Orbit, 2014; 33(2): 132–134 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2013.851256
C ASE REPORT
Late Orbital Floor Implant Migration Presenting as Recurrent Episcleritis Sobha Joseph and David Cheung
ABSTRACT A 53-year-old patient presented with recurrent epicleritis of the right eye for 6 months and progressive diplopia. He had a past history of orbital floor repair over 30 years. A CT scan showed a radiodense migrated orbital floor sheet implant in the maxillary sinus causing obstruction of the maxillary sinus ostium, secondary maxillary sinusitis with retrobulbar involvement. The silastic orbital implant was removed via a Caldwell Luc approach and resolution of the patient’s symptoms and signs quickly ensued. We discuss this late complication of orbital floor fracture repair presenting initially as recurrent episcleritis and maxillary sinusitis with intraorbital extension. This report also emphasizes the importance of history taking. Keywords: Episcleritis, inflammation, orbital floor repair, orbital implant
INTRODUCTION
Case Report
Both alloplastic and autogenic implants are used in the repair of orbital floor fractures to support the orbital soft tissues and prevent their further descent into the maxillary sinus. The late migration of alloplastic implants is very rare. We report a case of late migration of a silastic orbital floor implant 30 years after its insertion presenting as recurrent episcleritis.
A 53-year-old man presented with a 6-month history of recurrent painful red right eye. The vision was 6/6 in both eyes. Pupil reflexes, colour vision testing and
20 14
Orbit Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 01/16/15 For personal use only.
Ophthalmology Department, Russells Hall Hospital, Dudley, United Kingdom
FIGURE 2. Coronal CT scan showing a dislocated orbital floor sheet implant within the maxillary sinus abutting against and obstructing the internal opening of the maxillary sinus ostium, secondary maxillary sinusitis with intraorbital and intraconal extension.
FIGURE 1. Preoperatively patient had persistent inflammation not responding to topical steroids and developed restriction of elevation after 6 months of presentation.
Received 8 May 2013; Revised 14 August 2013; Accepted 30 September 2013; Published online 6 November 2013 Correspondence: Sobha Joseph, The Dudley Group NHS Foundation Trust, Ophthalmology, The Russells Hall Hospital, Dudley, W. Midlands, Dy1 2 HQ, United Kingdom. E-mail: [email protected]
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Late Complication of Orbital Floor Repair
FIGURE 3. Top: Preoperative Hess chart showing restriction of elevation. Bottom: Almost full motility returned after implant removal.
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2014 Informa Healthcare USA, Inc.
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134 Joseph & Cheung fundal examination were normal. Anterior segment examination showed inferior conjunctival chemosis with episcleral injection and full ocular motility. A preliminary diagnosis of episcleritis was made and he was treated with topical steroids for which he showed a good initial response. However, over the next 6 months of treatment his inflammation recurred and became unresponsive to his topical treatment and he started complaining of vertical diplopia. Ocular examination showed inferior bulbar chemosis, episcleritis and restriction of elevation (Figure 1). A CT scan was performed which showed dislocated orbital implant, secondary maxillary sinusitis with intraorbital and intraconal extension (Figure 2). On further questioning the patient admitted that he had forgotten that he had undergone surgery for an orbital floor fracture 30 years previously. The orbital silastic implant was removed by a Caldwell Luc approach and not replaced. Within 3 days the patient’s eye returned back to normal and full ocular motility returned. Repeat CT imaging showed that the maxillary sinusitis had completely resolved. The patient maintained full motility and a normal orbital/ocular exam (Figure 3).
Despite this, a low-grade foreign body reaction commonly occurs resulting in fibrous capsule formation. This can be advantageous in patients with late implant migration where it strengthens the residual orbital floor periosteum, negating the need for implant replacement as in our case report.3 Porous implants such as porous polyethylene differ by allowing fibrovascular ingrowth, thought to be contributory to their reported lower rate of migration.2 The late migration of alloplastic orbital floor implants is rare but can present in many different ways to the ophthalmologist-including proptosis, orbital haemorrhage, chronic sinusitis, facial cellulitis, dacryocystitis or extrusion through fornix.4–8 The careful choice of orbital floor implant material and meticulous surgery sometimes requiring implant fixation can help prevent this late complication.2 Patients presenting with recurrent inflammation or atypical clinical features of orbital disease may have forgotten about their previous orbital floor pathology; a good history taking is very important in pinpointing the diagnosis.
