Evolution of orbitotomy approaches

In the golden era of the ‘Greeks’ and ‘Romans’; proptosis was managed by performing venesection and purging on patients.^[1] In the 10^th century, Ali Ibn Isa treated proptosis by immersing face in cold saline water; upon failure of response lead plate was adjusted over the eye and it was left at gods mercy.

Extirpation or the present-day subtotal exenteration was performed by Bartisch in the late 1500s period for the outward protruding eyeball. The procedure involved impaling the eyeball with strong needle and thread for manipulation and traction. He then used spoon-shaped knife for extirpation of ocular tissues till bone has be reached leaving behind eyelids intact. One can read and only imagine how dreadful and inhumane this procedure was before the advent of anesthesia.

Orbital tumor removal through lower lid trans cutaneous route was first described by Thomas Hope of Scotland in a young girl with preservation of the globe.^[2] Hope credited his mentor, the famous French ophthalmologist, St. Yves, as having first successfully performed such an operation. Parker described using a transconjunctival incision in order to remove a cystic lesion from the lateral orbit most likely dermoid.^[3] De wecker and Carter also used lateral transconjunctival approach for accessing optic nerve.^[4] The difference in their approaches was that De wecker approached optic nerve by splitting tenons between lateral and inferior rectus followed by globe prolapse, whereas Carter disinserted lateral rectus which gave good visualization of optic nerve which was absent in De weckers technique. Herman Knapp also used a transconjunctival route for a tumor located in the deep intraconal space surrounding the optic nerve which was successfully removed with preservation of globe though vision could not be preserved.^[5]

Passavant was the first surgeon to perform lateral orbitotomy for an orbital vascular malformation. Independently Kronlein popular method of lateral orbitotomy performed by creating a crescent-shaped skin incision in the lateral side of orbit with the anterior convexity at the lateral orbital rim, and extending superiorly towards the hairline and inferiorly towards the ear.^[6] In his procedure creation of bone window increased access to the deep orbital tumors. The limitation of this procedure were limited working space and ugly postoperative scar.^[7] In 1901 Cirincione performed lateral orbitotomy by using S-shaped incision starting under brow.^[8]

In 1907, Rollet reported the first anterior orbitotomy, which involved making an incision beneath the brow and dissecting subperiosteally in order to gain entry to the orbit.^[9] Fronto ethmoidal mucocele with proptosis was managed by Lynch by placing incision in the superomedial orbital rim which extended from supratrochlear region to medial canthal area.^[10] This incision however, had complications like globe luxation into nasal cavity, webbing of medial canthal area, lacrimal system injury and superior oblique tendon injury.

Roentgen was the only imaging modality available at that time it was difficult to identify the intracranial extension. The limitation of incomplete removal of tumors with intracranial extension was overcome by Walter Dandy in 1922 by his intracranial approach.^[11] However, Dandy advocated exclusively transcranial approach for orbital tumors, though the most common cause of proptosis was endocrine related. Moreover, transcranial approach had limitations like mortality (4%), incomplete removal of tumor, meningitis, rhinorrhea, superior rectus weakness and ptosis. Davis approached optic nerve tumors by using lower lid incision.^[12] Reese performed lateral orbitotomy by direct incision on lateral canthus followed by canthotomy for approaching lesions located in deep orbit.^[13] Benedict introduced brow incision followed by periosteal elevation for nasal or temporal located superficial tumors.^[14] He also advocated transcranial approach for deep orbital tumors not accessible by his approach.

From 1886 to 1940, the majority of eye surgeons regarded the orbit as a deep, dark and bloody field with unrewarding surgical results. In 1947 Stallard performed lateral orbitotomy by using the Kroleins method but instead of crescent incision he used S shaped incision which was earlier described by Cirincione.^[15] The incision started in the lower end of lateral sub brow region, followed the curve of zygomatic arch and in the center of the arch, horizontal incision is placed. Similar incision was described by Dickson Wright which was later came to be known as classic Stellard-Wright incision. This incision had a complication of injury to facial nerve branches. Later it was modified into more curvilinear manner with shortened horizontal limb. The supra orbital part of the incision is hidden under eyebrow and the horizontal part under the skin fold of crow’s feet making the incision cosmetically acceptable.

Raynold Berke’s modified Kronleins approach by increasing the size of bony window from triangle to rectangle shape.^[7] In 1962, Byron Smith described lid splitting incision to gain access to the anterior superomedial orbit.^[16] Leone and Wolfley described the use of an incision in the natural upper eyelid crease to obtain access to the superomedial orbit.^[17], ^[18] The advantages of such an approach include a familiar route to the eyelid and the anterior orbit, minimal dissection with little risk to vital structures, excellent exposure of orbital structures, and simple wound closure with a practically unnoticeable scar.

