KAISER PERMANENTE SAN RAFAEL MEDICAL CENTER
ORBITAL SURGERY
DEPARTMENT OF OPHTHALMOLOGY
OCULOFACIAL PLASTIC & RECONSTRUCTIVE SURGERY
GREGG S. GAYRE, MD
BOARD CERTIFIED: AMERICAN BOARD OF OPHTHALMOLOGY
AMERICAN SOCIETY OF OPHTHALMIC PLASTIC & RECONSTRUCTIVE SURGERY

Anatomy and Diseases of the Orbit

The eye is confined by a rigid bony cavity called the “orbit.” The bones that make up the orbit surround and protect the eye and aid in the position the eyeball relative to the face. A system of muscles (for movement) and fat (for cushioning and stabilization) envelops the eye. The proper position and movement of the eye within the orbit is vital for normal vision and appearance. Critical blood vessels and nerves which contribute to normal vision, facial movements, and facial sensation pass within orbit and are easily damaged by orbital trauma or disease.

Surrounding the orbit on three sides are the air-filled sinuses. Because of their relative location to the orbit, the sinuses are frequently involved in orbital diseases and/or surgeries. Most commonly, infections may spread from an infected sinuses into the orbit. In such cases the orbital infection is often treated by draining the infected sinus.

The brain sits behind the orbits, and many nerves and blood vessels enter the orbit from around the brain. Some orbital problems are actually the result of disease further back, near or within the brain itself.

Many diseases can affect the orbit. Regardless of the diagnosis, common symptoms of orbital disease include eyeball displacement (usually forward), decreased or double vision, swollen and/or inflamed, eyelids, redness, eye irritation and pain.

Trauma can fracture and displace orbital bones. This may push the fat, muscles and/ or the eye into abnormal locations, such as into the sinuses. Typical consequences are double vision and disfigurement. Orbital fractures are often repaired using plastic and/or metal plates to replace and/ or secure fractured bones.

Orbital disease often occurs with thyroid problems. The inflammation that damages the thyroid gland also causes swelling of orbital muscles, which pushes the eye forward and/ or squeezes the nerve that connects the eye to the brain. Eye irritation, disfigurement, double vision, and vision loss can result. When orbital surgery is needed, the orbital bones are partially removed, allowing the muscles to expand into the sinuses.

Tumors can grow in the orbit. They may be benign and/ or congenital (present since birth), or they can be malignant. Malignancies can arise from inside the orbit, or they can travel there (metastasize) from cancers elsewhere. Tumors may also spread from the adjacent sinuses or overlying eyelid skin to secondarily involve the orbit. Surgery may be needed to diagnose, remove, or reduce the size of orbital tumors. Depending on the nature of the tumor, some tumors are not amendable to surgery. In such cases radiation or vascular embolization procedures may be need en lieu of or in addition to surgery.

When an eye is removed (enucleated) due to disease or injury, there are immediate and delayed effects on the orbit. If the volume of the lost eye is not replaced, the socket shrinks soon after enucleation causing a sunken appearance. Usually an implant of plastic or mineral is placed I the orbit to prevent this. Fat and muscle tissue continue to shrink over the years after surgery so that a sunken look may also occur later; also, the original implant can move, altering appearance. Years after removal of the eye, it may be necessary to add more implant material and/or reposition the previous implant.

Some disease of or around the brain can increase the pressure in the fluid around the optic nerve, which connects the eye to the brain. This may cause loss of vision. When it does, surgery may be advised to open the “sheath” that surrounds the nerve and release pressure.

Orbital Surgery

There are many variations of orbital surgery depending on the particular location and type of disease process. Nonetheless there are several generalizations true for all types of orbital surgery.

Orbital surgery is usually done with general anesthesia. There are many different types of orbital surgery. Sometimes no skin incision or only a very small and/or hidden one is needed to perform the operation. Other times larger incisions are needed and visible scars may result.

Depending on the procedure, you may go home the same day as surgery, or may be hospitalized for 1-2 days.

