The eye is a delicate and sensitive organ. An injury to the eye from contact sports or a motor vehicle accident can often result in trauma to the orbit. The orbit is the bony cavity of the skull that surrounds and protects the eye ball and includes muscles and nerves attached to the eye. The most common orbital injuries/disorders include orbital trauma and orbital tumors.
Orbital trauma may be associated with bruising and fracture of the orbital bone. If the trauma is severe, quick action needs to be taken to minimize the risk of long-term damage or vision impairment.Orbital trauma can be broadly classified into two types:
- Blunt force trauma: This type of trauma is more common in children. While at play, children may fall from a bicycle or engage in fist fights causing blunt force trauma which may break the bony orbit.
- Penetrating and perforating trauma: This type of trauma is generally seen in adults and is one of the most severe forms of eye injuries. Motor vehicle accidents or accidents in the workplace involving sharp tools may cause irreparable damage to the eye.
Orbital traumas may lead to eye problems such as double vision, painful eye movement and dramatic alterations to the normal anatomy of the orbit leading to disfigurement. , In severe injury when the eye cannot be saved, reconstructive surgery is employed to place a prosthetic eye. Treatment options will depend on the particular injury sustained. The treatment goal is to restore function and preserve aesthetics of the face.
Surgical Techniques for Treating Orbital Trauma
- Lid laceration repair: Early repair of lid lacerations provides less edema and better protection of the corneal tissue. Your surgeon will administer anesthesia and clean the wound by irrigating it with saline solution. Foreign bodies present in your eye will be removed and injury to the lid margin and canthus (corner point where the eyelids meet) will be repaired. Your surgeon will align the lid margin by using sutures. After the surgery, antibiotic or steroidal ointments may be applied to provide pain relief or prevent infection. A transparent eye shield may be placed to protect the treated eye.
- Lacrimal/Canalicular repair: The canaliculi constitute an important part of the lacrimal drainage system through which tears drain from the eyes. Injuries to the canalicular portion of the tear drainage system can often lead to lacerations of the canaliculi. Canalicular repair surgery is always performed under general anesthesia for children. In case of adults, either local anesthesia or monitored anesthesia with intravenous sedation is provided. The surgery involves microscopic repair and reattachment of the severed ends of the canaliculi.
- Cornoscleral tear repair: Repair of a corneoscleral tear involves treating the cornea, sclera (white part of the eye) and restoring the eyes’ original anatomy. For repairing the laceration, your surgeon will first evaluate the severity of damage, administer anesthesia and then if needed, suture the globe before exploring the wound. Your surgeon will suture the limbus (border of cornea and sclera), and perform procedures to treat the prolapsed iris or vitreous (gelatinous mass filling the space between the lens and back of the eye) if necessary. Your surgeon will then explore the scleral wound and repair the segments of scleral lacerations. The procedure is completed by injecting antibiotics into the vitreous, suturing the conjunctiva (scleral covering) and applying an eye patch.
- Traumatic cataract surgeries: A traumatic cataract develops when the eye lens gets damaged from either a blunt (snow ball, water balloon) or penetrating force. Surgical approaches vary depending on the extent and nature of the damage. A primary surgical approach involves simultaneous removal of the lens and corneal laceration repair, usually undertaken if the lens damage is clear and extensive. In a secondary surgery, the corneal laceration repair precedes cataractous lens removal. The secondary approach may be indicated in cases of severe corneal trauma with marked edema.
- Intraorbital foreign body removal: Any external object that gets embedded inside the orbit is referred to as an intraorbital foreign body (IOFB). An IOFB may get introduced into the eye by a freak accident such as a high-velocity gunshot or a mishap at the work place. Treatment depends on the nature and location of the injury in the eye. Immediate surgical removal is recommended for metal pieces. Also, certain foreign objects are allowed to remain in the eye if the removal is associated with greater damage.
