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Geschwulste der Augenhohle und ihre operative Behanlung
1026
AMERICAN JOURNAL OF OPHTHALMOLOGY
the practitioner, to be used in conjunction with Thiel's Atlas of Eye Diseases, which has become a classic. The present work clearly reflects the large clinical experience of its author, and it contains a concise and easily accessible summary of clinical and diagnostic features followed by therapeutic information. The 12 chapters deal with dis eases of the eyelids, lacrimal apparatus, orbit, conjunctiva, cornea, sciera, iris, lens, vitre ous, optic nerve, retina, and choroid. The suggestions for medical or surgical treatment are in line with the most recent advances in ophthalmology. The disadvantages of this book (other than its not being in English) are that no bibliography is included, and that the drugs are listed mostly by trade names rather than by their generic names. Thus, the therapeutic information is of limited use to the Ameri can ophthalmologist, even when he can over come the language barrier, for most of the drugs listed are known under different names in this country. It is safe to predict, however, that this book will be eminently successful as a standard source of reference in Germanspeaking countries, both for the ophthalmolo gist-in-training and the practitioner. Gunter K. von Noorden
GESCHWULSTE DER AUGENHOHLE UND IHRE OPERATIVE BEHANLUNG. By Harry Men
nig. Leipzig, Georg Thieme, 1970. Clothbound, 424 pages, black and white illustra tions, 47 color plates, author and subject index. This is certainly a most interesting, stimu lating, and at times, shocking book. As the title indicates, the book consists of two main parts: a discussion on orbital tumors and a description of their surgical treatment. The basic discussion on orbital tumors is excellent. The cases reported are based on the author's own experience during a 10year period at the University of Berlin. All in all, 148 patients are described, of which 126 were operated on. The cases are interest
DECEMBER, 1970
ing, precisely described, and well illustrated. Sketches of the location of the tumor in the orbit accompany each case and these are most informative. The color pictures are of poor quality. This fault does not lie with the author, but with the publishing company. The absence of histopathologic pictures is perhaps somewhat disturbing for anybody interested in ocular pathology, but this as pect of orbital lesions was obviously outside the scope of this book. Among the 123 orbital lesions operated on were 64 that the author calls "primary" or bital tumors. Into this group he also puts in traocular tumors invading the orbit. The most frequent benign orbital tumor was again the hemangioma. Included in this group were also meningiomas, orbital pseudotumors, eosinophilic granulomas, and other similar lesions. Twenty of the cases were malignant. The classification here is not very clear and not according to the generally accepted patho logic groupings. A number of these lesions were primarily intraocular (three melanomas and one retinoblastoma). Only four patients with malignant orbital lesions had clinically manifest lymph node métastases. These are, therefore, quite rare and the author advises against a prophylactic radical neck dissection. In general, he finds the prognosis of these tumors poor. Out of 16 operated patients who could be followed, only four appeared cured after five years. This could be due either to the fact that the orbital tumors are extremely malignant, or that they are diagnosed and treated too late. In 46 patients the orbit was invaded from adjacent structures, mostly the nasal sinuses. This is an unusually high percentage of cases and probably reflects the author's main interest in diseases of the nose and the nasal sinuses. These lesions he calls "secondary" tumors. Not much issue can be taken with this part of the book. Of course, one can always find a small detail which seems incorrect or with which ophthalmologists would not agree.
