The lateral fornix orbitotomy: a novel surgical corridor to lacrimal gland lesions

Purpose Current practice for diagnostic biopsy of lacrimal gland lesions entails an orbitotomy procedure via an upper eyelid crease or lateral canthotomy skin incision. We describe a novel surgical technique to address these lesions via the lateral conjunctival fornix. Methods Retrospective case series of all patients who underwent a lateral fornix orbitotomy procedure for incisional or excisional diagnostic biopsy of lacrimal gland lesions. The procedure involves a conjunctival incision in the lateral fornix remote from the openings of the lacrimal ductules, and an intraperiosteal surgical corridor to access the lacrimal gland. Results The study cohort included 16 patients (3 male, 13 female) with a mean age of 48.3 years (range, 24.0–78,9 years). The sampled lesions involved the orbital lobe in 14 patients, the palpebral lobe in 1 patient, and the entire gland in 1 patient. A histopathological diagnosis was obtained in all cases. Postoperatively, new moderate adduction deficit developed in one patient (6.3%) that recovered after adhesiolysis of the conjunctival scar. 3 patients (18.8%) experienced transient mild limitation of adduction or abduction. There was no new or worse ptosis or dry eye disease related to the surgery. The mean length of postoperative follow-up was 1.3 years (median 1.0 years, range, 0.6–4.7 years). Conclusion The lateral fornix orbitotomy approach was successful in obtaining biopsy specimens of histopathological diagnostic value. It provides transconjunctival access to the lacrimal gland without damage to the excretory lacrimal ductules or displacement of the eyelid support system. Key messages What is known • Traditional techniques to biopsy lacrimal gland lesions entail transcutaneous orbitotomy procedures via an upper eyelid crease or lateral canthus incision. • Transconjunctival approaches via the superolateral fornix are discouraged for the risk of damage to the excretory lacrimal ductules. What is new • The lateral fornix orbitotomy provides intraperiosteal extraconal access to the lateral orbit. • Lesions of the orbital or palpebral lobe of the lacrimal gland can be safely and effectively biopsied via a lateral fornix conjunctival incision.