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Sudden onset diplopia as a late complication of Supramid implant
Supramid implants are used in the repair of orbital floor fractures, but keep in mind the chance of intracapsular hemorrhage and secondary surgery.
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The goal in management of blowout fractures is to free up herniated soft tissue (fat, muscle and septae) and reposition it in the orbit. An implant is often used to cover the defect in the floor and prevent its re-herniation. Over the years, both autogenous and alloplastic materials have been used.
Autogenous implants have included fascia lata and bone grafting from the anterior maxillary wall, rib, split calvarium and tibia. Alloplastic grafts have included Teflon, Gelfilm, Supramid, porous polyethylene (Medpor), hydroxyapatite, silicone (Silastic), titanium and methylmethacrylate. Most ophthalmologists use alloplastic materials (commonly Supramid, Medpor and Teflon). These implants are readily available, easy to cut and mold to the orbital floor defect and relatively inexpensive.
The implants are relatively inert and develop a fibrous capsule that forms over weeks to months. Although complications are infrequent, they have been well described in the literature and include orbital infection, fistula formation, implant migration, extraocular muscle entrapment, dacryocystitis, hyperophthalmia, cyst formation, blindness, proptosis and hemorrhage into the fibrous capsule surrounding the implant.
In a 1992 article in Ophthalmology by Jordan et al, complications of alloplastic implants from four oculoplastic surgeons were reviewed. Out of the 17 patients who were identified, two had spontaneous hemorrhage into the capsule, one resolved with conservative management, and one required surgical drainage and removal of the implant.
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Complications
At the 2001 American Society of Ophthalmic Plastic and Reconstructive Surgeons Scientific Symposium, Philip Custer, MD, presented complications of Supramid implants. The retrospective study of 41 patients who underwent acute fracture repair or late orbital reconstruction with Supramid implants found five patients (12.2%) who experienced significant complications related to the implant. Four of these presented as a sudden onset of diplopia with globe displacement superiorly secondary to spontaneous hemorrhage into the implant pseudocapsule. The time from implantation to presentation of symptoms ranged from 21 days to 10 years. These complications were all treated with drainage of the hemorrhage, removal of the implant and marsupialization of the cyst.
The presentation caught our attention, and we were thankful that these complications had not happened to us over the years we have used Supramid. A year later, however, one patient who was 2 years post-repair of blowout fracture presented with a sudden onset of diplopia and superior globe elevation on the operative eye. CT scan without contrast showed a thickened mass along the floor of the orbit. Two years prior, the surgical treatment of his fracture included placement of a Supramid implant 0.4 mm thick, but the measurement on CT was 5 to 6 mm. Subsequent orbital exploration revealed a hemorrhage into a pseudocapsular cyst surrounding the implant. The implant was removed, the hemorrhage evacuated, and part of the cyst was excised. Postoperatively, the patient's symptoms improved dramatically.
Most recently, another patient presented with sudden onset of diplopia in primary gaze, a right hypertropia (Figure 1), and pain and restriction in upgaze. This patient had underwent a right orbital floor fracture repair with Supramid 37 months previously. CT scan showed a thickened mass along the inferior orbital rim (Figure 2). Upon surgical exploration, a pseudocapsular cyst was encountered surrounding the Supramid implant (Figure 3, arrow on implant). Upon incising the cyst wall, dark coagulum was found consistent with an old hemorrhage within the cyst (Figure 4, arrow on hemorrhage). This was evacuated, the implant removed (Figure 5) and part of the pseudocyst excised. Postoperatively the patient's diplopia and hyperglobus resolved (Figure 6), as did the pain and restriction in upgaze.
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Etiology
When discussing these events, it appears that the etiology is related to rupture of fine capillaries within the pseudocapsule surrounding the implant. The rupture of these capillaries may be related to migration of the implant. This accounts for the diplopia and hyperglobus with some proptosis. The initial treatment should consist of obtaining orbital imaging and possibly starting oral steroids. If the scans show a thickened capsule surrounding the implant or a cystic mass, then surgical intervention is indicated to facilitate a more rapid recovery and resolution of symptoms. The surgical management should consist of removal of the implant, drainage of the cyst and partial excision of the fibrous capsule. A secondary implant is not necessary, as the fibrous capsule acts as a pseudo-implant in preventing any re-herniation of orbital tissues.
In summary, Supramid implants are thin, cost-effective, readily available and serve as an excellent alloplastic material in the repair of orbital floor fractures. However, one should keep in mind the chance of intracapsular hemorrhage in a small percentage of cases and the possibility of a secondary surgery.
For Your Information:References:
- Mark R. Levine, MD, FACS, is a clinical professor of ophthalmology, Department of Ophthalmology, Case Western Reserve University. He can be reached at University Suburban Health Center, 1611 South Green Road, Suite 306A, South Euclid, OH 44121; 216-291-9770; fax: 216-291-0550.
- McCannel CA, Weinberg DA, Glasgow BJ, Goldberg RA. Intracapsular hemorrhage as a late complication of an orbital floor implant. Arch Ophthalmol. 1996;114(9):1156-1157.
- Jordan DR, St. Onge P, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology. 1992;99(10):1600-1608.
- Custer PL. Complications of Supramid orbital implants. ASOPRS Scientific Symposium. November 10, 2001.