Original Investigation
Lateral Canthal Position Following Lateral Orbitotomy and the Influence of Ocular Proptosis Pari N. Shams, B.Sc., M.R.C.P., F.R.C.Ophth., Meredith S. Baker, M.D., and Richard C. Allen, M.D., Ph.D., F.A.C.S. Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.
Purpose: Anecdotal evidence suggests that detachment of the lateral canthal tendon during lateral orbitotomy results in shortening of the horizontal palpebral aperture (HPA) and rounding of the lateral canthal angle (LCA). This study investigated the change in HPA and LCA following lateral orbitotomy and the effect of proptosis on the HPA. Methods: Retrospective, single surgeon, review of all cases undergoing lateral orbitotomy, comprising of a canthotomy and cantholysis and reconstruction of the lateral canthus using a single suture. The HPA and lateral canthal height (LCH) were measured on pre- and postoperative photographs using ImageJ software. Changes in the LCA and degree of proptosis were also investigated. Exclusion criteria included previous eyelid surgery, acute trauma, and less than 6 months’ follow up. Results: There were 41 cases of lateral orbitotomy in 27 patients, 67% female, average age 51 years. Twenty patients had thyroid eye disease of which 14 underwent bilateral surgery; the other 7 patients had a variety of orbital pathologies. Thirteen patients underwent unilateral orbitotomy with the contralateral eye serving as a control. Average follow up was 23 months. Overall, the HPA and proptosis were reduced by 0.6 mm (p = 0.143) and 3.4 mm (p < 0.001), respectively. A 0.2-mm reduction in HPA was observed for every 1-mm reduction in proptosis. A difference in post-orbitotomy HPA was observed between cases and their matched controls (p = 0.016). No rounding of the LCA or significant change in LCH was observed following lateral orbitotomy. Conclusions: The described technique of lateral orbitotomy and simple reconstruction do not appear to cause lateral canthal drift or rounding. There was no significant change in HPA or LCH. The degree of change of proptosis does appear to influence the change of HPA. (Ophthal Plast Reconstr Surg 2016;32:53–57)
N
umerous indications exist for surgical access to the lateral orbital wall, which include repair of orbital fractures, orbital decompression for thyroid orbitopathy, resection or biopsy of tumors, orbital reconstruction, and removal of foreign
Accepted for publication January 12, 2015. The authors have no financial or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.op-rs.com.). Address correspondence and reprint requests to Pari N. Shams, B.Sc., M.R.C.P., F.R.C.Ophth., Department of Ophthalmology and Visual Sciences, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: pari. [email protected] DOI: 10.1097/IOP.0000000000000418
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
bodies. Approaches to the lateral orbit have evolved over the years and include Burke’s modification of the Kronlein skin incision into a transverse incision extending 30 mm from the lateral canthus and the Stallard-Wright S-shaped incision from the lateral sub-brow along the lateral rim and extending horizontally along the lateral canthus.1,2 A disadvantage common to these techniques is the visible scar they create. To overcome this, surgeons today prefer to use an extended upper eyelid skin crease incision or a lateral canthotomy incision for lateral orbitotomy. The lateral canthotomy incision provides excellent surgical access to the lateral orbital wall and simultaneous access to the orbital roof and floor. While the access provided by lateral canthotomy and cantholysis is ideal, there are anecdotal reports on postoperative rounding of the lateral canthal angle (LCA), canthal dystopia with inferior or medial dislocation, and overriding of the upper eyelid relative to the lower eyelid.3 Although there are no published series reporting these complications of the lateral canthotomy incision, there are reports in the literature of techniques designed to avoid incising the lateral canthus, such as starting the incision 2 mm lateral to the canthus,4 the retrocanthal lateral orbitotomy,5 and the lateral triangle flap technique.6 Some surgeons devote a great deal of surgical time to the elaborate repair of the lateral canthus. The authors therefore set out to investigate whether this simple and efficient technique for exposure and reconstruction of the lateral canthus during a lateral orbitotomy was associated with the aforementioned surgical complications of lateral canthotomy incision.
