CASE REPORT

Watch the Screw. An Unusual Complication of Orbital Reconstruction Giulia Del Moro, MD,* Stefano Fabris, MD,y Pierluigi Longatti, MD,z and Giuseppe Scarpa, MDx Traumatic intraocular foreign bodies are a particular subset of open globe injuries usually caused by metal processing, blasts, or yard work. This case report presents a retained intraocular screw as a complication of mesh positioning during lateral orbit reconstruction after resection of a left spheno-orbital infiltrating meningioma. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:645.e1-645.e6, 2014

A 52-year-old woman presented with left eye proptosis that had worsened during the past 2 years. She underwent cerebral magnetic resonance imaging and subsequent computed tomographic (CT) scanning that showed an ‘‘en plaque’’ lesion infiltrating the left great sphenoid wing and lateral orbit wall and invading the ipsilateral orbit cavity (Figs 1, 2). Her left visual acuity, visual field, and ocular motility were normal. A left frontopterional craniotomy was performed and the extradural part of the lesion was completely removed by drilling the great sphenoid wing, the lateral orbit wall, and part of the orbital roof (Fig 3). To avoid enophthalmos, the orbit bone defect was reconstructed using paramagnetic a Bioplate 4-mm ovalheaded square-drive screw and titanium BioMesh (Bioplate Inc, Los Angeles, CA). During the procedure, a sudden crack of the remaining orbit roof caused slippage of the screwdriver and the mesh’s screw inside

the orbit. Although the metallic screw was visible on plain radiographs, its recovery was not possible. The orbital reconstruction was completed. The postoperative CT scan showed that the screw was within the ocular posterior chamber in association with vitreous hemorrhage (Figs 4, 5). A subsequent fundus oculi examination allowed visualization of the screw on the retinal surface. Its surgical removal was planned while the patient was kept under sedation to avoid any eye movement. The entry site of the screw was localized in the superotemporal quadrant, 14 mm posterior to the limbus, and sutured (Fig 6). Inspection of the fundus showed an extensive hemorrhagic choroidal detachment in the temporal side, with retinal and vitreal hemorrhages masking the entry site. No retinal detachment was detected. The foreign body was over the macula (Fig 7). Complete vitrectomy was performed after phacoemulsification of the lens with insertion of the intraocular lens in the capsular bag. Careful removal of blood clots and choroidal tissue was completed in the bed of the entry site where the retina was torn, followed by endolaser treatment. The foreign body was removed through a superonasal sclerotomy, 3.5 mm from the limbus, after having engaged it using a Prolene loop mounted on a backflush needle (Figs 8, 9).

*Medical Doctor, Department of Neurosurgery, Treviso Regional

of Padova, Piazza le Ospedale Civile 1, Treviso 31100, Italy; e-mail:

Traumatic retained intraocular foreign bodies are usually caused by metal processing, machine yard work, or exposure to explosives.1 This case report describes an unusual complication of mesh positioning during lateral orbit reconstruction after the removal of a left spheno-orbital infiltrating meningioma.

Report of Case

Hospital, University of Padova, Treviso, Italy.

[email protected]

yMedical Doctor, Department of Ophthalmology, Treviso Regional Hospital, Treviso, Italy.

Received October 21 2013 Accepted November 20 2013

zFull Professor, Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy. xProfessor, Department of Ophthalmology, Treviso Regional

Ó 2014 American Association of Oral and Maxillofacial Surgeons 0278-2391/13/01435-3$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.11.024

Hospital, Treviso, Italy. Address correspondence and reprint requests to Dr Del Moro: Department of Neurosurgery, Treviso Regional Hospital, University

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FIGURE 1. Preoperative gradient echo 3-dimensional gadoliniumenhanced T1-weighted axial magnetic resonance image with fat suppression. An ‘‘en plaque’’ gadolinium-enhanced lesion is causing swelling of the left great sphenoid wing and it is infiltrating the lateral wall of the left orbit. In proximity to the hyperostotic bone, a wide area of dural enhancement and intradural exophytic growth can be seen. Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

Clinical follow-up documented progressive visual improvement to complete recovery 45 days after treatment. At the 4-month follow-up, her left eye visual acuity was 10/10 with no scar retraction or retinal detachment (Figs 10, 11) and complete resolution of proptosis. The histopathologic report documented a World Health Organization grade I meningioma infiltrating the bone and soft tissues.

