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Reconstruction of the Floor of the Orbit*
1010
NOTES, CASES, INSTRUMENTS
RECONSTRUCTION OF THE FLOOR OF T H E ORBIT* R E P O R T O F A CASE
ISADORE GlVNER, M . D . New York I n a case of severe comminution of a malar bone associated with the floor of the orbit, the level of the eyeball may be displaced downward and the attachment of the inferior oblique muscle disturbed. Pfeiffer 1 reported 53 cases of traumatic enophthalmos. H e related the mechanism of the internal orbital fracture responsible for the posterior displacement of the eye to be as follows: " T h e posterior convex position of the floor bulges upward back of the eyeball in a position to receive most of the force transmitted by the eye. T h e floor is very thin, similar in weight to the lamina papyracea and is braced but slightly by the infra-orbital groove or canal. I n cases of more severe enophthalmos, the posterior portion is fractured and in cases of more severe displacement the entire floor is broken through." Central vision was destroyed in only 4 of 24 cases. Treatment is usually deferred from three to six months until residual inflammatory thickening and induration of soft tissue have disappeared. Wheeler 2 suggested the use of fascia lata gently tucked into the cavity. It should be completely covered so that it will not be exposed to air. Skin edges are prepared for the halving union and brought together by 000 chromic catgut. Converse 3 suggested bone as employed by Gillies. H e stated that there is clinical evidence of reossification and survival when these are placed against bone subperiosteally. Spaeth 4 utilized cartilage either mortized or cut to shape. H e emphasized the advantage of preserving * From the Ophthalmological Service of Beth David Hospital.
perichondrium if the cartilage is mortized. T h e following report is made of an extreme case which was improved with cartilage cut to shape and preserved from cadavers. Cadaver cartilage is removed under strictly aseptic conditions from individuals who have no communicable disease. T h e cartilage is cleansed and the perichondrium taken off. It is kept continuously in a refrigerator in a solution of normal saline (four p a r t s ) and solution of merthiolate (one p a r t ) . T h e solution is changed weekly. Culture of the solution must be made each time before use. C A S E REPORT
C. P., a white woman, aged 43 years, was admitted to the Beth David Hospital on November 29, 1944, after having jumped from a sixth floor with suicidal intention. I n addition to the injury of the left orbit, the patient had fractures of the frontal bone, the left zygoma, the nasal bones, mandible, head of the right humerus, transverse processes of the third and fourth lumbar vertebrae, pubis, neck of the left -femur, and the left tibia and fibula. H e r past history was irrelevant except for the fact that a diagnosis of involutional melancholia had been made previously. Ophthalmologic examination on J a n u a r y 12, 1945, showed the lower border of the left orbit to be 10 mm. lower than that of the right orbit. W i t h the exophthalmometer, measurements of 14 mm., in the right eye, and of 5 mm., on the left eye were found. T h e palpebral aperture of the right eye measured 10 m m . ; that of the left eye, 8 mm. I n the left palpebral aperture, one could see only 1 mm. of the cornea above the lower lid, for the rest of the eyeball was pushed down into the antrum (fig. 1 ) . T h e r e was a marked paresis of the left
.NOTES, CASES, INSTRUMENTS
1011
superior rectus and inferior oblique muscles. Hypotropia measured 60 P.D. On February 16th, after her more serious fractures had been cared for, a reconstruction of the floor of the orbit was undertaken. (1) A skin incision was made along the lower border of the left orbit down to the periosteum. The latter was incised, and the orbital content elevated subperiosteally. (2) The elevator was carried back for a distance of 12 mm. from the orbital rim.
Fig. 2 (Givner). Implanted cartilage inked in to show approximate position.
Fig. 1 (Givner). Patient reported by Pfeiffer* showing severe enophthalmos of somewhat less severity than was present in the case herewith reported.
