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Preseptal Transconjunctival Approach in Orbital Rim Fracture

Article  in  International Medical Journal (1994) · February 2014

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 International Medical Journal Vol. 21, No. 1, pp. 65 - 67 , February 2014 65
CASE REPORTS

Preseptal Transconjunctival Approach in Orbital Rim

Fracture

Shaifulizan Ab. Rahman1), Mohammad Khursheed Alam2)

ABSTRACT

Introduction: Preseptal transconjunctival approach is one of the alternative approaches to the inferior orbital rim and floor.
The main unwanted complications of surgical approaches dealing with orbital rim and floor fracture are eyelid malposition
(ectropion or entropion) and post unfavorable surgical scar. Concerning these problems the preseptal transconjunctival
approach was used in treating the fracture in this case.
Materials and methods: Patients with facial fracture, including le fort II, zygoma and isolated inferior orbital rim had under-
gone internal reduction and fixation with plating under general anesthesia. Patient required plating to the orbital rim. The pre-
septal transconjunctival approach was used in this case combined with lateral canthotomy.
Results: The case presented with neither ectropion nor post-surgical scar. There were no problems of instrumentation and
every step was accomplished efficiently.
Conclusion: This approach provides adequate surgical field for orbital floor and inferomedial part of the orbital rim.
However it requires additional lateral canthotomy for the lateral part of the orbital rim and wall.

KEY WORDS
preseptal transconjunctival approach, orbital rim, ectropion, lateral canthotomy

INTRODUCTION The capsulopalpebral fascia, which extends from the inferior rec-
tus to the tarsus, is the main retractor of the lower eyelid. The orbital
septum fuses inferiorly with the periosteum of the inferior orbital rim
Maxillofacial trauma refers to any injury to the face or jaw at the arcus marginalis and superiorly with the lower eyelid retractors
caused by physical force. Maxillofacial injury occurs in approximate- beginning approximately 5 mm inferior to the inferior tarsal border.
ly five to 33 per cent of patients experiencing severe trauma (Pohchi
et al., 2012). Access to the inferior orbital margin, which can be 2) Lateral canthal (Gioia et al., 1987)
extended, if required, to the orbital floor, may be gained by following Arising from the tendinous insertions of the pretarsal orbicularis
approaches: 1. Transconjunctival, 2. Infra orbital: a. Subciliary, b. oculi muscles and ligametous attachments of the tarsal plates, the lateral
Subpalpebral. Recent success of miniplates has placed a greater canthal tendon attaches to a thickening of periosteum at the lateral
emphasis on open reduction of zygomatic fractures and has obligated orbitaltubercle, located 2 mm inside the orbital rim. The preseptal orbic-
surgeons to search for incisions that provide adequate access with ularis oculi muscles are attached laterally to the periosteum of the zygo-
esthetic results. The transconjunctival incision fulfills this require- matic bone by a submuscular fascia and make up the lateral palpebral
ment for patients with fractures of the orbital rim and floor. Through raphe, which provides additional to the lower eyelids. In addition, to
a single incision with lateral extention, the lateral rim and floor can keep the eyelids against the globe, the lateral canthal tendon provides lat-
be repaired (Waite and Carr, 1991). Later it was developed for the eral movement of the canthal angle during abduction of the globe.
treatment of fractures and for the correction of congenital malforma-
tions (Rowe and William, 1994). Subsequent reports demonstrate the
efficacy of this approach not only for lower eyelid blepharoplasty but Report of case
also for repair of orbital fractures. There are two different routes for A 19 year old Malay male, a case of alleged road traffic accident
the transconjunctival approach: retroseptal and preseptal. Both of was referred to Oral & Maxillofacial Department. With sustained loss
these approaches have been described combined with detachment of of consciousness, he suffered from epistaxis and facial injuries.
the lateral canthus for wider exposure of the inferior orbital rim and Through the history he was a motorcyclist, skidded after avoiding a
floor. Recent authors have found that whatever routes of transcon- pedestrian crossing the road. On arrival at the casualty, he was orien-
junctival approach, both provide less complication to the lower eyelid tated and alert with full Glasgow Coma Skill (GCS). Vital sign were
compared to transcutaneous approach (Appling et al., 1993). stable, however noted to have mild fever. He denied any previous
medical illness and drug allergic. Despite of stable general condition,
Surgical anatomy of the eyelids he had tenderness over his fourth finger of left hand, which later
diagnosed as fracture of distal phalang of left fourth finger.
There are two important anatomical structures in performing the Extra oral examination revealed left upper eyelid ptosis with lat-
transconjunctival lateral canthotomy incision: eral part was avulsion. The left eye noted to have circumorbital
haematoma, subconjunctival ecchymosis and enophthalmus. The left
1) Lower eyelid (Hawes and Dortzbach, 1982)
Received on September 25, 2012 and accepted on December 3, 2012
1) School of Dental Sciences, Universiti Sains Malaysia
16150, Kubang Kerian, Kelantan, Malaysia
2) Orthodontic Unit, Universiti Sains Malaysia
16150, Kubang Kerian, Kelantan, Malaysia
Correspondence to: Shaifulizan Ab. Rahman
(e-mail: shaifulrahman@lycos.com)

C 2014 Japan International Cultural Exchange Foundation

& Japan Health Sciences University
66 Rahman S. A. et al.