VOL. 70, NO. 6
BOOK REVIEWS
This would be a picayune way of thinking. As a matter of fact, this treatise is quite comprehensive and could be a model of a monograph on orbital lesions. Nothing like this has appeared in the German literature since Birch-Hirschfeld 1 and even the mod ern English literature has nothing quite like it except for Reese's book,2 which covers the subject extremely well ; Off ret 3 has done the same for the French. It is the second part of the book, dealing with the surgical treatment of orbital tu mors, that is so extraordinarily different and sounds like a throwback into the dark past. The author attempts to remove all orbital tumors through the ethmoidal cells. The skin incision is made on the side of the nose cir cling the inner canthus, reaching from the brow down toward the nasolabial fold. All the ethmoidal cells are then removed and so is the medial wall of the orbit. The perios teum is then opened from the medial side. This approach is not new. It was at tempted decades ago, but given up again very quickly. Offret dismisses it as a most impractical and unsatisfactory approach. It is a strange way to open up a pyramid which has an easily approachable temporal side, but as the author is primarily an otolaryngologist, he would try to open the orbit via such a circuitous route. Obviously, there is not enough room to maneuver in this kind of opening and all kinds of extensions of the incision have to be made. These go either up ward or downward or in both directions. Most interesting for an ophthalmologist is the idea that the internal rectus muscle has to be put on a muscle hook that has to be intro duced through the appropriate nares ! The orbit can be opened from many sides. Obviously, the anterior orbitotomy is satis factory only in lesions which are small and lie either anterior to or close behind the or bital septum. In all other cases, the orbital bones have to be opened and this can be done in many ways. At present, the temporal orbi totomy is practically universally accepted. In the past, a few daring surgeons have at
1027
tempted to approach the orbit through the antrum. Obviously, this was a poor way and was soon dropped again. For a while the neurosurgeon tried to enter the orbit via the transfrontal orbitotomy. This was popular in this country some 30 years ago, but in mod ern times is hardly done anymore. The clas sical evaluation by Reese4 should put this ghost at rest forever. It is interesting, how ever, to note that in Europe, even at the present time, this thought seems to linger on in certain areas.5 In general, it is the fault of the ophthal mologists who leave the field by ommission to the neurosurgeon who has as little train ing and talent to operate in the orbit as the ophthalmologist has for intracranial surgery. A recent example of such a shocking relapse was an International Congress of Ultrason ics where the problem of orbital tumors was discussed by a group of neurosurgeons who behaved like frustrated ophthalmologists. It appeared that they would rather manhandle the frontal lobe, destroy the orbital roof, damage the levator muscle, and risk poor ex posure than refer the patient for a simple Kronlein operation. While it is difficult for us to understand why anybody would attempt to open the or bit from the medial side, it is interesting to speculate what brought the author to this un usual procedure. First of all, one has to realize that the au thor is an otolaryngologist who stumbled into the orbit either because the ophthalmolo gists in that university have by default given up orbital surgery or because he is a man of aggressive nature, who likes to expand his own specialty. The author also discusses enucleations and exenterations in this book. Apparently he does these as routine proce dures, as well as excision of eyelid tumors and plastic surgery of the eyelid. He also ad vises a new, simplified method of a blepharoptosis repair. This only proves that an oto laryngologist can learn any aspects of oph thalmic surgery ; whether this is desirable or not depends on the local situation.
1028
AMERICAN JOURNAL OF OPHTHALMOLOGY
Another explanation is that physicians be hind the Iron Curtain and especially in East Germany work in utter isolation. They can hardly ever attend any medical meetings of international character, nor can they easily obtain a book or a scientific journal pub lished in a non-communistic country. They work in a kind of vacuum and easily get off on a tangent. It is obvious that the modern literature on orbital tumors and orbital sur gery8 was not known to the author. Modern surgical approaches, such as the Reese-Berke variation of the Kronlein operation, or the temporalis muscle transplantation for exenteration, are unknown to him. Such an intel lectual isolation combined with monomania may lead a surgeon to follow methods or to establish hypotheses which have long been discarded, as they have been proven unsuc cessful, unrewarding, or untenable. It is not meritorious to repeat mistakes of our prede cessors or our older colleagues. We should learn from them and accept better methods as they become available. It would be ludi crous to test anew the value of cataract couching when cataract extractions have been found to be a superior way of treating this disease. It is interesting that this book comes from the Charité Medical School which, next door, houses such prominent, forward-looking, young German ophthalmologists as Busch mann, Comber, Goder, Lommatzsch, and Richter. Nevertheless, they seem to have left the field of orbital surgery, including the eyelids, to the otolaryngologists. When I first read about this method,7 I thought this was a transient aberration. However, the author has continued with his method with apparently some success.8 The
