Download Anterior Orbitotomy

Dr Dipali T Chavan
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New growth (cyst / neoplasm ) is palpable through the eyelids and is
judged mainly in front of the equator of the eyeball.
Exception : mixed cell neoplasm of the lacrimal gland
(approach through a lateral orbitotomy with resection of the lateral
half of the supra-orbital margin )
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Orbital foreign body
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Orbital abscess
Left anterior orbitotomy incisions
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For exposure of small osteomata
a meningo-encephalocele
an abscess behind the orbital periosteum
covering the pars plana of the ethmoid
A foreign body on the medial side of the orbit
as far back as the optic foramen.
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For new formations (neoplasm or cyst )in the
anterior part of the orbit except lacrimal
gland neoplasm
To explore a sinus in the upper lid to find and
remove a foreign body as far back as the
lesser wing of the sphenoid.
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For the exposure of a neuroma of the infraorbital nerve
New formations in the anterior part of the
orbit below the eye.
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For biopsy and digital exploration of a
doubtful retro-ocular neoplasm without
resection of the lateral orbital wall.
Transconjunctival incision can be used to
access the episcleral,central, or peripheral
surgical spaces.
 Subciliary incision allows dissection beneath
the orbicularis muscle to expose the inferior
orbital septum and orbital rim, minimizing
visible scarring. This can be done to expose the
peripheral surgical space.
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Upper eyelid crease can be done via the transeptal
route which provides entry into the peripheral
surgical space. This incision provides good
surgical approach and the scar is hidden.
The extra periosteal route upper eyelid incision
provides exposure to the superior orbital rim
where the periosteum can be incised allowing
entry into the subperiosteal space. This is mainly
indicated for evacuating a sub periosteal
hemmorhage or abscess
Transcutaneous Anterior Orbitotomy
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Transcutaneous anterior orbitotomy is used to access the anterior extraconal
orbital space to biopsy or excise small lesions located beneath the orbital
rims.With care and the use of retractors, deeper lesions to the level of the
posterior globe are accessible.
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An incision line is marked in the upper eyelid crease to access the superior orbit, or
2mm below the lower eyelid lash line to access the inferior orbit. The skin and
orbicularis muscle are opened with scissors to enter the postorbicular fascial
plane. A horizontal cut is made with a scalpel or scissors through the orbital
septum to enter the extraconal orbital space. If the lesion is not visible
immediately, careful palpation through the wound usually locates the structure.
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The fat lobules are gently separated with narrow malleable retractors and a Freer
periosteal elevator, taking care not to injure vascular structures . In the upper
eyelid, the levator muscle lies toward the superior side of the wound. In the lower
eyelid, the inferior oblique and rectus muscles lie on the inferior side of the
wound.
Anterior orbitotomy approach, upper
eyelid. A lid crease incision is cut,
and the orbital septum is opened.
Fat is then retracted, and the lesion
is identified for biopsy or removal.
The anterior view is the inverted
image as seen by the
surgeon. (Adapted with permission
from Dutton JJ. Atlas of ophthalmic
surgery, vol II. Oculoplastic,
lacrimal, and orbital surgery. St
Louis: Mosby-Year Book; 1991.)
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The lesion may then be biopsied or dissected carefully away from adherent tissues. All
bleeding points are cauterized meticulously with bipolar electrode forceps; care is
taken to avoid excessive traction on the orbital fat. The cutaneous wound is closed
with a running suture of 6-0 nylon or silk or with interrupted stitches of 7-0 Vicryl or
chromic gut.
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Transconjunctival Anterior Orbitotomy
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The transconjunctival approach to the anterior orbit is useful for lesions close to the
globe, for that portion of the optic nerve immediately posterior to the globe, and for
most anteriorly situated intraconal lesions. It also avoids skin incisions that may be
cosmetically objectionable in some patients.
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An incision is made through conjunctiva and anterior Tenon’s capsule, and the
dissection is carried in the episcleral space to the posterior globe . Disinsertion of one
rectus muscle will facilitate deeper dissection . The location of the incision depends on
the location of the orbital lesion. Posterior Tenon’s is opened to access the retrobulbar
compartment. Malleable retractors and rotation of the globe will provide adequate
visualization. In small orbits, however, working room and visualization may be very
limited.
General anaesthesia
 Local anaesthesia :removal of innocent
neoplasms and cycts
Contraindication: inflammatory disorders.
