Orbitotomy with Lacrimal Gland Biopsy

Procedure: The procedure shown in this video demonstrates an orbitotomy with incisional biopsy of the lacrimal gland. Introduction: Diseases of the lacrimal gland span a broad range of etiologies, including infectious, inflammatory, autoimmune and neoplastic. Biopsy of the lacrimal gland serves as a helpful diagnostic tool for pathologies that remain elusive after initial clinical workup. It is critical that the biopsy be performed transcutaneous rather than transconjunctivally to avoid damage to the secretory duct, which opens in the superior conjunctival fornix. Indications/Contraindications: Biopsy is indicated in cases of lacrimal gland lesions or enlargement that are not diagnosable with clinical, laboratory and radiologic workup. Incisional biopsy is contraindicated when a pleomorphic adenoma is suspected, as a complete excision is recommended to prevent malignant transformation of tumor seeds. Materials: Standard surgical eye instrumentation was used for this procedure, including a protective corneal shell, a no. 15 blade, small toothed forceps, Westcott scissors, bipolar cautery device, suction and a 6-0 plain gut suture. Results: This procedure allows for gross visualization, frozen tissue section, and histologic study of the sample. These pathology techniques may help identify both primary lacrimal gland pathology and systemic disorders presenting within the gland. Conclusion: Orbitotomy with incisional lacrimal gland biopsy is an important diagnostic procedure in cases of lacrimal gland lesions or enlargement, and should be performed via a transcutaneous approach.

A variety of local and systemic conditions manifest within the lacrimal gland and its surrounding structures. Pathologies of the lacrimal gland can be secondary to inflammatory, neoplastic, autoimmune, and infectious etiologies. Patients with lacrimal gland lesions may present with ophthalmic symptoms that include chemosis, pain, edema, dry eyes, proptosis, or conjunctival injection. Given the broad spectrum of ocular disease resulting in lacrimal gland inflammation, a biopsy can be considered to further characterize etiology. It is often recommended in cases that are not diagnosable with clinical, laboratory and imaging studies alone. Contraindications to an incisional biopsy include in cases of suspected pleomorphic adenomas, as this procedure can facilitate tumor seeding. This procedure may also be contraindicated in patients who are not fit for a surgical procedures or who have significant bleeding disorders. A transcutaneous incisional approach is recommended, as this method allows for sampling of the superficial orbital lobe of the lacrimal gland and decreases damage to secretory duct, which empties into the superior conjunctival fornix. Advantages to lacrimal gland biopsy include potential for macro and microscopic characterization of tissue structure and composition, increased diagnostic capability, and relatively low morbidity of the procedure. Complications and risks of this procedure include bleeding, infection, visual loss, double vision, dry eye, cutaneous scarring, orbital compartment syndrome.

Preoperative Workup: Initial evaluation includes thorough history, review of past medical conditions, and comprehensive ophthalmic exam. Imaging studies of the orbit may also be helpful in characterizing the size and nature of the lesion. Based on these initial findings, laboratory studies may be ordered to further evaluate etiology of disease. These include thyroid function tests, sedimentation rate, C-reactive protein, autoantibodies (antinuclear antibody, anti-double stranded DNA and antineutrophil cytoplasmic antibodies), rapid plasma reagin test, and serum protein electrophoresis. Anatomy and Landmarks: Comprehensive knowledge of upper eyelid anatomy and anatomic location of the lacrimal gland is critical for this procedure. The lacrimal gland is positioned in the superolateral aspect of the orbit and is comprised of the orbital and palpebral lobes, which are separated by the lateral horn of the levator aponeurosis. It is situated adjacent to the superior rectus and lateral rectus muscles. The size of the lacrimal gland may vary from person to person, however is usually symmetric bilaterally. Procedure Steps: A protective scleral shell is placed on the eye and local anesthetic is infiltrated along the upper eyelid crease, which is delineated with a surgical marking pen. A no. 15 blade is used to incise along the demarcated area. Next, Westcott scissors and small-toothed forceps are used to dissect posterior to the incision through the orbicularis muscle. The orbital septum is entered and retractors may be placed for visualization of the underlying lacrimal gland. Further dissection is performed to identify the lacrimal gland and separate it from the surrounding tissue. Small-toothed forceps are used to elevate the lacrimal gland and Westcott scissors are employed to carefully remove a piece of the gland. The harvested biopsy is placed in formalin. If lymphoma is a diagnostic consideration, another piece of tissue may be placed in saline to allow for flow cytometric analysis. Meticulous consideration of hemostasis within the orbit must be performed at this step, with bipolar cautery device readily available. The eyelid incision is then closed with absorbable suture. The scleral shell is removed and antibiotic ointment is applied along the incision site. As in all cases of orbitotomy surgery, the eye is not patched post-operatively to allow for observation for signs of orbital hemorrhage and to allow the patient to report any noted visual loss. If orbital hemorrhage is suspected, the surgical site should be reentered, inspected, and appropriately cauterized.

The primary goal of a lacrimal gland biopsy is to serve in diagnostic evaluation of gland lesions. Intraoperative gross visualization and frozen section of the specimen may help inform if further excision is required. In general, fibrotic lesions are often grossly white and solid. Lymphoproliferative disorders and malignancies tend to appear as pink and friable (Mombaerts, 2016). Moreover, infiltrative and inflammatory processes will often involve both the orbital and palpebral lobes (Gao, 2013). Specialized staining or flow cytometric analysis may also help determine an identifiable etiology. For instance, the presence of granulomatous pattern of inflammation may be indicative of foreign body, tuberculosis, or sarcoidosis. The presence of IgG-4 positive plasma cells is suggestive of IgG4-related disease, idiopathic orbital inflammation, granulomatosis with polyangiitis, sarcoidosis or lymphoproliferative disorder (Mombaerts, 2016).

Given the range of disease conditions that manifest within the lacrimal gland, orbitotomy with incisional biopsy holds critical diagnostic value. Established literature suggests that biopsy may lead to a definitive diagnosis for over half of the patients who undergo this procedure (Luemsamran, 2017). It is critical that the surgeon have a detailed knowledge of the orbit and upper eyelid anatomy in order to locate and biopsy the lacrimal gland. Important steps of this procedure include careful dissection through the orbicularis muscle and surrounding fat, identification and sampling of the lacrimal gland, and thorough hemostasis of the tissue. The majority of patients recover well with low rates of associated morbidity. Risks of orbitotomy with biopsy include the potential for orbital bleeding, infection, reduced lacrimal gland function, inflammation, and cutaneous scarring.

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