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
leak can be predicted by careful pre-operative assess-
ment and knowledge of anatomy. However, if encoun-
tered, exposure of dura is safe if care is taken to avoid
a tear.22 Even if a dural defect is created, the morbi-
dity associated with CSF leaks may be minimized if
promptly diagnosed and properly managed. Although
several studies report this complication, the manage-
ment of CSF leaks in orbital and lacrimal surgery is not
well described in the literature.
Incidence of CSF Leaks
The incidence of CSF leaks associated with orbital
and lacrimal surgery is relatively low. We reviewed the
incidence of CSF leaks in orbital exenteration, orbital
decompression, and dacryocystorhinostomy (DCR).
Although there is no literature on the incidence of CSF
leaks in other types of orbital surgery, it is also a risk
when orbital lesions involve the orbital roof or posterior
lateral wall, especially in erosive processes.13 Such
lesions may include malignant tumors as well as benign
lesions such as dermoids, cholesterol granulomas,
and eosinophilic granulomas. The highest reported
incidence of CSF leaks occurred in orbital exenter-
ations at a rate of 1.6--16.7% (Table 1).5,13,21,37,53 In
addition, in a series of 39 patients, de Conciliis noted
that dural exposure occurred in 20.5% of exentera-
tions and 30.8% of enlarged exenterations which
included excision of one or more orbital walls.13
Furthermore, in that study, 60% of CSF leaks and 75%
of dural exposures occurred in enlarged exenterations
involving resection of one or more orbital walls. For
orbital decompressions, CSF leaks occurred in 0--10%
of cases, with the highest incidence occurring with
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,
external lateral, swinging eyelid, and endoscopic
approaches.3,6,16,20,22,23,34,36,38,46,47 CSF leaks occur
very rarely in DCRs with a few case reports found in the
literature.2,14,17,18,35 CSF leakage is also a well-docu-
mented complication among other surgical proce-
dures in the area of the skull base. This is a risk
particularly during skull base surgery, functional
endoscopic surgery (FESS), and open ethmoidectomy.
We report our experience in four separate orbital
units at the Royal Adelaide Hospital, Adelaide,
Australia; the Corneoplastic Unit, East Grinstead,
United Kingdom; the Royal Brisbane and Women’s
Hospital, Brisbane, Australia; and the Royal Victorian
Eye and Ear Hospital, Melbourne, Australia. Our
combined incidences of CSF leak (diagnosed intra-
operatively) during exenteration, orbital decompres-
sion, and dacryocystorhinostomy are 1/154 (0.6%),
4/397 (1%), and 0/3504 (0%), respectively. The sole
case of CSF leak associated with orbital exenteration
for an orbital desmoplastic melanoma occurred while
cutting the optic nerve at the orbital apex. The orbital
decompressions for thyroid eye disease were per-
formed medially, either by a transcaruncular or
swinging eyelid approach, and laterally, by a swinging
eyelid or upper skin crease approach. All four cases of
CSF leakage during orbital decompression for
thyroid ophthalmopathy occurred while drilling out
the posterior lateral wall. The authors have not
encountered a CSF leak during endonasal, external,
redo DCR, or conjunctivo-DCR.
In addition, we found two cases of CSF leak
associated with excision of masses involving the orbital
roof. One of these was an orbital dermoid, and the
other was a recurrent adenoid cystic carcinoma. Both
CSF leaks could have been predicted preoperatively
due to the pathologically thinned orbital roof seen on
imaging (Fig. 1).
Preoperative Assessment
In many cases, exposure of dura and the risk of
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
were foreseen based on clinical data, or standard
x-ray, tomography of the orbit, and computed
tomography (CT).13 In general, patients undergoing
orbital exenteration or decompression will already
have CT of the orbits performed preoperatively.
With regard to lateral wall decompression, the
surgeon should look for variations in dimensions of
the greater wing of the sphenoid, which may differ
significantly between individuals.22 Medially, it is
important to evaluate for a low-riding fovea ethmoi-
dalis20,35 (the ethmoid roof) or cribiform plate,22,33
which form part of the skull base (Fig. 2). In addition,
the surgeon should proceed with caution if the
pathologic process is infiltrative or has thinned the
bone significantly,13,15 especially in areas at high risk
for encountering dura.
Other situations where CSF may be encountered
during orbital surgery include the orbital apex,13,15,46
which is adjacent to intracranial structures. In
addition, decompressions via the orbital roof or
orbitotomies involving the orbital roof may expose
dura (Fig. 3). The risk of dural exposure via the roof
will also be higher in erosive processes such as
malignant tumors, dermoids, cholesterol granulo-
mas, and eosinophilic granulomas. Caution is also
advisable in those cases where the bones of the skull
base have been altered by trauma, previous surgery, or
tumors such as osteomas or fibrous dysplasia. Three-
dimensional imaging may be particularly useful in
these situations and the use of stereotactic guidance
neurosurgical opinion for further recommendations
or assistance during surgery may be advisable.
