Lateral Orbitotomy Research Articles

Transorbital endoscopic assisted management of intraorbital lesions: lessons learned from our first 9 cases

The management of intraorbital lesions is challenging and it is strongly dependent to their nature, position and biological behaviour. Traditionally, the superior and lateral compartments of the orbit are addressed via lateral orbitotomy or transcranial approaches. Herein we present our preliminary experience in the management of selected supero-lateral intraorbital lesion through an endoscopic-assisted superior-eyelid approach. All cases of intraorbital lesion treated in two Italian tertiary care referral centres using a superior eyelid endoscopic-assisted transorbital approach were retrospectively reviewed. Nine patients have been analysed. The aim of surgery was diagnostic in 5 cases and curative in the remaining 4 patients. Significant tissue biopsy was obtained in all the five diagnostic procedures. Complete resection was obtained in 3/4 lesions. No major intra- or postoperative complications have been observed. Mean surgical time was 68 minutes. Mean hospitalization time was 4.4 days. All patients were satisfied about the surgical procedure, as emerged by the post-operative counselling. At present, the mean follow-up time is 18 months, ranging from 11 to 25 months. Our preliminary results are promising with successful functional and cosmetic outcomes and reduced morbidity for the patient. This approach should be considered as an option for selected intraorbital lesions.

A neurosurgical perspective to approaches to the orbit: A cadaveric study.

Neurosurgeons are getting increasingly involved in surgery for orbital tumours. The various approaches to the orbit can be challenging. The authors have demonstrated on cadavers the various approaches to the orbit which are required to be mastered by the neurosurgeon. The superior approaches which include the transcranial, supraorbital and the hybrid approaches are the most commonly utilized surgical approaches by the neurosurgeon for excision of orbital pathologies. The lateral orbitotomy is an elegant approach for excision of the tumours lateral to the optic Nerve and lacrimal gland tumours. The authors also demonstrate the medial approach through a medial orbitotomy which is a relatively unfamiliar approach to neurosurgeons. The importance of the various landmarks in each approach is emphasised along with the methods to minimize complications. It is imperative that neurosurgeons are intimately familiar with the microsurgical anatomy of the orbit and the various approaches to it.

Surgical anatomy of the cavernous sinus, superior orbital fissure, and orbital apex via a lateral orbitotomy approach: a cadaveric anatomical study.

Tumors of the middle fossa or cavernous sinus (CS), or intraorbital tumors, can penetrate each other through the superior orbital fissure (SOF) or neighboring tissue. These complicated pathologies are often treated with highly invasive surgical procedures. In this article, we demonstrate surgical anatomic dissections of the CS, SOF, orbital apex (OA), and dura mater extending to the periorbita from the middle fossa, by performing an epidural dissection via a lateral orbitotomy approach, and discuss findings that may provide guidance during surgery in these regions. Lateral orbitotomy was performed on latex-injected cadaver heads by making a 2-cm skin incision lateral to the lateral canthus, drilling the lesser and greater sphenoid wings that form the SOF borders, and removing the bone section between the middle fossa and orbit. Dura mater from the middle fossa to the periorbita was exposed to perform anterior clinoidectomy. Meningeal dura was dissected from the endosteal dura, which forms the lateral wall of the CS, to expose the CS, SOF, and OA for dissections. Changing the orientation of the microscope from posterior to anterior enabled regional control for dissection from the Gasserian ganglion to the OA. Cranial nerves that pass through the CS, SOF, and OA were dissected and exposed. The annular tendon was opened, revealing the oculomotor nerves and its branches, as well as the abducens and nasociliary nerves, which pass through the oculomotor foramen and course within the OA and orbit. This approach causes less tissue damage; provides control of the surgical area in spheno-orbital tumors invading the fissure and foramen by changing the orientation of the microscope toward the orbit, OA, SOF, CS, and middle fossa; and expands the indication criteria for lateral orbitotomy surgery. This approach, therefore, represents an alternative surgical method for excising complicated tumors in these regions.

The Lateral Orbitotomy Approach for Lesions Involving the Middle Fossa

Objective: Classically used for treatment of orbital lesions, the lateral orbitotomy with cantholysis can be combined with a temporal craniectomy for lesions involving the middle cranial fossa. We present a single-center experience with the lateral orbitotomy approach for lesions involving the middle fossa.

