Acta Neurochir (2014) 156:1891–1896
DOI 10.1007/s00701-014-2199-1
HOW I DO IT - NEUROSURGICAL TECHNIQUES
How I do it: the endoscopic endonasal optic nerve and orbital apex
decompression
Timothée Jacquesson & Lucie Abouaf &
Moncef Berhouma & Emmanuel Jouanneau
Received: 15 May 2014 / Accepted: 25 July 2014 / Published online: 22 August 2014
# Springer-Verlag Wien 2014
ABSTRACT
Background With the refinement of the technique, endoscop-
ic endonasal surgery increases its field of indications. The
orbital compartment is among the locations easily reached
through the nostril. This anteromedial approach has been
described primarily for inflammatory or traumatic diseases,
with few data for tumoral diseases.
Method Since 2010, this route has been used at our institution
either for decompression or for biopsy of orbital tumoral
diseases.
Findings/Conclusions Even if further studies are warranted,
this strategy proved to be beneficial for patients, with im-
provements in visual outcome. In this article, the authors
summarize their technique and their experience with
endonasal endoscopic orbital decompression.
Electronic supplementary material The online version of this article
(doi:10.1007/s00701-014-2199-1) contains supplementary material,
which is available to authorized users.
T. Jacquesson : M. Berhouma : E. Jouanneau
Skull Base Surgery Unit – Department of Neurosurgery B, Pierre
Wertheimer Neurological and Neurosurgical Hospital – Hospices
Civils de Lyon, Lyon, France
T. Jacquesson : E. Jouanneau
Research and Education Unit of Medicine, Claude Bernard
University Lyon 1, Lyon, France
L. Abouaf
Department of Neuro-ophthalmology (Pr A Vighetto), Pierre
Wertheimer Neurological and Neurosurgical Hospital – Hospices
Civils de Lyon, Lyon, France
E. Jouanneau
INSERM U1028, CNRS UMR5292, Neurosciences Research Center
of Lyon, Neuro-oncology and Neuro-inflammation team, Lyon,
France
T. Jacquesson (*)
Skull Base Surgery Unit – Department of Neurosurgery A, Pierre
Wertheimer Neurological and Neurosurgical Hospital – Hospices
Civils de Lyon, 59 Boulevard Pinel, 69394 Lyon, Cedex 03, France
e-mail: timothee.jacquesson@neurochirurgie.fr
Key points
• Nasal and sphenoidal anatomies determine the feasibility
and risks for doing an efficient medial optic or orbit
decompression.
• Techniques and tools used are those developed for pituitary
surgery.
• A middle turbinectomy and posterior ethmoidectomy are
mandatory to expose the medial wall of the orbit.
• The Onodi cell is a key marker for the optic canal and must
be opened up with caution.
• The lamina papyracea is opened first with a spatula and the
optic canal opened up by a gentle drilling under continuous
irrigation from distal to proximal.
• Drilling might always be used under continuous irrigation to
avoid overheating of the optic nerve. An ultrasonic device
can be used as well.
• The nasal corridor is narrow and instruments may hide the
infrared neuronavigation probe. To overcome this issue, a
magnetic device could be useful.
• Doppler control could be useful to locate the ICA.
• The optic canal must be opened up from the tuberculum of
the sella to the orbital apex and from the planum (anterior
cranial fossa) to the lateral OCR or ICA canal
• At the end of the procedure, the optic nerve becomes fre-
quently pulsatile, which is a good marker of decompression.
Keywords Skull base surgery . Minimally invasive
neurosurgery . Endoscopic endonasal surgery . Optic nerve
tumors . Orbital Tumors . Trans-sphenoidal approach
Introduction
With the development of the technique, endoscopic endonasal
surgery increases its field of application both for treating
diseases and accessing challenging anatomical locations [1].
Routinely used for pituitary surgery, the endoscopic naso-
