Conditions: Periocular Injury from Sinus Surgery

What is a periocular injury?

Inadvertent injury to the contents of the eye sockets, periocular injury, can occur during sinus surgery. While this is a rare event, this page will explain some of the potential injuries ranging from minor to major.

Anatomy

The images below show a thin slice of the anatomy of a face from a CT scan, as if it were looking back at you. The colorized image on the right shows the relevant structures labelled. In green, the thin bone comprising the ethmoid sinuses is shown. Surgery to remove this bone (ethmoidectomy) is performed with care to preserve the thin bone separating the sinuses from the orbit (eye socket) and cranial vault (where the brain is).

Anatomic Extent of Injuries

In sinus surgery, millimeters matter. Let’s walk through some scenarios of progressively worse injury to the orbit during ethmoid sinus surgery, removal of the ethmoid cells shown in green above. If the bone (shown in blue) between the sinus and the orbit incurs a small fracture, there may be no consequence, as it may heal within a few weeks of surgery. During that time, there would be a risk of bacteria spreading to the orbit and causing an infection (orbital cellulitis) or if one were to sneeze or blow the nose, air could be pushed into the orbit (orbital emphysema). If a blood vessel within the orbit were to bleed, bruising around the eye could develop or, if the blood vessel is an artery, the blood pumped into the orbit (orbital hematoma) could cause increased pressure and pain, which may be treated with treatments (including lateral canthotomy and inferior cantholysis) to relieve pressure on the eye and optic nerve to avoid development of visual loss, which may be permanent. If a fracture is larger, then some of the fat of the orbit could herniate into the sinus. If enough fat volume is lost from the orbit, the eyeball may sink backwards (enophthalmos), which may be cosmetically unnoticeable if mild. Going further, if a muscle that moves the eye (such as the medial rectus muscle) were injured, movement of the eye could be impaired, leading to double vision. This complication may be improved by subsequent eye muscle surgery. If a surgical instrument were to breach significantly further into the orbital contents, the eyeball or the optic nerve could be injured, causing permanent visual loss. Fortunately, the higher the severity of complication generally correlates to lower chances of happening. The ethmoid sinuses are used in this example, but surgery on the other sinuses (maxillary, frontal, and sphenoid) also pose some risk to the orbit.

HOw is periocular injury prevented?

Many factors go into maximizing safety during sinus surgery. The surgeon references the sinus CT scan prior to surgery to understand the individual variances present. Improved endoscopic visualization and technology and surgical experience and technique are key elements to minimizing risk in sinus surgery.

How is periocular injury identified?

Injury may become apparent during surgery, though some complications may manifest after surgery. A change in vision, including loss of vision in one eye or double vision, eye pain, or a bulging eye should prompt communication with the surgeon. The time elapsed from symptoms to treatment, if needed, may influence final outcome—the sooner the better.

How is periocular injury treated?

General guidelines for patients after sinus surgery involve avoidance of certain conditions. Nose blowing should not be done and sneezing, if unavoidable, should be done with an open mouth to release the pressure as freely as possible. High blood pressure may cause bleeding, so keeping blood pressure normal includes avoiding strenuous physical activity, enduring severe pain, and using one’s usual blood pressure medications, if applicable. Treatment for bleeding within the eye socket (orbital hematoma) includes a relatively small surgical procedure (lateral canthotomy and inferior cantholysis), which requires a relatively minor repair a week or two later. Infection within the orbit (orbital cellulitis) involves use of antibiotics and, if an abscess forms, surgical drainage. Injury to the muscles that move the eye may be improved with surgery on these muscles by an ophthalmologist.