CLINI AL ARTICLE

J Oral Maxillofac Surg

51:480-494,1993

Ophthalmic Complications Associated With

Orthognathic Surgery
DENNIS T. LANIGAN, DMD, MD,* KEN ROMANCHUK, MD, FRCS(C),t
AND CHARLES K. OLSON, DMD:f:

Ophthalmic complications are rare following maxillary osteotomies. Potential

complications include a decrease in visual acuity, extraocular muscle dysfunction,
neuroparalytic keratitis, and nasolacrimal problems involving both an increase or
a decrease in tearing. Ophthalmic injuries appear to be primarily mediated through
indirect injuries to neurovascular structures occurring from traction, compression,
or contrecoup injuries from forces transmitted during the pterygomaxillary dys-
junction using an osteotome or from fractures extending to the base of the skull
or orbit associated with the pterygomaxillary dysjunction or the maxillary down-
fracture. A review of the literature of previous ophthalmic complications as well
as eight new cases are reported. The possible etiologic basis for these injuries
is discussed in detail as well as treatment possibilities when appropriate.

Although a great deal of information is available in any cases of nasolacrimal injury or obstruction follow-
the literature regarding the ophthalmic complications ing inferior turbinectomy and Le Fort I maxillary su-
of maxillofacial trauma, little has been written regard- perior repositioning. Little et al? have discussed the
ing ophthalmic complications associated with orthog- possibility of transient epiphora following Le Fort I
nathic surgery."!" Tomasetti et all reported a lack of osteotomies due to surgical edema creating a functional
tearing in a 24-year-old woman following a Le Fort I obstruction ofHasner's valve of the distal lacrimal duct
osteotomy to correct maxillary retrusion. One month apparatus. The low incidence of permanent epiphora
after surgery, it was noted that the patient was unable is influenced by the angulation of the bony nasolacri-
to tear from the left eye. The ophthalmologic consultant mal canal and the ability of the distal lacrimal complex
thought there had been damage to the parasympathetic to undergo deformation of the soft tissue within the
fibers to the lacrimal gland. Limited tearing returned bony framework while still maintaining its patency.
by 5 months postoperatively, and there was normal The meatal opening of the nasolacrimal duct in the
function of the lacrimal gland by the eighth postop- roof of the inferior concha of the nose also affords ad-
erative month. ditional protection against permanent epiphora.
Demas and Sotercanos' discussed the possibility of You et al,!" in an experimental study, looked at the
injury to the nasolacrimal duct system following Le anatomy of the nasolacrimal canal with reference to
Fort I osteotomies with superior repositioning as well high mid facial osteotomies. The inferior orifices of the
as the risk to the canaliculi and lacrimal sac during the nasolacrimal canal were found to be superior to the
naso-orbital osteotomies associated with Le Fort II or simulated high Le Fort I osteotomy cuts in all their
Le Fort III osteotomies. They did not, however, report specimens. Le Fort I osteotomies immediately inferior
to the infraorbital foramen are thus relatively safe pro-
cedures for the nasolacrimal apparatus. In their spec-
.. Professor and Head, Division ofOral and Maxillofacial Surgery, imens, the course of the nasolacrimal canal was found
University of Saskatchewan, Saskatoon, Canada. to be positioned within a 5.5-mm wide zone that ex-
t Associate Professor, Department of Ophthalmology, University tended between the lacrimal sac and the anterior at-
of Saskatchewan, Saskatoon, Canada.
t In private practice, Portsmouth VA. tachment of the inferior turbinate on the anterior wall
Address correspondence and reprint requests to Dr Lanigan: Di- of the maxilla. Osteotomy cuts for modified Le Fort II
vision of Oral and Maxillofacial Surgery, College of Dentistry, Uni- or Le Fort III osteotomies should thus not be made in
versity of Saskatchewan, Saskatoon, SK, Canada S7N OWO.
this area. Freihofer and Brouns!' reported an impair-
© 1993 American Association of Oral and Maxillofacial Surgeons ment in the function of the lacrimal system in 4% of
0278-2391/93/5105-0003$3.00/0 all their high midface procedures. Keller and Sather'?

480
 LANIGAN, ROMANCHUK, AND OLSON 481

reported one patient who experienced nasolacrimal a normal-appearing disc with positive venous pulsa-
duct dysfunction in their series of 54 patients who had tions. The ophthalmologist who saw her in consultation
undergone a quadrangular Le Fort I osteotomy. Bilat- thought the findings were consistent with a diagnosis
eral, mild, sporadic, increased tearing was noted post- of Adie's pupil. It was uncertain whether this problem
operatively, which resolved spontaneously within the was a genuine complication of her orthognathic surgery
first year. or purely a coincidence. By 18 months postoperatively,
Watts2 was the first to report extraocular muscle the right pupil had almost totally recovered in both
dysfunction following a Le Fort I osteotomy. An 18- size and function, with only limited reduction in ac-
year-old woman with maxillary retrusion was treated commodation.
with a Le Fort I osteotomy with advancement. On the
first day postoperatively, the patient complained of Report of Cases
diplopia, and a right abducent nerve palsy with a lack
offunction ofthe right lateral rectus muscle was noted.
After 7 weeks, the abducent nerve palsy had completely In 1986, a questionnaire was sent to North American oral
and maxillofacial surgeons requesting information about
recovered. Carr and Gilbert' reported a case of an iso- major vascular complications associated with orthognathic
lated partial oculomotor nerve palsy following a Le surgery. Included in the almost 800 replies received were two
Fort I "Wake't-type osteotomy with advancement to cases dealing with ophthalmic complications. Since that time,
correct a midfacial retrusion secondary to a bilateral information has been obtained on an additional six cases.
cleft lip and palate deformity. Early on the first post-
operative day, the patient developed a right-sided ptosis Case 1
and divergent stabismus with diplopia. By the fourth
day after surgery, the ptosis had improved, as had the A 33-year-old woman was admitted for orthognathic sur-
gical correction of her malocclusion. She had a long-standing
range of extraocular muscle movements. By 8 weeks
history of facial pain and temporomandibular joint dysfunc-
postoperatively, there was full restoration ofeye move- tion, which was primarily muscular in origin, but that severely
ment and complete resolution of the diplopia. limited her masticatory function. Two years previously she
Reiner and Willoughby4 reported a case of a right had undergone a multiple segment Le Fort I osteotomy, bi-
abducent nerve palsy following a Le Fort I maxillary lateral sagittal mandibular ramus osteotomies, a genioplasty,
and a bone graft from the iliac crest to correct an open-bite
osteotomy with advancement and superior reposition-
malocclusion and a complex facial asymmetry. During this
ing in a 27-year-old woman with maxillary retrusion surgery, the posterior maxilla was impacted and the maxilla
and mandibular prognathism. The patient complained was rotated medially. Corticocancellous bone grafts were
of diplopia on the first day postoperatively, and the placed along the entire lateral aspect of the maxilla and in
right eye was unable to move into right lateral gaze. the pterygomaxillary regions. The surgery was uneventful and
initially the patient had some relief of her symptoms. The
Complete recovery occurred within 5 months post-
patient, however, experienced a recurrence of her severe
operatively. Uttley et al5 reported one patient who de- masticatory dysfunction owing to persistent muscle spasms
veloped a transient unilateral abducent nerve palsy fol- and severe incapacitating pain in the left temporomandibular
lowing the use of a Le Fort I osteotomy to approach a joint region, which did not respond to conservative treatment.
midline skull base tumor. This palsy resolved com- Some relapse of her malocclusion was noted. She retained
some facial asymmetry, with noticeable canting of her occlusal
pletely within 3 days. 0'Ryan6 mentions one additional
plane. The patient was reoperated with a Le Fort I osteotomy
case ofa transient neuropraxia of the VI nerve following with intrusion on the left-hand side, drop-down on the right
a Le Fort I osteotomy but gives no details regarding with interpositional bank bone grafting, and bilateral sagittal
this complication. ramus osteotomies of the mandible. The bony architecture
Four cases of carotid-cavernous sinus fistulae, with and consistency of the bone in the posterior maxillary regions
was thought to be significantly different from what the at-
resulting ophthalmic complications, have been re-
tending surgeon had noted at the initial surgery. A thin curved
ported following orthognathic surgery.P:" As these osteotome was used to achieve the pterygomaxillary dys-
cases have been reviewed in detail previously.v-" they junction. The dysjunction itself appeared to be satisfactory
are not discussed in this article. Sirikumora and Sugar" and the maxillary downfracture was accomplished easily with
reported a case of a right-sided tonic pupil in isolation minimal pressure. A minor area of bone that had not been
(Adie's pupil) following a Le Fort I osteotomy with separated about the posterior medial wall of the right max-
illary sinus was freed with minimal effort and force. The re-
advancement and drop-down in a 24-year-old woman mainder of the surgery was completed in a conventional
with a maxillary retrusion and vertical deficiency. On manner.
the first postoperative morning, the patient was noted Initially after surgery, the patient did not complain of any
to have a markedly dilated right pupil with no direct visual problems, nor did the nurses note any pupillary ab-
, or consensual light reflex. There was no proptosis and, normalities on routine postoperative status checks. The
morning after surgery, however, the patient complained of
although the patient complained of blurred vision on no light perception vision in the right eye, and she was noted
extreme left gaze, there was no diplopia or impairment to have a fixed, dilated right pupil. A consensual pupillary
of extraocular muscle movement. Fundoscopy revealed response was noted in the right eye, although this was di-
482 OPHTHALMIC COMPLICATIONS: ORTHOGNATHIC SURGERY

