My left eye had large orbital floor fracture during a vehicle accident 1 year ago, and was repaired with incision through the inside of the left lower eyelid. Now, I hate to notice the big difference in the shape of my eyes. Is this due to the incision (or scar) inside the eyelid? Will an eyelid surgery fix or minimize the difference?
Would Eyelid Surgery Correct Asymmetry After Orbital Fracture Repair?
Doctor Answers 6
Have an oculoplastic surgeon evaluate
According to the pictures that are present and the question, the left eye now becomes less dominant and has enophthalmus. The left orbit has sunken inward and downward, and the aperture of the eye is smaller compared to the opposite side. This is due to the actual injury itself. It is very difficult to fix and repair this problem, but an oculoplastic surgeon would be the best person for this type of problem.
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Eye asymmetry after orbital floor fracture repair.
You typically get the orbital floor repaired if there is entrapment of one of your eye muscles, that if left untreated, would prevent you from looking straight up without double-vision. You may also have had the fracture repaired because the eye-ball may have fallen down into the maxillary sinus, just below the orbital floor.
In any event, I see the asymmetry of your eyes. I can't tell if your left eye is still a bit lower than the right, or if your left eye is a bit smaller.
You should try to find a good frontal pre-injury photo. You should then consult a board-certified ophthalmologist, or oculoplastic surgeon to discuss your options.
Good luck, and best regards.
Orbital floor fracture
First, some asymmetry between the eyes is normal. When an orbital floor fracture occurs, it may be isolated only to the floor but may involve the zygoma body itself which can also contribute to an increased volume of the bony orbit. If you had the floor repaired with some permanent product or bone and only had an isolated orbital floor fracture, than you should have had a reasonable reconstruction of the bony orbital volume. This is provided that you had reasonable symmetry to begin with. To better evaluate you now, you would proabably need a repeat CT scan to assess the difference. I do not know is an "eyelid surgery" would benefit you at all if it is a bony issue.
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It looks like a very good result from your injury
The injury you describe would cause a major asymmetry of the eye shape without the excellent surgery you must have had. When the orbital floor fractures, the eyeball may sink back and down into the socket. Yours look pretty good now, but you could ask your surgeon about adding a little more support to the floor to enhance the symmetry. However, that's another big operation and there may still be some asymmetry.
You are enophthalmic on the left side
One of the major goals of orbital fracture repair is to restore the bony confines that surround the eye and the fat that supports it. When this is not done or not adequately done the orbit is left expanded by the fractures. The permits the orbital contents to occupy a larger volume and consequently the eye on the affected side looks smaller because it sits deeper in the orbit than the uninjury side. This decreased projection of the surface of the eye is called enophthalmos. It is generally thought that it is difficult to discern a difference that is 2 mm or less. In looking at your photos, I am going to guess that that you are 3 or 4 mm enophthalmic compared to the right side. Eyelid surgery is not the solution to this.
The first step in dealing with this issue to determine how effective the initial orbital fracture repair was in restoring orbital volume. At CT scan shows bone detail much better that an MRI and is the study of choice in this setting. It may make sense to further reconstruct the walls of the orbit. As an alternative, a sled of inert material can be placed on the floor of the orbit to help elevate the eye and push is forward.
I generally prefer ePTFE material for this purpose. This type of work can be done by a variety of specialties: oculoplastics, facial plastics, and general plastic surgery. However, being in the business of fixing other surgeon's work, I think that you will have the highest likelihood of success working with an aesthetically attuned oculoplastic surgeon. However, you may find yourself traveling to find the right surgeon even though you are in Boston which is blessed with fantastic medical resources. Having said that, I would recommend having a consultation with Peter Rubin, M.D. at the Mass Eye and Ear Infirmary.
Eyelid surgery after orbital fracture
Orbital floor fractures can lead to a variety of post-traumatic issues. From your photos it appears that you have lost volume in the left orbit which has resulted in a slightly sunken-in look to the left eye. Unfortunately, a consequence of orbital floor fractures is that the soft tissues surrounding the eyeball can herniate out of the orbit and into the adjacent sinus cavity. This can lead to loss of protrusion of the eye, or , in severe cases double vision due to entrapment of the small muscles of the eye. The repair you had helped to ameliorate this problem and luckily your vision has not been affected. Further aesthetic improvement would not be achieved with eyelid surgery, as the problem is due to an internal volume deficiency. To determine whether further reconstructive procedures are indicated, consultation with a plastic surgeon who specializes in craniofacial or maxillofacial surgery would be worthwhile.
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