Hatem Krema - Ocular Oncology Surgeries

Surgical Procedures in Ocular Oncology

Hatem Krema, MD, MSc, FRCS

Eyelid Tumours

Excision of a subcutaneous circumscribed mass(Dermoid cyst)

Pentagon Excision of lower eyelid margin tumour + Reese lateral canthotomy (For up to 40% eyelid margin defect)

Excision of BCC from the middle of lower eyelidReconstruction with Tenzel rotational flap (for > 40% eyelid defect)

Total Lower Eyelid Excision and Lamellar reconstruction of the eyelid

Lymphangioma of the eyelid and conjunctiva

Hatem Krema, FRCSEd

Excision and Reconstruction Plan

Hatem Krema, FRCSEd

Anterior lamella: Mustardé rotational cheek flap

Posterior lamella: Modified Hughes tarso-conjunctival flap

Hatem Krema, FRCSEd

Undermining the involved conjunctival quadrant

Hatem Krema, FRCSEd

Full thickness eyelid excision

Hatem Krema, FRCSEd

Complete excision of the involved conjunctiva and eyelid with hemostasis

Hatem Krema, FRCSEd

Hatem Krema, FRCSEd

Dissection of Mustardé rotational cheek flap

Hatem Krema, FRCSEd

Mustardé rotational cheek flapand contour sutures

Hatem Krema, FRCSEd

Modified Hughes tarso-conjunctival flap

Hatem Krema, FRCSEd

Conjunctiva

Tarsus

Appearance at the conclusion of surgery

Hatem Krema, FRCSEd

One day after surgery

Hatem Krema, FRCSEd

One week after surgery

Hatem Krema, FRCSEd

Four weeks after surgery (Separation of the eyelids)

Hatem Krema, FRCSEd

Preoperative and post operative compared

Hatem Krema, FRCSEd

Large medial canthal Basal Cell Carcinoma:

Excision and lamellar Reconstruction

Extensive Medial Canthal Basal Cell Carcinoma

Hatem Krema, FRCSEd

Excision and Reconstruction plan

Hatem Krema, FRCSEd

Excision of the tumor with margin control

Hatem Krema, FRCSEd

Dissection of Mustardé rotational flap

Hatem Krema, FRCSEd

Hatem Krema, FRCSEd

Glabellar flap and trans-nasal wiring

Reconstruction of posterior lamella with free tarso-conjunctival graft

Hatem Krema, FRCSEd

Hatem Krema, FRCSEd

Appearance at the conclusion of surgery

Hatem Krema, FRCSEd

Functional eyelids one week after surgery

Orbital Tumours

Excision of a lacrimal gland mass

Hatem Krema, FRCSEd

CT images

Bilateral lacrimal gland massesHatem Krema, FRCSEd

Marking skin incisionHatem Krema, FRCSEd

Skin crease incisionHatem Krema, FRCSEd

Orbital lobe is exposed beneath the septumHatem Krema, FRCSEd

Trans-septal orbital lobe deliveryHatem Krema, FRCSEd

Trans-septal orbital lobe excisionHatem Krema, FRCSEd

Closure of the woundHatem Krema, FRCSEd

Histopathology: Lacrimal gland lymphoma

Hatem Krema, FRCSEd

Eyelid crease incision + Trans-septal approach

for excision of pleomorphic adenoma of the lacrimal gland

Sub-brow skin incision + Trans periosteal approach

For excision of adenocarcinoma of the lacrimal gland

Hatem Krema, FRCSEd

Excision of Circumscribed Extraconal Mass

Clinical Presentation

Hatem Krema, FRCSEd

MRI images

Extraconal inferolateral orbital tumour Hatem Krema, FRCSEd

Subciliary skin incision + Trans-septal inferior orbitotomyHatem Krema, FRCSEd

Histopathology: Cavernous Hemangioma

Hatem Krema, FRCSEd

Before surgery One week after surgery

Hatem Krema, FRCSEd

Orbital Extraconal circumscribed tumors can be delivered through: Subciliary/ eyelid crease skin incision + Trans-septal approach

Hatem Krema, FRCSEd

Excision of a Circumscribed Intraconal Mass

Clinical Presentation

Hatem Krema, FRCSEd

CT images

Left intraconal inferolateral circumscribed orbital mass

Hatem Krema, FRCSEd

Transconjunctival fornix approach - Inferolateral orbitotomy

Hatem Krema, FRCSEd

Transconjunctival fornix approach - Inferolateral orbitotomy

Hatem Krema, FRCSEd

Before surgery Two weeks after surgery

Hatem Krema, FRCSEd

Shortest route to anterior intraconal masses is by Transconjunctival approach.

