Neurosurg Focus 10 (5):Article 3, 2001, Click here to return to Table of Contents

Surgery for orbital tumors. Part II: transorbital approaches

KIMBERLEY P. COCKERHAM, M.D., GHASSAN K. BEJJANI, M.D.,

JOHN S. KENNERDELL, M.D., AND JOSEPH C. MAROON, M.D.
Department of Ophthalmology, Allegheny General Hospital; and Department of Neurosurgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Orbital tumors can be excised or biopsy samples obtained via transorbital approaches, especially those located in
the anterior two thirds of the orbit. The indications and various surgical steps will be reviewed for the anterior, the
anteromedial, and the lateral approaches. Some of these approaches can be combined or extended to accommodate
large or deep-seated tumors.

KEY WORDS • orbital tumor • transorbital approach • orbitotomy •

anteromedial approach • tumor excision

Tumors may occur in all parts of the orbit. The key to
appropriate surgical management is to obtain good-quali-
ty preoperative imaging studies because even anteriorly
located lesions may have posterior extensions that are not
appreciated on clinical examination. Dermoid cysts, for
example, may have a dumbbell shape and intracranial ex-
tension. The safest yet most direct approach should be
used to reach orbital tumors or inflammatory processes. A
multidisciplinary approach with extraorbital approaches is
essential in complex tumors that involve multiple regions
or deep-seated orbital tumors that cannot be reached by
orbitotomy alone.10,16
TYPES OF TRANSORBITAL APPROACHES
There are four primary routes by which transorbital le-
sions can be reached: 1) the anterior orbitotomy without
osteotomy (superior [eyelid, supraorbital or subbrow inci-
sion] or inferior [transconjunctival, subciliary, or lower
eyelid incision]), or with osteotomy of the superior orbital
rim (for large lesions); 2) lateral orbitotomy; 3) medial or-
bitotomy; and 4) a combination of the lateral and medial
orbitotomies.
ORBITAL APPROACHES
Anterior Orbitotomy
The anterior approach to the orbit is useful for lesions
of the anterior two thirds of the orbit.5,7,8,12,14 This approach
was devised by Knapp11 in 1874 and popularized by Ben-
edict.2 The anterior orbitotomy is a misnomer because
bone removal is often not required. A biopsy sample of
infiltrating anterior orbital lesions is usually easily ob-
tained by fine needle aspiration. If this technique fails or
is unavailable, an anterior approach with incisional biop-
sy sampling can be performed. The place of incision is de-
termined by the tumor location (Fig. 1). A superior mass,
for instance, can be approached through an eyelid crease
incision or a supraorbital or subbrow incision.
Eyelid Crease Approach for Incisional Biopsy Sam-
pling of the Lacrimal Gland. A biopsy sample of lacrimal
gland lesions, such as lymphoma, sarcoidosis, or nonspe-
cific orbital inflammation, can be obtained through an
eyelid crease incision (Fig. 2). The procedure may be per-
formed after the patient has received a local anesthetic and
intravenous sedation in some cases, although general an-
esthesia is usually preferred because the lacrimal gland is
typically not easily anesthetized. The eyelid crease on the
affected side is marked and injected with a local anesthet-
ic. The skin and orbicularis fibers lateral to the region of
the levator are incised. Hemostasis is achieved using cau-
terization. Blunt dissection is carried down to the level of
the lacrimal gland. A biopsy specimen is then obtained
using an Ellman radiofrequency unit with the loop attach-
ment, a No. 15 blade, or blunt-tipped Westcott scissors.
Because the inflamed lacrimal gland can bleed briskly,
care must be taken to achieve complete hemostasis prior
to skin closure. A pressure patch is placed on the wound.
Biopsy samples of superior extraconal lesions are ac-
quired in a similar fashion, usually through a supraorbital
incision or subbrow incision.

Neurosurg. Focus / Volume 10 / May, 2001 1

 K. P. Cockerham, et al.

Fig. 1. Diagram showing incisions for orbital approaches. Reprinted with permission from Kennerdell, et al., Practical
Diagnosis and Management of Orbital Diseases. Boston: Butterworth-Heineman, 2001.

