Atlas Phẫu Thuật Mí Mắt Và Hốc Mắt – Jonathan Dutton (2012)

244
81
FIG. 81.5. Advance the Te on catheter to the nasal septum
and then withdraw it 3 to 4 mm. With a marking pen, make
a line on the e on catheter where it emerges at the canthal
angle. Partially withdraw the catheter to see the tip in the
osteum, and measure the distance from the tip to the ink mark.
Choose a Pyrex Jones tube equal to the marked distance on the
catheter.
FIG. 81.6. Cut the hub from the palpebral side of the Te on
catheter and push the Pyrex tube into the catheter end.
Pass a hemostat into the nose, grasp the tip of the catheter, and
pull it out while seating the Pyrex tube into position. Hold the
tube at its collar and pull the catheter free. T e tip of the tube
should rest at least 2 to 3 mm from the nasal septum.
FIG. 81.7. Anchor the Pyrex tube by passing a 6-0 silk suture
around the collar several times, and then through the
caruncle and out the skin of the adjacent eyelid. ie the
suture over a bolster.
FIG. 81.8. Complete the DCR by suturing the anterior
mucosal aps and closing the skin as for standard
dacryocystorhinostomy, Fig.79.13 (pp. 292 to 293).
FIG. 81.1. Proceed as for a standard dacryocystorhinos-
tomy, Fig. 79.1 through 79.11 (pp. 290 to 293), to closing of
the posterior mucosal aps.
FIG. 81.2. If the anterior tip of the middle turbinate lies
at the level of the surgical osteum, resect it. Inject local
anesthetic with epinephrine into the anterior portion of the
turbinate. Apply a straight hemostat across its base and crush
the tissue. Apply a curved hemostat vertically at the anterior
third of the turbinate. Cut at the crush marks with nasal
scissors. Cauterize the cut surfaces.
FIG. 81.3. Resect the anterior half of the caruncle with
Westcott scissors.
FIG. 81.4. Position the tip of a 14-gauge intravenous,
Te on-sheathed needle in the medial canthus 2 mm behind
the skin–mucosal junction and angle it 35 degrees medially
and downward. Push the needle through the medial canthal
tissues into the lacrimal sac and through the surgical osteum.
Keep the needle in front of the sutured posterior mucosal
aps. Withdraw the needle while holding the e on catheter
in place.
INDICATIONS: Complete obstruction o the individual and common canaliculi with or without nasolacrimal duct
obstruction.
Conjunctivodacryocystorhinostomy
POSTOPERATIVE CARE: Apply antibiotic ointment to the
suture line three to our times daily or 7 days. T e patient
is asked to irrigate the tube daily by instilling several drops
o saline solution into the medial cul-de-sac and inhaling
deeply with the opposite nostril occluded. I it becomes
occluded, the tube can be f ushed with saline solution
through a lacrimal canula and, i necessary, cleaned by
passing a number 2 or 3 Bowman probe through it.
POTENTIAL COMPLICATIONS:
Failure of the tube to drain—T is may result rom place-
ment o a tube that is too long and in contact with the
nasal septum. I signi cant septal deviation is present,
it should be corrected be ore lacrimal drainage surgery.
T e middle turbinate occasionally extends orward, and
i not resected, there may be insu cient space or the
tube.
Lateral migration of the tube—T is may be seen with a
tube that is in contact with the septum or one that is
too loose. It should be replaced with a shorter tube or a
tube with a modi ed neck collar, such as the Putterman-
Gladstone tube (Gunther-Weiss, Inc., Portland, OR).
Medial migration of the tube—Loss o the tube into the
medial canthal tissues occurs rom laxity o the tis-
sues and poor support o the tube. T e tube should be
replaced by one with a larger collar, or the neck o the
so t tissue opening can be excised and closed tightly
around the tube with several 6-0 Vicryl sutures.
Granuloma formation—Conjunctival granulomas around
the Pyrex tube can occur and may sometimes be so
extensive as to completely obstruct drainage. T ese
should be excised and treated with topical steroids or
several weeks.
Closure of the soft tissue opening—A lost tube should
be replaced within 1 week i possible. I the tube can-
not be replaced, a new opening is created with a ef on-
sheathed intravenous needle as be ore, without the need
or repeat dacryocystorhinostomy.

245
CHAP ER 81 ▼ Conjunctivodacryocystorhinostomy
FIG. 81.5
FIG. 81.6
FIG. 81.7
FIG. 81.8
FIG. 81.2
FIG. 81.3
FIG. 81.4
FIG. 81.1

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A
S WI H ANY SURGERY, HE INI IAL S EP IN PREPARA ION FOR ORBI AL SURGERY
is complete evaluation o the patient. A care ul history and clinical examination
and the use o modern imaging techniques can narrow the dif erential diagnosis
to one or just a ew possibilities. In most cases, this will make surgical exploration less
necessary than it was in the past. A detailed history o the orbital problem, including
its initial time o appearance, rate o change, and associated ndings such as proptosis,
diplopia, pain, or loss o vision, may help direct the physician to a more limited group o
diagnostic possibilities. Any past history o head trauma, sinus disease, or known previous
paraorbital tumor should be noted. A history o distant malignancy, endocrine disorder,
or other systemic disease may have a signi cant bearing on current orbital complaints.
A complete ophthalmic examination must be recorded. Measurement o visual acu-
ity with a current re raction is mandatory. Speci c tests or optic nerve unction, such
as pupillary reactions and color vision, are indicated to evaluate subtle visual impair-
ment. A visual eld test is obtained on all patients with suspected orbital disease. Any
deviation rom normal visual unction must be explained. T e presence o periorbital
edema or erythema, chemosis, ptosis, and decreased corneal or acial sensation is noted.
T e degree o proptosis, i any, and the direction o globe displacement are impor-
tant in localizing orbital pathologic processes. Ocular motility is care ully measured
and, i abnormal, a orced duction test is per ormed to distinguish between paralytic
and restrictive etiologies. Sequential changes in eyelid position, motility, or proptosis
recorded over several visits may give essential in ormation on subtle progression o the
disease process. It is o ten help ul to examine old photographs or a driver’s license to
help establish a time course or the orbital process.
T e anterior orbit is palpated beneath the bony rim or any abnormal masses or
tenderness. T e eyelids are everted and the deep ornices are examined. An intrana-
sal exam is also per ormed to rule out any concurrent or contiguous nasal or sinus
pathology.
Modern orbital imaging techniques provide critical in ormation on the speci c
location o lesions and their relationship to adjacent structures. Echography allows
determination not only o topographic contours and sur ace characteristics but also
o consistency, gross internal structure, and vascularity, all o which may be di cult
to detect with any other techniques. However, echography is limited to the anterior
orbit due to lack o penetration o sound waves. High-resolution orbital computerized
tomography (C ) yields images based on electron density dif erences and is especially
use ul or evaluation o bone and its relationship to any so t tissue anomalies. Orbital
C should be obtained in axial and coronal planes, with contrast enhancement and
bone window settings. Magnetic resonance imaging with at suppression and other
specialized techniques produces high-resolution, multiplanar so t tissue images based
on electromagnetic interactions between atomic nuclei in a magnetic eld. Weighting
o several dif erent tissue parameters provides a variety o contrast manipulations that
Orbital
Surgery
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248
can distinguish tissues based on subtle biochemical dif erences not separable on C .
Finally, the plain orbital x-ray series is an inexpensive, easily obtained study that can
sometimes provide use ul in ormation at a low cost.
I it is determined that surgical intervention is necessary, such preliminary studies
will indicate the most appropriate approaches and prepare the surgeon or potential
di culties. T ese imaging studies allow advanced planning or necessary consultations
and the assembly o an interdisciplinary surgical team when required.
Orbital surgery is indicated or the evaluation or treatment o orbital disease, or res-
toration o anatomic relationships ollowing trauma, or or cosmetic improvement o
congenital or acquired de ormity. Biopsy o mass lesions is an important technique that
may yield inadequate results unless extreme care is observed. Although some authors
advocate ne needle aspiration biopsy o orbital mass lesions under C or echographic
guidance, cytologic evaluation on such specimens requires experience and may be
inaccurate. In addition, the procedure carries the risk o orbital hemorrhage, which may
compromise vision and might require immediate surgical intervention. In some cases,
as with lymphoproli erative diseases, larger specimens may be necessary or complete
histologic and immunologic evaluation. For most orbital lesions, an open biopsy is pre-
erred i the lesion is accessible. Frozen section con rmation that the lesion has been
adequately sampled is recommended because some dif use masses may not be distin-
guished readily rom surrounding normal orbital tissues or associated in ammation on
visual examination alone during surgery.
Removal o orbital masses may be indicated when they are well de ned and result
in either unctional compromise or cosmetic de ormity. Benign tumors, such as hem-
angiomas, schwannomas, dermoid cysts, and mixed lacrimal gland tumors, and some
malignant lesions, can usually be dissected rom adjacent structures. More in ltrative
lesions, such as lymphangiomas or plexi orm neuro bromas, are usually impossible to
extirpate completely. When not amenable to medical therapy and when necessary to
restore unction, these lesions may be care ully debulked. Some residual tumor may
have to be le t behind to avoid injury to important orbital structures; there ore, recur-
rences are to be expected.
Orbital abscesses, either ollowing trauma or surgery or associated with sinusitis,
require direct drainage and antibiotic therapy. When loculated within the orbit, direct
drainage to the sur ace is appropriate. In the presence o sinus in ection, orbital and
sinus drainage through a combined orbital and transnasal approach in conjunction
with an otolaryngologist may be indicated. Because the ethmoid sinus is most re-
quently involved, an anterior medial orbitotomy usually gives adequate visualization.
raumatic injury to the orbit requently involves bony racture or hemorrhage.
Orbital rim ractures are easily accessible through anterior approaches and may be
repaired with miniplate xation o the displaced ragments. Orbital wall ractures,
which may be associated with so t tissue injury or incarceration, must be care ully
explored and realigned or replaced when necessary to restore unction or orbital vol-
ume. T e exact surgical approach depends on the nature and location o the ractures.
When more complex cranio acial ractures are involved, cooperation o an otolaryn-
gologist, plastic surgeon, or neurosurgeon may be necessary.
Dif use orbital hemorrhage ollowing trauma may produce massive proptosis
and occasionally increased intraocular pressure or optic nerve compression. Orbital
decompression with a lateral canthotomy is usually su cient to manage the potential
visual loss. I this ails, drainage o loculated pockets or bony decompression may be

