Appropriate orbital surgery depends on a fundamental understanding of ocular, ad nexal, and orbital anatomy combined with a familiarity with

the differential dia gnosis and relative incidence of orbital disease processes. This knowledge, comb ined with radiologic and laboratory information, can allow the patient the least traumatizing method of diagnosis and treatment. Improved instrumentation and anesthesia techniques, higher quality operating mic roscopes and fiberoptic illumination, and more accurate preoperative noninvasive imaging techniques have significantly advanced the armamentarium of the orbital surgeon in the past few decades. ORBITAL SURGICAL TECHNIQUES Orbital surgery in the modern era consists of two basic types of surgical approa ches to the orbit: anterior orbitotomy and lateral orbitotomy. Neurosurgical or transfrontal approaches to the orbital apex are not discussed here. These topics are covered in neurosurgery textbooks. Reese,1 in 1971, reported that more than 90 percent of all expanding processes of the orbit can be adequately evaluated w ith one or both of these surgical approaches. There are believed to be four surgical spaces within the orbit: two real spaces and two potential spaces.2 The first potential space of the orbit is the episcler al or Tenon space, which is the area between Tenon's capsule and the sclera, whi ch lies beneath it. The second is the subperiosteal space; this lies between the orbital bones and the overlying periosteum. Both the potential spaces of the or bit, in general, do not play a large role in orbital surgery. The real spaces of the orbit include the area outside the muscle cone of the orb it, involving the space between the intramuscular septa of the extraocular muscl es and the periosteum of the periorbital bones, and the central space, which inc ludes the muscle cone and the space within it. These two real spaces are importa nt in orbital surgery because most orbital pathologic processes can be found wit hin them. ANESTHESIA General anesthesia is preferred in most orbital surgical cases, although local b locks can be used in easily accessible anterior pathologic processes. Hypotensiv e techniques are recommended to improve hemostasis as well. ANTERIOR ORBITOTOMY Anterior orbital surgery can be approached in two main surgical techniques: eith er a transconjunctival anterior approach or an anterior transcutaneous approach through the lids along the orbital rim (Fig. 167 {nd}1). Bone removal can be obtai ned with either method. The decision to use one technique over the other usually depends on the actual location of the orbital lesion, whether it can be easily palpable through the skin or through conjunctiva, and whether partial excision o r biopsy versus complete total excision of the tumor mass is anticipated. The transconjunctival approach can be used to enter the orbit between the globe and the orbital rim, and it allows access to pathology located along the globe i tself, especially in cases involving problems such as orbital lymphoma and perim uscular tumors such as schwannomas and other neurogenic tumors. It can also prov ide exposure of lesions along the muscle cone. Usually a lateral canthotomy is r equired, with dissection through conjunctiva, orbicularis muscle, and orbital se ptum. Prolapsed orbital fat and damage to the oblique muscles are potential surg ical problems. Orbital rim or anterior orbital skin incisions can be made either superiorly alo ng the eyebrow itself, just beneath the eyebrow cilia, or inferiorly through an orbital rim or infraciliary approach, in which a large skin flap can be construc ted before entering the orbital rim inferiorly. With superior incisions along th e eyebrow itself, attention must be given to the important anatomic attachments superiorly, including the supraorbital vascular bundle and the trochlea, which l ies 4 mm behind the orbital rim superonasally. Once dissection is carried out to the level of the periosteum, the periosteum ca n be elevated with a periosteal elevator, entering the potential space between b one and the periosteum, with care being taken in the supranasal region; damage t o the trochlea and superior oblique muscle can result in binocular torsional dip lopia. It is important to close the periosteum with absorbable sutures superiorl