For the first few days after surgery there will be moderate pain, and possibly nausea. Your face will be bruised and swollen. You will be restricted from strenuous activity. Double vision is common after orbital operations. It usually lasts just a few weeks, but may be permanent and/ or require more surgery. Mild blurred vision and eye irritation are also common after orbital surgery.

In anticipation of surgery, it is very important to minimize your risk of bleeding. The orbit has a very rich blood supply and excessive bleeding may result in excessive bruising and swelling, need to abort the surgical procedure, failure of the procedure and possibly, permanent vision loss.

You will find an attached list of over-the-counter, prescription, and alternative medications that increase the risk of bleeding. In addition, it is very important to inform you doctor of any history of bleeding or clotting disorders.

Most orbital surgery is performed under general anesthesia. However, on occasion only IV sedation is necessary. It is therefore necessary that patients avoid eating or drinking after midnight on the morning of the procedure. Failure to comply will result in the cancellation of your surgery. Despite this warning it is important that you continue to take your regular medications with a small sip of clear fluids unless otherwise instructed by your doctor or nurse. If you have a condition that requires antibiotics before any invasive procedure, be sure to let your physician know, so that a prescription antibiotic can be provided in advance.

Prior to surgery, it is important that you secure a ride to and from the surgical center. It is also advised that you do not to rely on a taxi or public transportation in case you should require urgent medical attention in the immediate post-operative period. Failure to secure travel arrangements with a family member or friend may result in the cancellation of your surgery. Most patients will require assistance after surgery, and usually rely on a family member or friend for the first week after surgery. Extended assistance is usually unnecessary.

As with any surgical procedure, significant surgical complications are possible. The most dreaded complication of any surgery is a complication to your overall health (including death). Such complications are exceedingly rare and, in fact, your health is at greater risk from a motor vehicle accident on the way to or from surgery than from the actual procedure itself.

Additionally, when surgery is performed in the orbit, vision loss is possible. Again, in the hands of an experienced orbital surgeon, visual loss is rare, although mild temporary changes in vision may occur—see below. The exact risk for vision loss varies according to the type of orbital surgery performed, but in general can be estimated at 1-5%.

With any surgical procedure, a surgical scar in the skin is produced. The surgical wounds in most types of orbital surgery are minimal and barely noticeable. Where possible, these procedures are performed through a skin incision across the upper eyelid hidden in the eyelid crease, or within other natural folds of wrinkles. After the initial redness at the incision site resolves, scarring is minimal and not visible to the untrained eye. Occasionally, surgical scarring may result in an abnormally prominent scar or an asymmetric eyelid crease. For the vast majority of patients, these prominent scars or asymmetrical eyelid creases will resolve without need for further surgery. In rare instances, further surgical intervention will be required to treat abnormal scarring.

Other common risks of orbital surgery are failure to completely remove a tumor or failure to remove enough tissue to make an adequate diagnosis. In such cases further surgery may be necessary. Nerve damage or scarring can lead to permanent double vision which may be treated by prisms in your glasses or future muscle surgery. In some cases, despite further surgery, permanent double vision may occur. Failure to adequate position a sunken in or bulging eye may occur, requiring additional surgery. Prolonged swelling of the eyelids or conjunctiva (the clear lining of the eyeball) may occur. A drooping eyelid is common after orbital surgery and may persist for 3 to 6 months. In most cases the droop will resolve completely, but on occasion, surgical correction may be necessary.

Damage to the tear (lacrimal) gland may result in a chronic dry eye state. A temporary weakening of the eyelid closing muscles may result in failure of the eyelids to close completely. This is a temporary state that will resolve. During the period of healing, however, artificial tears and night-time lubricants may be necessary.

The sensory nerves of the eyelids and brows may also be affected by surgery. A mild numbness of the upper eyelids and lower eyelids is normal, but is temporary and will resolve completely. Surgery in the inferior orbit also typically results in dumbness extending throughout the cheek and possibly into the gums and teeth. This numbness is also temporary, but may take 3-6 months to resolve. On rare occasions, numbness may be permanent.

