A Plea for Lateral Orbitotomy: With Certain Modifications

THE frontiers of human interest and work are often disputed and, there is no exception in the anatomical dividing lines of the surgical specialties.It is particularly important that the surgeons who meet at the frontier of the orbital walls should know thoroughly how to respect and handle the structures in the neighbouring surgical fields and be prepared to deal effectively with any unexpected operative adversity and complication in their neighbour's region.It seems reasonable to claim that the contents of the orbit should be the province of the eye surgeon.With modem diagnostic aids, particularly good stereo-radiographs, it is possible to be fairly certain that a neoplasm is within the orbit and to note the osseous changes suggestive of intracranial extension which occurs in 16 per cent. of orbital neoplasms.Arteriography and venography, using a 60 per cent.contrast medium (Urografin-Schering), may help the diagnosis in a few cases, particularly a varix of the superior ophthalmic vein.The contrast medium reaches the ophthalmic artery in 98 per cent. of cases and extends to the frontal and supra-orbital arteries in 87 per cent.and in 74 per cent.the choroidal plexus is seen as a crescent.Displacement of the choroidal plexus remarked upon by the radiologists is, I think, of no more diagnostic value than the displacement of the eyeball, and variation in the course of the ophthalmic artery, normally tortuous, is not of great help.Venography by injection of the angular vein through the skin is technically difficult, for the head must be inclined downwards and the frontal and facial veins compressed during the injection.Probably the value in these studies is the demonstration of pathological vascularization around some space-occupying lesions and not in the displace- ment of the ophthalmic artery and choroidal plexus.Injection of sterile air into an orbit may also yield indefinite results.It is, of course, clearly evident that a neoplasm which involves both the orbit and the inside of the cranial cavity, or arises inside the nose, should be attacked by the neuro-surgeon and the ear, nose, and throat surgeon respectively, or by a combined team.When the neoplasm is within the orbit, is retro-ocular, or arises from the lacrimal gland, or is a dermoid with ramifications into the