Discussion Metallic mesh implants are commonly used in maxillofacial and plastic surgery to repair orbital fractures or reconstruct orbit walls.2 Titanium meshes have proved to be a safe and versatile material in the reconstruction of large orbital defects.3,4 Common complications of mesh implantation are reported to be infection, periorbital tissue adhesion causing impairment of ocular movements with diplopia, and enophthalmos.5 However, to the best of the authors’

UNUSUAL COMPLICATION OF ORBITAL RECONSTRUCTION

FIGURE 2. Preoperative computed tomogram showing an ‘‘en plaque’’ lesion causing hyperostosis of the left orbit and great sphenoid wing. Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

knowledge, there is no report in the literature describing a mesh screw retained within the eye as a complication of orbital wall reconstruction. The authors performed MedLine and Cochrane Library searches for screw + intraocular foreign body, screw + orbital + injury, mesh + eye + injury, and mesh + intraocular foreign body. Only 1 report was found that dealt with similar topics: the traumatic dislocation of a glass screw, albeit in the periorbital tissues.6 Similarly, a case of chronic intraocular foreign body causing restrictive strabismus has been reported.7 However, globe penetration was caused by the decubitus of a metallic mesh wire implanted more than 30 years before, and no further surgery was performed. The present case seems to be the first report in the literature of an intraoperative ocular complication owing to mesh positioning. Considered that mesh implantation has become a common practice in the repair of large orbital fractures and defects, it is important to bear in mind the potential danger of eye injury during this procedure, especially when the bone appears to be pathologic or frail.

DEL MORO ET AL

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FIGURE 3. Intraoperative photograph. The meningioma, infiltrating the temporal muscle (left), has been removed from great sphenoid wing, lateral wall, and the orbital roof. The periorbit was invaded and perforated by the tumor. Asterisk, lateral rectus muscle; arrowhead, sphenoid wing partially drilled; Orb. roof, medial portion of the orbital roof. Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

FIGURE 4. Postoperative computed tomogram showing the position of the screw. Sagittal reconstruction shows the screw in the posterior chamber of the left eye (arrow). Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

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UNUSUAL COMPLICATION OF ORBITAL RECONSTRUCTION

FIGURE 5. Postoperative computed tomogram showing the position of the screw. Axial plane shows the vitreous hemorrhage in the left portion of the left eye, next to the screw (arrow). The lateral orbit wall and part of the great sphenoid wing were reconstructed with titanium meshes. Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

FIGURE 6. Intraoperative photographs of the left eye. The foreign body entry site, in the superolateral quadrant, is highlighted (circle).

FIGURE 7. Intraoperative photographs of the left eye. At the fundus oculi, the screw is seen on the macula.

Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

DEL MORO ET AL

FIGURE 8. Intraoperative photograph. The screw, on the retinal surface, has been engaged with a Prolene loop mounted in a backflush needle.

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FIGURE 10. The scleral scar and suture of the entry site at 4-month follow-up. Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

FIGURE 9. The extracted oval-headed 4-mm paramagnetic screw (Bioplate).

FIGURE 11. Fundus oculi at 4-month follow-up.

Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

Del Moro et al. Unusual Complication of Orbital Reconstruction. J Oral Maxillofac Surg 2014.

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References 1. Parke DW III, Flynn HW Jr, Fisher YL: Management of intraocular foreign bodies: A clinical flight plan. Can J Ophthalmol 48:8, 2013 2. Gear AJ, Lokeh A, Aldridge J, et al: Safety of titanium mesh for orbital reconstruction. Ann Plast Surg 48:1, 2002 3. Luetjens G, Krauss JK, Brandis A, et al: Bilateral sphenoorbital hyperostotic meningiomas with proptosis and visual impairment: A therapeutic challenge. Report of three patients and review of the literature. Clin Neurol Neurosurg 113:859, 2011

UNUSUAL COMPLICATION OF ORBITAL RECONSTRUCTION 4. Jung SH, Ferrer AD, Vela JS, et al: Spheno-orbital meningioma resection and reconstruction: The role of piezosurgery and premolded titanium mesh. Craniomaxillofac Trauma Reconstr 4: 193, 2011 5. Gosau M, Sch€ oneich M, Draenert FG, et al: Retrospective analysis of orbital floor fractures—Complications, outcome, and review of literature. Clin Oral Invest 15:305, 2011 6. Piven I, Ben-Simon G: Foreign body from an eyeglass screw. Ophthalmology 117:641, 2010 7. Hwang CJ, Katowitz WR, Volpe NJ: Orbital metallic mesh causing chronic intraocular foreign body and restrictive strabismus. Ophthal Plast Reconstr Surg 23:312, 2007

Watch the screw. An unusual complication of orbital reconstruction.

Traumatic intraocular foreign bodies are a particular subset of open globe injuries usually caused by metal processing, blasts, or yard work. This cas...
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