Subbrow Approach to Superior Orbital Lesions. The
steps highlighting this approach are shown in Fig. 3. An
incision is made through the lower-brow follicles, parallel
to the orientation of the brow hair, to preserve as many fol-
licles as possible. The incision is continued to the level of
the orbital bone. The skin and subdermal tissues are re-
tracted. The periosteum (periorbita) is incised and dissect-
ed from the orbital bone, and the lesion is usually imme-
diately visible.
A pediatric Alice clamp or cryoprobe can be used to
pull the lesion forward as the blunt Westcott scissors and
long cotton-tipped applicators are used to release all adhe-
sions. Hemostasis is achieved with cauterization. The per-
iorbital incision may be closed with interrupted No. 5-0
vicryl sutures before closing the dura. A pressure patch is
placed on the wound.
Superior Approach With Superior Osteotomy. The
steps of this approach are illustrated in Fig. 4. Larger ex-
traconal superior orbital lesions cannot be removed by the
more simple approach. A superior osteotomy is needed.
The incision is made in a subbrow or in a supraorbital
position, and its horizontal extent should be generous (at
least 3 cm). A combination of No. 4-0 silk sutures and
retractors is used to improve visualization of the mass.
The supratrochlear and supraorbital neurovascular bun-
dles are visualized and preserved. The superior orbital rim
is removed using a sagittal saw. A cryoprobe or Alice
clamp is then used to remove the tumor, and the bone is
replaced and secured with titanium miniplates. In cases
of posterior superior orbital lesions, a craniotomy is nec-
essary.
A transconjunctival route may be used to approach infe-
rior orbital lesions, through a skin incision (subciliary or
lower eyelid) or via an extraorbital approach. The cryo-
probe is useful for extraction of deeper orbital masses.
Lateral Orbitotomy
The lateral approach was first proposed by Kronlein13 in
1889, and it was later modified by Berke.3 In 1976 we
described our modification of the Berke technique, advo-
cated the use of the surgical microscope, and designed
special microinstrumentation and a self-retaining orbital
retractor.15
The lateral orbitotomy is useful for retrobulbar lesions,
and it can be extended for more posterior lesions. The pro-
cedure involves temporary removal of the lateral wall of

Fig. 2. Diagrams illustrating an anterior orbitotomy performed via an eyelid crease approach. The skin and orbicularis
fibers are incised lateral to the region of the levator (A). The lesion is exposed and a biopsy sample is obtained (B) before
skin closure (C). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of Orbital
Diseases. Boston: Butterworth-Heineman, 2001.

2 Neurosurg. Focus / Volume 10 / May, 2001

Transorbital surgical approaches

terior wall is completed using a combination of rongeurs

and drills. The extent of resection depends on the location
of the lesion. The exposure can be extended posteriorly all
the way to the orbital apex.1,4
The lateral orbital periosteum is identified. A traction
suture is then placed under the lateral rectus muscle dis-
tally so that by pulling the traction suture the movement of
the muscle can be identified under the periorbita.
A periorbital incision is made, avoiding the lateral rec-
tus muscle (Fig. 5). The microscope is used if desired. The
lateral rectus is retracted inferiorly or superiorly, depend-
ing on the tumor location. Handheld retraction is used to
retract the globe anteriorly and to retract the orbital soft
tissues.
When the tumor is identified, it is dissected using sharp
and blunt techniques with cotton-tipped applicators,
microdissection instruments, or blunt-tipped scissors. A
cryoprobe with special elongated orbital tip is placed on
the lesion to provide traction. The tip freezes to the tumor,
but the sides of the probe do not freeze, thus allowing the
probe to be placed against other tissues in the orbit with-
out freezing them. The cryoprobe is sequentially replaced
as the tumor is rolled out. It is advisable to avoid pulling
the tumor with a great deal of force because this can dam-
age the tissues around it and lead to subsequent bleeding.
The process continues until the tumor is freed up entirely
and can be removed.
After achieving complete hemostasis, closure is begun
by smoothing the periorbita into position and verifying
that the lateral rectus is intact. The periorbita need not be
closed with sutures. The bone is replaced and held in posi-
Fig. 3. Diagrams showing an anterior orbitotomy performed via
a subbrow approach. Anterior orbitotomy approach to a subpe-
riosteal mass (A) via a subbrow approach. An incision is made
through the lower brow and parallel to the follicles to preserve
them (B). The periosteum is exposed and incised, exposing the
lesion (C). The tumor is then excised (D), and the periorbital inci-
sion closed with interrupted No. 5-0 vicryl sutures (E). The skin is
then closed with interrupted sutures (F). Reprinted with permission
from Kennerdell, et al., Practical Diagnosis and Management of
Orbital Diseases. Boston: Butterworth-Heineman, 2001.