DECLARATION OF INTEREST Comment Our case report described subluxation of an orbital floor implant into the maxillary sinus 30 years after initial surgery, probably resulting from initial medial migration and then downward slippage of lateral edge of the silastic sheet whilst still being propped up by the medial edge of the orbital floor bony defect. Obstruction of the maxillary sinus ostium led to maxillary sinusitis and mucocoele formation with intraorbital extension. Furthermore, the superior edge of the subluxed implant rubbed the surrounding orbital tissues further contributing to the clinical features of recurrent inflammatory signs and restrictive myopathy. The inflammation and diplopia quickly resolved on implant removal. The probability of late migration of an orbital floor implant is dependent on many factors including its composition, size of orbital floor defect and method of fixation.1–3 Although autologous bone grafts have a very low migration rate, biocompatible alloplastic materials are often preferentially used due to their ready availability.3 Many alloplastic materials exist, each with their reported advantages and disadvantages. Non-porous implants such as silastic and silicone are relatively inexpensive and have low risk of postoperative diplopia, thought to be related to their smooth surface and low fibrogenicity.
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Mauriello Jr JA, Fiore PM, Kotch M. Dacryocystitis. Late complication of orbital floor fracture repair with implant. Ophthalmology 1987;94(3):248–250. 2. Tabrizi R, Ozkan TB, Mohammadinejad C, Minaee N. Orbital floor reconstruction. J Craniofac Surg 2010; 21(4):1142–1146. 3. Brown AE, Banks P. Late extrusion of alloplastic orbital floor implants. Br J Oral Maxillofac Surg 1993; 31(3):154–157. 4. Vose M, Maloof A, Leatherbarrow B. Orbital floor fracture: an unusual late complication. Eye 2006;20(1):120–122. 5. Awan MA, Cheung CM, Sandramouli S, Mathews J. An unusual late complication of orbital floor fracture repair. Eye 2006;20(12):1454–1455. 6. Andrews AE, Hicklin L. Inflammatory nasal polyps: an unusual late complication of Silastic sheet repair of orbital floor fracture. J Laryngol Otol 2006 Feb;120(2):e1. 7. Lee DH, Joo YE, Lim SC. Migrated orbital silastic sheet implant mimicking bilateral sinusitis. J Craniofac Surg 2011; 22(6):2158–2159. 8. Rosen CE. Late migration of an orbital implant causing orbital haemorrhage with sudden proptosis and diplopia. Ophthalmic plastic and reconstructive surgery. Ophthal Plast Reconstr Surg 1996;12(4):260–262.
Orbit
C ASE REPORT
Late Orbital Floor Implant Migration Presenting as Recurrent Episcleritis Sobha Joseph and David Cheung
ABSTRACT A 53-year-old patient presented with recurrent epicleritis of the right eye for 6 months and progressive diplopia. He had a past history of orbital floor repair over 30 years. A CT scan showed a radiodense migrated orbital floor sheet implant in the maxillary sinus causing obstruction of the maxillary sinus ostium, secondary maxillary sinusitis with retrobulbar involvement. The silastic orbital implant was removed via a Caldwell Luc approach and resolution of the patient’s symptoms and signs quickly ensued. We discuss this late complication of orbital floor fracture repair presenting initially as recurrent episcleritis and maxillary sinusitis with intraorbital extension. This report also emphasizes the importance of history taking. Keywords: Episcleritis, inflammation, orbital floor repair, orbital implant
INTRODUCTION
Case Report
Both alloplastic and autogenic implants are used in the repair of orbital floor fractures to support the orbital soft tissues and prevent their further descent into the maxillary sinus. The late migration of alloplastic implants is very rare. We report a case of late migration of a silastic orbital floor implant 30 years after its insertion presenting as recurrent episcleritis.
A 53-year-old man presented with a 6-month history of recurrent painful red right eye. The vision was 6/6 in both eyes. Pupil reflexes, colour vision testing and
20 14
Orbit Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 01/16/15 For personal use only.
Ophthalmology Department, Russells Hall Hospital, Dudley, United Kingdom
FIGURE 2. Coronal CT scan showing a dislocated orbital floor sheet implant within the maxillary sinus abutting against and obstructing the internal opening of the maxillary sinus ostium, secondary maxillary sinusitis with intraorbital and intraconal extension.
FIGURE 1. Preoperatively patient had persistent inflammation not responding to topical steroids and developed restriction of elevation after 6 months of presentation.
Received 8 May 2013; Revised 14 August 2013; Accepted 30 September 2013; Published online 6 November 2013 Correspondence: Sobha Joseph, The Dudley Group NHS Foundation Trust, Ophthalmology, The Russells Hall Hospital, Dudley, W. Midlands, Dy1 2 HQ, United Kingdom. E-mail: [email protected]
132
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Orbit Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 01/16/15 For personal use only.
