Clinical Research
Surgical anatomy of the orbit. A systematic and clear study of a complex structure
Anatomía quirúrgica de la órbita. Un estudio sistematizado y claro de una estructura compleja
Juan F. Villalongaa, Amparo Sáenza,
, Juan M. Revuelta Barberoa, Ismael Calandrib, Álvaro Camperoa,c,d,e
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a LINT, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
b Cátedra de Neurología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
c Fellowship Albert L. Rothon Neuro-Microanatomy Lab, Gainesville, FL, United States
d Cátedra de Neurología, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina
e Servicio de Neurocirugía, Hospital Ángel C. Padilla, Tucumán, Argentina
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Rothon Neuro-Microanatomy Lab, Gainesville, FL, United States" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Cátedra de Neurología, Facultad de Medicina, Universidad Nacional de Tucumán, Tucumán, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Ángel C. Padilla, Tucumán, Argentina" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anatomía quirúrgica de la órbita. Un estudio sistematizado y claro de una estructura compleja" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1342 "Ancho" => 2987 "Tamanyo" => 408488 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Orbit nerves. (A) Superior view of the right orbit after resecting the orbit roof. (B) Cranial nerves in their pathway through the orbit, left side.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">O. a.: ophthalmic artery; Int. Car. a. internal carotid artery; O. n.: optic nerve; COM n.: common ocular motor nerve; V1: ophthalmic nerve.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">General neurosurgeons can face significant difficulties in surgical approaches to the orbit because of several factors: the relatively small volume of the structure, its four-sided irregular pyramid shape and the location between the craniofacial structures and the brain.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> Neurosurgeons who decide to tackle orbital surgery must have extensive anatomical knowledge of the structure. However, although many of the existing publications on orbit anatomy may show the complexity of the structure in great detail, they do not help to improve understanding.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this work is to systematise and simplify the anatomical study of the orbit from a surgical perspective, to facilitate understanding of the structure for the surgeon.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We carried out a review of the international literature on the subject and followed the principle of the rule of 7<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> to order the structures.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">For illustrative purposes, we have used photographs of cadaveric preparations and digital drawings. We studied six heads of adult cadavers fixed in formaldehyde and injected with coloured silicone. We dissected the orbit on both sides.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We did not include study of the eyeball, as it went beyond the purpose of this work.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The orbits are two cavities located symmetrically on either side of the nose (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Each one is shaped like a four-sided pyramid, with a posterior vertex, an anterior base and its axis set off from the sagittal plane at an angle of 20 degrees. This simple arrangement is key to human stereoscopic vision.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The vertex, the base and the walls are curvilinear and have perforations and irregularities through which the neurovascular bundles pass and the muscles are inserted. The vertex and the base are formed by a thick bone, while the bone forming the walls is thinner. Of the four walls, the lateral is the thickest and the medial the thinnest. The thickening of the bone at the apex and at the base protects the eyeball and the nerves from injury. One distinctive feature of the orbit is that its elements are organised into groups of seven: seven bones, seven intraorbital extraocular muscles and seven nerves.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Bones<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,3–5</span></a></span><p id="par0040" class="elsevierStylePara elsevierViewall">The orbit is formed by seven bones: frontal, ethmoid, lacrimal, sphenoid, zygomatic, palatine and maxilla. For study, the orbit is divided into lateral and medial wall, roof, floor, base and vertex.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The base of the orbit is formed at the upper end by the frontal bone, which has a recess through which the nerve and the supraorbital vessels pass. The lateral wall is formed by the zygomatic bone and the lower wall by the zygomatic bone laterally and in the superior to medial aspect by the maxilla. The inner wall is formed at its lower end by the frontal process of the maxilla and the upper end by the frontal bone. At the superior/medial end is the frontal sinus.