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Endoscopic OCH resection
matured from technique papers to larger multicenter out-
come studies.
11
A similar rigor must be applied to the endo-
scopic orbital literature in order to expand the knowledge
base in this, still nascent, field.
Orbital cavernous hemangioma (OCH) represents an
ideal index lesion to study for a variety of reasons. First, it
represents 1 of the most common tumors of the orbit ac-
counting for 5% to 15% of orbital masses. Although OCHs
have a predilection for the lateral intraconal space, likely
due to a mirroring of ophthalmic arterial vasculature, they
may be found throughout the orbit including the medial in-
traconal and extraconal spaces, as well as the optic canal.
12
Second, the technical complexity of endoscopic dissection
is facilitated by the presence of a robust fibrous capsule. Al-
though these lesions tend not to infiltrate into local tissue,
they are capable of incorporating adjacent blood vessels
and nerves into their capsule as they expand.
13
Histologi-
cally, OCHs demonstrate features of slow-growing venous
lesions with mature cellular components that do not tend
toward dysplasia or hypercellularity. Based on the classifi-
cation of the International Society for the Study of Vascular
Anomalies (ISSVA), these lesions should be characterized
as slow-flow cavernous venous malformations. Clinically,
OCHs are slow growing with a radiologic growth rate of
10% to 15% per year, resulting in displacement of the
globe (axial proptosis for intraconal lesions, nonaxial dis-
placement of the globe for extraconal masses) and, later,
visual loss. Expansion is thought to result from a cycle
of intravascular clot formation related to vascular stasis,
which leads to thrombosis, endothelial cell proliferation,
and subsequent recanalization into multiple clefts and vas-
cular channels.
14
Because of the slow growth rate, surgi-
cal resection is indicated for symptomatic lesions, whereas
smaller, asymptomatic lesions may be observed. The gen-
eral goal of surgical management is definitive resection be-
cause the fate of lesions after partial resection is not well
established in the literature.
14
The purpose of this study was to create a composite of
the collective global experience on purely endoscopic en-
donasal resection of OCHs from primary records. By com-
bining the experience of multiple international centers on
addressing a single type of pathology, we have been able
to generate a moderate series of an otherwise rare pro-
cedure. This, in turn, helps to eliminate the confounders
inherently associated with studies that group a range of het-
erogeneous lesions in order to generate a larger number of
cases. Through this effort, our international consortium en-
deavors to develop some basic recommendations that may
be extrapolated to other types of lesions and can serve as a
foundation for further growth in this field.
Materials and methods
This was an Institutional Review Board (IRB)-approved,
multi-institutional, international, retrospective study of
techniques and outcomes in endoscopic orbital surgery, and
was performed at the Massachusetts Eye and Ear Infirmary,
Boston, MA. A common 25-point questionnaire was sent to
6 highly experienced orbital surgery centers on 3 continents
(North America, n
=
3; Europe, n
=
2; and South America,
n
=
1). This study had extremely rigid inclusion criteria and
accepted only patients who underwent a strictly endoscopic
resection of a histopathologically proven OCH, although
external methods of medial rectus retraction were permit-
ted. The questionnaires covered specific elements of the
preoperative workup, intraoperative techniques, and post-
operative outcomes. All data was derived from primary
patient records by the operating surgical team. The final
data from each center was compiled and analyzed to quali-
tatively identify points of both consensus and variability in
techniques.
Results
Data from a total of 23 patients who underwent an endo-
scopic endonasal resection of an OCH were collected. The
population was comprised of 10 (43.5%) males and 13
(56.5%) females with a mean
±
standard deviation (SD)
age of 50.9
±
13.5 years. Fifteen (65.2%) lesions were lo-
cated on the right side, and 8 (34.8%) were located on the
left side. The majority of lesions were located within the in-
traconal space (60.9%) and the mean follow-up time was
25.3
±
23.0 months.
The most common presenting symptom was visual im-
pairment (65.2%) followed by proptosis (34.8%). Nearly
all patients underwent both computed tomography (CT)
(100.0%) and magnetic resonance imaging (MRI) (95.7%)
as part of the preoperative workup, whereas only 1 patient
(4.4%) underwent preoperative angiography (Table 1).
The mean surgical time was 150.7
±
75.0 minutes with a
mean blood loss of 82.7
±
49.6 mL. Eleven cases were per-
formed as a team approach including otolaryngology with
ophthalmology (26.1%) or neurosurgery (21.7%). The
most common approach utilized a single nostril (69.6%).
Binarial approaches (26.1%) were used exclusively in the
setting of intraconal lesions. Among the intraconal le-
sions, a 4-handed, binarial approach was utilized in 37.5%
of cases in contrast to a strictly 2-handed or 3-handed
unilateral approach for patients with extraconal lesions
(Fig. 1, Table 2). Bipolar cautery was used for hemostasis in
56.5% of cases, whereas monopolar cautery was avoided
in all cases.
The majority of cases (73.9%) achieved a complete re-
section and did not undergo any subsequent orbital recon-
struction. Among orbits that were reconstructed, 83.3%
utilized a mucosal graft, whereas 16.7% used fascia lata
(Table 3). Similarly, the majority of postoperative outcomes
were favorable, with 78.3% of cases resulting in a sym-
metric eye position. Immediate preservation of binocular
vision was achieved in 60.9% of patients (Table 4). All but
1 patient with postoperative diplopia resolved within 2 to
3 months. The etiology of diplopia for this patient with
was thought to be inadvertent injury to the inferior rectus
muscle.
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