Lateral orbitotomy with removal of the lateral orbital rim
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This is Richard Allen at the University of Iowa. This video demonstrates a lateral orbitotomy with removal of the lateral orbital rim. This patient has a history of orbital inflammation, s/p previous orbit decompression, but has continued exposure keratopathy and elevated intraocular pressure secondary to his proptosis. A lateral canthotomy is performed followed by inferior and superior cantholysis. 4-0 silk sutures are placed for traction through the lateral tarsus of the upper and lower lids. Dissection is then carried out through previous scar tissue to the lateral orbital rim. The lateral orbital rim is identified and the periosteum is incised with the monopolar cautery. A Freer periosteal elevator is used to dissect the periosteum from the underlying bone extraorbitally. The temporalis muscle is elevated which will often result in bleeding which can be controlled with packing with neurosurgical cottonoids. The periorbita is then elevated from the lateral orbital wall posterior to the zygomatico-sphenoid suture. One will often encounter the zygomatico-facial and zygomatic-temporal arteries which can be cauterized. The bone is then scored at the level of the superior extent of the zygomatic arch with the needle tip cautery. Superiorly, the bone is scored at the fronto-zygomatic suture. A sagittal saw is then used to make bone cuts at each of these markings. The cuts should be made to the level of the zygomatico-sphenoid suture. The malleable retractor is used to protect the eye. The second cut is then made inferiorly again at the level of the superior extent of the zygomatic arch. Irrigation is used and again the eye is protected with the malleable. Usually the bone is relatively mobile at this point; sometimes it will need to be out-fractured to mobilize it. The deep temporalis fascia is dissected from the bone externally and sometimes additional dissection will need to be performed intraorbitally. The bone can then be removed. In this case, the greater wing of the sphenoid can be exposed and additional decompression will be performed with the cutting bur. Usually, the lateral orbital rim will be replaced into position in instances where the bone was removed for exposure. This is performed with mini-plates. In this case, the bone will not be replaced in order to achieve maximal decompression. The lateral cantholysis is repaired by suturing the lateral upper and lower lid to the periorbita with 4-0 vicryl suture. The lateral canthotomy incision is repaired and the patient will be admitted overnight for observation.