Editorial
Oculoplastic and Orbital Surgery
Millennia in the Making
George B. Bartley, MD - Rochester, Minnesota
As part of the American Ophthalmological Society’s 150th
our subspecialty’s history. Why? Because some of his
birthday celebration in 2014,1 a representative from each
ocular adnexal descriptions were just plain wrong. Rather, I
subspecialty was invited to provide a brief account of the
confer my third milestone on Vesalius’ student and ultipast, present, and future of his or her respective area of
mately his successor as chair of anatomy at Padua, Gabriele
interest. Before offering my perspective on oculoplastic and
Falloppio, who, in his modest monograph in 1562,6 provided the ﬁrst good description of the levator palpebrae
orbital surgery, I must begin with a disclaimer. The historian
superioris in addition to demonstrating that the retractor
C. B. McCullagh, in a thoughtful essay about bias in
bulbi muscle does not exist in humansdan insight contrary
reporting historical events, opined that “both nature and
to the teachings of Vesalius.7
history are sublime, and any account of them is inevitably
Milestone 4 is for Georg Bartisch’s monumental Ophselective.”2 Therefore, the topics that I have selected to
feature inevitably reﬂect my personal biases. I have grouped
thalmodouleia of 1583.8 As with Celsus, many of Bartisch’s
depictions are easily recognizable: proptosis, ectropion,
15 highlights into the following rubrics: 5 milestones before
epibulbar and eyelid tumors, trichiasis, dacryocystitis, and
1864 (the year the American Ophthalmological Society
dermatochalasis. Some might argue, however, that Bartisch’s
[AOS] was founded), 5 notable advances between 1864 and
recommended treatment for removing excess eyelid skind
the present, and 5 challenges for oculoplastic and orbital
strangulation clampsdis a step backward from Celsus.
surgery going forward.
Choosing a ﬁfth and ﬁnal milestone from before 1864
Long before anyone knew about cupping, the choroid, or the
was a challenge. Carl von Graefe has been regarded by
chiasm, surgeons were whittling away on the ocular adnexa.
many as the founder of plastic
Our ﬁrst milestone is found nearly
surgery. His contributions indeed
38 centuries ago, around 1772 BCE,
Long before anyone knew about
with Hammurabi, the King of
were colossal, not to mention the
Babylon. The following passage cupping, the choroid, or the chiasm, gift of his son, Albrecht, to our
surgeons were whittling away on
from the Hammurabi Code has
ﬁeld. However, as with Vesalius
been interpreted putatively as a
and Falloppio, I have to move on
the ocular adnexa
description of an infected dacryofrom teacher to student and
cele: “If a physician operate[s] on a man for a severe wound
recognize Johann Dieffenbach as the founder of modern
with a bronze lancet and cause the man’s death; or open an
plastic surgery. Like Falloppio after Vesalius at Padua,
abscess (in the eye) of a man with a bronze lancet and destroy
Dieffenbach succeeded von Graefe as Professor of Surgery
the man’s eye, they shall cut off his ﬁngers.”3 Unfortunately,
at the University of Berlin on von Graefe’s death in 1840.
the account also conﬁrms that severe penalties for malpractice
Dieffenbach moved the ﬁeld forward tremendously with his
or poor outcomes have dogged surgeons since antiquity.
surgical textbooks in the 1840s,9,10 describing many operations that set the stage for modiﬁcations that we still use
We jump ahead to the acme of the Roman Empire to
today.
milestone number 2: the writings of Celsus. Even though
Next, I’d like to highlight 5 major advances from 1864 to
Hirschberg4 disparagingly asserted that Celsus was merely an
aggregator rather than an innovator, this work nevertheless is
the present. Given that plastic surgery is essentially applied
remarkable. Consider that, before the ﬁrst book of the New
anatomy, my ﬁrst milestone recognizes the marvelous conTestament had been written, Celsus included descriptions of
tributions of S. E. Whitnall, whose anatomy textbook,11 ﬁrst
published in 1921, is a tour de force. In addition to his
advancement and rotational ﬂaps to repair skin defects.
original observations, such as the eyelid ligament that bears
Additionally, his account of surgery for lax eyelids, from
his name, his descriptions are beautifully written and replete
roughly 30 CE, is astonishingly recognizable to blepharoplasty surgeons: “seize a fold of skin between ﬁnger and
with timeless insights. Although Whitnall was an anatomist,
thumb. consider how much to be removed for the lid to be
his book reads like a surgical atlas.
in a natural position. where the incision is to be made.
Milestone number 2 honors a member of the AOS,
mark by two lines of ink. the edges of the wound are
Wendell Hughes, whose AOS membership thesis in 1941
brought into apposition by one stitch. a sponge of cold is
was so extensive that it was not published in the Transbandaged on. on the fourth day the sutures are taken out and
actions, but rather as a standalone monograph 2 years
a salve for repressing inﬂammation is smeared on.”5
later.12 His work set a new standard for eyelid reconstrucMoving forward, any journey through medical history
tion or a term that he preferred, blepharopoiesis (and one
must at least pause and wave to Vesalius. However, my bias
that I’ve not yet had the courage to include in a surgical
is not to label De Humani Corporis Fabrica a milestone in
dictation or in a bill to Medicare).