necessary. Progressive loss o vision associated with proptosis and downward displace-
ment o the globe suggest a subperiosteal hematoma. T e diagnosis is con rmed with
orbital echography or C , and immediate drainage via an anteromedial orbitotomy
usually reverses the visual loss.
Massive proptosis associated with Graves’ orbitopathy may require orbital decom-
pression or treatment o threatened visual unction or or cosmetic dis gurement. It is
achieved by removal o the in erior, medial, and/or lateral orbital walls. In some Graves’
patients, the extraocular muscles are only minimally enlarged, but at volume is mark-
edly increased. Here, a at only decompression may be su cient. Bony decompression
may also be indicated or other expanding lesions o the orbit that cannot be surgically
extirpated.
Removal o the globe and part or all o normal orbital contents may be necessary
or management o neoplastic processes or or control o pain in a blind or phthisical
eye. It is also use ul or cosmetic improvement o congenital or traumatic ocular or
orbital de ormities. I only the globe is involved, enucleation or evisceration is indicated.
Neoplasms that extend into the orbit rom the globe or eyelids may require more radi-
cal exenteration o orbital so t tissues or cure. ▼
SUGGES ED FUR HER READING
Byrne SF, Green RL. Ultrasound of the Eye and Orbit. St. Louis, MO: Mosby; 2002,505p.
Doxanas M , Anderson RL. Clinical Orbital Anatomy. Baltimore, MD: Williams & Wilkins; 1984, 232p.
Conneely MF, Hacein-Bey L, Jay WM. Magnetic resonance imaging o the orbit. Semin Ophthalmol.
2008;23:179–189.
DiBernardo CW, Greenberg EF. Ophthalmic Ultrasound. A Diagnostic Atlas. 2nd ed. New York:
T ieme; 2006,154p.
Dutton JJ, Proia AD, Byrne SF. Diagnostic Atlas of Orbital Diseases. London, UK: WB Saunders;
2000,179p.
Dutton JJ. Radiographic evaluation o the orbit. In: Doxanas M , Anderson RL, eds. Clinical Orbital
Anatomy. Baltimore, MD: Williams & Wilkins; 1984, pp. 35-56.
Dutton JJ. Radiology of the Orbit and Visual Pathways. London, UK: Saunders Elsevier; 2010, 408p.
Goh PS, Gi M , Charlton A, et al. Review o orbital imaging. Eur J Radiol. 2008;66:387–395.
Kennerdell JS, Dekker A, Johnson BL, Dubois PJ. Fine-needle aspiration biopsy: its use in orbital
tumors. Arch Ophthalmol. 1979;97:1315–1317.
Krohel GB, obin DR, Chavis R. Inaccuracy o f ne needle aspiration biopsy. Ophthalmology.
1985;92:666–670.
Lemke AJ, Kazi I, Felix R. Magnetic resonance imaging o orbital tumors. Eur Radiol. 2006;16:2207–
2219.
Nerad JA. Techniques in Ophthalmic Plastic Surgery. A Personal Tutorial. London: Elsevier, Saunders;
2010:301–486.
Rootman J. Diseases of the Orbit. A Multidisciplinary Approach. Philadelphia, PA: JB Lippincott;
1988:628.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual Approach. Philadelphia, PA:
Lippincott-Raven; 1995:3–78.
Shields JA, Shields CL. Eyelid, Conjunctival, and Orbital Tumors. Philadelphia, PA: Lippincott, Wil-
liams & Williams; 2008:782–805.
Spoor C, Kennerdell JS, Dekker A, et al. Orbital f ne needle aspiration biopsy with B-scan guidance.
Am J Ophthalmol. 1980;89:274–277.
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251
A
SEC ION
Surgical Anatomy of
the Orbit

252
82
T e orbital oor is composed primarily o the maxillary
bone, with the zygomatic bone orming the anterolateral
portion, and the palatine bone lying at the posterior extent
o the oor. It is bounded laterally and posteriorly by the
in erior orbital f ssure. T e oor ends at the posterior limit
o the maxillary sinus and there ore does not extend to the
orbital apex. T e in raorbital groove begins at the in erior
orbital f ssure and runs orward in the maxillary bone.
At about 15 mm rom the orbital rim, this groove usually
becomes bridged over with a thin lamina o bone to orm
the in raorbital canal. Within this canal runs the maxillary
division o the trigeminal nerve with the maxillary artery.
T ese exit just below the central orbital rim at the in raor-
bital oramen. Surgery on the orbital oor during blow-out
racture repair or orbital decompression must include spe-
cial attention to these structures to avoid injury. T e orbital
oor is thinnest just medial to the canal, and this area is the
most common site or blow-out ractures.
T e medial orbital wall is composed largely o the lamina
papyracea o the ethmoid bone. T is thin plate separates
the orbit rom air cells o the ethmoid sinus labyrinth. It
is a requent site o racture in orbital trauma and is easily
breached during transnasal ethmoid sinus surgery. T e lam-
ina papyracea o ers little resistance to expanding ethmoid
sinus mucoceles and commonly transmits in ammatory
and in ectious processes rom sinusitis into the orbit.
Posterior to the ethmoid, the body o the sphenoid bone
completes the medial wall to the apex. T is portion o the
wall is quite thick and is only rarely involved in orbital
trauma or sinus pathology. T e medial wall ends at the
optic oramen, where the sphenoid orms the medial wall
o the optic canal.
Anterior to the ethmoid is the lacrimal bone, a thin plate
that contains the posterior lacrimal crest and orms the pos-
terior one-hal o the lacrimal sac ossa. In the midportion
o the ossa, the lacrimal bone joins the orbital process o
the maxillary bone. T e latter is a thick bone that orms
the medial orbital rim. During lacrimal bypass surgery,
entrance into the nose can be achieved easily with a hemo-
stat by applying gentle pressure on the lacrimal portion
o the ossa. In some individuals, the lacrimal–maxillary
suture is situated arther posterior so the maxillary bone
underlies most o the ossa. In such cases, a burr may be
necessary to remove enough bone to create a DCR osteum.
Within the rontoethmoid suture line in the superome-
dial orbit are two openings, the anterior and posterior eth-
moidal oramina. T e ormer lies about 20 mm rom the
anterior lacrimal crest, and the latter about 32 to 35 mm
behind the anterior crest and 6 to 10 mm anterior to the

he human orbit is a small, roughly pear-shaped cavity.
Within it is a complex array o tightly packed, juxta-
posed structures subserving visual unction. Filling the spaces
between the muscles, nerves, and vascular elements are cush-
ions o orbital at and connective tissue ascia, within which
even experienced orbital surgeons rarely see more than occa-
sional glimpses o anatomic detail. Yet the surgeon must have
an intimate knowledge o structural and unctional relation-
ships within the orbit, i surgery is to be per ormed success-
ully and without complication.
T e bony orbit is composed o seven bones that are sim-
plif ed rom a complex o dermal and endochondral ele-
ments o earlier vertebrates. T e orbital roo is composed
o the orbital plate o the rontal bone with a small contri-
bution rom the lesser wing o the sphenoid at the apex. T e
roo is a thin lamina separating the orbit anteriorly rom
the rontal sinus and posteriorly rom the anterior cranial
ossa. T e roo slopes backward and downward toward the
apex and ends at the optic oramen and the superior orbital
f ssure.
T e lateral wall is ormed by the greater wing o the sphe-
noid bone posteriorly and by the zygomatic process o the
rontal bone and the orbital process o the zygomatic bone
anteriorly. It lies at a nearly 45-degree angle to the midsag-
ittal plane. T e lateral wall is bounded below by the in erior
orbital f ssure and medially by the superior orbital f ssure.
Behind the thick lateral orbital rim, the wall becomes quite
thin where the zygomatic bone joins the greater sphenoid
wing at a vertical suture line. During a lateral orbitotomy,
cutting the rim through to this thin plate allows easy out-
ward racture o the bone. T e convoluted rontozygomatic
suture line runs approximately horizontal and crosses the
superotemporal rim near the lacrimal gland ossa. About
5 to 15 mm above this line, the rontal bone widens as it
passes around the ront end o the anterior cranial ossa.
T e surgeon must make note o this broadening contour
when planning the position o the superior bone cut in a
lateral orbitotomy. About hal way along the lateral wall,
in the sphenoid wing near the rontosphenoid suture, is a
small canal carrying an anastomotic branch between the
lacrimal and meningeal arteries. Elevation o the perior-
bita during lateral orbital dissection may result in brisk
bleeding rom this vessel, but the bleeding is usually easily
controlled with pressure. Just behind the zygomatico-
sphenoid suture line, the greater wing widens as it passes
around the anterior tip o the middle cranial ossa. While
the greater wing is removed during lateral orbitotomy pro-
cedures, the appearance o cancellous bone warns o the
imminent approach o dura.
Surgical Anatomy of the Orbit

