Anda di halaman 1dari 11

SURVEY OF OPHTHALMOLOGY VOLUME 53  NUMBER 3  MAY–JUNE 2008

DIAGNOSTIC AND SURGICAL


TECHNIQUES
MARCO ZARBIN AND DAVID CHU, EDITORS

Cerebrospinal Fluid Leaks in Orbital and Lacrimal


Surgery
Vanessa Limawararut, MD,1 Alejandra A. Valenzuela, MD,2
Timothy J. Sullivan, FRACS, FRANZCO,2 Alan A. McNab, FRACS, FRANZCO,3
Raman Malhotra, FRCOphth,4 Garry Davis, FRACS, FRANZCO,1
Nigel Jones, DPhil, FRACS, FFPMANZCA,5 and Dinesh Selva, FRACS, FRANZCO1

1
Oculoplastic and Orbital Division, Department of Ophthalmology & Visual Sciences, University of Adelaide, and South
Australian Institute of Ophthalmology, Adelaide, Australia; 2Eyelid, Lacrimal and Orbital Clinic, Department of
Ophthalmology, University of Queensland Medical School, Brisbane, Australia; 3Orbital Plastic and Lacrimal Clinic,
Royal Victorian Eye and Ear Hospital, Melbourne, Australia; 4Corneoplastic Unit, Queen Victoria Hospital, East
Grinstead, United Kingdom; and 5Department of Neurosurgery, Department of Surgery, University of Adelaide, Adelaide,
Australia

Abstract. Cerebrospinal fluid leakage is an uncommon but significant complication of orbital and
rarely lacrimal surgery which may have serious consequences including death. In a retrospective review
of four orbital units, we report an incidence of cerebrospinal fluid leak (diagnosed intraoperatively)
during exenteration, orbital decompression, and dacryocystorhinostomy of 1/154 (0.6%), 4/397 (1%),
and 0/3,504 (0%), respectively. We found two additional cases of cerebrospinal fluid leaks associated
with excision of orbital masses involving the orbital roof. In the literature, the incidence of
cerebrospinal fluid leaks associated with orbital exenterations and decompressions was 1.6--16.7% and
0--10%, respectively. Cerebrospinal fluid leaks occur very rarely in dacryocystorhinostomies with only
a few case reports found in the literature. Preventative measures, diagnosis, and management of this
complication are discussed. Knowledge of anatomy and thorough preoperative assessment may predict
areas at high risk for encountering cerebrospinal fluid leaks. Proper surgical technique further
minimizes the risk for this complication. If a cerebrospinal fluid leak occurs, however, prompt
diagnosis and management usually results in uncomplicated recovery. (Surv Ophthalmol 53:274--284,
2008. Ó 2008 Elsevier Inc. All rights reserved.)

Key words. cerebrospinal fluid leak  dacryocystorhinostomy  dural repair 


exenteration  lacrimal surgery  orbital decompression  orbital surgery

A cerebrospinal fluid (CSF) leak may complicate cerebral abscess, seizures, CSF hypotension with
orbital and, rarely, lacrimal surgery and may have position dependent headache syndrome, occult hem-
serious consequences including meningitis, delayed orrhage, and even death.15,27,42 In many instances, the

274
Ó 2008 by Elsevier Inc. 0039-6257/08/$--see front matter
All rights reserved. doi:10.1016/j.survophthal.2008.02.009
CEREBROSPINAL FLUID LEAKAGE 275

TABLE 1
Incidence of CSF Leaks in Exenteration
Author Incidence Treatment (n) Outcome
13
de Conciliis 5/39 (12.8%) Dural repair with temporalis muscle fascia Uncomplicated recovery (4) Death 15
or lyophilized heterologous dura  days postoperatively due to unrelated
packing with autogenous fat or pulmonary complications (1)
temporalis muscle
Bartley5 3/100 (3%) Conservative management-- Spontaneous resolution
Wulc53 3/18 (16.7%) Enlarged bone defect þ primary closure þ Uncomplicated recovery
gelfoam soaked in thrombin (2)
Enlarged bone defect þ primary closure
þ epicranium graft þ lumbar drain (1)
Rahman37 1/64 (1.6%) Local pericranial flap Uncomplicated recovery
Limawararut 1/154 (0.6%) Gelfoam, free flap (1) Uncomplicated recovery
(current study)

