Complications Associated with Alloplastic Implants used in Orbital Fracture Repair David R. Jordan, MD,l Pam St. Onge, MD,l Richard L. Anderson, MD, 2 James R. Patrinely, MD,3 Jeffrey A. Nerad, MD4 Background: The treatment of orbital wall fractures involves observation and/or surgical reduction with repositioning of herniated orbital tissues. To prevent reherniation of tissue and development of enophthalmos, the orbital floor or wall defect is commonly covered with an alloplastic implant. Complications associated with these implants are infrequent and generally appear as isolated case reports. Methods: The authors reviewed the files of four consultative oculoplastic surgeons and searched for individuals with complications secondary to their alloplastic implants used during orbital fracture repair. Findings: Seventeen patients were identified with a variety of complications related to their alloplastic implant. Conclusion: Although these implants are relatively inert and develop a fibrous capsule walling them off from the surrounding orbit, they remain foreign bodies and are thus subject to possible complications at any time. The authors review the spectrum of complications occurring with various alloplastic implants. Ophthalmology 1992;99: 1600-1608
The ideal management of orbital floor fractures has been a subject of controversy for many years. I - 3 Some orbital floor fractures require only observation while others require surgical reduction. When surgery is performed, the herniated, displaced orbital tissues are freed up and repositioned into the orbit. To prevent reherniation of this tissue, an implant is used to span the orbital floor defect. Many implants have been used, both autogenous and al-
Originally received: December 20, 1991. Revision accepted: April 30, 1992. I Oculoplastic, Orbital, Lacrimal Service, University of Ottawa, Ottawa, Ontario. 2 Department of Ophthalmology, University of Utah, Salt Lake City. 3 Department of Ophthalmology, Baylor College of Medicine, Houston. 4 Department of Ophthalmology, University oflowa Hospitals and Clinics, Iowa City. Supported in part by unrestricted grants from Research to Prevent Blindness, Inc, New York, New York, to the Department of Ophthalmology, Baylor College of Medicine, Houston, and the University of Utah, Salt Lake City. Reprint requests to David R. Jordan, MD, The Doctors Building, 267 O'Connor St, Suite 611, Ottawa, Ontario K2P 1V3, Canada.
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loplastic, including methylmethacrylate, Teflon, silicone, Supramid, Marlex, silastic, gelatin film (Gelfilm), bone, cartilage, and others. Ophthalmologists tend to use alloplastic implants in repair of orbital fractures while plastic and craniofacial surgeons favor the use of autogenous material (such as bone grafting), which have their own set of complications in addition to those that will be discussed. This article will focus on those problems seen with alloplastic materials. Common alloplastic implants in use today include Supramid (a nonabsorbable, inert polymer) and Teflon. These implants are readily available and can be easily trimmed to the desired shape before they are placed over the orbital defect. They are secured into position by wedging them into tissue, gluing them into position, or wiring them into place. Complications associated with alloplastic implants are infrequent and usually are reported as isolated case reports, Because these implants are relatively inert and develop a fibrous capsule early (weeks to months) after placement, there tends to be a false sense of security associated with their use. To appreciate the spectrum .-of complications occurring with these implants, we reviewed the files of four tertiary ophthalmic plastic and orbital surgeons at four different medical centers to document
Jordan et al . Alloplastic Implants complications associated with alloplastic implants. Seventeen patients were identified and are presented herein.
Materials and Methods The records of four consultative oculoplastic surgeons (DRJ, RLA, JRP, JAN) who routinely perform orbital fracture repair were reviewed to identify individuals who have had complications secondary to alloplastic orbital implants used for orbital wall fracture repair over the past to years. Seventeen such patients were identified (Table 1). Some were operated on by one of these surgeons and developed complications, others were referred to the authors after having had surgery elsewhere. Two of the patients (cases 13 and 14) were the subject of an earlier report. 2 Table 1 summarizes the pertinent clinical histories.
Discussion AlIoplastic orbital implants such as Supramid, Teflon, silicone, silastic, Marlex mesh, and Gelfilm are used frequently during repair of orbital floor fractures and are generally well tolerated. 4- 6 They serve to cover the orbital floor defect and prevent globe subluxation into the fracture site, and they also prevent scarring between the orbital contents and fracture site and sinus mucosa. The ideal orbital implant should provide good structural support over the defect, be nonreactive and well tolerated by surrounding tissues, be easily positioned, and be readily available. Most of the alloplastic implants in use today possess these qualities. Complications, however, may occur immediately after placement of the implant or years later. Reported complications include: orbital infection,6-8 fistula formation,7.9-12 implant migration,5,7 extraocular muscle entrapment,13 dacryocystitis,8,14 globe elevation (hyperophthalmia),6 proptosis secondary to hemorrhage into the implant fibrous capsule,15 cyst formation after partial absorption of gelatin film (Gelfilm) implant,4 and/ or visualloss.1 6-1 8 In the current study, the complications seen were divided into the following groups: fistula formation, migration, motility restriction, infection, globe elevation (hyperophthalmia), cyst formation, sudden proptosis, and optic nerve trauma (Table 2). In 6 of the patients (cases 1 through 6), a fistula developed that drained either externally through the skin or fornix (4 patients) or internally into one of the adjacent sinuses (2 patients). Those patients whose fistula formed into the sinus (cases 1 and 3) presented with intermittent orbital pressure associated with nose blowing or Val salva maneuvers (Figs 1A and 1B, 2A and 2B). Presumably, air was being blown directly into the orbit via the ethmoid sinus in 1 patient (case 1) and maxillary sinus in the other (case 3). The resultant air entering the orbit increased the orbital pressure and shifted the globe, which would explain the symptoms. The fistulous openings were visualized at the time of surgery, in each case, confirming this proposed
mechanism. The etiology of the fistula in these two cases may be related to implant erosion into the adjacent sinus as a result of constant pressure by the implant on the sinus mucosa. Alternatively, the implant may have migrated into the sinus, and slowly eroded the mucosa. In both cases, there was a delay of several months between the time of repair and the time the symptoms were noticed. Those patients whose fistula formed onto the skin or into the fornix presented with recurrent discharge (case S) or recurrent acute infections (cases 2, 4, and 6) (Figs 3A and 3B). The etiology of the fistula in these cases was believed to be a pressure necrosis by the alloplastic material on the adjacent tissue, migration of the implant toward skin or conjunctiva, or infection with wound breakdown. In case 4, the implant probably became infected shortly after implant placement. The developing infection then began tracking anteriorly on to skin to drain spontaneously. Implant migration, anteriorly through skin (cases 7 and 8) or interiorly within the orbit (case 9), was seen in 3 patients. Case 7 had the most obvious migration, as she presented with the implant grossly protruding from the lower lid (Fig 4). The implant had been placed S years earlier and 12 months before presentation without any history of infection begun to protrude through the lower lid. Case 8 had a contour deformity along the inferior orbital rim, which represented the migrated implant edge. In case 9, the affected eye was enophthalmic, hypoophthalmic, and there was a retracted left upper lid. With fracture repair, the volume deficit was corrected, the globe was elevated, and the upper lid returned to a normal position. Implant migration was suspected when the patient was seen in follow-up 9 months after the repair, and