minished in amplitude. The right eye was approximately 20

diopters exotropic and 10 diopters hypotropic. Fundoscopic
examination of the right eye revealed a normal-appearing
disc and spontaneous venous pulsations. On general digital
pressure, arterial pulsations were noted in the disc of the
right eye. Vision, fundoscopic examination, and confronta-
tion fields were grossly normal in the left eye. Extraocular
movements were full in all directions with the exception of
adduction of the right eye, which was incomplete but up to
almost 75% of the normal range. She had obvious ptosis of
the right eyelid and the margin ofthe right upper lid appeared
swollen and red. The clinical impression was of a complete
right optic nerve dysfunction and a partial right oculomotor
(III) nerve palsy.
A computed tomographic (CT) scan of the right orbit and
head was done immediately to rule out pressure in the optic
canal. The CT scans revealed multiple facial and basilar skull
fractures. These fractures included the roof of the right max-
illary sinus, the posterior wall of the right maxillary sinus,
and the pterygoid plates. There appeared to be a fracture
through the medial wall of the right orbit posteriorly. There
were fractures ofthe sphenoid bone on the right side extending
through the floor of the middle cranial fossa (Fig IA). A frac-
ture through the lesser wing of the right sphenoid bone ex-
tended just lateral to the optic foramen. A small bony frag-
ment, probably from the fracture of the roof of the right
maxillary sinus, was in close proximity to, or in contact with,
the right optic nerve in the region of the optic foramen near
the superior orbital fissure (Fig IB). There was diffuse en-
largement of the right optic nerve, probably related to edema,
primarily distal to the optic foramen and proximal to its ar-
rival at the optic disc. The optic nerve appeared intact and
unaffected proximal to the optic foramen. The medial rectus
muscle appeared swollen. No hematomas were noted in the
orbit.
Consultations were obtained from several experts in the
fields of neuro-ophthalmology and orbital pathology. Treat-
ment options suggested included high-dose intravenous ste-
roids, as well as the possibility ofsurgical exploration to deroof
the orbit to decompress the optic nerve. The consensus, how-
ever, was for high-dose dexamethasone sodium phosphate
(Decadron, Merck, Sharp, and Dohme, Pointe-Claire, Que-
bec, Canada) therapy, and the patient also preferred to have
no surgical intervention. The patient was advised that al-
though the prognosis for the recovery ofthe oculomotor nerve
function was good, the prognosis for recovery of optic nerve
function was guarded and she would likely remain perma-
nently blind in the right eye. The patient was initially treated
with Decadron, 40 mg IV every 6 hours for five doses, and
FIGURE I. A. The short arrow points to a fracture of the right
the dose was then lowered to 10 mg IV every 6 hours. The
lesserwingof the sphenoidextendingthroughthe floorof the middle
patient's third nerve palsy resolved quickly. By the time of
cranial fossa. The long arrow points toward a fracture of the left
her discharge, 5 days postoperatively, there was essentially
pterygoid plate. B. This CT scan cut demonstratesa fracture at the
complete resolution of the ptosis and the limitation of move-
back of the rightorbit. The arrow points towarda small fragment of
ment ofthe right medial rectus muscle. The pupil ofthe right
bone impingingon the optic nerve.
eye remained a bit more dilated than the left. The patient
did not regain any vision in the right eye and the blindness
has persisted.
The surgeon involved in this case thought that the influence and a more robust buttress of bone in this region. The ana-
of previous surgery and healing should be considered in the tomic differences in the pterygomaxillary region, as compared
etiology ofthis complication. A comparison between the ceph- with the first surgery, necessitated the surgeon having to po-
alometric radiograph taken before the first operation and sition the curved osteotome used to achieve the pterygo-
the radiograph prior to the second operation revealed a no- maxillary dysjunction somewhat closer to the base of the
ticeable increase in radiopacity in the posterior maxillary re- skull. These factors may have contributed to the aberrant
gions following the initial surgery. The posterior maxillary fractures that extended to the base of the skull and orbital
impaction and the bone grafting carried out in the pterygo- regions despite an apparent relatively atraumatic and routine
maxillary area were believed to have resulted in partial oblit- pterygomaxillary dysjunction and down fracture being noted
eration of the naturally occurring pterygomaxillary fissure at the time of surgery.
 LANIGAN, RO~IANCIIUK, AND OLSON 483

Case 2 The next morning, arrangements were made for an im-

mediate cr scan and for consultation with a ncuro-ophthal-
A 16-year-old girl with a rnidfacial retrusion was treated mologist. The cr scan was performed with thin sections
with a Le Fort I osteotomy with advancement. Numerous through the maxilla, orbits, optic canals, and the region of
attempts at intubation through the left nostril were unsuc- the sella. The results of the cr scan were basically negative,
cessful, resulting in bleeding, but the patient was subsequently with no evidence of unusual fractures causing any mechanical
intubated easily through the right nostril. The classic Le Fort disturbance around the optic nerve or of hemorrhage into
I osteotomy sequence was then followed, with the ptcrygo- the orbit or optic canal. The ncuro-ophthalmologist noted
maxillary dysjunction being carried out between the maxillary the visual acuity to be normal in the right eye, but there was
tuberosity and pterygoid plates. The maxilla was downfrac- no reaction to illumination of the left eye, and the patient
tured easily. No significant bleeding was encountered at that was completely blind . The pupils both reacted to light shone
time, and both descending palatine arteries were noted to be on the right eye, but there was no reaction to illumination
intact . Infraorbital rim suspension wires, in addition to in- of the left pup il. There was a 4+ left relative afferent pupillary
traosseous wires, were used for stabilization. At the comple- defect. Visual fields were normal in the right eye on con-
tion of the operation, the drapes were removed and the left frontation. Extraocular movements were full and the eyes
eye was noted to be extremely proptotic and tense. An oph- appeared aligned in all positions of gaze. There was a sub-
thalmology consultation was requested immediately, but no conjunctional hemorrhage laterally over the temporal aspect
cr scan was done. The maxilla was redownfractured, and of the sclera of the right globe and slight swelling of the upper
although minor mucosal bleeding was seen in the right an- and lower lids on the right. The examination of the external
trum, no hematoma was noted in the antra, nor did there eyes and anterior segments was otherwise unremarkable.
appear to be significant bleeding from the pterygornaxillary Fundoscopic examination revealed normal optic discs that
. regions. Copious blood was suctioned from the left nasal cav- were sharp and pinkish in color. The vessels,nerve fiber layer,
ity, however, and following this the orbital swelling and pro- and maculae appeared normal. There was no evidence of
ptosis decreased dramatically. vascular occlusion, retinal infarction, or retinal hemorrhage.
At this point, the ophthalmologist examined the eye and The ocular media were clear.
confirmed the diagnosis ofa retrobulbar hemorrhage. As the Based on his clinical exam ination and the cr scan findings,
intraocular pressure in the left eye was increased to 46 mm the neuro-ophthalmologist thought the visual loss in the left
Hg, the ophthalmologist first performed a lateral canthotomy, eye was due to a retrobulbar lesion of the left optic nerve,
including relaxing incisions of the superior and inferior cruxes either of the optic canal or intracranial portion. He was un-
of the lateral canthal ligaments to relieve orbital tension and certain as to the etiology of the condition, although there did
try to prevent central retinal artery occlusion or optic neu- not appear to be a mechanical disturbance in or around the
ropathy. An incision and drainage of the inferior medial re- optic nerve. He recommended the patient be maintained on
gion of the orbit was then performed through the lower lid a short course of oral steroids. By the second day postoper-
and a 0.25·inch Penrose drain placed. The patient was also ati vely, the nurses noted that the pupil of the left eye was not
given 500 mg of acetazolamine (Diamox, Lederle Labora- quite as widely dilated, and by the third day, the left pupil
tories, Markam, Ontario, Canada) and 50 mL ofa 25% man- was beginning to react very sluggishly and minimally to light.
nitol solution intravenously to reduce intraocular pressure The nurses recorded in their notes that the patient seemed
by pharmacologic means. The intraocular pressure after 30 to know when the flashlight was shone in the left eye and
minutes decreased to 34 mm Hg. The patient was sent to the that she appeared to be seeing some shadows briefly with the
surgical intensive care unit (lCU) for observation. In the ICU, left eye when the light was flashed into it. On the fourth day
the ophthalmologist noted very slight blanching of the optic postoperatively, the patient was again seen by the neuro-
nerve on fundoscopic examination, but all the blood vessels ophthalmologist and by another ophthalmologist for a seeond
appeared normal. The ophthalmologist placed the patient on opinion. They thought the left eye had no light perception
timolol maleate opthalmic solution (Merck, Sharp, and vision even with the bright light of the indirect ophthalmo-
Dohme) and pilocarpine in an effort to again reduce intra- scope. A marked left relative afferent pupillary defect was
ocular pressure. The patient's intraocular pressure quickly still present and the left pupil was completely nonreactive to
returned to normal values. She was discharged from hospital direct illumination. The globes appeared normal and there
4 days postoperatively. She has had no long-term problems was no proptosis. The fundi were virtually symmetric and
with visual acuity. identical. Ophthalmodynarnometry revealed no discrepancy
in diastolic pressure measurements in the two eyes. The
ophthalmologists suggested the patient be kept on steroids
Case 3 and ordered 80 mg prednisone daily.
The patient was reviewed by the neuro-opthalmologist 6
A 17-year-old girl with vertical maxillary excess and aper- da ys later. He noted that she now definitely had a pupillary
tognathia was treated by a Le Fort I osteotomy with intrusion reaction to light and the dilation ofthe left pupil had decreased
and a genioplasty. The surgery was carried out without in- markedly. The patient's vision in the left eye had improved
cident. The operation lasted approximately 3 hours and was somewhat and she was able to see hand movements in the
completed shortly after 3 PM. The patient was transferred to inferior portion of her left visual field. On fundoscopic ex-
an intensive care unit for postoperative monitoring. She had amination, there was still no evidence of any retrograde de-
been given 8 mg of Decadron IV preoperatively, another 4 generative changes in the opt ic nerve head or nerve fiber
mg at 8 PM, and was then to continue taking 4 rng three times layer. The patient was reviewed I week later; ie, 17 days
a day during her hospital stay. At 9 PM on the day of surgery, postoperatively. The left pupil reacted to bright light, but the
the patient first complained to the nurses of being unable to patient still had a 3+ Icft relative afferent pupillary defect.
see anything from her left eye. At that time, the left pupil She could see hand movements and count fingers only in the
appeared to react very slightly and slowly to light, constricting inferior portion of her visual field and along the inferior tem-
from 6 to 5 mm, and then back again. The right pupil was poral margin. On fundoscopic examination, there was now
5 mm in size and reacted briskly to light. some early evidence of nerve fiber layer atrophy in the inferior
484 OPHTHALMIC CO:\IPLlCATIONS: ORTHOGNATHIC SURGERY