Ó 2014 by the American Academy of Ophthalmology
Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ophtha.2014.09.017
ISSN 0161-6420/14
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Ophthalmology Volume -, Number -, Month 2014
Dr. Hughes is perhaps best known for his procedure to
reconstruct large defects of the lower eyelid. Two important
themes of his work were to repair “like with like” and to
accomplish “more with less.” Before this time, many
reconstructive operations were far more involved, that is to
say, far more invasive, than was necessary. After retirement,
Dr. Hughes continued to publish, including advice on using
motor oil rather than water in lawn rollers13 and instructions
on how to carve the perfect grapefruit.14 Ever the innovator.
Milestone number 3: imaging. The ﬁrst computed tomography scanner in North America was installed at Mayo
Clinic in June 1973. The initial examinations focused on
anatomic features north of the pituitary, but fortunately radiologists soon realized that the truly interesting pathology
was in the orbits, and within 2 months, a patient with
proptosis resulting from a retrobulbar cavernous hemangioma had been scanned. The highly pixilated images were
included in a seminal article that was published the
following year and coauthored by 2 AOS members, Thomas
P. Kearns (recipient of the Howe Medal in 1994) and John
W. Henderson.15
Contemporary computed tomography and magnetic resonance images provide inﬁnitely more information, including
real-time intraoperative navigational guidance, while
requiring far less imagination to interpret than those early
scans. The future of imaging seems boundless and may
include methods such as magnetic resonance elastography,
which has proven to be particularly useful in the characterization of hepatic ﬁbrosis and the subtypes of meningioma.16
Finally, I include under the rubric of “imaging” the
advent of endoscopy. When I began my career, the nose and
the sinuses were dark, inaccessible, mysterious, and nasty.
Nowadays, these areas are well-illuminated, accessible,
familiar. but still sometimes nasty.
My fourth milestone relates to the development of botulinum toxin by the 1998 Howe Medalist Alan Scott.
Although Dr. Scott’s initial research was on the treatment of
strabismus, which was the theme of his AOS thesis in
1981,17 the drug soon found use as a godsend therapy for
patients with essential blepharospasm and hemifacial
spasm.18 Of course, periocular injections for functional
purposes were noted to have side effects that could be
exploited for cosmetic beneﬁt, and the rest is history.
For my ﬁnal milestone of the present era, I wish to
highlight the establishment of our subspecialty as a bona
ﬁde discipline. For instance, our member organization, the
American Society of Ophthalmic Plastic and Reconstructive
Surgery, has existed now for 45 years19 and our journal,
Ophthalmic Plastic and Reconstructive Surgery, for 30. But
Burt Brent’s 1987 book, The Artistry of Reconstructive
Surgery,20 for me exempliﬁes how the road to recognition
has truly been achieved. The book’s cover features an
intriguing composite painting of more than 75 giants from
the world of plastic surgery. Included in this pantheon is an
ophthalmologist, the 2002 AOS Howe Medalist Crowell
Beard, whose contributions earned the respect of plastic
surgeons. Dr. Beard’s original work, and that of many
others, has helped to distinguish our ﬁeld as a distinct entity.
When I began my career, interactions with plastic surgery
were minimal. Today, plastic surgery residents rotate on our
service, we lecture to their department on a variety of oculoplastic and orbital topics, and we regularly work together
side-by-side in the operating room. Such collaborations are
a major advance, in my opinion, because patients are the
true winners.
What about the future of oculoplastic and orbital surgery? We have plenty of challenges. I shall mention just a
handful. First, it is great that we have botulinum toxin to
treat blepharospasm, but we don’t know what causes the
disease. Second, we still see way too many patients with
Graves’ ophthalmopathy, which has been the theme of any
number of AOS theses, including my own. Two hundred
years ago, Parry, Graves, and von Basedow conjectured that
thyroid disease and eye disease somehow were linked. Two
centuries later, we believe that the thyroid and the orbit
are entwined in some kind of pernicious immunologic
ballet, which we often treat by making holes in patients’
headsdorbital decompressiondto release evil humors.
Using surgery to treat cytokines is ﬁghting the wrong war.
Third, on the theme of combat and of making holes in
people’s heads, when treating cancer, we need to ﬁgure out
ways to eliminate the enemy without carpet bombing.
Resorting to exenteration is end-stage ophthalmology.
Regrettably, during my professional lifetime, our success
treating sebaceous gland carcinoma, Merkel cell carcinoma,
lacrimal gland adenoid cystic carcinoma, and melanoma has
been disappointing at best.
Fourth, in those instances when we must remove an eye,
we need to identify the perfect socket implant. Surgeons
have placed dozens of different varieties into innocent, unsuspecting sockets during the past century, but each has had
major drawbacks. Finally, watching a socket enter the death
spiral of severe contraction emphasizes that we need a better
understanding of abnormal wound healingdwhy it occurs
and how we can modulate it.
