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Glossary orbital walls subtend a 90 angle, and the medial walls are
roughly parallel to each other.
Cantholysis A surgical section of a canthus or a
canthal ligament.
Canthotomy An incision of the canthus.
The Orbital Rim
Dehiscence The opening of a previously closed The orbital rim is formed superiorly from the frontal
wound. It is often associated with contents emerging bone, laterally from the zygomatic bone, and inferiorly
from the open wound. from the zygomatic and maxillary bones (Figure 2). The
Enophthalmos A posterior displacement of the inferior-medial portion of the rim continues to form the
eyeball into the orbit. anterior lacrimal crest on the frontal process of the max-
Hypertelorism An increase in the interorbital illa, whereas the superior-medial rim continues to form
distance. the posterior lacrimal crest. Throughout, the rim is
Hypoesthesia Decreased tactile sensitivity. mainly rounded and thickened (greatest laterally). This
Lagophthalmos An incomplete or defective serves to protect the eye from trauma.
closure of the eyelids. A neurovascular bundle traverses through the medial
Meningitis An inflammation of the protective third of the superior rim. Often (75%), it consists of a
membranes covering the central nervous system. notch and the remainder of the time it travels through a
Mucocele A soft mucus-filled enlargement. true foramen, the supraorbital foramen. This is an impor-
Oculocardiac reflex A decrease in the pulse rate tant landmark both for brow surgery and to facilitate the
associated with traction applied to the extraocular identification of the inferior oblique. A vertical line from
muscles and/or compression of the eyeball. the notch to the inferior rim is the point anterior to where
Proptosis A forward displacement of the eye in the the inferior oblique originates. The infraorbital foramen,
orbit. conducting the infraorbital artery, vein and nerve, is also
Trochlea The fibrous loop in the superiomedial located in this vertical plane, usually 410 mm below the
orbit through which the tendon of the superior oblique central portion of the rim. When performing orbital floor
muscle passes. surgery, care must be taken in elevating the periosteum
below this level so as not to injure this bundle.
210
Orbital Bony Anatomy and Orbital Fractures 211
Figure 1 Anterior view of the bony orbit with horizontal and vertical dimensions indicated.
Figure 2 Anterior view of the bony orbit with the bones that form the orbital margin identified.
Figure 4 Inferior view of the roof of the bony orbit with the main bones identified.
Orbital Floor (Blowout) Fracture Using a curved iris scissors or monopolar cautery, the
incision is carried down to the lateral orbital rim perios-
Various approaches to the orbital floor have been
teum over the zygoma. The inferior crus of the lateral
described, including a subciliary incision or through a
canthal tendon is released (Figure 8(b)). The conjunctiva
laceration of the lower lid sustained during the injury;
and inferior lid retractors are incised just below the tarsus
however, the degree of postoperative sequelae, including
from the lateral canthus incision to just lateral to the
lower-eyelid retraction and lagophthalmos, has led to a
caruncle (Figure 8(c)). A Desmarres retractor can be
shift to a tranconjunctival approach. This approach is
used to retract the tarsal conjunctiva anteriorly. The inci-
associated with fewer complications and has gained wide-
sion is carried down to the orbital rim periosteum.
spread acceptance.
A malleable retractor is then used to retract the orbital
First, local anesthesia is infiltrated into the lateral canthal
septum and fat. The inferior orbital rim periosteum is
and lower eyelid with 1% lidocaine with epinephrine
incised and gently dissected from the orbital floor with a
(1:100 000) mixed 50:50 with 0.5% Marcaine (bupivacaine).
periosteal elevator (Freer or Coddle elevator; Figure 8(d)).
Forced ductions are performed bilaterally to determine
The malleable retractor is then repositioned in the subper-
the amount of restriction prior to repair. A 1015-mm
iorbital plane, and using a hand-over-hand technique, the
lateral canthotomy is performed in a relaxed skin tension
fracture is exposed (Figure 8(e)). Herniated orbital tissue is
line using a No. 15 Bard-Parker blade (Figure 8(a)).