253
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
optic canal. T ese oramina transmit branches o the oph-
thalmic artery and nasociliary nerve into the ethmoid sinus
and nose. T ese ethmoidal vessels are requently injured in
orbital trauma and are the major sources o subperiosteal
hematomas. During surgery on the medial orbital wall, the
position o these oramina must be kept in mind to avoid
injury and hemorrhage. In addition, these openings mark
the approximate level o the roo o the ethmoid labyrinth
and the oor o the anterior cranial ossa. T e cribri orm
plate may lie as much as 10 mm below this level, just medial
to the root o the middle turbinate, and there ore can be
ractured during medial wall surgery.
T e orbit is lined with the periorbita (periosteum plus
layers o ascia), which is loosely adherent to the orbital
bones. It is f rmly attached only at the arcus marginalis
along the orbital rim, at the lateral orbital tubercle, adjacent
to the trochlea, around the optic oramen, and along the
in erior and superior orbital f ssures. Where the periorbita
joins the margin o the optic canal and the superior orbital
f ssure, it is used to dura, so trauma or surgery in these
areas may be complicated by cerebrospinal uid leakage.
Suspended rom the periorbita and orming a com-
plex radial and circum erential web o interconnecting
slings are the connective tissue septa. T ese septa orm
f ne capsules around the intraconal and extraconal at
lobules. T ey also surround the extraocular muscles, the
optic nerve, and the neurovascular elements, and suspend
these structures to the adjacent orbital walls. T ese ascial
slings provide support and maintain constant spatial rela-
tionships between the anatomic structures during ocular
movements. T e presence o these septa is responsible
or transmission o restrictive orces rom incarcerated or
hemorrhagic in erior orbital at to extraocular muscles ol-
lowing trauma, even in the absence o true muscle entrap-
ment. Encircling septa around the optic nerve may serve to
conf ne hemorrhage, resulting in compressive optic neu-
ropathy ollowing trauma.
Within the orbital space are a number o structures
whose unction is to provide support, movement, and sen-
sory innervation to the globe. T e eye is an approximate
sphere that measures about 24 mm in diameter and is
situated in the anterior one-hal o the orbit. Attached to
it are the six striated extraocular muscles. T e our rectus
muscles arise posteriorly rom the annulus o Zinn, a
f brous band that is continuous with periorbita and dura at
the optic oramen. T e annulus surrounds the optic ora-
men and the central one-third o the superior orbital f s-
sure, through which neurovascular structures pass rom the
middle cranial ossa into the intraconal orbital space. T e
muscles run orward with only a thin layer o extraconal
at separating them rom periorbita along the orbital walls.
T e superior oblique muscle arises above the annu-
lus, just superior and medial to the optic oramen. It runs
orward along the superomedial orbital wall to the car-
tilagenous trochlea, through which its ligament slides,
be ore turning sharply laterally to insert on the supero-
posterior aspect o the globe. Removal o the trochlea with
periosteum during medial orbital surgery can be achieved
easily, but care must be taken to reattach it by closing the
periorbita along the orbital rim.
T e in erior oblique muscle arises anteriorly rom a
small depression just below and lateral to the lacrimal sac
ossa. It passes laterally and slightly backward to insert on
the in eroposterior sur ace o the globe near the macula.
Along its course, the sheath o the in erior oblique muscle
joins that o the in erior rectus muscle and enon’s capsule
just behind the orbital rim to orm Lockwood’s in erior
suspensory ligament. Slips o this structure pass laterally to
periosteum o the orbital wall and medially to join the pos-
terior crus o the medial canthal ligament. T e capsulopal-
pebral ascia extends anteriorly rom this ligament to the
in erior tarsal plate. During surgery in the in erior orbit,
additional care must be taken while opening the orbital
septum because the in erior oblique muscle and Lock-
wood’s ligament lie immediately behind the orbital rim.
T e levator superioris palpebrae muscle originates rom
the annulus o Zinn and the lesser sphenoid wing. It runs
orward along the orbital roo in close approximation to
the superior rectus muscle. Fine check ligaments intercon-
nect the levator to the superior rectus and to periosteum
o the rontal bone. Near the orbital rim, f ne suspensory
ligaments extend rom the levator sheath to the superior
conjunctival ornix. In addition, a horizontal condensation
within the muscle sheath orms the prominent transverse
ligament o Whitnall. T is ligament uses to the orbital wall
near the trochlea and around the lacrimal gland. Whitnall’s
ligament is an important suspensory structure or the
superior orbit and eyelid and should not be cut.
Anterior to Whitnall’s ligament, the levator muscle
passes into a thin, f brous aponeurosis that turns in eri-
orly and ans out into the eyelid. It inserts onto the in erior
two-thirds o the anterior tarsal ace. Medially and laterally,
the aponeurosis joins the canthal ligaments via extensions
known as the “horns.” T e levator muscle is unusually sen-
sitive to any superior orbital disease, such as mass lesions
or in ammation. T is sensitivity results in upper eye-
lid ptosis. T e latter is, there ore, a requent early sign o
orbital pathologic processes.
T e extraocular muscles are innervated by the third,
ourth, and sixth cranial nerves. T e oculomotor nerve
(N. III) arises rom the oculomotor nuclear complex in
the midbrain and exits at the medial border o the cere-
bral peduncle. It passes orward in the lateral cavernous
sinus, where it divides into a superior and in erior divi-
sion just be ore entering the intraconal space through the
superior orbital f ssure. T e superior branch innervates the
superior rectus and levator muscles. T e in erior branch
sends f bers to the in erior rectus, the medial rectus, and
the in erior oblique muscles. T ese branches are applied to
the inner sur ace o the muscles, where they are cushioned
and protected by the f brous muscle sheaths. However, the
branches may be injured during deep orbital surgery near
the apex, where they run ree within the orbital at. Run-
ning with the in erior division o the oculomotor nerve

SEC ION A ▲ Surgical Anatomy o the Orbit
254
to medial over the optic nerve a ter sending small sensory
branches that pass through the ciliary ganglion without
synapse and continue to the globe with the short ciliary
nerves. As it passes to the lateral side o the optic nerve,
the nasociliary gives o the long posterior ciliary nerves
that extend to the posterior globe. T e nasociliary nerve
continues orward in the medial orbit, where it gives rise
to the posterior and anterior ethmoidal nerves. It exits the
anterior orbit at the superomedial rim as the in ratrochlear
nerve.
T e arterial supply to the orbit is rom the internal
carotid system through the ophthalmic artery, with anas-
tomotic ow anteriorly rom the external carotid system
through the superf cial acial vessels. T e ophthalmic artery
enters the orbit through the optic canal, in erotemporal
to the optic nerve. In about 83% o individuals, the vessel
crosses over the nerve to the medial side; in the remaining
17%, it crosses below the nerve. Shortly a ter entering the
orbit, the ophthalmic artery gives o a number o branches
with some variability in the sequence. T e central retinal
artery is usually the f rst branch. It runs along the in e-
rior aspect o the optic nerve to penetrate the dura 1 cm
behind the globe. T e lacrimal artery generally arises next
and courses upward and orward, pierces the intermuscu-
lar septum, and runs extraconally to the lacrimal gland just
above the lateral rectus muscle. It gives rise to the zygo-
maticotemporal artery, which penetrates the lateral wall
at about the midorbit, and to the zygomatico acial artery,
which runs in erolaterally to exit through a small oramen
in the zygomatic bone. T rough the latter vessels, the lac-
rimal artery anastomoses with the external carotid system
via the transverse acial and superf cial temporal arteries.
T e lacrimal artery terminates in the lids as the lateral in e-
rior and superior palpebral arteries.
T e lateral and medial long posterior ciliary arteries
arise on either side o the lacrimal artery and run orward
parallel to the optic nerve. Each branches into one long and
8 to 10 short posterior ciliary arteries that penetrate the
sclera near the exit o the optic nerve. A number o nutri-
ent branches are given o in this region to the extraocular
muscles.
As the ophthalmic artery passes toward the medial orbit,
the supraorbital branch is given o . T is passes through
the intermuscular septum medial to the levator muscle
and runs orward with the rontal nerve to the supraorbital
notch. In the medial orbit, the ophthalmic artery gives rise
to the posterior and anterior ethmoidal arteries, which
enter the ethmoidal oramina. It then continues orward
as the naso rontal artery to exit just above the medial can-
thus. It gives o the in erior and superior medial palpebral
arteries to the eyelids and terminates as the supratrochlear
and dorsal nasal arteries, with anastomotic connections to
the angular vessels.
Venous drainage is through the superior and in erior
ophthalmic veins. T e superior ophthalmic vein originates
at the superomedial orbital rim rom branches o the angu-
lar, supratrochlear, and supraorbital veins. As it passes
are parasympathetic f bers that arise rom the Edinger-
Westphal subnucleus. T ese synapse in the ciliary ganglion
just lateral and in erior to the optic nerve, about 1.5 to 2 cm
behind the globe. T ey progress via the short ciliary nerves
to the ciliary body and the iris sphincter. T ere is no redun-
dancy to these nerves and they are easily injured during
orbital dissection, thus resulting in disturbances o pupil-
lary unction and accommodation.
T e trochlear nerve (N. IV) arises in the midbrain, exits
below the in erior colliculus, and passes orward in the lat-
eral cavernous sinus. It enters the extraconal space o the
superior orbit through the superior orbital f ssure above
the annulus o Zinn. It crosses over the superior rectus and
levator muscle complex and runs along the external sur ace
o the superior oblique muscle be ore penetrating its sub-
stance in the posterior third o the orbit. In this position
against the orbital roo , the trochlear nerve is easily dam-
aged during blunt trauma and rom lateral displacement o
periorbita during deep medial wall surgery.
T e abducens nerve (N. VI) arises in the pons and passes
orward in the cavernous sinus below the trochlear nerve.
It enters the orbit through the superior orbital f ssure and
annulus o Zinn to enter the intraconal space. T e nerve
runs laterally to supply the lateral rectus muscle.
T e optic nerve is a central nervous system tract that
arises rom the retinal ganglion cells. Nasal f bers decus-
sate in the optic chiasm. Fibers in the optic tracts continue
backward and synapse in the lateral geniculate nuclei, rom
which they radiate to the occipital cortex. T e orbital por-
tion o the nerve is somewhat redundant to allow or ocular
movement. It measures about 3 cm in length, takes a sinu-
soidal path rom the globe, curving downward and then
upward to the optic canal. In close approximation to the
nerve are the ophthalmic artery near the orbital apex and
the superior ophthalmic vein in the midorbit. Both o these
vessels lie superior to the nerve in most individuals. T e
central retinal artery runs along the in erolateral side o the
nerve to enter the dura at about 1 cm behind the globe.
T e short and long posterior ciliary arteries lie close to the
nerve or much o its length and are highly convoluted and
redundant near the globe.
Sensory innervation to the orbit is primarily rom the
ophthalmic division o the trigeminal nerve (N. V). T e
maxillary division supplies portions o the in erior orbit.
T e ophthalmic division divides in the cavernous sinus just
as the latter passes into the superior orbital f ssure. T e lac-
rimal nerve enters above the annulus o Zinn and proceeds
in the extraconal space just inside periorbita along the
superolateral orbit to the lacrimal gland and upper eyelid.
T e rontal nerve runs orward between the levator muscle
and the superior periorbita and exits the orbit at the supra-
orbital notch. At about the level o the posterior globe, it
gives rise to the supratrochlear nerve, which exits the orbit
at the superomedial rim.
T e nasociliary nerve, which is a branch o the ophthal-
mic division o the trigeminal, enters the orbit through the
superior f ssure and annulus o Zinn. It crosses rom lateral