the orbit to gain access to the entire lacrimal gland and lat-
eral, superolateral, and inferolateral tumors. Examples of
lesions suited to this approach include pleomorphic ad-
enomas and some cavernous hemangiomas.
The patient is placed in the supine position with the
head turned to side opposite the lesion. A lateral orbitoto-
my is performed after induction of general anesthesia. A
curvilinear incision is made, beginning in the lateral upper
brow, extending to the midlateral orbit, and then straight
back for 3 cm from the lateral canthus.
The periorbita of the lateral orbital wall is dissected
from the bone with blunt periosteal elevation. The lateral
canthus is tightly attached and is removed using the sharp
end of the periosteal elevator, sweeping from above or be- Fig. 4. Diagrams depicting an anterior orbitotomy and superior
low the canthus. The lateral periorbita is dissected poste- osteotomy. A generous subbrow incision is made (A). Retraction
riorly to the posterior one fourth of the orbit, exposing the facilitates tumoral exposure (B). The area of bone to be removed is
marked (C). The bone is removed using a sagittal saw (D), widen-
lateral orbital wall (Fig. 5). ing the exposure to the lesion. This approach is more suited to large
Angled cuts are made in the inferior and superior orbital extraconal lesions in which added exposure is needed. Reprinted
rims, angled slightly toward each other to remove a key- with permission from Kennerdell, et al. Practical Diagnosis and
stone portion of bone from the lateral orbital wall. After Management of Orbital Diseases. Boston: Butterworth-Heineman,
excising the anterolateral orbital wall, removal of the pos- 2001.

Neurosurg. Focus / Volume 10 / May, 2001 3


Fig. 5. Diagrams illustrating the lateral orbitotomy: A–F: In-
itial exposure. G and H: Periorbita opening and tumor resection.
The anatomical relationship of the temporalis, globe, sphenoid
bone, lacrimal gland, and globe are detailed (A). The skin incision
is outlined (B). The incision is deepened and the periosteum ex-
posed and incised (C). The temporalis muscle is dissected and
retracted posteriorly (D). The orbital rim is removed (E) and the
lateral orbital wall drilled down (F). The periorbita is opened (G)
and tumor exposed (H). m = muscle. Reprinted with permission
from Kennerdell, et al., Practical Diagnosis and Management of
Orbital Diseases. Boston: Butterworth-Heineman, 2001.
tion by nonabsorbable No. 4-0 nylon sutures. The perior-
bita and the slip of temporalis and periosteum are attached
at the lateral orbital margin with No. 5-0 nondyed vicryl
sutures (Fig. 6). Vertical mattress sutures are used to close
the subcutaneous tissue to approximate the wound edges,
and the skin is closed with a running suture. A pressure
patch is applied until the next morning.
Transconjunctival Medial Orbitotomy
The medial approach was described in 1973 by Gal-
braith and Sullivan6 to decompress the optic nerve and re-
lieve papilledema. We have used the same approach to re-
4 Neurosurg. Focus / Volume 10 / May, 2001
K. P. Cockerham, et al.
move anterior and medial tumors within the muscle cone.
We have also designed a special retractor for this ap-
proach.16
The medial orbitotomy is effective in the management
of small, medial orbital tumors such as cavernous heman-
giomas, schwannomas, hemangiopericytomas, and isolat-
ed neurofibromas. This procedure may be used in con-
junction with a sinus procedure in cases in which both
regions are involved. The medial orbitotomy is performed
after induction of general anesthesia. A medial peritomy
in which relaxing incisions are angled superiorly and in-
feriorly is used to expose the medial rectus muscle inser-
tion (Fig. 7).
The medial rectus is freed from its intramuscular sep-
tum and check ligaments and imbricated with No. 6-0 vi-
cryl suture, doubly locked at both borders, and severed
from the insertion site with blunt Westcott scissors. The
medial rectus is then gently retracted medially.
The medial orbital retractor is introduced, and the mal-
leable retractor or modified enucleation spoon is used to
retract the globe laterally. These can be attached to a bar
of the Leyla system.
Dissection is then performed using the microscope. The
microsurgical instruments, in conjunction with long cot-
ton-tipped applicators, are used to dissect the fat deeper
and deeper until the tumor is identified. Bipolar cautery is
used to coagulate the the sources of blood in the medial
orbital compartment and to remove the fat until the tumor
is identified. When a sufficient surface area is exposed, a
specially designed cryoprobe is applied to the tumor to
facilitate its manipulation. Using the cryoprobe to lift the
tumor, the posterior portions are progressively dissected
and the tumor is finally removed. If the tumor is such that
it cannot be resected intact, then it is often removed piece-
meal by using a pituitary cupped forceps. Occasionally bi-
polar cauterization or a CO2 laser is needed to reduce the
tumor. Because direct visualization is difficult, direct pal-
pation is often essential to confirm that the tumor is com-
pletely excised. The medial rectus is then reattached to its
insertion site, and the conjunctiva is closed. A pressure
patch is placed until the next morning.
Medial Lateral Orbitotomy
Large or posteriorly located medial orbital tumors may
be resected via transorbital approaches, but they require a
combined lateral–medial orbital approach. Large, primar-
ily medial intraconal tumors are ideally suited for this ap-
proach, particularly large neurofibromas or hemangiomas
located deep in the medial orbital compartment. The later-
al approach is identical to the previously described ap-
proach except the lateral incision is made directly through
the canthus, 3 cm posteriorly, in the fashion of Berke.3
This is done to allow the globe to be prolapsed into the
bone defect laterally so that more room can be obtained
medially to extract the tumor (Fig. 8).
Intraoperatively, 10 mg of Decadron and 1 gram of An-
cef are administered in all cases in which orbitotomy is
performed. A combination of antibiotic and steroid drops
is prescribed twice daily for at least the 1st week postop-
eratively. Patients in whom large tumors were resected are
placed on a 5-day course of prednisone postoperatively.
Transorbital surgical approaches

