Can I Get Orbital Box Osteotomies For A 2mm Reduction in Interpupillary Distance?

Q: Dr. Eppley,I am seeking a surgical evaluation regarding the feasibility of a Modified Subcranial Orbital Box Osteotomy specifically for the purposes of altering interpupillary distance (IPD) and vertical orbital positioning. My goal is a physical reduction of the IPD by 1mm to 2mm (bringing the pupils closer together) and a simultaneous vertical shift of the pupils by 0.5mm to 1mm. Given that I am strictly interested in a subcranial approach that avoids a frontal craniotomy and a coronal scalp incision, can a Modified Medial Orbital Wall Osteotomy be effectively utilized for narrowing the interorbital space rather than widening it? Specifically, how is the internal nasal and ethmoid anatomy managed to allow for a 1-2mm inward bone shift, and what are the primary risks to the nasolacrimal (tear) ducts and the origin points of the extraocular muscles at this specific magnitude of movement? Furthermore, is a vertical pupillary adjustment of 0.5-1mm surgically stable when performed alongside a medial shift, and does this combination of multi-vector bone movement significantly increase the risk of permanent diplopia (double vision) during the 6-12 month healing and settling phase?

A: For the very modest changes that you are seeking an orbital box osteotomy, by comparison, is an operation of magnitude that seems out of proportion to the goals. Particularly when you consider the potential risk as you have described. I might also add that I wish surgery was as precise as a millimeter  or two of controlled movements, particularly vertically, but the reality is it is not as precise as the movements you desire.

The point being is it is always important to match the operation to the size of the problem. Doing a big operation for a small defined change is disproportionate and the risk:benefit ratio is altered accordingly.

Dr. Barry Eppley

Plastic Surgeon