Orbital Volume Augmentation for Enophthalmos Following Ventriculoperitoneal Shunting: A Case Study in “Silent Brain Syndrome”

Abstract

A 21-year-old female with a history of infantile hydrocephalus and ventriculoperitoneal shunting presented with bilateral persistent tearing. Examination revealed marked bilateral enophthalmos, poor lower eyelid apposition to the ocular surface, and patent nasolacrimal systems. Radiographic imaging demonstrated expanded orbital volumes with high arching orbital roofs, sequestered air under the eyelids, short, straight optic nerves, and expanded paranasal sinuses. Surgical intervention included insertion of mesh and block implants within the subperiosteal space of the orbital roof, resulting in correction of enophthalmos, improved lower eyelid apposition and resolution of tearing. However, new onset myopic astigmatism and bilateral ptosis were noted postoperatively and treated successfully with corrective spectacles and ptosis repair. Current literature has demonstrated the benefit of orbital roof implants through a upper eyelid crease incision. The authors present a case that supports the utility of this approach and addresses its potential complications, including postoperative-induced astigmatism/myopia and ptosis.

Corneal Perforation associated with “Silent Brain Syndrome”

“…A decade later, Cruz et al proposed that enophthalmos was a specific form of shunt-related skull change secondary to reduction of cerebrospinal fluid pressure that can lead to progressive orbital bone changes (2) . Other reports have confirmed these findings (3)(4)(5)(6)(7) . Even though exposure keratopathy has been described in some of these cases, no corneal perforation has been reported so far.…”

“…Cranial bone growth in childhood is dependent on cerebrospinal fluid pressure, and its reduction with VPS can lead to various skull anomalies (7) . Post-shunting enophthalmos was associated with the upward expansion of the orbital roof and sphenoid sinus rather than loss or fibrosis of orbital fat (6) .…”

“…Shunt removal and correction of the intracranial hypotension may presumably prevent further enophthalmos progression. Implant augmentation of the orbital volume via an upper eyelid crease approach are recommended to restore globe-eyelid apposition (7) .…”

Widening Aging Eyes and Ending Outdoor Tearing with Retrobulbar Injections of Dermal Fillers

“…13 The only known literature reference of a resolution of tearing through a block implant referred to a 21-year-old woman with a history of infantile hydrocephalus who presented with bilateral persistent tearing. 14 Examination revealed marked bilateral enophthalmos, poor lower eyelid apposition to the ocular surface, and patent nasolacrimal systems. The insertion of a mesh and block implant within the subperiosteal space of the orbital roof resulted in the correction of enophthalmos, improved lower eyelid apposition, and resolution of tearing.…”