In the context of DCR surgery, clinicians should
obtain further imaging studies if abnormal anatomy is
suspected as in cases of craniofacial anomalies such as
clefting or frontal meningo-encephaloceles, prior
trauma, craniofacial surgery, or in the setting of
infiltrative processes. Surgeons should consider
obtaining a CT of the sinus and orbits, or computed
tomography dacryocystogram (CTDCG) if abnormal
anatomy is suspected. Scans should include fine cut
coronal sections and 3-D imaging may afford im-
proved guidance.
Intraoperative Measures to Avoid a CSF
Leak
HIGH-RISK AREAS
Intraoperatively, the surgeon should have an
intimate knowledge of the anatomy and approach
high-risk areas with caution. It is important to
recognize which areas are at risk for encountering
dura and intracranial structures. CSF leaks have been
well-documented during deep, posterior excavation
of the lateral wall (greater wing of the sphenoid)
during orbital decompression,22,23,36 especially with
a high-speed cutting burr. Dura may be encountered
while drilling the lateral wall in three possible areas.
First, dura may be exposed while drilling out
the marrow space if the inner table of the sphenoid
bone is penetrated (Fig. 4). Secondly, dura may be
CEREBROSPINAL FLUID LEAKAGE
Fig. 1. Imaging demonstrates the close proximity of this
orbital dermoid to the anterior cranial fossa. A CSF leak
may be anticipated in the area of thin orbital roof. A:
Coronal CT of the orbits. B: Coronal T1-weighted MRI.
Fig. 2. Coronal diagram of the orbits illustrates how CSF
leaks may occur due to the relationship of the medial
orbit and ethmoid sinus (es) to the fovea ethmoidalis (fe)
and cribiform plate (cp) that form part of the skull base.
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
space where relatively thin bone overlies the middle
cranial fossa. Finally, inadvertently drilling superiorly
through the orbital roof may expose dura in the
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
extirpation below the level of the ethmoidal vessels to
preclude entering the anterior cranial fossa.31 During
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
Postoperatively for persistent leaks confirmed
with beta-2 transferrin, the majority of leaks can be
localized with high-resolution CT.42 In a retrospec-
tive study, noncontrast high-resolution CT has been
shown to identify 30/42 (71%) of bone defects with
CSF leaks.49 If not localized on high-resolution CT,
further interventions that may be useful include
intrathecal injection of fluorescein,11,27,52 and
radionuclide or contrast-enhanced CT or MRI
cisternography.4,19
Intraoperative Management
EVALUATION OF THE SITE
Once a CSF leak is identified, appropriate man-
agement may minimize significant morbidity. The
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
meningitis due to blood entering the subarachnoid
space.15
A careful inspection of the dural laceration and
underlying brain is mandatory. The location and size
of the dural injury in association with the amount of
exposure surrounding the laceration, will determine
the types of repair possible. If the leak into the orbit is
small, it may close spontaneously3,5,20,35,46 as fat may
tamponade the area and aid closure. Nevertheless, an
attempt to repair the leak is advisable to avoid the
risks of persistent leakage.
Neurosurgical consultation is recommended for
further advice whenever dura is injured.
SURGICAL REPAIR
If there is adequate exposure and the edges of the
dural laceration can be readily apposed, primary
repair with 5-0 or 6-0 polyglactin or braided nylon
should be performed to create a watertight seal. Our
neurosurgeons recommend removal of enough bone
to expose the defect when possible for secure repair.
A 1-mm punch or diamond burr can be used for this
purpose. Many suggest an onlay graft, commonly
a layer of fat, temporalis muscle, or fascia, which may
then be placed over the exposed dura to further
ensure a watertight barrier.15
Other sources of autologous grafts include peri-
cranium and periorbita. Additional materials used
effectively include fascia lata, an osteomucoperiosteal
flap, mucous membrane and lyophilized heterolo-
gous dura.13 Although mucous membrane has been
used with success,13 its use may carry an increased risk
of infection. Human-derived dehydrated, lyophi-
lized, and sterilized dura have been used in neuro-
surgery and other surgical specialties for decades;
LIMAWARARUT ET AL
their use is discouraged, however, due to the risk of
Creutzfeldt Jacob or other acquired disease.32
Limited exposure of the dura, large areas of dural
loss, or unidentifiable defects may make primary
closure impossible. Such leaks may be managed by
placing an onlay graft against the dural rent or
suspected area of leakage and suturing the graft to the
surrounding dura. Graft materials described include
packing the area with autogenous fat, mucous
membrane, fascia lata, temporalis fascia and muscle,
cartilage, and a osteomucoperiosteal flap.4,17,50 As
described subsequently, these various graft materials
can also be combined with a variety of tissue adhesives
to create a watertight barrier.
In the case of orbital exenteration, packing
material can be placed in the socket to hold the plug
of muscle or fascia against the orbital apex.
