Developments in Ophthalmology Vol. 13

Series Editor W. Straub, Marburg a. d. Lahn

Basel · M ü n c h e n · Paris · London · New York · New De lh i · Singapore · Tokyo · Sydney

52nd Clinical Afternoon o f the University Eye Clinic in the Concert Hal l o f the Ernst von H ü l s e n - H a u s , Marburg a.d. Lahn, January 18, 1986

Complications in Modern Ophthalmic Surgery

Volume Editor /. Strempel, Marburg a. d. Lahn

90 figures, 2 color plates and 23 tables, 1987

Basel · M ü n c h e n · Paris · London · New York · New Delhi · Singapore · Tokyo · Sydney

Contents

Preface V I I Acknowledgements V I I Wolfgang Straub 65 Years. Congratulations to Prof. Dr . med. Dr . med. h.c.

Wolfgang Straub by M a r t i n Reim (Aachen) I X

Reim, M . ; Qinkler, G . (Aachen): Complications o f L i d Surgery 1 Severin, Μ. ; Kirchhof, Β.; Har tmann, C. (Köln) : Diffuse Epithelial Ingrowth after

Perforating Keratoplasty 9 Aust, W.; Wfrnhard , U . (Kassel) Defects o f Descemets Membrane as a

Complication in Cataract Extraction wi th Lens Implantat ion 20 Draeger, J.; Winter , R. (Hamburg): The Corneal Endothel ium as a Standard for the

Assessment o f Complications i n Microsurgery 30 Costa, G. (Rio de Janeiro): Complications i n Posterior Chamber Lens Implanta­

t ion 36 Domarus, D . von; Burk, R.; Sievers, H . (Hamburg/Kiel ) : Tissue Changes Induced

by Intraocular Lenses. A Histopathologic Study (wi th 1 color plate) 44 Schüt te , Ε.; Pötzsch, D . ; Schiefer, U . (U lm) : Combined Cataract-Glaucoma

Operation and Its Complications wi th 7-S-Intraocular Lens (with 1 color plate) 65 Neubauer, Η . ; Kirchhof, Β.; Arno ld , G. (Köln) : Complications after Modern Filter

Operations i n Glaucoma 70 Weder, W.; Lissel, U . ; Stöltzing, M . (Marburg a. d. Lahn): Complications and

Results after Trabeculotomy 78 Demeler, U . (Bremen): Direct Cyclopexy after Persistent Hypotony as a Complica­

t ion after Cyclodialysis and Gonio tomy 85 Lemmen, K . - D . ; Dimopoulos, S.; Kirchhof, Β.; Heimann, Κ. (Köln) : Keratopathy

Following Pars plana Vitrectomy wi th Silicone O i l F i l l ing 88 Kreissig, I . (Tüb ingen) : The Balloon-Gas-Procedure. Another Move towards

M i n i m u m Surgery 99 Wiegand, W. (Marburg a. d. Lahn): Complications o f Retinal Xenon-Arc Photo­

coagulation 107 Kaufmann, Η . (Giessen): Complications i n Eye Muscle Surgery 113 Welge-Lüssen, L . ; Schroeder, H .G . ; Glanz, Η . (Frankfurt /Marburg a. d. Lahn):

Complications i n Orbital Lesions 117 Schmidt, B.; Berghaus, A . (Berlin): Complications i n Frontal Defects 125

Contents V I

Strempel, I . (Marburg a. d. Lahn): Complications by L i q u i d Plastics i n Ophthalmic Surgery. Histopathologic Study 137

Beiter, G. ; Lerche, W.; Oberhauser, Μ. (Wiesbaden): Occlusion o f a Branch o f the Central Retinal Artery by a Corpus alienum as a Rare Complicat ion o f the Carotid Arteriography 147

Rossmann, Η . (Hamburg): Legal and Actuarial Technical Questions in Intraocular Complications 151

Subject Index 155

Dev. Oph tha l , vol . 13, pp. 125-136 (Karger, Basel 1987)

Complications of Frontal Defects Immobilization of the Eye

B. Schmidt*, A. Bergham* a Augenkl in ik und bHals-Nasen-Ohrenklinik, K l i n i k u m Steglitz der Freien Univers i tä t Berlin

In the preantibiotic era, there were occurrences of uncontrolled sinusitis that broke into the orbit and led to vision impairment and severe illness [Sariban and Freyens, 1979]. We are reporting on a patient (I.K.), born January 12, 1932, who developed an orbital phlegmon in 1946. With consid­erable organizational difficulties, it was possible at that time to provide her with one of the first antibiotic therapies. At the terminal stage, there was a change in the osseous orbit as well as the eye motility.