DECEMBER, 1970
advantages are not clear to an ophthalmolo gist. Why should the orbit be opened from the medial side through which the ethmoidal cells have to be removed, the nasal cavity has to be opened, and the aseptic wound is trans formed into a contaminated one? The expo sure is poor, the nose is in the way, and ma neuvering is impaired by the narrowness of the aperture. This method reminds me of an old Viennese proverb, "Why use a simple method when a complicated one is available." I am also reminded of Samuel Johnson9 ; what he said about female ministers when he compared them to dogs walking on their hindlegs applies equally to this type of surgical exposure: "It is not done well, but you are surprised to find it can be done at all." Frederick C. Blodi REFERENCES
1. Birch-Hirschfeld, A. : Die Erkrankungen der Orbita; Kurzes Handb. Ophth. I l l ; J. Springer, 1930. 2. Reese, A. B.: Tumors of the Eye. New York, McGraw-Hill (Hoeber Division), 1963. 3. Offret, G. : Les tumeurs primitives de l'orbite. Paris, Masson & Co., 1951. 4. Reese, A. B.: The role of the neurosurgeon in the treatment of orbital tumors. Am. J. Ophth. 58:140,1964. 5. Brihaye, J., Hoffmann, G. R., François, J. and Brihaye-van Geertruyden, M. : Les exophtalmies neuro-chirurgicales. Neurochirurgie 14:187, 1968. 6. Boniuk, M. (éd.) : Ocular and Adrexal Tu mors. St. Louis, Mosby, 1964. Moss, H. M. : Ex panding lesions of the orbit. Am. J. Ophth. 54:761, 1962. Second Congress European Ophth. Soc. : The Tumors of the Eye and Its Adnexa. Basel, S. Karger, 1966. 7. Mennig, H. : Klinische Erfahrungen bei der Operation von Orbitaltumoren; Ber. Tagung OtoNeuro-Ophth. Berlin, George Thieme, 1963. 8. Linnert, D. : Augenärztliche Befunde nach der operativen Behandlung von Orbitatumoren. Klin. Mbl. Augenhlk. 156:507, 1970. 9. Boswell's "Life of Dr. Johnson," Everyman's ed. I. 287.
AMERICAN JOURNAL OF OPHTHALMOLOGY
the practitioner, to be used in conjunction with Thiel's Atlas of Eye Diseases, which has become a classic. The present work clearly reflects the large clinical experience of its author, and it contains a concise and easily accessible summary of clinical and diagnostic features followed by therapeutic information. The 12 chapters deal with dis eases of the eyelids, lacrimal apparatus, orbit, conjunctiva, cornea, sciera, iris, lens, vitre ous, optic nerve, retina, and choroid. The suggestions for medical or surgical treatment are in line with the most recent advances in ophthalmology. The disadvantages of this book (other than its not being in English) are that no bibliography is included, and that the drugs are listed mostly by trade names rather than by their generic names. Thus, the therapeutic information is of limited use to the Ameri can ophthalmologist, even when he can over come the language barrier, for most of the drugs listed are known under different names in this country. It is safe to predict, however, that this book will be eminently successful as a standard source of reference in Germanspeaking countries, both for the ophthalmolo gist-in-training and the practitioner. Gunter K. von Noorden
GESCHWULSTE DER AUGENHOHLE UND IHRE OPERATIVE BEHANLUNG. By Harry Men
nig. Leipzig, Georg Thieme, 1970. Clothbound, 424 pages, black and white illustra tions, 47 color plates, author and subject index. This is certainly a most interesting, stimu lating, and at times, shocking book. As the title indicates, the book consists of two main parts: a discussion on orbital tumors and a description of their surgical treatment. The basic discussion on orbital tumors is excellent. The cases reported are based on the author's own experience during a 10year period at the University of Berlin. All in all, 148 patients are described, of which 126 were operated on. The cases are interest
DECEMBER, 1970
ing, precisely described, and well illustrated. Sketches of the location of the tumor in the orbit accompany each case and these are most informative. The color pictures are of poor quality. This fault does not lie with the author, but with the publishing company. The absence of histopathologic pictures is perhaps somewhat disturbing for anybody interested in ocular pathology, but this as pect of orbital lesions was obviously outside the scope of this book. Among the 123 orbital lesions operated on were 64 that the author calls "primary" or bital tumors. Into this group he also puts in traocular tumors invading the orbit. The most frequent benign orbital tumor was again the hemangioma. Included in this group were also meningiomas, orbital pseudotumors, eosinophilic granulomas, and other similar lesions. Twenty of the cases were malignant. The