Orbital surgery is a specialized field focusing on the delicate structures within the bony eye socket, known as the orbit. This procedure addresses conditions affecting the eye, surrounding muscles, nerves, and connective tissues within this confined space. The primary goals of orbital surgery are to protect vision, restore proper function, and often improve the appearance of the eye and face. Due to the sensitive nature of these structures, surgeries are typically performed by highly trained oculoplastic surgeons, sometimes collaborating with neurosurgeons or ear, nose, and throat (ENT) specialists.
Understanding the Orbital Region
The orbit is a roughly pyramidal, rigid bony cavity that houses and protects the eyeball (globe). This socket is formed by seven different bones and tapers toward the back of the skull, connecting to the brain cavity through channels for nerves and blood vessels.
Within this limited space, the orbit contains the globe, the extraocular muscles for eye movement, the optic nerve, and the lacrimal gland for tear production. It also includes fat and connective tissue that cushions and stabilizes the eye. The bony walls of the orbit are thin in places, especially on the floor and the medial side, making them susceptible to trauma and allowing communication with the adjacent sinuses and the brain.
Conditions That Require Orbital Surgery
A variety of serious medical conditions and traumatic injuries can affect the orbit, necessitating surgical intervention to prevent vision loss or severe disfigurement.
One common reason for surgery is the presence of an orbital tumor or cyst, which may be benign or malignant. These growths can press on the optic nerve or displace the eyeball, causing blurred vision, double vision, or noticeable bulging.
Orbital trauma frequently requires surgical repair, particularly for a “blowout fracture,” where blunt force breaks the thin bones of the floor or medial wall. If a large fracture occurs, orbital contents like fat or muscle can drop into the adjacent sinuses, potentially trapping eye muscles and causing severe double vision or a sunken appearance. Trauma surgery involves realigning and securing fractured bones, often using plates or implants, to restore the orbit’s anatomy.
Thyroid Eye Disease (TED), also known as Graves’ orbitopathy, is another frequent indication. This autoimmune condition causes inflammation and swelling of the eye muscles and fat, increasing pressure within the orbit. This excess pressure can push the eyes forward (proptosis) and may compress the optic nerve, potentially leading to permanent vision loss.
Other conditions demanding orbital surgery include severe infections, such as an orbital abscess or cellulitis, which require immediate drainage to prevent infection spread. Inflammatory conditions and congenital anomalies resulting in a deformed eye socket may also be treated surgically. Surgery is often performed to obtain a tissue sample (biopsy) for diagnosis, in addition to removing the mass or foreign body.
Common Surgical Approaches
The surgical method depends on the location, size, and nature of the problem being treated. The primary goal is to reach the affected area with minimal disruption to healthy tissue and maximum preservation of vision.
For lesions near the front of the eye socket, a minimally invasive approach is preferred, often using incisions hidden within the eyelids or the inner corner of the eye. These include transconjunctival or transcaruncular approaches, which involve incisions through the conjunctiva or the pink tissue at the inner corner of the eye. This technique avoids external skin scars, making it cosmetically appealing for repairing orbital floor fractures or accessing certain tumors. When a lesion is more anterior, transcutaneous approaches are used, with external incisions placed in natural folds like the eyelid crease or under the brow.
For deeper or more complex lesions, especially those near the back of the orbit, surgeons may use more extensive methods, sometimes collaborating with other specialists. The endoscopic endonasal approach accesses the orbit through the nasal cavity and sinuses, often used for medial wall tumors or orbital decompression. Orbital decompression, common for severe Thyroid Eye Disease, involves removing or thinning bony walls and sometimes removing orbital fat to create space, allowing the eye to settle back and relieving pressure on the optic nerve.
Preparation and Post-Operative Care
Preparation for orbital surgery typically begins with detailed imaging, such as a CT scan or MRI, to accurately map the pathology and plan the surgical route. Patients are advised to stop taking blood-thinning medications and certain supplements, like aspirin or Vitamin E, for up to two weeks before the procedure to minimize bleeding risk. A responsible adult must be available to drive the patient home and provide assistance for the first 24 hours following the operation.
Following the procedure, patients should expect a recovery period, with the initial phase lasting about one to two weeks. Swelling and bruising around the eyes are common and are managed by applying cold compresses and keeping the head elevated, including sleeping with two or three pillows. Patients are instructed to avoid strenuous activities, heavy lifting, and bending over, as these actions can increase pressure in the head and potentially cause complications.
Specific restrictions, such as avoiding blowing the nose or drinking through a straw after a fracture repair, are given to prevent air from entering the soft tissues around the eye. Follow-up appointments monitor healing, remove any non-dissolvable sutures, and check for complications like temporary double vision. Complete recovery time and follow-up care vary based on the complexity of the original condition and the extent of the surgical intervention.