Hatem Krema, FRCSEd

Excision of a large Circumscribed Intraconal Mass

Clinical Presentation

Hatem Krema, FRCSEd

Imaging

Previous CT (Axial view) MRIHatem Krema, FRCSEd

Transconjunctival Superolateral OrbitotomyHatem Krema, FRCSEd

Transconjunctival Superolateral OrbitotomyHatem Krema, FRCSEd

Histopathology: Neurofibroma with myxoid degeneration

Hatem Krema, FRCSEd

Three Weeks After Surgery

Hatem Krema, FRCSEd

Large encapsulated intraconal tumours can still be delivered through Transconjunctival approach..

Hatem Krema, FRCSEd

Cryoextraction of a large Intraconal Circumscribed Mass

Clinical Presentation

Lateral CanthotomyHatem Krema, FRCSEd

Limbal based Periotomy and hooking of musclesHatem Krema, FRCSEd

Disinsertion of two recti muscles Hatem Krema, FRCSEd

Retraction of the globe and orbital fatHatem Krema, FRCSEd

Cryoextraction of the tumor out of orbitHatem Krema, FRCSEd

Tumor is delivered completely out of orbitHatem Krema, FRCSEd

Recti muscles are sutured in placeHatem Krema, FRCSEd

Lateral canthotomy is resuturedHatem Krema, FRCSEd

Conjunctiva is resuturedHatem Krema, FRCSEd

Resolution of proptosis one week after surgery

Hatem Krema, FRCSEd

Incision Biopsy of a Diffuse Orbital Mass

Clinical presentation and imaging

Rapid proptosis in a patient with history of breast cancer

Hatem Krema, FRCSEd

Incision Biopsy of an Orbital Metastasis

1.Crease incision, trans-septal exposure 2.Determine the appropriate biopsy site

3.Mark a block of tissue with a knife 4.Remove the tissue block with scissorsHatem Krema, FRCSEd

Stepwise Approach in Management of a Diffuse Orbital Tumour

Clinical Presentation

Right slow proptosis after orbital biopsy 9 years beforeHistopathology: Angiolymphoid Hyperplasia

Hatem Krema, FRCSEd

Previous Management History

- Two debulking surgeries that were followed by Recurrence.

- Several 2-weeks courses of full- dose systemic steroids were followed by Recurrence.

- 40 Gys of fractionated stereotactic radiotherapy ended by Recurrence.

Hatem Krema, FRCSEd

Imaging at initial visit

Diffuse orbital mass encompassing lateral rectus muscle

Hatem Krema, FRCSEd

Management: Step 1= medical “down-staging”

3 months course of combination of Prednisolone 30 mg/day

+Azathioprine 50 mg/ day

Hatem Krema, FRCSEd

After 3 months of medical treatment

No further regression of proptosis after 8 weeks of treatment

Before medical treatment

Hatem Krema, FRCSEd

MRI repeated after medical therapy

MRI T1 (Contrast enhancement + fat suppression)

MRI T1 (Axial View)

Hatem Krema, FRCSEd

Management: Step 2 : Surgical excision of tumor remnants from the lateral and medial aspects of the lateral rectus

Hatem Krema, FRCSEd

Patient is maintained on 5 mg oral steroids/ every 2 daysNo recurrence after 4 years of follow-up

Before surgical excision 3 weeks after surgical excision

Hatem Krema, FRCSEd

Lid-Sparing Orbital Exenteration

Initial Presentation

Hatem Krema, FRCSEd

Previous Biopsy: Conjunctival Mucoepidermoid Carcinoma

En- block Excision of all orbital contents

Hatem Krema, FRCSEd

Dissecting the eyelids into anterior and posterior lamellae

Hatem Krema, FRCSEd

En- block Excision of all orbital contents

Hatem Krema, FRCSEd

Sparing of the anterior lamellae of both eyelids

Hatem Krema, FRCSEd

Suturing anterior lamellae of both eyelids

Hatem Krema, FRCSEd

Orbital socket is formed 2 weeks after exenteration

Hatem Krema, FRCSEd

Patient is fitted with orbital prosthesis

Hatem Krema, FRCSEd

“Lid sparing” exenteration provides rapid rehabilitation, but might not be indicated if the patient is to receive adjuvant radiotherapy.

