Orbital Adherence Syndrome Secondary to Titanium Implant Material

PURPOSE: To report the association of extraocular motility restriction and/or eyelid retraction after orbital fracture repair using titanium. METHODS: Retrospective review of 10 consecutive patients who presented with diplopia and/or cicatricial eyelid retraction following the use of titanium implants for orbital fracture repair. RESULTS: Ten patients (8 male, mean age 29 years old) presented with orbital adherence syndrome after a primary procedure, by other surgeons, for an orbital fracture. Fractures had been repaired using titanium mesh along an orbital wall (10/10) and/or a titanium plate that was positioned over the orbital rim (4/10). Six of the 10 patients (60%) presented with cicatricial eyelid retraction and 9 of 10 (90%) presented with extraocular motility restriction resulting in diplopia. During the subsequent surgical repair of these patients, an intense fibrotic adherence was noted between the titanium implant within the orbit or periorbital tissues. All patients with diplopia undergoing secondary surgical intervention improved following the removal of the titanium and replacement with 0.4-mm nylon implants (Supramid), placed in a "wraparound" fashion along the orbital floor and medial wall. Cicatricial eyelid retraction was repaired by lysis of fibrotic tissue and elevation of the lower eyelid with full-thickness skin grafts. CONCLUSION: Titanium orbital implants may lead to the adherence of orbital and periorbital structures resulting in restrictive diplopia and/or eyelid retraction. Restrictive diplopia can be improved by the secondary replacement of titanium implants with nylon foil implants, although cicatricial eyelid retraction or ectropion requires additional reconstructive procedures for improvement.