exposure of dura with the risk of a subsequent CSF very rarely in DCRs with a few case reports found in the
leak can be predicted by careful pre-operative assess- literature.2,14,17,18,35 CSF leakage is also a well-docu-
ment and knowledge of anatomy. However, if encoun- mented complication among other surgical proce-
tered, exposure of dura is safe if care is taken to avoid dures in the area of the skull base. This is a risk
a tear.22 Even if a dural defect is created, the morbi- particularly during skull base surgery, functional
dity associated with CSF leaks may be minimized if endoscopic surgery (FESS), and open ethmoidectomy.
promptly diagnosed and properly managed. Although We report our experience in four separate orbital
several studies report this complication, the manage- units at the Royal Adelaide Hospital, Adelaide,
ment of CSF leaks in orbital and lacrimal surgery is not Australia; the Corneoplastic Unit, East Grinstead,
well described in the literature. United Kingdom; the Royal Brisbane and Women’s
Hospital, Brisbane, Australia; and the Royal Victorian
Eye and Ear Hospital, Melbourne, Australia. Our
Incidence of CSF Leaks combined incidences of CSF leak (diagnosed intra-
The incidence of CSF leaks associated with orbital operatively) during exenteration, orbital decompres-
and lacrimal surgery is relatively low. We reviewed the sion, and dacryocystorhinostomy are 1/154 (0.6%),
incidence of CSF leaks in orbital exenteration, orbital 4/397 (1%), and 0/3504 (0%), respectively. The sole
decompression, and dacryocystorhinostomy (DCR). case of CSF leak associated with orbital exenteration
Although there is no literature on the incidence of CSF for an orbital desmoplastic melanoma occurred while
leaks in other types of orbital surgery, it is also a risk cutting the optic nerve at the orbital apex. The orbital
when orbital lesions involve the orbital roof or posterior decompressions for thyroid eye disease were per-
lateral wall, especially in erosive processes.13 Such formed medially, either by a transcaruncular or
lesions may include malignant tumors as well as benign swinging eyelid approach, and laterally, by a swinging
lesions such as dermoids, cholesterol granulomas, eyelid or upper skin crease approach. All four cases of
and eosinophilic granulomas. The highest reported CSF leakage during orbital decompression for
incidence of CSF leaks occurred in orbital exenter- thyroid ophthalmopathy occurred while drilling out
ations at a rate of 1.6--16.7% (Table 1).5,13,21,37,53 In the posterior lateral wall. The authors have not
addition, in a series of 39 patients, de Conciliis noted encountered a CSF leak during endonasal, external,
that dural exposure occurred in 20.5% of exentera- redo DCR, or conjunctivo-DCR.
tions and 30.8% of enlarged exenterations which In addition, we found two cases of CSF leak
included excision of one or more orbital walls.13 associated with excision of masses involving the orbital
Furthermore, in that study, 60% of CSF leaks and 75% roof. One of these was an orbital dermoid, and the
of dural exposures occurred in enlarged exenterations other was a recurrent adenoid cystic carcinoma. Both
involving resection of one or more orbital walls. For CSF leaks could have been predicted preoperatively
orbital decompressions, CSF leaks occurred in 0--10% due to the pathologically thinned orbital roof seen on
of cases, with the highest incidence occurring with imaging (Fig. 1).
a coronal approach (Table 2).3,6,16,20,22,23,34,36,38,46,47,48
Most studies reported incidences ranging from 0--4.5%
with transconjunctival, transcaruncular, transantral, Preoperative Assessment
external lateral, swinging eyelid, and endoscopic In many cases, exposure of dura and the risk of
approaches.3,6,16,20,22,23,34,36,38,46,47 CSF leaks occur CSF leak can be predicted by performing a careful
276 Surv Ophthalmol 53 (3) May--June 2008 LIMAWARARUT ET AL

TABLE 2
Incidence of CSF Leaks in Orbital Decompression
Author Approach Incidence Treatment (n) Outcome
3
Bailey Swinging eyelid 2/97 (2%) Conservative management (1) Uncomplicated recovery
Leak patching (1)
Goldberg22 Coronal 2/20 (10%) Tissue glue (2) Uncomplicated recovery
Baylis6 Transantral 0/24 (0%) -- --
Garrity20 Transantral 15/428 (3.5%) Conservative management Uncomplicated recovery
(11) Surgical repair (4)
Fatourechi16 Transantral 1/22 (4.5%) Surgical repair 4 months Uncomplicated recovery
later (1)
Shorr47 Transantral 2/84 (2.4%) Not reported Not reported
Shorr47 Transconjunctival 1/33 (3.0%) Conservative management Uncomplicated
Schaefer38 Combined endoscopic 1/72 (1.4%) Conservative management (1) Uncomplicated recovery
and transconjunctival
Graham23 Transcaruncular or 2/63 (3.1%) Primary repair (2) Uncomplicated recovery
endoscopic
Nadeau34 Endoscopic and 1/73 (1.4%) Nasal turbinate flap and Uncomplicated recovery
external lateral Surgical
Paridaens36 Swinging eyelid 2/198 (1.0%) Temporalis muscle fascia graft Uncomplicated recovery
(1) Lumbar drain (1)
Limawararut External lateral, 4/397 (1.0%) Temporalis muscle graft (1) Uncomplicated recovery
(current study) Swinging eyelid Temporalis muscle graft þ
cyanoacrylate (1) Orbital fat
(1) Bone wax (1)

pre-operative assessment. In De Conciliis’s series of should be considered in preoperative planning. A