METHODS This study is a retrospective chart review of consecutive cases of lateral orbitotomy performed by a single surgeon (R.C.A.) at the University of Iowa Hospitals and Clinics between 2009 and 2013. The indications for surgery included orbital decompression for thyroid eye disease (TED), incision biopsy or excision biopsy of orbital lesions causing mass effect or functional deficit. The primary outcome measures were a change following lateral orbitotomy in 1) the horizontal palpebral aperture (HPA), 2) the lateral canthal height (LCH), 3) LCA, and 4) ocular proptosis. Exclusion criteria were 1) previous eyelid surgery, 2) cases undergoing surgery for acute trauma, 3) congenital or acquired periocular abnormality other than those caused by the presenting orbital pathology or TED, and 4) less than 6 months’ postoperative follow up. The same surgical technique was used to expose the lateral orbital rim in all cases, which involved a horizontal canthotomy and a superior and inferior cantholysis, and the same technique was used to reconstruct the lateral canthus using a single, simple, circular suture at the lateral canthus. Surgical technique to expose the lateral orbital rim (see Video, Supplemental Digital Content, http://links.lww.com/IOP/A107) Local anesthetic with epinephrine is injected transcutaneously in the lateral canthal region and the lateral upper and lower eyelid, and in the inferior and lateral conjunctival cul-de-sacs. A lateral canthotomy
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is performed using a scalpel blade or microdissection needle extending the incision through the soft tissue down to the periosteum of the lateral orbital rim. An inferior (Fig. 1A) and superior (Fig. 1B) cantholysis are performed with a microdissection needle, detaching the eyelids from the orbital rim. Two 4-0 silk traction sutures are placed in lateral upper and lower eyelids, capturing the tarsal plate (Fig. 1C). The lateral orbital rim is exposed with a Freer elevator. Surgical technique to reconstruct the lateral canthus (see Video, Supplemental Digital Content, http://links.lww.com/IOP/A107).
The lateral upper and lower eyelid are reapproximated to the periorbita using a single armed 4-0 vicryl suture on a P2 or ½ circle needle which is first passed reverse mounted through the periorbita, in a posterior to anterior direction (Fig. 1D), then through the inferior crus of the lateral canthal tendon (LCT; Fig. 1E) with a good purchase of the tarsal plate, coming out through the gray line at the eyelid margin 2 mm from its cut edge. The needle is then forward mounted and passed through the superior eyelid margin at the gray line 2 mm from the cut edge and advanced through the superior crus of the LCT (Fig. 1F),
FIG. 1. Intraoperative clinical photographs showing exposure of the lateral orbital rim and reconstruction of the lateral canthus: (A) an inferior and (B) superior cantholysis are performed with a microdissection needle, detaching the eyelids from the orbital rim. C, Two 4-0 silk traction sutures are placed in lateral upper and lower tarsal plate allowing good exposure to the lateral orbital rim. For the reconstruction, the lateral upper and lower eyelid are reapproximated to the periorbita using a 4-0 vicryl suture on a ½ circle needle. D, This is first passed reverse mounted through the periorbita, in a posterior to anterior direction, and (E) then through the inferior crus of the lateral canthal tendon (LCT), coming out through the gray line 2 mm from its cut edge. F, The needle is then forward mounted and passed through the superior eyelid margin 2 mm from the cut edge and advanced through the superior crus of the LCT. G, Finally, the suture is passed back though the periorbita parallel to the first pass, in an anterior to posterior direction. H, The suture is then tied which reforms the lateral canthal angle.
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Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
ensuring a good purchase of the tarsal plate. Finally, the suture is passed back though the periorbita parallel to the first pass, in an anterior to posterior direction, to emerge 3 to 4 mm superior to the first pass of the suture (Fig. 1G). The suture is then tied which reforms the LCA and pulls the lateral canthus laterally (Fig. 1H). The lateral canthotomy skin incision is closed with interrupted 7-0 vicryl sutures. Pre- and postoperative computer-based digital facial photographs were analyzed using Image J 1.47 software,7 which was used to measure the HPA and the LCH (the height of the lateral canthus above the medial canthus). The presence or absence of rounding of the LCA was recorded. In all cases, both the left and the right side were measured. In cases where unilateral surgery was carried out, the contralateral side was used as a control. The scale of measurement on each photograph and on each side of the face was calibrated by setting the white-to-white corneal diameter as 12 mm. The HPA of each eye was measured in millimeters from the medial to the lateral canthus (Fig. 2A,B). The LCH was measured by drawing a horizontal line through the medial canthus and recording the vertical height of the lateral canthus in millimeters above this line (Fig. 2C,D). The degree of ocular proptosis, the distance from lateral orbital rim to the corneal apex, was measured using a Hertel exophthalmometer, with the pre- and post operative measurement on each patient using the same intercanthal distance. These measurements were obtained from the patients’ clinical chart. Other complications of lateral orbitotomy, such as infection, wound dehiscence, or persistent edema, within 3 months of surgery were recorded. Statistical Methods. Differences in proportions for continuous, normally distributed data were carried out using the t test. The Mann-Whitney rank sum test was used for nonparametric data. Statistical analyses were performed using SigmaPlot version 12.5 for Windows (Systat Software, Inc., San Jose, CA, U.S.A.). This study followed the tenets of the Declaration of Helsinki and was approved by the institutional research board of the University of Iowa (IRB ID no.: 201406758).