Figure 8 (a) A lateral canthotomy incision is made down to the periosteal level in order to expose the lateral canthal periosteum. This is
important in order to be able to reattach the tarsoteninous strap. (b) Next, a lateral cantholysis is performed, which detaches the inferior
crus of the lateral canthal tendon from the lateral orbital rim. (c) This incision is made transconjunctivally to extend the horizontal length
of the eyelid to the caruncle medially, at a distance of 4 mm below the inferior border of the tarsus. (d) Using a periosteal elevator, the
subperiosteal dissection is begun. The periosteum is thicker at the arcus marginalis, and can be grasped to aid dissection. (e) The
retraction of the orbital contents superiorly is performed with a malleable retractor, and a subperiosteal pocket is formed. (f) Herniated
orbital tissues are elevated in order to visualize the fracture site completely and ensure there is no remaining trapped tissue remaining at
the fracture site.
Orbital Bony Anatomy and Orbital Fractures 215
Figure 9 (a) The retractors and periosteum are closed, followed by reattachment of the lateral canthal tendon to the periosteum at
the lateral orbital rim. (b) Careful approximation of the eyelid margins during closure is important, which are here closed using a
horizontal mattress suture.
through the conjunctiva and Tenons capsule just medial fracture site with blunt dissection until the entire rim of
to the bulk of the caruncle and extends superiorly and the fracture can be identified. The fracture can be
inferiorly in the fornices. Dissection is then carried just enlarged if the orbital contents are entrapped.
posterior to the lacrimal sac. A malleable retractor is used A template is cut and placed over the fracture site to
to retract the globe and orbital tissues. The periosteum is adequately span the entire bony defect. An alloplastic
incised posterior to the lacrimal sac, and periosteal eleva- sheet of Medpor is then cut using the template and placed
tors are used to expose the fracture. Once all edges of the over the defect. If the defect is greater than 50% of the
fracture have been exposed, a Medpor sheet, or equivalent medial wall or unstable, a combined titanium alloplastic
barrier sheet, can be placed to cover the entire fracture sheet (MED TITAN) can be used to fix the defect. Care
(Figure 11). No fixation screws or sutures are needed. must be taken to protect the lacrimal sac by placing a
Forced ductions are then checked to assure there is no notch in the sheet. Combined floor and medial wall frac-
entrapment of muscle. tures are repaired using the lateral canthotomy approach
Lynch incision or a direct approach can be used if the to the floor combined with the medial Lynch or transcar-
fracture is large or if combined with a large floor defect. uncular approach. The anterior periorbita is closed with
The medial canthal area is infiltrated with local anes- 5-0 polyglactin suture in an interrupted fashion, the
thetic. The Lynch incision is performed by marking a deep tissues are closed with interrupted or running 5-0
gull wing approximately 5 mm anterior to the medial polyglactin suture, and the skin is closed with a running
canthus (Figure 12). Hemostasis is obtained with mono- 6-0 Fast Absorbing Plain Gut suture. Antibiotic ointment
polar cautery and the periosteum is exposed. The perios- is applied over the wound.
teum is incised and elevated using a Freer elevator. The
lacrimal sac and medial canthal tendon are elevated with
ZygomaticMaxillary Complex Fractures
the periosteum. A malleable retractor is positioned in the
(Tripod)
subperiosteal space, and the full extent of the fracture is
exposed (Figure 13). Then, as with the smaller fractures, Zygomaticmaxillary complex fractures involve the infe-
the herniated orbital tissue is gently elevated through the rior and lateral orbital rim, zygomatic arch, and lateral
Figure 11 (a) Axial view of the transcaruncular approach to the medial extraperiosteal orbital space, indicated by the black arrow.
(b) View of the medial orbital wall. Retractors are used to displace the lacrimal sac medially, while another retractor displaces the
orbital contents temporally.
Figure 12 (a) Lynch incision. (b and c) Variations of the standard Lynch incision.
