Dr Dipali T Chavan

 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 )  Orbital foreign body  Orbital abscess

Left anterior orbitotomy incisions

    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.

  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.

  For the exposure of a neuroma of the infra orbital nerve New formations in the anterior part of the orbit below the eye.

 For biopsy and digital exploration of a doubtful retro-ocular neoplasm without resection of the lateral orbital wall.

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Transconjunctival incision can be used to

access the episcleral,central, or peripheral surgical spaces.

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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.

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

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Transcutaneous Anterior Orbitotomy

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.

 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.

 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.)

    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.

Transconjunctival Anterior Orbitotomy

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.

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.

     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

   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.

-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.

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.

 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 blood spaces 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.

     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.

     Good stereoscopic radiographs Metal guides Berman’s locator Magnet Pair of forceps

   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.

 Sinuses passing from the lids posteriorly into the orbit are explored and any sequestra , foreign matter and debris removed.

 Inj methylene blue in peroxide solution will help in identification of non-metallic FBs.

 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 : 4 th postop day

Thank you !