British Journal of Plastic Surgery (2005) 58, 1029–1032
CASE REPORT
Potential blindness: an unusual complication of lateral canthopexy Jonathan A. Brittoa,*, Raymond Buncicb, Oren Lapida, John H. Phillipsa a
Centre for Craniofacial Care and Research, Hospital for Sick Children, 555 University Avenue, Toronto, Ont., Canada M5G 1X8 b Department of Ophthalmology, Hospital for Sick Children, 555 University Avenue, Toronto, Ont., Canada M5G 1X8 Received 26 February 2004; accepted 22 April 2005
KEYWORDS Canthopexy; Craniofrontonasal dysplasia; Hypertelorism
Summary Lateral canthopexy is a commonly performed procedure in craniofacial and cosmetic surgery. In craniofacial surgery, lateral canthal fixation is performed in conjunction with a wide range of transcranial or subcranial procedures during the process of soft tissue re-suspension. A number of fixation materials have gained popular use. A case of craniofrontonasal dysplasia is reported in which a wire loop canthopexy fixation has become disengaged 3 months after a history of trauma and rotated to present a sharp surface against the sclera. Urgent surgical exploration prevented the apparently imminent complication of globe penetration with associated threat to vision. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
Wire fixation of the lateral canthus is a commonly performed adjunct to craniofacial surgery, and is undertaken as part of the process of re-suspension of the soft tissue envelope after earlier subperiosteal degloving of the face. Fine wire (28 gauge, or 3/0 mounted) is passed on a curved needle through the lateral canthal tendon in continuity with the tarsal plate of the lower eyelid, and may be anchored to a variety of sites. Efficient positioning of the canthus and lower eyelid is achieved by fixation to the superolateral inner surface of the orbit on the frontal bone periosteum, or by * Corresponding author. Now at: St Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Essex CM1 7ET, UK. E-mail address:
[email protected] (J.A. Britto).
trans-osseous fixation with a wire loop. The most common complication of this procedure is lower lid and canthal malposition as a result of poor accuracy of primary fixation or by subsequent loosening of the post-fixed canthus. Craniofrontonasal dysplasia is a rare X-linked disorder that maps to a 13-cM region on Xp22. It commonly presents in girls, and features coronal synostosis, hypertelorbitism, broad nasal root with or without a bifid nasal tip, poor quality course hair, and splinter haemorrhages in the nail beds.1–3 Affected children present to craniofacial centres requesting correction of the hypertelorbitism, frontocranial remodelling, and rhinoplasty. Surgical approaches to address the hypertelorbitism optimally involve transcranial access and include the
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.04.023
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Figure 1 An 11-year-old girl, having previously undergone box translocation of the orbits, presented with a painful left eye. Conjunctival thickening, scleral reddening, and left eye pain on lateral gaze are noted. The remaining ophthalmic examination was unremarkable.
horizontal orbital ‘box’ translocation introduced by Tessier,4,5 and frontofacial bipartition, described by Van der Meulen.6 Whilst the two approaches differ in principle and detail, both procedures involve an osteotomy to the lateral orbital wall in continuity with an osteotomy line running from lateral to medial in the floor of the frontal fossa/ roof of the orbit.
Case report An 11-year-old girl presented subacutely with a painful left eye, blurred vision and epiphora following a road traffic accident 3 months previously. A history of 6 days of nausea and vomiting, with pain over the left brow and forehead was elicited. On examination the patient had pain and
J.A. Britto et al.
Figure 3 Surgical exploration under general anaesthesia, via an upper lateral blepharoplasty approach. An embedded plate and screw in the lateral orbital wall project towards the sclera, but do not match the shape of the object on the CT scan. The plate and screw were removed.
tenderness on palpation of the left eyelid and orbit, corresponding to an area of conjunctival thickening and reddening of the globe (Fig. 1). There was pain in the left eye and limitation on left eye abduction. The characteristic V-pattern exotropia demonstrated by this patient group7 was also observed. Globe pressures were normal, the anterior chambers were deep and quiet, and the rest of the ophthalmic examination was unremarkable. It was noted that the patient had an established diagnosis of craniofrontonasal dysplasia and had previously undergone a box horizontal translocation of the orbits 7 years previously. A right-sided medial canthal vertical dystopia of 1 mm was noted compared to the left side, whereas the lateral canthal position was symmetrical with a slight down slanting lateral cant (1 mm on the right, 2 mm on the left). The palpebral aperture was bilaterally
Figure 2 Axial CT scan reveals a foreign body in the left lateral orbit associated with the lateral orbital wall (white arrow). Similar views in corresponding CTs over the previous 4 years also show the foreign body, which had been asymptomatic up until the time of a road traffic accident.