Infection is also a potential complication of any surgical procedure. Fortunately, infection after orbital surgery is very rare. You will be given an antibiotic ointment to apply to the incision site 4 times daily until your sutures dissolve or are removed. Oral antibiotics are also prescribed for 7 to 10 days.

In most cases dissolvable sutures are utilized to close your surgical incisions. These sutures are delicate. Avoid manipulating or rubbing your incision sites. As the sutures dissolve, itching and a slight increase in redness may occur. This is normal. Over the counter Benadryl® and ice may help with itching. Please avoid using home remedies or other over- the-counter remedies as they may cause an abnormal reaction in the delicate eyelid skin. If your surgical incisions opens: do not panic; continue to apply your antibiotic ointment and notify your physician.

Most orbital surgery requires that a pressure bandage be used for 1 to 2 days after surgery. Once the patch is removed ice packs are applied and are utilized for the next 48 hours in order to minimize swelling. Specialized ice packs are available at the pharmacy; however they are often expensive and function poorly. Many patients prefer to use a package of frozen peas as they easily conform to the curves of the face. Alternatively, bath cloths, soaked in an ice bath function well. Swelling is best minimized by applying ice for 20 minute intervals followed by 20 minutes without ice, then repeating. Cold compresses should be used at a minimum of 15 minutes out of the hour, every hour, while awake.

Despite the use of ice-packs, swelling, and bruising are normal after surgery, and if a dressing has been applied tightness may be present. Try to sleep with your head elevated on 2 pillows for 4 days. Do not rub the operative site. A slight amount of oozing from the incision is normal. The surface of the eye will also appear blood-shot and bruised for the first 10-14 days after surgery.

After surgery, it is normal to be somewhat drowsy, but try to eat a light, soft meal the evening following your surgery. If a dressing is taped over your eye, leave it in place for until your physician or nurse permits removal. The dressing should be kept dry. If oozing or bleeding occurs on the surface of the dressing, call the office.

A small amount of oozing from your surgical incisions is normal for the first 24 to 48 hours. However, it is always best to call the office of your doctor for any excessive swelling, bruising, pain, bleeding, or a fever above 101 degrees.

For the first two weeks after surgery, avoid straining the operative site. Limit your activities for 14 days. Avoid sneezing and coughing when possible. Afrin nasal spray may be necessary to treat a stuffy nose. No bending over or lifting objects greater than 15 pounds. Apply the antibiotic ointment to the incision four times a day, until your post-operative visit.

The second day may show the most swelling and discoloration. Swelling and bruising may persist for up to several weeks. If you had surgery on both sides of the face or on both eyes, it is not uncommon for one side to show more swelling. Try to sleep on your back for 2 weeks with your head slightly elevated (on two pillows, if possible).

After surgery or after any dressing is removed during the post-operative period, apply iced gauze pads to the operated eyelid for 2-3 days. Continue to put antibiotic ointment on the incision four times a day until your follow-up office visit. You may wash your face gently with a mild soap and water, but avoid vigorous scrubbing. You may shower and wash your hair with a mild shampoo 2-3 days after surgery. Non-dissolvable sutures will be removed 5-7 days after the surgery and you can begin to wear make-up at that time

After utilizing ice packs for 48 hours, discontinue and switch to warm compresses. Heat will help to hasten the resolution of any bruising or swelling that has developed. Use a warm bath cloth or heating pad for 15 minutes, up to four times daily. Be careful not to burn the delicate eyelid skin.

You may begin to wear contact lenses after 7 days. You may resume an exercise program after 2 weeks. Swelling, bruising, red and bumpy incision lines, numbness, tingling, hardness, crusting, itching, and tearing are normal and will go away with healing after several weeks or even months.

Mild discomfort after surgery is normal, though most patients remark that pain is in fact minimal. You will be given a prescription pain control medication at the time of surgery as well as medications to prevent nausea.

Post-operative healing time varies from patient to patient. It is advisable not to schedule travel plans or important events within four weeks of surgery. This will allow adequate time to heal. For most, swelling and bruising resolves within two weeks. It is not uncommon however, for patients to appreciate prolonged double vision and persistent mild blurring of vision. It is okay to patch your eye in order to neutralize the double vision. Alternatively, you can “black out” the lens in your glasses to neutralize the double vision. As you heal, temporary prisms may be used to correct for the double vision.

