J Korean Ophthalmol Soc.  2019 Dec;60(12):1295-1300. 10.3341/jkos.2019.60.12.1295.

Loss of Reflex Tearing after Maxillary Orthognathic Surgery Case Report and Literature Review

• Bang SR
• Lee TE
• You IC
• Cho NC
• Ahn M

• KMID: 2466185
• DOI: http://doi.org/10.3341/jkos.2019.60.12.1295

Abstract

PURPOSE
To report a case of unilateral loss of reflex tearing after double-jaw surgery with anatomy and mechanism.
CASE SUMMARY
A 32-year-old woman complained of a 3-year history of loss of tearing in her left eye. She had undergone double-jaw surgery 3 years prior to correct her malocclusion. In orbital computed tomography (CT) images, there were no specific findings, with the exception of a fractured left pterygoid plate, possibly caused by the double-jaw surgery. The tear break-up times of both eyes were similar, with non-specific findings on slit lamp examination. We diagnosed loss of reflex tearing due to pterygopalatine ganglion injury based on her history, physical examination and orbital CT findings.
CONCLUSIONS
Nerve damage due to artificial fracture may occur during double-jaw surgery and may result in loss of reflex tearing, thus, pre-operative evaluation of basic lacrimal secretion and a reflex tearing test are important. Once the loss of reflex tearing due to nerve injury occurrs, orbital CT scans are needed for diagnosis. Ophthalmologist examination is necessary to confirm the mechanism of loss of reflex tearing and changes in the anatomical structure.

Keyword

Absent reflex; Orthognathic surgery; Postoperative complication; Pterygopalatine fossa

MeSH Terms

Adult
Diagnosis
Female
Ganglion Cysts
Humans
Malocclusion
Orbit
Orthognathic Surgery*
Physical Examination
Postoperative Complications
Pterygopalatine Fossa
Reflex*
Reflex, Abnormal
Slit Lamp
Tears*
Tomography, X-Ray Computed

Figure

• 

  Figure 1 Types of Le Fort osteotomy (A, B). Thick black lines across the skull are osteotomy line of each type.

• 

  Figure 2 A coronal section of case patient's facial computed tomography. The image shows fractured lateral and medial pterygoid plates of the left side (white arrows).

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  Figure 3 Pterygopalatine ganglion and pterygoid plate anatomy. (A) Greater petrosal nerve originates from temporal bone and joins deep petrosal nerve to form vidian nerve. Vidian nerve reaches pterygopalatine ganglion. (B) Pterygopalatine fossa (dark blue region, blank arrow) and pterygopalatine ganglion (yellow spot inside dark blue region, black arrow) in real skull image. (C) Axial computed tomography (CT) view of medial pterygoid plate (white arrows) and lateral pterygoid plate (yellow arrows). (D) Coronal CT view of medial pterygoid plate (white arrows) and lateral pterygoid plate (yellow arrows). (E) Medial pterygoid plate (white arrows) and lateral pterygoid plate (black arrows) in the skull. (F) Lateral image of lateral pterygoid plate (black arrow) and pterygopalatine fossa (yellow arrow, dark blue region). Pterygopalatine ganglion is located in pterygopalatine fossa.

• 

  Figure 4 Pterygoid plate fracture in Le Fort I osteotomy. (A) Pterygoid plate and pterygopalatine fossa may be damaged in the process of displacing the maxilla backward by cutting the pterygomaxillary junction. (B) Thick black line across maxilla (white arrows) is osteotomy line, which passes pterygopalatine fossa (blank arrow) and can injure the pterygopalatine ganglion (black arrow).

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