Transorbital endoscopic assisted management of intraorbital lesions: lessons learned from our first 9 cases.

The management of intraorbital lesions is challenging and it is strongly dependent to their nature, position and biological behaviour. Traditionally, the superior and lateral compartments of the orbit are addressed via lateral orbitotomy or transcranial approaches. Herein we present our preliminary experience in the management of selected supero-lateral intraorbital lesion through an endoscopic-assisted superior-eyelid approach. All cases of intraorbital lesion treated in two Italian tertiary care referral centres using a superior eyelid endoscopic-assisted transorbital approach were retrospectively reviewed. Nine patients have been analysed. The aim of surgery was diagnostic in 5 cases and curative in the remaining 4 patients. Significant tissue biopsy was obtained in all the five diagnostic procedures. Complete resection was obtained in 3/4 lesions. No major intra- or postoperative complications have been observed. Mean surgical time was 68 minutes. Mean hospitalization time was 4.4 days. All patients were satisfied about the surgical procedure, as emerged by the post-operative counselling. At present, the mean follow-up time is 18 months, ranging from 11 to 25 months. Our preliminary results are promising with successful functional and cosmetic outcomes and reduced morbidity for the patient. This approach should be considered as an option for selected intraorbital lesions.

Investigation of the diagnosis and surgery of orbital neurilemomas

Objective To investigate the diagnosis and surgery of orbital neurilemomas. Methods The data of 32 eyes of 32 patients with pathologically confirmed obital neurilemoma were analyzed retrospectively. Results Of 32 cases with orbital neurilememas , 18 patients were male(56.25%), 14 patients were female(43.75%). A/B ultrasound were applied in 32 cases, and neurilemomas was found low to medium reflect or echo in the ultrasound. CT scanning illustrated soft tissue with high density mass in 26 cases, 6 cases were heterogeneity. MR imaging were examed in 10 cases and most of the neurilememas located in the muscle cone or in the superior part of the orbit. Surgical approach was lateral orbitotomy in 18 cases(56.25%), anterior orbitotomy in 12 cases(37.50%), transcranial orbitotomy in 2 cases(6.25%). Visual acuity was improved in 8 eyes(25.00%), remained unchanged(46.87%), and decreased in 9 eyes(28.13%). Early postoperation ptosis in 7 eyes (21.87%), disturbance of eyeballs in 9 eyes(28.13%), and 2 eyes(6.25%) occurred recurrence. Conclusion Modern medical imaging, especially CT scanning and MRI, can demonstrate the site, configuration, and characteristics of the tumors, and contribute to the diagnosis and surgical approach.Complete orbital neurilemomas extirpation can decrease the rate of recurrence and complication. Key words: Orbital neoplasma; Neurilemomas, orbital; Computed tomography; Magnetic resonance imaging; Extirpation

Epithelial-Myoepithelial Carcinoma of the Lacrimal Gland 14 Years After En Bloc Resection of a Pleomorphic Lacrimal Gland Adenoma

Fourteen years after en bloc resection of an orbital pleomorphic adenoma, a 61-year-old female patient developed progressive left proptosis on the same side. A CT scan revealed a round, well-circumscribed, heterogeneously enhancing mass in the lacrimal fossa of the left orbit without calcification or bone erosion. An MRI scan showed a lesion that was hypointense on T1-weighted images and heterogeneously isointense on T2-weighted images. The tumor was completely resected through combined anterior and lateral orbitotomy. On histopathology, the specimen was identified as epithelial-myoepithelial carcinoma. After surgery, the patient received adjuvant therapy with irradiation of the orbit. At a 36-month follow-up evaluation, the patient remained tumor-free. Epithelial-myoepithelial carcinoma, a very uncommon tumor of the orbit, apparently behaves like a low-grade malignancy and is associated with good survival rates. However, a good prognosis for survival is tentative at best, in part because of the rarity of the lesion.

Lateral Canthal Position Following Lateral Orbitotomy and the Influence of Ocular Proptosis.