Complication of lateral canthopexy
1031 a free-floating wire loop, with sharp edge against the lateral sclera (Figs. 4 and 5). A break point in the wire loop was clearly evident. The wire was also removed and the wound irrigated and closed.
Discussion
Figure 4 Further exploration reveals a loose loop of wire free in the lateral orbit, with a twist and point orientated towards the injured sclera. The wire fragment was removed intact.
symmetrical, with no telecanthus, but a mild residual hypertelorism (intercanthal distance 35 mm). No acute relapses in facial aesthetic had been noted by child or family in the early posthypertelorism repair, or more recently prior to this presenting event. Orbital pathology was suspected, and the patient underwent a CT scan. Axial view revealed a foreign body to be impinging the globe at the level of the left midlateral orbital wall (Fig. 2), and urgent exploration was, therefore, undertaken to prevent eventual globe penetration. Surgical access was achieved via an upper lateral blepharoplasty approach. A plate and screw system, which had been previously placed at the lateral orbital margin, was noted to be prominent against the lateral globe and were removed (Fig. 3). The position and orientation of this hardware did not appear to match that noted on the scan, however, and deeper exploration of the lateral orbit revealed
Figure 5 The wire loop fragment displayed after removal from the orbit.
Lateral canthopexy is an important manoeuvre in craniofacial surgery to restore lower eyelid position and prevent the symptoms and complications of lower lid malposition, epiphora, and corneal damage. Correct positioning of the lateral canthus and lower eyelid also has important aesthetic consequences. The patient in this case had undergone a transcranial horizontal translocation of the orbits, during which circumorbital subperiosteal dissection and lateral orbital wall osteotomies had been performed. Subsequent lateral canthal fixation had been done with wire sutures, looped through the lateral orbital margin at a suitable level to position the lower eyelid against the translocated globe. Most commonly, complications of lateral canthopexy result from poor technique, such as poor positioning of the fixation or loosening of the post-fixed canthus. In this case an unusual delayed complication has resulted from fracture of the wire fixation, and the resultant free floating wire loop has threatened to puncture the globe. It may be that the lateral orbital wall osteotomies of the box orbital translocation had resulted in poor bone quality to which to anchor the lateral canthal fixation at time of initial surgery. The plate/screw system that was removed at this surgery had not been used to primarily fix the cathopexy wire, as primary trans-osseous fixation of canthopexies is preferred, rather than placing reliance upon a plate/screw system that is itself subject to local bony remodelling and loosening. Examination of axial CT scans done annually for the previous 4 years indicated that the prominent wire loop at the mid-lateral orbital margin is present throughout this time, but was asymptomatic. It is likely that the wire loop, although prominently protruding into the translocated orbit and, therefore, abutting the globe, was not sharply abrading the sclera until displaced from its bone anchorage by the road traffic accident. This unusual complication was nevertheless of sufficient clinical significance to require exploration, thereby preventing potential scleral laceration and globe rupture. Paediatric craniofacial surgeons have moved increasingly towards the use of bioresorbable fixation techniques to limit patient morbidity. Resorbable fixation of the lateral canthus is not commonly
1032 performed. The circumstances of this case, however, suggest that a soft permanent suture fixation of the lateral canthus, through a transosseous drill hole if necessary, will pose less risk to the eye than metallic wire fixation in the event of displacement by local trauma.
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3. 4. 5.
References
6. 7.
1. Orr DJ, Slaney S, Ashworth GJ, Poole MD. Craniofrontonasal dysplasia. Br J Plast Surg 1997;50(3):153–61. 2. Pulleyn LJ, Winter RM, Reardon W, McKeown C, Jones B,
Hayward R, et al. Further evidence from two families that craniofrontonasal dysplasia maps to Xp22. Clin Genet 1999; 55(6):473–7. Tan ST, Mulliken JB. Hypertelorism: nosologic analysis of 90 patients. Plast Reconstr Surg 1997;99(2):317–27. Tessier P. Orbital hypertelorism. Scand J Plast Reconstr Surg 1972;6:135–55. Tessier P, Guiot G, Derome P. Orbital hypertelorism II. Scand J Plast Reconstr Surg 1973;7:39–58. Van der Meulen JC. Median faciotomy. Br J Plast Surg 1979; 32(4):339–42. Roarty JD, Pron GE, Siegal Bartelt J, Posnick JG, Buncic JR. Ocular manifestations of frontonasal dysplasia. Plast Reconstr Surg 1994;93:25–30.