portion of the nerve, although the optic disc was still normal When reviewed 3 days later, the patient complained of
in appearance. The ophthalmologist began to taper the pred- blurred vision and a burning sensation of the left eye. She
nisone levels at this time. When the patient was seen next, 2 was still found to have a moderate amount ofcentral punctate
weeks later, her visual field in the left eye had expanded erosions in the left cornea but had improved from the last
somewhat and she could now sec over two thirds of the in- appointment. The patient also was noted to have anesthesia
ferior hemifield. Her vision was still limited to counting fingers of her left cornea, likely due to an injury to fibers from the
as her field, as yet, did not extend to fixation. On fundoscopic nasociliary branch of the first division of the trigeminal nerve
examination, there was progression to mild optic atrophy in resulting in ncuroparalytic keratitis. lIer vision at that time,
the left optic disc. There was some nerve fiber layer bundle without correction, had dropped from 20/20 before her or-
defects noted in the arcuate regions, more so inferiorly than thognathic surgery to 20/100 in the left eye; her vision in the
superiorly. right eye remained at 20/20. The patient was told to tape the
When the patient was reviewed 6 weeks later, her exami- left eye elosed at night and to usc copious amounts ofmeth-
nation had not changed significantly. She could sec well ylcellulose lubricant during the day. Three days later, 25 days
enough inferiorly in her left visual field to count fingers at postoperatively, the patient was reexamined by the ophthal-
about 3 to 5 ft. At the tangent screen, she could detect a 10- mologist. He found no moisture in the left eye except for the
mm white object in the inferior portion of her visual field, drops that the patient was using. The vision in the left eye
but she' could not detect any hand movements superiorly. had deteriorated further to 20/200. Marked punctate changes
Dilated fundoscopic examination demonstrated optic atro- of the cornea were again noted centrally. The methylcellulose
phy, with marked attenuation of the nerve fiber layer, more drops were discontinued and the patient was started on a
so inferiorly than superiorly. The findings on fundoscopic preservative-free polyvinyl alcohol ocular lubricant drops
examination were consistent with the degree of visual field (Refresh; Allergan, Markam, Ontario, Canada), every 2 to 3
loss. The patient's visual condition had basically stabilized hours, and petrolatum-mineral oil compound ocular lubri-
at this stage and she was left long term with some visual cant ointment (Lacrilube; Allergan), three to four times during
function in her inferotemporal field in the left eye, but the the day. No improvement was noted in tearing when the
superior field of vision did not return. patient was seen 2 days later, but there was some improve-
The surgeon involved in this case thought the problem was ment in the surface of the left cornea and her vision in the
a complication related to hypotensive anesthesia rather than left eye had improved to 20/70.
to the orthognathic surgery. The systolic blood pressure, as Five days later, 34 days postoperatively, the patient was
measured by a sphygmomanometer on the arm, had been rechecked. Her eyes were still dry, but she was complaining
maintained at 60 to 70 mm Hg for approximately a 3-hour of less burning and itching. There was essentially no change
period, with the patient in a 15° reverse Trendelenburg po- in her cornea. When the patient was seen 2 weeks later, she
sition. This indirect measurement of blood pressure may not said her left eye felt somewhat better when it was kept well
have been sufficiently accurate to assess such low arterial lubricated, although the eye still burned and felt irritated and
pressures. lIer preoperative blood pressure values had been her vision was somewhat blurred. The ophthalmologist noted,
measured between 98/62 and 120/80. much improvement in the left cornea, with only a small
amount of punctate changes and improved visual acuity in
Case 4 the left eye to 20/25-2. The patient was started on vitamin
A ophthalmic solution in an effort to heal some of the epi-
A 42-year-old woman with severe apertognathia was treated thelial changes in the cornea.
with a multisegmental Le Fort I osteotomy with superior Two weeks later, 9 weeks postoperatively, further im-
repositioning. The pterygomaxillary dysjunction was achieved provement was noted on examination of the cornea, although
with a small, curved chisel placed in the pterygornaxillary the left eye remained dry. A Schirmer's test under anesthesia,
fissures. The maxilla was down fractured without difficulty. showed secretion of tears in both eyes to be minimal. The
No problems were encountered at the time of surgery or in ophthalmologist had noted that the patient tended to have
the immediate postoperative period. Five days postopera- borderline dry eyes even before the orthognathic surgery, but
tively, the patient did not complain of any eye symptoms this situation had definitely worsened postoperatively. A CT
when seen for her first postoperative visit. Eight days post- scan was done to look for a possible etiology for the patient's
operatively, the patient telephoned her oral and maxillofacial dry eye. The CT scan was reported as basically normal except
surgeon to say that her left eye felt dry and itchy, with a for postsurgical fractures of the pterygoid plates and posterior
sensation like "sand in her eyes." These sensations had begun lateral wall of the right maxillary sinus.
during her drive to her home state, which has a drier climate. When the patient was reviewed by the ophthalmologist 10
It was suggested that the patient sec an ophthalmologist, which weeks postoperatively, vision had improved to 20/20 in the
she did immediately. The ophthalmologist found she had dry left eye and a small pool of lubricant was noted in the lacrimal
eyes and blepharitis. She was treated with combination dexa- lake ofthe left eye. The condition ofthe cornea had improved.
methasone, neomycin, polymyxin B (Maxitrol, Alcon, Mis- At a visit 13 weeks postoperatively, the vision in the left eye
sissauga, Ontario, Canada), an anti-inflammatory antibiotic remained normal, although no new lubrication had devel-
ophthalmic solution three times a day, and combination oped. The patient's eye felt normal unless she forgot to use
dextran 70 and dyroxypropyl methylcellulose (Tears Natu- the lubricant. She was now using the lubrication only once
rale, Alcon), an artificial tears eye lubricant, every 3 hours every 3 hours, whereas initially, she was using it every 20
while awake. The patient returned I week later complaining minutes.
that her eyes were no better. She was again found to have At 15 weeks postoperatively, a trial using a hydroxypropyl
dry eyes and blepharitis, with the left side being much worse cellulose insert (Lacrisert; Merck, Sharp, and Dohme) was
than the right. Marked superficial epithelial changes and ero- begun to sec if this would improve the dry eye condition.
sions were noted in the left eye. The Maxitrol solution was Initially, with the Lacrisert, the eye felt more irritated and
discontinued and the patient was taught to do lid scrubs twice by the afternoon her vision was more blurred than when
a day. She was told to put copious amounts ofmethylcellulose using the ointment and drops. By 20 weeks postoperatively,
on the eyes. she felt comfortable using the Lacrisert and her tearing had
LANIGAN, ROMANCHUK. AND OLSON 485