255
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. 2nd ed. Lon-
don, UK: Elsevier; 2011,262p.
Hayreh SS. T e ophthalmic artery, III: branches. Br J Ophthalmol. 1962;
46:212–247.
Hayreh SS, Dass R. T e ophthalmic artery, II: intraorbital course. Br J
Ophthalmol. 1962;46:165–185.
Kakizaki H, akahashi Y, Asamoto K, et al. Anatomy o the superior
border o the lateral orbital wall: surgical implications in deep lat-
eral orbital wall decompression surgery. Ophthal Plast Reconstr Surg.
2011;27:60–63.
Koornnee L. Details o the orbital connective tissue system in the adult.
Acta Morphol Neerl Scand. 1977;15:1–34.
Koornnee L. T e architecture o the musculof brous apparatus in the
human orbit. Acta Morphol Neerl Scand 1977;15:35–64.
Koornnee L. Orbital septa, anatomy and unction. Ophthalmology.
1979;86:876–880.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual
Approach. Philadelphia, PA: Lippincott-Raven; 1995:79–146.
Sacks JG. Peripheral innervation o the extraocular muscles. Am J
Ophthalmol. 1983;95:520–527.
Sevel D. T e origins and insertions o the extraocular muscles: develop-
ment, histologic eatures, and clinical signif cance. Trans Am Oph-
thalmol Soc. 1986;84:488–526.
akahashi Y, Kakizaki H, Nakano . Accessory ethmoidal oramina: an
anatomical study. Ophthal Plast Reconstr Surg. 2011;27:125–127.
Whitnall SE. Anatomy of the Human Orbit and Accessory Organs of
Vision. 2nd ed. London, UK: Ox ord Medical Publishers; 1932,467p.
Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven;
1985,75p.
backward along the medial orbit, it is joined by branches
rom the medial and superior rectus muscles, the levator
muscle, the superior vortex veins, the anterior ethmoidal
vein, and collateral branches rom the in erior ophthalmic
vein. At about the midorbit, it crosses to the lateral orbit
just below the superior rectus muscle. It is joined by the
lacrimal vein and continues posteriorly to enter the cavern-
ous sinus through the superior orbital f ssure.
T e in erior ophthalmic vein has an indistinct origin in a
plexus o small vessels in the in erior orbit. It passes back-
ward along the in erior rectus muscle, picking up branches
rom the in erior rectus muscle, the in erior oblique mus-
cle, the in erior vortex veins, and the lateral rectus muscle.
A branch exits through the in erior orbital f ssure to join
the pterygoid plexus be ore the vessel terminates at the
superior ophthalmic vein just be ore the last enters the
cavernous sinus.
SUGGES ED FUR HER READING
Abed SF, Shams P, Shen S, et al. A cadaveric study o the morphometric
and geometric relationships o the orbital apex. Orbit. 2011;30:72–76.
Doxanas M , Anderson RL. Clinical Orbital Anatomy. Baltimore, MD:
Williams & Wilkins; 1984,232p.
Dutton JJ. Radiology of the Orbit and Visual Pathways. London, UK:
Saunders Elsevier; 2010:32–48.

SEC ION A ▲ Surgical Anatomy o the Orbit
256
FIG. 82.1. Bony anatomy of the orbit in frontal view. 1, Frontal bone. 2, Sphenoid
bone. 3, Frontozygomatic suture. 4, Sphenozygomatic suture. 5, Zygomatic bone.
6, In erior orbital ssure. 7, In raorbital sulcus. 8, In raorbital oramen. 9, Supraorbital
notch. 10, Superior orbital ssure. 11, Optic canal. 12, Posterior ethmoidal
oramen. 13, Anterior ethmoidal oramen. 14, Ethmoid bone. 15, Lacrimal bone.
16, Lacrimal sac ossa. 17, Maxillary bone.
FIG. 82.2. T e lateral orbital wall, external view. 1, Greater wing o the sphenoid
bone. 2, Squamous portion o the temporal bone. 3, Zygomatic arch o the temporal
bone. 4, Frontal bone. 5, Frontozygomatic suture. 6, Zygomatic bone. 7, Maxillary
bone.
FIG. 82.3. T e medial orbital wall, intraorbital view. 1, Anterior ethmoidal
oramen. 2, Posterior ethmoidal oramen. 3, Optic canal. 4, Foramen rotundum.
5, Sphenoid bone. 6, Pterygopalatine oramen. 7, In raorbital groove. 8, Maxillary sinus.
9, Frontal bone. 10, Ethmoid bone (retroilluminated to show air cells). 11, Nasal bone.
12, Lacrimal bone. 13, Fossa. 14, Maxillary bone. 15, In raorbital oramen.

257
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
FIG. 82.1
1
9
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12
13
14
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17
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3
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FIG. 82.2
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FIG. 82.3

SEC ION A ▲ Surgical Anatomy o the Orbit
258
FIG. 82.4. Coronal cross section through the periorbital region at the level of
the ocular equator. 1, Frontal bone. 2, Periorbita. 3, Zygomatic bone. 4, In raorbital
neurovascular bundle. 5, Maxillary sinus. 6, Maxillary bone. 7, Cerebrum. 8, Anterior
ethmoid sinus cells. 9, Ethmoid bone. 10, Middle turbinate. 11, In erior turbinate.
FIG. 82.5. Coronal cross section through the orbit at the level of the ocular
equator. 1, Supraorbital neurovascular bundle. 2, Superior rectus muscle. 3, Lacrimal
gland. 4, Lateral rectus muscle. 5, In erior oblique muscle. 6, In erior rectus muscle.
7, Levator palpebrae superioris muscle. 8, Superior oblique muscle. 9, Optic disc.
10, Medial rectus muscle. 11, Sclera. 12, In erior extraconal orbital at.

259
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
1
7
8
9
10
11
2
3
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5
6
FIG. 82.4
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12
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FIG. 82.5

SEC ION A ▲ Surgical Anatomy o the Orbit
260
FIG. 82.6. Super cial anatomy of the orbit in lateral view. 1, Superior rectus
muscle. 2, Lacrimal nerve. 3, Ophthalmic division o the trigeminal nerve. 4, Cavernous
sinus. 5, rigeminal (semilunar) ganglion. 6, Maxillary division o trigeminal nerve.
7, Lateral rectus muscle. 8, Levator palpebrae superioris muscle. 9, Levator aponeuro-
sis. 10, Lacrimal gland. 11, Zygomatico acial nerve and artery. 12, Zygomatic nerve.
FIG. 82.7. Anatomy of the intraconal orbital space in lateral view. 1, Superior
division o the oculomotor nerve. 2, Optic nerve. 3, Annulus o Zinn. 4, In erior
division o the oculomotor nerve. 5, In raorbital nerve. 6, Superior rectus muscle.
7, endon o the superior oblique muscle. 8, Lateral rectus muscle (cut). 9, In erior
oblique muscle. 10, In erior rectus muscle.

261
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
1
7
8
9
10
11
12
2
3
4
5
6
FIG. 82.6
1
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8
9
10
2
3
4
5
6
FIG. 82.7

SEC ION A ▲ Surgical Anatomy o the Orbit
262
FIG. 82.8. Sensory and motor nerves of the orbit in lateral view. 1, Posterior
ethmoidal nerve. 2, Nasociliary nerve. 3, Superior division o the oculomotor nerve.
4, Oculomotor nerve. 5, rochlear nerve. 6, In erior division o the oculomotor nerve.
7, Ciliary ganglion. 8, Short posterior ciliary nerves. 9, Anterior ethmoidal nerve.
10, Superior oblique muscle. 11, In ratrochlear nerve. 12, Medial rectus muscle.
13, Lacrimal sac. 14, Long posterior ciliary nerves. 15, In erior rectus muscle.
FIG. 82.9. Arterial system of the orbit in lateral view. 1, Lacrimal artery. 2, Anterior
ethmoidal artery. 3, Posterior ethmoidal artery. 4, Internal carotid artery. 5, Ophthalmic
artery. 6, Central retinal artery. 7, Maxillary artery. 8, Supraorbital artery. 9, Naso rontal
artery. 10, In ratrochlear artery. 11, Dorsal nasal artery. 12, Medial palpebral artery.
13, Medial posterior ciliary artery. 14, Lateral posterior ciliary artery. 15, In raorbital
artery.

263
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
1
11
12
13
14
15
9
10
2
3
4
5
6
7
8
FIG. 82.8
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15
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6
7
8
FIG. 82.9

SEC ION A ▲ Surgical Anatomy o the Orbit
264
FIG. 82.10. Venous system of the orbit in lateral view. 1, Superior ophthalmic
vein. 2, Anterior ethmoidal vein. 3, Cavernous sinus. 4, Central retinal vein. 5, In erior
ophthalmic vein. 6, In raorbital vein. 7, Supraorbital vein. 8, Supratrochlear vein.
9, In ratrochlear vein. 10, Lacrimal vein. 11, Superior vortex veins. 12, In erior vortex
veins. 13, Angular vein.
FIG. 82.11. Super cial anatomy of the orbit in superior view. 1, rochlea,
2, Superior oblique muscle. 3, rochlear nerve. 4, Optic nerve. 5, Ophthalmic
artery. 6, Oculomotor nerve. 7, Levator palpebrae superioris muscle. 8, Lacrimal
gland. 9, Superior rectus muscle. 10, Lateral rectus muscle. 11, Abducens nerve.
12, Ophthalmic division o the trigeminal nerve. 13, rigeminal (semilunar) ganglion.

265
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
1
2
3
4
5
6
7
8
9
10
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12
13
FIG. 82.10
1
2
3
4
5
6
7
8
9
10
11
12
13
FIG. 82.11

SEC ION A ▲ Surgical Anatomy o the Orbit
266
FIG. 82.12. Neurovascular anatomy of the super cial orbital space in superior
view. 1, Supratrochlear nerve. 2, Supratrochlear vein. 3, In ratrochlear vein.
4, Supraorbital vein. 5, Supraorbital artery. 6, Frontal nerve. 7, Supraorbital nerve,
medial branch. 8, Supraorbital nerve, lateral branch. 9, Lacrimal nerve. 10, Lacrimal
artery. 11, Lacrimal vein.
FIG. 82.13. Sensory and motor nerves of the deep intraconal orbital space in
superior view. 1, In ratrochlear nerve. 2, Anterior ethmoidal nerve. 3, Long posterior
ciliary nerve. 4, Posterior ethmoidal nerve. 5, Nasociliary nerve. 6, Superior division
o the oculomotor nerve. 7, Oculomotor nerve. 8, Short posterior ciliary nerve.
9, Abducens nerve. 10, Ciliary ganglion. 11, In erior division o the oculomotor nerve.
12, Frontal nerve (cut). 13, rochlear nerve (cut).

267
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
1
2
3
4
5
6
7
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11
FIG. 82.12
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FIG. 82.13

SEC ION A ▲ Surgical Anatomy o the Orbit
268
FIG. 82.14. Arterial system of the intraconal orbital space in superior view.
1, Medial palpebral artery. 2, Dorsal nasal artery. 3, Naso rontal artery. 4, Anterior
ethmoidal artery. 5, Posterior ethmoidal artery. 6, Internal carotid artery.
7, Supraorbital artery. 8, Lacrimal artery. 9, Zygomatico acial artery. 10, Lateral
posterior ciliary artery. 11, Medial posterior ciliary artery. 12, Ophthalmic artery.
FIG. 82.15. Venous system of the intraconal orbital space in superior view.
1, Supratrochlear vein. 2, In ratrochlear vein. 3, Supraorbital vein. 4, Anterior
ethmoidal vein. 5, Central ophthalmic vein. 6, Superior vortex veins. 7, Lacrimal vein.
8, In erior ophthalmic vein. 9, Superior ophthalmic vein.