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The medial aspect is formed, from anterior to posterior, by the frontal process of the superior maxilla, the lacrimal bone, the quadrangular lamina of the ethmoids, which constitutes the centre of the inner wall and separates the orbit from the nasal cavity, and the sphenoid bones. The ethmoid bone is articulated upwards with the frontal bone (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Between the two are the anterior and posterior ethmoidal foramina, respectively. These foramina house: branches of the nasociliary nerve, a branch of the ophthalmic nerve, which is in turn a branch of the trigeminal nerve, branches of the ophthalmic artery; and the anterior and posterior ethmoidal arteries, respectively. The cranial openings of the ethmoidal foramina are related with the anterior and posterior borders of the ethmoidal cribriform plate and help to divide the orbit into bulbar and retrobulbar. Between the union of the sphenoid and ethmoid bones is the optic foramen, where the optic nerve and the ophthalmic artery pass through.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The thicker lateral wall separates the orbit from the temporal fossa at its anterior end and from the middle cranial fossa at its posterior end. It is made up of the zygomatic bone, which has no contact with the brain, and forms the anterior border of the temporal fossa, through which the temporal muscle passes. In turn, it continues on deep to the greater wing of the sphenoid bone, which is the anterior border of the middle cranial fossa in the endocranium. This spatial arrangement is the basis of lateral orbital approaches, as a temporal craniotomy together with a pure zygomatic osteotomy allows access to lesions without the need for a combined cranio-orbital approach. At its anterior end, the lateral wall is continuous with the frontal bone at the roof of the orbit. However, at the posterior end it is interrupted at the sphenoid bone by the superior orbital fissure. The lacrimal foramen, through which the recurrent meningeal branch of the ophthalmic artery runs, is anterior and superior to the superior orbital fissure.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The floor of the orbit is formed by the superior maxillary bone and the zygomatic bone, which is continuous on its posterior wall with the orbital process of the palatine bone. The palatine bone has two portions: a horizontal, which forms the posterior part of the hard palate, and a vertical portion, with one process directed to the sphenoids and another to the orbit. Both join with the superior maxillary to form the floor of the orbit. The floor separates the orbit from the maxillary sinus. At the posterior end of the floor of the orbit is the inferior orbital fissure and on the medial side, the nasolacrimal duct. The inferior orbital fissure is an important surgical landmark, as through this the orbit communicates with the pterygopalatine fossa and, in turn, through it, with the nasal cavity. Through the outermost segment of the inferior orbital fissure, the orbit comes into contact with the temporal and infratemporal fossae.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The roof of the orbit is formed by the frontal bone, which articulates deep to the lesser wing of the sphenoid and the ethmoid.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Muscles<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,5</span></a></span><p id="par0070" class="elsevierStylePara elsevierViewall">There are seven extraocular muscles: four rectus, two oblique and the levator palpebrae superioris (LPS) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Only the inferior oblique muscle is attached to the inner wall of the orbit. The four rectus muscles and the superior oblique are indirectly attached to the vertex of the orbit through a ring of fibrous tissue known as the common tendinous ring or annulus of Zinn. The superior oblique muscle passes through the trochlea, a rounded tendon attached to the trochlear fossa of the frontal bone in the superior internal angle of the orbit.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The annulus of Zinn is inserted along the vertex of the orbit, surrounding the opening of the optical canal and the central part of the superior orbital fissure. Inside the ring pass: the optic nerve, the ophthalmic artery, the external ocular motor (EOM) nerve, the common ocular motor (COM) nerve, divided into its two branches, superior and inferior, and the ophthalmic branch of trigeminal nerve. Outside the ring pass the trochlear nerve and the frontal and lacrimal branches of the trigeminal nerve (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Vessels<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,6</span></a></span><p id="par0080" class="elsevierStylePara elsevierViewall">As it has both endocranial and exocranial parts, the orbit is irrigated by the internal carotid (Int. Car.) artery, through the ophthalmic artery, and the external carotid (Ext. Car.) artery, through the infraorbital branch of the maxillary artery.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The ophthalmic artery is a branch of the supraclinoid segment of the Int. Car. artery. The origin of the ophthalmic artery is, in general, medial to the anterior clinoid process, below the optic nerve (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). It enters alongside the optic nerve though the optic canal and is found on the lateral and inferior walls. Once the ophthalmic artery enters the orbital cavity, it remains on the lateral wall of the orbit, where it gives off dural branches. Then, accompanied by the nasociliary nerve, it crosses over the optic nerve (85% of cases) and ends parallel to the medial aspect of the orbit where it gives off the terminal branches of the supratrochlear artery and the angular artery. It is important to note that in 15% of the cases the ophthalmic artery crosses under the optic nerve. Knowing the path of the ophthalmic artery is important when opening up the falciform ligament, to avoid iatrogenic injury. The ophthalmic artery gives off the central retinal, supraorbital, palpebral, lacrimal, short ciliary, long ciliary, infratrochlear, supratrochlear and nasal dorsal arteries. It also sends out dural branches and can therefore be compromised in skull-base injuries.