improved but was still subnormal. A repeated Schirmer's test However, the Le Fort I osteotomy with intrusion was com-
showed normal lacrimation in the right eye, but lacrimation pleted successfully. The pterygomaxillary dysjunction was
in the left eye was still markedly decreased. The cornea was achieved using a curved osteotome. The right descending
clear and her vision remained at 20/20 in the left eye. The palatine neurovascular bundle had to be cut and ligated to
cornea still had no sensation. anow for sufficient bone removal in the region of the right
By I year postoperatively, there had been no noticeable pterygoid plate. There was no mention in the operative report
further increase in tearing. The patient was continuing to use of whether the right pterygoid plate was intact or whether it
artificial tears four to five times a day and a lubricating oint- was fractured and/or detached from the skull base.
ment at night. By 2 years postoperatively, the patient sub- The patient's initial postoperative course was uneventful.
jectively felt that her symptoms of a dry eye had decreased At a follow-up examination 3 months following her surgery,
significantly.She continued, however, to use the artificial tears however, she complained of a burning sensation in the right
in the left eye three times a day. A Schirmer's test showed eye at nighttime. She was referred to an ophthalmologist,
equal tear production in both eyes and her vision remained who saw her 2 months later. The ophthalmologist diagnosed
at 20/20. She had increasing return of sensation of the left a punctate keratopathy in the right eye and treated her with
cornea, although sensation to the superior one third was still topical ocular lubricants. A formal evaluation of tear pro-
lessthan on the right. The patient did not find her ophthalmic duction was not performed until I month later, 6 months
problems a particular inconvenience because they did not after her surgery. The examination revealed a marked relative
interfere with her usual lifestyle. She was sufficiently happy reduction in tear production in the right eye. Visual acuity
with the results of her orthognathic surgery to state she would and corneal sensation were normal in both eyes. A cr scan
have the surgery again without hesitation even if meant en- of the head was reported as normal, with no evidence of an
during the eye problems. intracranial mass lesion as a cause of the patient's unilateral
"dry eye."
CaseS Thirteen months after her orthognathic surgery, the patient
was referred to a neuro-ophthalmologist for a second opinion
A 39-year-old woman with vertical maxillary excess, man- regarding her dry eye. The patient stated that her symptoms
dibular retrognathia, and facial asymmetry was treated by u had remained stable over the past year. She had noted blurring
Le Fort I osteotomy with intrusion, bilateral sagittal man- in the right eye toward evening, irritation in the right eye in
dibular ramus osteotomies with advancement and rotation, the morning, occasional redness in the right eye, decreased
and a genioplasty. The pterygomaxillary dysjunction was sensation over her right cheek bone, and a "cool" sensation
carried out utilizing a curved osteotome and the downfracture in her right nasal passage when she inspired. She was using
was accomplished easily. The patient's initial postoperative Hypotears (polyvinyl alcohol artificial tears, lolab, Peterbor-
course was uneventful. Eight weeks postoperatively, however, ough, Ontario, Canada) three to four times a day and Lac-
she saw her optometrist in consultation because she was ex- rilube, an ocular lubricating ointment, at bedtime. On ex-
periencing difficulty in wearing contact lenses owing to a amination, her uncorrected visual acuity was 20/15
continual complaint of dryness in the right eye. She also noted bilaterally. The patient's extraocular muscle movements were
decreased lacrimation after crying and complained of slight normal and her confrontation visual fields were full. Both
photophobia in the right eye. These problems had first been pupils reacted briskly to light, from 6 to 3 mm, with no af-
noted about I month following surgery. The optometrist ferent pupillary defect. Dilated examination of the fundi re-
noted her pupils to be equal, round, and responsive to light. vealed normal discs, retinal vessels, and maculae. There was
No afferent pupillary defect was noted. Extraocular muscle mild hypesthesia to light touch over the right malar area in
mobility and external ocular examination were within normal the distribution of the zygomaticofacial nerve. Slit-lamp ex-
limits. Her refractive status showed normal 20/20 vision at amination was positive for mild blepharitis. The cornea and
distance and near. The cornea appeared normal, with no conjunctiva of the right eye showed mild to moderate punc-
punctate lesions. A dilated fundoscopic examination revealed tate staining in the interpalpebral zone. The remainder of
a normal optic disc, macula, and peripheral retina. Biomi- the anterior segment of the right eye was unremarkable. A
croscopy revealed a one third decrease in the lacrimal lake tear meniscus was present on the right. A Schirmer's test
of the right eye as compared with that of the left eye. The revealed0 mm of wetting in the right eye and normal wetting,
optometrist thought that the patient's inability to wear contact greater than 20 mm in 5 minutes, in the left eye.
lenses was due to poor wetting from the decrease in the lac- The ophthalmologist thought that the findings of keratitis
rimallake in the right eye. He suggested that she stop wearing sicca in the right eye, combined with ipsilateral malar hyp-
contact lenses and prescribed new eyeglasses. esthesia and dryness of the turbinates, was highly character-
The problem with dryness and slight photophobia has per- istic of damage to the pterygopalatine ganglion. He thought
sisted, although it is subjectively somewhat better 14 months that there were two possible indirect mechanisms that could
postoperatively. She notices more tearing when crying. The have resulted in damage to the ganglion. The first involved
dryness has resulted in no significant sequelae except with contiguous spread ofa postoperative inflammatory response
the difficulty in wearing contact lenses. There have been no into the region of the pterygopalatine fossa, with resultant
ocular complications. On a repeated examination, there was damage to the tissues there. The second mechanism could
no superficial staining of the cornea, no superficial punctate involve interruption of the vascular supply to the ganglion
keratitis, and no redness or discomfort of the eye. through damage to the descending palatine or maxillary ar-
teries. The ophthalmologist did not consider the possibility
Case 6 of extension of untoward fractures into the pterygopalatine
fossa damaging the ganglion either directly or indirectly via
A 20-year-old woman with vertical maxillary excess and compression from edema or hematoma formation. He
. mandibular retrognathia was scheduled for a Le Fort I os- thought it unlikely that the patient's level of tear production
teotomy with intrusion and a mandibular advancement. An would change significantly with time. The ophthalmologist
abnormal sagittal split of the left mandibular ramus forced recommended the patient increase the frequency of artificial
abandonment of the mandibular advancement procedure. tears in the right eye to every hour while awake and suggested
486 OPHTHALMIC COMPLICATIONS: ORTHOGNATHIC SURGERY