269
CHAP ER 82 ▼ Surgical Anatomy o the Orbit
1
2
3
4
5
6
7
8
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12
FIG. 82.14
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FIG. 82.15

270
SECTIONB
T
he orbitotomy procedures include a number o opera-
tions or access into the various orbital so t tissue com-
partments. T e specif c approach selected depends on the
type and location o the pathologic process, involvement o
adjacent bone or paraorbital areas, the need or wide surgical
margins, and the requirements or adequate exposure.
T ere are three surgical spaces o interest to the orbital
surgeon and each requires specif c consideration or appro-
priate visualization. T e subperiosteal compartment is a
potential space between the orbital bony walls and perior-
bita. Access to this space is necessary or repair o orbital
wall ractures or or decompression o expanding orbital
volume, as in Graves’ orbitopathy. T is compartment is
the location or accumulation o subperiosteal hematomas
ollowing blunt trauma and or subperiosteal abscesses
associated with ethmoid or rontal sinusitis. Expanding
mucoceles and some intracranial lesions, such as sphenoid
wing meningiomas, may involve only this compartment.
Bone lesions, such as epidermoid and aneurysmal bone
cysts, cholesterol granulomas, and eosinophilic granulo-
mas are also requently largely conf ned to the subperi-
osteal space. Access is through a transperiosteal anterior
or lateral orbitotomy, or via a transcaruncular medial
approach.
T e extraconal or peripheral orbital space lies between
the periorbita and the ascial septa that interconnect the
extraocular muscles. T is septal system is ar more com-
plex than once believed, and it is unusual or lesions to be
precisely conf ned to the extraconal space alone. Access
to the extraconal orbital space may be through a transcu-
taneous transseptal orbitotomy i in the anterior orbit or
through a lateral orbitotomy i deeper.
T e intraconal, or central orbital, space is delimited by the
extraocular muscle cone rom the annulus o Zinn to pos-
terior enon’s capsule. It is not a clearly def ned compart-
ment, however, because the intermuscular septum is largely
incomplete posteriorly and poorly def ned anteriorly. Lesions
requently extend between the extraconal and intraconal
compartments without regard to these artif cial boundar-
ies. Optic nerve gliomas and sheath meningiomas are typi-
cally located within the muscular cone. Any surgery on the
optic nerve, or example, biopsy or sheath decompression,
requires access to this compartment. T e surgical approach
is via a lateral orbitotomy or deep lesions or an anterior orbi-
totomy or lesions immediately behind the globe. A superior
transcranial orbitotomy is necessary or lesions that involve
the orbital apex or or those extending intracranially into the
cavernous sinus or middle cranial ossa.
Orbitotomy Procedures
Between the intraconal and extraconal spaces are the
extraocular muscles that may be the sites or orbital pathol-
ogy, such as myositis, or metastatic tumors. T ey are usu-
ally approached by the anterior or lateral routes, depending
on the depth o the lesion.
T e specif c surgical procedures described here give
direct access to certain structures to minimize trauma
to adjacent tissues. T e anterior orbitotomies are used
or lesions in the anterior orbit to the level o the poste-
rior globe. T e transcutaneous anterior orbitotomy gives
excellent exposure in all quadrants. In the lower eyelid, the
incision is best placed in a subciliary position or better
cosmesis. A transconjunctival incision combined with dis-
insertion o the in erior crus o the lateral canthal ligament
will give wide exposure to the in erior orbit or access to the
subperiosteal space and orbital oor. In the upper eyelid,
the incision may be placed within the eyelid crease. rans-
periosteal or transseptal entrance to the orbit is achieved
by dissecting upward beneath the orbicularis muscle to the
appropriate layer.
T e lateral orbitotomy involves removal o the lateral
orbital rim and varying amounts o the greater sphenoid
wing. It allows wide access to the deep orbital contents
and optic nerve and is pre erred or excision o most ret-
robulbar lesions. Superior extension o the superior bony
cut gives better exposure to the lacrimal gland or en bloc
excision within its ossa. T e lateral orbitotomy may be
combined with other approaches, or example, the medial
orbitotomy, or better visualization o the deep medial wall.
T e superior orbitotomy is per ormed through a trans-
rontal or temporo rontal osteoplastic craniotomy. It
requires the joint e orts o the orbital surgeon and a neu-
rosurgeon. T is route provides the only adequate and sa e
exposure to the orbital apex and is mandatory or lesions
that extend between the orbit and the intracranial com-
partment.
For anterior orbitotomies, local inf ltrative anesthetic
may be used i the lesion is small and situated close to the
orbital rim. However, or lengthy procedures or or those
deeper in the orbit, general anesthesia is pre erred. Intra-
operative hypotension monitored by the anesthesiologist
may be o some benef t in reducing the risk o hemorrhage.
More so than in any other procedures in ophthalmology,
knowledge o anatomic detail and precise technique is nec-
essary or success ul orbital surgery. Meticulous attention
to hemostasis must be assured throughout surgery or visu-
alization and be ore closure to prevent postoperative com-
plications. For many deeper dissections in the extraconal

or intraconal spaces, particularly with lateral orbitotomies,
low suction drainage may be used or 24 hours i complete
hemostasis cannot be assured.
A ter adequate exposure is achieved, dissection pro-
ceeds slowly and with great deliberation. Magnif cation and
microdissecting instruments are used to gently separate
the lesion rom adjacent normal structures. Light traction
on the lesion is usually necessary to allow posterior dissec-
tion. T is may be achieved with orceps, but or more vas-
cular lesions, a cryoprobe allows traction without sur ace
bleeding. Dissection around the optic nerve is particularly
hazardous because o delicate pial vessels that penetrate its
sur ace and the close approximation o the posterior ciliary
nerves.
SUGGESTED FURTHER READING
Anterior Orbitotomy
Priel A, Oh S-R, Kikkawa DO, Korn BS. Surgical approaches to the orbit
and optic nerve. In: Black EH, Nesi FA, Calvano CJ, et al., Smith and
Nesi’s Ophthalmic Plastic and Reconstructive Surgery. New York:
Springer; 2012:793–810.
Leone CR. Surgical approaches to the orbit. Ophthalmology. 1979;86:
930–941.
Rootman J. Diseases of the Orbit: A Multidisciplinary Approach. London,
UK: JB Lippincott; 1988:33–50.
Medial Orbitotomy
Cheng JW, Wei RL, Cai JP, Li Y. ransconjunctival orbitotomy or orbital
cavernous hemangiomas. Can J Ophthalmol. 2008;43:234–238.
Krohel GB. Orbital surgery. In: Smith BC, Delia Rocca RC, Nesi FA, Lis-
man RD, eds. Ophthalmic Plastic and Reconstructive Surgery. St.
Louis, MO: Mosby-Year Book; 1987.
McCord CD. Oculoplastic Surgery. New York: Raven Press; 1981.
Edgin WA, Morgan-Marshall A, Fitzsimmons D. ranscaruncular
approach to medial orbital wall ractures. J Oral Maxillofac Surg
2007;65:2345–2349.
Lateral Orbitotomy
Berke RN. A modif ed Kronlein operation. Arch Ophthalmol. 1954;51:
609–632.
Halli RC, Mishra S, Kini YK, et al. Modif ed lateral orbitotomy approach:
a novel technique in the management o lacrimal gland tumors.
J Craniofac Surg. 2011;22:1035–1038.
Harris GJ, Logani SC. Eyelid crease incision or lateral orbitotomy.
Ophthal Plast Reconstr Surg. 1999;15:9–16.
Jones BR. Surgical approaches to the orbit. Trans Ophthalmol Soc UK.
1970;90:269–281.
Kennerdell JS, Maroon JC. Microsurgical approaches to intraorbital
tumors: technique and instrumentation. Arch Ophthalmol. 1976;94:
1333–1336.
Kim JW, Yates BS, Goldberg RA. otal lateral orbitotomy. Orbit.
2009;28:320–327.
Leone CR. Surgical approaches to the orbit. Ophthalmology. 1979;86:
930–941.
Mariniello G, Maiuri F, de Divitiis E, et al. Lateral orbitotomy or removal
o sphenoid wing meningiomas invading the orbit. Neurosurgery.
2010;66:287–292.
McCord CD. A combined lateral and medial orbitotomy or exposure o
the optic nerve and orbital apex. Ophthal Surg. 1978;9:58–66.
McNab AA, Wright JE. Lateral orbitotomy—a review. Aust N Z J Ophthal-
mol. 1990;18:281–286.
Nemet A, Martin P. T e lateral triangle ap—new approach or lateral
orbitotomy. Orbit. 2007;26:89–95.
Rootman J, Stewart B, Goldberg RA. Orbital Surgery. A Conceptual
Approach. Philadelphia, PA: Lippincott-Raven; 1995:151–392.
Wright JE. Orbital surgery. In: Silver B, ed. Ophthalmic Plastic Surgery.
3rd ed. San Francisco, CA: American Academy o Ophthalmology;
1977.
Wright JE. Surgical exploration o the orbit. Trans Ophthalmol Soc UK.
1979;99:238–240.
Yuen HK, Chong YH, Chan SK, et al. Modif ed lateral orbitotomy or
intact removal o orbital dumbbell dermoid cyst. Ophthal Plast Recon-
str Surg. 2004;20:327–329.
271
SEC ION B ▼ Orbitotomy Procedures