Anecdotal evidence suggests that detachment of the lateral canthal tendon during lateral orbitotomy results in shortening of the horizontal palpebral aperture (HPA) and rounding of the lateral canthal angle (LCA). This study investigated the change in HPA and LCA following lateral orbitotomy and the effect of proptosis on the HPA. Retrospective, single surgeon, review of all cases undergoing lateral orbitotomy, comprising of a canthotomy and cantholysis and reconstruction of the lateral canthus using a single suture. The HPA and lateral canthal height (LCH) were measured on pre- and postoperative photographs using ImageJ software. Changes in the LCA and degree of proptosis were also investigated. Exclusion criteria included previous eyelid surgery, acute trauma, and less than 6 months' follow up. There were 41 cases of lateral orbitotomy in 27 patients, 67% female, average age 51 years. Twenty patients had thyroid eye disease of which 14 underwent bilateral surgery; the other 7 patients had a variety of orbital pathologies. Thirteen patients underwent unilateral orbitotomy with the contralateral eye serving as a control. Average follow up was 23 months. Overall, the HPA and proptosis were reduced by 0.6 mm (p = 0.143) and 3.4 mm (p < 0.001), respectively. A 0.2-mm reduction in HPA was observed for every 1-mm reduction in proptosis. A difference in post-orbitotomy HPA was observed between cases and their matched controls (p = 0.016). No rounding of the LCA or significant change in LCH was observed following lateral orbitotomy. The described technique of lateral orbitotomy and simple reconstruction do not appear to cause lateral canthal drift or rounding. There was no significant change in HPA or LCH. The degree of change of proptosis does appear to influence the change of HPA.

Management of a blinding orbital apex cyst in a 14-year-old girl.

This study was conducted to highlight the diagnostic and management challenges of orbital apex lesions. It is a retrospective report of a 14-year-old female who presented with no perception of light vision in her left eye following a 1-year history of left unilateral axial proptosis. Her computed tomography scan revealed a mass surrounding the optic nerve which was reported to be an optic nerve glioma. She had lateral orbitotomy and a cystic mass was dissected and excised. Systemic steroids and antibiotics were administered. Visual recovery was achieved in the immediate postoperative period. At discharge, her visual acuity was counting finger in the left eye. Visual recovery in the orbital apex lesions is possible if the patient is diagnosed early and managed promptly but delayed presentation and diagnostic challenges could lead to irreversible blindness.

Orbital Abducens Nerve Schwannoma: A Case Report and Review of the Literature

Intraorbital schwannoma is a rare tumor which accounts for about 1–2% of all neoplasms of the orbit. Orbital schwannomas most commonly arise from the sensory branches of the trigeminal nerve. On the other hand, intraorbital abducens nerve schwannomas are extremely rare, with a search of the English literature identifying only four cases of intraorbital abducens nerve schwannoma. This is the 5th reported case of an orbital schwannoma arising from the terminal branch of the abducens nerve to the lateral rectus muscle. We report a case of an intraorbital abducens nerve schwannoma in a 51-year-old man with no signs of neurofibromatosis. The tumor was totally excised with functional preservation of the nerve by a zygomatic approach with lateral orbitotomy. With knowledge of these anatomic features, total removal of the tumor with preservation of the abducens nerve function might be possible.

Clinical Characteristics and Surgical Treatment of Intraorbital Foreign Bodies in a Tertiary Eye Center.

Intraorbital foreign body is relatively rare and therefore is often misdiagnosed in clinical practice. The purpose of this report is to summarize the clinical features of intraorbital foreign bodies and their surgical management. A retrospective study of clinical cases. Clinical manifestations, imaging findings, and surgical treatments in patients with intraorbital foreign bodies, who were seen at the Zhongshan Ophthalmic Center of Sun Yat-sen University between January 2002 and July 2013, were retrospectively reviewed. Of the 22 cases reviewed, 19 were men and 3 women with a mean age of 22.2 years. Patients ≤14 years of age accounted for 45.5% of the cases. The right orbit was affected in 10 patients and the left in 12 patients. Organic intraorbital foreign bodies comprised 72.7% of the patients. Foreign body locations within the orbit were superior (40.9%), medial (27.3%), lateral (18.2%), and inferior (9.1%). Half of the patients presented with preoperative visual impairments and 45.5% with limited motility/strabismus and ptosis. Orbital imaging revealed that organic foreign bodies consisted of a strip, rod-like high-density image surrounding soft tissue on CT scan and hypointense on both T1WI and T2WI with MRI images. Complete removal of the intraorbital foreign body was accomplished by anterior orbitotomy in 21 patients and lateral orbitotomy in the remaining patients. Removal was achieved in a single surgery for 21 patients whereas 2 surgeries were required for the remaining patients. No postoperative complications were reported in any of the patients. Intraorbital foreign bodies requiring surgical removal mostly involved organic foreign bodies. These were most commonly found in male children. Orbital imaging played a critical role for an accurate presurgical diagnosis. Anterior orbitotomy provided the best surgical outcomes.