RESULTS Forty-one cases of lateral orbitotomy, performed on 27 patients, fulfilled the inclusion criteria. The average age of patients was 51 years (range 15–80), 67% were female. Twenty of 27 (74%) patients had TED of which 14 (70%) underwent bilateral orbital decompression. Seven of 27 (26%) patients had a variety of other orbital lesions: cavernous hemangioma (n = 2), sphenoid wing meningioma (n = 1), venous-lymphatic
Lateral Canthal Position Following Lateral Orbitotomy
vascular malformation (n = 1), lymphoma (n = 1), orbital inflammation (n = 1), and pleomorphic adenoma (n = 1). Thirteen of 27 (48%) patients underwent unilateral orbitotomy with the contralateral eye serving as a control. The average follow up following lateral orbitotomy was 23 months (range 6–47). Among all cases undergoing lateral orbitotomy (n = 41), the average pre- and postoperative HPA was 30.5 mm and 29.9 mm, respectively. The HPA was reduced by an average of 0.6 ± 0.5 mm (range 0 mm to −1.9 mm), which was not statistically significant (p = 0.14). However, a statistically significant reduction in post-orbitotomy HPA (0.29 mm) was observed between cases (0.31 mm; n = 13) and their matched controls (0.02 mm; p = 0.016). The average pre- and postoperative proptosis was 23 mm and 20 mm, respectively. Proptosis was reduced by an average of 3 ± 2 mm (0 to 7 mm), which was statistically significant (p
Lateral Canthal Position Following Lateral Orbitotomy and the Influence of Ocular Proptosis Pari N. Shams, B.Sc., M.R.C.P., F.R.C.Ophth., Meredith S. Baker, M.D., and Richard C. Allen, M.D., Ph.D., F.A.C.S. Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.
Purpose: Anecdotal evidence suggests that detachment of the lateral canthal tendon during lateral orbitotomy results in shortening of the horizontal palpebral aperture (HPA) and rounding of the lateral canthal angle (LCA). This study investigated the change in HPA and LCA following lateral orbitotomy and the effect of proptosis on the HPA. Methods: Retrospective, single surgeon, review of all cases undergoing lateral orbitotomy, comprising of a canthotomy and cantholysis and reconstruction of the lateral canthus using a single suture. The HPA and lateral canthal height (LCH) were measured on pre- and postoperative photographs using ImageJ software. Changes in the LCA and degree of proptosis were also investigated. Exclusion criteria included previous eyelid surgery, acute trauma, and less than 6 months’ follow up. Results: There were 41 cases of lateral orbitotomy in 27 patients, 67% female, average age 51 years. Twenty patients had thyroid eye disease of which 14 underwent bilateral surgery; the other 7 patients had a variety of orbital pathologies. Thirteen patients underwent unilateral orbitotomy with the contralateral eye serving as a control. Average follow up was 23 months. Overall, the HPA and proptosis were reduced by 0.6 mm (p = 0.143) and 3.4 mm (p < 0.001), respectively. A 0.2-mm reduction in HPA was observed for every 1-mm reduction in proptosis. A difference in post-orbitotomy HPA was observed between cases and their matched controls (p = 0.016). No rounding of the LCA or significant change in LCH was observed following lateral orbitotomy. Conclusions: The described technique of lateral orbitotomy and simple reconstruction do not appear to cause lateral canthal drift or rounding. There was no significant change in HPA or LCH. The degree of change of proptosis does appear to influence the change of HPA. (Ophthal Plast Reconstr Surg 2016;32:53–57)
N
umerous indications exist for surgical access to the lateral orbital wall, which include repair of orbital fractures, orbital decompression for thyroid orbitopathy, resection or biopsy of tumors, orbital reconstruction, and removal of foreign
Accepted for publication January 12, 2015. The authors have no financial or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.op-rs.com.). Address correspondence and reprint requests to Pari N. Shams, B.Sc., M.R.C.P., F.R.C.Ophth., Department of Ophthalmology and Visual Sciences, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: pari. [email protected] DOI: 10.1097/IOP.0000000000000418