classification here is not very clear and not according to the generally accepted patho logic groupings. A number of these lesions were primarily intraocular (three melanomas and one retinoblastoma). Only four patients with malignant orbital lesions had clinically manifest lymph node métastases. These are, therefore, quite rare and the author advises against a prophylactic radical neck dissection. In general, he finds the prognosis of these tumors poor. Out of 16 operated patients who could be followed, only four appeared cured after five years. This could be due either to the fact that the orbital tumors are extremely malignant, or that they are diagnosed and treated too late. In 46 patients the orbit was invaded from adjacent structures, mostly the nasal sinuses. This is an unusually high percentage of cases and probably reflects the author's main interest in diseases of the nose and the nasal sinuses. These lesions he calls "secondary" tumors. Not much issue can be taken with this part of the book. Of course, one can always find a small detail which seems incorrect or with which ophthalmologists would not agree.
VOL. 70, NO. 6
BOOK REVIEWS
This would be a picayune way of thinking. As a matter of fact, this treatise is quite comprehensive and could be a model of a monograph on orbital lesions. Nothing like this has appeared in the German literature since Birch-Hirschfeld 1 and even the mod ern English literature has nothing quite like it except for Reese's book,2 which covers the subject extremely well ; Off ret 3 has done the same for the French. It is the second part of the book, dealing with the surgical treatment of orbital tu mors, that is so extraordinarily different and sounds like a throwback into the dark past. The author attempts to remove all orbital tumors through the ethmoidal cells. The skin incision is made on the side of the nose cir cling the inner canthus, reaching from the brow down toward the nasolabial fold. All the ethmoidal cells are then removed and so is the medial wall of the orbit. The perios teum is then opened from the medial side. This approach is not new. It was at tempted decades ago, but given up again very quickly. Offret dismisses it as a most impractical and unsatisfactory approach. It is a strange way to open up a pyramid which has an easily approachable temporal side, but as the author is primarily an otolaryngologist, he would try to open the orbit via such a circuitous route. Obviously, there is not enough room to maneuver in this kind of opening and all kinds of extensions of the incision have to be made. These go either up ward or downward or in both directions. Most interesting for an ophthalmologist is the idea that the internal rectus muscle has to be put on a muscle hook that has to be intro duced through the appropriate nares ! The orbit can be opened from many sides. Obviously, the anterior orbitotomy is satis factory only in lesions which are small and lie either anterior to or close behind the or bital septum. In all other cases, the orbital bones have to be opened and this can be done in many ways. At present, the temporal orbi totomy is practically universally accepted. In the past, a few daring surgeons have at
1027
tempted to approach the orbit through the antrum. Obviously, this was a poor way and was soon dropped again. For a while the neurosurgeon tried to enter the orbit via the transfrontal orbitotomy. This was popular in this country some 30 years ago, but in mod ern times is hardly done anymore. The clas sical evaluation by Reese4 should put this ghost at rest forever. It is interesting, how ever, to note that in Europe, even at the present time, this thought seems to linger on in certain areas.5 In general, it is the fault of the ophthal mologists who leave the field by ommission to the neurosurgeon who has as little train ing and talent to operate in the orbit as the ophthalmologist has for intracranial surgery. A recent example of such a shocking relapse was an International Congress of Ultrason ics where the problem of orbital tumors was discussed by a group of neurosurgeons who behaved like frustrated ophthalmologists. It appeared that they would rather manhandle the frontal lobe, destroy the orbital roof, damage the levator muscle, and risk poor ex posure than refer the patient for a simple Kronlein operation. While it is difficult for us to understand why anybody would attempt to open the or bit from the medial side, it is interesting to speculate what brought the author to this un usual procedure. First of all, one has to realize that the au thor is an otolaryngologist who stumbled into the orbit either because the ophthalmolo gists in that university have by default given up orbital surgery or because he is a man of aggressive nature, who likes to expand his own specialty. The author also discusses enucleations and exenterations in this book. Apparently he does these as routine proce dures, as well as excision of eyelid tumors and plastic surgery of the eyelid. He also ad vises a new, simplified method of a blepharoptosis repair. This only proves that an oto laryngologist can learn any aspects of oph thalmic surgery ; whether this is desirable or not depends on the local situation.