she switch to Refresh, artificial tears without preservati ves, A right turbinate reduction, in conjunction with an outfrac-
to decrease the likelihood of developing an allergic response. ture of the right inferior turbinate, was performed in an at-
He also suggested the patient apply warm compresses each tempt to open the right nasal airway. The patient was dis-
day because the concomitant blepharitis interferes with the charged on the third day postoperati vely. Discharge
lipid layer of the tear film and leads to increased tear evap- medications includ ed oxyrnetazoline hydrochloride (Afrin;
oration. The ophthalmologist thought that this regimen might Schering , Kenilworth, NJ) 0.05% nasal spray, two sprays in
clear the patient's mild keratopathy, but if corneal changes each nostril every 12 hours as requir ed for nasal congestion
persisted, she might be a candidate for punctal occlusion . and phenylpropanolamine syrup 2 tsp four times a day.
The patient has continued to function well, however, solely On her second postoperative visit, which was the II th day
with the use of Lacrilube ophthalmic ointment at bedtime postoperatively, the patient told her oral and maxillofacial
and the use of artificial tears as needed during the day. Punc- surgeon that she was exp eriencing significant tearing from
tate occlusion has not been needed , although the patient did the right eye. Seven weeks postoperatively, the tearing in the
undergo a temporary trial of dissolvable lacrimal plugs. The right eye increased, became purulent in nature, and the eye
plugs did subjectively seem to result in increased watering in became painful. The mucous membranes of her right nose
her right eye, but the patient did not think it was necessary were noted to be swollen to the extent that the patient could
to continue this treatment. not breathe at all through her right nostril. She was given a
prescription for cefadroxil, 500 mg, twice a day for I week,
and gentamicin ophthalmic solution (Genoptic; Allergan),
Case 7 two drops to the right eye three to four times a 'day, Three
days later, the patient was reexamined and the drainage from
A 15-year-old girl with a midfacial retrusion and anterior the right eye was found to be decreased and less purulent.
mandibular vertical excess was treated by a Le Fort I oste- An unsuccessful attempt was made to infracture the right
otomy with advancement and a genioplasty. The Le Fort I inferior turbinate under intravenous sedation and local anes-
osteoiomy was carried out in a conventional fashion and the thesia. The patient was instructed to take pseudoephedrine
pterygoid plates were separated from the posterior aspect of hydrochloride (Actifed; Burroughs Wellcome, Inc, Kirkland,
the maxillary tuberosities with a curved osteotome. The Quebec, Canada) tablets and to use nasal spray once a day.
maxilla was downfractured using Tessier spreaders. Following One week later , the patient still found it difficult to breathe
adequate mobilization and segmentalization into two seg- through the right nostril , but found that taking the Actifed
ments, the maxilla was fixed into its new position using in- tablets on a regular basis every 4 to 6 hours did help to control
terosseous wires in the zygomatic buttress areas bilaterally. the watering from her right eye.
No problems were encountered at the time of surgery and Fourteen weeks postoperatively, the patient saw an ear,
the patient's initial postoperative course was uneventful. nose, and throat (ENT) surgeon in consultation. The right
At a visit 5 months postoperati vely, the patient complained nasal cavity was examined with a rhinoscope and found to
of excessive tearing from the right eye since her surgery. Ini- be completely occluded by a severely deviated nasal septum.
tially, this was minor, but the problem had become progres- The deviat ion began just past the caudal end of the septum.
sively worse. The patient was subsequently referred to an An attempt was made to examine the nose with a fiberoptic
ophthalmologist to see whether the epiphora was related to scope, but even following decongestion of the nose with Afrin
an alteration in the nasolacrimal duct as a result of her max- spray and topical 3% cocaine, the only visible opening was
illary surgery. The ophthalmologist noted that the patient inferior and too narrow for a fiberoptic scope to be passed.
had a very full, watery tear lake on the right side. The lids No palpable swelling of the nasolacrimal duct was noted.
and puncta were in normal position and she had a good blink The ENT surgeon thought it was possible that the patient's
mechanism. An enlarged, nontender tear sac was palpable. epiphora could be eliminated by performing a septoplasty
The valve at the junction of the common canaliculus with because the fact that her increased tearing improved with
the lacrimal sac was competent, but there was obstruction of Actifed suggested that mucosal edema rather than occlusion
the patient's nasolacrimal duct. ofthe nasal opening ofthe nasolacrimal duct might be playing
Ten months postoperatively, the patient underwent a dac- a role in its etiology. He advised that if the epiphora persisted,
ryocystorhinostomy (OCR) and a good anastamosis was cre- an ophthalmology consultation would obviously be indicated
ated . Silicone tubes were placed through the nasolacrimal to have the nasolacrimal duct cannulated to ascertain the
system and through the anastamosis in the nose. These tubes location of the obstruction.
were removed 5 months later. The patient has been asymp- Seven months postoperatively, the patient underwent a
tomatic since the DCR. scptoplasty and a right partial turbin ectomy with infracturing
of the right inferior turbinate. The maxillary internal fixation
Case 8 plate around the right piriform fossa was removed at the
same time. Following surgery, the excessive tearing stopped
A 42-year-old woman was admitted for treatment of max- and the patient's nasal breathing became excellent for the
illary hypoplasia and mandibular prognathism. She had a first time she could remember. Very occasionally, however,
long-standing history of difficulty in breathing through her when she blows her nose, the patient feels a sensation as if
right nostril because of a deviated nasal septum and of right air were coming out of her right tear duct.
maxillary sinusitis. The patient had been taking antihista-
mines before her orthognathic surgery. She was treated with Discussion
a multisegmental Le Fort I osteotomy, bilateral sagittal man-
dibular ramus osteotomies, a genioplasty, a submental Iipee- Because so little information is available regarding
tomy, and a right malar Proplast II (Vitek Inc, Houston, TX) ophthalmic complications following orthognathic sur-
implant augmentation. At the time of the maxillary down-
fracture, the right maxillary sinus was noted to have 'boggy' gery, the literature regarding ophthalmic injuries as-
mucous membranes suggestive of a chronic sinusitis. The sociated with facial fractures was reviewed to see what
mucous membranes of the left maxillary sinus were normal. pertinent information could be gained. The highest in-
LANIGAN, ROMANCHUK, AND OLSON 487

cidence of serious ophthalmic injuries occurs in con- Hendy," and Lanigan and Guest." in their investi-
junction with midfacial or frontal bone fractures.19 The gations of the pterygomaxillary dysjunction using a
midfacial fractures most apt to be associated with ocu- curved osteotome, have described high fractures of the
lar complications are comminuted zygomatic fractures, pterygoid plates with subsequent disruption of the
orbital floor fractures, and Le Fort II or Le Fort III pterygopalatine fossa and with possible fractures ex-
fractures rather than isolated Le Fort I fractures. 2Q-25 tending to the base of the skull. Renick and Syming-
In view of the paucity of reports of ophthalmic com- ton," using postoperative CT scans to assess the pter-
plications following Le Fort I fractures, where injuries ygomaxillary region following a Le Fort I osteotomy,
occur in an uncontrolled fashion, it is not surprising found a similar pattern of pterygoid plate fractures to
that so few cases have been reported following orthog- that described in Robinson and Hendy's" experimental
nathic surgery specifically related to the operation itself. study. In many cases, pterygoid plates assessed to be
Injuries to the cornea could occur, of course, from intact clinically were not found to be intact on a CT
contact with alcohol-based or detergent skin prepara- scan. This suggeststhat pterygoid plate fractures cannot
tions, incomplete eyelid closure, or from an accidental be excluded as a contributing factor in unexplained
injury during retraction. postoperative complications even if they were thought
Based on previous reports in the literature, and the to be intact at surgery." .
cases presented in this report, it appears that potential Ifuntoward fractures extend to the base ofthe middle
ophthalmic complications following Le Fort I osteot- cranial fossa in areas such as the foramen lacerum or
omies fall into four main categories: I) a decrease in carotid canal, as has been reported,14,17,18,32 then in-
visual acuity, 2) extraocular muscle dysfunction, 3) juries to the internal carotid artery can result, including
neuroparalytic keratitis, and 4) lacrimal apparatus carotid-cavernous sinus fistula or stroke. Anatomic
problems, including both epiphora and keratitis sicca. variations, such as bony defects or incomplete ossifi-
Ophthalmic injuries after orthognathic surgery appear cation, can occur at the base of the skull,32,33,34 and
to be mediated primarily through damage to nerves or abnormally thick posterior walls of the maxilla and
vascular supply. Because direct injuries to the optic pterygoid plates also can occur," which put patients
nerve, cranial nerves III, IV, and VI supplying the ex- at increased risk during the pterygomaxillary dysjunc-
traocular muscles, the nerves supplying the nasolacri- tion or maxillary down fracture. Anatomic abnormal-
mal apparatus, and the first division of the trigeminal ities may be more common in patients with craniofacial
nerve are unlikely to occur from the osteotomies as- malformations 17,32,35,36 or following previous maxillo-
sociated with the Le Fort I procedure, indirect injuries facial trauma or orthognathic surgery (case I). Varia-
to the involved neurovascular structures must have oc- tions in the anatomy of the sella tursica, sphenoid
curred. Indirect injuries could result from traction, sinus, and sphenoid bone may be of particular impor-
compression, or contrecoup injuries to neurovascular tance in terms of increased risk for ophthalmic com-
structures from forces transmitted during the ptery- plications following orthognathic surgery.P Fujii et al37
gomaxillary dysjunction using an osteotome or from studied the optic canal/sphenoid relationship in ca-
damage sustained by fractures extending to the base of davers and found that 9% of optic nerves were devoid
the skull or orbit. Fine fissure fractures, which can be of medial osseous cover and 78% were covered by 0.5
noted at surgery or autopsy, cannot always be detected mm or less of bone. The middle cranial fossa is the
on ordinary radiographs" or even on CT scans. These smallest and structurally most complicated of the three
untoward fractures are most apt to occur during pter- cranial fossae and is the most vulnerable part of the
ygomaxillary dysjunction with an osteotome or during skull base to injuries either following facial trauma or
the maxillary down fracture, particularly if a traumatic orthognathic surgery. Lines offracture tend to continue
separation occurs between the maxillary tuberosity and in the axis ofthe striking force," so it is not surprisingly
the pterygoid plates or a difficult downfracture is en- that occasionally untoward fractures occur toward the
countered. base of the skull or orbit in association with the pter-
It is interesting to note that the vast majority of ygomaxillary dysjunction, especially if the osteotome
ophthalmic complications that have been reported fol- is positioned incorrectly" or ifthere are associated un-
lowing Le Fort I osteotomies have involved right-sided favorable anatomic variants. Nerve or vascular damage
structures. Although this may have occurred purely by can occur if fracture lines extend to foramina contain-
chance, it could perhaps be related to surgical technique ing neurovascular structures. The longer the intracra-
or to subtle anatomic differences between the right and nial course of the nerve, the more vulnerable it is to
left sides. Because the majority of surgeons are right such damage." This is why the abducent (VI) nerve is
.handed, there also may be differences in how the pter- particularly vulnerable to injury following trauma or
ygomaxillary dysjunction and maxillary down fracture craniofacial surgery.
is achieved between the two sides. Evidence to support the conjecture that ophthalmic
Wikkeling and Koppendraaier.P Robinson and complications of orthognathic surgery are related to
488 OPHTHALMIC COMPLICATIONS: ORTHOGNATHIC SURGERY

