Transorbital Neuroendoscopic Surgery (TONES)

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Article initiated by:
Rachel Sage Zhang, Anne Barmettler, MD
All contributors:
Anne Barmettler, MD
Assigned editor:
Review:
Assigned status Update Pending
.


Surgical Therapy

Background

Transorbital neuroendoscopic surgery (TONES) is a minimally invasive surgical technique which uses the eye socket (orbit) as a natural corridor to access the brain, skull base, and paranasal sinuses. TONES involves the passage of endoscopic instruments through or alongside orbital contents to allow for coplanar visualization with space above and below the skull base as a less invasive alternative to more traditional craniotomy.[1][2] The technique includes several variations in approach corresponding to the four orbital quadrants (superior eyelid crease, lateral retrocanthal, precaruncular, and preseptal lower eyelid), each providing access to distinct anatomical targets.[3]

History

In 2010, Moe, Bergeron, and Ellenbogen at the University of Washington were the first to formalize the concept of utilizing the orbit as a surgical corridor into the skull base. Their initial publication described an anatomic study and prospective analysis of 20 TONES procedures performed in 16 patients with anterior skull base pathologies, including cerebrospinal fluid (CSF) leak repair, optic nerve decompression, cranial base fracture repair, and removal of skull base tumors. The study reported no significant complications or treatment failures and described four separate access ports that allowed wide exposure for surgical manipulation and correction of the pathology.[1]

The largest early case series was published in 2016 by Ramakrishna et al., including 40 patients who underwent 45 TONES procedures between 2006 and 2013. Indications included CSF leak repair (n=16), traumatic fractures (n=8), tumors (n=11), meningoencephaloceles (n=5), hematoma (n=1), and infections (n=4). Surgical success was achieved in all patients, with minimal morbidity and no mortality.[4]

This technique was then adopted and refined by several international groups. In 2017, Jeon, Hong, and Kong at Yonsei University and Samsung Medical Center in South Korea advanced the endoscopic transorbital approach (ETOA) through the superior eyelid crease for access to Meckel’s cave and middle cranial fossa tumors.[5] In 2018, Di Somma et al. then provided a detailed cadaveric anatomical study of the superior eyelid transorbital route, defining three modular corridors to the anterior and middle cranial fossae.[6]

By 2021, the first comprehensive systematic review of TONES included 23 studies and 69 clinical patients, establishing TONES as a legitimate neurosurgical method to address skull base pathology.y.[2] More recently, comprehensive reviews have described TONES and its variants including the expanding range of transorbital targets, surgical techniques, and multiportal approaches.[3] As of May 2026, a systematic review and meta-analysis pooled data from 11 studies comprising 269 patients and provided one of the first systematic evaluations of complication rates, confirming the safety profile for the TONES approach.[7]

Relevant Anatomy 

To safely perform TONES, it is crucial to understand the relevant orbital and periorbital anatomy.  

Figure 1. Anatomical illustration depicting seven bones of the orbital cavity. The lateral wall is highlighted in yellow, the orbital floor is highlighted in orange, and the medial wall is highlighted in blue. Caption courtesy of Susan Luo, MD, EyeWiki Article Bony Anatomy of the Orbit: https://eyewiki.org/Bony_Anatomy_of_the_Orbit. Image Source from AAO Image Bank: https://www.aao.org/education/image/orbital-decompression.

The orbit is a pyramidal structure comprised of seven key bones (frontal, zygomatic, maxillary, greater and lesser wings of the sphenoid, ethmoid, lacrimal, and palatine bones). The four walls of the orbit serve as important landmarks: 

  • Superior wall / roof: formed by the orbital plate of the frontal bone and the lesser wing of the sphenoid bone, with access to the anterior cranial fossa.[8][9]
  • Inferior wall / floor: formed by the zygomatic, maxillary, and palatine bones, with access to the infratemporal fossa through the inferior orbital fissure (IOF).[10]
  • Medial wall: formed by the lamina papyracea of the ethmoid bone, the lacrimal bone, and the body of the sphenoid bone. The medial wall is the thinnest wall and utilized in precaruncular approaches.[3]
  • Lateral wall: formed by the zygomatic bone anteriorly and the greater wing of the sphenoid posteriorly. The lateral wall is the thickest wall, serving as the primary corridor for lateral TONES approaches to the middle cranial fossa and cavernous sinus.[8][9]

