Case highlight:

A 64-year-old man with partial seizures underwent resection of a meningioma arising from the lateral wall of the cavernous sinus using a transorbital eyebrow lacrimal keyhole approach (TELKA). By removing the lip of the superolateral orbital rim (“lacrimal keyhole”) through an eyebrow incision, the surgical team achieved optimal microscopic and endoscopic visualization without hazardous globe retraction.

What is the TELKA approach?

TELKA is a minimally invasive transorbital route via a discreet eyebrow incision. A targeted osteotomy of the superolateral orbital rim creates an efficient corridor to the lateral cavernous sinus, limiting soft-tissue dissection and brain retraction.

Indications and targets

• Meningiomas of the lateral wall of the cavernous sinus
• Spheno-orbital and anterolateral skull base lesions
• Selected extradural or interdural lesions
• Patients for whom minimal soft-tissue disruption and cosmetic benefits are priorities
  

Patient presentation

Partial seizures with MRI demonstrating a lesion along the lateral cavernous sinus wall. Neuro-ophthalmologic evaluation is essential before surgery.

Surgical steps (summary)

1. Eyebrow incision and subperiosteal exposure of the superolateral rim
2. Lacrimal keyhole osteotomy removing the orbital rim lip
3. Combined microscopic and angled endoscopic visualization
4. “Chopstick technique” with malleable rotative suction
5. Interdural dissection and tumor debulking
6. Hemostasis and reconstruction preserving orbital anatomy
   

Why choose TELKA?

• Excellent panoramic and close-up visualization
• Minimal brain and globe retraction
• Small, cosmetically discreet incision
• Direct lateral-to-medial access to the cavernous sinus
  

Risks and considerations

• Diplopia, ptosis, or cranial nerve III–VI palsy
• Transient orbital edema or alignment disorders
• CSF leak, infection, bleeding
• Possible need for postoperative radiotherapy

Postoperative course & follow-up

• Early ophthalmologic and neurologic assessment
• Typically mild postoperative pain and swelling
• MRI follow-up and seizure management
• Often faster recovery compared to larger craniotomies

Technical pearls

• Precise drilling of the lacrimal keyhole to avoid eye retraction
• Use of angled endoscopes and chopstick technique
• Respect for interdural anatomy of the lateral cavernous sinus
  

FAQ

Is TELKA always possible?

No—depends on tumor size, extension, and neuro-vascular relationships.

Is the scar visible?

Often very discreet, hidden in the eyebrow.

Is the eye retracted?

The keyhole removes the rim lip specifically to avoid globe traction.

Hospital stay?

Usually shorter than with traditional craniotomies.

Will I need radiotherapy?

Sometimes, depending on residual tumor and pathology.

source: https://thejns.org/view/journals/j-neurosurg/j-neurosurg-overview.xml