Your Questions

Q: Dr. Eppley, I am interested in orbital dystopia corrective surgery. I have vertical orbital dystopia as a result of craniofacial trauma when I was a child. There were no orbital bone fractures that I know of.The severity of my condition seems to be very similar to the case study posted on your web page. In your case study, you’ve seem to have done a orbital approach alone. However, research on the web has led me to believe that surgical correction for this deformity can be very complex as stated by these 2 doctors where one describes a very invasive intracranial approach. So my question is would you be able to perform the correction using an orbital approach alone. Attached is a picture of my eyes. I would guess that the right eye is at least 5mm lower than the left. I would like to know what procedure you would recommend.

A: Vertical orbital dystopia refers to one eye being lower than the other as a result of the shape or size of the orbital box (bones) in which the eyeball resides. A 3D CT scan can precisely determine the bony component of the orbital dystopia by looking at the periorbital bones. Generally in cases of 5mm or less orbital dystopia, this is completely correctable by an intra-orbital approach. This is done by building up the orbital floor and inferior orbital tim. In reading the comments from the other doctors, although well intended, they are not accurate in how smaller amounts of orbital dystopia can be treated. By your picture, you are correct in that the eye is about 5mms lower than the left and could be lifted by the described infraorbital approach. Be aware that as the eye comes up,  however, it will be further buried under the upper eyelid by a similar amount. This means that the upper eyelid will need to be elevated by a ptosis repair, either done at the same time or as a separate surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in yourresults in treating facial asymmetry. I have a pronounced vertical orbital dystopia (I’m not sure if this is the result of plagiocephaly, though I highly suspect it is given the other imbalances in my face). I would like to know my options for treating this.  I have attached pictures for your review.

A: Thank you for sending your pictures. I can clearly see that you have a mild to moderate case of right orbital dystopia. (5mms of horizontal pupillary discrepancy) The entire orbital box is situated lower than that of the left side, affecting every surrounding structure from a lower eyebrow/brow bone down to an orbital rim-malar deficiency.

There are two fundamental strategies for dealing with these orbital discrepancies. The first is a complete orbital box change. Dealing with changing the fundamental problem through an orbital box osteotomy is too extreme is my opinion for the magnitude of your dystopia.  Therefore, I would recommend an alternative approach of multiple camouflage procedures. At the minimum, I would use an orbital floor-rim implant with hydroxyapatite cement which could be extended out on to the lower cheek bone. One could also use other types of implants such as Medpor or Gore-Tex which can be custom carved to fit during surgery. Ideally I would get a skull model fabricated from a 3-D CT scan to make an exact implant that reconstructs the bone levels to the opposite side. The lower eyelid would then be resuspended/tightened  which would move the lower lid level up, particulalry the outer half. One could also treat the upper orbit through either an endoscopic browlift approach with brow bone modification  through an upper eyelid approach. You can see with this camouflage approach it is a function of how far you want to go in treating all components of your orbital dystopia.

Dr. Barry Eppley

Indianapolis, Indiana