The superior orbital fissure (SOF) lies between the greater and lesser wings of the sphenoid and is important to divide the lateral and medial surgical corridors. It allows for the passage of cranial nerves III, IV, V1, and VI, as well as the superior ophthalmic vein.[6]

The IOF is located between the greater wing of the sphenoid, maxillary, and zygomatic bones. It connects the orbit to the infratemporal and pterygopalatine fossae, allowing for transorbital access to the infratemporal and parapharyngeal space.[10]

The optic canal is located at the apex of the orbit, medial to the SOF. It transmits the optic nerve (CN II) and the ophthalmic artery.[11][12]

 There are five main bone pillars identified as consistent surgical references for the TONES approach: the lesser wing of the sphenoid with access to the anterior cranial fossa, the sagittal crest (medial aspect of the greater wing of the sphenoid) which landmarks the middle cranial fossa’s floor, the anterior clinoid process with access to the opticocarotid region, the middle cranial fossa floor with access to Meckel’s cave and the lateral cavernous sinus, and the petrous apex with access to the posterior cranial fossa.[13]

The orbital periosteum, or periorbita, is the key tissue plane for TONES. Subperiosteal dissection allows the orbital contents to be mobilized medially, creating a working corridor between the periorbita and the bony orbital wall without violation of orbital fat or direct manipulation of the globe and extraocular muscles.[1][14] During lateral approaches, the sphenofrontal suture serves as a crucial landmark.[15]  

Several key neurovascular structures are encountered during TONES procedures. These include the optic nerve (CN II) at the orbital apex through the optic canal, the oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) nerves through the cavernous sinus and SOF, the trigeminal (CN V) branches (V1 through the SOF, V2 through the foramen rotundum, V3 through the foramen ovale), the internal carotid artery (ICA) in its paraclival and cavernous segments, and the middle meningeal artery in the infratemporal fossa.  

Patient Selection

Indications

A broad and expanding range of pathologies can be treated with a TONES approach.[1][2][3]

The most common indication for TONES is neoplastic lesions. In a systematic review and meta-analysis of 269 patients who underwent endoscopic transorbital neurosurgery, the most frequent indication was meningioma (60.6% of cases). Spheno-orbital meningiomas are particularly well-suited for TONES, and other meningiomas from the sphenoid wing extending to the cavernous sinus, olfactory groove meningiomas, and anterior clinoid meningiomas have also been successfully treated.[7][16][17][18][19] For these tumors, the primary goal is not gross-total resection (GTR) but rather orbital decompression and subtotal resection with planned adjuvant radiosurgery. Endoscopic transorbital optic canal decompression with extradural anterior clinoidectomy has been described for meningiomas causing optic neuropathy, with 13 of 14 patients in the study experiencing postoperative improvement or stable visual function.[12] The second most common indication was schwannomas (12.0%), with trigeminal schwannomas particularly amenable to TONES.[7][20] Further, TONES has also been indicated for additional tumors including cavernous hemangiomas, gliomas, epidermoid and dermoid cysts, chondrosarcomas, metastases, Langerhans cell histiocytosis, fibrous dysplasia, lymphoma, and hemangiopericytoma.[5][21][22]

One of the original indications for TONES was cerebrospinal fluid (CSF) leak repair, and it remains a common application. In the original foundational series by Moe et al., CSF leak repair was the procedure most frequently performed.[1] In their retrospective review of 45 TONES procedures in 2016, Ramakrishna et al. reported successful repair of all 16/16 CSF leaks.[4]

TONES has also been used in the context of trauma for the repair of cranial base fractures, particularly those involving the anterior skull base and orbital roof.[1][4] The most common congenital or developmental indication is meningoencephaloceles.[4][23]

Orbital and skull base infections, including subperiosteal abscesses, have also been managed using TONES.[24]

Contraindications

There are several instances in which TONES is not a recommended approach or should be used with additional considerations.  