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Fig. 1 a: Anatomical view view
of the sphenoid sinus. DM: dura-
mater of the sella turcica; OP:
optic Prominence; CP: carotid
prominence; OCR: Lateral Optico
Carotid Recess; PS: Planum
Sphenoidal. b: anatomical data
after large opening of the
sphenoid and ethmoidal sinuses.
ON: Optic Nerve; C5 ICA: C5
portion of the Internal Carotid;
ST: Sella Turcica
sphenoidal route provides minimally-invasive access to the
medial compartment of the orbit and the optic nerve. This
has been underused for tumoral diseases [10, 9]. Thus, a
visual impairment can result from compression due to
inextensible bony walls. The extradural approach with
the aperture of the optic canal, anterior clinoidectomy, or
lateral orbitotomy is routinely performed for decompres-
sion, with some morbidity [7] and the medial nasal ap-
proach represents another option. This route can also be
used for tumor biopsy or removal, although inadequate
instrumentation still prevents expansion of indications [3].
We describe the tips and tricks for optic and orbital
endoscopic endonasal decompression.
Relevant surgical anatomy
Lateral to the sella turcica is the optic canal (OC) with the C5
paraclinoid portion of the Internal Carotid Artery (ICA)
(Fig. 1a). The medial and lateral optico-carotid recesses re-
spectively correspond to the middle and the anterior clinoid
processes.
The OC is in close contact with the Onodi Cell (the most
posterior ethmoidal cell) (Fig. 2 a and b).
The orbital apex prolongs anteriorly along the OC and lies
above the superior orbital fissure (Fig. 1b).
The orbit is limited medially by the laminae papyracea
(cells of the lateral massa of the ethmoid) (Fig. 2a) and
inferiorly by the maxillary sinus.
Description of the technique
Positioning and anesthesia
The patient’s positioning and pre-operative steps are similar to
regular pituitary cases and have been previously described [2].
Acta Neurochir (2014) 156:1891–1896
Nasal phase
A uninostril approach, on the same side of the optic nerve or
orbit we want to reach, is used. A 0° short rigid endoscope
(18 cm length, 4 mm diameter, Storz®, Tuttlingen, Germany)
is introduced inside the nostril and a middle turbinectomy
is first done followed by a posterior ethmoidectomy
(Fig. 2 a and b).
Sphenoidal phase
The mucosa is coagulated medially to the sphenoid ostium
and the posterior bony septum is pushed away until the
contralateral ostium can be seen. The vomer is then removed
using a bone forceps, and the sphenoidotomy is enlarged
laterally to expose the optic nerve and ICA (Fig. 1a).
Orbital apex and optic canal opening
When starting to work around the optic nerve, a long endo-
scope (30 cm) is positioned in the upper part of the nostril and
secured in the holder. The surgical tools can be passed below
the endoscope. The thin lamina papyracea is first opened up
with a spatula. The opening of the OC is done from distal to
proximal to the tuberculum of the sella by a gentle drilling,
and the bone pellicle is finally removed with a spatula or with
a bone punch. The OC aperture must be as large as possible,
especially at the superior and inferior parts of the OC until the
planum and the OCR, respectively. A clockwise 180° of
freedom of the optic nerve may be expected (Fig. 3 a and b).
The medial orbital decompression can be extended as anteri-
orly as needed according to the tumor anatomy (Fig. 4).
Closure and postoperative care
Sinuses and the nostril are cleaned with saline solution and the
hemostasis checked. No nasal packing is needed.
Postoperatively, no intensive care is needed. Vision and
nasal flow are regularly checked for the first few days. A CT
Acta Neurochir (2014) 156:1891–1896 1893

