Treatment Options in Vertical Orbital Dystopia
Q: Dr. Eppley, I was looking through your patient pictures and found a 43-year old male who had surgery to correct his vertical dystopia. He opted for cheek augmentation with an implant, but even in the after-picture I can see his vertical dystopia is still there, although very much improved. The inner corner of the affected eye (medial canthus) is slightly lower than the opposite side. This is also the case with me. I have slight vertical dystopia (left eye higher than right with the medial canthus being lower on right eye as well) but is there any disadvantages/advantages by going for orbital box osteotomy rather than cheek augmentation? I know it’s a highly delicate surgery with certain risks but I imagine the result being better. Do you have any experience in this type of surgery?
A: The key in treating a vertical orbital dystopia (VOD), in which there is no perfect result obtainable, is to get appearance improvement WITHOUT causing any other aesthetic issues. This is why in smaller or more aesthetic VOD patients (6mms or less of horizontal pupillary discrepancy, building up the bone deficiencies and adjusting the soft tissues around it is the aesheticaily safer approach.
Orbital box osteotomies are reserved for more severe cases of VOD where the aesthetic tradeoffs to do so (risks of adverse scalp scar, bony irregularities, palpable hardware, lower eyelid retraction, numbness and even frontal nerve weakness) may be worth it for the degree of bony change.
But the most assured way to trade off into numerous new aesthetic problems is to apply a big operation( orbital box osteotomy) for a much smaller problem. (vertical orbital dystopia < 6mms)
Dr. Barry Eppley