39 exenterations, 50% (4/8) cases of dural exposure neurosurgical opinion for further recommendations
were foreseen based on clinical data, or standard or assistance during surgery may be advisable.
x-ray, tomography of the orbit, and computed In the context of DCR surgery, clinicians should
tomography (CT).13 In general, patients undergoing obtain further imaging studies if abnormal anatomy is
orbital exenteration or decompression will already suspected as in cases of craniofacial anomalies such as
have CT of the orbits performed preoperatively. clefting or frontal meningo-encephaloceles, prior
With regard to lateral wall decompression, the trauma, craniofacial surgery, or in the setting of
surgeon should look for variations in dimensions of infiltrative processes. Surgeons should consider
the greater wing of the sphenoid, which may differ obtaining a CT of the sinus and orbits, or computed
significantly between individuals.22 Medially, it is tomography dacryocystogram (CTDCG) if abnormal
important to evaluate for a low-riding fovea ethmoi- anatomy is suspected. Scans should include fine cut
dalis20,35 (the ethmoid roof) or cribiform plate,22,33 coronal sections and 3-D imaging may afford im-
which form part of the skull base (Fig. 2). In addition, proved guidance.
the surgeon should proceed with caution if the
pathologic process is infiltrative or has thinned the Intraoperative Measures to Avoid a CSF
bone significantly,13,15 especially in areas at high risk Leak
for encountering dura.
Other situations where CSF may be encountered HIGH-RISK AREAS
during orbital surgery include the orbital apex,13,15,46 Intraoperatively, the surgeon should have an
which is adjacent to intracranial structures. In intimate knowledge of the anatomy and approach
addition, decompressions via the orbital roof or high-risk areas with caution. It is important to
orbitotomies involving the orbital roof may expose recognize which areas are at risk for encountering
dura (Fig. 3). The risk of dural exposure via the roof dura and intracranial structures. CSF leaks have been
will also be higher in erosive processes such as well-documented during deep, posterior excavation
malignant tumors, dermoids, cholesterol granulo- of the lateral wall (greater wing of the sphenoid)
mas, and eosinophilic granulomas. Caution is also during orbital decompression,22,23,36 especially with
advisable in those cases where the bones of the skull a high-speed cutting burr. Dura may be encountered
base have been altered by trauma, previous surgery, or while drilling the lateral wall in three possible areas.
tumors such as osteomas or fibrous dysplasia. Three- First, dura may be exposed while drilling out
dimensional imaging may be particularly useful in the marrow space if the inner table of the sphenoid
these situations and the use of stereotactic guidance bone is penetrated (Fig. 4). Secondly, dura may be
CEREBROSPINAL FLUID LEAKAGE 277

Fig. 3. When expecting to encounter dura as in the case


illustrated, intraoperative assistance by a neurosurgeon
may be helpful. A: CT of the orbit shows a large orbital
dermoid. B: 3D bone reconstructions illustrate a large
defect in the orbital roof. C: Intraoperative photo shows
exposure of dura (d).

encountered while drilling posterior to the marrow


Fig. 1. Imaging demonstrates the close proximity of this space where relatively thin bone overlies the middle
orbital dermoid to the anterior cranial fossa. A CSF leak cranial fossa. Finally, inadvertently drilling superiorly
may be anticipated in the area of thin orbital roof. A: through the orbital roof may expose dura in the
Coronal CT of the orbits. B: Coronal T1-weighted MRI.
anterior cranial fossa. All four of our cases of CSF
leaks during orbital decompression occurred while
drilling out the posterior lateral wall with a cutting
drill. Surgeons should consider switching from
a cutting to a diamond burr (Fig. 5) when excavating
the deep posterior lateral wall as this is much less
likely to engage soft tissue such as dura. Alternatively,
the whole of the lateral wall drillout can be performed
with a diamond burr (an irrigating diamond burr is
useful if available), although this will take longer than
using a cutting burr initially followed by a diamond
burr.
CSF leaks may also occur in the medial orbit
through the fovea ethmoidalis6,15 or cribiform plate.
During transantral or transnasal endoscopic orbital
decompression, the skull base should be identified in
order to avoid it. Leone suggested keeping bony
Fig. 2. Coronal diagram of the orbits illustrates how CSF
leaks may occur due to the relationship of the medial extirpation below the level of the ethmoidal vessels to
orbit and ethmoid sinus (es) to the fovea ethmoidalis (fe) preclude entering the anterior cranial fossa.31 During
and cribiform plate (cp) that form part of the skull base. DCR, the surgeon must be aware that an osteotomy no
278 Surv Ophthalmol 53 (3) May--June 2008 LIMAWARARUT ET AL

Fig. 5. When drilling out the posterior lateral wall,


surgeons should consider switching from a cutting drill
(c) to a diamond burr (d) which is much less likely to
engage soft tissue such as dura.

higher than the superior aspect of the fundus of the


lacrimal sac can be expected to be several millimeters
inferior to cribriform plate;10,46 however, there are
anatomic variations between individuals. Kurihashi
concluded that if the posterior nasal window is
enlarged more than 3 mm above the medial canthal
tendon, a bony opening will be formed in the anterior
cranial fossa floor in 6/28 of cadavers studied.29
Therefore, it is important to enlarge the superior
aspect of the osteotomy just enough to expose the
fundus of the lacrimal sac or approximately 2 mm
superior to the medial canthal tendon.