Fig. 2 a: cranio-facial axial CT

showing the thin lamea
papyracea, the medial wall of the
orbit, and the OC (Onodi Cell)
posterior ethmoidal cell in direct
contact with the ON (Optic
Nerve). b: Cranio-facial coronal
CT showing the OC and the ON

scan is done on day one and the patient is discharged from the
hospital at day three.
An endoscopic nasal check-up is done within three weeks after
the surgery. Visual and MRI evaluation is planned at three months
and thereafter, depending on the underlying disease.
Indications (Fig. 4)
Inflammatory (Grave’s orbitopathy) or traumatic diseases represent
traditional indications of endonasal orbital decompression [5, 8].
This may also be discussed in the case of tumors of the
optic nerve or orbital apex, mainly for meningiomas when a
visual impairment occurs (Fig. 5). For spheno-orbital me-
ningiomas, this approach can be used first to decompress the
optic nerve before doing the regular lateral orbitotomy.
Indeed, in many cases, the hyperostosis stays lateral, and
this may reduce optic nerve suffering during the second
procedure.
This approach can also be used to realize tumor biopsies
or removal when the tumors are located medially into the
orbit.

Fig. 3 a: Operative view of the

sphenoid sinus with the ON
(Optic Nerve), the Orbital apex,
the C5 ICA (C5 portion of the
ICA), the TS (tuberculum of the
Sella) and the planum. b:
Operative view after the optic
nerve and the orbital apex
decompression. The DM (Dura-
Mater) of the planum and the TS
(Tuberculum of the Sella) have
been exposed to ensure a
complete optic decompression
1894
Fig. 4 Examples of tumors that may benefit from an endonasal endoscopic surgery. a: Optic nerve sheath meningioma. b: Optic nerve sheath
meningioma. c: Spheno-orbital meningioma
Limitations
Complex sphenoid septa and/or weak pneumatization can lead
to exposure difficulties with time-consuming and risky dril-
ling [4]. The same difficulties can be encountered in cases of
medial hyperostosis.
As soon as the periorbita is opened up, the orbital fat and
muscles get out. Thus, orbital tumors may be hard to identify
and remove, as retractors for orbital content are still missing.
How to avoid complications
– Pre-operative assessment of imaging exams (CT-scan and
MRI, angioMRI) must study the anatomy to anticipate
surgical difficulties (megaturbinates, septal deviation,
sphenoid pneumatization and septas, length of the OC,
hyperostosis, ICA positioning).
– Careful opening of the Onodi cell is mandatory to avoid
ON injury.
– Keeping the bone of the C5 ICA canal intact is useful to
decrease the vascular risk when opening the inferior part
of the optic canal.
– Posterior ethmoidal arteries must be identified.
Acta Neurochir (2014) 156:1891–1896
– The surgeon may be aware that the ophthalmic artery can
emerge from the medial or inferior part of the optic canal
in cases of biopsy or removal [6].
– Dura mater of the anterior skull base is fragile in this
location and must be pushed away when drilling to avoid
a CSF leak.
Specific perioperative considerations
Preoperatively, a cranio-facial CT and MRI are done and used
for neuronavigation during the surgery. Mandatorily, a visual
assessment includes bilateral visual acuity, fundoscopy, and
computerized visual field.
A rigorous preoperative preparation is systematic, includ-
ing nasal rinsing and iodine ointment the day before and just
before surgery.
Postoperatively, no intensive care is needed. Vision as well
as nasal flow are checked every two hours the first night and
twice daily thereafter. A Ct scan is done at day one and the
patient is dischargesd from the hospital at day two or three.
An endoscopic nasal check-up is done within two or
three weeks after the surgery to control mucosae and sinus
Acta Neurochir (2014) 156:1891–1896
Fig. 5 a and b: Ophthalmologic results before (up) and after (down) an endonsasal endoscopic optic nerve and orbital apex decompression for a spheno-
orbital meningioma (decompression between the two arrows). Both the visual acuity and field have been improved
healing. Postoperative visual and MRI evaluation is planned at
three months and thereafter depending on the underlying
disease.
Specific information to give to the patient
Patients have to be aware of potential visual and vascular
risks. As for pituitary surgery, the postoperative rhinological
discomfort and CSF leak rate are very minimal. Finally, the
patient must be aware that coughing, sneezing, or blowing the
nose may result in exophthalmia because of air getting into the
orbit and, therefore, should be avoided during the first days.
Conclusion
The nasal route is a smart one for reaching the optic or orbital
compartments for various diseases but is still underused for
tumoral ones. This may represent an easy way to decompress
the optic canal or orbital apex in case of medial tiny bone but
needs specific training and materials. Further evaluations of
functional results are required. Tumor biopsies can also be
done but tumor removal still requires a refinement of the
1895
available instrumentation, particularly orbital fat retractors
and angled instruments.
Conflict of interest None.
References
1. Berhouma M, Messerer M, Jouanneau E (2012) Shifting paradigm in
skull base surgery: Roots, current state of the art and future trends of
endonasal endoscopic approaches. Rev Neurol (Paris) 168(2):121–
134
2. Berhouma M, Messerer M, Jouanneau E (2012) Occam’s razor in
minimally invasive pituitary surgery: tailoring the endoscopic
endonasal uninostril trans-sphenoidal approach to sella turcica. Acta
Neurochir (Wien). doi:10.1007/s00701-012-1510-2
3. Cebula H, Lahlou A, De Battista JC, Debry C, Froelich S (2010)
Endoscopic approaches to the orbit. Neurochirurgie 56(2–3):230–
235
4. Hart CK, Theodosopoulos PV, Zimmer LA (2009) Anatomy of the
optic canal: a computed tomography study of endoscopic nerve
decompression. Ann Otol Rhinol Laryngol 118(12):839–844
5. Jiang RS, Hsu CY, Shen BH (2001) Endoscopic optic nerve decom-
pression for the treatment of traumatic optic neuropathy. Rhinology
39(2):71–74
1896
6. Locatelli M, Caroli M, Pluderi M, Motta F, Gaini SM, Tschabitscher
M, Scarone P (2011) Endoscopic transsphenoidal optic nerve decom-
pression: an anatomical study. Surg Radiol Anat 33(3):257–262
7. Mariniello G, Bonavolontà G, Tranfa F, Maiuri F (2013) Management
of the optic canal invasion and visual outcome in spheno-orbital
meningiomas. Clin Neurol Neurosurg 115(9):1615–1620
8. Michel O, Oberländer N, Neugebauer P, Neugebauer A,
Rüssmann W (2001) Follow-up of transnasal orbital
Acta Neurochir (2014) 156:1891–1896
decompression in severe Graves’ ophthalmopathy. Ophthalmology
108(2):400–404
9. Netuka D, Masopust V, Belšán T, Profantová N, Beneš V (2013)
Endoscopic endonasal resection of medial orbital lesions with intra-
operative MRI. Acta Neurochir (Wien) 155(3):455–461
10. Sia DIT, Chan WO, Wormald PJ, Davis G, Selva D (2012)
Decompression of benign orbital apex lesion via medial endoscopic
approach. Orbit 31(5):344–346