Retroseptal Transconjunctival Approach to Orbital Floor Blowout Fracture

Video Type: CVideo
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Author: Jose Marchena
Published:
Specialties: Craniofacial and Pediatric Plastic Surgery, Facial Plastic Surgery, Head and Neck Surgery, Ophthalmology, Oral Maxillofacial, Otolaryngology, Reconstructive
Schools: Ben Taub Hospital, Harris Health System, The University of Texas Health Science Center at Houston
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Basic Info

The transconjunctival approach was first described by Bourquet in 1924 and then modified by Tessier in 1973 for exposure of the orbital floor and maxilla for the treatment of facial trauma.

This approach can be carried out either in a preseptal plane by separating the orbital septum from within the eyelid (preseptal approach) or posterior to the septum and eyelid (retroseptal approach) by making an incision through the bulbar conjunctiva directly above the orbital rim.

The main advantage of the retroseptal approach is that it does not involve dissection and disruption of the eyelid itself, therefore, reducing the incidence of post-operative lid laxity and position abnormalities.

This video will show a retroseptal approach to an orbital floor blowout fracture. A lateral inferior cantholysis is performed to facilitate eversion and retraction of the lower eyelid.

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Procedure

Retroseptal Transconjunctival Approach to Orbital Floor Blowout Fracture

Indications

(1) Entrapment of herniated orbital contents causing restriction of ocular movement or occulocardiac reflex
(2) Defects that are large and/or posterior to the equator of the globe and cause globe position abnormalities leading to
diplopia or asymmetry of the palpebral fissures

Contraindications

(1) Coexisting unstable comminuted periorbital fractures requiring more extensive access and reconstruction of the orbital frame
(2) Lack of vision in contralateral eye
(3) Presence of a subcilary laceration
(4) Certain acute penetrating globe injuries

Instrumentation

Setup

Standard setup for midface or oculoplastic procedure

Preoperative Workup

(1) Maxillofacial CAT scan
(2) Complete eye exam, including:
a. Vision
b. Pupillary reactivity
c. Intra-ocular pressure
d. Funduscopic examination
e. Eye movement
f. Visual fields
(3) Forced duction test if there is movementclinical restriction of eye movement

Anatomy and Landmarks

(1) Tarsal plate of the lower eyelid
(2) Lateral canthal tendon
(3) Puncta and caruncule
(4) Orbital rim and infraorbital nerve and foramen
(5) Inferior orbital fissure
(6) Insertion of the inferior oblique muscle
(7) Lacrimal sac
(8) Anterior ethmoidal artery

Advantages/Disadvantages

Advantages:
(1) Direct approach to the orbital rim and floor
(2) Easily extended medially into a retrocaruncular approach to access the medial orbital wall
(3) The retroseptal approach does not violate the integrity of the lid which reduces the risk of abnormal lid laxity and lid position
(4) Lack of external scars

Disadvantages:
(1) Herniation of orbital fat into the surgical field
(2) May provide inadequate access to large floor and medial wall fractures or when extensive reconstruction of the orbital frame is necessary

Complications/Risks

(1) Unrecognized detachment or transection of the inferior oblique muscle
(2) Injury to the lacrimal sac during medial extension
(3) Failure to properly execute and repair the inferior cantholysis leading to lid malposition or deformity of the palpebral fissure
(4) Improper placement of the orbital floor implant
(5) Bleeding which may lead to retrobulbar hematoma formation
(6) Injury to cornea/sclera
(7) Blindness

Disclosure of Conflicts

None

Acknowledgements

Harris Health System Corporate Communications
Harris Health Media Relations
The University of Texas Health Science Center at Houston

References

Tessier, P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg. 1973; 1: 3

Uemura T, Watanabe H, Masumoto K, et al. Transconjunctival Approach for Zygomatic Fracture: A Single Surgeon’s Experience of More Than 20 Years. Plastic and Reconstructive Surgery Global Open. 2016;4(6):e757. doi:10.1097/GOX.0000000000000748.

Cornelius, C; Gellrich, N; Hillerup, S; Kusumoto, K; Schubert, W; Fusetti, S. (12- 2009) Transconjunctival lower-eyelid approaches. Retrieved from www.aofoundation.org/

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