272
83
separate the fat lobules with narrow malleable retractors and
a Freer periosteal elevator, taking care not to injure vascular
structures. In the upper eyelid, the levator muscle lies on the
inferior side of the wound. In the lower eyelid, the inferior
oblique and inferior rectus muscles lie at the upper side of the
wound.
FIG. 83.6. Perform a biopsy of the lesion or carefully
dissect around its surface to separate adherent tissues.
Meticulously cauterize any bleeding points with bipolar
electrode forceps. ake care not to put excessive traction on
the orbital fat.
FIG. 83.7. Do not repair the orbital septum. If a lower eyelid
subciliary incision was used, reform the eyelid crease by xing
the orbicularis muscle to the capsulopalpebral fascia with sev-
eral interrupted 7-0 chromic stitches about 4 to 5 mm below
the lid margin.
FIG. 83.8. Close the cutaneous wound with a running suture
of 6-0 fast-absorbing plain gut stitches. In the upper eyelid,
reform the lid crease by passing every second or third bite of
the skin suture through the levator aponeurosis.
FIG. 83.1. Mark an incision line in the upper eyelid crease
for access to the superior orbit or 2 mm below the lower
eyelid lash line for access to the inferior orbit. Place the
incision line temporally, nasally, or across the eyelid width,
depending on the size of the lesion.
FIG. 83.2. With a scalpel blade, cut the skin along the
marked line. ent up the skin edges with forceps and cut
through the orbicularis muscle with scissors to enter the
postorbicular fascial plane. Identify the orbital septum as the
glistening white membrane with yellowish fat visible behind it.
FIG. 83.3. Dissect along the orbital septum toward the
orbital rim, freeing attachments to the orbicularis muscle.
FIG. 83.4. With a scalpel or scissors, make a horizontal
cut through the orbital septum over the lesion to enter
the extraconal orbital space. T e lesion may be visible or if
somewhat more posterior, orbital fat will prolapse through the
septal defect.
FIG. 83.5. If the lesion is not immediately visible, carefully
palpate through the wound to locate the structure. Gently
INDICATIONS: Access to the anterior extraconal orbital space or biopsy or excision o small lesions.
Transcutaneous, Transseptal Anterior
Orbitotomy
POSTOPERATIVE CARE: Place a f rm dressing over the
wound or 12 to 24 hours. Apply antibiotic ointment to the
suture line three to our times daily or 1 week.
POTENTIAL COMPLICATIONS:
Lower eyelid ectropion—T is is caused by injury to the
capsulopalpebral ascia with loss o tarsal stability. It is
more common in older patients who have preexisting
eyelid laxity.
Lower eyelid epiblepharon—T is may result rom ailure
to re orm the lid crease and ailure to f x the preseptal
orbicularis muscle to the eyelid retractors. I noted post-
operatively, a secondary crease ormation is curative.
Diplopia—Injury to the in erior oblique muscle may ol-
low in erior anterior orbital dissection. In the superior
medial orbit, the superior oblique trochlea is easily
injured by overly aggressive dissection.
Upper eyelid ptosis—Lesions in the superior anterior
orbit may be adherent to the levator aponeurosis or
muscle. ransient ptosis ollowing surgery is quite com-
mon and usually resolves a ter several weeks. Perma-
nent ptosis may result rom injury to the aponeurosis or
to Whitnall’s ligament.
Lacrimal gland injury—T e lacrimal gland lies in the ante-
rior–superior orbit just behind the septum. It may be
displaced orward by mass lesions. Injury to the gland usu-
ally does not cause problems, but damage to the lacrimal
secretory ducts may result in epiphora or a retention cyst.
Lagophthalmos—Attempted closure o the orbital sep-
tum or postoperative scarring and shortening may cause
lagophthalmos on attempted lid closure. T is may be
repaired secondarily by lysis o scar bands or opening o
the septum and placing the lid on a Frost traction suture
or 4 to 5 days.

273
CHAP ER 83 ▼ ranscutaneous, ransseptal Anterior Orbitotomy
FIG. 83.1
FIG. 83.2
FIG. 83.3
FIG. 83.4
FIG. 83.5
FIG. 83.6
FIG. 83.7
FIG. 83.8

274
84
FIG. 84.5. If access to the extraconal space is desired,
make a small cut in the periorbita with a scalpel blade
while avoiding the rectus muscles and continue the cut
posteriorly with scissors. Take care to cut only periorbita to
avoid injuring deeper orbital structures.
FIG. 84.6. Retract orbital fat and the levator muscle with
narrow malleable retractors for visualization. Following
biopsy or excision of the lesion, use gentle bipolar cautery to
attain complete hemostasis.
FIG. 84.7. Close the periorbita over the orbital rim with
interrupted 4-0 Vicryl sutures.
FIG. 84.8. Close the orbicularis muscle with several
interrupted 6-0 chromic sutures and the skin with a
running stitch of 6-0 fast-absorbing plain gut.
FIG. 84.1. Mark an incision line 2 mm below the lower
eyelid lash line for access to the orbital oor and the
inferior orbit. For access to the superior orbit or orbital roof,
mark the incision line along the lower edge of the brow or
within the upper eyelid crease.
FIG. 84.2. With a scalpel blade, cut the skin along the
marked line. Tent up the skin edges with forceps and
cut through orbicularis muscle with scissors to enter the
postorbicular fascial plane.
FIG. 84.3. Dissect in the postorbicular fascial plane along
the anterior surface of the orbital septum to the orbital
rim. With a scalpel blade, make a cut in the periosteum 2 mm
anterior and parallel to the orbital rim edge, along the entire
width of the incision.
FIG. 84.4. Dissect the periosteum over the orbital rim with
a Freer periosteal elevator. Continue elevating the periosteum
from the orbital bones until the site of pathologic process is
visible. In the medial superior orbit take care to avoid injuring
the trochlea while separating it and periorbita from the frontal
bone.
INDICATIONS: Access to the extraperiosteal orbital space or biopsy or excision o lesions adjacent to the periosteum
and orbital bones, or drainage o subperiosteal hematomas or subperiosteal abscesses, or or repair o orbital wall
ractures.
Transcutaneous, Transperiosteal Anterior
Orbitotomy
POSTOPERATIVE CARE: Apply a moderately f rm dress-
ing to the eye and orbit or 24 hours and intermittent iced
compresses or another 24 hours. Avoid excessive pres-
sure. Place antibiotic ointment on the suture line three
to our times daily or 1 week. I a paranasal sinus was
entered during surgery, appropriate systemic antibiotics
are administered or 7 days.
POTENTIAL COMPLICATIONS:
Postoperative orbital hemorrhage—T is rare complica-
tion can be avoided by meticulous attention to hemo-
stasis during surgery. An expanding hematoma is
heralded by progressive proptosis, deep orbital pain,
and decreasing vision. A C scan and an echogram
help localize the blood pocket. reatment may require
immediate surgical decompression, either through the
original surgical wound or through an alternate, more
direct route to the hematoma.
Extraocular muscle paresis—T is is caused by excessive
manipulation or traction on the muscle during surgery.
It is usually temporary and unction recovers a ter sev-
eral days to weeks. When permanent, later strabismus
surgery may be needed to correct residual diplopia.
Eyelid edema and ptosis—T is is seen requently, particu-
larly with superior orbital surgery because upper eyelid
unction is more vulnerable to uid accumulation and
in ammatory processes. Iced compresses are applied
or 48 hours to help minimize edema. T e ptosis usually
resolves a ter several days to weeks.

275
CHAPTER 84 ▼ Transcutaneous, Transperiosteal Anterior Orbitotomy
FIG. 84.1
FIG. 84.2
FIG. 84.3
FIG. 84.4
FIG. 84.5
FIG. 84.6
FIG. 84.7
FIG. 84.8

276
85
FIG. 85.5. Place six half-length 4-0 silk sutures around the
wound edges and clamp the sutures to the drapes for better
exposure. Separate periosteum over the lateral orbital rim and
into the temporalis fossa. With a Freer elevator, push a gauze
sponge between periosteum and the bone of the temporalis
fossa to facilitate clean dissection of the muscle. Allow several
minutes for hemostasis.
FIG. 85.6. At the level of the frontozygomatic suture line,
place wide malleable retractors on either side of the bony
orbital rim to protect the soft tissues. Cut through the bone
with an oscillating saw, angling the cut slightly inferiorly and
parallel to the orbital roof. Make the cut 1 cm deep and extend
it to the thin bone along the sphenozygomatic suture.
FIG. 85.7. Move the malleable retractors inferiorly to the
upper surface of the zygomatic arch. Make a cut 1.5 cm deep
through the orbital rim just above the arch. Angle the cut
slightly upward.
FIG. 85.8. Drill a hole 1 mm in diameter near the rim on
either side of each cut. Use a malleable retractor to protect
periorbita.
FIG. 85.1. Mark an S-shaped incision line from the inferior
lateral brow, along the lateral orbital rim, and inferolater-
ally along a laugh line at the upper border of the zygomatic
arch. Alternatively, the incision line is placed in the upper eye-
lid crease and extended laterally 1 to 2 cm beyond the orbital
rim (see Fig. 89.1 to 89.5, p. 352-353).
FIG. 85.2. With a scalpel blade, cut the skin along the
marked line. With scissors, complete the cut through
orbicularis muscle and deep fascia to the periosteum of the
orbital rim.
FIG. 85.3. Incise the periosteum 2 mm outside the bony rim
around the lateral orbit from the superior to the inferior
corners of the wound. Separate periosteum from bone with a
periosteal elevator.
FIG. 85.4. Elevate periorbita from the lateral orbital wall
for a distance of 3 to 4 cm. If bleeding is encountered from
vessels penetrating the lateral wall, insert a small sponge and
apply gentle pressure for several minutes.
INDICATIONS: Access to the deeper intraconal orbital space, lacrimal gland, and optic nerve.
Lateral Orbitotomy

277
CHAPTER 85 ▼ Lateral Orbitotomy
FIG. 85.1
FIG. 85.2
FIG. 85.3
FIG. 85.4
FIG. 85.5
FIG. 85.6
FIG. 85.7
FIG. 85.8

FIG. 85.9. With a sturdy rongeur, grasp the bony rim and fracture the bone
outward. Cut any adherent tissue from the bone with scissors. Wrap the bone in
saline-soaked gauze and place it aside.
FIG. 85.10. Remove the thin bone of the greater sphenoid wing from the lateral
orbital wall with rongeurs. Normally, removal is not extended beyond the level of
cancellous bone. If necessary for greater apical exposure, continue removing bone
with extreme caution to avoid injury to dura that is overlying the temporal lobe.
Bleeding from the bone is controlled with surgical wax.
FIG. 85.11. Identify the lateral rectus muscle by grasping its insertion at the
globe and rotating the eye medially. With scissors, open the periorbita by making a
vertical cut just inferior or superior to the muscle.
FIG. 85.12. Dissect through the orbital fat by bluntly separating the interlobular
capsules with a Freer elevator or dissectors. Magni cation with loupes or an
operating microscope is important. Gentle palpation helps identify the lesion or optic
nerve.
FIG. 85.13. Carefully dissect around the lesion, staying close to its capsule,
and bluntly separate it from adjacent orbital tissues. If more rm adhesions are
present, cut them with scissors after bluntly separating them into thin bers to
identify any structures that might be running through them. Traction on the lesion
may be achieved with application of a retinal cryoprobe to its surface.
FIG. 85.14. After biopsy or removal of the lesion, close periorbita with inter-
rupted 6-0 Vicryl sutures. Leave several gaps in the closure for drainage. If adequate
hemostasis cannot be assured, place a low-vacuum drain into the temporalis fossa
and out a cutaneous puncture wound adjacent to the incision inferiorly.
FIG. 85.15. Replace the lateral orbital rim and secure it with 4-0 prolene or nylon
sutures passed through the predrilled holes. If future magnetic resonance imaging
studies will not be needed, 28-gauge stainless steel wire may be used.
FIG. 85.16. Close periosteum over the orbital rim with interrupted 4-0 Vicryl
stitches. Repair the orbicularis muscle with 6-0 Vicryl and the skin with 6-0 fast-
absorbing plain gut or prolene sutures.
278 SECTION B ▲ Orbitotomy Procedures

