Effects of midface surgery on ocular outcomes in patients with orbital/midface malformations


The investigators evaluated corrective surgery procedures to determine their effect on ocular outcomes.

A smiling child sits in a chair, preparing to undergo an eye exam. Image credit: ©georgerudy – stock.adobe.com

The study emphasized the importance of appropriate ophthalmologic evaluation of patients in relation to surgical decision-making. Image credit: ©georgerudy – stock.adobe.com

Dutch investigators from Erasmus Medical Center, Rotterdam, the Netherlands, reported that midface surgery has direct and indirect substantial effects on several ocular outcomes. The research team was led by Parinaz Rostamzad, MD, PhD, from the Department of Plastic and Reconstructive Surgery.

The investigators explained that orbital and midface malformations occur in multiple congenital craniofacial disorders, eg, craniosynostosis, facial clefts and craniofrontonasal dysplasia. The orbital malformations in craniofacial disorders include hypertelorism (significantly increased interorbital distance), orbital dystopia (abnormal displacement of the orbit and its contents) and midface hypoplasia (underdevelopment of the midface).

The patient presentations can include proptosis leading to incomplete eyelid closure and exposure keratitis, the inability to develop binocular vision, eye motility disorders, refractive errors and decreased visual acuity. As a result, some patients require surgical correction of the midface and orbits.

Different surgical corrections can be undertaken depending on the deformity, such as orbital box osteotomy (OBO) for hypertelorism; Le Fort III (LFIII) to advance the midface and zygomas and correct the nose and improve malocclusion and enlarge the upper airway; monobloc (MB) to enlarge the skull volume to reduce high intracranial pressure, midface advancement, improvement of proptosis, upper airway obstruction and malocclusion; and facial bipartition (FB) to correct hypertelorism and functional correction of V-shaped malocclusion if needed. The investigators evaluated these procedures to determine their effect on the ocular outcomes.

Dr Rostamzad and colleagues conducted a retrospective study of all patients with craniofacial disorders who had previously undergone a midface surgery to gain a better understanding of the short-term effects of the surgeries on patients with orbital/midface malformations. The literature has few reports on this patient population because of the small numbers of patients.

The study identified 63 patients who underwent the following procedures: 2 patients were treated by OBO, 20 LFIII, 26 MB, and 15 FB.

Preoperatively, 39 patients (61.9%) had strabismus, the most common form of which was exotropia (n = 27, 42.9%) followed by esotropia (n = 11, 17.5%). Postoperatively, the strabismus significantly worsened (P = 0.035) in the 63 patients.

Preoperatively, 9 patients did not have binocular vision (n = 33) (27.3%), in 8 it was poor (24.2%), moderate in 15 (45.5%), and good in 1 (3.0%). Postoperatively, the binocular vision improved significantly (P < 0.001).

Preoperatively, the mean visual acuity (VA) in the better eye was 0.16 logarithm of the minimum angle of resolution (logMAR), and 0.31 logMAR in the worse eye.

Finally, astigmatism was present preoperatively in 46 patients (73.0%) and hypermetropia in 37 patients (58.7%). No statistical difference was seen between the preoperative and postoperative VA levels (n= 51, P = 0.058)

“This study emphasized the high prevalence of ocular anomalies in patients with syndromic craniosynostosis with both preoperative and postoperative midface hypoplasia and/or orbital malformations, and therefore, we suggest that patients undergo proper ophthalmologic and orthoptic examinations at least once preoperatively (0–6 months before midface surgery) and postoperatively (3–12 months after midface surgery), or earlier in case of ocular emergency,” the investigators commented.

They also pointed out that because the strabismus worsened after MB and FB, timely communication between the ophthalmologist and craniofacial surgeons about strabismus surgery and midface surgery is necessary to avoid additional or multiple strabismus surgeries.

They also noted that the VA both improved and decreased after midface surgery, which may have resulted from correctly wearing glasses or noncompliance with amblyopic occlusion therapy; they advised that this should be discussed with patients and their parents. Some patients need occlusion or spectacle therapy, and that treatment can be continued properly after midface surgery to prevent development of amblyopia and VA decreases.

“This study emphasized the importance of appropriate ophthalmologic evaluation of patients, which could aid in the surgical decision-making and timing regarding the various pathologies in these children,” the investigators concluded.


1. Rostamzad P, Pleumeekers MM, Versnel SL, Loudon SE. Effect of midface surgery on ocular outcomes in patients with orbital and midface malformations. J Clin Med. 2023;12:3862;https://doi.org/10.3390/jcm12113862

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