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The orbit's main drainage pathway is the superior ophthalmic vein, formed by tributaries from the superior/medial sector of the orbit. The inferior ophthalmic vein arises from tributaries from the lateral/inferior wall of the orbit. These veins are connected to each other on the base of the orbit by anastomoses formed by the facial and angular veins. The inferior ophthalmic vein can drain directly into the cavernous sinus. However, it most commonly joins the superior ophthalmic vein to form a common trunk and this drains into the cavernous sinus.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Nerves<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,5,7,8</span></a></span><p id="par0095" class="elsevierStylePara elsevierViewall">There are seven nerves in the orbit (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A). Except for the optic nerve, which passes through the optic canal, they all pass through the superior orbital fissure.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The optic nerve (i.e. cranial nerve II) innervates the retina. In its intracanalicular and intraorbital course, it is covered by dura and arachnoid mater. Upon entering the orbit through the optic foramen, it crosses the medial sector of the common annular tendon, along with the ophthalmic artery, and travels to the eyeball. The ciliary ganglion is located on the lateral side of the optic nerve, at the union of the anterior 2/3 and the posterior 1/3.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The CMO nerve is responsible for the innervation of the extraorbital muscles, apart from the external rectus and superior oblique muscles. It enters the vertex of the orbit and divides into two branches: superior and inferior. Both branches pass through the annulus of Zinn on the lateral side. At this point, the nasociliary nerve can be found between the superior and inferior branches. Once they enter the orbit, the superior branch innervates the superior muscle complex (constituted by the LPS and the superior rectus muscle). The inferior branch supplies the inferior rectus, the internal rectus and the inferior oblique muscles. In its path it leaves an ascending collateral, which reaches the ciliary ganglion, responsible for parasympathetic innervation. These fibres synapse in the ciliary ganglion and then continue as short ciliary nerves to the sphincter pupillae.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The COM nerve is responsible for the motor innervation of the external rectus muscle. It is formed by the union of various fibres inside the cavernous sinus (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B). On entering the orbit it crosses the annulus of Zinn, lateral to the fibres of the COM nerve, and continues along the lateral wall of the orbit until it reaches the external rectus muscle.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The trochlear nerve is responsible for the innervation of the superior oblique muscle. It enters the orbit through the superior orbital fissure, outside the annulus of Zinn, and continues along the medial wall until reaching the superior oblique muscle.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The ophthalmic nerve (V1) is exclusively sensory. Its innervation territory includes the eyelids, the forehead, the eyeball, the cornea and the nasal cavities. Lacrimal secretion is ensured by the branch from the sphenopalatine ganglion and by the communicating branch of the maxillary nerve. The ophthalmic nerve gives off three branches: lacrimal, frontal and nasociliary. The lacrimal nerve, after entering the orbit outside the ring of Zinn, continues along the lateral wall and sends out one branch that communicates with the zygomatic nerve (branch of V2) for the lacrimal gland, and a medial branch for the upper eyelid. The frontal nerve enters from outside the ring of Zinn and continues through the superior wall of the orbit. On reaching the orbital rim, it divides into two branches: internal frontal (supratrochlear) and external frontal (supraorbital). The internal frontal nerve supplies the forehead, nose and upper eyelid. The external frontal nerve traverses the supraorbital fissure and ascends under the skin of the forehead. The nasociliary nerve penetrates the orbit through the annulus of Zinn. Its collateral branches are: sensory (towards the ciliary or ophthalmic ganglion); long ciliary nerve (to the eyeball); and sphenoethmoidal branch (to the mucosa of the ethmoidal cells and sphenoid sinus). The nasociliary nerve branches off on the lateral wall of the orbit, forming the internal nasal nerve (i.e. anterior ethmoidal) and external nasal nerve (i.e. infratrochlear). The internal nasal nerve passes through the cribriform plate and innervates the mucosa of the lateral walls, while the external nasal nerve innervates the mucosa of the lacrimal ducts.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Despite its relatively small volume, the orbit can be affected by a variety of intrinsic and extrinsic lesions. The excision of intraconal lesions can be difficult and, in some cases, requires the combined experience of more than one specialist.