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
bodies. Approaches to the lateral orbit have evolved over the years and include Burke’s modification of the Kronlein skin incision into a transverse incision extending 30 mm from the lateral canthus and the Stallard-Wright S-shaped incision from the lateral sub-brow along the lateral rim and extending horizontally along the lateral canthus.1,2 A disadvantage common to these techniques is the visible scar they create. To overcome this, surgeons today prefer to use an extended upper eyelid skin crease incision or a lateral canthotomy incision for lateral orbitotomy. The lateral canthotomy incision provides excellent surgical access to the lateral orbital wall and simultaneous access to the orbital roof and floor. While the access provided by lateral canthotomy and cantholysis is ideal, there are anecdotal reports on postoperative rounding of the lateral canthal angle (LCA), canthal dystopia with inferior or medial dislocation, and overriding of the upper eyelid relative to the lower eyelid.3 Although there are no published series reporting these complications of the lateral canthotomy incision, there are reports in the literature of techniques designed to avoid incising the lateral canthus, such as starting the incision 2 mm lateral to the canthus,4 the retrocanthal lateral orbitotomy,5 and the lateral triangle flap technique.6 Some surgeons devote a great deal of surgical time to the elaborate repair of the lateral canthus. The authors therefore set out to investigate whether this simple and efficient technique for exposure and reconstruction of the lateral canthus during a lateral orbitotomy was associated with the aforementioned surgical complications of lateral canthotomy incision.
METHODS This study is a retrospective chart review of consecutive cases of lateral orbitotomy performed by a single surgeon (R.C.A.) at the University of Iowa Hospitals and Clinics between 2009 and 2013. The indications for surgery included orbital decompression for thyroid eye disease (TED), incision biopsy or excision biopsy of orbital lesions causing mass effect or functional deficit. The primary outcome measures were a change following lateral orbitotomy in 1) the horizontal palpebral aperture (HPA), 2) the lateral canthal height (LCH), 3) LCA, and 4) ocular proptosis. Exclusion criteria were 1) previous eyelid surgery, 2) cases undergoing surgery for acute trauma, 3) congenital or acquired periocular abnormality other than those caused by the presenting orbital pathology or TED, and 4) less than 6 months’ postoperative follow up. The same surgical technique was used to expose the lateral orbital rim in all cases, which involved a horizontal canthotomy and a superior and inferior cantholysis, and the same technique was used to reconstruct the lateral canthus using a single, simple, circular suture at the lateral canthus. Surgical technique to expose the lateral orbital rim (see Video, Supplemental Digital Content, http://links.lww.com/IOP/A107) Local anesthetic with epinephrine is injected transcutaneously in the lateral canthal region and the lateral upper and lower eyelid, and in the inferior and lateral conjunctival cul-de-sacs. A lateral canthotomy
53
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
P. N. Shams et al.
is performed using a scalpel blade or microdissection needle extending the incision through the soft tissue down to the periosteum of the lateral orbital rim. An inferior (Fig. 1A) and superior (Fig. 1B) cantholysis are performed with a microdissection needle, detaching the eyelids from the orbital rim. Two 4-0 silk traction sutures are placed in lateral upper and lower eyelids, capturing the tarsal plate (Fig. 1C). The lateral orbital rim is exposed with a Freer elevator. Surgical technique to reconstruct the lateral canthus (see Video, Supplemental Digital Content, http://links.lww.com/IOP/A107).
