------------------------------------------------------------------------------- TITLE: EYE COMPLICATIONS IN ENT SURGERY SOURCE: UTMB, DEPT. OF OTOLARYNGOLOGY, GRAND ROUNDS DATE: August 31, 1988 RESIDENT PHYSICIAN: Ray Fontenot, M.D. FACULTY ADVISOR: Francis B. Quinn, M.D. DATABASE ADMINISTRATOR: Melinda McCracken ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. ANATOMY AND PHYSIOLOGY A. The walls of the orbit consists of the lacrimal, maxillary, sphenoid, ethmoid, frontal, palatine and zygomatic bones. B. The soft tissues, consisting of the globe, nerves, fat, vessels and muscles,are confined within the bony walls and orbital septum anteriorly. C. The eyelids consist of conjunctiva, tarsus, fat, septum, muscle, and skin. D. The lacrimal drainage system consists of the upper and lower puncta, upper and lower canaliculi, lacrimal sac, and lacrimal duct. E. In order to avoid injury to any vital structures the limitations of safe dissection must be known and appreciated. The lateral aspect of the orbit is the safer area to begin dissections. Laterally and inferiorly the limits of safe dissection are approximately 25mm. The anterior aspect of the inferior orbital fissure is about 25 mm posterior to the infraorbital foramen. Superiorly and medially dissection is safe for approximately 30 mm from the superior orbital rim and anterior lacrimal crest. The distance from the anterior lacrimal crest to the optic canal is 42 mm. From the superior orbital rim to the superior orbital fissure the distance is 40mm. II. PREOPERATIVE EVALUATION A. Document pre-existing injuries. Photographic documentation is important. B. Visual acuity. Measurement with a hand near card or Snellen wall chart. Ophthalmologic consultation should be obtained for more accurate assessment. C. Extraocular muscle range of motion should be examined in all cardinal directions. Document any diplopia. D. Schirmer's test for tearing function. It is very important to document a dry eye preoperatively. E. Lid laxity is determined by pulling the lower eye lid anteriorly and observing how quickly it snaps back into position. The tarsus of the lower lid should not be easily pulled greater than 6-8 mm. from the globe. F. Examination of the fundus is especially important in ocular trauma. Intraocular injuries may preclude repairs to the surrounding areas. III. GENERAL CONSIDERATIONS A. The surgeon and assistants should avoid any unnecessary pressure or traction upon the globe. B. The eyes need to covered with moistened 4X8's during cases adjacent to the eyes. C. If the surgical procedure involves manipulations about the eye a temporary tarsorrhaphy should be considered. D. A malleable tissue retractor can be placed between the globe and a drill bit perforation site in order to prevent accidental globe perforation. E. Eye pads saturated with saline should cover the eyes during any ENT laser procedures. III. TRAUMA A. The preoperative evaluation is very important because a complication may develop if certain injuries are not detected initially. B. Traumatic telecanthus can be missed on the initial examination secondary to facial swelling. Physical clues to its presence include blunting of the palpebral fissure and absence of the caruncle. The eyelashes and lid margin can be retracted laterally, decrease of bow stringing of the medial canthal tendon and lid margin indicates medial canthal tendon damage. The intercanthal distance is usually half the interpupillary distance. The average intercanthal distance is 30-35 mm. Repair consists of either open or closed reduction of the medial canthal tendon and lacrimal bone. C. Enophthalmos results from orbital fat herniation, orbital wall expansion, or atrophy and contraction of orbital contents. It is frequently associated with hypophthalmos and motility problems. Diplopia is a variable finding. The findings of diplopia and muscle entrapment with forced duction testing assist in identifying patients with possible injuries to the inferior and medial orbital walls. Early exploration and repair is preferable. This allows easier dissection and more satisfactory results. Detection of problems at a later time requires alloplastic or bony augmentation of the orbital walls. Augmentation along the equatorial aspect of the globe elevate, while