untoward fractures or to compression, traction, or right cavernous sinus. The neuropraxia of the abducent
contrecoup injuries occurring in association with the nerve in this case most likely occurred in the cavernous
pterygomaxillary dysjunction or maxillary downfrac- sinus owing to the sphenoid bone fracture, with dis-
ture is to this point limited. Hiranuma et al,38 in an placement ofa fracture fragment through the sella tur-
experimental study, looked at strain distribution during sica onto the medial surface of the cavernous sinus.
separation of the pterygomaxillary suture by osteo- Because the abducent nerve is more medial than any
tomes. Although their study was not completely anal- other cranial nerves that enter the cavernous sinus, it
ogous to a clinical situation because it was performed is the one most likely to be involved, although the rel-
on dry skulls, it did measure a large tensile and com - ati ve position ofthe cranial nerves varies from posterior
pressive strain at the medial pterygoid plate on the side to anterior within the cavernous sinus. In view of the
of osteotome application. The strain on the medial extensive nature of the fractures, it was fortunate that
pterygoid plate was increased if the pterygomaxillary other cranial nerves, including the optic nerve, or the
osteotome was not angulated correctly to avoid pos- carotid or ophthalmic arteries also were not involved.
terior-superior compression of the pterygoid process. In case I of this report, a postoperative CT scan
Although their strain gauges showed the intensity of showed multiple fractures extending to the base of the
the strain distribution to be highest at the ipsilateral skull and orbit. The fractures involved the roof of the
medial pterygoid plate area during the pterygomaxillary right maxillary sinus and extended through the medial
dysjunction, the strain was widely distributed within wall of the right orbit posteriorly, with fractures of the
the skull. This could perhaps result in compression, right sphenoid bone extending through the floor of the
traction, or contrecoup injuries to neurovascular middle cranial fossa. A fracture through the right lesser
structures. It is certainly not unusual to note fractures wing of the sphenoid bone extended just lateral to the
ofthe pterygoid plates clinically, similar to those noted optic foramen. The fracture of the roof of the right
experimentally, following the pterygomaxillary dys- maxillary sinus posteriorly appeared to be the source
junction and maxillary downfracture. Pterygoid plate of the small bone fragment that was noted in close
fractures, however, are fortunately not routinely as- proximity or touching the optic nerve in the region of
sociated with complications such as hemorrhage.l? the the right optic foramen and superior orbital fissure.
development of arteriovenous fistulas l 6 •39 or false The optic foramen lies between the two roots of the
aneurysms," or neurologic" or ophthalmic problems. lesser wing of the sphenoid bone, whereas the superior
. This is because it is not necessarily the presence of orbital fissure is situated between the lesser and greater
pterygoid plate fractures per se but the underlying wings ofsphenoid bone (Fig 2). Whether the optic nerve
mechanism that caused them in the first place that may was injured directly by impingement of the small bone
be responsible for these rare complications. In a very fragment or more indirectly is uncertain. The fact that
small percentage of patients, certainly much less than blindness was delayed in onset, however, suggests an
I %, clinical evidence of an ophthalmic complication indirect cause. The oculomotor nerve was likely dam-
is noted. aged as it traverses the superior orbital fissure. Both
If one looks at the reported cases of ophthalmic the superior and inferior divisions appeared to be in-
complications following orthognathic surgery in the volved because the patient presented with ptosis, my-
literature and in this report, what evidence exists to driasis, and dysfunction of the medial rectus muscle,
suggest that problems encountered with the pterygo-
maxillary separation or maxillary downfracture may
have contributed to these complications? The most
obvious examples are the case presented by Reiner and Supl'~rblLaI
Optic canal notch.loramen
Willoughby" of an abducent nerve palsy following a 1r.I..u1l'-Y ptOCMol
o' Irontal bone
Le Fort I osteotomy and case I in this report. In Reiner Ponerk)r and an»rior
ethmokSforemen
and Willoughby's case, a postoperative CT scan dem-
_bene
onstrated a comminuted fracture through the body of
f,ontoryg~~~~;----',._-y-,,-,~,.....:.o,.,..\......J Orb ital process
the sphenoid bone passing through the sella tursica, .,.;:y ~1'>t--t+--ofethmoid bor\t!
with lateral displacement of a bony fragment onto the o~~~~~~e~S~nC~ -+--t--t--if- O+-H-Poslerlor t.ef'imal bon-t
01sphenoid ~""';;;~tr-f-+--An tertor lacrimal t,*St
medial surface of the right cavernous sinus. A com- Interior Orbital OrtHta! prO~1S o.
Fissura pal.Vne bono
minuted fracture of a portion of the greater wing of Zygomaticolic ial--,,""------'
loramen ~--if.;::,.,;'t--lnhoort>".1
the sphenoid bone in the middle cranial fossa, just lat- foramen
eral to the foramen rotundum, also was noted. There
was medial displacement of some of the fragments
leading to a narrowing of the foramen rotundum, and
there was slight effacement of the inferior aspect of the FIGURE 2. The bony anatomy of the orbital region.
LANIGAN, ROMANCHUK, AND OLSON 489

although function of the muscle also may have been was either displaced bone spicules from a fracture that
affected by swellingof the muscle itself. As they emerge extended upward to the inferolateral margin of the right
from the superior orbital fissure, the superior division superior orbital fissure causing injury to the abducent
of the III nerve passes above the optic nerve, whereas nerve from compression ofthe nerve from hemorrhage,
the inferior division passes below the optic nerve. The or a neuropraxia from transmitted forces from the use
remainder of the neurovascular structures in the su- of the osteotome. Watts thought the last explanation
perior orbital fissure were spared. was the more likely in view ofthe fact that tomography
In the case reported by Carr and Gilbert? ofa partial did not show any obvious extension of fractures to the
third nerve palsy following a Le Fort I "Wake"-type superior orbital fissure and because of the rapid recov-
osteotomy, it may be purely coincidental that the pa- ery of the nerve palsy.
tient had a bilateral cleft lip and palate deformity and The transient bilateral increased tearing reported by
that the oculomotor nerve problem happened on the Keller and Sather'? following a high "quadrangular"
same side as the more severe cleft. It is quite possible, Le Fort I osteotomy is not unexpected. Early transient
however, that the altered anatomy in this patient may epiphora following a Le Fort I osteotomy is usually
have put him at higher risk of sustaining an untoward secondary to edema that leads to a functional blockage
fracture(s) extending to the base of the skull. The partial of drainage of tears rather than from any neurologic
third nerve palsy in this case was delayed in onset, and damage. The damage to the nasolacrimal duct leading
the patient had completely recovered by 8 weeks. Carr to obstruction reported in Case 7 of this report is more
and Gilbert thought it was likely caused by a neuro- difficult to explain. The patient was treated with a con-
praxia induced either through forces directly trans- ventional Le Fort I osteotomy, and only interosseous
mitted to the nerve during separation of the pterygoid wires in the zygomatic buttress areas were used for fix-
plates or perhaps through delayed, ascending edema ation, so it is difficult to postulate direct damage from
and hematoma formation. Although a partial oculo- the orthognathic surgery to nasolacrimal structures
motor palsy of this type may have been caused by a unless unusual extension offracture lines occurred su-
lesion involving both rami of the third nerve, at or periorly during the downfracture using the Tessier
about the superior orbital fissure, no fractures extending spreaders.
to the superior orbital fissure were noted on conven- In performing maxillofacial surgery, two areas of the
tional radiography or on a CT scan, nor was there any nasolacrimal system are particularly vulnerable to in-
evidence ofa retrobulbar hematoma. It also is unusual advertent injury-the distal orifice ofthe lacrimal duct
that the abducent nerve was spared because it is nor- and the anterior wall of the nasolacrimal sac. The in-
mally more vulnerable to damage than most structures creased tearing reported in case 8 appears to be due to
running through the superior orbital fissure owing to obstruction of the distal orifice of the nasolacrimal
its location in the most inferolateral aspect of the fis- duct by mucosal swelling. A decreased right nasal air-
sure.' Anatomic anomalies in a patient with a bilateral way occurred from an increase in deviation of an al-
cleft lip and palate deformity may perhaps have led to ready deviated nasal septum and the outfracturing of
the rami of the oculomotor nerve being located more the right inferior turbinate carried out in conjunction
inferiorly than normal, leading to their involvement, with the maxillary orthognathic surgery.
while sparing the more predictable abducent nerve in- We also received information about two additional
jury.' The presence of clefts also may have directed cases of postoperative epiphora but complete records
edema and hematoma formation superiorly to the in- unfortunately were no longer available. Both cases in-
ferior and superior orbital fissure areas. A case of volved 15-year-old girls, who underwent Le Fort I os-
blindness and total ophthalmoplegia, where the damage teotomy and superior repositioning of the maxilla in
to the involved cranial nerves was speculated to have the mid 1970s. It was this surgeon's customary practice
occurred from pressure generated by postoperative at that time not to perform a complete osteotomy of
swelling transmitted to the superior orbital fissure and the lateral wall of the nose. Once all the osteotomies
optic foramen from the pterygopalatine fossa, has been were completed, the maxilla was down fractured with
reported previously." Rowe disimpaction forceps. In both cases,a rather large
In the case of a transient unilateral abducent nerve lateral nasal wall osseous spur fractured off near the
palsy presented by Watts.' the pterygomaxillary dys- root of the inferior nasal turbinate. In the postoperative
junction was more difficult to achieve than normal. period, both patients complained of epiphora, although
The normal osteotome used for this purpose was un- one case resolved within 3 months. In the second case,
available so a larger, curved osteotome had to be used, the epiphora persisted for 9 months and was then suc-
.which was more difficult to position. The right ptery- cessfully resolved by a dacryocystorhinostomy.
goid plate was separated first. Watts speculated that the The lack of tearing after Le Fort I osteotomies, first
most likely explanation for the abducent nerve palsy reported by Tomasetti et all and subsequently in this
 490 OPHTHALr.IIC COMPLICATIONS: ORTIlOGNATIIIC SURGERY