the lid retraction had returned with some globe displacement inferiorly. In reviewing the operative notes, there was minimal intraoperative fixation of the implant in each of these cases. In case 9, the implant was secured with cyanoacrylate glue, but presumably it must have released, allowing the implant to migrate. Infection occurred in four patients (cases 2, 4, 6, and 10). In case 2, recurrent cellulitis involving the eyelid and cheek area was secondary to exposure of a silicone floor implant in the inferior fornix (fistula). The exposed implant was probably due to pressure necrosis between the patient's prosthesis edge and the fornix. In case 4, a swollen lower eyelid developed 2 weeks after surgery and then developed into a fistula anteriorly onto the skin with purulent discharge. In case 6, the patient presented with two bouts of lower lid cellulitis, and then a fistula developed at the lateral canthus through which the implant could be visualized (Figs 3A and 3B). The patient in case 10 presented with acute dacryocystitis and a history of orbital fracture repair (presumably floor and medial wall) (Fig SA). After examining the computed tomography scan, it was our opinion that the implant might have been impinging on the nasolacrimal sac (Figs SB and SC). At the time of dacryocystorhinostomy, the implant was found protruding into the sac wall. It was our opinion that pressure on the lacrimal sac by the implant caused a nasolac-
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Ophthalmology Volume 99, Number 10, October 1992 Table 1. Patient Data Age Patient (yrs)/ No. Sex
Type of Fracture
Implant Used
Time of Repair to Time of Problem
45/M Floor, medial wall
Supramidon floor and medial wall
11 mos
2
25/M Floor, inferior rim
Silicone on floor and rim
10 yrs
3
41/M Floor fracture
Supramid on floor and medial wall
9mos
4
53/F
Floor, zygoma maxillary face
Supramid on floor
3 wks
5
35/M Floor fracture
Teflon on floor
2 yrs
6
Supramidon floor
2 mos
7
50/M Floor fracture, medial and lateral wall fracture 30/F Floor fracture
5 yrs
8
51/F
Supramidon floor Silicone sheet on floor
9
20/M Floor fracture
Supramid on floor
9 mos
10
52/F
11
35/F
12
Floor, zygoma fracture
Orbital fracture (floor and/or medial wall) Floor fracture
Teflon on medial wall
2 mos
20 yrs
Presenting Problem
Implant protruding through skin Residual enophthalmos, contour deformity along orbital rim Recurrence of enophthalmos and lid retraction Pain and swelling medial canthus over 3 weeks with dacryocystitis
Migration of implant onto skin Migration of implant anteriorly over rim
2 wks
Upgaze worse following orbital floor fracture
1O/M Floor fracture
Supramidon floor
4wks
13
32/M Floor and inferior rim
1yr
14
21/M Floor fracture
Multiple silicone sheets on floor Gelfilm on floor
Restricted upgaze and pulling feeling post orbital floor repair Globe elevation
24mos
Mass over inferior rim, anterior orbit
15
45/F
Floor fracture
Gelfilm on floor
21 mos
Mass in anterior inferior orbit
16
23/M Floor fracture and rim fracture 20/F Floor fracture
Teflon
26 mos
Orbital rim discomfort, globe elevation and proptosis Sudden proptosis with diplopia
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Supramid
3 mos
Treatment
Implant removed, fistula into ethmoids cauterized, problem resolved Recurrent cellulitis lower lid Fistula, inferior fornix Silicone implant removed, to floor implant cellulitis and fistula resolved Pressure feeling, diplopia, Fistula, maxillary Implant removed, globe protrusion and sinus to floor granulation tissue globe elevation implant and between implant and granulation tissue sinus removed, no further problems Lid swelling with cellulitis Infection in implant Implant removed, no and fistula formation space with fistula further problems formation anteriorly Orbital discomfort and Fistula formation Implant removed, no further problems recurrent discharge fornix to floor implant Implant infection, Implant removed Recurrent eyelid cellulitis and fistula formation fistula, implant to skin Fistula, ethmoids to implants with air entering orbit
Supramid on floor
17
Cause
Recurrent pressure feeling in socket on valsalva
Orbital implant migration up medial wall Implant impinging on nasolacrimal sac Motility restriction secondary to implant Motility restriction secondary to implant Stacked silicone sheets Cyst formation secondary to Gelfilm reabsorption Cyst formation secondary to Gelfilm reabsorption fIemorrhageinto capsule around implant fIemorrhage into capsule around implant
Implant removed Implant removed, volume augmented with cartilage Implant repositioned and wired to inferior rim Implant removed during time of dacryocystorhinostomy Implant simply removed, motility returned to normal Implant simply removed, systems resolved, motility normalized Silicone sheets removed, volume augmented with cartilage Cyst removed
Cyst removed
Implant removed, cystic contents evacuated Resolution with conservative measures
Jordan et al
Alloplastic Implants
Table 2. Complications Associated with Alloplastic Implants Fistula formation Onto skin, into fornix Into sinus Migration Within orbit Into adjacent sinus Anteriorly to skin Motility restriction Impingement of extraocular muscle or fascia surrounding muscle Infection Associated with implant with or without fistula Secondary to pressure on nasolacrimal sac Globe elevation Inflammatory tissue around the implant Too thick or too many implants Cyst formation Hemorrhage into capsule around implant Cyst formation Partial reabsorption of implant Hemorrhage into capsule around implant Proptosis Hemorrhage into capsule around implant Air blown into orbit Optic nerve trauma Direct trauma to optic nerve Associated with hemorrhage and associated pressure on optic nerve
rimal outflow delay and subsequent dacryocystitis. Improper implant positioning or migration of a well-positioned implant with pressure on the lacrimal sac and resultant stagnation of the nasolacrimal contents undoubtedly contributed to the development of this problem. Restricted motility was present in two individuals (cases 11 and 12), presumably secondary to the posterior end of the implant impinging on the inferior rectus or the perimuscular fascia. In case 11, the restricted motility was believed to be secondary to the implant since the ocular restriction occurring postoperatively in upgaze and pulling sensation were not present before orbital fracture repair. The symptoms were quite bothersome for the patient, a school teacher, who was annoyed by the symptoms while looking up to use the chalkboard. Orbital inflammation in the operative field with dysfunction of the inferior rectus was considered, but no improvement occurred over a 3week rest period. Implant removal without additional dissection or manipulation allowed this patient to regain her normal upgaze. In the other patient (case 12), there had been an improvement in motility with the initial orbital fracture repair in downgaze but only limited improvement in upgaze despite placement of a Supramid implant and repositioning of orbital tissue. In addition, the patient had a pulling feeling in the socket when looking up. When this patient was re-explored at 4 weeks, no additional orbital tissue entrapment was found. The implant
was removed, and the upgaze deficit was returned to normal over the next few weeks. Presumably, some perimuscular fascial restriction secondary to the implant was limiting full upgaze in this patient. In both instances, forced ductions were done during the initial surgery before and after implant placement and suggested good motion in upgaze. If the forced duction done after implant placement suggested restricted motility, it would have been important to remove the implant and reposition it. If the motility restriction is only manifest after surgery, repeat forced ductions are important and computed tomography scanning may be beneficial in helping to confirm the restriction is secondary to the implant. 8 Globe elevation (hyperophthalmia) occurred in two patients. In one patient (case 13), it was due to stacking of multiple plates. In the other patient (case 3), excess granulation tissue between the Supramid implant and orbital floor was identified at the time of re-exploration and removed. It was this granulation tissue along with the
Figure 1. A, patient 1. Eleven months after orbital fracture repair, this patient presented with a pressure sensation in the socket during valsalva maneuvers. B, computed tomography scan shows air along the orbital floor.