</p><p id="par0130" class="elsevierStylePara elsevierViewall">When choosing the approach, it is important to know the relationship between the lesion to be removed and the optic nerve.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">If the lesion is located in the <span class="elsevierStyleItalic">anterior sector</span>, an excision can be performed without the need for osteotomies, using a transcutaneous or transconjunctival approach.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">10,11</span></a> A good example of this is the <span class="elsevierStyleItalic">trans-palpebral approach</span>. This begins with a tarsorrhaphy for protection of the cornea. The incision in the skin is made parallel to the superior palpebral groove on a natural fold. We then proceed to dissection of the orbicularis oculi muscle of the eyelid, always staying on it to avoid affecting the LPS muscle. Next, the skin is raised together with the orbicularis oculi muscle en bloc to avoid devitalisation of the skin plane. Finally, an incision is made on the periosteum of the superior border of the orbital cavity. Subperiosteal dissection towards the four quadrants allows greater access to the frontozygomatic suture (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A–D). Another way to enter the anterior sector of the orbit is through an incision in the distal part of the eyebrow, which allows the same field of visualisation as the previous approach, but with a worse outcome from an aesthetic point of view. The route is chosen according to the experience of the head surgeon.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">If greater exposure of the muscle, vascular or nerve structures is required, or the lesion is located in the <span class="elsevierStyleItalic">posterior sector</span> of the orbit, a craniotomy is necessary, using a method such as the <span class="elsevierStyleItalic">frontal/orbital approach</span>.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> This involves an incision which begins at the lower edge of the zygomatic arch, just anterior to the tragus, and extends behind the hairline to the contralateral pupillary line. A subgaleal dissection is then performed until fatty tissue is recognised above the temporal aponeurosis. From there, the surgeon advances with interfascial dissection in order to protect the frontal branch of the facial nerve. The orbital rim is then exposed above and the zygomatic arch below, and further advance is made subperiosteally until the entire orbital rim, the zygomatic arch and the posterior sector of the zygomatic bone are exposed. The temporal muscle is then disinserted and retracted. Lastly, a frontal-temporal-sphenoid craniotomy is performed, leaving the bony structure of the orbit exposed. Next, a series of orbital osteotomies is performed. First the orbital rim is sectioned 1<span class="elsevierStyleHsp" style=""></span>cm lateral to the frontal medial border of the craniotomy. Then, the cut is extended backwards through the roof of the orbit approximately 3<span class="elsevierStyleHsp" style=""></span>cm; from there the cut changes direction and heads towards the inferior orbital fissure through the lateral orbital wall. The osteotomy is completed by sectioning the orbital rim just above the junction of the zygomatic arch with the zygomatic bone as far as the inferior orbital fissure. Removal of the bone leaves the peri-orbit exposed (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Pure intraorbital lesions can be excised without the need to open the dura mater. However, when the lesions involve the optic foramen, or extend to the chiasm, the dura mater has to be opened and the frontal lobe retracted to allow better visualisation.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">14–16,18</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Once into the orbital cavity, there are three different access routes to choose from, depending on the location of the disease to be treated.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Medial</span> access is gained through the space between the superior oblique muscle, which is retracted medially, and the LPS and superior rectus muscles, which are retracted laterally. This approach exposes the optic nerve along the gap from the eyeball to the optic foramen. It is the most direct surgical approach to the apical part of the optic nerve.</p><p id="par0160" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">central route</span>, the LPS muscle is retracted medially, and the superior rectus is retracted laterally. The central approach is the shortest and most direct path to the middle portion of the intraorbital segment of the optic nerve.</p><p id="par0165" class="elsevierStylePara elsevierViewall">For <span class="elsevierStyleItalic">lateral</span> access, the optic nerve is exposed between the external rectus muscle, which is retracted laterally, and the LPS and superior rectus muscles, which are retracted medially. This provides a wider working space than the medial or central approach and is the best of the three pathways for exposing the deep lateral apical area of the optic nerve.</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lateral wall</span> lesions which are intraconical and small in size can be resected using the classic lateral approach to the orbit.