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Year : 2019  |  Volume : 22  |  Issue : 9  |  Page : 1307-1310

Management of ocular dystopia and lacrimal pathway obstruction in old multiple midfacial fractures: Case report

1 Resident of Ophthalmology Department, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
2 Plastic and Reconstructive Surgery Division, Ophthalmology Department, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Date of Acceptance31-May-2019
Date of Web Publication6-Sep-2019

Correspondence Address:
Dr. Y Irawati
Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Kimia Street No. 8, Central Jakarta - 10440
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_460_18

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Midfacial fracture is discontinuity of the bone affect maxilla, palate, zygomatico-maxillary complex, nasal bones, orbits, nasal-orbital-ethmoid complex, and frontal sinus. Delayed treatment can lead to malunion or nonunion bone. A 28 years old man presented with epiphora of the left eye and upgaze diplopia. There were enophthalmos, hypoglobus of the left eye, flat nasal bridge, and depressed left malar eminence. CT scan examination revealed multiple fractures of left nasal bone, left and right anterolateral wall of maxillary sinuses, left medial orbital wall and orbital floor, and left zygomatic bone. Lacrimal irrigation test showed obstruction of left nasolacrimal duct. He underwent osteotomy and fixation with plate and screw, orbital floor reconstruction with silicone block implant, external dacryocystorhinostomy with silicone tube insertion procedure. In delayed treated malunion of midfacial fracture, fixation with plate and screw after refracture using an osteotome and orbital floor reconstruction with silicone block can be a good option for restoring normal anatomy. External dacryocystorhinostomy with silicone tube insertion is an effective treatment for post traumatic nasolacrimal duct obstruction.

Keywords: Management, old multiple midfacial fracture, orbital reconstruction

How to cite this article:
Casalita V, Irawati Y. Management of ocular dystopia and lacrimal pathway obstruction in old multiple midfacial fractures: Case report. Niger J Clin Pract 2019;22:1307-10

How to cite this URL:
Casalita V, Irawati Y. Management of ocular dystopia and lacrimal pathway obstruction in old multiple midfacial fractures: Case report. Niger J Clin Pract [serial online] 2019 [cited 2022 Dec 8];22:1307-10. Available from:

   Introduction Top

Midfacial fracture is defined as discontinuity of the bone that may affect maxilla, palate, zygomaticomaxillary complex, nasal bones, orbits, nasal-orbital-ethmoid complex, and frontal sinus. Facial fractures mainly occur at young age with the average age being 20–40 years. Men are commonly affected than women with a ratio of 4:1.[1] These injuries are predominantly caused by motor vehicle accidents, followed by assault, sporting injuries, and home and occupational accidents.[1],[2] Disjunctions of the facial skeleton result in dysmorphic appearance and may cause many structure dysfunctions.

In midface trauma, dacryostenosis occur most commonly with the involvement of naso-orbito-ethmoidal complex, which include medial orbital wall as a part of the structure. Study by Becelli et al. reported posttraumatic epiphora in 46.5% of patients with naso-orbito-ethmoid fractures, and 29.3% of which experienced permanent epiphora.[3]

Delayed treatment can lead to malunion, in which bones heal in abnormal position, or nonunion, that is healing cessation without union of the bones. These complications can cause both functional and cosmetic deformity. In those instance, corrective surgery is required using osteotomies with rigid internal fixation, alloplastic implants, or bone grafting.[4],[5]

This case features multiple orbital, maxillary, and zygomatic fractures that result in significant diplopia, enophthalmus, and flattening of the cheek bone, complicated by nasolacrimal duct obstruction due to delayed surgical intervention. The aim of this case report is to describe the management approach that may lead to restoring optimal lacrimal excretory function, ocular functions, and esthetic outcomes.

   Case Report Top

A 28-year-old man, whose consent form was obtained from, presented with epiphora of the left eye and diplopia in upward gaze due to facial trauma seven months before. General examination showed flat nasal bridge and depressed left malar eminence. The ophthalmological examination revealed visual acuity was 6/6 with correction on both eyes. The intraocular pressure (IOP) of the right and left eyes were examined with Non-Contact Tonometry (NCT) and resulted in 11.3 mmHg and 9.7 mmHg respectively. The right eye examination was within normal limit. Examination of the left eye showed hypoglobus, enophthalmos, and eye movement restricted to superior, superonasal, and superotemporal gaze. There was discontinuity without crepitation on the superolateral and inferolateral left orbital rim on palpation. There was displacement of the medial canthus inferotemporally, and the shape was round. The lateral canthus was also displaced inferiorly and the superior sulcus was deep. The palpebral fissure of the right and left eyes were 25 mm and 23 mm wide horizontally, and 9 mm and 7 mm vertically, respectively. The intercanthal distance was 39 mm. The nasal bridge was flattened and left zygomatic eminence was depressed compared to the right side [Figure 1].
Figure 1: (a and b). Facial deformity including telecanthus, left enophthalmos, and hypotrophy, flattening of the nasal bridge and left cheek bone; (c-e). Left eye movement restricted to superior, superonasal, and superotemporal gaze