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Figure 3. A, patient 6. Two months after extensive orbital fracture repair, this patient presented with recurrent lower eyelid cellulitis and a fistula that had developed at the lateral canthus. B, the orbital implant is easily seen in the fistula tract (arrow).
Figure 2. A, patient 3. Ten months after orbital fracture repair, the patient presented with right globe elevation and proptosis after nose blowing. B, computed tomography scan shows air in the orbit along the orbital fioor.
floor implant that was elevating the patient's globe. Implant removal and removal of granulation tissue around the fistula entering maxillary antrum was curative. Cyst formation due to partial resorption of a Gelfilm implant occurred in two individuals (cases 14 and 15) and was the subject of an earlier report4 (Figs 6A-C). Gelfilm is an absorbable, rigid, nonporous, nonantigenic gelatin film available in sheet's of O.075-mm thickness. It has been used successfully as a dural substitute, as a pleural patch, and in the middle ear. 19,20 A major appeal of Gelfilm is that it is absorbable, and, therefore, late complications are theoretically avoidable. There were two cases (cases 16 and I 7) of sudden proptosis secondary to presumed hemorrhage within the fibrous capsule surrounding the orbital implant. The patient in case 16 presented 26 months after floor fracture repair with a tender infraorbital rim and tender maxillary sinus (developing over several hours). He was noted to have
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left globe elevation and 2 mm of proptosis as well as a pseudoptosis. He was treated with Ampicillin and observed for a presumed maxillary sinusitis. After 2 days of antibiotic administration, there was no improvement, and a computed tomography scan was performed. The scan
Figure 4. Patient 7. Five years after orbital fracture repair, the patient presented with implant extrusion.
Jordan et al . Alloplastic Implants
Figure 5. A, patient 10. This patient presented with dacryocystitis 20 years after orbital fracture repair. B, computed tomography scan shows the implant medially, protruding into ethmoid sinus (arrow). C, a more anterior cut of the computed tomography scan shows dilated lacrimal sac and radiopaque tip of Teflon implant (arrow) adjacent to the superiomedial aspect of the sac.
showed a large cystic subperiosteal mass over the left orbital floor implant. The presumed diagnosis was infected implant versus possible hemorrhagic cyst. There was no other evidence of abscess formation or active inflammatory process in the lid or orbit. The patient felt well systemically. As the visual acuity was not compromised, conservative treatment, including coverage with antibiotics, was undertaken. The proptosis and orbital rim discomfort did not resolve, and 4 weeks after presentation, the patient's orbit was explored, and the implant and 4 ml of a yellow mucoid material believed to be consistent with degenerated blood products were removed (Fig 7). It was our opinion that this case scenario was consistent with a hemorrhagic cyst rather than infection or a sinus
mucosa-lined cyst. As the cyst wall was not examined histopathologically, this cannot be confirmed. The patient in case 17 also presented 3 months after fracture repair with the sudden onset (minutes) of a fullness in her eye socket and double vision. Results of examination showed 3 mm of proptosis and gross motility restriction (Fig 8A). Ultrasonography and computed tomography scanning showed a cystic cavity consistent with a hematoma along the orbital floor in the area of the floor implant (Fig 8B). A conservative management plan was instituted, and the patient's symptoms and signs resolved without sequelae. The implant was not removed. Mauriello and colleagues 15 reported three such individuals presenting with proptosis and having a history of orbital
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Figure 6. A, patient 14. Two years after receiving a Gelfilm implant for fracture repair, the patient presented with a mass along the right inferior orbital rim and some globe elevation. B, cystic structure dissected from anterior orbit. C, cystic structure is transected and a gelatinous material came out.