Biodegradable Fixation of the Orbital Rim After Lateral Orbitotomy.

To describe authors' experience with repair of the lateral orbital rim with poly-L/DL-lactic acid (PDLLA) biodegradable plates using ultrasonic pin fixation after lateral orbitotomy with bone flap. The authors retrospectively reviewed all patients who underwent a lateral orbitotomy with bone flap for biopsy of orbital tumors at their institution from January 2010 to May 2013. All patients underwent an orbitotomy by either a lateral eyelid crease incision or lateral canthotomy/cantholysis approach. A lateral bone flap was fashioned in the usual manner, extending from the frontozygomatic suture down the lateral rim for approximately 2 cm. The bone flap was repaired in each case with either a 6 or 7 hole PDLLA plate and secured with ultrasonic PDLLA pin fixation. Twenty-four patients were identified who underwent a lateral orbitotomy with bone flap. Of these patients, 10 were repaired with PDLLA plates. The average age of the patients with PDLLA bone flap fixation was 55 years (range 5-85). The average follow-up time was 12.9 months (range 4-42). Indications included 4 lacrimal gland tumors, 4 intraconal tumors, and 2 lateral orbital tumors. Final diagnosis included lymphoma (3), squamous cell carcinoma (1), neuroblastoma (1), amyloid (1), fibrous tissue (1), sarcoidosis (1), cavernous hemangioma (1), and idiopathic orbital inflammation (1). Three patients had edema of the surrounding soft tissues after surgery, all but 1 resolved by postop month 3. There were 2 cases of transient temporal numbness that resolved by postop month 1. There were no cases of vision loss, extraocular motility deficit, infection, or need for removal of the implant before absorption. PDLLA biodegradable plates with ultrasonic pin placement provide a safe, effective means for lateral rim fixation after orbitotomy with bone flap.

Optic Nerve Sheath Fenestration: Current Preferences in Surgical Approach and Biopsy.

Optic nerve sheath fenestration (ONSF) has evolved since its inception in 1872. Surgical approaches include a lateral orbitotomy, a medial orbitotomy, or a superomedial lid crease. The actual fenestration can be done with slits or a window excision with biopsy. Each variation has its advantages and disadvantages. We describe the current preferences in surgical approach and biopsy for ONSF and examine the value of biopsy in patients who have undergone ONSF. Eight-question survey and retrospective, noncomparative case review. All American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) members are invited to participate in a survey and ONSFs from 1998 to 2013 at the University of Iowa Hospital and Clinics. Data from the survey was analyzed and patient records were reviewed. Preferred surgical approach, type of fenestration, and biopsy results. Sixty-four percent of responding ASOPRS members (150/236) have not performed an ONSF in the last year. One third of that group has performed an ONSF in the last 5 years. Fifty-nine percent perform a medial; 10%, a lateral and 31%, a superomedial approach. Seventy-three percent perform a window fenestration, and about half of those surgeons send the specimen for pathologic evaluation. Anecdotally, some biopsies from surgeons who were surveyed have revealed new diagnoses. In a chart review of 90 cases of ONSF, no biopsy gave an unexpected result. The medial approach for ONSF is most common in our respondents; however, the superomedial lid crease incision is gaining popularity for its efficiency and elegance. Three quarters of surgeons remove a window and a quarter fenestrate with slits. Optic nerve sheath biopsy has limited diagnostic value. In the absence of any evidence to suggest a diagnosis other than idiopathic intracranial hypertension, the usefulness of biopsy during fenestration is low.

Clinical analysis of transcranial orbitotomy approach on cranio-orbital tumors.

