclusion: The proposed technique can be considered by the head and neck reconstructive surgeon as a good option in extended orbital exenteration.

The purpose of this study is to report our experience with the use of artificial dermis grafts for orbital socket reconstruction following orbital exenteration (OE). A retrospective study was conducted in our ocular oncology centre from May 2018 to June 2020 in patients undergoing OE for orbital malignancies in whom an artificial dermis device (Integra® template, 2 layers) was used for reconstruction. Data recorded included demographics, previous and adjuvant treatments, aetiologies, surgical procedure, surgical reconstruction, complications and follow-up. The main outcome measure was the time between OE and the full granulation of the cavity. Ten patients (mean age, 71.3 years [43–92]) were included. Tumours originated from the conjunctiva (n = 5, 50%), eyelid (n = 3, 30%) and orbit (n = 2, 20%). Nine patients underwent total OE, and one required enlarged OE. Orbital reconstruction was performed using an artificial dermis alone (n = 9, 90%) or combined with regional flaps (n = 1, 10%). The mean granulation time was 3.3 weeks (2–4). Three (30%) patients received adjuvant radiotherapy 1 month post-surgery. The mean time to spontaneous epithelialization was 9.4 weeks (6–12). Preoperative and postoperative radiotherapy was not associated with a delayed epithelialization of the socket (p = 0.463 and p = 0.236, respectively). One (10%) and 2 (20%) patients experienced postoperative socket infection and an ethmoidal fistula, respectively. The mean follow-up was 11.6 months (6–16). Using artificial dermis grafts alone or with regional flaps appears to be a viable surgical procedure for orbital socket reconstruction. They reduce surgical morbidity and hospital stay. Preoperative and postoperative radiotherapy does not seem to delay socket healing.

Most head and neck cancers require aggressive surgical resection followed by external beam radiation therapy. The carotid artery can be injured by surgery or radiation resulting in a delayed "blowout." A patient who had undergone orbital exenteration for a lacrimal adenoid cystic carcinoma (ACC) followed by external beam radiation presented 16 years later with arterial bleeding from the orbit caused by "blowout" of the cavernous internal carotid artery (ICA). We review the literature on carotid blowout syndrome (CBS) and treatment. The patient was emergently transferred to a hybrid operating room and underwent a balloon occlusion test (BOT) and endovascular sacrifice of the ICA with no neurological deficits postoperatively. Emergent endovascular embolization is an effective treatment for an intracranial ICA blowout in this first reported case of a blowout through the orbit. Elevated radiation dose and lack of tissue coverage may put the cavernous ICA at risk for this delayed complication.

PURPOSE: To review the clinical features and treatment-associated outcomes of primary orbital melanoma among cases reported in the literature and to present a case treated with orbital exenteration and post-operative radiotherapy. METHODS: Case reports and case series on primary orbital melanoma published in the literature between 1980 and 2020 were reviewed. Data collected included patient demographics, presenting ocular symptoms, diagnostic imaging, histology, management, and outcomes. RESULTS: Eighty-eight cases of primary orbital melanoma were reviewed. The average age at presentation was 45 years and 58% of patients were male. The most common presenting symptoms and signs were proptosis (73%), decreased visual acuity (32%), pain (14%), diplopia (15%), and palpable mass (9%). Imaging frequently showed a well-circumscribed enhancing lesion. Diagnosis was made by histology in all cases, and orbital blue nevus was identified in 42%. In the majority of cases, treatment consisted of orbital exenteration (54%) or excision (38%). Adjuvant radiotherapy was given in 47% of cases. For the 72 patients with reported outcomes, 36% had metastases, 15% had local recurrence, and 32% died of metastatic disease. Patients who received surgery and radiotherapy had improved survival compared to those who received surgery alone (p = .01). There was no difference in survival between those who underwent orbital exenteration or excision (p = .16). CONCLUSIONS: Primary orbital melanoma is a rare malignancy and should be considered in patients with a history of unilateral proptosis and a well-defined orbital mass on imaging. Surgery remains the mainstay of treatment. Adjuvant radiotherapy may improve patient survival.

PURPOSE OF REVIEW The purpose of this review is to examine current trends in reconstruction following orbital exenteration. Defects ranging from isolated exenteration to more complex midface resections are explored. RECENT FINDINGS Goals of reconstruction include separating the sino-orbital cavities and creating a safe, stable wound that can withstand adjuvant radiation. When planning for orbital rehabilitation, it is important to create a concave cavity that can accommodate a prosthesis. This is primarily achieved through secondary granulation or split-thickness skin grafts. Recently, the use of dermal allografts has been investigated and shown good success with epithelization of the orbital cavity. For complex orbitomaxillectomy defects, musculocutaneous free tissue flaps remain the mainstay for reconstruction. SUMMARY Reconstructive options following orbital exenteration are based on extent of the defect, need for postoperative radiation, and plans for orbital rehabilitation with prosthesis.

PURPOSE: Information regarding risk of metastasis and disease-related death (DD) from conjunctival squamous cell carcinoma (SCC) is relatively scarce. We explored prognostic factors for orbital exenteration, local recurrence, nodal metastasis, and DD in patients with conjunctival SCC. DESIGN: Retrospective cross-sectional study. METHODS: All consecutive patients with conjunctival SCC treated by the senior author at MD Anderson Cancer Center during1999–2018 were included. Survival curves were estimated using the Kaplan-Meier method, and survival differences were assessed using 2-sided log-rank tests. RESULTS: The study included 44 patients (24 men;20 women); median age was 64 years (range, 40–90). T categories at presentation were as follows: Tis, 20 patients; T2, 8; T3, 9; and T4, 7. Eighteen patients (41%) had tumors exclusively in the bulbar conjunctiva; 26(59%) had non-bulbar conjunctival involvement. The median follow-up time was 29.2 months (95% CI: 21.8–44.3). Orbital exenteration was performed in 10 cases (23%) and was associated with T3 or more advanced disease at presentation (p

Objective To evaluate the outcomes of orbital exenteration with temporalis muscle flap repair of the socket and secondary healing of the anterior surface of the flap in ocular, conjunctival, and eyelid malignancies. Design Retrospective single-centre study. Participants Consecutive patients who underwent total exenteration for malignancy with temporal muscle flap repair of the socket between December 2009 and January 2016. Methods We report the outcomes of this surgical technique in terms of healing without fistula formation and time to epithelialization. Results Twenty-nine patients underwent surgery using this technique. Diagnoses consisted of 18 conjunctival melanomas, 2 choroidal melanomas, 6 squamous cell carcinomas, 2 sebaceous cell carcinomas, and 1 basal cell carcinoma. Mean age at surgery was 70.7 years and mean follow-up was 27.4 months. On histological analysis, tumour excision was complete in 25 patients, of whom 3 had an orbital recurrence after exenteration (3 conjunctival melanomas). Four patients had incomplete tumour excision, of whom 3 underwent postoperative orbital radiotherapy with no subsequent orbital recurrences. Complete epithelialization of the socket occurred in mean 7.9 weeks (range 2–16 weeks). Flap necrosis occurred in 1 patient after postoperative radiotherapy (with sino-nasal fistula formation); 2 other patients developed sino-orbital fistulas. Conclusion After orbital exenteration, spontaneous epithelialization of the socket may take up to several months. Use of a temporalis muscle flap can reduce the duration of socket healing postoperatively, even if left to heal by secondary intention. This may facilitate early postoperative radiotherapy when indicated. Aesthetic results are acceptable and local surgical complications are rare.