fracture repair 13, 16, and 20 years after the reconstruction. The etiology was probably due to rupture of fine capillaries occurring within the pseudocapsule around the implant. In all three individuals, computed tomography scanning was helpful in demonstrating either a cyst or abnormal mass in the area of the implant. There were no cases of visual loss in the current series. Visual loss is the most serious complication reported with orbital fracture repair. 16- 18 This is most commonly due to direct injury to the optic nerve or orbital hemorrhage with compression of the optic nerve. Because the optic nerve is located posterior and superior (cushioned in fat) to the orbital fracture, it is hard to imagine how the actual implant could injure the nerve unless it was excessively long and narrow and driven into the apical area with undue force. Converse et al 16 believed this may have been the mechanism in one of their patients. It is far more likely that optic nerve injury is a result of retractor malposition and excessive force during the procedure, causing direct optic nerve trauma, or a result of orbital hemorrhage, causing compression of the optic nerve blood supply. To avoid the possibility of apical compression, the implant should, as a rule, never extend beyond the posterior wall of the maxillary sinus. Reviewing the complications seen in this report and others brings to mind a number of features that need to
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be highlighted about these implants. From a patient standpoint, although these implants are relatively inert, cause little tissue reaction, and are walled offby a fibrous capsule, they should not be ignored, as problems can occur long after their placement. Mauriello 13 reported on 3 patients in whom complications developed secondary to orbital floor Teflon implants 13, 16, and 20 years after blowout fracture repair. The patient should be aware that alloplastic implants are foreign bodies and that they are subject to complications such as infection, erosion, migration, restriction of ocular motility, cyst formation, sudden proptosis, and possible visual loss. Treatment of such problems involves either removing the implant or re-exploring and repositioning the implant. From a surgical standpoint, when using an implant, a number of points should be mentioned. It is important to release and reposition the orbital tissues and visualize the entire fracture margin. The implant should cover the boundaries of the fracture without any residual orbital tissue herniation. Otherwise, entrapment by the implant may occur. Forced duction studies at the onset of surgery and after implant placement are extremely important to avoid the possibility of muscle entrapment secondary to implant placement. If the implant is positioned and repeated forced ductions suggest restriction, the implant should be removed and re-evaluated. A change in size
Jordan et al . Alloplastic Implants but rather a review to outline possible complications related to those implants and to offer suggestions for preventing problems. The overall incidence of complications with orbital floor implant is believed to be low, but an exact number cannot be stated for a number of reasons. Because complications can occur 15 to 20 or more years after implant placement, one would have to follow a group of orbital fracture patients for a prolonged period of time to appreciate the long-term sequelae. These patients often are young and not permanently settled, thus it is hard to follow patients for this length of time in one center. Several of the patients in this article had moved into one of the authors' areas after having had their surgery elsewhere some
Figure 7. Computed tomography scan shows a mass along the left orbital floor (arrow). An orbital floor implant also is seen (arrowhead).
and shape may be required. When using these implants, a subperiosteal position is best. It is important to avoid implant protrusion into one of the sinuses or anteriorly in the area of the nasolacrimal crest or too close to the orbital rim. The implant size should be adjusted accordingly, and use of the smallest implant to adequately cover the defect is best. It is important to be sure no pressure is being put on sensitive areas such as the optic nerve, infraorbital nerve, and lacrimal sac. Sharp edges also should be avoided. Fixation of the implant is important to decrease migration. The most secure way is to attach the implant to the orbital rim area by wire or suture material. Alternatively, the implant may be wedged into the anterior edge of the fracture site by erecting a tongue on the anterior edge of the implant, the so-called "Beyer's Notch.,,21 The entire anterior edge of the implant may be simply tucked under the anterior fracture lip as another means for securing its position. Tse 22 has reported cyanoacrylate tissue adhesive to secure the implant, while Mauriello l3 has suggested that perforations be placed in the alloplastic sheets (if not already present) to allow ingrowth of fibrous tissue and further secure the implant. In summary, alloplastic implants are used commonly in the repair of orbital floor fractures and generally are well tolerated. Complications related to implants are relatively uncommon but may present in varied ways over many postoperative years. These potential complications should be explained to patients before surgery, especially because follow-up may not be performed by the operating surgeon when a complication occurs. This report should not be viewed as an indictment of alloplastic implants
Figure 8. A, patient 17. Patient presented 3 months after fracture repair with sudden onset of right-Sided orbital fullness. B, mass sitting along the right orbital floor.
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months or years before. Similarly, several of the patients with orbital fractures in each author's chart review had moved since their surgery and no forwarding address was available at the time of this review. Thus, we will never know whether they had problems.
References 1. Dutton JJ. Management of blowout fractures of the orbital floor. I. Editorial. Surv Ophthalmol 1991 ;35:279-80. 2. Manson PM, IliffN. Management of blow-out fractures of the orbital floor. II. Early repair of selected injuries. Surv Ophthalmol 1991 ;35:280-92. 3. Putterman AM. Management of blow-out fractures of the orbital floor. III. The conservative approach. Surv Ophthalmol 1991;35:292-8. 4. Loftfield K, Jordan DR, Fowler J, Anderson RL. Orbital cyst formation associated with Gelfilm use. Ophthalmic Plast Reconstr Surg 1988;3:187-91. 5. Burres SA, Cohn AM, Mathog RH. Repair of orbital blowout fractures with Marlex mesh and Gelfilm. Laryngoscope 1981;91: 1881-6. 6. Browning CWo Alloplast materials in orbital repair. Am J Ophthalmol 1967;63:955-62. 7. Weintraub B, Cucin RL, Jacobs M. Extrusion of an infected orbital-floor prosthesis after 15 years. Plast Reconstr Surg 1981 ;68:586-7. 8. Mauriello JA Jr, Fiore PM, Kotch M. Dacryocystitis: late complication of orbital floor fracture repair with implant. Ophthalmology 1987;94:248-50. 9. Goldman RJ, Hessburg Pc. Appraisal of surgical correction in 130 cases of orbital floor fracture. Am J Ophthalmology 1973;76: 152-5.
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10. Alpar JJ. Unusual complication of orbital floor blowout fracture repair. Ann Ophthalmol 1977;9: 1173-6. 11. Aronowitz JA, Freeman BS, Spira M. Long-term stability of Teflon orbital implants. Plast Reconstr Surg 1986;78: 166-73. 12. Wolfe SA. Correction of a lower eyelid deformity caused by multiple extrusions of alloplastic orbital floor implants. Plast Reconstr Surg 1981 ;68:429-32. 13. Mauriello JA Jr. Inferior rectus muscle entrapped by Teflon implant after orbital floor fracture repair. Ophthalmic Plast Reconstr Surg 1990;6:218-20. 14. Kohn R, Romano PE, Puklin JE. Lacrimal obstruction after migration of orbital floor implant. Am J Ophthalmol 1976;82:934-6. 15. Mauriello JA Jr, Flanagan JC, Peyster RG. An unusual late complication of orbital floor fracture repair. Ophthalmology 1984;91:102-7. 16. Converse JM, Smith B, Obear MF, Wood-Smith D. Orbital blowout fractures: a ten-year survey. Plast Reconstr Surg 1967;39:20-36. 17. Nicholson DH, Guzak SJ Jr. Visual loss complicating repair of orbital floor fractures. Arch Ophthalmol 1971 ;86:36975. 18. Lederman IR. Loss of vision associated with surgical treatment of zygomatic-orbital floor fracture. Plast Reconstr Surg 1981;68:94-8. 19. Holzer F. The fate of gelatin film in the middle ear. Arch OtolaryngoI1973;98:319-21. 20. Laval J. The use of absorbable gelatin film (Gelfilm) in ophthalmic surgery. NY State J Med 1958;58:2399-401. 21. Smith BC, Putterman AM. Fixation of orbital floor implants. Description of a simple technique. Arch Ophthalmol 1970;83:598. 22. Tse DT. Cyanoacrylate tissue adhesive in securing orbital implants. Ophthalmic Surg 1986;17:577-80.