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Lacrimal irrigation testing (Anel test) of the left eye showed negative result in both superior and inferior punctal approaches, with pus regurgitation from inferior punctum. There was a hard stop on probing examination. The Goldmann diplopia test revealed diplopia on superior part of the binocular vision field which started to appear when the patient had eye movement at approximately 20° to 30° in every direction that involved superior component. Hess screen chart examination showed movement restriction to superior and temporal gaze of the left eye and partial overmovement to the nasal direction as well [Figure 2].
Figure 2: (a) Superior gaze diplopia found in Goldmann binocular visual field chart. (b) Hess screen chart showing movement restriction of the left eye to superior and temporal gaze

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The CT scan examination [Figure 3] and three-dimensional CT-Scan [Figure 4] revealed multiple fractures of left proximal nasal bone, left medial orbital wall, left and right anterolateral wall of maxillary sinuses, and left zygomatic bone. There were also bilateral maxillary sinusitis and left frontal sinusitis, and nasal septum deviation to the right side.
Figure 3: CT scan (a and d). Coronal plane showing left orbital volume enlargement, orbital floor defect, medial wall collapses and lateral orbital rim discontinuity; (b and e). Axial plane reveals enopthalmus of the left eye, defect of the lateral and medial orbital wall, and bilateral maxillary sinusitis; (c and f). Orbital tissue entrapment inferiorly showed in sagittal plane

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Figure 4: (a-d) Three-Dimensional reconstruction CT scan showed multiple fractures of nasal bone, left medial orbital wall, orbital floor, left maxilla and zygomatic bone

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In this patient, nasal bone fracture and septal deviation are found in central midface area; hence, the patient needs to be planned secondary septoplasty reconstruction and transnasal wiring by the ear, nose, and throat department.

   Surgery correction Top

This patient underwent the surgery on September 1, 2017 at Department of Ophthalmology, Cipto Mangunkusumo Hospital, Jakarta. The surgery begun with subciliary incision that was made along the lower eyelid margin and extending to lateral canthus about 1 cm in length. Undermining was done until periosteum of the inferior orbital rim was exposed. Skin incision was made 10 mm from medial canthus along anterior lacrimal crest. Undermining was done until periosteum of the medial orbital rim was exposed. Osteotomy of medial orbital rim and removal of bone callus were performed. Entrapped periorbital tissue was removed and gingivo-buccal sulcus opening was created to reach the fracture site. Osteotomy was made and excessive bone callus were removed. Fracture reduction of displaced fragment of zygoma and maxilla bone was carried out, followed by plate and screw fixation. Silicone block was placed over the orbital floor that adjusted to the correct fit. Periosteum was sutured and finally the skin was stitched with continuous and interrupted suture. Afterward, the external DCR with silicone tube insertion procedure was performed. Postsurgery medications included topical and oral anti-inflammatory and antibiotic drugs.

On three months follow up, the condition was found stable with good cosmetics and irrigation test revealed a positive result [Figure 5]. Postoperative Goldmann diplopia chart showed no diplopia in superior visual field. Hess screen chart showed no more restriction to superior gaze of the LE, but there was still restriction to temporal gaze [Figure 6]. There was no change of visual acuity in both eyes. Postoperative IOP of both eyes were reexamined with NCT and resulted within normal pressure (right eye 11.5 mmHg; left eye 9.2 mmHg).
Figure 5: (a) Slightly lower LE position. (b) remaining enophthalmus of the left eye. (c–e) No restriction in upgaze movements

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Figure 6: (a). Diplopia in superior gaze had subsided; (b). Hess screen chart shows improvement in superior movement of the left eye

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The facial bone structure was symmetric and diplopia improved after the surgery. Epiphora caused by obstructed lacrimal drainage system had resolved, with positive irrigation test results in both superior and inferior lacrimal puncta.