more posterior placement projects the globe anteriorly. D. Nasolacrimal apparatus injuries are usually due to sharp trauma. Epiphora is the end result without adequate repair. The site of injury must be closely examined and repaired carefully. Stents are necessary during the healing process. E. Eyelid injuries require careful identification of all layers. Individual closure of each layer is required for acceptable cosmetic and functional results. IV. GRAVES' EXOPHTHALMOS A. Graves' ophthalmopathy is an uncommon disease with orbital congestion and proptosis. The ocular muscles enlarge and compress the optic nerve at the apex. Proptosis can lead to corneal ulcerations. Both conditions can lead to blindness. Surgical decompression is indicated if medical therapy fails to control these conditions. B. Dollinger described the Kronlein temporal approach in 1911 with removal of a portion of the lateral orbital wall. C. Ogura described the transantral approach in 1957. The inferior and medial walls of the orbit are removed via the maxillary sinus. This affords good anterior decompression and relief of proptosis. D. Decompression is also possible via an external ethmoidectomy approach. The medial orbital wall and floor medial to the infraorbital nerve are removed. Periosteum is incised mainly posteriorly. V. SINUS SURGERY A. Preoperatively a careful history is important, especially if endoscopic surgery is planned. Aspirin use needs to be stopped prior to surgery. If epinephrine use is contraindicated, alternative approaches may be necessary. The CT of the sinuses should be evaluated closely for the course of the optic nerve and its relationship to the posterior ethmoid and the sphenoid sinuses. The size and shape of these sinuses are variable. The posterior ethmoid air cells can project above and around the sphenoid sinus. There is greater risk of close contact with the optic canal in this situation. In one study 8% of the optic canals projected into the posterior ethmoid cells and 50% in the sphenoid sinus. Visual acuity needs to be noted. Draping of the patient should allow direct observation of the eyes. B. The lamina papyracea is very thin and is easily perforated. The presence of orbital fat needs to be quickly recognized. Injury to nearby vessels is possible and an orbital hematoma may develop. Prompt notice of this can help to avoid serious complications such as blindness. To relieve pressure in the event of bleeding, lysis of the lateral canthal tendon is necessary. C. The optic nerve is at risk during both endoscopic surgery and external ethmoidectomy. Externally dissection should not extend beyond the posterior ethmoid artery. As mentioned above the optic nerve may project into the posterior ethmoid and sphenoid air cells. Failure to distinguish it from an air cell may lead to blindness. VI. SEPTORHINOPLASTY. A. The nasolacrimal duct is at risk during lateral osteotomy. Thomas et al studied the risk of injury to the lacrimal drainage apparatus during lateral osteotomy. Using various osteotomes the distances from the osteotomy lines to the nasolacrimal duct were measured. The closest distance to the lacrimal crest was 4 mm. No direct injuries were noted. The increased thickness of the maxillary bone near the lacrimal fossa tended to protect the sac. They stressed use of osteotomes instead of saws, avoidance of subperiosteal tunnels, and low curving osteotomies following the nasomaxillary groove. B. Epiphora is usually temporary and lasts 1-2 weeks. It is probably secondary to localized edema. VII. INFERIOR TURBINATE INJECTION A. There are rich anastomoses between the nasal and ocular vessels. Cases of both permanent and temporary blindness have been reported after steroid injection of the nasal turbinates. B. The technique consists of initial cocaine vasoconstriction of the inferior turbinates. Only the inferior turbinate should be injected. 