Fig. 6. Diagrams showing closure of the lateral orbitotomy. The orbital osteotomy is secured in place by using the
predrilled holes and nonabsorbable sutures (A). The temporalis fascia and periosteum/periorbita complex are closed (B).
The skin is then closed (C). Reprinted with permission from Kennerdell, et al., Practical Diagnosis and Management of
Orbital Diseases. Boston: Butterworth-Heineman, 2001.

CONCLUSIONS
Most orbital tumors can be safely approached via the
transorbital routes. They require instruments and skills
that are atypical for the general ophthalmologist. The
presence of important neurovascular structures within the

Fig. 7. Diagrams depicting stages in a medial orbitotomy. The

medial orbitomy is used for well-circumscribed lesions in the intra-
conal medial region (A). A medial peritomy with relaxing incisions
exposes the medial rectus muscle insertion (B). The latter is freed
and imbricated (C). The medial orbital retractor is placed with the
enucleation spoon used to retract the globe laterally (D). The mi-
croscope is brought in and dissection performed to isolate the tu-
mor. The ophthalmic cryoprobe is useful to hold the tumor (E).
After excision of the tumor, direct palpation is often essential to
confirm complete excision because direct visualization is difficult.
The medial rectus is then reattached to its insertion site and the con-
junctiva is at the limbal site of the relaxing incisions (F). Reprinted
with permission from Kennerdell, et al., Practical Diagnosis and
Management of Orbital Diseases. Boston: Butterworth-Heine-
man, 2001.
Fig. 8. Diagrams illustrating step in the mediolateral orbitoto-
my. The medial lateral orbitotomy is ideal for large medial intra-
conal tumors (A). The skin incision is straight or slightly curved to
follow a dominant laugh line (B). A lateral canthotomy–cantholy-
sis is performed. The lateral rim and wall are removed, as already
described in Fig. 5 (C). A medial transconjunctival orgitomy is per-
formed, as outlined in Fig. 7 (D). The globe is retracted laterally
into the defect created by the lateral orbitotomy by using a spoon
retractor, and the tumor is exposed (E). Reprinted with permission
from Kennerdell, et al., Practical Diagnosis and Management of
Orbital Diseases. Boston: Butterworth-Heineman, 2001.

Neurosurgical Focus / Volume 10 / May, 2001 5


orbital fat contents makes dissection tedious. Many of the
instruments required to facilitate orbital surgery are readi-
ly available from ophthalmological and neurosurgical in-
strument companies. Unlike a typical ophthalmological
procedure, the surgeon’s index finger is essential to pal-
pate and occasionally provide dissection for deep masses.
Cotton-tipped applicators are very helpful for performing
blunt dissection and retraction when working in the orbital
fat. In addition to the standard instruments that are useful
in orbital tumor surgery such as the wire lid speculum,
blunt Westcott scissors, the Stevens and Green hooks,
other specific orbital instruments are required—malleable
retractors, curved scissors and forceps with specialized 6-
inch length, and a cryoprobe.9,14,17 There is no fixed orbital
retractor system currently available that can be easily used
and that is superior to manual retraction. We are currently
working to develop a newer practical and efficient retrac-
tor system, which combines orbital retractors with special-
ized shapes and the neurosurgical Leyla system.
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Acknowledgement
The authors would like to acknowledge Mrs. Alexis Ferencz for
her assistance in preparing this manuscript.
Manuscript received April 13, 2001.
Accepted in final form May 3, 2001.
Address reprint requests to: Ghassan K. Bejjani, M.D., Tristate
Neurosurgical Associates–UPMC, 200 Lothrop Street, Suite 5C,
Pittsburgh, Pennsylvania 15213. email: bejjanigk@msx.upmc.edu.