A piece of costal cartilage was then shaped to fit the defect, arching upward and elevating the eye 12 mm. Bleeding was controlled (fig. 2). (3) The periosteum was reunited with chromic catgut, and the orbicularis reinforced with the same type of suture. The skin was closed with interrupted dermal sutures, and a pressure bandage applied. The patient was put on sulfadiazene systemically. The first dressing was done after five days. The first postoperative result showed the globe to have returned to the palpebral aperture, but with a noticeable hypotropia (fig. 3). The status of the patient at the time of writing this is: At 105 mm., the right eye * Acknowledgment is made to Dr. R. L. Pfeiffer and to the Archives of Ophthalmology for permission to use this photograph. The latter appeared on page 724. See reference 1.
measures 14 mm.; the left eye, 8 mm. Vision is: R.E., with a +0.50D. cyl. ax. 180°., 20/20; left eye, with a piano, 20/20. The remainder of the examination, including media, tension, fields, and fundi, shows nothing abnormal in either eye. In making a survey of materials used for cranioplasty, one finds such substances as animal bone, celluloid, aluminum, gold, silver plate, platinum, decalcified bone and buttons of bone. More recently, use has been made of bone chips and whole blood. Alloplastic substances such as vitalium have received attention, but plates of this material are difficult to mold and get into shape. In September,
Fig. 3 (Givner). Patient as pictured nine months after the operation.
1012
NOTES, CASES, INSTRUMENTS-
1942, Col. R. G. Spurling ( M C ) performed the first cranioplasty with tantalum implant, in the Walter Reed H o s pital. This material is valuable because: ( 1 ) It is relatively inert in tissues, although a thin, translucent, connectivetissue capsule does appear about this element when used in the form of tantalum foil. ( 2 ) It is malleable, without loss of strength. Flat sheets, .015 and .020 in. thick and 6 in. square, are now available. Certain resins such as plexiglass (methamethylacrylate (appear to be entirely inert in tissues and may yet prove valuable.
CONCLUSION
Interest of this case lies in the fact that: 1. It is an addition to the literature describing how good visual function was preserved in spite of marked traumatic enophthalmos. 2. T h e perichondrium is not absolutely necessary for a successful subperiosteal implant. 3. A periosteal implant may be taken from cadavers and put in as an arch to elevate the globe without interfering with intraocular pressure or function.
REFERENCES
'Pfeiffer, R. L. Arch, of Ophth., 1943, v. 30, Dec, p. 721. 2 Wheeler, J. M. Collected papers. New York, Columbia University Press, 1939, p. 427. 3 Converse, J. M. Arch, of Ophth., 1944, v. 31, April, p. 323. 1 Spaeth, E. B. Principles and practice of ophthalmic surgery. Philadelphia, Lea & Febiger, 1939. p. 75.
NOTES, CASES, INSTRUMENTS
RECONSTRUCTION OF THE FLOOR OF T H E ORBIT* R E P O R T O F A CASE
ISADORE GlVNER, M . D . New York I n a case of severe comminution of a malar bone associated with the floor of the orbit, the level of the eyeball may be displaced downward and the attachment of the inferior oblique muscle disturbed. Pfeiffer 1 reported 53 cases of traumatic enophthalmos. H e related the mechanism of the internal orbital fracture responsible for the posterior displacement of the eye to be as follows: " T h e posterior convex position of the floor bulges upward back of the eyeball in a position to receive most of the force transmitted by the eye. T h e floor is very thin, similar in weight to the lamina papyracea and is braced but slightly by the infra-orbital groove or canal. I n cases of more severe enophthalmos, the posterior portion is fractured and in cases of more severe displacement the entire floor is broken through." Central vision was destroyed in only 4 of 24 cases. Treatment is usually deferred from three to six months until residual inflammatory thickening and induration of soft tissue have disappeared. Wheeler 2 suggested the use of fascia lata gently tucked into the cavity. It should be completely covered so that it will not be exposed to air. Skin edges are prepared for the halving union and brought together by 000 chromic catgut. Converse 3 suggested bone as employed by Gillies. H e stated that there is clinical evidence of reossification and survival when these are placed against bone subperiosteally. Spaeth 4 utilized cartilage either mortized or cut to shape. H e emphasized the advantage of preserving * From the Ophthalmological Service of Beth David Hospital.