SURGICAL TECHNIQUE
Using appropriate surgical technique may mini-
mize the risk of dural trauma. Frequent reference to
imaging during the procedure may help guide the
surgeon. Another intraoperative measure which may
play a significant role in avoiding CSF leaks is using
appropriate instrumentation. For example, during
DCRs, sharp rongeurs are important during creation
=
Fig. 4. High-risk areas for encountering dura in the
lateral wall of the orbit. A: Axial view. B: Sagittal view. 1.
While drilling out the marrow space (ms), the inner table
of the greater wing of the sphenoid (gws) bone may be
penetrated. 2. While drilling posterior to the marrow
space the relatively thin bone overlying the middle cranial
fossa (mcf) may be penetrated. 3. While drilling superiorly
through the orbital roof the anterior cranial fossa (acf)
may be entered. iof 5 inferior orbital fissure; sof 5
superior orbital fissure.
CEREBROSPINAL FLUID LEAKAGE 279

of the osteotomy. The surgeon should avoid a twisting


or rotational force to the rongeurs while enlarging
the posterior nasal window as a linear fracture may
extend from the defect.35 It is important to remember
that the posterosuperior aspect of the bony window is
closest to the cribiform plate.2 Fayet reported a CSF
leak due to forced reclining of the nasal septum
associated with endonasal DCR.17 The nasal septum
exhibited an unusual insertion onto the cribriform
plate instead of the crista galli.
In addition, intraoperative use of monopolar
cautery in areas of thin orbital bone may contribute
to the incidence of CSF leaks.13,53 One of our CSF
leaks occurred this way during endoscopic anterior
orbitotomy for an orbital dermoid involving the roof.
The monopolar was used to destroy dermoid lining in
a crevice that could not be reached by currettage, with
resultant CSF leak. Hence, surgeons should avoid
injudicious overcautery in high-risk areas.
Good visualization of the operative field through-
out surgery is vital for delineating the relevant
anatomy. A 30- or 70-degree endoscope may improve
visualization of areas such as the orbital roof when
dealing with erosive lesions.44 A stereotactic-assisted
approach may also be helpful in areas at high risk
of encountering dura (Fig. 6). This is particularly
relevant where the normal bony anatomy has been
distorted by lesions that involve bone such as
osteomas or fibrous dysplasia, and the skull base is
being approached from below.43
If dura is exposed intraoperatively, one should
avoid dural injury by minimizing manipulation. Even
small focal trauma or venous bleeding can create
a seizure focus or occult hemorrhage that may be
appreciated only after the operation.15

Diagnosis
If a CSF leak is encountered during orbital or
lacrimal surgery, prompt diagnosis and treatment
usually leads to favorable results. Diagnosis at the time
of surgery can be made when leakage of clear fluid is
seen in areas at high risk for encountering dura.
When CSF and blood are mixed together, diagnosis
can be difficult. CSF separates from blood when
placed on filter paper and produces a ring or halo
sign. However, this is not exclusive to CSF and can
lead to false-positive results. Glucose content can be
done rapidly; this is also unreliable, however, because
glucose in CSF cannot be distinguished from that in Fig. 6. A stereotactic assistance such as the Stealth system
blood, tears, or nasal secretion. Hence, measuring may be helpful, particularly where normal bony anatomy
glucose from the discharge is generally of little value has been distorted by lesions that involve bone such as
osteomas or fibrous dysplasia, and the skull base is being
in the peri-operative setting. Beta-2 transferrin assay is
approached from below. A: T1-weighted axial MRI of orbit
a marker protein specific to CSF. It has high sensitivity demonstrates a sphenoid wing meningioma. B: The
and specificity, can be performed rapidly, and is the Stealth stereotactic system was used to facilitate tumor
test of choice at most of our institutions. debulking.
280 Surv Ophthalmol 53 (3) May--June 2008 LIMAWARARUT ET AL

