Endoscopic Transorbital Excision of an Intraconal Hemangioma

ABSTRACT: Intraconal orbital tumors require a surgical approach tailored to their relationship with the optic nerve. Endoscopic transorbital surgery offers a minimally invasive corridor for lesions located lateral to the nerve. It avoids the morbidity of traditional cranio-orbital approaches. We present a step-by-step operative video of excision of an intraconal cavernous hemangioma through the endoscopic transorbital approach in a 55-year-old man with progressive left-eye proptosis and facial pain. Under endoscopic visualization, through a lateral canthal incision, the lateral canthal tendon and crura were divided, the periorbita opened, and the tumor dissected and removed en bloc without orbital bone drilling. Postoperative vision and extraocular movements were preserved. This case demonstrates step-by-step operative nuances of the safety and efficacy of the endoscopic transorbital route for appropriately selected intraconal lesions.Pearls and Pitfalls:Review detailed orbital anatomy and preoperative imaging. Protect the globe with a moist shield throughout the procedure. Adequately release the lateral canthal tendon to create a proper corridor, and retract it using stay sutures. Use 0°/30° endoscopes and perform gentle, circumferential dissection. One should strive to preserve the orbital fat and prefer its retraction to prevent postoperative fibrosis and enophthalmos. Excision of fat should be as minimal as possible. Avoid lesions medial to or crossing the optic nerve-these are contraindications. Ensure good visualization; poor exposure increases the risk of injury. Handle the optic nerve and extraocular muscles with extreme care to prevent deficits. Avoid unnecessary bone drilling. Be cautious with large vascular tumors; piecemeal removal can increase bleeding and risk incomplete excision.