279
CHAPTER 85 ▼ Lateral Orbitotomy
FIG. 85.9
FIG. 85.10
FIG. 85.11
FIG. 85.12
FIG. 85.13
FIG. 85.14
FIG. 85.15
FIG. 85.16

280 SECTION B ▲ Orbitotomy Procedures
POSTOPERATIVE CARE: Place a f rm but not tight dress-
ing over the globe or 24 hours. Intravenous steroids may
be administered or 24 hours i there was any manipu-
lation around the optic nerve. I a drain is placed, apply
minimal continuous suction. Remove the drain a ter 24
hours. Apply antibiotic ointment to the suture line three
to our times daily or 1 week. Remove any nonabsorbing
skin sutures a ter 5 to 7 days.
POTENTIAL COMPLICATIONS:
Lateral rectus muscle paresis—T is is caused by exces-
sive traction on the muscle during lateral orbital expo-
sure. It is best not to displace the muscle with a suture
loop but rather to use a broad retractor. Muscle weak-
ness is typically temporary. Any permanent def cit can
be repaired with strabismus surgery a ter 4 to 6 months.
Upper eyelid ptosis—Some edema and ptosis are inevita-
ble ollowing deep orbital surgery. T ese usually resolve
a ter several days to weeks. It is unusual or ptosis to
be permanent unless injury to the levator has occurred
during superior orbital surgery. Permanent ptosis can
be corrected by any appropriate ptosis repair a ter 4 to
6 months.
Orbital hemorrhage—Meticulous hemostasis during sur-
gery is mandatory, and excessive traction on orbital at
and other structures must be avoided. A drain in the
temporalis ossa should be placed i there is persistent
oozing. I there is signif cant bleeding postoperatively,
the wound is opened and the bleeding point controlled
directly.
Pupillary paralysis—Deep orbital dissection near the optic
nerve may cause injury to the ciliary nerves. Extreme
care is used and magnif cation is essential. Patients with
postoperative pupillary paralysis will requently recover,
but recovery may take many months to a year or more.
Blindness—T is un ortunate complication is exception-
ally rare and is associated with deep dissection o lesions
in contact with the optic nerve, or exploration into the
orbital apex. It may result rom compression o the
nerve with retractors or injury to the small vessels along
the pia. Any postoperative bleeding must be decom-
pressed immediately.

281
SECTIONC
S
urgery directed at the bony orbital walls is indicated or
a variety o conditions that requently involve traumatic
ractures. Clinical signs that suggest bony disruption include
orbital edema, emphysema and hemorrhage, enophthalmos,
motility disturbance, and in raorbital anesthesia. Orbital rac-
tures may be simple or complex, depending on the source o
injury, the orce o impact, and the direction o the compres-
sive vectors applied. Fractures are requently associated with
so t tissue injury, particularly o the globe. A thorough ocular
examination is essential be ore any surgical manipulation.
Clinical evaluation includes radiographic studies to
conf rm and delineate the racture boundaries and to rule
out the presence o retained oreign bodies. T e plain
orbital series, including the Waters and Caldwell rontal
projections and both lateral views, can provide some use-
ul in ormation where computed tomography (C ) is not
available. Multiplanar C with bone windows allows much
better evaluation o so t tissue relationships to the racture
site. Magnetic resonance imaging (MRI) o ers little here
because the proton density o bone is too low to yield a
signif cant signal. However, i signif cant so t tissue injury
is suspected, especially intracranial, an MRI is a valuable
adjunct study.
Simple orbital rim ractures usually result in cosmetic
de ormity only, without causing visual threat unless the
bone ragment is displaced into the orbit. T ey are best
repaired primarily, typically through cutaneous incisions
with miniplate f xation. Rim ractures requently involve
adjacent bones such as the maxillary or rontal sinuses, or
the zygomatic arch, so that cooperation with an otolaryn-
gology colleague may be appropriate.
Blow-out ractures o the orbital oor result rom
hydraulic compression o orbital contents. T ese rac-
tures occur most requently just medial to the in raorbital
canal where the bone is thinnest. Anesthesia o the cheek
and upper gum suggests injury to the in raorbital nerve.
Spontaneous recovery o sensation is usual over several
months. Vertical diplopia and a positive orced duction test
may result rom entrapment o the in erior rectus muscle
or, more likely, its ascial attachments in the racture site.
T ese complications are also seen with contusion injuries
to the muscle. In the latter case, motility unction typically
improves over several weeks, while the hematoma resolves.
Failure to improve over several weeks suggests mechanical
restriction, which requires surgical exploration.
Early enophthalmos is caused by an inward displace-
ment o the orbital tissues rom an increase in volume o
the orbital cavity. It may be associated with downward
Surgery on the Orbital Walls
displacement o the globe when the racture site primarily
involves the oor. Enophthalmos and hypo-ophthalmos
alone usually do not cause diplopia but may be o cosmetic
consequence. When these conditions are signif cant, early
surgical intervention is indicated. Associated orbital hem-
orrhage may initially mask enophthalmos, which becomes
mani est only a ter several weeks when the hematoma
resolves. Late enophthalmos, which may occur a ter several
years or even a ter several decades, results rom progres-
sive at atrophy. It is repaired with volume augmentation o
the orbital contents.
Medial wall ractures are o ten associated with those o
the oor and more commonly result in orbital emphysema.
Medial rectus muscle entrapment is uncommon but when
present may produce a horizontal diplopia. Enophthalmos
may be signif cant even with pure ethmoid ractures. Injury
to the lacrimal drainage system can be seen with more
anterior medial rim or nasomaxillary ractures across the
nasolacrimal canal. I injury is suspected, lacrimal system
intubation is per ormed with silicone stents. Some cases
require later dacryocystorhinostomy.
Orbital decompression is indicated to expand the bony
walls when increased orbital so t tissue volume is pres-
ent. T e procedure is used most requently or Graves’
orbitopathy associated with optic nerve compression or
severe proptosis and lagophthalmos. However, this opera-
tion is also commonly per ormed or aesthetic reduction
o disf guring proptosis. T e operation involves intentional
out racturing o selected orbital walls, usually into adjacent
paranasal sinuses. T e transorbital route via anterior–in e-
rior orbitotomy is used or removal o the orbital oor.
Medially, the transcaruncular approach provides excellent
access or an ethmoidectomy. T is begins just posterior to
the origin o the in erior oblique muscle and the posterior
lacrimal crest and extends backward to the posterior eth-
moid and sphenoid sinuses. Extirpation o the ethmoid air
cells should not extend higher than the ethmoidal oram-
ina, which serve as an anatomic guide to the lowest approx-
imate level o the cribri orm plate.
In decompression or cosmetic reduction o propto-
sis only, it is su cient to remove bone rom the anterior
two-thirds o the orbit and thus avoid the potential com-
plications o more posterior apical surgery. However, or
compressive optic neuropathy, expansion closer to the apex
is requently needed. Here medial and/or lateral wall sur-
gery should be carried back as close to the apex as possible.
Although the medial wall can be decompressed through
a lower eyelid incision, in most cases, a transcaruncular

incision gives much better medial wall exposure and a
more predictable apical exenteration o the posterior eth-
moid cells.
Some authors have advocated superior wall removal to
augment the e ect o decompression. T e additional ben-
ef t is minimal, however, and in general does not justi y
the added risk. Removal or thinning o the lateral wall may
be use ul and can add several millimeters to decompres-
sion o the globe. In addition, lateral wall decompression
may allow greater exposure o the medial wall and more
complete ethmoid exenteration in very congested orbits.
Removal o both the lateral and medial walls, but not the
oor, is currently pre erred by many surgeons as a balanced
decompression to minimize vertical globe displacement.
In the procedures below, we describe a standard combined
medial and oor decompression, as well as individual
decompressions o the medial, lateral, and in erior walls
that can be combined in any combination.
In all operations or orbital decompression, periorbita
must be opened widely to allow at lobules to prolapse into
the bony de ects. Without this step, surgery is likely to be
ine ective. In Graves’ orbitopathy, f brosis o the interlobu-
lar ascial septa may prevent prolapse. Care ul blunt dis-
section to separate these is necessary, but in some cases,
the e ect o decompression is still disappointing.
Most surgery on the orbital walls is per ormed under
general anesthesia. T e nasal cavity is packed with cotto-
noid strips soaked in 4% cocaine or substitute and 0.25%
phenylephrine or vasoconstriction, and to aid sinus drain-
age. Because o the small but def nite risk o visual loss,
unilateral surgery is pre erred at any one time. I there are
no visual complications, the second orbit can be decom-
pressed several days or weeks later.
One additional procedure along the orbital walls is vol-
ume augmentation o the orbital contents or reduction o
the bony contour. ypically, this is indicated or anophthal-
mic enophthalmos and superior sulcus de ormity caused by
progressive at atrophy. Although the ocular prosthesis can
be modif ed within limits, it is unwise to make it too thick
and heavy because doing so only accelerates orbital and eye-
lid laxity. Volume augmentation can also be done or enoph-
thalmos with a seeing eye. Reduction o orbital bony volume
is commonly achieved with subperiosteal implantation o
alloplastic materials such as a pre ormed acrylic implant or
layered sheets o polyethylene. A transperiosteal approach
to the oor or other wall is utilized, and the implant is f xed
to the orbital rim to prevent orward migration.
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SECTION C ▼ Surgery on the Orbital Walls 283