Postoperatively for persistent leaks confirmed their use is discouraged, however, due to the risk of
with beta-2 transferrin, the majority of leaks can be Creutzfeldt Jacob or other acquired disease.32
localized with high-resolution CT.42 In a retrospec- Limited exposure of the dura, large areas of dural
tive study, noncontrast high-resolution CT has been loss, or unidentifiable defects may make primary
shown to identify 30/42 (71%) of bone defects with closure impossible. Such leaks may be managed by
CSF leaks.49 If not localized on high-resolution CT, placing an onlay graft against the dural rent or
further interventions that may be useful include suspected area of leakage and suturing the graft to the
intrathecal injection of fluorescein,11,27,52 and surrounding dura. Graft materials described include
radionuclide or contrast-enhanced CT or MRI packing the area with autogenous fat, mucous
cisternography.4,19 membrane, fascia lata, temporalis fascia and muscle,
cartilage, and a osteomucoperiosteal flap.4,17,50 As
described subsequently, these various graft materials
Intraoperative Management can also be combined with a variety of tissue adhesives
EVALUATION OF THE SITE to create a watertight barrier.
In the case of orbital exenteration, packing
Once a CSF leak is identified, appropriate man- material can be placed in the socket to hold the plug
agement may minimize significant morbidity. The of muscle or fascia against the orbital apex.
goal of management with all leaks is to create and
maintain a watertight repair. This will decrease the
risks of excessive CSF drainage, infection (particu-
larly if the leak is into a sinonasal cavity), and aseptic TISSUE ADHESIVES AND ALLOPLASTIC
meningitis due to blood entering the subarachnoid MATERIALS
space.15 Recently, tissue adhesives have been used success-
A careful inspection of the dural laceration and fully in closing dural defects. Although often used in
underlying brain is mandatory. The location and size conjunction with an onlay graft to further seal the
of the dural injury in association with the amount of repair, using an adhesive alone may be adequate in
exposure surrounding the laceration, will determine very small dural defects without tissue loss. Tisseel
the types of repair possible. If the leak into the orbit is fibrin glue22 (Baxter Healthcare Corp., Deerfield, IL)
small, it may close spontaneously3,5,20,35,46 as fat may has been used with favorable results in CSF leaks to
tamponade the area and aid closure. Nevertheless, an the orbit. It consists of human fibrinogen (screened
attempt to repair the leak is advisable to avoid the for human immunodeficiency virus and hepatitis B)
risks of persistent leakage. and bovine thrombin. It is available in four sizes
Neurosurgical consultation is recommended for ranging from 0.5 to 5.0 ml and is in a deep-frozen state
further advice whenever dura is injured. and must be thawed for approximately 20 minutes at
room temperature prior to use. A solid fibrin matrix is
SURGICAL REPAIR created in 5 minutes. The needle must be changed
If there is adequate exposure and the edges of the between applications due to immediate clogging of
dural laceration can be readily apposed, primary the needle (Fig. 7). Cyanoacrylate glue applied to
repair with 5-0 or 6-0 polyglactin or braided nylon a dry surgical field has also been effective in closure of
should be performed to create a watertight seal. Our CSF leaks.50
neurosurgeons recommend removal of enough bone Bone wax23 has also been described in situations
to expose the defect when possible for secure repair. where the leak arises from the depth of a relatively
A 1-mm punch or diamond burr can be used for this small bony defect. The aim is to fill the bone defect
purpose. Many suggest an onlay graft, commonly preventing CSF leakage into the orbit while the dura
a layer of fat, temporalis muscle, or fascia, which may seals itself. However, bone wax should be used with
then be placed over the exposed dura to further caution as Bolger8 reported three cases of CSF leaks
ensure a watertight barrier.15 that were associated with bone wax. The authors
Other sources of autologous grafts include peri- proposed that bone wax controls bleeding during
cranium and periorbita. Additional materials used craniotomy but may also stent a defect open,
effectively include fascia lata, an osteomucoperiosteal preventing fibrin deposition, spontaneous healing,
flap, mucous membrane and lyophilized heterolo- and closure. Furthermore, there have been cases of
gous dura.13 Although mucous membrane has been granulomas associated with bone wax in the orbit.26
used with success,13 its use may carry an increased risk Additional materials used in the repair of CSF leaks at
of infection. Human-derived dehydrated, lyophi- other sites include the use of gelfoam in epidural
lized, and sterilized dura have been used in neuro- blood patches41 and vicryl mesh in the repair of dural
surgery and other surgical specialties for decades; defects.51 Hydroxyapatite cement has been used
CEREBROSPINAL FLUID LEAKAGE 281

Fig. 7. Tisseel fibrin glue consists of human fibrinogen


(screened for human immunodeficiency virus and hepa-
titis B) and bovine thrombin. The needle must be
changed between applications due to immediate clogging
of the needle.

successfully in otorrhea to repair small bone defects,30


although there are no reports of its use in the orbit.
Recently, dural adhesives, such as DuraSeal9,24
(Confluent Surgical, Inc., Waltham, MA, USA) and
BioGlue28,56 (Cryolife, Inc., Kenneshaw, GA, USA)
have been used by neurosurgeons with success.
DuraSeal consists of a clear, water-soluble amine
solution and a blue polyethylene glycol solution
(Fig. 8) that when mixed form a hydrogel, which is
absorbed after several weeks (Fig. 9). It forms a spray
and the applicator can only be used once. BioGlue Fig. 9. DuraSeal forms a hydrogel (arrow) which sprays
contains bovine albumin and glutaraldehyde that on and is absorbed after several weeks.
when mixed produces a flexible mechanical seal in 20
seconds with bonding strength reached in 2 minutes. schwannoma surgery compared to cases without
In one report,56 BioGlue was seen to persist at the BioGlue (12.5%).45 Hence, further large, long-term
surgical site 2 years postoperatively. Although used studies to evaluate the use of DuraSeal and BioGlue in
effectively to repair CSF leaks in the neurosurgery the orbit are needed.
literature,28,56 Sen reported an increased incidence
of CSF leaks (62.5%) when BioGlue was used to seal AUTHORS’ EXPERIENCE
the interface between the petrosal cavity and external During our case of CSF leakage during orbital
oblique muscle fascia in translabyrinthine vestibular exenteration, the site of leakage at the optic nerve
stump was clamped and covered with gelfoam. The
leak sealed within an hour while a free flap and split
thickness skin graft were harvested. Of the four CSF
leaks that occurred during orbital decompression,
two were repaired with a temporalis muscle graft and
sealed with either Tisseel fibrin glue or cyanoacrylate
glue. One case was sealed with orbital fat alone. The
last case was sealed with bone wax around the bony
defect. Of the CSF leaks during orbitotomies of the
roof, one measuring 10 mm was closed primarily with
6-0 polyglactin after the bony defect was enlarged with
ronjeurs to improve exposure. An onlay fat graft was
placed, and further sealed with Tisseel (Fig. 10). This
was repaired by the neurosurgical team. The other
small leak occurred in a crevice that was sealed with
Tisseel alone. All repairs were successful and led to
uncomplicated recoveries.
Fig. 8. DuraSeal consists of a clear, water-soluble amine In the authors’ experience, the majority of leaks
solution and a blue polyethylene glycol solution. encountered during orbital surgery tend to be
282 Surv Ophthalmol 53 (3) May--June 2008 LIMAWARARUT ET AL