The lateral upper and lower eyelid are reapproximated to the periorbita using a single armed 4-0 vicryl suture on a P2 or ½ circle needle which is first passed reverse mounted through the periorbita, in a posterior to anterior direction (Fig. 1D), then through the inferior crus of the lateral canthal tendon (LCT; Fig. 1E) with a good purchase of the tarsal plate, coming out through the gray line at the eyelid margin 2 mm from its cut edge. The needle is then forward mounted and passed through the superior eyelid margin at the gray line 2 mm from the cut edge and advanced through the superior crus of the LCT (Fig. 1F),
FIG. 1. Intraoperative clinical photographs showing exposure of the lateral orbital rim and reconstruction of the lateral canthus: (A) an inferior and (B) superior cantholysis are performed with a microdissection needle, detaching the eyelids from the orbital rim. C, Two 4-0 silk traction sutures are placed in lateral upper and lower tarsal plate allowing good exposure to the lateral orbital rim. For the reconstruction, the lateral upper and lower eyelid are reapproximated to the periorbita using a 4-0 vicryl suture on a ½ circle needle. D, This is first passed reverse mounted through the periorbita, in a posterior to anterior direction, and (E) then through the inferior crus of the lateral canthal tendon (LCT), coming out through the gray line 2 mm from its cut edge. F, The needle is then forward mounted and passed through the superior eyelid margin 2 mm from the cut edge and advanced through the superior crus of the LCT. G, Finally, the suture is passed back though the periorbita parallel to the first pass, in an anterior to posterior direction. H, The suture is then tied which reforms the lateral canthal angle.
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© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 32, No. 1, 2016
ensuring a good purchase of the tarsal plate. Finally, the suture is passed back though the periorbita parallel to the first pass, in an anterior to posterior direction, to emerge 3 to 4 mm superior to the first pass of the suture (Fig. 1G). The suture is then tied which reforms the LCA and pulls the lateral canthus laterally (Fig. 1H). The lateral canthotomy skin incision is closed with interrupted 7-0 vicryl sutures. Pre- and postoperative computer-based digital facial photographs were analyzed using Image J 1.47 software,7 which was used to measure the HPA and the LCH (the height of the lateral canthus above the medial canthus). The presence or absence of rounding of the LCA was recorded. In all cases, both the left and the right side were measured. In cases where unilateral surgery was carried out, the contralateral side was used as a control. The scale of measurement on each photograph and on each side of the face was calibrated by setting the white-to-white corneal diameter as 12 mm. The HPA of each eye was measured in millimeters from the medial to the lateral canthus (Fig. 2A,B). The LCH was measured by drawing a horizontal line through the medial canthus and recording the vertical height of the lateral canthus in millimeters above this line (Fig. 2C,D). The degree of ocular proptosis, the distance from lateral orbital rim to the corneal apex, was measured using a Hertel exophthalmometer, with the pre- and post operative measurement on each patient using the same intercanthal distance. These measurements were obtained from the patients’ clinical chart. Other complications of lateral orbitotomy, such as infection, wound dehiscence, or persistent edema, within 3 months of surgery were recorded. Statistical Methods. Differences in proportions for continuous, normally distributed data were carried out using the t test. The Mann-Whitney rank sum test was used for nonparametric data. Statistical analyses were performed using SigmaPlot version 12.5 for Windows (Systat Software, Inc., San Jose, CA, U.S.A.). This study followed the tenets of the Declaration of Helsinki and was approved by the institutional research board of the University of Iowa (IRB ID no.: 201406758).
RESULTS Forty-one cases of lateral orbitotomy, performed on 27 patients, fulfilled the inclusion criteria. The average age of patients was 51 years (range 15–80), 67% were female. Twenty of 27 (74%) patients had TED of which 14 (70%) underwent bilateral orbital decompression. Seven of 27 (26%) patients had a variety of other orbital lesions: cavernous hemangioma (n = 2), sphenoid wing meningioma (n = 1), venous-lymphatic
Lateral Canthal Position Following Lateral Orbitotomy
vascular malformation (n = 1), lymphoma (n = 1), orbital inflammation (n = 1), and pleomorphic adenoma (n = 1). Thirteen of 27 (48%) patients underwent unilateral orbitotomy with the contralateral eye serving as a control. The average follow up following lateral orbitotomy was 23 months (range 6–47). Among all cases undergoing lateral orbitotomy (n = 41), the average pre- and postoperative HPA was 30.5 mm and 29.9 mm, respectively. The HPA was reduced by an average of 0.6 ± 0.5 mm (range 0 mm to −1.9 mm), which was not statistically significant (p = 0.14). However, a statistically significant reduction in post-orbitotomy HPA (0.29 mm) was observed between cases (0.31 mm; n = 13) and their matched controls (0.02 mm; p = 0.016). The average pre- and postoperative proptosis was 23 mm and 20 mm, respectively. Proptosis was reduced by an average of 3 ± 2 mm (0 to 7 mm), which was statistically significant (p
