The Future of Orbital Surgery

one day, but I can identify areas that I hope will improve. In this monograph, I will review a bit of the history of orbital surgery that got us to where we are now. It is interesting to see which concepts and techniques were abandoned, and which ones stuck. We will look at the ideas and technologies that most significantly pushed our discipline along to the next level. Then, I will consider the areas in which our current concepts and techniques are still most wanting. By tracking the trajectory of the development of the discipline of orbital surgery, and assuming a certain amount of inertia, perhaps we can best imagine where it is going.

So many advances have allowed us to refine our ability to care for patients that it is hard to define the most important ones. In Table 1, I have listed the five advances that strike me as the critical steps in the evolution of orbital surgery. Physiology and histology underlie all of our decision making in orbital surgery, and as we understand more about the pathophysiology of disease (from an increasingly molecular and genetic perspective), it will drive all the upstream advances. I would include in this category advances that are anatomically based; I would not take anything away from the great historic anatomists (Fig. 1) who essentially described all of the gross structures as accurately as our best modern dissectors, but what has improved is continued imaginative application of anatomy to create new approaches. A perfect example of this in my opinion, and one of the great leaps in orbital surgery of all time, was the realization by Paul Tessier that the bony orbital and cranial skeleton could be taken apart and reconstructed.

Anesthesia and asepsis created the ability to perform safe surgery, and effective biologicals provided the means of

Table 1 The Five Big Steps Leading to Modern Orbital Surgery

1.Physiology and histology; the ability to construct a differential diagnosis

2.The development of anesthesia and asepsis, resulting in practical surgery

3.Effective biologicals: anti-inflammatories and antibiotics

4.Imaging technology: CT and MRI

5.Small incision surgical techniques

Figure 1 Five hundred years ago, Leonardo DaVinci drew with substantial accuracy many orbital anatomic relationships.

treating not only the medical arm of orbital disease, but also of treating some of the inevitable iatrogenic sequelae of surgery.

Imaging technology has powerfully changed our discipline. The orbit and cranial cavities are spectacular in the degree of critical delicate soft tissue structures packed intricately into a complex bony superstructure, and threedimensional imaging has revolutionized orbitocranial diagnosis and surgical planning more, I suspect, than any other surgical specialty.

Finally, small incision surgical techniques and other minimally invasive or noninvasive technologies have advanced our ability to help our patients. We surgeons strut about proudly, bragging of our surgical successes, but cutting our patients is still a brutal process and every advance that minimizes the collateral damage to normal structures is a gift.

In Table 2, I have listed five limitations of modern orbital surgery that I believe most significantly attenuate our ability to help our patients. These limitations are both technical, relating to the gross nature of surgical instrumentation and technique compared to the extraordinary delicacy of tissues, and also biologic, reflecting our inability to diagnose and mod-

Table 2 Limitations of Modern Orbital Surgery

1.Surgery is still invasive: normal tissue is destroyed.

2.Surgery is not fine enough for infiltrative benign lesions such as lymphangioma and neurofibroma.

3.Surgical oncology fails because we cannot identify microscopic tumor margins preoperatively, so that we almost always remove too much or too little tissue.

4.Reconstructive and aesthetic surgeries fail because of poor control of wound healing; unpredictable fibrosis too often limits our best efforts.

5.Surgery fails because we cannot replace lost functioning parts.

ify the biologic processes that cause disease and that affect our surgical interventions in the postoperative period.

In Table 3, I have assembled a list of the five technologies that I believe have the best chance to help us overcome our current limitations. This is the riskiest part, of course, and if I am fortunate to be around in 20 or 30 years, I hope that I will get a smile from this monograph not only at my own expense for naivety and presumption, but also perhaps for some accurate guesses. It would be most disappointing of all to be correct on all five, because that would imply that our best evolving technologies were not eclipsed by some entirely new branch of science or intellectual pursuit.

Perhaps I can conclude with some illustrative cases (Cases 1–4) that point out some of the historic limitations, best current technologies, and hopes for the future. As I said

Table 3 Technologies That Will Help Us Defy These Limitations in the Future

1.Endovascular and nanotechnology leading to smaller and no incisions.

2.Better imaging including cellular level biological in vivo imaging.

3.Better control of surgical biology: premanufactured custom grafts, custom tissue implants, and better control of wound healing at a biological level.

4.Ability to control the immune system at a molecular level, so that there will be specific tests and treatments for Graves’ and other autoimmune disease.

5.Detection and therapy of genetic alterations that are risk factors or proximate cause of disease.

in my speech to Jack Rootman at the Vancouver Orbital Disease Seminar on March 16, 2002, Jack’s greatest professional legacy is his family of devoted fellows, who filled up a substantial chunk of the auditorium when they walked up to honor him. Participating in the magical process of teaching and learning medicine, being fortunate to have mentors like Jack Rootman who have so powerfully shaped me, and accepting the responsibility of passing down not only the knowledge but also the tradition, has provided the most fulfilling experiences of my life.

REFERENCES

1.Troutman RC, Converse JM, Smith B. Plastic and Reconstructive Surgery of the Eye and Adnexa. Washington: Butterworths, 1962:77–91.

2.Spaeth EB. The Principles and Practice of Ophthalmic Surgery. Philadelphia: Lea & Febiger, 1941:30–34, 51–90.

3.The American Society of Ophthalmic Plastic and Reconstructive Surgery: The First Twenty-Five Years (1969–1994). In: Reifler DM, ed. History of Ophthalmic Plastic Surgery (2500 BC–AD 1994). San Francisco: Norman Publishing, 1994.

4.Clayton M, Philo R. . Leonardo Da Vinci: The Anatomy of Man. Boston: Bulfinch Press, 1992.