defects with limited exposure. Hence, when primary


closure is not technically possible, our preference is
to repair larger defects with an autologous graft and
further seal the defect with adhesive. Small defects
may be sealed with tissue adhesives alone. In most
cases, surgical repair was performed by the orbital
surgeon. However, the neurosurgery team occasion-
ally repaired the CSF leaks depending on the
experience of the orbital surgeon. In all cases,
neurosurgery was consulted for further recommen-
dations postoperatively.

Postoperative Management
POSTOPERATIVE PRESENTATION
Following repair of a CSF leak, the patient should
be monitored postoperatively for continued leakage.
Rarely, an unrecognized dural tear may be diagnosed
only in the postoperative period. Persistent CSF
leakage may present as CSF hypotension syndrome.39
This is characterized by postural headaches, which
may be accompanied by neck tenderness, nausea,
vomiting, photophobia, blurry vision, and sixth
cranial nerve palsy.40 Head imaging should be
performed to rule out an intracranial hemorrhage.
Rhinorrhea, and rarely, orbitorrhea may occur. The
latter may simulate tears if conjunctiva has been
damaged; this has been reported only with trauma,
however.1,7,25 If a CSF leak is suspected, patients
should remain under strict neurological observation.
The surgeon should examine the patient carefully for
leakage at the wound site after lateral decompression,
or rhinorrhea in the case of medial decompression or
DCR surgery. After a CSF leak has been confirmed
with studies, neurosurgery and otolaryngology con-
sults should be obtained as appropriate.

CONSERVATIVE MANAGEMENT
Conservative management includes avoiding
straining activities such as nose-blowing or coughing,
and the use of stool softeners. Elevating the head may
reduce venous pressure resulting in reduced CSF
pressure. Prophylactic antibiotics are often used in
cases of CSF leaks; their use remains controversial,
however. Although intravenous penicillin in adults
and ampicillin in children is thought to decrease the
incidence of meningitis,55 Yilmazlar54 found that
Fig. 10. Repair of CSF leak during orbitotomy for prophylactic antibiotics did not affect rates of
a recurrent adenoid cystic carcinoma involving the orbital meningitis in cases of CSF leakage complicating skull
roof. A: The dural defect (arrow) measured approximately base fractures. Many surgeons avoid antibiotics to
10 mm. B: After the bony defect was enlarged with reduce development of resistant organisms.27 The
ronjeurs for adequate exposure, the dural defect was
repaired with primary closure with 6-0 vicryl, an overlying neurosurgeons at our institutions believe that antibi-
fat graft (f), and further seal with Tisseel (t). otics are not necessary; patients are often treated with
antibiotics by other covering physicians, however.
Acetazolamide reduces the production of CSF and
has been used to treat CSF leaks. Of our cases of CSF
CEREBROSPINAL FLUID LEAKAGE 283

