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Approach to orbital surgery.

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simplified slide for orbital surgery.

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Approach to orbital surgery.

  2. 2. INTRODUCTION • Requires delicacy of a neurosurgeon, the strength of an orthopaedic surgery, and the 3-dimensional sense of a general surgeon. • Comfort & success are based on surgeon’s knowledge of the relationships among the orbital structures & ability to approach the orbit from different directions & angles.
  3. 3. SURGICAL SPACES 1. Subperiosteal (subperiorbital) surgical space 2. Extraconal surgical space 3. Episcleral (sub-tenon) surgical space 4. Intraconal surgical space (central) 5. Subarachnoid surgical space
  4. 4. INSTRUMENTS Stryker saw with finger twitch, bony rongeurs
  5. 5. INSTRUMENTS Sewall, wright
  6. 6. ORBITOTOMY – SUPERIOR APPROACH 1. Trancutaneous incisions 2. Transconjunctival incision
  7. 7. ORBITOTOMY – SUPERIOR APPROACH • Transcutaneous incisions : an incision through the upper eyelid crease offers good access to the superior orbital rim & periosteum, with a HIDDEN scar. • Cosmetic result is better with an eyelid crease incision >> supraorbital rim. • Eyelid crease incision leds to access to orbital rim by superior dissection in the postorbicularis fascial plane anterior to orbital septum. • After rim exposure, incision is made in arcus marginalis,then periosteum is separated from the frontal bone of the orbital roof.
  8. 8. ORBITOTOMY – SUPERIOR APPROACH • Upper eyelid crease may also be used for entry into the medial intraconal space, which requires exposure of the medial edge of the levator muscle & dissection through the intermuscular septum • Used for exposure & fenestration of the retrobulbar ON, in case of IIH.
  9. 9. ORBITOTOMY – SUPERIOR APPROACH • A coronal flap is used to expose superior orbital lesions. • Useful for transcranial orbitotomies & for extensive lesions of the superior orbit & sinuses which requires bone removal.
  10. 10. ORBITOTOMY – SUPERIOR APPROACH • Transconjunctival approach to reach the SN, episcleral, intraconal, or the extraconal surgical spaces but dissection must be performed medial to levator muscle to prevent ptosis. • Vertical eyelid splitting of upper lid at the junction of the medial & central thirds allows extended exposure to removal of SM intraconal tumors. • Vertical incision of eyelid & levator aponeurosis to expose SM intraconal space. • Less chance postop ptosis & eyelid retraction syndrome.
  11. 11. ORBITOTOMY – INFERIOR APPROACH • Suitable for masses that are visible or palpable in the inferior conjunctival fornix of the lower eyelid, as well as for deeper extraconal orbital masses. • Access by dissecting between the inferior & lateral recti. • Also used for orbital floor # repair or decompression.
  12. 12. ORBITOTOMY – INFERIOR APPROACH • Trancutaneous approach :Minimal scarring by use of an infraciliary blepharoplasty incision in the lower eyelid & dissection beneath the orbicularis muscle to expose orbital septum & inferior orbital rim. • Extended subciliary incision or an in incision in the lower lid crease allows exposure to the rim. • Orbital floor # are reached by the subperiosteal route.
  13. 13. ORBITOTOMY – INFERIOR APPROACH • Transconjunctival incisions has largely replaced transcutaneous route. • Incision made through the inferior conjunctiva & lower eyelid retractors. • Exposure of the floor is optimised when incision is combined with lateral canthotomy & cantholysis. • Incision of the bulbar conjunctiva & tenon capsule allows to episcleral space. • If Inferior Rectus is retracted, intraconal space can be accessed.
  14. 14. ORBITOTOMY – MEDIAL APPROACH • Careful to avoid damaging the medial canthal tendon, lacrimal canaliculi & sac, trochlea, superior oblique tendon & the muscle, inferior oblique muscle, and the sensory nerves & vessels along the medial aspect of superior orbital rim.
  15. 15. ORBITOTOMY – MEDIAL APPROACH • Transcutaneous incision :Tumors within or near the lacrimal sac, the frontal or ethmoidal sinus & the medial rectus can be approached.(Lynch/ Frontoethmoidal incision) ; 9-10 mm medial from medial canthal angle.
