Letters OBSERVATION
Enucleation as Endoscopic Sinus Surgery Complication Functional endoscopic sinus surgery (FESS) is a commonly performed procedure that has a risk of serious ophthalmic complications. We report a case of complete enucleation as a complication of FESS. Report of a Case | A 42-year-old man with sinonasal polyposis, nasal septal deviation, and no previous sinus surgery underwent septoplasty and endoscopic polypectomy (FESS) involving the maxillary and ethmoid sinuses. Prior to surgery, visual acuity was 20/20 OU without correction. The otolaryngology operative note described using a microdebrider to remove
uncharacteristic-appearing polyps from what was thought to be the right maxillary sinus until right enophthalmos was noted and the operation was halted. The patient was then transferred from the outpatient surgery center to the emergency department for definitive ophthalmology evaluation and management. Bedside examination showed right-sided periorbital ecchymosis with apparent severe enophthalmos (Figure 1A and B). With the eyelids manually opened, only hematoma was visible. The left eye was normal, including dilated fundus examination findings. Computed tomography revealed a soft-tissuedensity mass in the right orbit with no obvious eye structure and with violation of the right lamina papyracea with air tracking into the orbit (Figure 1C). Subsequent pathologic exami-
Figure 1. Preoperative and Intraoperative Findings A
D
Inferior
B
Superior
E
Inferior
C
Superior
A, Periorbital ecchymosis. B, Enophthalmos. C, Computed tomographic scan showing the right orbit with no identifiable globe. D, Medial wall defect (arrowhead). E, Optic nerve stump (arrowhead), lacerated periosteum, and exposed orbital floor bone.
jamaophthalmology.com
(Reprinted) JAMA Ophthalmology Published online April 16, 2015
Copyright 2015 American Medical Association. All rights reserved.
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Letters
nation of the material labeled “right maxillary sinus” removed in the original sinus surgery showed orbital contents including adipose and muscle tissue but no globe contents. A second operation was performed the same day to explore and repair the orbit, revealing an extensive hematoma and a defect in the medial orbital wall. The orbital floor was intact with lacerated periosteum (Figure 1D and E). The entire right globe, most of the orbital fat, and most of the extraocular muscles were absent. No conjunctiva beyond the inferior tarsal plate and only 10 mm of conjunctiva above the superior tarsus remained. The right optic nerve was identified and found to be severed where it would have been attached to the globe (Figure 1E). Initially a 20-mm Medpor implant (Stryker) was placed, and although it was possible to close the Tenon capsule and conjunctiva over the implant, this resulted in eversion of the lower eyelid. A tiny conformer was customized in an attempt to create an inferior fornix, and Frost sutures were used to normalize the eyelid eversion. Significant orbital volume deficit remained at the end of surgery. Because of the significant orbital volume deficit, the orbital implant was replaced 5 days later with a large dermal fat graft from the right hip. However, the patient developed progressive orbital volume deficit, likely due to poor vascularity of the orbit contributing to fat atrophy of the graft (Figure 2). He was referred to general plastic surgery for consideration of a free-flap graft with microvascular anastomosis. Discussion | The rates of major and minor complications of FESS are estimated to be 0.5% to 1% and 5%, respectively, with up to half of these complications involving the orbit.1-3 Violation of the lamina papyracea is the most common event and occurs more often when performing maxillary antrostomy and more often on the right side (attributed to more difficulty with visualization and equipment manipulation by a right-handed surgeon approaching the right side).1 Risk factors for complications include surgeon inexperience, prior surgery, and severity of disease or anomalous anatomy.4 Published ophthalmic complications of FESS include extraocular muscle, optic nerve, and orbital bone damage as well as orbital hemorrhage and globe penetration, but this is the first case to our knowledge of complete loss of the majority of the orbital contents including the globe. In addition to the loss of a healthy eye, such extensive tissue loss makes reconstruction challenging.
A
B
A, Frontal view. The patient reported that the eye appeared to be sinking in with time. B, View from below, highlighting residual enophthalmos.
Author Affiliations: Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland. Corresponding Author: Shannath L. Merbs, MD, PhD, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N Wolfe St, Maumenee 505, Baltimore, MD 21287 ([email protected]). Published Online: April 16, 2015. doi:10.1001/jamaophthalmol.2015.0706. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Grant reported serving as a consultant for Stryker CMF. No other disclosures were reported. 1. Hosemann W, Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013;12:Doc06. 2. Castellarin A, Lipskey S, Sternberg P Jr. Iatrogenic open globe eye injury following sinus surgery. Am J Ophthalmol. 2004;137(1):175-176. 3. Dunya IM, Salman SD, Shore JW. Ophthalmic complications of endoscopic ethmoid surgery and their management. Am J Otolaryngol. 1996;17(5):322-331.