Surgical Techniques for Treating Orbital Tumors
An enhanced understanding of ocular tumors and improved diagnostic capabilities in recent years has resulted in a variety of treatment options for orbital tumors. Depending on your particular situation, surgical options include:
- OSSN Excision + CRYO + AMG: OSSN or Ocular surface squamous neoplasia is an umbrella term for tumors that begin in the conjunctiva and may eventually invade the cornea. The traditional treatment method for OSSN is surgical excision of the tumor. This surgery uses a “no touch technique”, implying that the tumor is not touched with any surgical instruments during the surgery. This is done to reduce the risk of tumor seeding (spread of tumor to adjoining tissues). During this surgery, absolute alcohol is applied over the corneal component of OSSN. The alcohol brings about cellular devitalization allowing the tumor cells to be easily peeled off. The peeled tumor cells are sent for pathological examination.
Double freeze-thaw cryotherapy is applied to the corneal limbus (border of cornea and sclera) and conjunctival margins. Cryotherapy is believed to reduce the recurrence rate by killing the residual tumor cells, if any. Also, as wide margins are recommended in the surgical excision of the tumor, the ocular surface is often left with a large size defect. An AMG (amniotic membrane graft) is used to cover the defect. The AMG is secured on to the sclera with fibrin glue.
- Lacrimal Gland Biopsy: Lacrimal glands are the almond-shaped glands located above and to the side of each eye. Occasionally, the cells in this gland start multiplying abnormally, resulting in tumor of the lacrimal gland. Lacrimal gland biopsy involves removal of a small amount of tissue for microscopic examination in order to make a definite diagnosis of cancer.
- Intralesional steroid injection: Intralesional steroids are injected just inside the septum in the rim of the orbit to treat certain types of orbital tumors. Triamcinolone acetonide is a commonly used intralesional steroid.
- Orbital Incisional Biopsy: During this procedure, a moderate amount of tissue is surgically removed from the mid or posterior orbit and sent to a pathologist for examination. The excised tissue is usually representative of the abnormal orbital tumor. This surgery is performed under general anesthesia.
- Lipodermoid/Dermoid/Epidermoid Excision: Lipodermoid, dermoid and epidermoid are conditions that develop when a normal tissue overgrows in an abnormal location. They differ from each other in composition and their respective locations in the eye. Surgical excision is recommended in dermoid and epidermoid conditions, if the patient suffers from irritation and disturbance of vision. During the surgery, the skin overlying the dermoid is cut open along with the adjoining tissues to reveal the dermoid. The dermoid is then excised free of the surrounding tissue. Surgery is very rarely recommended in lipodermoids because of associated complications.
- Orbitotomy + Debulking: The surgical biopsy to examine and make a definite diagnosis of orbital tumors is called orbitotomy. There are different types of orbitotomies such as Lateral Orbitotomy, Anterior Orbitotomy, Medial Orbitotomy, and a combination of the Lateral and Medial Orbitotomies. One of these different orbitotomy procedures is used depending on the location and the size of the tumor. At times, it is not possible or advisable to remove the entire tumor. In such instances, only a part of the malignant tumor is removed by a surgery called debulking.
- Exenteration: Exenteration of the orbit is a surgical procedure to treat potentially life-threatening malignant tumors that involve the eyelids or structures around or behind the eye. This is an extensive surgery during which the eye ball, the surrounding tissue, conjunctiva and eyelids are removed. The socket is reconstructed with the help of a split thickness skin graft usually taken from the thigh. Exenteration surgery is a “last-resort” surgery undertaken only when the tumor cannot be completely removed by other treatment interventions that leave the eye ball intact with the hope of retaining vision.
- Conjunctival Biopsy + AMG: Conjunctival biopsy is a safe diagnostic procedure for well-circumscribed (with definite boundaries) anterior orbital tumors that include hemangioma, schwannoma, and soft tissue dermoid cysts. During this procedure, an incision is made in the fornix (space behind the eyelids) of the conjunctiva. Using scissors and cotton applicator sticks, blunt dissection is carried out until the tumor is exposed. The next attempt is directed to extract the tumor intact. The tumor sample is sent to a pathologist for microscopic examination. An AMG (innermost layer of placenta) is used to reconstruct the conjunctival defect following removal of the tumor. Conjunctival biopsy is simple, has low morbidity, is cost-effective and is a less time consuming procedure.