leakage, one was started on acetazolamide and all 4. Barette R, Verreault J: Demonstration of periorbital cere-
brospinal fluid leak by radionuclide cisternography. Clin
were treated with antibiotics. All cases of CSF leaks Nucl Med 14:309, 1989
resulted in uncomplicated recoveries. 5. Bartley GB, Garrity JA, Waller RR: Orbital exenteration at
the Mayo clinic 1967--1986. Ophthalmology 96:268--74, 1989
6. Baylis HI, Call NB, Shibata CS: The transantral orbital
SURGICAL INTERVENTION
decompression (Ogura Technique) as performed by the
If CSF leakage continues after several days, the ophthalmologist. Ophthalmology 87:1005--12, 1980
7. Bhatoe HS: Missile injuries of the anterior skull base. Skull
consulting neurosurgeon may place a spinal catheter to Base 14:1--8, 2004
effectively manage the leak. This has been used 8. Bolger WE, Tadros M, Ellenbogen RG, et al: Endoscopic
successfully in post-surgical and traumatic CSF leaks.12 management of cerebrospinal leak associated with the use of
bone wax in skull-base surgery. Otolaryngol Head Neck
Although excessive drainage through the lumbar Surgy 132:418--20, 2005
spinal catheter can result in tension pneumocranium 9. Boogaarts JD, Grotenhuis JA, Bartels RH, et al: Use of
and a subdural or epidural hematoma, this is not a novel absorbable hydrogel for augmentation of dural
repair: results of a preliminary clinical study. Neurosurgery
common. Advances in endoscopic technique have 57(Suppl):146--51, 2005
improved the ability to operate in a less invasive fashion. 10. Botek AA, Goldberg SH: Margins of safety in dacryocysto-
Endonasal endoscopic repair of leaks at the cribiform rhinostomy. Ophthal Surg 24:320--2, 1993
11. Briggs RJS, Wormald PJ: Endoscopic transnasal intradural
plate may be considered.27 The surgeon may consider repair of anterior skull base cerebrospinal fluid fistulae. J
exploring the site to assess whether repair has been Clin Neurosci 11:597--9, 2004
ideal. Persistent or large CSF leaks that are inaccessible 12. Buchanan RJ, Brant A, Marshall LF: Traumatic Cerebrospi-
nal Fluid Fistulas, in Winn HR (ed): Youmans Neurological
endonasally may require craniotomy and repair. Surgery. Philadelphia, PA, W.B. Saunders, 2004, p 5629
13. de Conciliis C, Bonavolonta G: Incidence and treatment of
dural exposure and CSF leak during orbital exenteration.
Ophthal Plast Reconstr Surg 3:61--194, 1987
Summary 14. Dryden RM, Wulc AE: Pseudoepiphora from cerebrospinal
CSF leakage is a rare but potentially serious fluid leak: case report. Br J Ophthalmol 70:570--4, 1986
15. Ebersold MJ: Five things oculoplastic surgeons should know
complication of orbital and lacrimal surgery. Knowl- about neurosurgery. Ophthal Plast Reconstr Surg 16:247--9,
edge of anatomy and thorough pre-operative assess- 2000
ment may predict areas at high risk for encountering 16. Fatourechi V, Garrity JA, Bartley GB, et al: Results of
transantral orbital decompression performed primarily for
CSF leaks. Proper surgical technique further mini- cosmetic indications. Ophthalmology 101:938--42, 1994
mizes the risk for this complication. Many options 17. Fayet B, Racy E, Assouline M: Cerebrospinal fluid leakage
exist for management and repair which usually result after endonasal dacryocystorhinostomy. J Fr Ophtalmol 30:
129--34, 2007
in uncomplicated outcomes. Although further large 18. Fayet B, Racy E, Assouline M: Complications of standardized
studies are necessary to compare the efficacy of endonasal dacryocystorhinostomy with unciformectomy.
various techniques and materials, this may be difficult Ophthalmology 111:837--45, 2004
19. Flynn BM, Butler SP, Quinn RJ, et al: Radionuclide
given the rarity of this complication. cisternography in the diagnosis and management of cerebro-
spinal fluid leaks: the test of choice. Med J Aust 146:82--4, 1987
20. Garrity JA, Fatourechi V, Bergstralh EJ, et al: Results of
transantral orbital decompression in 428 patients with severe
Method of Literature Search Graves’ ophthalmopathy. Am J Ophthalmol 116:533--47, 1993
Literature search was based on a Medline search with 21. Goldberg RA, Kim JW, Shorr N: Orbital exenteration: results
of an individualized approach. Ophthal Plast Reconstr Surg
Pubmed including references published before Febru- 19:229--36, 2003
ary 2007. The keywords used in the search were 22. Goldberg RA, Weinberg DA, Shorr N, et al: Maximal, three-
cerebrospinal fluid leak, CSF leakage, orbital surgery, wall, orbital decompression through a coronal approach.
Ophthal Surg Lasers 28:832--43, 1997
exenteration, orbital decompression, dacryocystorhinostomy. 23. Graham SM, Brown CL, Carter KD, et al: Medial and lateral
Articles were restricted to those in English and other- orbital wall surgery for balanced decompression in thyroid
language publications with English abstracts. Refer- eye disease. Laryngoscope 113:1206--9, 2003
24. Grotenhuis JA: Costs of postoperative cerebrospinal fluid
ences within these articles were also obtained for review. leakage:1-year, retrospective analysis of 412 consecutive
nontrauma cases. Surg Neurol 64:490--3, 2005
25. Ide CH, Webb RW: Penetrating transorbital injury with
cerebrospinal orbitorrhea. Am J Ophthalmol 71:1037--9,
References 1971
26. Katz SE, Rootman J: Adverse effects of bone wax in surgery
1. Baba M, Tachizawa T, Takizawa H, et al: Penetrating of the orbit. Ophthal Plast Reconstr Surg 12:121--6, 1996
transorbital intracranial foreign body. No Shinkei Geka 10: 27. Kerr JT, Chu FW, Bayles SW: Cerebrospinal fluid rhinorrhea:
869--74, 1982 diagnosis and management. Otolaryngol Clin North Am 38:
2. Bagheri A, Naghibozakerin J, Yazdani S: Cerebrospinal fluid 597--611, 2005
leakage during dacryocystorhinostomy in a patient with 28. Kumar A, Maartens NF, Kaye AH: Evaluation of the use of
meningoencephalocele. Eur J Ophthalmol 15:500--3, 2005 BioGlue in neurosurgical procedures. J Clin Neurosci 10:
3. Bailey KL, Tower RN, Dailey RA: Customized, single-incision, 661--4, 2003
three-wall orbital decompression. Ophthal Plast Reconstr 29. Kurihashi K, Yamashita A: Anatomical consideration for
Surg 21:1--9, 2005 dacryocystorhinostomy. Ophthalmologica 203:1--7, 1991
284 Surv Ophthalmol 53 (3) May--June 2008 LIMAWARARUT ET AL