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">17,18</span></a> The incision begins in front of the ear and extends anteriorly along the upper edge of the zygoma, turning upwards along the lateral border of the orbit to expose the superficial temporal artery and vein, and the zygomatic-temporal nerve. The fascia of the temporal muscle is incised, respecting the muscle retracted posteriorly. The periosteum is exposed and moved aside to expose the frontal bone and the zygomatic bone. On the anterior wall of the lateral orbital rim, two sections are made using an electric saw, the first 1<span class="elsevierStyleHsp" style=""></span>cm above the frontozygomatic suture and the second 1<span class="elsevierStyleHsp" style=""></span>cm below. The cut is extended to the lateral wall and then the plate fractured in order to remove it. Excess bone can be ground away for better visualisation of the structures. The external rectus muscle is retracted and an incision is made on the periorbital fascia to expose the contents of the orbit. A variant of this classic approach is extending the incision made in the trans-palpebral approach laterally (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>E–J).</p><p id="par0175" class="elsevierStylePara elsevierViewall">Lesions of the medial aspect of the orbit can be treated using a transnasal endoscopic approach.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18–23</span></a> This is a minimally invasive method which allows access to the medial aspect of the orbit. The approach is made through the natural ostium of the maxillary sinus, which is opened up after a partial uncinectomy, to expose the inferior/medial angle of the orbit. A sphenoethmoidectomy and a large medial antrostomy are performed to expose the medial orbital wall. The lamina papyracea is gently perforated and finally removed with a spatula. The entry through the lamina papyracea is made below the level of the ethmoid foramen to avoid damaging the ethmoid arteries and reduce the risk of retrobulbar haemorrhage and loss of vision. Once the lamina papyracea is removed, the medial aspect of the orbit is exposed. In general, the superior/medial angle of the orbit is preserved to maintain the permeability of the frontal recess. The endonasal approach minimises external scars and has a better aesthetic outcome. In comparison, external approaches require skin incision and significant displacement of orbital structures, including the eyeball; they also have the disadvantage of suboptimal visibility compared to the endonasal approach. For these reasons, when feasible, the endoscopic endonasal technique can be considered a safe and effective surgical option for dealing with the optic nerve and the medial orbital compartments.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0180" class="elsevierStylePara elsevierViewall">We have undertaken a systematisation of the orbital anatomy with clear illustrations in order to simplify the study of this structure. A full understanding of the anatomy of the orbit is key to classifying a lesion and provides a solid foundation when it comes to choosing the most appropriate treatment approach.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0185" class="elsevierStylePara elsevierViewall">This research did not receive specific financial assistance from public sector agencies, the commercial sector or non-profit organisations.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1261126" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1167941" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1261127" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1167940" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Bones" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Muscles" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Vessels" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Nerves" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-14" "fechaAceptado" => "2019-04-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1167941" "palabras" => array:4 [ 0 => "Orbit" 1 => "Anatomy" 2 => "Skull base" 3 => "Surgical treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1167940" "palabras" => array:4 [ 0 => "Órbita" 1 => "Anatomía" 2 => "Base de cráneo" 3 => "Tratamiento quirúrgico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The orbit is a structure of interest for many medical specialties. Surgical approaches to the orbit present significant difficulties for the general neurosurgeon. Whoever decides to practice orbital surgery must have vast anatomical knowledge of this structure. However, although many of the existing publications about orbital anatomy show the complexity of this structure in detail, they fail to facilitate their understanding.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The purpose of this study was to systematise and simplify the anatomical study of the orbit from a surgical perspective, to facilitate its understanding.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A review of the international literature on the subject was carried out, and the principle of the rule of 7 was followed for its ordering. For illustration purposes, photographs of cadaveric preparations and digital drawings were used.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The orbits are 2 cavities located symmetrically on both sides of the nose. They have a pyramidal shape, with 4<span class="elsevierStyleHsp" style=""></span>sides, a posterior vertex, an anterior base and their axis established from the sagittal plane at a 20-degree angle. A distinctive feature of the orbit is that its elements are organised into groups of seven: 7<span class="elsevierStyleHsp" style=""></span>bones, 7<span class="elsevierStyleHsp" style=""></span>intraorbital extraocular muscles and 7<span class="elsevierStyleHsp" style=""></span>nerves.