Tarsal Plate

Conjunctiva

Orbital Septum

Orbicularis Oculi

Periosteum
Incision
Line
Figure 2. Pre and post operative picture of the patient

Figure 1. Surgical anatomy diagram adopted from Rowe &

William, 1994

Figure 3. Imaging (OMV radiograph and CT scan) showing the

fracture site

Figure 4. Post operative OMV of the patient

(a) (b)
Figure 5. showing the incision over the conjunctiva (a) and clear
operative field with no fat interfering (b).

zygoma region was tender to palpation. The patient also noted to

have outward projection of zygomatic arch resulted in asymmetrical
of the face with increase width of left face laterally. However the
visual acuity and eye reflex are intact with no diplopia. Intra oral Figure 6. lateral cantotomy
examination revealed limited mouth opening with derangement of
occlusion, probably because of left side posterior gagging. The left
side maxilla was mobile with split in the midline of palate. The upper
occlusion level was lower on the left side however the airway was
fixation with plating was discussed together with patientÅfs parent.
not affected. The patient was in pain, after the insertion of IV access
Ach bars were placed to the patient prior the operation.
tramadol 50 mg together with cefuroxime 750 mg was given.
The radiographic picture of occipitomental view of 0 and 30
degree revealed comminuted fracture of the inferior orbital rim, Operative procedure
zygomatic arch and anterior maxillary wall. Further investigation
Standard toweling was done with green line after povidone swab.
with CT scan was conducted to assess the orbit, however no evidence
After the elevation of the left zygoma through the temporal incision
of bony fragment within the optic canal and extra ocular muscle
and identification of frontozygomatic suture fracture site through the
entrapment. The other laboratory results of the patient were favor.
lateral eyebrow incision, plan was made to expose the orbital rim
Diagnosis of unilateral Le Fort II with comminuted zygomatic frac-
through transconjunctival approach. A forced duction test was per-
ture was made. The treatment planning of open reduction and internal
 Preseptal Transconjunctival Approach in Orbital Rim Fracture 67

Table 1. Types of Complications encountered by Westfall, offers a simple alternative to the transcutaneous approach. In the pre-
1991; Mullins, 1997 sent case, it was found that surgical access to fracture sites was ade-
quate and manipulation of the bony fragments was not restricted.
Types of complications Westfall CT et al Mullins JB et al However, care must be taken out for not to injure the thin orbital sep-
(1200 cases)- 1991 (400 cases)-1997 tum, eyeball as well as the eyelid. (Westfall et al, 1991) in the review
Vertical eyelid laceration/ 2 2
of 1200 cases of transconjuctival approach over the period of 8 years,
have encountered several complications such as cicatricial entropion,
avulsion lower eyelid retraction, canthal dehiscence, lower eyelid avulsion,
Horizontal laceration/ 2 - canalicular laceration, buttonhole laceration of the lower eyelid, con-
buttonhole
junctiva chemosis, and lacrimal sac laceration.
Many authors (Wray et al, 1977; Holtmann et al, 1981; Apling
Canthal dehiscence 1 - WD et al, 1993; Baumann and Ewers, 2001) believe that the transcon-
Entropion 1 1 juctival approach with lateral canthotomy is superior to the transcuta-
neous, particularly subciliary approach because it provides excellent
Ectropion 1 1 exposure with a lower incidence of eyelid retraction and ectropion.
Hematoma 1 1 Transconjunctival approach has two routes of access to the orbital rim
which are pre and postseptal. In the present case, the preseptal tech-
Conjunctival chemosis 1 1 nique was used as it was advocated that the connection between the
Lacrimal sac laceration 1 1 septum and the inferior palpebrum plays the most important role in the
inferior palpebra position. However (Manganello-Souza and Freitas
Conjunctiva granuloma - 8 RR, 1997) found that the complications from both routes seem to have
no significant difference. On our little experience, the preseptal tech-
nique provided clear surgical field. However through the years with the
Table 2. Comparative studies of various incisions development of the skill and experience the complications from this
technique can be reduced, as presented by (Baumann & Ewers R,
Authors Eyelid incision Results
2001) where overall complication rate was only 2% (1 case of tarsal
(incidence of ectropion) plate laceration and 1 case of temporary entropion). Whatever type of
Wray et al.,1997 Subciliary skin flap 19/45 transconjunctival approach they seem to have minimal complications
and obviously with no incision is made on the skin, the scarring is not
Transconjunctival 0/45
the worry, nevertheless the complication is found to be temporary.
retroseptal Furthermore, the complications which arise successfully treated by
Holtmann et al., 1981 Eyelid crease 1/36 many authors. However there are a few contraindications associated
with this technique such as monocular eye functioning patient, acute or
Orbital rim 0/37
chronic conjunctival disease, anophthalmic socket with ocular prosrhe-
Appling et al.,1993 Subciliary 3/25 sis and a previous scleral buckle procedure for retinal detachment
skin-muscle flap (Appling, 1993). Although through the discussion this technique is
Transconjunctival 0/33
found superior and popular than other transcutaneous approach, how-
ever the latter technique should not be neglected as the former tech-
preseptal nique require a thorough anatomical knowledge, skill and experience.
Baumann, 2001 Transconjunctival 2/99
preseptal
CONCLUSION

This approach provides adequate surgical field for orbital floor and
formed then the 5-0 vicryl suture was placed into the tarsus of lower inferomedial part of the orbital rim. However it requires additional lat-
eyelid margin. Another suture of 4-0 silk was placed perconjunctival- eral canthotomy for the lateral part of the orbital rim and wall.
ly to the inferior rectus muscle elevating upward and inward the eye-
ball. The 2% lignocaine with 1:80000, adrenaline was infiltrated to
the incision site under the conjunctival. REFERENCES
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