Orbital floor reconstruction surgery repairs the thin bone beneath the eye when it has been damaged by trauma, tumour removal, or previous surgery, restoring the eye’s natural position and support. This case study follows one patient’s journey through orbital floor reconstruction surgery, led by consultant oral and maxillofacial surgeon Mr Nabeel Bhatti, and co-managed with consultant strabismus surgeon Nadeem Ali. It shows what this surgery can achieve — not only in clinical terms, but in a patient’s everyday life.
“Here’s a heart-warming double vision story.” — Nadeem Ali
What Is Orbital Floor Reconstruction Surgery?
The orbital floor is the thin plate of bone that forms the base of the eye socket, separating the eye from the sinus below. It supports the eyeball and the muscles that control eye movement. When this bone is damaged, the eye can sink, sit too low, or lose the muscle support it needs to move correctly.
Orbital floor reconstruction surgery rebuilds this bone using a graft or implant, restoring the socket’s shape and giving the eye the structural support it needs to function and sit correctly again. It is typically carried out by an oral and maxillofacial surgeon, an oculoplastic surgeon, or occasionally jointly with an ophthalmologist, depending on the cause and complexity of the damage.
What Causes Orbital Floor Damage?
- Facial trauma, such as a blunt injury to the eye area (a common cause of what is often called a “blowout fracture”)
- Tumour removal, where surgery near the eye socket disrupts or removes part of the supporting bone
- Previous facial or sinus surgery, which can occasionally weaken or displace the orbital floor
- Congenital or developmental conditions affecting the facial skeleton, in rarer cases
In the case discussed here, the damage followed treatment for a maxillary (upper jaw) tumour, illustrating how orbital floor reconstruction surgery is sometimes a necessary second stage after cancer treatment, rather than the result of an accident.
The Patient’s Story: Why Orbital Floor Reconstruction Was Needed
The patient had previously been treated for a maxillary tumour. The tumour removal successfully addressed the cancer, but it left the bony floor of his right eye socket damaged, causing the eye to sit noticeably lower than normal. This is a recognised risk whenever surgery near the orbit disrupts the bone that supports and positions the eye.
How Is Orbital Floor Reconstruction Surgery Performed?
Mr Nabeel Bhatti carried out orbital floor reconstruction surgery to rebuild the damaged bone and restore the eye to its correct level. Depending on the size and location of the defect, reconstruction can involve a titanium mesh plate, a resorbable sheet, or, less commonly, a bone graft taken from elsewhere in the body. The surgeon accesses the orbital floor either through an incision inside the lower eyelid or, in some cases, through the mouth, to avoid a visible scar on the face.
This reconstructive step was essential groundwork: without a properly rebuilt orbital floor, no amount of subsequent eye muscle surgery could achieve a lasting result. The reconstruction also revealed a further complication in this case — the right eye no longer moved downward and instead pointed persistently upward.
Restoring correct bone position is a principle Mr Bhatti applies across his wider facial reconstruction and facial asymmetry surgery work, where precise skeletal alignment underpins the entire outcome, whether the cause is trauma, tumour surgery, or a developmental discrepancy.
Diagnosing a Severe Eye Misalignment
Assessment found a significant vertical misalignment: 35 prism dioptres in primary gaze, worsening to 65 prism dioptres in downgaze. The deviation was so pronounced that the patient did not consciously notice double vision, because the misaligned image was hidden beneath his upper eyelid. Orthoptic testing confirmed the full extent of the problem, and clarified that the misalignment was a downstream consequence of the orbital floor injury rather than a separate, unrelated eye condition.
The Real-World Impact: A Career on the Line
The patient worked as a professional bus driver. Bus driving regulations require good visual acuity in both eyes and no double vision. Once the misalignment was identified, he no longer met the licensing criteria and had to stop working, losing his income.
“Saying ‘live with it’ or ‘use a patch’ was not an option.” — Nadeem Ali
A patch or a “live with it” approach wasn’t a realistic solution for someone who needed to return to safe, licensed driving. This is part of why orbital floor reconstruction surgery, followed by carefully staged correction of any resulting misalignment, matters so much in cases like this: the goal isn’t only a structurally sound eye socket, but a return to normal, functional life.
“I generally try to underpromise and overdeliver. But I really wanted to give this man hope.” — Nadeem Ali
What Happens After Orbital Floor Reconstruction?