TISSUE ADHESIVES AND ALLOPLASTIC
MATERIALS
Recently, tissue adhesives have been used success-
fully in closing dural defects. Although often used in
conjunction with an onlay graft to further seal the
repair, using an adhesive alone may be adequate in
very small dural defects without tissue loss. Tisseel
fibrin glue22 (Baxter Healthcare Corp., Deerfield, IL)
has been used with favorable results in CSF leaks to
the orbit. It consists of human fibrinogen (screened
for human immunodeficiency virus and hepatitis B)
and bovine thrombin. It is available in four sizes
ranging from 0.5 to 5.0 ml and is in a deep-frozen state
and must be thawed for approximately 20 minutes at
room temperature prior to use. A solid fibrin matrix is
created in 5 minutes. The needle must be changed
between applications due to immediate clogging of
the needle (Fig. 7). Cyanoacrylate glue applied to
a dry surgical field has also been effective in closure of
CSF leaks.50
Bone wax23 has also been described in situations
where the leak arises from the depth of a relatively
small bony defect. The aim is to fill the bone defect
preventing CSF leakage into the orbit while the dura
seals itself. However, bone wax should be used with
caution as Bolger8 reported three cases of CSF leaks
that were associated with bone wax. The authors
proposed that bone wax controls bleeding during
craniotomy but may also stent a defect open,
preventing fibrin deposition, spontaneous healing,
and closure. Furthermore, there have been cases of
granulomas associated with bone wax in the orbit.26
Additional materials used in the repair of CSF leaks at
other sites include the use of gelfoam in epidural
blood patches41 and vicryl mesh in the repair of dural
defects.51 Hydroxyapatite cement has been used
CEREBROSPINAL FLUID LEAKAGE
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
contains bovine albumin and glutaraldehyde that
when mixed produces a flexible mechanical seal in 20
seconds with bonding strength reached in 2 minutes.
In one report,56 BioGlue was seen to persist at the
surgical site 2 years postoperatively. Although used
effectively to repair CSF leaks in the neurosurgery
literature,28,56 Sen reported an increased incidence
of CSF leaks (62.5%) when BioGlue was used to seal
the interface between the petrosal cavity and external
oblique muscle fascia in translabyrinthine vestibular
Fig. 8. DuraSeal consists of a clear, water-soluble amine
solution and a blue polyethylene glycol solution.
281
Fig. 9. DuraSeal forms a hydrogel (arrow) which sprays
on and is absorbed after several weeks.
schwannoma surgery compared to cases without
BioGlue (12.5%).45 Hence, further large, long-term
studies to evaluate the use of DuraSeal and BioGlue in
the orbit are needed.
AUTHORS’ EXPERIENCE
During our case of CSF leakage during orbital
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.
In the authors’ experience, the majority of leaks
encountered during orbital surgery tend to be
282 Surv Ophthalmol 53 (3) May--June 2008
Fig. 10. Repair of CSF leak during orbitotomy for
a recurrent adenoid cystic carcinoma involving the orbital
roof. A: The dural defect (arrow) measured approximately
10 mm. B: After the bony defect was enlarged with
ronjeurs for adequate exposure, the dural defect was
repaired with primary closure with 6-0 vicryl, an overlying
fat graft (f), and further seal with Tisseel (t).
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
prophylactic antibiotics did not affect rates of
meningitis in cases of CSF leakage complicating skull
base fractures. Many surgeons avoid antibiotics to
reduce development of resistant organisms.27 The
neurosurgeons at our institutions believe that antibi-
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
leakage, one was started on acetazolamide and all
were treated with antibiotics. All cases of CSF leaks
resulted in uncomplicated recoveries.
SURGICAL INTERVENTION
If CSF leakage continues after several days, the
consulting neurosurgeon may place a spinal catheter to
effectively manage the leak. This has been used
successfully in post-surgical and traumatic CSF leaks.12
Although excessive drainage through the lumbar
spinal catheter can result in tension pneumocranium
and a subdural or epidural hematoma, this is not
common. Advances in endoscopic technique have
improved the ability to operate in a less invasive fashion.
Endonasal endoscopic repair of leaks at the cribiform
plate may be considered.27 The surgeon may consider
exploring the site to assess whether repair has been
ideal. Persistent or large CSF leaks that are inaccessible
endonasally may require craniotomy and repair.
Summary
CSF leakage is a rare but potentially serious
complication of orbital and lacrimal surgery. Knowl-
edge of anatomy and thorough pre-operative assess-
ment may predict areas at high risk for encountering
CSF leaks. Proper surgical technique further mini-
mizes the risk for this complication. Many options
exist for management and repair which usually result
in uncomplicated outcomes. Although further large
studies are necessary to compare the efficacy of
various techniques and materials, this may be difficult
given the rarity of this complication.
Method of Literature Search
Literature search was based on a Medline search with
Pubmed including references published before Febru-
ary 2007. The keywords used in the search were
cerebrospinal fluid leak, CSF leakage, orbital surgery,
exenteration, orbital decompression, dacryocystorhinostomy.
Articles were restricted to those in English and other-
language publications with English abstracts. Refer-
ences within these articles were also obtained for review.
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The authors reported no proprietary or commercial interest in
any product mentioned or concept discussed in this article.
Reprint address: Prof. Dinesh Selva, FRACS, FRANZCO, South
Australian Institute of Ophthalmology, The Royal Adelaide
Hospital, Level 8, North Terrace, Adelaide, SA 5000, Australia.