Is There Risk Of Damaging The Optic Nerve in Vertical Orbital Dystopia Surgery?

Q: Dr. Eppley, I am writing to you regarding an issue that has troubled me for a very long time; I have a very pronounced skeletal facial asymmetry, visible mainly around the eyes, eyebrows, and cheekbones (zygomatic bones), but also affecting the ears and jaw. In fact, almost all the bony structures show a vertical and volumetric discrepancy between the two sides (confirmed by a 3D CT scan).

I have read almost all the articles on your blog regarding the procedure you perform for vertical orbital dystopia (correcting up to 5mm of vertical difference using an implant).

I have a few questions regarding this:

– In your opinion, what is the extent of the discrepancy between my two orbits?

– Is there a risk of double or blurred vision, or of damaging the optic nerve?

– Since the asymmetry isn’t limited to the eyes, what else do you think should be done to “improve” my appearance and reduce the asymmetry?

– My previous surgeon proposed a zygomatic osteotomy and an orbital implant of a few millimeters, but nothing to raise the eyelids or eyebrows; what is your take on that?

A: In answer to your vertical orbital, dystopia questions;

1) I would estimate that your vertical orbital dystopia is at least 5 mm difference if not more.

2) Anytime you dissect and elevate the soft tissues off of the orbital floor there is always the risk of some potential visual disturbances. In my experience, it most likely could be some temporary double vision. But the greater the orbital floor implant, the more likely that is to occur.

3) Vertical orbital dystopia is not isolated to just the eyeball itself. All of the surrounding bones are lower particularly that of the infraorbital rim and cheek whose correction is part of the custom orbital – malar implant.  This is why just sticking an implant on the orbital floor is an in adequate/incomplete approach to its treatment.

4) One of the key concepts to grasp in the surgical treatment of vertical orbital dystopia is that it is not just a bone problem, everything is lower that surrounds the eyeball, including the eyelids, and very often the eyebrow. If you simply raise up the eye even a few millimeters and don’t adjust the eyelids around them you were going to increase lower lid scleral show and create ptosis of the upper eyelid… problems which you currently do not have. The comprehensive surgical treatment of vertical orbital dystopia requires a combination bony and soft tissue approach.

Dr Barry Eppley

Plastic Surgeon