  • Posterior fossa lesions: a transorbital approach provides limited access to the posterior cranial fossa. Due to the restricted working space and reduced surgical maneuverability, TONES is not considered an ideal approach for posterior fossa pathology.[5]
  • Highly vascular lesions with extensive major vessel encasement: These lesions pose a significant hemorrhagic risk through a narrow transorbital corridor. The constricted operative field in TONES limits the ability to achieve vascular control and major complications including cerebral artery infarction and intraoperative hemorrhage have been reported in cases with complex vascular pathology.[21]
  • Very large tumors which exceed the working space of the transorbital corridor: These tumors can require combined or staged approaches to achieve adequate resection.[19]
  • Spheno-orbital meningiomas with excessive medial or inferior extension: TONES is best used for spheno-orbital meningiomas with lateral involvement. When there is excessive medial or inferior extension, these tumors may require combination with endoscopic endonasal approaches as part of a multistage treatment strategy.[6][17]
  • Extensive intracavernous tumor involvement: The cavernous sinus contains CN III, IV, V1-3, and VI in proximity, and aggressive resection through a transorbital approach carries an increased risk of CN injury. In these instances, subtotal resection with adjuvant radiosurgery is favored to minimize neurological deficits.[16] 

TONES is a technically demanding procedure which requires specific expertise in endoscopic skull base surgery. It should be reserved for dedicated high-volume centers with multidisciplinary teams including neurosurgery, ophthalmology, oculoplastics, and otolaryngology.[17][25]

Surgical Technique

Figure 2. Courtesy of Kenneth M. Downes, EyeWiki Article Sphenoid Wing Meningioma. Axial T1 post gadolinium MRI image showing a diffuse sphenoid wing meningioma involving the left orbital apex, and cavernous sinus exerting a mass effect on the pons and orbital structures.

Pre-Operative Evaluation

Prior to any transorbital procedure, a comprehensive baseline ophthalmological evaluation should be completed as a baseline for postoperative comparison. This includes best-corrected visual acuity (BCVA), external examination with assessment of eyelid and globe position, pupillary examination for a relative afferent pupillary defect (RAPD), ocular alignment and extraocular motility, slit-lamp examination, intraocular pressure (IOP) measurement, and dilated fundus examination of the retina and optic nerve. Further, as transorbital procedures place the globe and optic nerve uniquely at risk, this baseline should be supplemented with formal visual field testing using automated perimetry, color vision testing, Hertel exophthalmometry, and spectral-domain optical coherence tomography (SD-OCT) of the macular ganglion cell–inner plexiform layer (GCIPL) and peripapillary retinal nerve fiber layer (pRNFL).[26]

Preoperative neuroimaging includes MRI with contrast and high-resolution CT. MRI with contrast is the primary modality to characterize soft tissue lesions, delineate the extent of tumors, and evaluate nearby neurovascular structures.[23] High-resolution CT is crucial to evaluate bony anatomy including thickness of the orbital wall, extent of hyperostosis, and the dimensions of the surgical corridor. Mean working distance has been measured at approximately 6.1 ± 0.4 cm, and the lateral working angle increases by approximately 20° after removal of the lateral orbital rim.[9][15] CT angiography or MR angiography is recommended when lesions are in close proximity to the internal carotid artery (ICA) or other major vessels.  

Preoperative imaging can be loaded into a neuronavigational system in order to provide real-time intraoperative guidance. CT can be used to direct bony drilling at the optic canal and anterior clinoid processes, while contrast-enhanced MRI and angiographic sequences localize the cavernous sinus margins and ICA during tumor dissection.[5][16]

Surgical Approaches

TONES employs several different approaches, each defined by the skin incision site and the orbital quadrant used for entry. The chosen approach depends on the location and extent of target pathology.[3] TONES procedures can be conceptualized by three key phases: (1) the extraorbital phase: skin incision and dissection through soft tissues to the orbital rim, (2) the intraorbital phase: subperiosteal dissection, orbital content mobilization, and identification of bony landmarks, and (3) the intracranial phase (bone drilling, dural exposure, and tumor resection).[16]

