Orbital Surgery

Orbit is the bony socket that houses the eyeball and all the associated structures that support its function like muscles, nerves and blood vessels.  These are surrounded by fat which acts as cushion to protect the eyeball. A wide array of conditions including infections, inflammations, vascular malformations, trauma and tumors can affect the different structures in the orbit which can inturn compromise the visual function of the eye and eye health.

When these problems occur, patients often present with protrusion of the eyeball (proptosis), double vision, loss of vision, pain and swelling. Evaluation with a trained orbital specialist is important to appropriately evaluate and treat the underlying problem.

1. ORBITAL INFECTIONS

Orbital cellulitis and preseptal cellulitis are the major infections of the ocular adnexal and orbital tissues and are common in children. Orbital cellulitis is an inflammation of the soft tissues of the eye socket behind the orbital septum, a thin tissue which divides the eyelid from the eye socket. Infection isolated anterior to the orbital septum is considered to be preseptal cellulitis.

Most commonly caused by an acute spread of infection into the eye socket from either the adjacent sinuses, skin or from spread through the blood. The most common infectious pathogens include gram positive streptococcal and staphylococcal species.

The diagnosis of orbital cellulitis is based on clinical examination.The presence of orbital signs such as proptosis, pain with eye movements, ophthalmoloplegia, optic nerve involvement as well as fever and leukocytosis confirm the diagnosis. CT scan of the orbit is done and gives the clinician information regarding the presence of sinusitis, subperiosteal abscess, stranding of orbital fat, or intracranial involvement.

In cases of mild to moderate orbital cellulitis with no optic nerve involvement, the initial management of the patient remains medical and requires admission to the hospital and initiation of i.v. antibiotics. The patient is followed closely in the hospital setting for progression of orbital signs and development of complications. In case of orbital abscess formation, surgical drainage of the pus collection may be needed. A multi-disciplinary approach is usually warranted for patients with orbital cellulitis under the care of pediatricians, ENT surgeons and oculoplastic surgeons.

2. ORBITAL TUMORS

These are tumors arising from the various tissues behind and around the eye; present in the bony socket, including muscles, blood vessels, fat, lymphoid tissue, lacrimal gland, optic nerve and peripheral nerves. They can be benign or malignant. Metastatic cancer can come from other parts of the body to form an orbital tumor.

Most patients with orbital tumors notice a bulging of the eyeball or double vision (diplopia). Certain cancers may cause pain and visual loss due to compression of the optic nerve.

Thorough clinical evaluation along with orbital imaging studies like CT or MRI scan help in determining the probable “clinical” diagnosis. Surgical biopsy called an orbitotomy (anterior or lateral) gives the definitive diagnosis about the type and severity of the cancer. During biopsy a specimen is sent to an ophthalmic pathologist who helps determine the exact diagnosis.

When possible, orbital tumors are totally removed. If they cannot be removed or if removal will cause too much damage to other important structures around the eye, a piece of tumor may be removed, sent for evaluation by a pathologist and the patient is treated with radiation and/or chemotherapy. Occasionally an orbital tumor is too big or involves the sinuses and requires more extensive surgery with bone-flaps. In such cases multidisciplinary team approach alongside with ENT surgeon, neurosurgeon and oncologist may be required.

Depending on the size of the tumor, tissue of origin, orbital compartment involved and proximity to vital structures like optic nerve; orbital surgery can have varied complications and the risk : benefit ratio is always taken into account before embarking on surgery. Complications include swelling, bruising, bleeding, double vision which may be transient, decrease or loss of vision.

If tumors cannot be removed during surgery, most orbital tumors can be treated with external beam radiation therapy. Certain rare orbital tumors require removal of the eye and orbital contents. However, in select cases alternative therapies (e.g. orbital radiotherapy and chemotherapy) can be used to treat residual tumor to spare vision and the eye. Depending on grade and stage of disease recurrence rates vary for individual cancers.

3. ORBITAL FRACTURES

Orbital fractures are common after trauma to the face. The thin bones of the eye socket can “blow out” or break into the surrounding sinuses. These fractures can occur in isolation or combined with other facial bone fractures, eyelid lacerations, tear drain injuries, and bleeding within and around the eye. These injuries occur all to commonly from fist fights, car accidents, sporting activities, and even simple falls. Orbital fractures with significant tissue prolapsed into the surrounding sinuses, double vision, or numbness of the cheek and/or lips should be repaired in a timely fashion, usually within several weeks. Surgery performed at a later time may still be worthwhile, but may be less effective. As an oculoplastic specialist, Dr. Adulkar is an experienced orbital surgeon and will evaluate the fracture to determine whether surgery is necessary. She performs the surgery through an incision along the inside of the eyelid, leaving little if any external scars from the fracture repair.