Monday, January 11, 2016

Ask the Doctor: Which Surgery First?

CCA posts a monthly blog series called, "Ask the Doctor." You can submit your questions to Annie Reeves ([email protected]) and we will ask Dr. Earl Gage of Kids' Plastic Surgery in St. Louis to answer them. Thanks Dr. Gage for helping spread information and resources for our cranio families! Today's question is about a course of treatment for a 9-year-old boy with nystagmus.

Ask the Doctor

Question: My 9-year-old son has no specific diagnosis, but has has many of the same general diagnosis's as children with CFND.  In addition he has congenital nystagmus.  Opinions have varied on the sequence of surgeries for him and possible combination of surgery regarding hypertelorism and midface, Lefort III.  Is there a specific benefit in the order of the surgeries?  Is it safe to do these surgeries together?  Is possible that surgery to correct hypertelorism will have a positive benefit for a child with nystagmus? 

Answer: With regard to sequencing of the hypertelorism correction and the Lefort III surgery, there probably is not a right answer. Opinions will vary from surgeon to surgeon, and there are many factors that need to be considered. For instance, how significant is the hypertelorism? Does the child snore and have sleep apnea? If the child has sleep apnea, is it effectively being managed with CPAP or other strategies? Is the child being teased, and if so, what aspect of the child’s appearance is attracting the negative attention?  Are there problems with biting and chewing as a result of the poor midface growth and the relationship of the teeth?  If there are no sleep or apnea concerns and the hypertelorism and appearance of the eyes seem to be the biggest concern, then correcting the hypertelorism might be the higher priority.  If there are obstructive apnea and sleep concerns, then this might weigh in favor of doing the Lefort surgery first.  It is my opinion that doing orbital surgery and a Lefort III at the same time would be too much surgery and may unnecessarily increase the risk of infection and other complications.  

As for the possible effects of hypertelorism correction on your child’s nystagmus, this is not my area of expertise. However, based on discussions with a pediatric ophthalmology colleague, I would say it is not likely that correction of the orbit position would have any impact on the nystagmus. There are many causes of nystagmus, most of which relate to intrinsic problems with the eye itself, central nervous system disease or optic nerve problems. I would not expect any of these common causes to be altered by mechanically moving the position of the orbit. I strongly encourage you, however, to ask your ophthalmologist for an opinion since he or she knows your child’s situation best.

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