"There are many indications for orbital surgery, but the goals are always the same: to gain access to a specific location in the orbit and to do so safely, and to achieve optimal cosmetic outcome," said Dr. Gausas, director, Oculofacial and Orbital Surgery, Scheie Eye Institute, University of Pennsylvania, Philadelphia. "This always has to be balanced with the risks that are specific to orbital surgery, which include optic nerve damage, damage to the muscles, and possible leakage of cerebrospinal fluid. These goals can be best achieved by selection of the appropriate surgical approach."
She said she believes that, to select the surgery best suited for a patient, it is best to understand the history of orbital surgery. Kronlein pioneered the lateral bone flap in 1888 for dermoid tumors of the orbit; this technique later was modified by Berke for improved exposure and cosmesis and then was modified further by Stallard and Wright, she explained.
"Each of these lateral approaches with a bone flap provides successful access to tumors in the retrobulbar space. As with all surgery, orbital surgery has continued to evolve and follow the trend of smaller incisions, which provides decreased time in the operating room and morbidity, improved healing time, and improved cosmesis. Adequate exposure and safety, however, must be maintained in the orbit," Dr. Gausas said.
Orbital surgery has evolved further by moving the incision inward. The Berke approach, she pointed out, can be modified to a lateral canthotomy and cantholysis without a bone flap, which provides excellent access to tumors that are deep in the orbital lateral space. Another way to hide incisions further is by use of the swinging eyelid flap approach, with extension of the incision transconjunctivally; this approach allows access to large lesions in the anterior orbital space. Another method, the Stallard-Wright approach, can be altered by bringing the incision inward into the lid crease, thus improving cosmesis. This method, with or without a bone flap, is useful for lesions in the lateral orbital space, according to Dr. Gausas.
Another modification described by Pelton and Patel is achieved by bringing the lid crease incision in medially, which provides access to the medial intraconal space or the optic nerve. "This approach involves a blunt dissection in a plane between the medial rectus muscle and the superior oblique tendon. In a patient with a superomedial extraconal lesion causing downward displacement of the globe, the approach provided excellent exposure for removal of the tumor," Dr. Gausas said.
The incision also can be moved farther in past the eyelids to the conjunctiva via a conjunctival incision at the limbus with muscle disinsertion. "This provides excellent access to the retrobulbar intraconal orbital space," she said. Dr. Gausas described a case in which a lesion lateral to the optic nerve was located by disinserting the lateral rectus muscle, which provided excellent exposure and removal of the lesion.
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