30. Kveton JF, Goravalingappa R: Elimination of temporal bone 45. Sen A, Green KM, Khan MI, et al: Cerebrospinal fluid leak
cerebrospinal fluid otorrhea using hydroxyapatite cement. rate after the use of BioGlue in translabyrinthine vestibular
Laryngoscope 110:1655--9, 2000 schwannoma surgery: a prospective study. Otol Neurotol 27:
31. Leone CR, Piest KL, Newman RJ: Medial and lateral wall 102--5, 2006
decompression for thyroid ophthalmopathy. Am J Ophthal- 46. Shaefer SD, Soliemanzadeh P, Della Rocca DA, et al:
mol 108:160--6, 1989 Endoscopic and transconjunctival orbital decompression
32. Martinez-Lage JF, Perez-Espejo MA, Palazon JH, et al: for thyroid-related orbital apex compression. Laryngoscope
Autologous tissues for dural grafting in children: a report 113:508--13, 2003
of 56 cases. Childs Nerv Syst 22:139--44, 2005 47. Shorr N, Seiff SR: The four stages of surgical rehabilitation
33. McCord CD: Current trends in orbital decompression. of the patient with dysthyroid ophthalmopathy. Ophthal-
Ophthalmology 92:21--33, 1985 mology 93:476--83, 1986
34. Nadeau S, Pouliot D, Molgat Y: Orbital decompression in 48. Siracuse-Lee DE, Kazim M: Orbital decompression: current
Graves’ orbitopathy: a combined endoscopic and external concepts. Curr Opin Ophthalmol 13:310--6, 2002
lateral approach. J Otolaryngol 34:109--15, 2005 49. Stone JA, Castillo M, Neelon B, et al: Evaluation of CSF
35. Neuhaus RW, Baylis HI: Cerebrospinal fluid leakage after leaks: high-resolution CT compared with contrast-enhanced
dacryocystorhinostomy. Ophthalmology 90:1091--5, 1983 CT and radionuclide cisternography. Am J Neuroradiol 20:
36. Paridaens D, Lie A, Grootendorst RJ, et al: Efficacy and side 706--12, 1999
effects of ‘swinging eyelid’ orbital decompression in Graves’ 50. Tse DT, Panje WR, Anderson RL: Cyanoacrylate adhesive
orbitopathy: a proposal for standardized evaluation of used to stop CSF leaks during orbital surgery. Arch
diploplia. Eye 20:154--62, 2006 Ophthalmol 102:1337--9, 1984
37. Rahman I, Cook AE, Leatherbarrow B: Orbital exenteration: 51. Vergheggen R, Schulte-Baumann WJ, Hahm G, et al: A new
a 13 year Manchester experience. Br J Ophthalmol 89:1335-- technique of dural closure—experience with a vicryl mesh.
40, 2005 Acta Neurochir 139:1074--9, 1997
38. Schaefer SD, Soliemanzadeh P, Della Rocca DA, et al: 52. Wormald PJ, McDonough M: The bath-plug closure of
Endoscopic and transconjunctival orbital decompression for anterior skull base cerebrospinal fluid leaks. Am J Rhinol 17:
thyroid-related orbital apex compression. Laryngoscope 299--305, 2003
113:508--13, 2003 53. Wulc AE, Adams JL, Dryden RM: Cerebrospinal fluid
39. Schievink WI, Maya MM, Riedinger M: Recurrent spontane- leakage complicating orbital exenteration. Arch Ophthal-
ous spinal cerebrospinal fluid leaks and intracranial hypo- mol 107:827--30, 1989
tension: a prospective study. J Neurosurg 99:840--2, 2003 54. Yilmazlar S, Arslan E, Kocaeli H, et al: Cerebrospinal fluid
40. Scheivink WI, Meyer FB, Atkinson JL, et al: Spontaneous leakage complicating skull base fractures: analysis of 81
spinal cerebrospinal fluid leaks and intracranial hypoten- cases. Neurosurg Rev 29:64--71, 2006
sion. J Neurosurg 84:598--605, 1996 55. Youmans JR: Neurological surgery: A comprehensive refer-
41. Schievink WI, Vittorio MM, Atkinson JLD, et al: Surgical ence guide to the diagnosis and management of neurosurgical
treatment of spontaneous spinal cerebrospinal fluid leaks. problems. Philadelphia, PA, WB Saunders, 1973, pp 981--92
J Neurosurg 88:243--6, 1998 56. Yuen T, Kaye AH: Persistence of Bioglue in spinal dural
42. Schwaber MK, Netterville JL, Coniglio JU: Complications of repair. J Clin Neurosci 12:100--1, 2005
skull base surgery. Ear Nose Throat J 70:648--60, 1991
43. Selva D, Chen C, Wormald PJ: Frontoethmoidal osteoma:
a stereotactic-assisted sino-orbital approach. Ophthal Plast The authors reported no proprietary or commercial interest in
Reconstr Surg 19:237--8, 2003 any product mentioned or concept discussed in this article.
44. Selva D, Lai T, Krishnan S: Orbitofrontal cholesterol Reprint address: Prof. Dinesh Selva, FRACS, FRANZCO, South
granuloma: Percutaneous endoscopic-assisted curettage. Australian Institute of Ophthalmology, The Royal Adelaide
J Laryngol Otol 117:892--4, 2003 Hospital, Level 8, North Terrace, Adelaide, SA 5000, Australia.