Ablation with bipolar wet-field diathermy safe, effective for low-flow vascular lesions of orbit

Keypoints:

San Francisco-The management of diffuse, low-flow vascular lesions is difficult, but ablation with bipolar wet-field diathermy is as effective as standard surgery, less invasive, and safe, according to Devron H. Char, MD, director, The Tumori Foundation, San Francisco.

Several options have been tried to manage posteriorly fed orbital venous varices and diffuse lymphangiomas, including surgery, embolization, and sclerosing therapy, he said. Dr. Char said he became interested in finding the most effective approach many years ago when, as a visiting professor at a major ophthalmologic center, he was shown two patients who had undergone 6 to 8 hours of surgery.

"Both of them had a good cosmetic result after surgical management for these lesions, but both of them had no light perception, which was not an optimal outcome," Dr. Char said.

The mean age of the patients in the series was 20 years, and the mean age at which they had developed a lymphangioma was 6 years. All patients presented symptoms. Mean follow-up was 4 years, with a range of 6 months to 11 years, he said.

The initial four patients were treated with CO₂ laser therapy because Dr. Char used that approach regularly at that time in combined neurosurgical-orbital cases.

"Frankly, we then found it was easier to use wet-field bipolar cautery, which we also used a lot in combined orbital-neuro cases. It worked just as well, so we switched to that technique," he said.

"The CO₂ laser gives you an advantage because it gives you precise, fairly good hemostasis in small vessels. It does need a microscope, and we use it now mainly for meningiomas and capillary hemangiomas. The problem with it is that it involves a certain amount of set-up time, and that makes it a more cumbersome therapeutic option," Dr. Char added.

"We started to use the wet-field bipolar cautery originally because of some of the neurosurgical vascular lesions, which were often high-flow lesions that could not be entirely embolized. We found that it worked as well as or better than the CO₂ laser," Dr. Char said.

Response to therapy

All 15 patients in the study had a response to therapy, five with complete resolution that persisted through the most recent follow-up visit, seven with marked improvement, and three with some improvement. Two of the cases involving minimal improvement later required additional debulking procedures; the patients subsequently have done well, he said.

"The most important point, I think, is that we saw no complications with this approach," Dr. Char said. "Unlike my experience with various forms of sclerosing therapy, where I often get a great deal of edema after the initial injection, in these cases we just have not had that, and we had no visual loss in any of these cases.

"For a phase I/II study I think you'd say we saw good local control with minimal morbidity and excellent hemostasis. We didn't see any inflammation," he added.

He cautioned, however, that this approach has some limitations. "There's no question even with a 4-year mean follow-up that some more of these cases will need more therapy," Dr. Char said. "This is not a complete cure, but I think it's a safe way of dealing with what for me is a difficult orbital problem."