The aims of this study were to investigate 21 cases of transcranial orbitotomy for cranio-orbital tumors and evaluate the clinical value of the surgical approach. A retrospective study was done on 21 patients with cranio-orbital tumors. According to the tumors' location, shape, boundary, and invasion on the images, coronal scalp flap approach, subfrontal approach, or pterion approach for transcranial orbitotomy was performed. The surgical route was coronal scalp flap approach in 7 cases (including 3 cases combined with lateral orbitotomy), subfrontal approach in 6 cases, or pterion approach in 8 cases (including 1 case combined with evisceration of orbit). Tumors were en bloc resection in 4 cases, block resection or curettage in 13 cases, and incomplete resection in 4 cases. Postoperatively, the mean reduction in exophthalmos was 4 mm; maximum reduction was 11 mm. Ocular movement restriction was made better in 10 of 14 patients, whereas there was no change in 4 of 14 patients. Ophthalmoplegia occurred in 2 cases, complete ptosis occurred in 3 cases, and mydriasis occurred in 3 cases. No vision loss or cerebrospinal fluid leak was observed. Fourteen patients were followed up, including 2 patients with metastatic carcinoma who died dead because of systemic metastasis; 2 patients had a recurrence (schwannoglioma and meningioma). No recurrence was found in the other 10 patients. Cranio-orbital tumors can be removed effectively through transcranial orbitotomy, whereas operative approach is convenient to the surgical procedure and can offer better exposure. Being familiar with the tumors' location, adhesion, and invasion, coupled with the skilled surgical techniques, would improve the results and reduce serious complications.

Intra-conal cavernous haemangioma orbit

Orbital cavernous haemangiomas are most frequent intra-conal, intra-orbital primary tumor in adults. They represent 4% of all orbit tumors and 9-13% of all intracranial cavernous haemangiomas. Forty-two-year-old female came with complaints of protrusion of right eye (RE) since 3 months associated with diminution of vision, headache, and eye ache. Absolute proptometry was 28 mm OD and 20 mm OS. 2 mm of the inferior scleral show was seen in RE. Axial computed tomography (CT) showed unilaterally, moderately enhancing, homogeneous, smooth-contoured mass. The patient underwent right lateral orbitotomy with mass excision under general anesthesia. The histopathological evaluation proved it to be a cavernous haemangioma. We report a case of intra-orbital, intra-conal cavernous hemangioma occurring in a 42-year-old female presenting with proptosis. The tumor was diagnosed on CT and was removed using lateral orbitotomy approach. Patient had significant improvement in symptoms with the mild deterioration of vision.

Lateral orbitotomy approach for removing hyperostosing en plaque sphenoid wing meningiomas. Description of surgical strategy and analysis of findings in a series of 88 patients with long-term follow up.

Background:Sphenoid wing meningiomas extending to the orbit (ePMSW) are currently removed through several transcranial approaches. Presenting the largest surgical cohort of hyperostosing ePMSW with the longest follow up period, we will provide data supporting minilateral orbitotomy with excellent exposure for wide resection of all compartments of the tumor.Methods:A retrospective survival analysis is made of the data cumulated prospectively during a period of 34 years, including 88 cases of ePMSW with a mean follow up period of 136.4 months. The impact of preoperative variables upon different outcome measures is evaluated. Standard pterional craniotomy was performed in 12 patients (C) while the other 76 cases underwent the proposed modified lateral miniorbitotomy (LO).Results:There were 31 men and 57 women. The age range varied between 12 and 70 years. Patients presented with unilateral exophthalmos (Uex) ranging between 3 and 16 mm. Duration of proptosis before operation varied between 6 months and 16 years. The status of visual acuity (VA) prior to operation was: no light perception (NLP) in 16, light perception (LP) up to 0.2 in 3, 0.3–0.5 in 22, 0.6–0.9 in 24, and full vision in 23 patients. Postoperatively, acceptable cosmetic appearance of the eyes was seen in 38 cases and in 46 mild inequality of < 2 mm was detected. Four cases had mild enophthalmos (En). Among those who had the worst VA, two improved and one became almost blind after operation. The cases with VA in the range of 0.3–0.5 improved. Among those with good VA (0.5 to full vision), 2 became blind, vision diminished in 10, and improved or remained full in the other 35 cases. Tumor recurrence occurred in 33.3% of group C and 10.5% of group LO (P = 0.05). The major determinant of tumor regrowth was the technique of LO (P = 0.008).Conclusion:Using LO technique, the risky corners involved by the tumor is visualized from the latero-inferior side rather than from the latero-superior avenue. This is the crucial milestone to achieve aggressive removal of all the involved compartments of the lesion. Satisfactory cosmetic result is reported using mini LO technique after widely exposing and removing the hyperostotic bone down to the subtemporal fossa with only simple repair of the dura without cranioplasty.

