Acquired Vertical Binocular Diplopia Following a Rugby Match. Case Example. Case J.S. Case J.S. 7/12/12. ! CC: Double vision
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1 Acquired Vertical Binocular Diplopia Following a Rugby Match Case Example Daniel R. Lefebvre, M.D. Case J.S.! CC: Double vision! HPI: 23 y/o white male! H/O Right orbital floor fracture Feb 2009 (assaulted)! Repaired with silicone sheet and microscrew fixation! Some persistent vertical diplopia in downgaze post-operatively, not interfering with activities observed! Stable until 3 weeks prior to re-presentation Oct 2011 Case J.S.! Hit to face during Rugby match! Worsened vertical diplopia in primary gaze shortly thereafter! No loss of vision! No nausea or vomiting 1
2 DDx AcquiredVertical Binocular Diplopia Cranial Nerve III Palsy Cranial Nerve IV Palsy Skew Deviation (central vestibular disturbance) Brainstem or cerebellar injury Multiple sclerosis Head trauma Extra-ocular Muscle Restriction (e.g. fracture, inflamm., mass) Neuromuscular Junction Pathology (e.g. myasthenia) Sashank Prasad, Nicholas J. Volpe and Madhura A. Tamhankar Neurology 2009;72;e93 PMHx! Reactive Airway Disease! Obsessive Compulsive Disorder! Attention Deficit Disorder! Varicocele Medications! Lexapro 2
3 FHx & SHx! Art Student! Denies smoking! No family history of eye disorders POHx! Right orbital floor blowout fracture Feb 2009 s/p assault! Per notes Restricted motility in upgaze and downgaze OD! Repaired with silicone sheet and microscrew fixation! Physiologic cupping OU Exam V SC 20/20 20/20 Pupils: 4 2 OU; No APD T Orbits soft to retropulsion OU MRD1: +0.5 OD, +3 OS Hertel Exophthalmometry: Base 91 OD 16 OS 15 3
4 Motility SLE L/L/A: C/S: Grossly WNL OU W/Q OU K: Clear OU AC: D/Q OU I: Flat OU, WNL OU L: Clear OU DFE ON pink & sharp OU C/D: 0.45 OU Mac: Retinal Striae OD, Flat OS Vessels: WNL OU Vitreous: Clear OU Periphery: OD: 4 DA inferior globe indentation OS: WNL 4
5 Right Eye Mild exophthalmos hyperglobus Limitation of infraduction Macular striae and inferior globe indentation History of prior orbital fracture repair History of new trauma Thoughts? Perimetry! HVF 24-2 from patient s optometrist office was normal 5
6 6
7 Diagnosis:! Inflammatory capsule around silicone sheet with likely intracapsular hemorrhage brought on by trauma hematic cyst chocolate cyst Treatment:! Removal of silicone implant and drainage of cyst / blood 7
8 Pre-Op Post-Op Month 1 Full Motility No diplopia Delayed Chocolate Cyst After Blowout Fracture Case Report: 42 y/o female Orbital floor fracture repaired age year hx: recurrent RLL edema and hypesthesia, diplopia, proptosis Eventual removal of silicone sheet Apparently migrated, abrading infraorbital NV bundle Thick brown fluid recovered Symptoms resolved completely Sutula FC, Palu RN. Delayed Chocolate Cyst After Blow- Out Fracture. Ophthal Plast Recon Surg. 7(4): cases of hemorrhage around alloplastic implant 3 silicone 1 unknown Occurred 5 to 18 years post-operatively All presented with diplopia / hyperglobus developing over months 3 out of 4 were removed; 1 managed conservatively 8
9 4 cases with delayed complications silicone orbital implants Occurred 1.5 to 20 years post-operatively Worsening diplopia Recurrent orbital cellulitis Lower lid retraction with restricted upgaze Orbital abcess Implant removal required in all cases Histology: significant inflammation and fibrosis around implant Implant Options in Orbital Fracture Repair! Autologous:! Bone (calvarial, iliac crest, rib, etc.)! Cartilage (nasal septum, ear)! Etc.! Alloplastic: (some examples)! Titanium mesh! Silicone (Silastic)! Porous Polyethylene (Medpor, Synpor)! Nylon foil (SupraFOIL)! Also: Xenografts, Bioceramics (HA), etc. Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011) Autologous: Bone! Split calvarial, iliac creast, maxilla, rib! Advantages: strength, rigidity, vascularization, biocompatibility! Disadvantages:! Difficult to work with and shape! Donor site morbidity! Unpredictable resorption! Dural tears / hemorrhage Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011)
