Mydriasis during Orbital Floor Fracture Reconstruction: A Novel Diagnostic and Treatment Algorithm

Abstract

Orbital floor fractures are the most commonly encountered traumatic fractures in the facial skeleton. Mydriasis that is detected during orbital floor fracture reconstruction may cause significant distress to surgeons, as it may be associated with sinister events such as visual loss. It is not an uncommon problem; previous studies have shown the incidence of mydriasis to be 2.1%. The combination of careful preoperative evaluation and planning, as well as specific intraoperative investigations when mydriasis is encountered, can be immensely valuable in allaying surgeons' anxiety during orbital floor fracture reconstruction. In this review article, the authors discuss the common causes of mydriasis and present a novel systematic approach to its diagnostic evaluation devised by our unit that has been successfully implemented since 2008.

Transient Ipsilateral Mydriasis During Correction of Left Blowout Fracture

“…1 Unilateral mydriasis can be a life-threatening neurosurgical emergency, such as expanding aneurysm, intracranial hemorrhage, cerebral neoplasm, cerebral compression, meningeal infiltration, or tentorial herniation, rather than a bilateral one. [2][3][4] Several cases of postoperative anisocoria have been reported.…”

Transdermal Scopolamine and Perioperative Anisocoria in Craniofacial Surgery

“…5,6 Intraoperative mydriasis can be a sign indicative of visual loss if the optic nerve is damaged. However, iatrogenic damage to the optic nerve is very uncommon given its posterior location (the optic canal is located 45 mm posterior to the infraorbital rim).…”

“…The most (2) Cerebral anoxia common surgical cause of transient unilateral anisocoria is attributed to traction of the inferior oblique, causing brief neuropraxia to the parasympathetic postganglionic fibers that follow the muscle. 6,8,9 The contralateral eye should be evaluated if mydriasis is noted intraoperatively. Intraoperative and postoperative unilateral mydriasis in mid and posterior orbital floor injuries and repair often suggests manipulation of the ciliary ganglion with resulting temporary or permanent damage.…”

Unilateral Mydriasis After Maxillary Osteotomy: A Case Series and Review of the Literature

“…42,43 Local anesthetic also can diffuse from deposition near the lids or conjunctiva to cause cycloplegia and mydriasis. 7 Mydriasis and abducens palsy have been reported after administration of local anesthesia; case 2's presentation could be the result of local anesthesia, although the duration of palsy was slightly longer than typical. 43 Given the duration of symptoms in case 2, local anesthesia could have contributed, but the patient's situation was likely multifactorial.…”

“…11,13,23 When anisocoria develops during orbital dissection, it is most commonly secondary to dissection of or traction on the inferior oblique muscle and its accompanying parasympathetic fibers; neurapraxia is a common cause of anisocoria secondary to orbital floor fracture repair. 7,25 Intraorbital hemorrhage from direct damage to orbital vessels, a transected ethmoidal artery, or traction on the orbital fat causing vessel rupture can lead to compression in the posterior orbit. 18,26 Hemorrhage from vessels injured during maxillary mobilization also can extend locally, as can edema.…”