perichondrium if the cartilage is mortized. T h e following report is made of an extreme case which was improved with cartilage cut to shape and preserved from cadavers. Cadaver cartilage is removed under strictly aseptic conditions from individuals who have no communicable disease. T h e cartilage is cleansed and the perichondrium taken off. It is kept continuously in a refrigerator in a solution of normal saline (four p a r t s ) and solution of merthiolate (one p a r t ) . T h e solution is changed weekly. Culture of the solution must be made each time before use. C A S E REPORT
C. P., a white woman, aged 43 years, was admitted to the Beth David Hospital on November 29, 1944, after having jumped from a sixth floor with suicidal intention. I n addition to the injury of the left orbit, the patient had fractures of the frontal bone, the left zygoma, the nasal bones, mandible, head of the right humerus, transverse processes of the third and fourth lumbar vertebrae, pubis, neck of the left -femur, and the left tibia and fibula. H e r past history was irrelevant except for the fact that a diagnosis of involutional melancholia had been made previously. Ophthalmologic examination on J a n u a r y 12, 1945, showed the lower border of the left orbit to be 10 mm. lower than that of the right orbit. W i t h the exophthalmometer, measurements of 14 mm., in the right eye, and of 5 mm., on the left eye were found. T h e palpebral aperture of the right eye measured 10 m m . ; that of the left eye, 8 mm. I n the left palpebral aperture, one could see only 1 mm. of the cornea above the lower lid, for the rest of the eyeball was pushed down into the antrum (fig. 1 ) . T h e r e was a marked paresis of the left
.NOTES, CASES, INSTRUMENTS
1011
superior rectus and inferior oblique muscles. Hypotropia measured 60 P.D. On February 16th, after her more serious fractures had been cared for, a reconstruction of the floor of the orbit was undertaken. (1) A skin incision was made along the lower border of the left orbit down to the periosteum. The latter was incised, and the orbital content elevated subperiosteally. (2) The elevator was carried back for a distance of 12 mm. from the orbital rim.
Fig. 2 (Givner). Implanted cartilage inked in to show approximate position.
Fig. 1 (Givner). Patient reported by Pfeiffer* showing severe enophthalmos of somewhat less severity than was present in the case herewith reported.
A piece of costal cartilage was then shaped to fit the defect, arching upward and elevating the eye 12 mm. Bleeding was controlled (fig. 2). (3) The periosteum was reunited with chromic catgut, and the orbicularis reinforced with the same type of suture. The skin was closed with interrupted dermal sutures, and a pressure bandage applied. The patient was put on sulfadiazene systemically. The first dressing was done after five days. The first postoperative result showed the globe to have returned to the palpebral aperture, but with a noticeable hypotropia (fig. 3). The status of the patient at the time of writing this is: At 105 mm., the right eye * Acknowledgment is made to Dr. R. L. Pfeiffer and to the Archives of Ophthalmology for permission to use this photograph. The latter appeared on page 724. See reference 1.
measures 14 mm.; the left eye, 8 mm. Vision is: R.E., with a +0.50D. cyl. ax. 180°., 20/20; left eye, with a piano, 20/20. The remainder of the examination, including media, tension, fields, and fundi, shows nothing abnormal in either eye. In making a survey of materials used for cranioplasty, one finds such substances as animal bone, celluloid, aluminum, gold, silver plate, platinum, decalcified bone and buttons of bone. More recently, use has been made of bone chips and whole blood. Alloplastic substances such as vitalium have received attention, but plates of this material are difficult to mold and get into shape. In September,
Fig. 3 (Givner). Patient as pictured nine months after the operation.
1012
NOTES, CASES, INSTRUMENTS-
1942, Col. R. G. Spurling ( M C ) performed the first cranioplasty with tantalum implant, in the Walter Reed H o s pital. This material is valuable because: ( 1 ) It is relatively inert in tissues, although a thin, translucent, connectivetissue capsule does appear about this element when used in the form of tantalum foil. ( 2 ) It is malleable, without loss of strength. Flat sheets, .015 and .020 in. thick and 6 in. square, are now available. Certain resins such as plexiglass (methamethylacrylate (appear to be entirely inert in tissues and may yet prove valuable.
CONCLUSION
Interest of this case lies in the fact that: 1. It is an addition to the literature describing how good visual function was preserved in spite of marked traumatic enophthalmos. 2. T h e perichondrium is not absolutely necessary for a successful subperiosteal implant. 3. A periosteal implant may be taken from cadavers and put in as an arch to elevate the globe without interfering with intraocular pressure or function.
REFERENCES
'Pfeiffer, R. L. Arch, of Ophth., 1943, v. 30, Dec, p. 721. 2 Wheeler, J. M. Collected papers. New York, Columbia University Press, 1939, p. 427. 3 Converse, J. M. Arch, of Ophth., 1944, v. 31, April, p. 323. 1 Spaeth, E. B. Principles and practice of ophthalmic surgery. Philadelphia, Lea & Febiger, 1939. p. 75.