Late Complication of Orbital Floor Repair
FIGURE 3. Top: Preoperative Hess chart showing restriction of elevation. Bottom: Almost full motility returned after implant removal.
!
2014 Informa Healthcare USA, Inc.
Orbit Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 01/16/15 For personal use only.
134 Joseph & Cheung fundal examination were normal. Anterior segment examination showed inferior conjunctival chemosis with episcleral injection and full ocular motility. A preliminary diagnosis of episcleritis was made and he was treated with topical steroids for which he showed a good initial response. However, over the next 6 months of treatment his inflammation recurred and became unresponsive to his topical treatment and he started complaining of vertical diplopia. Ocular examination showed inferior bulbar chemosis, episcleritis and restriction of elevation (Figure 1). A CT scan was performed which showed dislocated orbital implant, secondary maxillary sinusitis with intraorbital and intraconal extension (Figure 2). On further questioning the patient admitted that he had forgotten that he had undergone surgery for an orbital floor fracture 30 years previously. The orbital silastic implant was removed by a Caldwell Luc approach and not replaced. Within 3 days the patient’s eye returned back to normal and full ocular motility returned. Repeat CT imaging showed that the maxillary sinusitis had completely resolved. The patient maintained full motility and a normal orbital/ocular exam (Figure 3).
Despite this, a low-grade foreign body reaction commonly occurs resulting in fibrous capsule formation. This can be advantageous in patients with late implant migration where it strengthens the residual orbital floor periosteum, negating the need for implant replacement as in our case report.3 Porous implants such as porous polyethylene differ by allowing fibrovascular ingrowth, thought to be contributory to their reported lower rate of migration.2 The late migration of alloplastic orbital floor implants is rare but can present in many different ways to the ophthalmologist-including proptosis, orbital haemorrhage, chronic sinusitis, facial cellulitis, dacryocystitis or extrusion through fornix.4–8 The careful choice of orbital floor implant material and meticulous surgery sometimes requiring implant fixation can help prevent this late complication.2 Patients presenting with recurrent inflammation or atypical clinical features of orbital disease may have forgotten about their previous orbital floor pathology; a good history taking is very important in pinpointing the diagnosis.
DECLARATION OF INTEREST Comment Our case report described subluxation of an orbital floor implant into the maxillary sinus 30 years after initial surgery, probably resulting from initial medial migration and then downward slippage of lateral edge of the silastic sheet whilst still being propped up by the medial edge of the orbital floor bony defect. Obstruction of the maxillary sinus ostium led to maxillary sinusitis and mucocoele formation with intraorbital extension. Furthermore, the superior edge of the subluxed implant rubbed the surrounding orbital tissues further contributing to the clinical features of recurrent inflammatory signs and restrictive myopathy. The inflammation and diplopia quickly resolved on implant removal. The probability of late migration of an orbital floor implant is dependent on many factors including its composition, size of orbital floor defect and method of fixation.1–3 Although autologous bone grafts have a very low migration rate, biocompatible alloplastic materials are often preferentially used due to their ready availability.3 Many alloplastic materials exist, each with their reported advantages and disadvantages. Non-porous implants such as silastic and silicone are relatively inexpensive and have low risk of postoperative diplopia, thought to be related to their smooth surface and low fibrogenicity.
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Mauriello Jr JA, Fiore PM, Kotch M. Dacryocystitis. Late complication of orbital floor fracture repair with implant. Ophthalmology 1987;94(3):248–250. 2. Tabrizi R, Ozkan TB, Mohammadinejad C, Minaee N. Orbital floor reconstruction. J Craniofac Surg 2010; 21(4):1142–1146. 3. Brown AE, Banks P. Late extrusion of alloplastic orbital floor implants. Br J Oral Maxillofac Surg 1993; 31(3):154–157. 4. Vose M, Maloof A, Leatherbarrow B. Orbital floor fracture: an unusual late complication. Eye 2006;20(1):120–122. 5. Awan MA, Cheung CM, Sandramouli S, Mathews J. An unusual late complication of orbital floor fracture repair. Eye 2006;20(12):1454–1455. 6. Andrews AE, Hicklin L. Inflammatory nasal polyps: an unusual late complication of Silastic sheet repair of orbital floor fracture. J Laryngol Otol 2006 Feb;120(2):e1. 7. Lee DH, Joo YE, Lim SC. Migrated orbital silastic sheet implant mimicking bilateral sinusitis. J Craniofac Surg 2011; 22(6):2158–2159. 8. Rosen CE. Late migration of an orbital implant causing orbital haemorrhage with sudden proptosis and diplopia. Ophthalmic plastic and reconstructive surgery. Ophthal Plast Reconstr Surg 1996;12(4):260–262.
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