Lateral micro-orbitotomy as the technique of choice for orbital pseudotumor in IgG4-RD. Case report and review of the literature.

Immunoglobulin G4-related disease (IgG4-RD) is characterized by a systemic fibroinflammatory infiltrate that often involves the orbit in addition to other tissues. Thus it has to be considered in the differential diagnosis of orbital tumors. We report the clinical case of a 64-year-old woman who presented with right mydriasis, progressive proptosis and paralysis of the third cranial nerve of 1 year of evolution. Cranial MRI identified an intraconal lesion of the right orbit, located between the external and inferior rectus muscles and the optic nerve, and she was scheduled for surgery by transcranial approach with lateral micro-orbitomy. A satisfactory macroscopic excision was achieved with no remarkable complications and a definitive deferred histological result of pseudotumor by IgG4-RD. Follow-up for 24 months showed no tumor recurrence, and the patient clinically improved from ophthalmoplegia. This case highlights the efficacy of lateral orbitotomy in the etiologic diagnosis and successful therapeutic outcome of complex orbital lesions associated with IgG4-RD pseudotumor.

The Lateral Orbitotomy Approach for Intraorbital Lesions.

The lateral orbitotomy approach (LOA) was first described by Kronlein in 1888 and has since been subject to many modifications and variations. When considering orbital approaches, the location of the pathology is often more important in decision making than the type of pathology. The LOA is best suited for access to intraconal and extraconal lesions lateral to the optic nerve. Pathologies treated via the LOA include primary orbital tumors, extraorbital tumors with local extension into the orbit, and distantly metastatic lesions to the orbit. These all often initially manifest with vision loss, oculomotor deficits, or proptosis. The expertise of a multidisciplinary team is needed to execute safe and effective treatment. Collaboration between many specialties may be required, including ophthalmology, neurosurgery, otolaryngology, plastic surgery, oncology, and anesthesiology. The modern technique involves either a lateral canthotomy or eyelid crease incision with removal of the lateral orbital wall. It affords many advantages over a pterional craniotomy, primarily a lower approach morbidity and superior cosmetic outcomes. Reconstruction is fairly simple and the rate of complications-vision loss and extraocular muscle palsy-are low and infrequently permanent. Deep orbital apex location and intracranial extension have traditionally been considered limitations of this approach. However, with increased surgeon comfort, modern technique, and the adoption of endoscopy, these limits have expanded to even include primarily intracranial pathologies. This review details the LOA, including the general technique, its indications and limitations, reconstruction considerations, complications, and recent data from case series. The focus is on microscopic access to intraorbital lesions.

Pure Endoscopic Lateral Orbitotomy Approach to the Cavernous Sinus, Posterior, and Infratemporal Fossae: Anatomic Study.

Objective The aim of this anatomic study is to describe a fully endoscopic lateral orbitotomy extradural approach to the cavernous sinus, posterior, and infratemporal fossae. Material and Methods Three prefixed latex-injected head specimens (six orbital exposures) were used in the study. Before and after dissection, a computed tomography scan was performed on each cadaver head and a neuronavigation system was used to guide the approach. The extent of bone removal and the area of exposure of the targeted corridor were evaluated with the aid of OsiriX software (Pixmeo, Bernex, Switzerland). Results The lateral orbital approach offers four main endoscopic extradural routes: the anteromedial, posteromedial, posterior, and inferior. The anteromedial route allows a direct route to the optic canal by removal of the anterior clinoid process, whereas the posteromedial route allows for exposure of the lateral wall of the cavernous sinus. The posterior route is targeted to Meckel's cave and provides access to the posterior cranial fossa by exposure and drilling of the petrous apex, whereas the inferior route gives access to the pterygopalatine and infratemporal fossae by drilling the floor of the middle cranial fossa and the bone between the second and third branches of the trigeminal nerve. Conclusion The lateral orbitotomy endoscopic approach provides direct access to the cavernous sinus, posterior, and infratemporal fossae. Advantages of the approach include a favorable angle of attack, minimal brain retraction, and the possibility of dissection within the two dural layers of the cavernous sinus without entering its neurovascular compartment.

Lateral orbital approach: Gateway to intraorbital lesions.

Several approaches to the intraorbital space have been described in the literature. Selection of a proper approach to intraorbital lesions depends on various factors including the location of the tumor, the size of the lesion, and the probable pathology anticipated. The approach should provide a good exposure of intraorbital anatomical structures, allow their functional preservation, and provide good cosmetic results. Intraconal lesions of the orbit usually necessitate transcranial approaches although some intraconal and laterally situated lesions could be removed effectively via lateral orbitotomy. Lateral orbitotomy is a well-known approach for lesions of the lateral orbital cone. In this case report, the lateral orbital approach has been used for exposure of intraorbital lesion, as it is minimally invasive compared to the transcranial approach.

Evaluation of the lateral orbital approach in management of zygomatic bone fractures.

Zygomatic maxillary fractures, also known as tripod fractures, are usually the result of a direct blow to the body of the zygoma. Tripod fracture consists of (a) zygomatic arch fracture, (b) fracture of the lateral orbital wall, and (c) fracture of the inferior orbital floor. The purpose of this study is to evaluate the functional and esthetic outcome following this lateral orbital approach in the management of zygoma fracture. This study was carried out in VMS Dental College, Salem, and in a private hospital. This study was based on the experience gained from a retrospective study of the 30 lateral orbital approaches that were used in 30 patients with fractures of the zygomatic complex, which were conducted for a period of 8 years between January 2003 and January 2011. In the retrospective study, all the 30 patients were able to open the mouth completely; eyeball movements were normal; esthetically, all patients appeared normal. There were no sinusitis or visual problems in any of the studied patients. We conclude that the lateral orbital approach is an ideal option in reduction and treatment of zygomatic bone and arch fractures.