A team of surgeons performed the first Transorbital neuroendoscopic surgery at Groote Schuur Hospital, Cape Town.
THERE is a saying that “eyes are the window to the soul”. But doctors at Groote Schuur Hospital, Cape Town are taking this expression a step further and are using eyes as a pathway to reaching the most intricate parts of the brain.

Although Transorbital neuroendoscopic surgery (Tones) was pioneered at the University of Washington and later at the University of California, both universities had never used Tones to operate on the opposite side of the brain.

In a ground-breaking and the first such keyhole operation to be performed in the world, a multidisciplinary team of surgeons have used the eye socket as a corridor to reach the temporal lobe at the base of the skull to repair a lesion - a procedure which would have been very risky to perform using the traditional methods due to associated complications and the post-operative trauma to the tissue.

The team - which consisted of an ear, nose and throat (ENT) specialist, Professor Darlene Lubbe, a neurosurgeon, Professor Patrick Sample, and an ophthalmologist, Dr Hamzah Mustak - used the left eye cavity to get to the right side of the brain of Faieza Abdol of Athlone.

It is difficult to view and operate on when using other techniques.

Abdol, a 64-year-old diabetes and hypertension patient suffered from a spontaneous cerebrospinal fluid leak - a condition where part of her brain lining tore and got stuck in the bone, causing the leaking of the brain fluid. If not corrected the defect could have led to other complications such as meningitis.

Lubbe said Abdol, regarded as an “unstable” patient because of her age and chronic conditions, would have been a high-risk patient to operate on using other techniques.

“In fact we tried to operate on her using the keyhole procedure that goes through the nose, but we had to stop the operation even before we started as she became very unstable while on the operating table,” she said.

It was after a few weeks of bouncing ideas around that the team of doctors came up with the idea of using the left eye socket to get to the right side of the bony defect.

“This turned out to be the best decision as it gave us a direct view and space to work on without the risk of damaging the surrounding nerves and blood vessels. Had we used other techniques such as going through the nose, we would have only been able to view it, but it would have been much harder to fix. We would have had to drill away the nerves and blood vessels to get a decent view,” Lubbe said.

According to the trio, the new technique not only allows surgeons direct access to the most intricate parts of the brain, such as brain tumours and other cranial defects, but it offers much quicker recovery time, leaves no visible scars on the patient, and makes it possible to operate on high-risk patients who otherwise would be deemed inoperable.

Until recently, doctors could only perform cranial surgery by either opening the skull - a procedure that is considered very invasive, or using a keyhole surgery that uses patients’ nostrils as an entry point.

The nose procedure is widely used in South Africa, but some of its drawbacks are that it can cause nerve damage and harm to the bone due to considerable drilling involved.

Lubbe said although the hospital pioneered Tones surgery two years ago, and had performed 40 such operations so far, it was the first time that doctors used an eye to reach the opposite side of the brain.

Following the resounding success of the latest surgery, the team would next month head to the US to share their experience and teach other doctors at the North American Skull-base meeting to be held in New Orleans.

Mustak said the Tones procedure was better in so many ways. Not only was it less complicated, but it allowed different specialists who often worked in a “fragmented” manner to work as a team.

“In medicine the more one becomes specialised the more fragmented the system becomes. There is a tendency among doctors to work on their own as they become specialised, but this negatively affects the patient who has to consult with different doctors over a long period.

“So the patient would have to get from one doctor to another without actually getting treatment.

Sample said: “Working as a team allowed us to sit down and think more, and now we have found the best approach that has made the operation more effective. Previously one specialist would do incomplete treatment and refer to other specialists for them to complete the job, but this resulted in a lot of inconvenience for the patient.

“Now we are able to complete the treatment at once using a very sophisticated technique that would not leave a patient with complications such as epilepsy or damage to the eye, as is the case with traditional techniques,” he said.