   Discussion Top

One of the problems faced in postponed fracture repair is malunion. Without immediate management, fracture sites start to heal spontaneously 10 to 14 days after trauma along with fibrovascular tissue formation, causing permanent facial deformity and functional problem. Such delayed cases may require surgical correction such as loosening of the bony fragment by refracting previous fracture sites with an osteotome and rigid internal fixation or plugging up the defect area using alloplastic implants or autogenous bone grafts. Small contour defects can also cover by soft tissue fillers.[2] Nonunion needs more aggressive treatment including exposure of the fracture site, fibrous tissue debridement, reduction, fixation, and autogenous bone grafting to bridge bony gaps and enhance healing.

In this case, there was malunion where bone fusion and callus formation on zygomaticomaxillary fracture sites so that permanent malalignment of temporal and inferior orbital rims had occurred. Therefore, osteotomy on fracture line was carried out and excessive bone callus removed in order to obtain sufficient mobility and bilateral orbital rim and zygomatic eminence symmetry, continued by fixation using mini plates and screws.

Plates and screws were used to reposition the zygomatic and fixate the refracture lines. The entrapped inferior orbital tissue in the maxillary sinus was released and silicone block implant was placed to close the floor defect.

In spite of achieving esthetic and functional restoration, some problems need to be resolved in the central midface area, including nasal bone fracture and septal deviation, that give the appearance of nasal bridge flattening, telechantus, and blunting of medial canthal angle. It is important to plan the secondary septoplasty reconstruction and transnasal wiring by the ear, nose, and throat department for this patient.

In delayed surgery of facial fractures (commonly more than two weeks), particularly with the nasoorbitoethmoid involvement, lacrimal obstruction can develop by one of following mechanisms: (1) malpositioning of nasoorbitoethmoidal fractures with subsequent permanent compression of lacrimal pathways; (2) further bone loss in the lacrimal area; and (3) retractions of scars involving the lacrimal system.[6] Early primary repair of nasoorbitoethmoidal fractures with wide open reduction and stable fixation helps reduce the rate of posttraumatic permanent lacrimal dysfunction.[6],[7] The locations of the lacrimal pathway blockage are variable, but the bony part is more vulnerable. According to a study by Xiao et al. on 63 patients with lacrimal system failure post nasoorbitoethmoid fracture, 61.90% of the obstruction was observed in the bony nasolacrimal canal.[8]

In conclusion, reconstruction of delayed treatment or old multiple midfacial fracture is challenging due to permanent remodeling of bones and periorbital soft tissue, and it also deals with adjacent vital structure. Refracturing the bones by osteotomy and realigning the displaced fragments with internal fixation and bone plates techniques is a complex procedure requiring surgical expertise and good clinical experience. Nasolacrimal duct obstruction is one of the complications encountered in medial wall fracture. Dacryocystorhinostomy procedure is the effective treatment for posttraumatic dacryostenosis, giving high success rate. Although it is difficult to have perfect results, significant improvement of the facial appearance can still be achieved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Reddy LV, Pagnotto M. Midface fractures. In: Fonseca RJ, editor. Maxillofacial Surgery. 2nd ed, vol 14. Philadelphia: Elsevier; 2009. p. 239-55.  Back to cited text no. 1
Gentile MA, Tellington AJ, Burke WJ, Jaskolka MS. Management of midface maxillofacial trauma. Atlas Oral Maxillofacial Surg Clin N Am 2013;21:69-95.  Back to cited text no. 2
Becelli R, Renzi G, Perugini M, Iannetti G. Craniofacial traumas: Immediate and delayed treatment. J Craniofac Surg 2000;11:265-9.  Back to cited text no. 3
Morris CD, Tiwana PS. Diagnosis and treatment of midface fractures. In: Fonseca RJ, Walker RV, Barber HD, Powers MP, Frost DE, editors. Oral and Maxillofacial Trauma. 4th ed, vol 17. Philadelphia: Elsevier; 2013. p. 416-50.  Back to cited text no. 4
Bowling B. Lacrimal drainage system. In: Bowling B, editor. Kanski's Clinical Ophthalmology. 7th ed, vol 2. Philadelphia: Elsevier; 2016. p. 63-75.  Back to cited text no. 5
Becelli R, Renzi G, Mannino G, Cerulli G, Iannetti G. Posttraumatic obstruction of lacrimal pathways: A retrospective analysis of 58 consecutive naso-orbitoethmoid fractures. J Craniofac Surg 2004;15:29-33.  Back to cited text no. 6
Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and incidence of nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg 1985;38:116-21.  Back to cited text no. 7
Xiao CW, Fan XQ, Fu Y, Zhou HF, Lin M, Ji J. Obstruction of lacrimal pathways in naso-orbital-ethmoid fractures and the relationship between lacrimal obstruction andfracture types. Chinese Journal of Ophthalmology 2007;43:1073-6.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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