Of note, the challenges that I have highlightedd
blepharospasm, Graves ophthalmopathy, oncology, and
wound healingdlikely will be treated nonsurgically in the
future, which may have signiﬁcant implications for our
subspecialty.
On that theme, I would have liked to explore the advances that oculoplastic surgery has made in learning when
not to operate, for instance, in many cases of orbital blowout
fractures. We know that observation is often appropriate, but
some surgeons in some specialties continue to operate on
virtually every fracture. This is unconscionable in contemporary medicine and emphasizes the need for better interdisciplinary collaboration.
Also, time constraints have prohibited more than a
passing mention of lacrimal disease, which is a major part of
our practices. It also would have been enlightening to review a few creative ideas that fortunately didn’t quite catch
on, such as the use of chopsticks rather than forceps and
patient-torturing devices to bolster a skin graft.21
In closing, it is humbling to realize that Celsus, Bartisch,
or Dieffenbach likely could scrub right in on some of the
operations we do today. Although, come to think of it,
scrubbing might seem to be a puzzling ritual to them. And
they might well be puzzled by the embarrassing behavior
that sometimes characterizes our specialty, for instance,
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Editorial
billboards advertising that Medicare will pay for eyelid lifts.
I suggested at the beginning of this editorial that our subspecialty is the oldest among our profession, and at times
our actions seem to resemble the oldest profession. Perhaps
I should have included the necessity to continually pursue
professionalism as another challenge going forward.
Regardless, oculoplastic and orbital surgery is a unique
facet of ophthalmology, crossing boundaries with several
other surgical and medical disciplines and comprising
arguably the widest spectrum of operations in its repertoire:
the repair of eyelid malpositions such as ptosis, retraction,
ectropion, and entropion; trauma; trichiasis; a gamut of
lacrimal disorders; evisceration, enucleation, and exenteration; tumors; the reconstruction of an endless variety of
adnexal and facial defects; orbital, socket, and sinus surgery;
and, of course, an increasing palette of cosmetic offerings.
But one thing is certain: our subspecialty is the most fun.
Acknowledgment. References 3e6 and 9e12 provided courtesy of Mayo Clinic Libraries History of Medicine Collection.
References
1. Albert DM. A sesquicentennial salute to the American
Ophthalmological Society. Ophthalmol 2014;121:1493–4.
2. McCullagh CB. Bias in historical description, interpretation,
and explanation. History and Theory 2000;39:39–66.
3. Harper RF. The code of Hammurabi King of Babylon.
Chicago: University of Chicago Press; 1904:79.
4. Hirschberg J. Die Geschichte der Lidbildung. Handb.d. ges
Augenh. 2nd ed. 14: zweite Abteilung. Graefe-Saemisch;
1911:96e109.
5. Celsus AC. De Medicina. Spencer WG, trans. vol. 3. Cambridge, MA: Harvard University Press; 1935:338–43.
6. Falloppio G. Observationes anatomicae. 1562.
7. Albert DM, Edwards ED, eds. The History of Ophthalmology.
Cambridge, MA: Blackwell Science; 1996:256.
8. Bartisch G. Ophthalmodouleia, 1583. Blanchard D. J.-P.,
trans. Ostend, Belgium: Wayenborgh; 1996.
9. Dieffenbach JF. Die operative chirurgie. Leipzig: Brockhaus;
1845.
10. Dieffenbach JF. Die operative chirurgie. Leipzig: Brockhaus;
1848.
11. Whitnall SE. The anatomy of the human orbit and accessory
organs of vision. London: Henry Frowde and Hodder &
Stoughton; 1921.
12. Hughes WL. Reconstructive surgery of the eyelids. St. Louis:
C.V. Mosby Co; 1943.
13. Hughes WL. Another tip on old oil (letter). Popular Mechanics
1977;147:26.
14. Hughes WL. More thoughts on grapefruit [letter]. Changing
Times: The Kiplinger Magazine 1984;38:91.
15. Baker HL, Kearns TP, Campbell JK, Henderson JW.
Computerized transaxial tomography in neuro-ophthalmology.
Am J Ophthalmol 1974;78:285–94.
16. Litwiller DV, Lee SJ, Kolipaka A, et al. Magnetic resonance
elastography of the ex-vivo bovine globe. J Magn Reson Imaging 2010;32:44–51.
17. Scott AB. Botulinum toxin injection of eye muscles to
correct strabismus. Trans Am Ophthalmol Soc 1981;79:
734–70.
18. Scott AB, Kennedy RA, Stubbs HA. Botulinum A toxin injection as a treatment for blepharospasm. Arch Ophthalmol
1985;103:347–50.
19. The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Reiﬂer DM, ed. San Francisco:
Norman Publishing, 1994.
20. Brent B. The artistry of reconstructive surgery. St. Louis: CV
Mosby Co; 1987.
21. Sheehan JE. Plastic surgery of the orbit. New York: Macmillan
Company; 1927:143,303.
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