1028
AMERICAN JOURNAL OF OPHTHALMOLOGY
Another explanation is that physicians be hind the Iron Curtain and especially in East Germany work in utter isolation. They can hardly ever attend any medical meetings of international character, nor can they easily obtain a book or a scientific journal pub lished in a non-communistic country. They work in a kind of vacuum and easily get off on a tangent. It is obvious that the modern literature on orbital tumors and orbital sur gery8 was not known to the author. Modern surgical approaches, such as the Reese-Berke variation of the Kronlein operation, or the temporalis muscle transplantation for exenteration, are unknown to him. Such an intel lectual isolation combined with monomania may lead a surgeon to follow methods or to establish hypotheses which have long been discarded, as they have been proven unsuc cessful, unrewarding, or untenable. It is not meritorious to repeat mistakes of our prede cessors or our older colleagues. We should learn from them and accept better methods as they become available. It would be ludi crous to test anew the value of cataract couching when cataract extractions have been found to be a superior way of treating this disease. It is interesting that this book comes from the Charité Medical School which, next door, houses such prominent, forward-looking, young German ophthalmologists as Busch mann, Comber, Goder, Lommatzsch, and Richter. Nevertheless, they seem to have left the field of orbital surgery, including the eyelids, to the otolaryngologists. When I first read about this method,7 I thought this was a transient aberration. However, the author has continued with his method with apparently some success.8 The
DECEMBER, 1970
advantages are not clear to an ophthalmolo gist. Why should the orbit be opened from the medial side through which the ethmoidal cells have to be removed, the nasal cavity has to be opened, and the aseptic wound is trans formed into a contaminated one? The expo sure is poor, the nose is in the way, and ma neuvering is impaired by the narrowness of the aperture. This method reminds me of an old Viennese proverb, "Why use a simple method when a complicated one is available." I am also reminded of Samuel Johnson9 ; what he said about female ministers when he compared them to dogs walking on their hindlegs applies equally to this type of surgical exposure: "It is not done well, but you are surprised to find it can be done at all." Frederick C. Blodi REFERENCES
1. Birch-Hirschfeld, A. : Die Erkrankungen der Orbita; Kurzes Handb. Ophth. I l l ; J. Springer, 1930. 2. Reese, A. B.: Tumors of the Eye. New York, McGraw-Hill (Hoeber Division), 1963. 3. Offret, G. : Les tumeurs primitives de l'orbite. Paris, Masson & Co., 1951. 4. Reese, A. B.: The role of the neurosurgeon in the treatment of orbital tumors. Am. J. Ophth. 58:140,1964. 5. Brihaye, J., Hoffmann, G. R., François, J. and Brihaye-van Geertruyden, M. : Les exophtalmies neuro-chirurgicales. Neurochirurgie 14:187, 1968. 6. Boniuk, M. (éd.) : Ocular and Adrexal Tu mors. St. Louis, Mosby, 1964. Moss, H. M. : Ex panding lesions of the orbit. Am. J. Ophth. 54:761, 1962. Second Congress European Ophth. Soc. : The Tumors of the Eye and Its Adnexa. Basel, S. Karger, 1966. 7. Mennig, H. : Klinische Erfahrungen bei der Operation von Orbitaltumoren; Ber. Tagung OtoNeuro-Ophth. Berlin, George Thieme, 1963. 8. Linnert, D. : Augenärztliche Befunde nach der operativen Behandlung von Orbitatumoren. Klin. Mbl. Augenhlk. 156:507, 1970. 9. Boswell's "Life of Dr. Johnson," Everyman's ed. I. 287.