Superior Eyelid Crease

The superior eyelid crease approach is the most commonly used TONES approach. Surgeons make a 2-3 cm incision along the natural superior eyelid crease, allowing for cosmetic concealment of the surgical scar. Dissection continues through the orbicularis oculi to the orbital rim. The periorbita is then subperiosteally dissected along the orbital roof and lateral wall, and orbital contents are displaced medially and inferiorly. The greater wing of the sphenoid is drilled to expose the middle cranial fossa dura and the lesser wing can be drilled to access the anterior cranial fossa. In extended approaches, a lateral orbital rim osteotomy may be performed to increase the working angle by approximately 20°.[5][9]

The three modular corridors of the superior eyelid crease approach include a lateral corridor to the middle cranial fossa (bone removed lateral to the SOF exposing the temporal pole, lateral cavernous sinus wall, and middle fossa floor), a lateral corridor to the anterior cranial fossa (bone removal above the SOF exposing the frontobasal area), and a medial corridor to the opticocarotid area (bone removed medial to the SOF exposing the optic nerve, ICA, and anterior clinoid process). [6]

The superior eyelid crease approach is optimal to provide access to targets including the anterior cranial fossa, middle cranial fossa floor, lateral cavernous sinus wall, Meckel’s cave, orbital apex, optic canal, and spheno-orbital region.[5][6]

Lateral Retrocanthal

In the lateral retrocanthal approach, an incision is made at the lateral canthus, posterior to the canthal angle. A lateral canthotomy excises at the lateral canthal angle to expose the lateral canthus tendon. An inferior cantholysis is then performed to cut the inferior crus of the tendon. Further subperiosteal dissection continues along the lateral orbital wall and the sphenofrontal suture (SFS) serves as a key surgical landmark. The SFS can be used to identify 3 key surgical corridors: the superomedial, superolateral, and inferolateral. The superomedial reaches the medial anterior cranial fossa and the opticocarotid region, the superolateral corridor reaches the lateral anterior and middle cranial fossa, and the inferolateral corridor reaches the lateral middle cranial fossa.[15]

Lateral Trans-Eyebrow

The lateral trans-eyebrow approach involves a 3 cm incision in the lateral eyebrow skin providing access to the lateral orbital compartment. Subperiosteal dissection of the periorbita then permits intermittent medialization of the eyeball and access to the orbital apex via intramuscular corridors without mechanical retraction of the oculomotor muscles. This approach is well-suited for intraconal lesions of the lateral orbital compartment and orbital apex meningiomas.[14] 

Preseptal Lower Eyelid

The preseptal lower eyelid approach involves an incision to the inferior eyelid with subperiosteal dissection to the IOF, providing access to the infratemporal fossa (ITF) and the parapharyngeal space. During the preseptal lower eyelid approach, the zygomatic bone and the greater wing of the sphenoid are drilled to form the boundaries of the IOF. Once the upper head of the lateral pterygoid muscle is removed from the ITF, 7 distinct anatomical planes are encountered, each with its own distinct neurovascular contents. Targets of this approach include the ITF, the pterygopalatine fossa, and the parapharyngeal space including the prestyloid and postsyloid segments.[10]

Precaruncular (Medial)    

The precaruncular approach involves an incision medial to the caruncle to access the medial orbit, ethmoid sinuses, and medial skull base. This approach is often used in conjunction with endoscopic nasal approaches for 360° circumferential access to orbital tumors.[27]  

Combined & Multiportal

 TONES can be combined with other minimally invasive approaches, such as the endoscopic approach, in order to expand surgical reach and access orbital tumors or address medial/inferior tumor extensions which are unreachable by TONES alone.[27] TONES in combination with retrosigmoid craniotomy can also be used to address dumbbell-shaped tumors extending into the posterior cranial fossa. Subtotal resection via TONES has also been followed by adjuvant Gamma Knife radiosurgery for residual tumor in the cavernous sinus in a staged approach.[3][16][19]

Complications

TONES has demonstrated a favorable safety profile in published clinical series and systematic reviews.