  17. 17. ORBITOTOMY – MEDIAL APPROACH • Transconjunctival incision : incision in bulbar conjunctiva, allows entry into extraconal or episcleral surgical space to expose the region of the ant. ON for examination, biopsy, or sheath fenestration. • If the posterior ON or muscle cone needs to be seen, a lateral/medial orbitotomy. • Lateral orbitotomy with removal of the lateral orbital wall allows the globe to be displaced temporally, thus maximising medial access to the deeper orbit.
  19. 19. ORBITOTOMY – MEDIAL APPROACH • Transcaruncular approach : incision through the posterior third of the caruncle or the conjunctiva immediately lateral to the caruncle allows excellent exposure of the medial periosteum • Advantage of better cosmetic result than Lynch incision, but the surgeon must be careful to protect the lacrimal canaliculi & remain posterior to lacrimal apparatus. • Combination of transcaruncular & inferior transconjunctival incision allows exposure of the inferior & medial orbit : medial wall #, medial orbital bone decompression, & for drainage of medial subperiosteal abscesses.
  21. 21. ORBITOTOMY – LATERAL APPROACH • Used when a lesion is located within the lateral intraconal space, behind the equator of the globe, or in the lacrimal gland fossa. • Previously, traditional S-shaped Stallard-Wright skin incision, extending from beneath the eyebrow laterally & curving down along the zygomatic arch, allowed good exposure of the rim but a noticeable scar. • Newer approach, upper eyelid crease incision or a lateral canthotomy : Both allowed exposure of the lateral orbital rim & anterior portion of zygomatic arch • Dissecting through the periorbita & then intermuscular septum, above/below lateral rectus posterior to globe provides access to the retrobulbar space.
  24. 24. ORBITOTOMY – LATERAL APPROACH • If not adequately exposed through a soft-tissue lateral incision, an oscillating saw/ bony rongeurs to remove the bone of the lateral rim. • Good exposure by retraction of the lateral rectus muscle. • Tumours can be prolapsed into the incision by gentle traction on eyelid. • Maintain hemostasis – cryo , Allis, suture (cavernous hemangioma),placing a drain. • Lateral orbital rim is usually replaced & sutured through predrilled tunnels in the rim or rigid fixation with plating systems
  26. 26. ORBITAL DECOMPRESSION • Surgical procedure to improve the volume- to- space discrepancy, occurs primarily in TED. • Goal is to allow the enlarged muscles & orbital fat to expand into periorbital spaces • Relieves pressure on the ON & its blood supply & reduces proptosis. • Historically, removal of the medial orbital wall & much of orbital floor. • Approach currently used is transconjunctival incision combined with a lateral cantholysis • Burring down the medial surface of the lateral wall further causes decompression. • Removal of retrobulbar fat further reduces proptosis.
  29. 29. POST OPERATIVE CARE FOR ORBITAL SURGERY • Elevation of the head • Ice compression • Administration of steroids • Placement of drain (24-36 hrs) • Regular check-up of VA • Avoid patching
  30. 30. SPECIAL SURGICAL TECHNIQUES • Fine needle aspiration biopsy : lymphoid lesions, secondary tumours, suspected metastatic tumors, blind eyes with ON tumors. • Masses or traumatic injuries : frontal craniotomy or Frontotemporal OR Orbitozygomatic approach.
  31. 31. COMPLICATIONS OF ORBITAL SURGERY • Decreased or lost vision : excessive traction on the globe or ON, contusion of the ON, postop infxn, hemorrhage which leads to increased intraorbital pressure & consequent ischaemic injury to the ON. • Severe pain should be evaluated for orbital hemorrhage. • Decreased VA, proptosis, ecchymosis, increased IOP , afferent pupillary defect : Consideration for reopening. • Hypoaesthesia following orbital floor repair, along with downward displacement of globe & postop exacerbation of upper eyelid retraction. • Motility disorder • 3rd CN injury : Superior orbital tumor resection, risk of ciliary ganglion injury. • Other : ptosis, neuroparalytic keratopathy, pupillary changes, VH, detached retina, forehead hypothesia, keratitis sicca, CSF fluid leak, & infection.
  32. 32. REFERENCES 1. AAO 2014-15 section 07 - Orbit, eyelids & lacrimal system. 2. Oculoplastic Surgery - Leatherbarrow_ Brian.