The ideal management of orbital floor fractures has been a subject of controversy for many years. I - 3 Some orbital floor fractures require only observation while others require surgical reduction. When surgery is performed, the herniated, displaced orbital tissues are freed up and repositioned into the orbit. To prevent reherniation of this tissue, an implant is used to span the orbital floor defect. Many implants have been used, both autogenous and al-
Originally received: December 20, 1991. Revision accepted: April 30, 1992. I Oculoplastic, Orbital, Lacrimal Service, University of Ottawa, Ottawa, Ontario. 2 Department of Ophthalmology, University of Utah, Salt Lake City. 3 Department of Ophthalmology, Baylor College of Medicine, Houston. 4 Department of Ophthalmology, University oflowa Hospitals and Clinics, Iowa City. Supported in part by unrestricted grants from Research to Prevent Blindness, Inc, New York, New York, to the Department of Ophthalmology, Baylor College of Medicine, Houston, and the University of Utah, Salt Lake City. Reprint requests to David R. Jordan, MD, The Doctors Building, 267 O'Connor St, Suite 611, Ottawa, Ontario K2P 1V3, Canada.
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loplastic, including methylmethacrylate, Teflon, silicone, Supramid, Marlex, silastic, gelatin film (Gelfilm), bone, cartilage, and others. Ophthalmologists tend to use alloplastic implants in repair of orbital fractures while plastic and craniofacial surgeons favor the use of autogenous material (such as bone grafting), which have their own set of complications in addition to those that will be discussed. This article will focus on those problems seen with alloplastic materials. Common alloplastic implants in use today include Supramid (a nonabsorbable, inert polymer) and Teflon. These implants are readily available and can be easily trimmed to the desired shape before they are placed over the orbital defect. They are secured into position by wedging them into tissue, gluing them into position, or wiring them into place. Complications associated with alloplastic implants are infrequent and usually are reported as isolated case reports, Because these implants are relatively inert and develop a fibrous capsule early (weeks to months) after placement, there tends to be a false sense of security associated with their use. To appreciate the spectrum .-of complications occurring with these implants, we reviewed the files of four tertiary ophthalmic plastic and orbital surgeons at four different medical centers to document
Jordan et al . Alloplastic Implants complications associated with alloplastic implants. Seventeen patients were identified and are presented herein.
Materials and Methods The records of four consultative oculoplastic surgeons (DRJ, RLA, JRP, JAN) who routinely perform orbital fracture repair were reviewed to identify individuals who have had complications secondary to alloplastic orbital implants used for orbital wall fracture repair over the past to years. Seventeen such patients were identified (Table 1). Some were operated on by one of these surgeons and developed complications, others were referred to the authors after having had surgery elsewhere. Two of the patients (cases 13 and 14) were the subject of an earlier report. 2 Table 1 summarizes the pertinent clinical histories.
Discussion AlIoplastic orbital implants such as Supramid, Teflon, silicone, silastic, Marlex mesh, and Gelfilm are used frequently during repair of orbital floor fractures and are generally well tolerated. 4- 6 They serve to cover the orbital floor defect and prevent globe subluxation into the fracture site, and they also prevent scarring between the orbital contents and fracture site and sinus mucosa. The ideal orbital implant should provide good structural support over the defect, be nonreactive and well tolerated by surrounding tissues, be easily positioned, and be readily available. Most of the alloplastic implants in use today possess these qualities. Complications, however, may occur immediately after placement of the implant or years later. Reported complications include: orbital infection,6-8 fistula formation,7.9-12 implant migration,5,7 extraocular muscle entrapment,13 dacryocystitis,8,14 globe elevation (hyperophthalmia),6 proptosis secondary to hemorrhage into the implant fibrous capsule,15 cyst formation after partial absorption of gelatin film (Gelfilm) implant,4 and/ or visualloss.1 6-1 8 In the current study, the complications seen were divided into the following groups: fistula formation, migration, motility restriction, infection, globe elevation (hyperophthalmia), cyst formation, sudden proptosis, and optic nerve trauma (Table 2). In 6 of the patients (cases 1 through 6), a fistula developed that drained either externally through the skin or fornix (4 patients) or internally into one of the adjacent sinuses (2 patients). Those patients whose fistula formed into the sinus (cases 1 and 3) presented with intermittent orbital pressure associated with nose blowing or Val salva maneuvers (Figs 1A and 1B, 2A and 2B). Presumably, air was being blown directly into the orbit via the ethmoid sinus in 1 patient (case 1) and maxillary sinus in the other (case 3). The resultant air entering the orbit increased the orbital pressure and shifted the globe, which would explain the symptoms. The fistulous openings were visualized at the time of surgery, in each case, confirming this proposed
mechanism. The etiology of the fistula in these two cases may be related to implant erosion into the adjacent sinus as a result of constant pressure by the implant on the sinus mucosa. Alternatively, the implant may have migrated into the sinus, and slowly eroded the mucosa. In both cases, there was a delay of several months between the time of repair and the time the symptoms were noticed. Those patients whose fistula formed onto the skin or into the fornix presented with recurrent discharge (case S) or recurrent acute infections (cases 2, 4, and 6) (Figs 3A and 3B). The etiology of the fistula in these cases was believed to be a pressure necrosis by the alloplastic material on the adjacent tissue, migration of the implant toward skin or conjunctiva, or infection with wound breakdown. In case 4, the implant probably became infected shortly after implant placement. The developing infection then began tracking anteriorly on to skin to drain spontaneously. Implant migration, anteriorly through skin (cases 7 and 8) or interiorly within the orbit (case 9), was seen in 3 patients. Case 7 had the most obvious migration, as she presented with the implant grossly protruding from the lower lid (Fig 4). The implant had been placed S years earlier and 12 months before presentation without any history of infection begun to protrude through the lower lid. Case 8 had a contour deformity along the inferior orbital rim, which represented the migrated implant edge. In case 9, the affected eye was enophthalmic, hypoophthalmic, and there was a retracted left upper lid. With fracture repair, the volume deficit was corrected, the globe was elevated, and the upper lid returned to a normal position. Implant migration was suspected when the patient was seen in follow-up 9 months after the repair, and the lid retraction had returned with some globe displacement inferiorly. In reviewing the operative notes, there was minimal intraoperative fixation of the implant in each of these cases. In case 9, the implant was secured with cyanoacrylate glue, but presumably it must have released, allowing the implant to migrate. Infection occurred in four patients (cases 2, 4, 6, and 10). In case 2, recurrent cellulitis involving the eyelid and cheek area was secondary to exposure of a silicone floor implant in the inferior fornix (fistula). The exposed implant was probably due to pressure necrosis between the patient's prosthesis edge and the fornix. In case 4, a swollen lower eyelid developed 2 weeks after surgery and then developed into a fistula anteriorly onto the skin with purulent discharge. In case 6, the patient presented with two bouts of lower lid cellulitis, and then a fistula developed at the lateral canthus through which the implant could be visualized (Figs 3A and 3B). The patient in case 10 presented with acute dacryocystitis and a history of orbital fracture repair (presumably floor and medial wall) (Fig SA). After examining the computed tomography scan, it was our opinion that the implant might have been impinging on the nasolacrimal sac (Figs SB and SC). At the time of dacryocystorhinostomy, the implant was found protruding into the sac wall. It was our opinion that pressure on the lacrimal sac by the implant caused a nasolac-