Jones in 1970 first described trans-frontal approach for tumors located superior to optic nerve in mid to posterior orbit.^[19] Later in 1982, Jane described a supraorbital approach to tumors and aneurysms of the suprasellar area, as well as to orbital lesions.^[20] Al-Mefty modified this approach by incorporating the superior and lateral orbital walls.^[21] Delashaw described the temporal and orbital extension of the supraorbital exposure.^[22] The inferior extension of the supraorbital craniotomy by removal of the orbital rim was also described by Delfini using an alternative technique with two bone flaps.^[23] Rootman rightly described these procedures as “Panoramic Orbitotomy” owing to wide field of exposure for surgeons.^[24]

A cosmetically acceptable incision in place of lynch incision was given by Balch in 1998 in the form of transcaruncular approach, which gave access to deep part of medial orbit upto apex.^[25] Garcia also described similar approach but for treating medial wall fracture or orbit.^[26] Later this incision was popularized by Goldberg.^[27] In 1999 Herman described trans-nasal endoscopic approach in a case of inferomedial located orbital cavernous hemangioma in the posterior orbit.^[28]

Recent advances

In 2002 Lai et al. conducted a study where they used a trans-caruncular approach in order to remove frontoethmoidal mucoceles. The authors made an incision over the caruncle to reach the medial orbital wall periosteum and obtained a good exposure of the mucocele and removed them. They used to put a trans-nasal tube before closing the wound. It was concluded that transcaruncular approach was safe and provided a wide exposure for medial orbital.^[29]

In 2005 Nemet et al. described a “Lateral triangle flap” technique, where the authors made an upper eyelid skin crease incision and skin incision from the lateral canthal angle. The incisions were joined laterally at the outer margin of the lateral orbital rim, just beyond the lateral orbital margin. The triangular skin muscle flap was raised medially, based at the canthal angle, providing maximal exposure of the lateral and superolateral orbital wall. The method was found to provide good exposure and satisfactory cosmetic outcomes.^[30]

A lateral retrocanthal, minimally invasive, canthus sparing approach was published by Moe et al in 2007. The authors initially conducted a cadaver study to develop a transconjunctival lateral surgical technique in order to reach the orbital floor and roof without effecting the structural integrity of the eyelid support system. They performed the technique on 30 patients and eventually found this procedure to be safe yet providing a rapid access to the lateral orbit with ample exposure. They also added that this incision could be extended in a single continuous incision to the medial orbit. However, the structural integrity of the lateral retinaculum was unaffected. The wound healing was rapid, without tissue distortion or scars.^[31]

Pillai et al. in 2008 described the transconjunctival endoscopic approach to the optic nerve and the medial intraconal orbit using a 2.7 mm diameter rigid endoscope in 7 cadavers. He concluded that the procedure is easy to perform and does not cause much damage to the adjacent muscles. Infact, it can result in cosmetically satisfying outcomes.^[32]

Finger et al. in 2011 published a new technique of obtaining an orbital biopsy using the vitrectomy cutter. In this technique also known as “Finger’s aspiration cutter technique(FACT)’’, first the lesion is palpated, and entry sites are marked with stains. Based on the site, an incision is made using either a Wescott scissors for conjunctiva or a no 11 blade for skin; the vitrectomy cutter shafts were entered and using a bimanual technique; holding the lesion by one hand and controlling the vitrectomy cutter with the other, biopsy was obtained. The advantage of this procedure was that it does not require any sutures.^[33]

The endoscopic approach to the lateral orbit was employed by Lyson et al. in 2014, where he initially used navigation guided target marking, followed by a 1.5cm skin incision within a skin wrinkle behind the lateral canthus. Using a bone drill an opening was created in the lateral orbital wall to gain access to the orbital compartment. They were able to successfully remove extraconal epitheliod hemangiomas and extraconal cavernous angiomas in the lateral retrobulbar space.^[34]

Similarly, GuangMing Zhou in November 2018 described the use of navigation-guided endoscopy combined with deep lateral orbitotomy for removing small tumors at the lateral orbital apex. After skin incision, exposure of the lateral wall and its fracture, a navigation-guided microdrill and rongeur were used to remove the greater wing of the sphenoid bone posteriorly until the dura mater was encountered to provide adequate exposure of the orbital apex. After this, intraorbital dissection was performed with a standard endoscope guided by navigation, tumor was visualized and thus removed. It seemed to be a feasible, efficient, and safe approach.^[35]

In 21^st century, there has been a boom in the incorporation of various imaging modalities in the planning of orbital surgeries. The first description of “Frameless image-guided neuronavigation” in orbital surgery was published by Hejazi et al. in 2005. The author used a frameless infrared-based neuronavigation system in the microsurgical removal of 11 orbital tumors. He used a transconjunctival approach in the removal of the tumours. The study concluded that the use of the navigation system reduces the intra-operative risk and increased the effectiveness of microsurgical orbital procedures.^[35]

Surgical approaches