In a 2026 systematic review and meta-analysis of 269 patients, the following complication rates were reported: 16% (95% CI: 9–25%) of patients with transient facial numbness in the V2 distribution, 9% (95% CI: 4–18%) with medial gaze palsy, 6% with diplopia (most cases being transient), 4% with ptosis (typically transient with spontaneous recovery), 3% with wound infection, 1% with new-onset visual dysfunction, and 1% with a CSF leak. Of note, mortality was 0% and nearly half of patients experienced improvements in visual function postoperatively.[7]

In a 2025 meta-analysis of 240 cases, there was a 2.5% rate of CSF leak, with a significantly higher risk for intra-axial compared with extra-axial tumors. 66.6% of CSF leaks resolved with conservative management and the natural repositioning of orbital contents to original position after surgery was suggested to reduce postoperative CSF leak.[28]

Another study of 41 endoscopic transorbital approach (ETOA) procedures assessed retinal and optic nerve integrity using optical coherence tomography (OCT), finding no subclinical retinal or optic nerve injury after 12 months of follow-up. In patients with and without orbital involvement, not statistically significant changes in macular ganglion cell layer (GCL) and peripapillary retinal nerve fiber layer (RNFL) thickness were found to be within physiological variability or explained by preexisting optic neuropathy or resolution of preoperative edema. Of note, visual acuity, visual fields, color vision, and pupillary responses either improved or remained stable.[26]

Outcomes

For tumor resection, the extent of resection using the TONES approach varies depending on tumor type and location. For meningiomas, the rates of gross-total resection (GTR) range from 28.8% to 81.8% depending on tumor subtype and extent.[16][19] For spheno-orbital meningiomas in particular, GTR is not the primary goal; rather, TONES is used for initial orbital decompression and subtotal resection with planned adjuvant radiosurgery. In a multicenter Italian study of 52 spheno-orbital meningiomas, GTR was performed in 28.8% of cases, subtotal resection in 23.1%, and partial resection in 48.1%.[18] For trigeminal schwannomas, a multicenter study of 50 cases demonstrated 70% GTR and 18% near-total resection with no regrowth or recurrence over a mean follow-up of 21.9 months.[20]

TONES consistently improves patient symptoms. In one case series, mean proptosis improved from 5.7 ± 2.7 mm to 1.5 ± 1.4 mm and median best corrected visual acuity (BCVA) improved from 20/100 to 20/40.[29] In the aforementioned multicenter Italian multicenter study, proptosis resolved in 50 of 52 patients and visual acuity improved in 31% of cases.[18]18 Diplopia also improved in case series of 58 and 22 patients with diplopia improved in 87% and 75.9% of patients respectively.[6] [17]

Length of hospital stays was notably short at 1.15 days and 2.4 ± 1.3 days in 2 case series of sphenoid wing meningioma patients and spheno-orbital tumor patients respectively, reflecting the minimally invasive nature of the TONES approach.[16][17]

Long-term data remains limited given the recent introduction of the technique. In a meta-analysis of 269 patients and 11 observational studies, mean follow-up was 27.6 ± 15.1 months.[7] Further studies with longer follow-up and comparisons are needed to evaluate long-term efficacy of TONES and recurrence rates.    