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Ophthalmology Volume 99, Number 10, October 1992 Table 1. Patient Data Age Patient (yrs)/ No. Sex
Type of Fracture
Implant Used
Time of Repair to Time of Problem
45/M Floor, medial wall
Supramidon floor and medial wall
11 mos
2
25/M Floor, inferior rim
Silicone on floor and rim
10 yrs
3
41/M Floor fracture
Supramid on floor and medial wall
9mos
4
53/F
Floor, zygoma maxillary face
Supramid on floor
3 wks
5
35/M Floor fracture
Teflon on floor
2 yrs
6
Supramidon floor
2 mos
7
50/M Floor fracture, medial and lateral wall fracture 30/F Floor fracture
5 yrs
8
51/F
Supramidon floor Silicone sheet on floor
9
20/M Floor fracture
Supramid on floor
9 mos
10
52/F
11
35/F
12
Floor, zygoma fracture
Orbital fracture (floor and/or medial wall) Floor fracture
Teflon on medial wall
2 mos
20 yrs
Presenting Problem
Implant protruding through skin Residual enophthalmos, contour deformity along orbital rim Recurrence of enophthalmos and lid retraction Pain and swelling medial canthus over 3 weeks with dacryocystitis
Migration of implant onto skin Migration of implant anteriorly over rim
2 wks
Upgaze worse following orbital floor fracture
1O/M Floor fracture
Supramidon floor
4wks
13
32/M Floor and inferior rim
1yr
14
21/M Floor fracture
Multiple silicone sheets on floor Gelfilm on floor
Restricted upgaze and pulling feeling post orbital floor repair Globe elevation
24mos
Mass over inferior rim, anterior orbit
15
45/F
Floor fracture
Gelfilm on floor
21 mos
Mass in anterior inferior orbit
16
23/M Floor fracture and rim fracture 20/F Floor fracture
Teflon
26 mos
Orbital rim discomfort, globe elevation and proptosis Sudden proptosis with diplopia
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Supramid
3 mos
Treatment
Implant removed, fistula into ethmoids cauterized, problem resolved Recurrent cellulitis lower lid Fistula, inferior fornix Silicone implant removed, to floor implant cellulitis and fistula resolved Pressure feeling, diplopia, Fistula, maxillary Implant removed, globe protrusion and sinus to floor granulation tissue globe elevation implant and between implant and granulation tissue sinus removed, no further problems Lid swelling with cellulitis Infection in implant Implant removed, no and fistula formation space with fistula further problems formation anteriorly Orbital discomfort and Fistula formation Implant removed, no further problems recurrent discharge fornix to floor implant Implant infection, Implant removed Recurrent eyelid cellulitis and fistula formation fistula, implant to skin Fistula, ethmoids to implants with air entering orbit
Supramid on floor
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Cause
Recurrent pressure feeling in socket on valsalva
Orbital implant migration up medial wall Implant impinging on nasolacrimal sac Motility restriction secondary to implant Motility restriction secondary to implant Stacked silicone sheets Cyst formation secondary to Gelfilm reabsorption Cyst formation secondary to Gelfilm reabsorption fIemorrhageinto capsule around implant fIemorrhage into capsule around implant
Implant removed Implant removed, volume augmented with cartilage Implant repositioned and wired to inferior rim Implant removed during time of dacryocystorhinostomy Implant simply removed, motility returned to normal Implant simply removed, systems resolved, motility normalized Silicone sheets removed, volume augmented with cartilage Cyst removed
Cyst removed
Implant removed, cystic contents evacuated Resolution with conservative measures
Jordan et al
Alloplastic Implants
Table 2. Complications Associated with Alloplastic Implants Fistula formation Onto skin, into fornix Into sinus Migration Within orbit Into adjacent sinus Anteriorly to skin Motility restriction Impingement of extraocular muscle or fascia surrounding muscle Infection Associated with implant with or without fistula Secondary to pressure on nasolacrimal sac Globe elevation Inflammatory tissue around the implant Too thick or too many implants Cyst formation Hemorrhage into capsule around implant Cyst formation Partial reabsorption of implant Hemorrhage into capsule around implant Proptosis Hemorrhage into capsule around implant Air blown into orbit Optic nerve trauma Direct trauma to optic nerve Associated with hemorrhage and associated pressure on optic nerve
rimal outflow delay and subsequent dacryocystitis. Improper implant positioning or migration of a well-positioned implant with pressure on the lacrimal sac and resultant stagnation of the nasolacrimal contents undoubtedly contributed to the development of this problem. Restricted motility was present in two individuals (cases 11 and 12), presumably secondary to the posterior end of the implant impinging on the inferior rectus or the perimuscular fascia. In case 11, the restricted motility was believed to be secondary to the implant since the ocular restriction occurring postoperatively in upgaze and pulling sensation were not present before orbital fracture repair. The symptoms were quite bothersome for the patient, a school teacher, who was annoyed by the symptoms while looking up to use the chalkboard. Orbital inflammation in the operative field with dysfunction of the inferior rectus was considered, but no improvement occurred over a 3week rest period. Implant removal without additional dissection or manipulation allowed this patient to regain her normal upgaze. In the other patient (case 12), there had been an improvement in motility with the initial orbital fracture repair in downgaze but only limited improvement in upgaze despite placement of a Supramid implant and repositioning of orbital tissue. In addition, the patient had a pulling feeling in the socket when looking up. When this patient was re-explored at 4 weeks, no additional orbital tissue entrapment was found. The implant
was removed, and the upgaze deficit was returned to normal over the next few weeks. Presumably, some perimuscular fascial restriction secondary to the implant was limiting full upgaze in this patient. In both instances, forced ductions were done during the initial surgery before and after implant placement and suggested good motion in upgaze. If the forced duction done after implant placement suggested restricted motility, it would have been important to remove the implant and reposition it. If the motility restriction is only manifest after surgery, repeat forced ductions are important and computed tomography scanning may be beneficial in helping to confirm the restriction is secondary to the implant. 8 Globe elevation (hyperophthalmia) occurred in two patients. In one patient (case 13), it was due to stacking of multiple plates. In the other patient (case 3), excess granulation tissue between the Supramid implant and orbital floor was identified at the time of re-exploration and removed. It was this granulation tissue along with the
Figure 1. A, patient 1. Eleven months after orbital fracture repair, this patient presented with a pressure sensation in the socket during valsalva maneuvers. B, computed tomography scan shows air along the orbital floor.