Frontal sinus operations were performed in 1949 and 1952; a mucocele of the left frontal sinus was removed in 1980.

The patient presented in the ENT Department of Steglitz Medical Center in 1982. A part of the left frontal bone and the roof of the orbit were missing; the left eye was directed upwards and hardly movable (fig. 1). Of utmost importance to the patient at that time, aside from her desire for cor­rection of the defective eye position, was apparently cosmetic revision of the conspicuous frontal defect with involvement of the orbital margin.

We decided to offer the patient a new type of defect treatment with porous polyethylene [Berghaus, 1985]. Experimental studies have shown that the material is not resorbed and can easily be adjusted as required by virtue of its thermoplastic properties. The implant suitable for an individual case is formed from the patient's face with the aid of a plaster cast.

Porous polyethylene (PHDPE) has a pore size of about 150 μπι (fig. 2). It is known that the pore system is usually completely filled up with bone within a few weeks after implantation [Klawitter et al., 1976; Spector et al., 1976; Berghaus et al., 1984]. Stable implant anchorage is thus achieved (fig. 3).

For surgical access, we chose a bitemporal incision behind the hairline, which leaves no visible scars. The defect can be easily demonstrated from

Schmidt / Berghaus 126

Fig. 1. Patient's face when she presented in 1982. The frontal sinus and the roof o f the orbit are missing. The left eye is higher.

Fig. 2. Cut surface o f porous polyethylene. Open pore system. S E M X 500.

here. Care must be taken not to reopen the infundibulum of the frontal sinus towards the nose. In this case, we first filled the defective cavity with bone fragments from the iliac crest (fig. 4) and then covered the orbital mar­gin area with a profile plate of porous polyethylene formed on the plaster cast of the patient's face (fig. 5, 6). Having had further good results with this synthetic material in the meantime, we now use it to fill up the entire cavity

Complications o f Frontal Defects 127

Fig. 5. A profile plate o f porous polyethylene for correction o f frontal defects.

Schmidt / Berghaus 128

Fig. 6. Profile plate intraoperatively.

Fig. 7. Filling of a frontal defect with a perforated PHDPE block.

Fig. 8. X-ray before (left) and 1 year after correction of the frontal defect with iliac crest bone and a profile plate of porous polyethylene (right). Ossification of the defect area.

Complications of Frontal Defects 129

in such cases (fig. 7). The material permits smooth and symmetrical contour­ing of the forehead. The postoperative course has been normal up to the present time. The result of the intervention was and has remained satis­factory. Radiological comparison preoperatively and 1 year postoperatively shows the expected ossification of the former large defect cavity after filling with iliac crest bone (fig. 8). Even 3 years postoperatively, the cosmetic result remained essentially unaltered (see fig. 14).

After reconstruction of the forehead and the roof of the orbit, the patient underwent cosmetic and functional restoration of the eye position. The left eye was in divergence: far 9°, near 17° with a negative vertical divergence: far 14°, near 17.5°. A lowering of the left eye was not possible (fig. 9a). With no signs of irritation in the right eye, the left eye evidenced a narrow pupil with posterior synechia, apparently as the result of an old intraocular inflamma­tion in connection with the orbital phlegmon. A diplopia examination on the tangent scale was not possible, since the axes of the eyes were outside the measuring range. Vision: +3.25-1.25/100°= 1.2, right eye; +3.15-1.0/90°, left eye.

In the first operation, wide adhesions of Tenon's capsule and the sarco-lemmas were divided. Circumscribed areas of scar tissue were noticed. The musculus rectus superior was freed, and the conspicuously thin musculus rectus inferior was likewise rid of cicatricial funiculi and slightly anteposi-tioned.

The following squint angle was found postoperatively: far: D 10 — V D 6°; near: D 17 — V D 10°.

On the whole, there was freeer motility. With fixation on the right, it was then also possible to perform a tangent-scale test according to Harms (fig. 10a) as well as a synoptometric examination (fig. 11). Binocular vision was even restored with a prism correction. At first, there was still suppression for the left eye, but binocular vision for far and near was possible after further exercise.

A further operation was performed half a year later. The now stronger rectus inferior was resected by 3 mm, likewise the rectus internus.