Dry eye symptoms may also temporarily develop following eyelid surgery. For most patients, the use of a non-preservative artificial tear solution every 1-2 hours as needed is recommended to alleviate this condition. It is normal to experience blurry vision after eyelid surgery. This is due to a temporary change in your refraction as result of altered blinking and eyelid position. Do not be concerned, this should improve quickly in the first few weeks after surgery. Occasionally mild blurry vision may last up to three months. However, significant loss of vision, especially accompanying extreme swelling of the eyelids and pain is NOT normal and your physician should be notified.

Most patients undergoing orbital surgery require post-operative visits at one day, one week, and one month following surgery. Occasionally more visits are necessary. As with any surgery, no guarantee can be placed on the outcome or cosmetic result of treatment following orbital surgery.

Orbital surgery is an affective means of improving visual function and/ or your facial appearance. I hope that you have found this information helpful and I would appreciate your feedback on how to improve this guide so that it will be helpful to future patients.

Frequently Asked Questions:

What are the risks of orbital surgery?
Bleeding for several days after surgery; droopy eyelid (ptosis); wound infection; persistent drooping of the eyelid; blindness; numbness of the face, cheek and forehead; asymmetry in appearance of the two orbits; double vision; persistent swelling of the eyelid or conjunctiva, prominent scarring; need for further surgery; ETC.

What are the symptoms that my eyes are dry and require lubrication?
Tearing, foreign body sensation, redness and blurred vision are common features of dry eye.

How long will the surgery take?
Orbital surgery typically takes 2 hours. However, the pre-operative evaluation requires up to 30 minutes and patients may require up to 2 hours observation in the post-op holding area.

Why is hospitalization necessary?
Patients are hospitalized for pain control and to monitor for signs that your vision may be compromised. Should vision threatening complications occur, you will be immediately available to return to the operating room, should it become necessary.

What types of conditions are not amendable to orbital surgery?
Typically diffuse disease processes and vascular lesions that infiltrate the normal structures of the orbit cannot be removed by surgical means for fear that excision would lead to vision loss. Vascular tumors that communicate the brain or carotid arteries are also not practically treated by surgical means as attempted removal can lead to excessive bleeding, stroke and death.

How is double vision treated?
Double vision is treated by patching until it resolves. For mild to moderate double vision, a prism can be placed on your glasses or incorporated into your prescription to neutralize the double image. If double vision has not resolved within six months, it may be necessary to undergo surgical correction to minimize the double vision in straight ahead and reading gaze. Double vision in extreme fields of gaze or when looking up are often not treated.

What types of orbital implants are used?
Most implants are synthetic materials made of porous plastic or corral material that become incorporated by your body’s own tissue. These implants have a very reliable history and are resistant to rejection. On occasion, infection may require removal of the implants.

Will my surgery be covered by my insurance?
Most orbital conditions are covered by insurance. Only procedures that are deemed as purely cosmetic are exempt. Because the vast majority of orbital disease results from trauma or systemic disease (such as thyroid eye disease), these conditions are fully covered.

I am a diabetic, are there special precautions?
As a rule, diabetics heal more slowly and have a higher risk of complications. It is important to have your blood sugar under tight control prior to surgery. Additionally, it is very important that you discuss with your physician and nurse, how to take your normal a.m. dose of insulin or oral glucose control medications. In most instances, your doctor will recommend avoiding taking oral glucose control medications and short acting insulin on the morning of surgery. Please confirm this with your doctor or nurse.

Should I take my regular medications on the morning of surgery?
Despite the rule of no eating or drinking after midnight on the morning of surgery, In most instances it is important to take your regular prescribed medications on the morning of surgery with a sip of clear fluid. Failure to do so could result in cancellation of your surgery.

What number should I call in case of emergency?
(415) 444-2000 and explain that you have recently had eyelid surgery and need to speak to Dr. Gayre or the eye specialist covering his “on-call” patients.