y to maintain normal suspension of upper eyelid structures. Inferior orbital rim incisions can be made directly at the level of the orbital rim or can be performed using the infraciliary approach; again care must be take n to avoid damage to the infraorbital nerve and vessels. Although the inferior a pproach does not, in general, allow good access to posteriorly displaced structu res within the orbit or with lacrimal gland and other lateral tumors, it is an e xcellent approach to excise an anteriorly displaced tumor such as an orbital der moid, to treat orbital fractures, and to obtain biopsy specimens of infiltrative tumors of the orbit (i.e., potential metastatic orbital processes). LATERAL ORBITOTOMY Lateral orbitotomy and variations of it have been used in ophthalmology for more than 100 yr. Although Kronlein3 is generally thought to have been the first to d evelop a technique of lateral orbitotomy, history reveals that other surgeons in Germany (Wagner) and France (Passavant) also contributed to the development of methods allowing access to the retrobulbar space by removing the lateral bone ri m and orbital wall.4 Kronlein3 first described a surgical technique for the removal of orbital dermoid cysts in 1888; he reported that a crescentic incision in the lateral orbit prov ided access to the retrobulbar space. Over the years, several modifications of t his basic technique have been developed, with the most important modification of fered by Burke and Reese4 in the 1950s. The current technique for lateral orbitotomy, in general, involves a combination of a lazy S-shaped or curvilinear incision in a vertical plane along the latera l orbital rim, with extension of this incision in a horizontal manner from the l evel of the lateral canthus toward the ear (Fig. 167 2A). Sometimes lateral cantho tomies with isolation and retraction of the lateral canthal tendon may be necess ary for improved orbital exposure. The lateral orbitotomy skin incision can be made in a curvilinear manner in the lateral two thirds of the eyebrow at the level of the bone orbital rim. The inci sion should be continued below the insertion in the lateral canthal tendon and c arried posteriorly for 4 to 4.5 cm (Fig. 167 2A {nd}C). Dissection can be then be pe rformed through the various subcutaneous layers, including the orbicularis muscl e, to the level of the periosteum along the frontal-zygomatic suture line. At this point, traction sutures or a self-retaining retractor may be used to ret ract the skin muscle flap at the level of the temporalis muscle. The periosteum can then be incised parallel to the orbital margin. Careful elevation of the per iosteum both anteriorly and posteriorly along the orbital rim will allow exposur e of the orbital cavity. The key bony anatomic structure exposed is the suture l ine, which is composed of the lateral aspect of the frontal bone and the frontal process of the zygoma (see Fig. 167 2C). The temporalis muscle must also be eleva ted and reflected posteriorly after the muscle is partially disinserted by incis ing the periosteum. At this time, a 25- to 30-mm segment of orbital bone containing the frontal-zygo matic suture line can be removed (see Fig. 167 2D and E). Malleable retractors can be used to protect the orbital contents posteriorly. The rotary or circular saw can be used to make horizontal cuts in the superior and inferior bony margins. A bone rongeur can then be used to rock the bony segment back and forth to break the hinge. If more posterior bone resection to the level of the sphenoid is nec essary, further bites can be obtained with the bone ronguer. Up to 50 percent mo re exposure can be achieved using this method. Care must be taken at this point to avoid excessive orbital bleeding either from the subperiosteal space or as a result of temporalis muscle trauma. The periorbita can now be seen. To enter the orbital contents, the periorbita ca n be incised by making a T-shaped incision with the T on its side (see Fig. 167 2F and G). The lateral rectus muscle may be tagged at this point to provide better orientation of orbital structures. The orbital contents must be very carefully dissected because the lateral rectus muscle and multiple intramarginal adhesions between the fat and other neurosensory structures may be found here, with poten tial damage to adjacent ocular structures. This portion of surgery should be com pleted by closure of the periorbita using absorbable sutures, with some allowanc

e being made for the escape of blood or serous fluid. The lateral wall bone fragment can be replaced, if necessary, by drilling burr h oles in the adjacent stable facial bone and passing 26- or 28-gauge orthodontic steel wire through in an effort to reposition the lateral bony orbital rim (see Fig. 167 2A {nd}I). The Synthes Corporation (Paoli, PA) has produced a titanium mesh implant to provide similar bony stabilization laterally. In cases such as orbit al decompression associated with thyroid disease or malignant proptosis, it is b est not to replace the bone because this will detract from the decompressive eff ects. Usually minimal cosmetic blemish is noted postoperatively despite the loss of bone. The periosteum should be closed, if possible, with absorbable sutures. Placement of a rubber catheter or Penrose drain for blood drainage should also be conside red (see Fig. 167 2J). The subcutaneous tissue is closed at this time and a light dressing is applied as well; one must monitor visual acuity and check for the pr esence of intraorbital hemorrhage and hematomas frequently within the first 24 t o 48 hr. Orbital drains can be removed at that time. MEDIAL ORBITOTOMY In certain situations, excellent exposure can be obtained with a transconjunctiv al medial approach, removing the insertion of the medial rectus muscle after tag ging it with a traction suture. This allows the surgeon to gain significantly mo re exposure posteromedially and along the muscle cone itself to search for any p rocesses that could involve medial tumors or trauma to the medial aspect of the orbit. In addition, optic nerve sheath fenestrations (discussed in Section 11) c an be performed using this approach. Other approaches for accessing the medial orbital space, including the ethmoid o r Lynch transcutaneous incision or the transantral Caldwell-Luc operation, can a lso be considered. Descriptions of these techniques are found in otolaryngology textbooks. Combined medial and lateral approaches can also be used, especially f or the diagnosis of apical tumors and in cases of optic nerve decompression.