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A systematisation of the orbital anatomy was performed with clear illustrations to simplify its study. The understanding of the anatomy of the orbit is vital to classify lesions and provides a solid basis when choosing the most appropriate approach for their treatment.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La órbita es una estructura de interés para diversas especialidades médicas. Los abordajes quirúrgicos de la órbita presentan una dificultad significativa para el neurocirujano general. Quien decide incursionar en cirugía orbitaria debe tener un vasto conocimiento anatómico de esta estructura. Sin embargo, gran parte de las publicaciones existentes sobre anatomía de la órbita muestran detalladamente la complejidad de esta estructura, pero no logran facilitar su entendimiento. El propósito del presente trabajo es sistematizar el estudio anatómico de la órbita desde una perspectiva quirúrgica, de modo sencillo, que permita facilitar su entendimiento.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realizó una revisión de la literatura mundial sobre el tema y se siguió el principio de la regla del 7<span class="elsevierStyleHsp" style=""></span> para su ordenamiento. Para ilustrar se utilizaron fotografías de preparados cadavéricos y dibujos digitales.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las órbitas son 2<span class="elsevierStyleHsp" style=""></span>cavidades ubicadas simétricamente a ambos lados de la nariz. Tienen una forma piramidal, de 4<span class="elsevierStyleHsp" style=""></span>lados, con un vértice posterior, una base anterior y con su eje establecido desde el plano sagital en un ángulo de 20 grados. Una característica distintiva de la órbita es que sus elementos están organizados en grupos de a 7: 7<span class="elsevierStyleHsp" style=""></span>huesos, 7<span class="elsevierStyleHsp" style=""></span>músculos extraoculares intraorbitarios y 7<span class="elsevierStyleHsp" style=""></span>nervios.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se realizó una sistematización de la anatomía orbitaria con claras ilustraciones a fin de simplificar su estudio. La comprensión de la anatomía de la órbita es clave para clasificar una lesión y proporciona una base sólida a la hora de elegir el abordaje más adecuado para su tratamiento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Villalonga JF, Sáenz A, Revuelta Barbero JM, Calandri I, Campero Á. Anatomía quirúrgica de la órbita. Un estudio sistematizado y claro de una estructura compleja. Neurocirugia. 2019;30:259–267.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2850 "Ancho" => 2187 "Tamanyo" => 768536 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Orbit. (A) Superior endocranial view of both orbits; both orbital roofs were resected exposing the periorbita. (B) Bone structure of the orbit, front view.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Int. Car. a.: internal carotid artery; O. n.: optic nerve.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1066 "Ancho" => 2500 "Tamanyo" => 482104 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Intraorbital extraocular muscles. (A) Lateral view after resecting the roof and the lateral wall of the orbit, left side. (B) Front view after resecting the eyeball.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">sup. O. m.: superior oblique muscle; inf. O. m.: inferior oblique muscle; sup. R. m.: superior rectus muscle; inf. R. m.: inferior rectus muscle; ext. R. m.: external rectus muscle; int. R. m.: internal rectus muscle; O. a.: ophthalmic artery; LPS m.: levator palpebrae superioris.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1059 "Ancho" => 2500 "Tamanyo" => 383797 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Ophthalmic artery. (A) Origin of the left ophthalmic artery, superior endocranial view. (B) Origin of both ophthalmic arteries and their initial path, left side.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">O. a.: ophthalmic artery; Int. Car. a. internal carotid artery; sup. H. a.: superior hypophyseal artery.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1342 "Ancho" => 2987 "Tamanyo" => 408488 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Orbit nerves. (A) Superior view of the right orbit after resecting the orbit roof. (B) Cranial nerves in their pathway through the orbit, left side.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">O. a.: ophthalmic artery; Int. Car. a. internal carotid artery; O. n.: optic nerve; COM n.: common ocular motor nerve; V1: ophthalmic nerve.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 4211 "Ancho" => 1625 "Tamanyo" => 588670 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Transpalpebral approach. (A) Tarsorrhaphy for protection of cornea. (B) Site of incision in upper eyelid. (C) Dissection of the orbicularis oculi muscle of the eyelid. (D) Retraction in block revealing the orbit. (E–J) Lateral approach to the orbit from a transpalpebral approach.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 2894 "Ancho" => 2167 "Tamanyo" => 850233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Frontal-orbital approach. (A) Skin incision. (B) Exposure of the orbital bone plane. (C–E) Orbital osteotomies. (F) Exposure of the periorbita.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microsurgical anatomy of the orbit: the rule of seven" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Martins" 1 => "I.E. Costa e Silva" 2 => "A. Campero" 3 => "A. Yasuda" 4 => "L.R. Aguiar" 5 => "M. 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