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Objectives: To describe an anatomic and clinical outcome study of transorbital neuroendoscopic surgical (TONES) for the repair of complex anterior cranial fossa (ACF) cerebrospinal fluid (CSF) leaks.

Design: Anatomic cadaver investigation and clinical outcomes evaluation.

Methods: An anatomic cadaver study was undertaken to determine the anatomic feasibility of the TONES approaches for repair of CSF leaks, and determine the optimal approaches for these repairs. A targeted outcome analysis was performed on 10 consecutive patients who underwent 12 ACF CSF leak repairs by TONES.

Results: The cadaver study demonstrated that the entire ACF can be accessed by TONES. Due to the rise and angulation of the orbital roof above the interorbital ACF, the precaruncular (PC) approach optimal for a coplanar target approach in the interorbital ACF, and the superior lid crease (SLC) trajectory is preferable for procedures involving the supraorbital ACF. There were no complications in the 12 clinical procedures. Fifty percent of the cases were revisions, referred after up to five previous craniotomies and endoscopic procedures; all TONES repairs were successful with a single operation.

Conclusions: The use of TONES to repair ACF CSF leaks was demonstrated to be technically feasible in cadaver and clinical studies. The SLC approach was optimal for supraorbital ACF leaks; the PC approach was preferable for interorbital ACF pathology. TONES was shown to be highly effective for treating complex pathology that was refractory to correction through frontal craniotomy and /or transnasal endoscopy, providing safe, minimally disruptive direct coplanar routes for target approach and manipulation.

Objective: To prospectively evaluate the safety, effectiveness, and utility of orbital and transorbital endoscopic surgery.

Study design: Case series with planned data collection.

Setting: Level 1 trauma center and tertiary academic hospital.

Subjects and methods: Consecutive sample of 107 patients undergoing orbital or transorbital endoscopic operations.

Main outcome measures: Ability to achieve intraoperative goals using endoscopic approach; occurrence of predetermined intraoperative or postoperative complications.

Results: One hundred seven patients (aged 6-83 years) underwent orbital or transorbital endoscopic surgery for 6 different indications. Seven incisions were used. Endoscopic orbitotomies were made through all 4 orbital walls to access surrounding structures. Intraoperative goals were achieved endoscopically in 106 patients. Mean follow-up was 3 months (mean ± SD, 3.0 ± 3.5). No complication was directly related to surgical approach or use of endoscopy. Seventeen complications were detected in 2 categories: persistent diplopia and persistent vision change. No patient had vision loss. No nonfracture patient suffered a complication. Subgroup analysis demonstrated no difference in surgical success rates when compared with transnasal and transantral medial orbital wall and orbital floor repair and cerebrospinal fluid leak repair. Endoscopic visualization was advantageous in several respects: superior visualization and lighting, particularly posterior to the equator of the globe; image magnification; and video monitoring for education and operating room staff involvement. It also facilitated surgical navigation and computer-aided reconstruction.

Conclusion: Orbital and transorbital endoscopy are versatile, effective, and safe approaches useful for addressing diverse urgent and elective problems. In appropriate clinical situations, these procedures may offer better access and visualization than open or transnasal approaches.