A Plea for Lateral Orbitotomy

Abstract

There has been of lateta trend to advise exploration of all orbital tumours throughi the transfrontal route. Such an operation is of course in the province of the neurosurgeon. Perhaps one reason for this is the statement of so eminent a neurosurgeon as W. E. Dandy (1943) that in his experience in 75 to 80%,/, of cases both the and the cranial cavity are involved in a neoplasm which causes unilateral proptosis. Another reason is the reluctance and timidity of some eye surgeons to undertake the surgical approach through the lateral wall of the (lateral orbitotomy Kronlein's operation)-a route in my opinion fully justifi able, and one to be preferred to the transfrontal approach in the case of a neoplasm the physical signs of which show it to be entirely within thc orbital cavity. Increasing hyper metropia may well bp diagnostic of a tumour limited to the orbit. Good stereoscopic radiographs of the orbital walls and optic foramina andc canals are helpful in excluding extraorbital extension. Dandy made the following comment about orbital tumours: As a matter of fact it is rarely possible before operation to be certain whether or not the tumour also lies within the cranial chamber as so many of them do. Harvey Jackson (1945) cannot agree with this statement, and he writes: fact my experience is that by careful clinical examination, by judicious radiography and by suit able application of laboratory investigation, not only is the diagnosis of tumour to be reached, but its ramifications regularly revealed and not infrequently its pathological nature surmised. Nevertheless, in discussing treatment hte writes: My opinion concurs absolutely with that of Dr. Dandy in that the transfrontal route is preferable in every way. Through a frontal osteoplastic flap a more direct and more adequate exposure is obtainable, any extension intra crania4ly is approachable, less interference with ocular motility ensues, and there remains no visible and ugly scar. As for the replacement of a prominent eye by one that in addition pulsates, this is I think a more direct and more adequate exposure is obtained by lateral orbitotomy in cases where it is known that the neoplasm is limited to the orbit. The suggestion that after lateral orbitotomy the patient has an ugly scar is untrue. By suturing the incision carefully in two layers, by using for the skin a plastic hook, No. 4 eye atraumatic needles, with 00 black silk, and by placing the sutures 3 mm. apart and 2 mm. from the edges of the incision, the scar is reduced to a thin line which is not obvious The case report given below illustrates failure to remove an orbital tumour by the transfrontal route in July, 1945, and its successful excision through the lateral orbital approach in February, 1946. Incidentally Maurice Drell (1944) also reports a case in which the neurosurgeon failed to find a tumour of the through the transfrontal route. In the following case I came upon the neoplasm quite easily after temporarily removing the lateral wall of the and retracting the external rectus muscle upwards. The neo plasm was dissected from the optic nerve and the eyeball. I do not think the access could have been more direct, and the exposure was certainly adequate. The note made on July 10. 1945, after left transfrontal craniotomy was Lno neoplasm vtisible in the orbit Case Report