Surgical Anatomy

See the section above on Orbital Decompression. Surgical Technique

First of all, an orbital decompression of the medial wall is done without incising any periosteum at this stage. The optic nerve can often be decompressed in the lateral wall of the sphenoid, but extreme care is needed to avoid heating the bone over it. There has

Orbital Apices
Fig. 14.49 Peroperative computer-guided images during the removal of a chordoma pressing on the orbital apex.

been debate whether the sheath of the optic nerve should be incised or not. There is insufficient evidence in favor of this (Jiang et al., 2001). Incising the sheath not only runs the risk of producing a CSF leak but could compromise some of the vascular supply of the optic nerve (Fig. 14.49).

Postoperatively it is vital to monitor the vision quarter-hourly for one hour, and then hourly for 4 hours, although decompression is rarely associated with any deterioration in vision. In fact, the immediate or early results of decompression are frequently extremely gratifying. The patient should be instructed not to blow their nose or stifle sneezes for 4 days in order to avoid surgical emphysema (Fig. 14.50).

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