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This fine publication is intended for the occasional orbital surgeon. The author states that it should also be helpful for the student preparing for higher degrees. I am sure that only Dr McNab's modesty prevents him making the more accurate statement that it should be essential reading for the intending specialist, not only in Ophthalmology but also in Plastic and ENT surgery. Furthermore, general surgeons working in isolated or rural practice or in developing countries without ready access to an orbital surgeon will find this a key publication. The first chapter deals with orbital anatomy. It is illustrated with CAT scans and line drawings that demonstrate the applied anatomy of the orbit with clarity. Then follows a chapter on the diagnosis of orbital lesions. An extension of the first, this chapter is replete with MRI and CAT scans. An ability to read such scans is essential for the orbital surgeon because frequently a diagnosis can be made on the radiological appearance of a lesion. A useful list of common disorders then follows and the frequency of each is alluded to. The breadth of this list emphasises the importance of early biopsy in orbital disease. It is common for orbital lesions to be treated conservatively because of the reluctance of the surgeon to embark on an unfamiliar operation. This can have serious consequences in the case of malignant disease. The fourth chapter describes the choice of surgical approach to the orbit - a vital aspect of orbital surgery. If the approach is inadequate it may be impossible to find an orbital tumour. Anterior and lateral approaches are described in manner that should encourage any competent ophthalmic surgeon to undertake them. Dr McNab reminds us that the transcranial approach is useful for apical tumours - an approach that should be undertaken with the assistance of a neurosurgeon. The description of the lateral orbitotomy is excellent, but I would point out that the Gigli saw is useful for removal of the lateral orbital wall, especially when an oscillating saw is not available. It allows the direction of the cut to be easily varied so that the curve of the cranium can be followed, with a resultant improvement in exposure. In his description of exenteration, Dr McNab indicates the importance of preparing the patient for what is a disfiguring operation. I agree that a careful description of the operation and an accurate account of the disfigurement it produces are important - but may be insufficient. A liaison psychiatrist is invaluable in bringing the patient to a realisation and an acceptance of the implications of the operation. The technique of allowing the orbit to granulate after exenteration is given prominence although it extends convalescence for several weeks. The transplantation of the anterior portion of the temporalis muscle through the lateral orbital well to fill the orbit should be within the scope of the surgeon. Perhaps this operation could be described in the third edition of this book The description of orbital decompression for thyroid eye disease is useful. This operation can be sight saving in cases of malignant exophthalmos. It is a difficult operation even in the hands of an experienced orbital surgeon. The occasional surgeon would be advised to seek the assistance of an ENT surgeon when first attempting the procedure. It is an extension of the external ethmoidectomy operation with which such surgeons are familiar. I found the section on orbital trauma to be particularly helpful. Dr McNab emphasises that not all blowout fractures should be explored and provides sensible indications for intervention. He advises that the operation should be delayed for several days and only undertaken in the presence of diplopia or marked enophthalmos. Dr McNab rightly devotes most of Chapter 9 to orbital cellulitis, a disease that may require urgent surgery, and he describes the surgical techniques with clarity. This chapter is especially important for general surgeons working in isolated areas, as the disease can result in a catastrophic loss of sight unless it is treated aggressively. The book concludes with an excellent dissertation on the aetiology, diagnosis and treatment of epiphora. Of particular interest is the description of the management of canalicular injury and obstruction, utilising techniques refined by Dr McNab. In summary, this is an admirable practical manual for the occasional orbital surgeon. Candidates for higher degrees in several surgical disciplines will find it worth reading. It should be on the bookshelf of all general surgeons working in isolation. I recommend it unreservedly. JEK Galbraith OBE
This is available for purchase through the Library's Bookshop Service, or available for loan through the library. Contact the library for more details.
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