0.5 cc. of kenalog 40 is slowly injected submucosally at the anterior aspect of each inferior turbinate using a 25 gauge needle on a tuberculin syringe. C. The steroid material needs to be of small particle size, 10 micron size. Examples are triamcinolone acetonide (Kenalog), triamcinolone diacetate (Aristocort), or prednisolone tertiary- butylacetate (Hydeltra-TBA). D. Other side effects include localized bleeding. A diffuse, painless, facial flushing is possible for 24-48 hours. Lumbar and posterior thoracic pain may be present for 30 minutes. A vasovagal response can be seen secondary to the needle insertion. VIII. BLEPHAROPLASTY. A. The preoperative evaluation is so very important. An objective evaluation of the visual fields is necessary. Any asymmetries should be pointed out and discussed. B. Blindness is the most serious complication. It is rare and has always been associated with fat removal. The importance of cauterizing the stump remaining after fat removal is stressed. Hematomas need to be evacuated. C. Ectropion can develop because of excessive skin removal. The amount of skin excision should be determined with the patient looking up and the mouth opened. The presence of lid laxity can also contribute to ectropian formation. Excised skin should be preserved in case a skin graft is necessary. A lid tightening procedure can correct a problem with laxity. D. The presence a dry eye should be determined preoperatively with a Schirmer's test. Lubricants may be necessary. IX. FACIAL NERVE PARALYSIS. A. Due to the lack of corneal protection the eye dries out with formation of ulcerations and vision changes. Conservative measures include taping the eye closed at night and the use of lubricants. B. A tarsorrhaphy may be required for adequate protection. The eyelid margins are denuded and sutured together until scarring occurs. C. A gold weight can be placed into the upper eyelid for a more dynamic procedure. Weights tend to work best with lid paresis. An implant of appropriate weight is selected to allow lid closure secondary to gravity. D. Spring like devices can be implanted in the lid. These work better with total lid paralysis. May uses 0.3mm orthodontic wire to fashion the springs. Each is shaped for the individual. It can be placed only in the upper lid or both upper and lower lids. He reports 87% success and no extrusions when using a dacron mesh wrap in the lid portion of the spring. E. Strips of temporalis muscle can be used as slings to the upper and lower eyelids. This may benefit tissues which are sagging in long term facial paralysis. ------------------------------------------------------------------------------- BIBLIOGRAPHY 1. King, JH; et al: An Atlas of Ophthalmic Surgery. J. B. Lippincott, Philadelphia, 1981. 2. Johns, ME: Complications in Otolaryngology-Head and Neck Surgery. B.C. Decker Inc, Philadelphia, 1986. 3. Beyer-Machule, CK: Plastic and Reconstructive Surgery of the Eyelids. Thieme-Stratton Inc, New York, 1983. 4. Smith, BC; et al: Ophthalmic Plastic and Reconstructive Surgery. C.V. Mosby Company, St. Louis,1987. 5. Raval, B; et al: Normal Anatomy for Multiplanar Imaging. Williams and Wilkins, Los Angeles, 1987. 6. Schaefer, SD; et al: Orbital Decompression for Optic Neuropathy Secondary to Thyroid Eye Disease. Laryngoscope, 98, July 1988, 712-717. 7. Kent, KJ; et al: Margins of Safety with Transantral Orbital Decompression. Laryngoscope, 98, august 1988, 815-817 8. May, M: Paralyzed Eyelids Reanimated with a Closed-Eyelid Spring. Laryngoscope, 98, April 1988,382-385. 9. McCollough, EG; et al: Blepharoplasty. Archives of Otolaryngology-Head and Neck Surgery, 114, June 1988, 645-648. 10. May, M: Gold Wight and Wire Spring Implants as Alternatives to Tarsorrhaphy. Archives of Otolaryngology-Head and Neck Surgery, 113, June 1987, 656-660. 11. Bansberg, SF; et al: Relationship of Optic Nerve to Paranasal Sinuses as Shown by Computed Tomography. Otolaryngology-Head and Neck Surgery, 96, April 1987, 331-335. 12. Mabry, RL: Visual Loss After Intranasal Corticosteroid Injection. Archives Otolaryngology, 107, august, 1981, 484-486. 13. Mabry, RL: Intranasal Corticosteroid Injection: Indications, Technique, and Complications. Otolaryngology-Head and Neck Surgery, 87, Mar-Apr 1979, 207-211. 14. Thomas, JR; et al: Steps for a Safer Method of Osteotomies in Rhinoplasty. Laryngoscope, 97, June 1987, 746-747. 15. Mathog, RH; et al: Posttraumatic Enophthalmos and Diplopia. Otolaryngology-Had and Neck Surgery, 94, January 1986, 69-77. 16. Cummings, CW; et al Otolaryngology-Head and Neck Surgery. C.V. Mosby Company, St. Louis, 1986. --------------------------------END------------------------------------