Following orbital floor reconstruction, patients are typically monitored for swelling, bruising, and changes in eye movement or sensation, which can take weeks to fully settle. Any remaining misalignment, as in this case, is usually reassessed only once the initial swelling has resolved, since early measurements can be unreliable. Where correction of eye muscle position is still needed afterwards, this is usually staged, to allow careful reassessment between procedures.
In this case, the team planned a two-stage eye muscle operation, carried out three months apart, to restore properly aligned, single vision:
- Stage one: Right superior rectus recession (9mm) and left inferior rectus recession (7mm)
- Stage two: Right inverse Knapp procedure, with left superior rectus resection (7mm) and left lateral rectus recession (7mm)
This staged approach allowed the team to reassess progress between operations and fine-tune the correction needed for stable, lasting alignment.
The Outcome
Following the second operation, the patient achieved properly aligned eyes with single vision — free of the double vision and misalignment that had disrupted his life. He also met the visual standard required to hold his bus driving licence again.
“Thanks to God, at the end of it he had aligned eyes, single vision, and he is now back driving buses in London again.” — Nadeem Ali
He is now back behind the wheel, driving buses in London.
“Such a challenging case. Thanks for sharing, Nadeem — incredible you were able to correct his motility and achieve a great globe position.” — Mr Nabeel Bhatti
What Are the Risks of Orbital Floor Reconstruction Surgery?
As with any surgery near the eye, risks can include infection, bleeding, temporary or, rarely, permanent changes in eye sensation or movement, implant-related complications, and the possibility of further surgery if correction is incomplete. These risks are always discussed individually during consultation, since the right approach and materials depend heavily on the size, location, and cause of the orbital floor defect. Published clinical literature on orbital fracture management, such as the review by Boyette et al. in Clinical Ophthalmology (available via PubMed Central), outlines these considerations and the range of surgical approaches used internationally, which is broadly consistent with the staged, carefully planned approach used in this case.
Why This Case Matters
This case shows why orbital floor reconstruction surgery is often the essential first step before any further correction of eye position or movement can succeed. The initial reconstructive work by Mr Nabeel Bhatti to rebuild the orbital floor, combined with the carefully staged strabismus surgery led by Nadeem Ali, together restored both function and quality of life for this patient.
Outcomes in facial reconstruction and eye surgery aren’t only measured in clinical terms — they’re measured in the everyday things they make possible, including, in this case, getting back to work and back on the road.
About Mr Nabeel Bhatti
Mr Nabeel Bhatti (GMC 7043459) is a dual-qualified consultant oral and maxillofacial surgeon. He graduated in dentistry from the Royal London Hospital in 2002, then completed medical training at Guy’s and King’s College Hospital, followed by higher specialist surgical training on the London Oral and Maxillofacial Surgery rotation, with experience at UCLH, Great Ormond Street, and Barts Health NHS Trust.
He is a Consultant Surgeon at the Royal London Hospital, where his NHS practice focuses on facial trauma and complex oral and maxillofacial referrals, and he is an Honorary Senior Clinical Lecturer at Queen Mary University of London. His areas of interest include orthognathic and facial asymmetry surgery, TMJ surgery, post-traumatic deformity, and reconstructive facial surgery, including orbital floor reconstruction and condylar head reconstruction.
Mr Bhatti consults and operates in London, with a practice based at Battersea Power Station and surgery undertaken at accredited London hospitals and clinics, including affiliations in the Harley Street area.
Frequently Asked Questions
What is orbital floor reconstruction surgery?
What causes the need for orbital floor reconstruction surgery?
Can orbital floor damage affect eye movement?
Is orbital floor reconstruction surgery performed alongside eye muscle surgery?
How long does it take to recover from orbital floor reconstruction surgery?
Who is suitable for orbital floor reconstruction surgery?
Book a Consultation
If you or someone you know has orbital, facial trauma, or facial reconstruction concerns, arrange a consultation with Mr Nabeel Bhatti in London for a considered, consultant-led assessment.
Written by Mr Nabeel Bhatti
Consultant oral, maxillofacial & facial plastic surgeon, Harley Street, London.
AT A GLANCE
Mr Nabeel Bhatti
Consultant oral, maxillofacial & facial plastic surgeon.