Orbital Bony Anatomy and Orbital Fractures 217
wall of the maxillary sinus. Left uncorrected, these frac- tarsal conjunctiva inferiorly, and the incision is deepened
tures may produce flattening and depression of the cheek to the orbital periosteum. The orbital septum and fat are
in addition to impingement on the coronoid process of the retracted with a malleable retractor and the inferior
mandible, leading to pain and difficulty in opening the orbital rim periosteum is incised. A periosteal elevator is
mouth. These fractures should be repaired within the first used to dissect the periosteum from the orbital floor and
2 weeks of injury with open, meticulous anatomic reduc- malleable retractors are then used to expose the full
tion of the fracture and fixation. extent of the fracture using a hand-over-hand technique
The lateral canthal and lower-eyelid areas are infil- (Figure 8). To ensure the exact realignment and stabili-
trated with local anesthetic. A lateral canthotomy is per- zation of the maxillary buttress, a superior buccal sulcus
formed as shown in Figure 8. Using the monopolar incision is made from the base of the canine to the base of
cautery, the incision is carried down to the lateral orbital the second bicuspid (Figure 14). The subperiosteal plane
rim periosteum over the zygoma. The upper and lower is created to expose the fracture. The displaced bone is
crus of the lateral canthal tendon are released, and the reduced to the correct anatomic position using a towel
lateral wall periosteum is incised 2 mm lateral to the clip or Kolker clamp. The fragments can be stabilized with
orbital rim and gently dissected from the zygoma and miniplates. The periosteum over the lateral and inferior
maxillary bone to define the fracture sites. The perios- orbital rims is closed with interrupted 5-0 polyglactin
teum is then dissected from the lateral orbital wall. The sutures. The upper and lower crus of the lateral canthal
conjunctiva and inferior lid retractors are incised below tendon are reunited with a 5-0 polyglactin suture, and this
the tarsus from the lateral canthus to just lateral to the suture is secured to the lateral orbital periosteum. The
caruncle. A Desmarres retractor is used to retract the lateral canthal angle is reformed with a 6-0 polyglactin
suture placed in the gray line of the upper, and then lower,
eyelid. The lateral canthotomy skin incision is reapproxi-
mated with 6-0 Fast Absorbing Plain Gut suture in a
running or interrupted fashion. The conjunctival incision
is not closed, whereas the buccal incision is closed with
3-0 chromic sutures. Antibiotic ophthalmic ointment is
placed in the inferior fornix and over the lateral canthus.
Postoperative Care
Figure 14 (a) At 1015 mm superior to the mucogingival junction, a gingivobuccal (sublabial) incision is made at the level of the first
molar tooth. (b) As the incision proceeds anteriorly, it is made for inferiorly as it nears the piriform rim. This is 5 mm superior to the
mucogingival junction.
218 Orbital Bony Anatomy and Orbital Fractures
eyelid because of tense swelling should be evaluated migration, motility restriction, infection, globe elevation,
immediately and may necessitate the release of sutures cyst formation, proptosis, and optic nerve trauma. As
and a return to the operating room to manage any persis- mentioned earlier, care should be taken to avoid injury
tent bleeding. Pupils are often unreliable after surgery to the lacrimal sac by appropriately sizing the implant and
due to the effects of epinephrine in the local anesthetic cutting a notch as described. A thorough understanding of
and systemic medications given by the anesthesia staff. orbital and facial anatomy combined with appropriate
As with care following orbital fractures, patients are surgical techniques will help limit these complications.
warned not to blow their nose as air can enter into the
orbit, and, if allowed to develop sufficient pressure, it can See also: Cranial Nerves and Autonomic Innervation in
lead to vision loss via central retinal artery occlusion. Air the Orbit; Orbital Masses and Tumors; Orbital Vascular
in the orbit can be drained with a large bore needle and Anatomy.
syringe of sterile water. The presence of bubbles in the
water confirms the release of air. Intravenous antibiotics
are recommended at the time of surgery if an implant is Further Reading
placed, and generally the patients are given postoperative
antibiotics for 57 days. Antibiotic ointment is placed in Doxanas, M. T. and Anderson, R. L. (1984). Clinical Orbital Anatomy.
the fornices and on any surgical wounds at the end of the Baltimore, MD: Williams and Wilkins.
Dutton, J. J. (1994). Atlas of Clinical and Surgical Orbital Anatomy.
surgery and then used twice a day for 1 week. Sports and Philadelphia, PA: W.B. Saunders Company.
significant exertion can be resumed around 6 weeks post- Wobig, J. L. and Dailey, R. A. (2004). Oculofacial Plastic Surgery. New
operatively. York: Thieme.
Zide, B. M. and Jelks, G. W. (2006). Surgical Anatomy around the Orbit:
Complications associated with orbital implants are The System of Zones A Continuation of Surgical Anatomy of the
infrequent; however, they may include fistula formation, Orbit. Philadelphia, PA: Lippincott Williams and Wilkins.