Socket covered by the anterior lamellae flap

Socket covered by granulation tissue (Laissez-faire)

Hatem Krema, FRCSEd

Primary Surgical Excision of Orbital Capillary Haemangioma

Case 1: Inferior Orbital Hemangioma(Inducing Right Hypertropia)

Hatem Krema, FRCSEd

MRI

Hatem Krema, FRCSEd

Sub-ciliary skin incision and tumour exposureHatem Krema, FRCSEd

Trans-septal inferior orbitotomyHatem Krema, FRCSEd

Total excision with blunt dissection through subciliary skin incision + trans-septal inferior orbitotomy

Hatem Krema, FRCSEd

Wound closure

Hatem Krema, FRCSEd

Histopathology: Capillary Hemangioma

Hatem Krema, FRCSEd

Two weeks after surgery: Resolution of the hypertropia

Pre-operative Post operativeHatem Krema, FRCSEd

Case 2: Diffuse Periocular Capillary Hemangioma(Involving Eyelids, Conjunctiva & Orbit)

Hatem Krema, FRCSEd

MRI

Hatem Krema, FRCSEd

Skin incisions and tumor extension

Hatem Krema, FRCSEd

Delivery of the subcutaneous component of the hemangioma

Hatem Krema, FRCSEd

Delivery of the orbital component of the tumor

Hatem Krema, FRCSEd

Total excision by sliding the tumor out under the medial canthal tendon

Hatem Krema, FRCSEd

Wound Closure

Hatem Krema, FRCSEd

Histopathology: Capillary Hemangioma

Hatem Krema, FRCSEd

Pre-operative Post operative

Two weeks after surgery

Hatem Krema, FRCSEd

Pediatric orbital capillary hemangioma can be surgically excised, when indicated, with intact tumor wall to prevent amblyopia.

Hatem Krema, FRCSEd

Management of limbal squamous cell carcinoma

Surgical Excision 1. Alcohol (absolute 70%) corneal epitheliectomy

2. + Lamellar keratosclerectomy

3. Triple freeze- thaw of the conjunctival margins

Hatem Krema, FRCSEd

Reconstruction

If less than one quadrant involved Primary conjunctival closure.

Alternatives: - Free Conjunctival graft from the other eye

- Amniotic membrane

Hatem Krema, FRCSEd

Intraocular Tumours

Surgical Resection of an iridociliary melanoma

Hatem Krema, FRCSEd

Radioactive Plaque Insertion

Hatem Krema, FRCSEd

Hatem Krema, FRCSEd

Radioactive Plaque Insertion (Example 2)

Dosimetry

Hatem Krema, FRCSEd

Periotomy at the involved quadrant

Hatem Krema, FRCSEd

Muscle bridle sutures

Hatem Krema, FRCSEd

Transillumination

Hatem Krema, FRCSEd

Dummy plaque application + repeating transillumination

Hatem Krema, FRCSEd

Preplacing scleral sutures

Hatem Krema, FRCSEd

Inserting the radioactive plaque in position

Hatem Krema, FRCSEd

Fixing the radioactive plaque in position

Hatem Krema, FRCSEd

Resuturing the conjunctiva

Hatem Krema, FRCSEd

Before Treatment After Treatment

Treatment Outcome

Hatem Krema, FRCSEd

Enucleation

360 degree Periotomy

Hatem Krema, FRCSEd

Subtenon blunt dissection

Hatem Krema, FRCSEd

Hanging sutures of the four recti muscles

Hatem Krema, FRCSEd

Cauterization and myotomy of the two oblique muscles

Hatem Krema, FRCSEd

Isolation of the globe from all extraocular muscle attachments

Hatem Krema, FRCSEd

Delivering the globe out of the orbit and section of the optic nerve

Hatem Krema, FRCSEd

The globe is delivered by outward traction on the muscle stumps

Hatem Krema, FRCSEd

Securing haemostasis of the orbital socket

Hatem Krema, FRCSEd

Insertion of a medpore implant

Hatem Krema, FRCSEd

Implant is secured within the orbital socket

Hatem Krema, FRCSEd

Suturing the recti muscles by imbrication over the orbital implant

Hatem Krema, FRCSEd

Closure of the Tenon’s capsule with interrupted sutures and conjunctiva with continuous suture

Hatem Krema, FRCSEd

Satisfactory Cosmetic Outcome

Enucleation OSEnucleation OSEnucleation OD

Surgical Procedures in Ocular Oncology

Hatem Krema, MD, MSc, FRCS