A new concept of the sympathetic pathways to the eye

The sympathetic pupillociliary pathways controlling the dilatation of the pupil in man have been recorded by many authorities as passing via the first and/or second thoracic (dorsal) rami to the lower part of the stellate (first thoracic) ganglion. It has been stated by these and other authorities that the removal of the lower part of the stellate ganglion and/or resection of the first and/or second thoracic rami would produce a Horner's syndrome. This currently accepted concept of the sympathetic pathways to the eye we believe to be incorrect. Our entire clinical experience has consistently contradicted the findings and reports of other investigators. It is suggested that the ability afforded by a new surgical approach to reach, dissect, and exactly control the line of resection without undue trauma to the stellate ganglion has made possible for the first time a definitive statement concerning the entry of the pupillociliary pathways into the sympathetic chain. It is, therefore, postulated that the preganglionic neurons controlling the pupil enter the upper portion of the stellate ganglion by a separate paravertebral route leaving the ventral roots of the eighth cervical, first and/or second thoracic nerves. Our entire clinical experience refutes the concept that these pathways pass via the first ramus communicans to the first thoracic ganglion. This thesis is based on and supported by the results of new surgical approach originally designed to permit a more direct exposure and to overcome many of the deficiencies of current surgical approaches. The anterior transthoracic, transpleural wound employed allows a more direct approach and a more accurate and complete dissection of this segment of the sympathetic supply to the head, neck, upper extremity, heart, and coronary vessels without incurring the undesirable sequela of a Horner's syndrome in 93% of patients.