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Figure 3. A, patient 6. Two months after extensive orbital fracture repair, this patient presented with recurrent lower eyelid cellulitis and a fistula that had developed at the lateral canthus. B, the orbital implant is easily seen in the fistula tract (arrow).
Figure 2. A, patient 3. Ten months after orbital fracture repair, the patient presented with right globe elevation and proptosis after nose blowing. B, computed tomography scan shows air in the orbit along the orbital fioor.
floor implant that was elevating the patient's globe. Implant removal and removal of granulation tissue around the fistula entering maxillary antrum was curative. Cyst formation due to partial resorption of a Gelfilm implant occurred in two individuals (cases 14 and 15) and was the subject of an earlier report4 (Figs 6A-C). Gelfilm is an absorbable, rigid, nonporous, nonantigenic gelatin film available in sheet's of O.075-mm thickness. It has been used successfully as a dural substitute, as a pleural patch, and in the middle ear. 19,20 A major appeal of Gelfilm is that it is absorbable, and, therefore, late complications are theoretically avoidable. There were two cases (cases 16 and I 7) of sudden proptosis secondary to presumed hemorrhage within the fibrous capsule surrounding the orbital implant. The patient in case 16 presented 26 months after floor fracture repair with a tender infraorbital rim and tender maxillary sinus (developing over several hours). He was noted to have
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left globe elevation and 2 mm of proptosis as well as a pseudoptosis. He was treated with Ampicillin and observed for a presumed maxillary sinusitis. After 2 days of antibiotic administration, there was no improvement, and a computed tomography scan was performed. The scan
Figure 4. Patient 7. Five years after orbital fracture repair, the patient presented with implant extrusion.
Jordan et al . Alloplastic Implants
Figure 5. A, patient 10. This patient presented with dacryocystitis 20 years after orbital fracture repair. B, computed tomography scan shows the implant medially, protruding into ethmoid sinus (arrow). C, a more anterior cut of the computed tomography scan shows dilated lacrimal sac and radiopaque tip of Teflon implant (arrow) adjacent to the superiomedial aspect of the sac.
showed a large cystic subperiosteal mass over the left orbital floor implant. The presumed diagnosis was infected implant versus possible hemorrhagic cyst. There was no other evidence of abscess formation or active inflammatory process in the lid or orbit. The patient felt well systemically. As the visual acuity was not compromised, conservative treatment, including coverage with antibiotics, was undertaken. The proptosis and orbital rim discomfort did not resolve, and 4 weeks after presentation, the patient's orbit was explored, and the implant and 4 ml of a yellow mucoid material believed to be consistent with degenerated blood products were removed (Fig 7). It was our opinion that this case scenario was consistent with a hemorrhagic cyst rather than infection or a sinus
mucosa-lined cyst. As the cyst wall was not examined histopathologically, this cannot be confirmed. The patient in case 17 also presented 3 months after fracture repair with the sudden onset (minutes) of a fullness in her eye socket and double vision. Results of examination showed 3 mm of proptosis and gross motility restriction (Fig 8A). Ultrasonography and computed tomography scanning showed a cystic cavity consistent with a hematoma along the orbital floor in the area of the floor implant (Fig 8B). A conservative management plan was instituted, and the patient's symptoms and signs resolved without sequelae. The implant was not removed. Mauriello and colleagues 15 reported three such individuals presenting with proptosis and having a history of orbital
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Figure 6. A, patient 14. Two years after receiving a Gelfilm implant for fracture repair, the patient presented with a mass along the right inferior orbital rim and some globe elevation. B, cystic structure dissected from anterior orbit. C, cystic structure is transected and a gelatinous material came out.
fracture repair 13, 16, and 20 years after the reconstruction. The etiology was probably due to rupture of fine capillaries occurring within the pseudocapsule around the implant. In all three individuals, computed tomography scanning was helpful in demonstrating either a cyst or abnormal mass in the area of the implant. There were no cases of visual loss in the current series. Visual loss is the most serious complication reported with orbital fracture repair. 16- 18 This is most commonly due to direct injury to the optic nerve or orbital hemorrhage with compression of the optic nerve. Because the optic nerve is located posterior and superior (cushioned in fat) to the orbital fracture, it is hard to imagine how the actual implant could injure the nerve unless it was excessively long and narrow and driven into the apical area with undue force. Converse et al 16 believed this may have been the mechanism in one of their patients. It is far more likely that optic nerve injury is a result of retractor malposition and excessive force during the procedure, causing direct optic nerve trauma, or a result of orbital hemorrhage, causing compression of the optic nerve blood supply. To avoid the possibility of apical compression, the implant should, as a rule, never extend beyond the posterior wall of the maxillary sinus. Reviewing the complications seen in this report and others brings to mind a number of features that need to
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be highlighted about these implants. From a patient standpoint, although these implants are relatively inert, cause little tissue reaction, and are walled offby a fibrous capsule, they should not be ignored, as problems can occur long after their placement. Mauriello 13 reported on 3 patients in whom complications developed secondary to orbital floor Teflon implants 13, 16, and 20 years after blowout fracture repair. The patient should be aware that alloplastic implants are foreign bodies and that they are subject to complications such as infection, erosion, migration, restriction of ocular motility, cyst formation, sudden proptosis, and possible visual loss. Treatment of such problems involves either removing the implant or re-exploring and repositioning the implant. From a surgical standpoint, when using an implant, a number of points should be mentioned. It is important to release and reposition the orbital tissues and visualize the entire fracture margin. The implant should cover the boundaries of the fracture without any residual orbital tissue herniation. Otherwise, entrapment by the implant may occur. Forced duction studies at the onset of surgery and after implant placement are extremely important to avoid the possibility of muscle entrapment secondary to implant placement. If the implant is positioned and repeated forced ductions suggest restriction, the implant should be removed and re-evaluated. A change in size
Jordan et al . Alloplastic Implants but rather a review to outline possible complications related to those implants and to offer suggestions for preventing problems. The overall incidence of complications with orbital floor implant is believed to be low, but an exact number cannot be stated for a number of reasons. Because complications can occur 15 to 20 or more years after implant placement, one would have to follow a group of orbital fracture patients for a prolonged period of time to appreciate the long-term sequelae. These patients often are young and not permanently settled, thus it is hard to follow patients for this length of time in one center. Several of the patients in this article had moved into one of the authors' areas after having had their surgery elsewhere some
Figure 7. Computed tomography scan shows a mass along the left orbital floor (arrow). An orbital floor implant also is seen (arrowhead).