Transcutaneous Endoscopic Orbital Surgery: A Less Morbid Alternative to Lateral Orbitotomy

Background: Retrobulbar lesions of the orbit situated lateral to the optic nerve are difficult to access. In this article, the authors would like to present a new perspective to approach these lesions where the goals of surgery are met with minimal complications.Methods: A retrospective analysis of patients’ charts was performed.Results: For approaching retrobulbar lesions an endoscopic technique was developed. Four patients (2 male and 2 female patients) presenting with retrobulbar lesions lateral to the optic nerve have been included in this study. Two patients underwent endoscopic drainage for orbital abscess and two patients were successfully biopsied endoscopically. No intra-operative complications were noted. Open procedures such as lateral orbitotomy were avoided in all the cases.Conclusion: Transcutaneous orbital endoscopy is a safe and a versatile technique to approach retrobulbar lesions lateral to the optic nerve. It can be used as an effective alternative to lateral orbitotomy for well selected cases. One can obtain adequate material for histopathological examination and also drain deep-seated orbital abscess using this technique. It would be possible with increasing experience to use this technique for extended applications.

Recurrent Cholesterol Granuloma of the Orbit

A 40-year-old woman presented with a 1-year history of left proptosis and hypoglobus. Eight years ago, she had undergone the surgical removal of left orbital cholesterol granuloma by Krönlein lateral orbitotomy. MRI showed a lesion of high T1-signal intensity and heterogeneous T2-signal intensity, which did not demonstrate gadolinium enhancement. The lesion was excised via a sub-brow skin incision, and careful drilling and curettage of the affected bony surface of the superolateral orbit were also performed. The diagnosis of orbital cholesterol granuloma was made by histopathologic examination. There was no evidence of tumor recurrence after 2 years of follow up. The authors present a rare case of recurrent cholesterol granuloma of the orbit and its successful surgical treatment with complete excision of the tumor and the surrounding bony base.

Endoscopic lateral orbitotomy.

BackgroundLateral orbitotomy can be minimalized using contemporary endoscopy.MethodsAnatomy of the temporal fossa/orbital wall junction is described. The attachment of the temporal fascia is cut off from the orbital rim through a 1.5 cm skin incision in the lateral orbital wrinkle. The temporal muscle is detached from the bone to create a space for the telescope. An appropriate bone opening in the lateral orbital wall is created with the aid of neuronavigation to handle intraorbital pathology.ConclusionEndoscopic lateral orbitotomy is an original alternative to the microsurgical Krönlein approach and yields good functional and cosmetic results.Electronic supplementary materialThe online version of this article (doi:10.1007/s00701-014-2205-7) contains supplementary material, which is available to authorized users.

Long term surgical outcomes of orbital cavernous haemangiomas (low-flow venous malformations) as performed in a tertiary eye hospital in China

ObjectiveTo assess the long term efficacy and safety of surgical management of orbital cavernous haemangiomas (OCH) as performed in a tertiary eye hospital in China. MethodsA retrospective study with 74 OCH patients treated in the Eye Hospital, at the Zhongshan Ophthalmic Center, of Sun Yat-Sen University was performed covering a period from January 2002 to April 2010. The surgical approach, treatment results and visual outcome were recorded and analysed. ResultsSurgery was performed in all 74 patients and all tumours were completely removed. Among them, 93% of the cases (69/74) underwent anterior orbitotomy, with 43% (30/69) by a cutaneous approach, 57% (39/69) by a conjunctival approach and only 7% of the cases (5/74) used a lateral orbitotomy. The mean follow-up time was 4.6 years (range 2.0 to 10.0 years). Visual acuity improved in 32.4% of cases and deteriorated in 8.2% of cases. No residual proptosis existed. A complicated permanent pupil change was present in three cases and only one case showed a permanent slight motility deficit. Two cases with multiple masses recurred at two years after the first surgery, but neither recurring as assessed at 2 and 5 years after the second surgery. ConclusionsMost OCHs can be removed by anterior orbitotomy, using either a cutaneous or conjunctival approach. Anterior orbitotomy is a safe, convenient and effective surgical approach for OCH.