report, is a more difficult problem to explain. This is suggests that the nerve damage may have occurred
. particularly so when a true dry eye (keratitis sicca) is quite proximally unless one postulates different injuries
combined with corneal anesthesia (neuroparalytic ker- resulting in nerve damage at multiple sites. The damage
atitis), as in case 4, which leaves the cornea particularly to nerves concerned with lacrimation in case 6 appears
vulnerable. Tomasetti et all thought that lack oftearing to have occurred in the pterygopalatine fossa, possibly
in their case was related to an extension of fractures involving the pterygopalatine ganglion.
associated with the left pterygoid plate fracture they Decreased visual acuity or blindness has been re-
noted at surgery. They did not specifically mention ported following craniofacial surgery? but not previ-
where the fractures extended, but consideration should ously following orthognathic surgery. One additional
be given to their extending to the base of the skull to case of blindness following a Le Fort I osteotomy was
involve the foramen lacerum or pterygoid canal, to the reported in addition to the three cases presented in this
inferior orb ital fissure, or to a disruption involving the report, but it was not possible to obtain details of this
pterygopalatine fossa itself. They considered several case from the surgeon involved. There is no doubt that
etiologic possibilities for damage to the nerves invol ved fractures extending toward the base of the skull in the
with lacrimation, including that the pterygopalatine middle cranial fossa, or toward the orbit, have the po-
ganglion itself was injured, that the postganglionic tential to lead to this complication. Posttraumatic cases
parasympathetic fibers running with the maxillary of blindness have been reported, however, where no
nerve in the pterygopalatine fossa were injured," or obvious fractures could be visualized even on a CT
that the zygomatic branch of the maxillary nerve was scan. Although CT scans are useful in the delineation
injured either by a bony spicule or by entrapment in of fractures of the orbit and in the optic canal regions,
a "crack" fracture. They largely discounted the first a fracture could be missed if the thickness of the cut
two possibilities because of a lack of concurrent par- (ic, 5 mm rather than 2 mm) and the plane of ori en-
esthesia over the course of the maxillary nerve. Patients tation are not appropriate." A fracture of the optic
generally exhibit at least transient numbness over the canal is certainly not necessary for damage to the optic
distribution of the infraorbital branch of the maxillary nerve to occur, and its presence is merely an indication
nerve after Le Fort I osteotomies, but involvement of of the excessive energy delivered to the region of the
the zygomatic branch, such as was noted in case 6, is optic canal and subsequently transmitted to the optic
most unusual. Tomasetti et all did not consider more nerve." Hairline fractures may occur that are too small
proximal damage invol ving the greater petrosal ner ve to be visualized radiographically, or other mecha-
or the vidian nerve, although this is also a possibility. nism(s) may be involved, likely associated with the
It should be borne in mind that the postganglionic pterygomaxilIary dysjunction, that result in compres-
parasympathetic fibers involved with lacrimation are sion, traction , or contrecoup injuries to neurovascular
all non myelinated and, as such, are more susceptible structures supplying the orbit. Hiranuma et al 38 have
to injury than are myelinated fibers. I It is therefore shown that the pterygomaxillary dysjunction creates
possible for an injury to involve a nerve trunk and only strains that are widely distributed within the cranio-
result in enough damage to selectively injure the more maxillofacial complex. These strains may be intensified
vulnerable non myelinated fibers while sparing the less if the correct technique is not used or unusual anatomic
susceptible myelinated fibers. features are present. Dutton and Al-Quruiny" have
The surgeons involved in cases 4 and 5 were unable discussed the effects of injuries to the globe resulting
to speculate as to the etiology of the dry eye that oc- from distortion and concussion secondary to maxil-
curred following orthognathic surgery. The patient in lofacial trauma.
case 5 never underwent any additional diagnostic in- A traumatic optic neuropathy is the most common
vestigations, such as a cr scan , postoperatively, cause of permanent visual loss following blunt mid-
whereas the patient in case 6 had a CF scan done 9 facial traurna.P An injury to the optic nerve is rarely
weeks postoperatively. The CT scan showed fractures the result of direct injury by osseous compression, lac-
of both pterygoid plates and the posterolateral wall of eration, or hemorrhage into the nerve itself. The most
the right maxilIary sinus. It is possible that additional common mechanism appears to be indirectly via hem-
fractures extending to the pterygopalatine fossa or base orrhage into the optic nerve sheath or contusion of the
of the skull resulted in damage to the nerve(s) invol ved nerve with resulting edema and compression leading
with lacrimation. The fact that the patient in case 4 to a secondary compromise of the vascular supply and
had borderline dry eyes even before the orthognathic nerve infarction.P Although injuries to the optic nerve
surgery and lived in a very dry climate may have con - can occur anywhere along its length, the most common
tributed to her problems. This patient also had anes- traumatic optic neuropathy occurs from canalicular
thesia of the left cornea from damage to the nasociliary optic nerve damage. The orbital portion of the optic
branch of the first division of the trigeminal nerve. This nerve is somewhat loose and so is able to stretch with
 LANIGAN, ROMANCHUK, AND OLSON 491