and shape may be required. When using these implants, a subperiosteal position is best. It is important to avoid implant protrusion into one of the sinuses or anteriorly in the area of the nasolacrimal crest or too close to the orbital rim. The implant size should be adjusted accordingly, and use of the smallest implant to adequately cover the defect is best. It is important to be sure no pressure is being put on sensitive areas such as the optic nerve, infraorbital nerve, and lacrimal sac. Sharp edges also should be avoided. Fixation of the implant is important to decrease migration. The most secure way is to attach the implant to the orbital rim area by wire or suture material. Alternatively, the implant may be wedged into the anterior edge of the fracture site by erecting a tongue on the anterior edge of the implant, the so-called "Beyer's Notch.,,21 The entire anterior edge of the implant may be simply tucked under the anterior fracture lip as another means for securing its position. Tse 22 has reported cyanoacrylate tissue adhesive to secure the implant, while Mauriello l3 has suggested that perforations be placed in the alloplastic sheets (if not already present) to allow ingrowth of fibrous tissue and further secure the implant. In summary, alloplastic implants are used commonly in the repair of orbital floor fractures and generally are well tolerated. Complications related to implants are relatively uncommon but may present in varied ways over many postoperative years. These potential complications should be explained to patients before surgery, especially because follow-up may not be performed by the operating surgeon when a complication occurs. This report should not be viewed as an indictment of alloplastic implants
Figure 8. A, patient 17. Patient presented 3 months after fracture repair with sudden onset of right-Sided orbital fullness. B, mass sitting along the right orbital floor.
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months or years before. Similarly, several of the patients with orbital fractures in each author's chart review had moved since their surgery and no forwarding address was available at the time of this review. Thus, we will never know whether they had problems.
References 1. Dutton JJ. Management of blowout fractures of the orbital floor. I. Editorial. Surv Ophthalmol 1991 ;35:279-80. 2. Manson PM, IliffN. Management of blow-out fractures of the orbital floor. II. Early repair of selected injuries. Surv Ophthalmol 1991 ;35:280-92. 3. Putterman AM. Management of blow-out fractures of the orbital floor. III. The conservative approach. Surv Ophthalmol 1991;35:292-8. 4. Loftfield K, Jordan DR, Fowler J, Anderson RL. Orbital cyst formation associated with Gelfilm use. Ophthalmic Plast Reconstr Surg 1988;3:187-91. 5. Burres SA, Cohn AM, Mathog RH. Repair of orbital blowout fractures with Marlex mesh and Gelfilm. Laryngoscope 1981;91: 1881-6. 6. Browning CWo Alloplast materials in orbital repair. Am J Ophthalmol 1967;63:955-62. 7. Weintraub B, Cucin RL, Jacobs M. Extrusion of an infected orbital-floor prosthesis after 15 years. Plast Reconstr Surg 1981 ;68:586-7. 8. Mauriello JA Jr, Fiore PM, Kotch M. Dacryocystitis: late complication of orbital floor fracture repair with implant. Ophthalmology 1987;94:248-50. 9. Goldman RJ, Hessburg Pc. Appraisal of surgical correction in 130 cases of orbital floor fracture. Am J Ophthalmology 1973;76: 152-5.
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10. Alpar JJ. Unusual complication of orbital floor blowout fracture repair. Ann Ophthalmol 1977;9: 1173-6. 11. Aronowitz JA, Freeman BS, Spira M. Long-term stability of Teflon orbital implants. Plast Reconstr Surg 1986;78: 166-73. 12. Wolfe SA. Correction of a lower eyelid deformity caused by multiple extrusions of alloplastic orbital floor implants. Plast Reconstr Surg 1981 ;68:429-32. 13. Mauriello JA Jr. Inferior rectus muscle entrapped by Teflon implant after orbital floor fracture repair. Ophthalmic Plast Reconstr Surg 1990;6:218-20. 14. Kohn R, Romano PE, Puklin JE. Lacrimal obstruction after migration of orbital floor implant. Am J Ophthalmol 1976;82:934-6. 15. Mauriello JA Jr, Flanagan JC, Peyster RG. An unusual late complication of orbital floor fracture repair. Ophthalmology 1984;91:102-7. 16. Converse JM, Smith B, Obear MF, Wood-Smith D. Orbital blowout fractures: a ten-year survey. Plast Reconstr Surg 1967;39:20-36. 17. Nicholson DH, Guzak SJ Jr. Visual loss complicating repair of orbital floor fractures. Arch Ophthalmol 1971 ;86:36975. 18. Lederman IR. Loss of vision associated with surgical treatment of zygomatic-orbital floor fracture. Plast Reconstr Surg 1981;68:94-8. 19. Holzer F. The fate of gelatin film in the middle ear. Arch OtolaryngoI1973;98:319-21. 20. Laval J. The use of absorbable gelatin film (Gelfilm) in ophthalmic surgery. NY State J Med 1958;58:2399-401. 21. Smith BC, Putterman AM. Fixation of orbital floor implants. Description of a simple technique. Arch Ophthalmol 1970;83:598. 22. Tse DT. Cyanoacrylate tissue adhesive in securing orbital implants. Ophthalmic Surg 1986;17:577-80.
