The Upper Lid Split Orbitotomy: Review of Technique and Case Report

            The surgical approach options are limited when intraconal or superomedial extraconal access is necessary in the orbit.  A transverse upper eyelid approach provides access to this area, but does so at the expense of transecting the levator apparatus leading to postoperative ptosis.  Conversely, a vertically oriented incision of the upper eyelid only divides the muscles and allows appropriate function post-operatively.  Meticulous closure ensures appropriate realignment of the tarsus and lid border to provide cosmesis. In the case report included in this review, a patient sustained multiple gun shot wounds and had a retained foreign body in the right superomedial orbit. This report reviews that case, and the surgical technique.

In order to expose the superomedial orbit or intraconal space, a vertically oriented, full-thickness incision is planned.  It is designed to be perpendicular to the tarsus at the junction of the medial third and lateral two thirds of the upper eyelid. This incision traverses the skin, tarsus, orbicularis and palpebral conjuctiva.  It is critical that this incision be perpendicular to the lid margin to allow for esthetics and to prevent transection of any portion of the levator apparatus.  The incision is continued with the scissors, splitting Müller’s muscle to the fornix of the eyelid, extending into the bulbar conjuctiva to the limbus. The extraconal fat exposed in this space is dissected bluntly, exposing the superior and medial recti muslces, as well as the superior oblique.  Care must be taken at this stage not to damage the superior oblique tendon as it loops posterolaterally from the trochlea.  Blunt dissection is utilized to locate the area of surgical interest in the extraconal or intraconal spaces. Intraconal access is available via dissection between the superior and medial rectus muscles.  Caution is to be had while dissecting in this area to avoid damaging important neurovascular structures that came into the field (supraorbital nerves, supratrochlear nerve, infratrochlear nerve, supraorbital artery/vein, supratrochlear artery/vein).  Upon access to the area of interest, the planned procedure (biopsy, muscle release, retreival of foreign body, etc.) can be carried out.  After completion of the procedure, perfect reapproximation of the lid margins and tarsus during closure allow for cosmesis upon healing. 

The patient reported in this review sustained a gunshot wound to the right cheek with the bullet retained in the right superomedial orbit.  Given the location of the bullet on the available imaging, the most appropriate surgical approach for foreign body retrieval was the vertical lid split.  This approach was carried out, and the bullet was retrieved successfully.  Meticulous closure was performed to realign the tarsus, muscle, skin and conjuctiva and the patient had a good cosmetic result during his time in follow up.

          This approach is seldom reported in the literature likely as a result of the infrequency in the necessity to employ it.  It allows a safe, simple dissection to the intraconal and superiomedial extraconal spaces of the orbit.  The key with this approach is in the perpendicularity in relation to the levators and tarsus followed by meticulous tarsal realignment during closure.  Adherence to these two principles will allow for appropriate cosmesis upon healing.

References

1. Smith B. The anterior surgical approach to orbital tumors. Trans Am Acad Ophthalmol Otolaryngol 1966;70:607-11.
2. Prabhakaran VC, Selva D. Vertical lid split approach for optic nerve sheath decompression. Indian Journal of Ophthalmology 2009;57(4):305-6.
3. Ing E. Vertical Upper-Lip Split Incision for Access to a Severely Restricted Superior Rectus Muscle in a Patient with Graves Ophthalmopathy. Journal of American Association for Pediatric Ophthalmology and Strabismus 2005;9:394-5.
4. Kersten RC, Kulwin DR. Vertical lid split orbitotomy revisitied. Ophthal Plast Reconstr Surg 1999; 15:425-8.