eye movements or eyeball compression and can thus of the bleeding following malar or orbital floor fractures
withstand fairly strong shearing forces." The canalic- can be subperiosteal from the infraorbital artery or ex-
ular portion of the nerve is more vulnerable, however, tracoronally from perforating branches of the infraor-
because it is encased in a tight bony canal where it is bital artery.50,51 With arterial bleeding, there can be a
partially adherent to the periosteum of the sphenoid substantial rise in intraorbital pressure, followed by a
bone. Although a fracture is not necessary to cause rise in intraocular pressure. The blood supply to the
damage to the optic nerve, a fracture through the optic retina is primarily via a branch of the ophthalmic ar-
canal could result in a direct compression or contusion tery, the central retinal artery (Fig 3). Although central
of the nerve or could have a shearing effect on the retinal artery occlusion is possible, it is a rare cause of
meningeal layers of the optic nerve or on the nerve visual loss because the anatomic location of the central
itself. A close anatomic relationship exists between the retinal artery within the optic nerve tends to protect
optic canal, the lesser and greater wings of the sphenoid it. The long and short posterior ciliary arteries lie within
bone, and the sphenoid and ethmoid sinuses." This the extraocular muscle cone and enter the eye around
should be borne in mind if a fracture extends to the the optic nerve to supply the uveal tract and anterior
base of the middle cranial fossa following a Le Fort I optic nerve (Fig 3). An injury within the confines of
osteotomy (case I). the extraocular muscles or penetration by bone spicule's
Manfredi et al 26 used CT scans to study facial frac- from the orbital floor or elsewhere into the intraconal
tures associated with blindness and found the most space may result in rupture of vessels posterior to the
significant findings in the demonstration of indirect globe, particularly the short posterior ciliary arteries.
injury to the optic nerve were a lesser sphenoid wing The intraconal space is almost completely closed except
fracture or a subdural hematoma in the optic nerve for a small posterolateral communication with the ex-
sheath. Evidence of sphenoethmoidal sinus hemor- tracoronal peripheral space. A retrobulbar hemorrhage
rhage on conventional radiographs should make one into the muscle cone leads to increased pressure that
suspicious of the possibility of an optic canal fracture could compress and eventually occlude the posterior
with associated optic nerve injury. Anderson et al 46 ciliary arteries and lead to anterior optic nerve head
think that indirect optic nerve injury is secondary to ischemia and visual loss.P:" Intraocular pressure can
the stretching, tearing, torison, or contusion ofthe optic increase to the extent that it only compromises the
nerve and its blood supply, which is caused not just circulation of the optic disc without affecting the central
from the momentum of the eyeball and orbital contents retinal circulation."
being absorbed by the fixed canalicular portion of the The etiology of the retrobulbar hemorrhage reported
optic nerve but also by skeletal distortion caused by in case 2 is uncertain. The most likely arterial vessels
forces remote from the initial impact. This impact involved with hemorrhage following a Le Fort I oste-
could occur during the pterygomaxillary dysjunction. otomy are the descending palatine and sphenopalatine
Babajews" reported that there appears to be no direct branches of the maxillary artery." It is highly unlikely
correlation between the severity of the maxillofacial that the descending palatine arteries were involved be-
injury and visual disturbance, so there is a possibility cause they were noted to be intact intraoperatively,
that this complication could occur following Le Fort and no significant hemorrhage was encountered when
I osteotomies. the maxilla was redownfractured. Involvement of the
The moment at which loss of vision occurs appears
to be ofsignificant importance in establishing prognosis
. . .,_---Supr~orbi1al
and therapeutic intervention. Ifblindness is immediate supratrochIHr_;;;~:::::~~_-J.~
Artery
Artery

and complete, the prognosis is poor despite treatment.

Ifvisualloss is delayed, progressive, or incomplete, then
it may be ameliorated by massive doses of steroids or
surgical decompression of the optic nerve. 26,48 Surgery Anterior Ethmoldal-----iT~\L. I-++f-- Anterior Cmlry
should be considered if hematoma or bony fragments Artory Artory

are impinging on theoptic nerve and steroids are un- Long Posterior
Posterior Ethmoidal -----.l;~WJt-".~l\ltli.r~I-f;...-hffT- Clliory Artory
successful in improving vision. Optic nerve de- Artory •

compression is most effective if done early, closer to ShortPOSl.rior _ _----'r---T--'~ 1-T7'---locrimal Artory
cmory Artery
the time of injury,"? Centr.1 Retinal
Anterior Clinoid I t+liiiii-if----- Artery
Retrobulbar hemorrhage has been reported as a rare Process ------ Ophlholmic Artory
complication offacial fractures, usually malar or orbital Optic N e r v e - - - _ .
floor fractures, but no cases following reduction of Le ri----- Inl.rna'Carotid
Artory
. Fort I maxillary fractures or following orthognathic
surgery have been reported previously.P'!' The source FIGURE 3. The arterial supply to the orbit and globe.
492 OPHTHALMIC COMPLICATIONS: ORTHOGNATHIC SURGERY

sphenopalatine artery is a possibility because the patient anesthesia using hypotensive techniques to reduce
was obviously having significant left-sided epistaxis, hernorrhage.P:" Little" reported three cases of " retinal
which might have been secondary to sphenopalatine thrombosis" in 27,930 cases of controlled hypotensive
arterial damage. Sphenopalatine arterial hemorrhage general anesthetics. Most of the reported cases of
could lead to bleeding into the orbital cavity via a con- blindness associated with general anesthesia, however,
nection from the pterygopalatine fossa through the in- have been related to compression of the eye during
ferior orbital fissure. The etiology of the left-sided ep- surgery from, eg, a face mask , head rest, or sheet roll, 57·
istaxis is somewhat uncertain, however, and it may 60 although systemic hypotension does appear to be a
have been due to the traumatic intubation attempts factor in some of the reported cases. One case of vit-
through the left nostril. Injury to the anterior ethmoidal reous hemorrhage leading to a decrease in visual acuity
artery is possible from a traumatic intubation but for following hypotensive anesthesia, in which there was
such an injury to result in retrobulbar hemorrhage one no pressure on the eyes at any time, has been reported."
would have to postulate a disruption into the ethmoid Optic neuropathy can thus occur in conjunction with
sinuses, with a subsequent slow ooze of blood between systemic hypotension even if intraocular pressure is
the medial wall ofthe orbit and the orbital tissues. This normal. It is more likely to occur, however, when there
is a possibility in this case. If the patient had a significant is preexisting optic nerve disease, such as nerve damage
deviation of her nasal septum, combined with multiple from open-angle glaucoma, or if there is systemic vas-
traumatic intubation attempts, this could have resulted cular disease such as preexisting hypertension, arterio-
in a disruption into the ethmoidal sinuses. The fact sclerosis, carotid insufficiency, or diabetes.
that the orbital swelling and proptosis decreased dra- Retinal ischemia can occur from unilateral central
matically following suctioning of copious amounts of retinal artery occlusion and choroidal ischemia from
blood from the left nasal cavity would tend to support posterior ciliary artery occlusion, both related to ocular
the conjecture that there was a direct communication compression with or without systemic hypotension
between the nasal cavity and orbit via a fractured lam- during general anesthesia/" Blood flow to the eye oc-
ina papyracea. A third possibility for the cause of the curs against the pressure of the intraocular tension, an
retrobulbar hemorrhage is that shearing or traction equilibrium that can be upset by increased intraocular
forces at the time of the pterygomaxillary dysjunction tension or systemic hypotension." Progressively in-
disrupted a vessel in the orbit. A fourth option is pos- creasing levels of intraocular pressure, elevated well
sible damage to the infraorbital artery or a tributory above diastolic and probably even temporarily above
when placing the infraorbital suspension wire. No sig- systolic blood pressure for a critical period of time, will
nificant hemorrhage was noted from this area at the cause a shutdown of perfusion of blood to the choroid
time of the wire replacement, although this does not and retina.f As the retinal arteries are end arteries,
preclude subsequent persistent minor bleeding inside occlusion of these vessels produces blindness of the
the orbit from this source . portion of the retina supplied. Occlusion of the central
The surgeon involved in case 3, in which a patient retinal and posterior ciliary arteries produces a char-
had a permanent decrease in visual acuity in the left acteristic fundoscopic appearance that, in the early
eye following a Le Fort I osteotomy, thought this was stages, may include retinal edema, a cherry-red spot in
a complication related to hypotensive anesthesia. Cen- the macula, dilated retinal arterioles, and edema of the
tral retinal artery occlusion could have occurred if the optic disc. Arteriolar narrowing, optic atrophy, and fo-
systolic blood pressure was maintained below 60 mm cal retinal hypopigmentation or hyperpigmentation
Hg over an extended period , but this would be an un- may be noted later. 62 When ischemia affects all intra-
usual complication in a young, healthy woman. More- ocular tissues, including the layers of the retina, the
over, the early typical fundoscopic appearance of cen- outer retina suffers more than the inner retina, and the
tral retinal artery occlusion following hypotensive damage seen is similar to that seen in choroidal in-
anesthesia, an edematous retina with a cherry-red spot farction. 63 ·
at the macula, was lacking. No swelling of the optic Paresis of extraocular muscles is an uncommon
nerve was seen on the CT scan, which is a common complication following Le Fort I osteotomies. Because
accompaniment of optic neuropathy due to systemic these muscles are fixed posteriorly to a tendinous ring,
hypotension. Although the CT scan of the orbits and the annulus of Zinn/" they will be put on a stretch,
optic canals were reported as normal, this does not together with their accompanying neurovacular struc-
necessarily rule out traumatic damage to the optic nerve tures, if the orbital contents are subjected to traction,
in its intracanalicular portion. There does not appear compression, or contrecoup forces during the ptery-
to be sufficient evidence, however, to support positively gomaxillary dysjunction. The oculomotor and abdu-
one diagnosis over the other. cens nerves are situated within the common tendinous
Unilateral blindness has been reported following ring, whereas the trochlear nerve is situated outside
LANIGAN, ROMANCHUK, AND OLSON 493

specific ophthalmologic surgical intervention, although

this may be indicated at times.
Opt ic nerve ---;;'--i-f-
Acknowledgment
Ophthalmic -nn"=:iU
artery
The authors would like to thank those oral and maxillofacial sur-
geons and their ophthalmologic colleagues who mad e details of their
cases availabl e to us. and Dr LA. Al-Qurainy for his helpful sugges-
Inferior oph thalmic tion s.
\lein

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