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Moe KS, Bergeron CM, Ellenbogen RG. Transorbital Neuroendoscopic Surgery. Oper Neurosurg. 2010;67(3):ons16-ons28. doi:10.1227/01.NEU.0000373431.08464.43
  2. ↑ 2.0 2.1 2.2 Houlihan LM, Staudinger Knoll AJ, Kakodkar P, et al. Transorbital Neuroendoscopic Surgery as a Mainstream Neurosurgical Corridor: A Systematic Review. World Neurosurg. 2021;152:167-179.e4. doi:10.1016/j.wneu.2021.04.104
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 De Simone M, Zoia C, Choucha A, Kong DS, De Maria L. The Transorbital Approach: A Comprehensive Review of Targets, Surgical Techniques, and Multiportal Variants. J Clin Med. 2024;13(9):2712. doi:10.3390/jcm13092712
  4. ↑ 4.0 4.1 4.2 4.3 Ramakrishna R, Kim LJ, Bly RA, Moe K, Ferreira M. Transorbital neuroendoscopic surgery for the treatment of skull base lesions. J Clin Neurosci Off J Neurosurg Soc Australas. 2016;24:99-104. doi:10.1016/j.jocn.2015.07.021
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Jeon C, Hong CK, Woo KI, et al. Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results. J Neurosurg. 2019;131(4):1126-1135. doi:10.3171/2018.6.JNS181099
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Di Somma A, Andaluz N, Cavallo LM, et al. Endoscopic transorbital superior eyelid approach: anatomical study from a neurosurgical perspective. J Neurosurg. 2018;129(5):1203-1216. doi:10.3171/2017.4.JNS162749
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Arend RB, Peroni BZ, Ribeiro FV, et al. Safety profile and surgical outcomes of the endoscopic transorbital approach as a skull base surgical corridor: a systematic review and meta-analysis. Neurosurg Rev. 2026;49(1):403. doi:10.1007/s10143-026-04321-x
  8. ↑ 8.0 8.1 Agosti E, Alexander AY, Plou P, et al. 360° around the orbit: key surgical anatomy of the microsurgical and endoscopic cranio-orbital and orbitocranial approaches. Neurosurg Focus. 2024;56(4):E2. doi:10.3171/2024.1.FOCUS23866
  9. ↑ 9.0 9.1 9.2 9.3 Serioli S, Nizzola M, Plou P, et al. Surgical Anatomy of the Microscopic and Endoscopic Transorbital Approach to the Middle Fossa and Cavernous Sinus: Anatomo-Radiological Study with Clinical Applications. Cancers. 2023;15(18):4435. doi:10.3390/cancers15184435
  10. ↑ 10.0 10.1 10.2 Gerges MM, Godil SS, Younus I, Rezk M, Schwartz TH. Endoscopic transorbital approach to the infratemporal fossa and parapharyngeal space: a cadaveric study. J Neurosurg. 2020;133(6):1948-1959. doi:10.3171/2019.7.JNS191743
  11. ↑ Demartini Z, Zanine SC. Microanatomic Study of the Optic Canal. World Neurosurg. 2021;155:e792-e796. doi:10.1016/j.wneu.2021.08.144
  12. ↑ 12.0 12.1 Kim JH, Hong CK, Shin HJ, Kong DS. Feasibility and efficacy of endoscopic transorbital optic canal decompression for meningiomas causing compressive optic neuropathy. J Neurosurg. 2024;140(2):412-419. doi:10.3171/2023.5.JNS2326
  13. ↑ Codes M, Mosteiro A, Tafuto R, et al. Endoscopic transorbital approach bone pillars: a comprehensive stepwise anatomical appraisal. Neurosurg Focus. 2024;56(4):E5. doi:10.3171/2024.1.FOCUS23846
  14. ↑ 14.0 14.1 Luzzi S, Zoia C, Rampini AD, et al. Lateral Transorbital Neuroendoscopic Approach for Intraconal Meningioma of the Orbital Apex: Technical Nuances and Literature Review. World Neurosurg. 2019;131:10-17. doi:10.1016/j.wneu.2019.07.152
  15. ↑ 15.0 15.1 15.2 Chibbaro S, Ganau M, Scibilia A, et al. Endoscopic Transorbital Approaches to Anterior and Middle Cranial Fossa: Exploring the Potentialities of a Modified Lateral Retrocanthal Approach. World Neurosurg. 2021;150:e74-e80. doi:10.1016/j.wneu.2021.02.095