10 Autologous: Cartilage! Nasal Septum or Ear Cartilage! Advantages:! Easier to harvest than bone! Easier to shape! Lasts years (very little resorption)! Minimal donor site morbidity! Potential benefit, e.g. nasal septoplasty! Disadvantages:! Potential size limitation! Surgical time / donor site Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011) Alloplastic: Titanium Mesh! Advantages:! Good for large orbital defects! May come pre-formed! Rigid! Disadvantages:! Rigid! Chronic Inflammation Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011) patients h/o orbit fx repair using titanium mesh 9/10 Diplopia from EOM restriction / adherence 5/10 Eyelid retraction and diplopia 1/10 eyelid retraction only 6 Patients underwent removal of hardwar Significant fibrosis / inflammation ~5mm away from mesh 10
11 Alloplastic: Silicone! Advantages:! Easy to work with! Smooth surface! Cheap! Disadvantages:! Risk of migration! Inflammatory cyst / capsule formation! Not rigid! Laxenaire et al: 137 pts with silicone sheets in orbit! 19 (13.8%) required removal (migration, cellulitis, fistula, ) Laxenaire A, et al. Complications of silastic implants used in orbital repair. Rev Stomatol Chir Maxillofac. 1997;98:96-9 Alloplastic: PPE Porous Polyethylene! Medpor, Synpor! Pores allow tissue ingrowth / vascularization / fixation! Advantages:! Easy to work with! No inflammatory capsule formation! Generally doesn t require fixation (stable)! Disadvantages! Expensive! Potential scarring / adherence to orbital tissues Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011) Retrospective PPE Facial Implants 370 facial implants / 178 operations / 11 years 4 infections (1 paranasal, 3 malar) 145 = internal orbital implants (fracture / tumor recon) Zero of these required removal / revision 11
12 Alloplastic: Nylon Foil! SupraFOIL! Advantages:! Cheap! Thin! Easy to work with, pliable! Disadvantages! Some risk of motility (decreased with screw fixation)! Not rigid Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011) orbital fractures repaired with SupraFOIL All with at least one titanium screw for fixation f/u 3 days to 8.7 years (avg. 363 days) 1 acute orbital hemorrhage (POD 2) 2 late infections (POD 683; POD 984) Conclude SupraFOIL to be safe Safety improved by titanium screw fixation (decreased migration) Composites! Titanium plus porous polyethylene or nylon! Medpor TITAN! Synpor 12
13 Composites barrier sheets Non-porous surface overlay on porous polyethylene sheet Theoretically reduces risk of tissue adherence to porous surface E.g. barrier surface faced to orbit / extraocular muslces M-T-M: Medpor Titan Medpor B-T-M: Barrier Titan Medpor B-T-B: Barrier Titan - Barrier 29 y/o male R floor fx PO-Year 3: Medpor Titan B-T-M Awoke with hyperglobus and diplopia Implant / cyst / blood removed Replaced with Medpor Titan M-T-M Conclusion Many options available for orbital fracture repair Autologous bone or cartilage was considered gold standard Infrequently used due to time / second site Variety of alloplastic materials available All with associated benefits and detriments There is no perfect implant 13
14 References 1. Sashank Prasad, Nicholas J. Volpe and Madhura A. Tamhankar Neurology 2009;72;e Sutula FC, Palu RN. Delayed Chocolate Cyst After Blow-Out Fracture. Ophthal Plast Recon Surg. 7(4): Gilhotra JS, McNab AA, McKelvic P, O Donnell BA. Late orbital haemorrhage around alloplastic orbital floor implants: a case series and review. Clinical and Experimental Ophthalmology. 2002:30; Warrier S, et al. Delayed Complications of Silicone Implants Used in Orbital Fracture Repairs. Orbit 27:147-51, Lee HB, Nunery WR. Orbital Adherence Syndrome Secondary to Titanium Implant Material. Ophthalmic Plastic and Reconstructive Surgery. 25(1) Laxenaire A, et al. Complications of silastic implants used in orbital repair. Rev Stomatol Chir Maxillofac. 1997;98: Baino, F. Biomaterials and implants for orbital floor repair. Acta Biomaterialia 7(2011) Yaremchuk MJ. Facial Skeletal Reconstruction Using Porous Polyethylene Implants. Plastic and Reconstructive Surgery 111(6); Park DJ, Garibaldi DC, Iliff NT, Grant MP, Merbs SL. Smooth Nylon Foil (SupraFOIL) Orbital Implants in Orbital Fractures: A Case Series of 181 Patients. Ophthalmic Plastic and Reconstructive Surgery 2008; 24(4): Mihora LD, Holck DE. Hematic Cyst in a Barrier-Covered Porous Polyethylene/Titanium Mesh Orbital Floor Implant. Ophthalmic Plastic and Reconstructive Surgery 2011; 27(5):e
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