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The site of incision is marked with genetial voilet
Inject 1ml xylocaine 2% with adrenaline chloride
incision of adequate length made for exposure
and removal of growth. It is deepened through
the orbicularis fascia and muscle.
 Bleeding points sealed by diathermy
coagulation.
 Retraction of wound edges is made by the
insertion of no 1 black silk sutures into the edges
of the incision
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Orbital septum is identified and opened in
the line of the incision.
Orbital fat is pushed aside with blunt
dissector down to the covering of the new
formation.
Orbital retractors are inserted to hold the
tissues aside and the cyst / neoplasm / foreign
body is exposed.
It is essential to keep close to the wall and not to
work in a false tissue plane outside this.
 Dermoid cyst :
-capsule of an epidermoid cyst is generally white.
Capsule of a dermoid cyst is yellow ,brown/ red .
-MC in upper temporal quadrant.
-it slowly increases in size ,eventually to erode the
roof of the orbit and supra-orbital margin , but
rarely adherent to the bone and the dura.
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-if dura is opened in the dissection of the cyst it is closed
with a square of fascia lata or temporal fascia.
-it is inadvisable to follow cyst into the anterior and
middle cranial fossae ,into the nasal cavity or upto the
apex of the orbit (attached to the optic nerve sheath)
-when the surgical access to the posterior part of the
cyst is very difficult on account of its size , aspiration
of the cyst contents through a needle passed
obliquely through the cyst wall is done.
after clamping opening, needle is withdrawn and
dissection is completed.
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MC in upper nasal quadrant
Associated with an osseous defect in the skull through
which passes a band of tissue connecting the cyst with
the meninges.
Aspiration of the part of fluid on exposure is
diagnostic.
Cyst is ligatured with two strands of catgut at its base
near the roof of the orbit.
-a cut is made between the ligatures and the cyst is
removed.
Associated osseous defect may be covered by an
osteoplastic flap.
Antibiotics and chemotherapy : if risk of meningitis.
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Hydatid cyst
MC in upper nasal quadrant
Before operating , aspirate the contents and
search for hooklets.
Injection of formalin 1% for 5 minutes ,
followed by excision of the cyst wall.
Failure to complete removal of the entire cyst
causes swelling , chemosis , mild sepsis
Hemangioma:
-A fibrous capsule of varying thickness
surrounds hemangioma.
-at some places dilated thinly-lined bloodspaces project from the surface of the
neoplasm.
In some cases it is advisable to use gloved
forefinger for completing the separation of
the neoplasm from the orbital tissues ,which
will cause less harm than cutting instruments.
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After removal of new formation , space can
be packed with gelatin sponge.
In some case it is drained for 24-48 hours.
Orbital septum & orbicularis is closed.
Muscle is closed by catgut 5/0.
Skin incision is closed by interrupted sutures
of 3/0 silk
Incision : Along Supra-orbital margin or along
lateral 2/3 of the infra-orbital margin .
 Pain, disability ,inflammation due to foreign
body (FB) are indications for its removal.
 FB >1 cm should be removed if these are causing
mechanical defects in ocular movements or
pressing on nerves to extra-ocular muscles and
the optic nerve.
 FB within 5mm of the equator of the eyeball or
just in front of optic foramen : anterior
orbitotomy is done.
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Good stereoscopic radiographs
Metal guides
Berman’s locator
Magnet
Pair of forceps
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A foreign body at the orbital entrance to the
optic canal: boomerang incision along the
upper nasal quadrant of the orbit.
Passage of the posterior ethmoid artery
through a foramen at a junction of the upper
& medial wall of the orbit is 1 cm in front of &
in the plane of the optic foramen .
Below and posterior to the artery periosteum
is incised anteroposteriorly for 1 cm. FB
removed with small curette.
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Sinuses passing from the lids posteriorly into
the orbit are explored and any sequestra ,
foreign matter and debris removed.
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Inj methylene blue in peroxide solution will
help in identification of non-metallic FBs.
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Sinus is curetted and filled with appropriate
antibiotic cream.
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Post op treatment :
The patient is nursed sitting up to fascillitate
drainage.
First dressing :24 hours post op.
If Sero-sanious discharge still present then
drainage tube left in place for another 24
hours.
Stitches removal : 4th postop day
Thank you !