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Karımzada G, Evleksiz Karımzada D, Erol G, et al. Transorbital neuroendoscopic surgery for treatment of sphenoid wing meningiomas extending to the cavernous sinus: clinical implications and a technical illustration. Neurosurg Focus. 2024;56(4):E8. doi:10.3171/2024.1.FOCUS23857
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Zoli M, Sollini G, Rustici A, et al. Endoscopic Transorbital Approach for Spheno-Orbital Tumors: Case Series and Systematic Review of Literature. World Neurosurg. 2023;177:e239-e253. doi:10.1016/j.wneu.2023.06.026
  18. ↑ 18.0 18.1 18.2 Dallan I, Serioli S, de Notaris M, et al. Transorbital management of selected spheno-orbital meningiomas: Insights from a multicentric retrospective Italian study of 52 cases. Neurosurg Rev. 2025;48(1):696. doi:10.1007/s10143-025-03840-3
  19. ↑ 19.0 19.1 19.2 19.3 Carnevale JA, Pandey A, Ramirez-Loera C, et al. Endonasal, supraorbital, and transorbital approaches: minimal access endoscope-assisted surgical approaches for meningiomas in the anterior and middle cranial fossae. J Neurosurg. 2024;140(1):38-46. doi:10.3171/2023.5.JNS23103
  20. ↑ 20.0 20.1 Kong DS, Kim YH, Lee WJ, Kim YH, Hong CK. Indications and outcomes of endoscopic transorbital surgery for trigeminal schwannoma based on tumor classification: a multicenter study with 50 cases. J Neurosurg. 2023;138(6):1653-1661. doi:10.3171/2022.9.JNS22779
  21. ↑ 21.0 21.1 Yoo J, Park HH, Yun IS, Hong CK. Clinical applications of the endoscopic transorbital approach for various lesions. Acta Neurochir (Wien). 2021;163(8):2269-2277. doi:10.1007/s00701-020-04694-y
  22. ↑ Han X, Yang H, Wang Z, et al. Endoscopic transorbital approach for skull base lesions: a report of 16 clinical cases. Neurosurg Rev. 2023;46(1):74. doi:10.1007/s10143-023-01980-y
  23. ↑ 23.0 23.1 Mathios D, Bobeff EJ, Longo D, et al. The lateral transorbital approach to the medial sphenoid wing, anterior clinoid, middle fossa, cavernous sinus, and Meckel’s cave: target-based classification, approach-related complications, and intermediate-term ocular outcomes. J Neurosurg. 2024;140(3):677-687. doi:10.3171/2023.6.JNS23678
  24. ↑ Mathios D, Bobeff EJ, Longo D, et al. The lateral transorbital approach to the medial sphenoid wing, anterior clinoid, middle fossa, cavernous sinus, and Meckel’s cave: target-based classification, approach-related complications, and intermediate-term ocular outcomes. J Neurosurg. 2024;140(3):677-687. doi:10.3171/2023.6.JNS23678
  25. ↑ Tong JY, Sung J, Chan W, Psaltis AJ, Selva D. Transorbital endoscopic approaches: Applications in orbital surgery. Surv Ophthalmol. 2026;71(3):941-950. doi:10.1016/j.survophthal.2025.11.003
  26. ↑ 26.0 26.1 Matas J, Di Somma A, Liras V, et al. Retinal and Optic Nerve Integrity After Endoscopic Transorbital Skull Base Surgery Assessed by Optical Coherence Tomography. Neurosurgery. 2026;99(2):311-323. doi:10.1227/neu.0000000000003856
  27. ↑ 27.0 27.1 Jeon C, Hong SD, Woo KI, et al. Use of endoscopic transorbital and endonasal approaches for 360° circumferential access to orbital tumors. J Neurosurg. 2021;135(1):103-112. doi:10.3171/2020.6.JNS20890
  28. ↑ Corvino S, Berardinelli J, Corazzelli G, et al. Surgical risk of CSF leakage following endoscopic transorbital approach for anterior and middle skull base pathologies: a systematic review and meta-analysis. Neurosurg Rev. 2025;48(1):282. doi:10.1007/s10143-025-03426-z
  29. ↑ Kong DS, Young SM, Hong CK, et al. Clinical and ophthalmological outcome of endoscopic transorbital surgery for cranioorbital tumors. J Neurosurg. 2019;131(3):667-675. doi:10.3171/2018.3.JNS173233
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