284
86
a distance o 3.5 to 4 cm posterior to the rim. Use malleable
retractors to hold periorbita away rom the bones. Periodically
check the pupil to ensure it is not dilated rom iatrogenic optic
nerve compression.
FIG. 86.6. Locate the thinnest part of the oor. It is usually
medial to the in raorbital canal and will appear translucent.
Punch a small hole through this area with a hemostat.
FIG. 86.7. With rongeurs, take out the orbital oor medial
to the infraorbital canal. Remove bone back to the posterior
wall o the maxillary sinus, medially to the thick bone at the
maxillary strut, and laterally to the edge o the in raorbital
canal.
FIG. 86.8. With a Freer elevator, gently fracture the roof
of the infraorbital canal upward. Take care not to injur the
in raorbital neurovascular bundle. Remove the ractured bone
with orceps. Fracture the oor o the canal downward in
similar ashion. Alternatively, the bony in raorbital canal and
groove can be le t intact to support the maxillary nerve and
globe.
FIG. 86.1. Pack the inferior and middle nasal meatus with
cottonoid strips soaked in 4% cocaine or substitute and
0.25% phenylephrine for vascular constriction.
FIG. 86.2. Mark a subciliary incision 2 mm below the
lower eyelid lash line from just inferior to the punctum
to the lateral canthus. Incise the skin with a scalpel blade.
Alternatively, a transconjunctival incision may be used, placed
just below the tarsus (see Orbital Decompression, In erior Wall,
Transconjunctival, Fig. 88.1, pp. 350-351).
FIG. 86.3. Tent up the skin edges with forceps and
transect the orbicularis muscle with scissors to enter the
postorbicular fascial plane.
FIG. 86.4. Dissect inferiorly in the postorbicular fascial
plane, anterior to the orbital septum, to the inferior orbital
rim.
FIG. 86.5. Incise periosteum 2 mm outside the orbital rim
with a scalpel and dissect it over the bony rim with a Freer
elevator. Continue elevating periorbita of the orbital oor or
INDICATIONS: Expansion o the bony orbital contour, primarily in thyroid orbitopathy or cosmetic reduction o
proptosis or optic nerve compression, when extraocular muscles are enlarged.
Orbital Decompression, Inferior
and Medial Walls

285
CHAPTER 86 ▼ Orbital Decompression, In erior and Medial Walls
FIG. 86.1
FIG. 86.2
FIG. 86.3
FIG. 86.4
FIG. 86.5
FIG. 86.6
FIG. 86.7
FIG. 86.8

SECTION C ▲ Surgery on the Orbital Walls
286
FIG. 86.9. With rongeurs, remove the remainder of the orbital oor between the
infraorbital canal and the lateral wall of the maxillary sinus.
FIG. 86.10. Move the malleable retractors medially and elevate periorbita from
the medial orbital wall. Do not disturb periorbita anterior to the posterior lacrimal
crest to avoid injury to the lacrimal sac and in erior oblique muscle. Do not extend
dissection o periorbita more than 5 mm superior to the medial canthal ligament
because this carries risk o injury to the ethmoidal arteries.
FIG. 86.11. Punch through the lamina papyracea with a hemostat and exenterate
the anterior and posterior ethmoid cells with ethmoidectomy or pituitary
forceps. Do not extend the dissection through the medial wall o the ethmoid
labyrinth. Take care not to extend the dissection more than 5 cm posterior to
the medial orbital rim unless decompression into the sphenoid sinus is desired.
Alternatively, the medial wall can be per ormed through a transcaruncular incision
(see chapter 87, p. 348-349).
FIG. 86.12. Pack the exenterated ethmoid sinus with cottonoid strips soaked
in local anesthetic with epinephrine for 10 minutes or until bleeding has been
controlled. Remove the packs.
FIG. 86.13. Place two narrow malleable retractors to expose the inferior perior-
bita. With scissors, make several longitudinal cuts in periorbita, medial and lateral to
the in erior rectus muscle. Extend the cuts posteriorly toward the orbital apex. Orbital
at should prolapse through the wound. I necessary, gently tease apart the interlobu-
lar septa using scissors in a spreading maneuver but do not put excessive traction on
the at.
FIG. 86.14. Move the malleable retractors to the medial wall and open periorbita
just below the medial rectus muscle. Remove the retractors and massage the globe
with gentle, intermittent pressure to urther prolapse the orbital at through the
incisions in periorbita.
FIG. 86.15. Approximate periorbita to periosteum over the inferior orbital rim
with 4-0 Vicryl sutures.
FIG. 86.16. Reform the lower eyelid crease if necessary by xing orbicularis
muscle to the orbital septum with several 7-0 chromic stitches 4 mm below the
incision line. Close the skin with interrupted stitches o 6-0 ast-absorbing plain gut.

287
CHAPTER 86 ▼ Orbital Decompression, In erior and Medial Walls
FIG. 86.9
FIG. 86.10
FIG. 86.11
FIG. 86.12
FIG. 86.13
FIG. 86.14
FIG. 86.15
FIG. 86.16

SECTION C ▲ Surgery on the Orbital Walls
288
POSTOPERATIVE CARE: A drain is not necessary i
adequate hemostasis has been assured. A moderately
f rm dressing is applied or 24 hours. Antibiotic ointment
is placed on the suture line three to our times daily or
7 days. Systemic antibiotics and nasal decongestants are
prescribed or 1 week.
POTENTIAL COMPLICATIONS:
Inadequate decompression—Opening o the periorbita
to allow prolapse o orbital at signif cantly enhances the
decompressive e ect. With longstanding orbital in am-
mation, excessive f brosis may prevent prolapse o at
resulting in poor decompression. Blunt separation o at
with scissors during surgery may help.
Sinusitis—Postoperative sinusitis is rare and is due to
drainage obstruction rom blood clots and mucosal
debris. It is e ectively treated with systemic antibiotics.
Nasal bleeding—T is results rom inadvertent entrance
into the nose and laceration o nasal mucosa during
ethmoidectomy. Chemical cautery may be help ul, but
control o bleeding may require nasal packing or sev-
eral days.
Diplopia—Bilateral orbital decompression in patients
who do not have preexisting motility disturbance rarely
results in diplopia. When it is seen, it is usually tran-
sient. Persistent strabismus a ter 4 to 6 months requires
surgery or correction.
In raorbital nerve anesthesia—T is results rom trauma
to the in raorbital nerve during removal o the bony
in raorbital canal. It is usually transient with unction
recovering a ter several weeks to months.
Visual loss—T is uncommon, dreaded complication may
result rom excessive compression on the optic nerve and
its vascular supply when retractors are placed deep into
the apex. Care should also be taken not to apply continu-
ous pressure on the globe. T e pupil should be monitored
throughout the case. Hemostasis is mandatory.
Cerebrospinal f uid leak—T e position o the cribri orm
plate is quite variable and may lie as much as 1.5 cm
below the roo o the ethmoid sinus. Small leaks can be
managed by packing at against the dural tear, and reso-
lution may be hastened with the use o a lumbar drain
or several days. Appropriate antibiotics are adminis-
tered or 10 days.

(Trang không có chữ)

290
87
Keep all dissection in erior to this level to avoid injury to the
cribri orm plate.
FIG. 87.6. With the Freer elevator, fracture the lamina
papyracea outward. T en using a Kerrison rongeur, remove
the lamina and air cells o the ethmoid sinus. Alternatively,
we o ten place a moistened cottonoid sponge against the
lamina, and using the Freer, depress the thin bone into the
sinus.
FIG. 87.7. Once hemostasis has been achieved, open medial
periorbita with slits above and below the medial rectus
muscle. With a blunt scissors, gently separate the interlobular
ascial membranes to allow the orbital at to prolapse into the
exenterated sinus.
FIG. 87.8. Reapproximate the caruncle with an interrupted
suture of 6 0 fast absorbing plain gut, and repair the
conjunctival incision above and below with a running or
several interrupted sutures of the same material.
FIG. 87.1. Place a speculum beneath the eyelids to expose
the medial canthus. Grasp the caruncle with a toothed
orceps and transect it along its mid-vertical line.
FIG. 87.2. With a Westcott scissors, extend the wound
several millimeters superiorly and inferiorly. ake care to
remain in the ornix so as not to injure the canaliculi.
FIG. 87.3. With a Steven scissors, spread the wound and
continue the dissection behind Horner’s muscle to the
posterior lacrimal crest.
FIG. 87.4. With a narrow malleable retractor, pull the orbital
tissues laterally to expose the medial orbital wall for a dis
tance of about 2 cm behind the posterior lacrimal crest.
FIG. 87.5. Using a scalpel or periosteal elevator, make a
2 cm cut just behind the posterior lacrimal crest to expose
the lamina papyracea. Elevate periosteum of the medial wall
and care ully identi y the anterior ethmoid oramen and artery.
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
Orbital Decompression, Transcaruncular
Medial Wall
POSTOPERATIVE CARE AND POTENTIAL COMPLI-
CATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.

291
CHAP ER 87 ▼ Orbital Decompression, ranscaruncular Medial Wall
FIG. 87.1
FIG. 87.2
FIG. 87.3
FIG. 87.4
FIG. 87.5
FIG. 87.6
FIG. 87.7
FIG. 87.8

292
88
canal. If possible, try not to tear the sinus mucosa to avoid
excessive bleeding.
FIG. 88.6. Expand the opening by removing additional bone
with a Kerrison rongeur. Extend this opening from the thicker
bone at the maxillary strut medially, to the infraorbital canal in
the central orbit. Take care not to injure the infraorbital nerve
or vessels. Similarly, make an opening through the oor lateral
to the infraorbital canal and remove bone to the lateral wall of
the maxillary sinus.
FIG. 88.7. Open the inferior periorbita with scissors by
making several slits medial and lateral to the inferior rectus
muscle to allow fat prolapse. Apply gentle pressure on the
globe with the eyelids closed to help further prolapse the fat
into the sinus. A spreading maneuver with scissors can help
tear the membranes between fat lobules.
FIG. 88.8. Reapproximate the periosteum along the orbital
rim with several interrupted sutures of 4 0 Vicryl. Close the
conjunctival incision with a running stitch of 6-0 fast-absorbing
plain gut.
FIG. 88.1. Place a 4 0 silk suture through the lower eyelid
margin and evert the lid over a Desmarres retractor. Make a
horizontal incision through the conjunctiva and capsulopalpebral
fascia with a scalpel blade 1 to 2 mm below the inferior tarsus.
FIG. 88.2. Using Westcott scissors, carry the dissection inferi
orly between the orbital septum and the orbicularis muscle.
FIG. 88.3. Expose the inferior orbital rim from medial to
lateral to visualize the arcus marginalis. If extraconal fat is to
be removed, it can be dissected from the orbital oor and the
intermuscular septum and removed en bloc with cautery and
cutting.
FIG. 88.4. Using a scalpel blade, incise periosteum along
the orbital rim just outside the arcus. With a Freer dissector,
elevate periorbita from the orbital oor back for a distance
of about 3 to 4 cm. A small anastomotic vessel will often be
encountered extending from the inferior periorbita to the
infraorbital bundle. Cauterize this and cut it.
FIG. 88.5. Break a small hole through the maxillary bone
with a small hemostat or elevator medial to the infraorbital
INDICATIONS: Expansion of the bony orbital contour, primarily in thyroid orbitopathy for cosmetic reduction of
proptosis or optic nerve compression, when extraocular muscles are enlarged.
Orbital Decompression, Transconjunctival
Inferior Wall
POSTOPERATIVE CARE AND POTENTIAL COMPLI-
CATIONS: See care and complications as for Orbital
Decompression, Inferior and Medial Walls, p. 346.