Jessica R. Chang, MD Michael P. Grant, MD, PhD Shannath L. Merbs, MD, PhD
E2
Figure 2. Postoperative Examination Findings With Ocular Prosthesis
4. Bhatti MT, Stankiewicz JA. Ophthalmic complications of endoscopic sinus surgery. Surv Ophthalmol. 2003;48(4):389-402.
JAMA Ophthalmology Published online April 16, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a BYU Harold B Lee Library User on 05/18/2015
jamaophthalmology.com
Enucleation as Endoscopic Sinus Surgery Complication Functional endoscopic sinus surgery (FESS) is a commonly performed procedure that has a risk of serious ophthalmic complications. We report a case of complete enucleation as a complication of FESS. Report of a Case | A 42-year-old man with sinonasal polyposis, nasal septal deviation, and no previous sinus surgery underwent septoplasty and endoscopic polypectomy (FESS) involving the maxillary and ethmoid sinuses. Prior to surgery, visual acuity was 20/20 OU without correction. The otolaryngology operative note described using a microdebrider to remove
uncharacteristic-appearing polyps from what was thought to be the right maxillary sinus until right enophthalmos was noted and the operation was halted. The patient was then transferred from the outpatient surgery center to the emergency department for definitive ophthalmology evaluation and management. Bedside examination showed right-sided periorbital ecchymosis with apparent severe enophthalmos (Figure 1A and B). With the eyelids manually opened, only hematoma was visible. The left eye was normal, including dilated fundus examination findings. Computed tomography revealed a soft-tissuedensity mass in the right orbit with no obvious eye structure and with violation of the right lamina papyracea with air tracking into the orbit (Figure 1C). Subsequent pathologic exami-
Figure 1. Preoperative and Intraoperative Findings A
D
Inferior
B
Superior
E
Inferior
C
Superior
A, Periorbital ecchymosis. B, Enophthalmos. C, Computed tomographic scan showing the right orbit with no identifiable globe. D, Medial wall defect (arrowhead). E, Optic nerve stump (arrowhead), lacerated periosteum, and exposed orbital floor bone.
jamaophthalmology.com
(Reprinted) JAMA Ophthalmology Published online April 16, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a BYU Harold B Lee Library User on 05/18/2015
E1
Letters
nation of the material labeled “right maxillary sinus” removed in the original sinus surgery showed orbital contents including adipose and muscle tissue but no globe contents. A second operation was performed the same day to explore and repair the orbit, revealing an extensive hematoma and a defect in the medial orbital wall. The orbital floor was intact with lacerated periosteum (Figure 1D and E). The entire right globe, most of the orbital fat, and most of the extraocular muscles were absent. No conjunctiva beyond the inferior tarsal plate and only 10 mm of conjunctiva above the superior tarsus remained. The right optic nerve was identified and found to be severed where it would have been attached to the globe (Figure 1E). Initially a 20-mm Medpor implant (Stryker) was placed, and although it was possible to close the Tenon capsule and conjunctiva over the implant, this resulted in eversion of the lower eyelid. A tiny conformer was customized in an attempt to create an inferior fornix, and Frost sutures were used to normalize the eyelid eversion. Significant orbital volume deficit remained at the end of surgery. Because of the significant orbital volume deficit, the orbital implant was replaced 5 days later with a large dermal fat graft from the right hip. However, the patient developed progressive orbital volume deficit, likely due to poor vascularity of the orbit contributing to fat atrophy of the graft (Figure 2). He was referred to general plastic surgery for consideration of a free-flap graft with microvascular anastomosis. Discussion | The rates of major and minor complications of FESS are estimated to be 0.5% to 1% and 5%, respectively, with up to half of these complications involving the orbit.1-3 Violation of the lamina papyracea is the most common event and occurs more often when performing maxillary antrostomy and more often on the right side (attributed to more difficulty with visualization and equipment manipulation by a right-handed surgeon approaching the right side).1 Risk factors for complications include surgeon inexperience, prior surgery, and severity of disease or anomalous anatomy.4 Published ophthalmic complications of FESS include extraocular muscle, optic nerve, and orbital bone damage as well as orbital hemorrhage and globe penetration, but this is the first case to our knowledge of complete loss of the majority of the orbital contents including the globe. In addition to the loss of a healthy eye, such extensive tissue loss makes reconstruction challenging.
A
B
A, Frontal view. The patient reported that the eye appeared to be sinking in with time. B, View from below, highlighting residual enophthalmos.
Author Affiliations: Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland. Corresponding Author: Shannath L. Merbs, MD, PhD, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N Wolfe St, Maumenee 505, Baltimore, MD 21287 ([email protected]). Published Online: April 16, 2015. doi:10.1001/jamaophthalmol.2015.0706. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Grant reported serving as a consultant for Stryker CMF. No other disclosures were reported. 1. Hosemann W, Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2013;12:Doc06. 2. Castellarin A, Lipskey S, Sternberg P Jr. Iatrogenic open globe eye injury following sinus surgery. Am J Ophthalmol. 2004;137(1):175-176. 3. Dunya IM, Salman SD, Shore JW. Ophthalmic complications of endoscopic ethmoid surgery and their management. Am J Otolaryngol. 1996;17(5):322-331.
Jessica R. Chang, MD Michael P. Grant, MD, PhD Shannath L. Merbs, MD, PhD
E2
Figure 2. Postoperative Examination Findings With Ocular Prosthesis
4. Bhatti MT, Stankiewicz JA. Ophthalmic complications of endoscopic sinus surgery. Surv Ophthalmol. 2003;48(4):389-402.
JAMA Ophthalmology Published online April 16, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a BYU Harold B Lee Library User on 05/18/2015
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