Hatem Krema - Ocular Oncology Surgeries
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Transcript of 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