After this operation, binocular vision could be achieved without prisms. The Bagolini test was positive for far and near. The squint angle was as follows: far: C 1°+VD 1°; near: C5°+VD 1-2°. There was a fusion angle of 10° in adduction and 3° in abduction; 5° in the verticals. There was now a small binocular visual field (fig. 13a); the double-image scheme (fig. 10b) and the synoptometric findings (fig. 12) of course still showed a residual angle in the secondary positions.

Schmidt / Berghaus 130

Fig. 9. a Picture in nine visual lines. The left eye is higher and can hardly be moved, particularly not lowered, b After Tenon and muscle surgery, the eyes are parallel for the primary position, but a movement deficit is sti l l evident in deorsumduction to the left.

Complications o f Frontal Defects 131

F i x a t i o n b y r i g h t eye (red glass r i g h t ) upwards

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F i x a t i o n b y l e f t eye ( red glass l e f t ) upwards

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o u t ( Df f u s i o n Dossibilitv f 08 -15

downwards

Fig. 10. Tangent scale according to Harms, a The squint angle can be measured wi th right f ixat ion after the first operation. The double image lies outside the tangent w i t h left fixation, b After the 2nd operation i n pr imary position and upward binocular vision.

Schmidt / Berghaus 132

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Complications o f Frontal Defects 133

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Schmidt / Berghaus 134

Field of binocular single vision

Distance from screen: 2,5 m K. Inge

a 20° 0° 20°

Field of b inocular single vision

Distance from screen: 2,5 m K. Inge 20.6.85

b 20° 0° 20°

Fig. 13. a A t first, there is only a small binocular visual field, b A quarter o f a year after the last operation, the binocular visual field has become much larger.

The final result was complete visual acuity on both sides. Right eye still normal; unaltered narrow pupil in left eye. Vision: 1.2 on the right; 1.0 on the left. The squint angle is: C 4 — VD 1°; fusion range 36° in adduction and 6° in abduction; synoptometric (fig. 12) and tangent-scale examinations (fig. 10b) show only slight divergence in primary position. The greatest dif­ference is still evident in deorsumduction to the left (fig. 12). The binocular

Complications o f Frontal Defects 135

Fig. 14. Patient I . K . 3.5 years after frontal bone surgery and three-quarters o f a year after completion o f reconstructive eye surgery. The forehead and roof o f the orbit are normal. The light reflexes in the eyes are straight.

visual field was now also increased (fig. 13b). There is no forced head pos­ture. Of course, the motility of the left eye is limited, particularly in deor-sumduction (fig. 9b). There was slight enophthalmus of the left eye; Hertel difference: 2 mm.

Summary

A case where the severe course o f an orbital phlegmon led to a functionally and cosmetically poor condit ion is presented. Thir ty-f ive years later, i t was possible to achieve a satisfactory result through several operations performed wi th interdisciplinary cooperation. The orbit and forehead were reconstructed w i th porous polyethylene, thus ensuring a cosmetically good result. In two operations, the left eye was freed from its upward fixation through cicatrectomy and mobil izat ion o f the mucles, so that the eyes were straight again i n the primary position. There is a l imi ted binocular visual field. Binocular vision could be restored again after an interruption o f 35 years.

Schmidt / Berghaus 136

References

Berghaus, Α.: Porous polyethylene in reconstructive head and neck surgery. Archs Otolar. Ill: 154-160(1985).

Berghaus, Α.; Mulch , G.; Handrock, Μ.: Porous polyethylene and proplast. Their behav­iour in a bony implant bed. Archs Oto-Rhino-Lar. 240: 115-123 (1984).

Klawitter , J.J.; Bagwell, J.G.; Weinstein, S.M.; Sauer, B.W.; Pruitt , J.R.: A n evaluation o f bone growth into porous high density polyethylene. J. biomed. Mater. Res. 10: 311-323 (1976).

Sariban, E.; Freyens, P.: Les atteintes orbitaires des sinusites aigües chez l'enfant. Acta oto-rhino-lar. belg. 33: 927-935 (1979).

Spector, M . ; Hemming , W.R.; Kreutner, Α.: Bone growth into porous high-density poly­ethylene. J. biomed. Mater. Res. 7: 595-603 (1976).

Prof. Dr . Barbara Schmidt, Augenklinik, K l i n i k u m Steglitz der Freien Univers i tä t Berlin, Hindenburgdamm 30, D-1000 Berlin 45