Correlation between fracture morphology of orbital floor fractures and the incidence of retrobulbar hematoma: A retrospective radiological and clinical study.

Orbital Emphysema

Orbital wall fractures result from external impact injuries which cause an abrupt increase in intraorbital pressure.1 Patients usually present to the emergency room with periorbital swelling and limited eye movements, with or without changes in vision. Relatively common in the Philippines, these fractures are frequently caused by violent assault followed by vehicular accidents involving motorcycles.2 Among 119 maxillofacial trauma cases seen and treated by the Department of Otorhinolaryngology of the East Avenue Medical Center from 2008-2009, 42 were diagnosed as cases of orbital fractures with 36% having concomitant involvement of the orbital floor. Various techniques in diagnosis and treatment developed in the past 20 years, each having its own strengths and weaknesses. The challenge of choosing which among these methods will best achieve the goals of function and aesthetics always confronts surgeons, particularly in a developing country setting. 
 We present a case of bilateral orbital floor fractures with diplopia repaired with conchal auricular cartilage graft in a 22 year old female.
 
 CASE REPORT
 A 22 year old female was immediately brought to our emergency room following a head-on collision with an Asian utility vehicle while driving a motorcycle without a helmet. She was conscious and coherent with stable vital signs.
 On examination, contusion hematomas were noted over both periorbital areas. Visual acuity was 20/30 OD and 20/40 OS with bilateral limitations of extraocular muscle movement. Bilateral ocular pressures were measured at 14.6 mmHg. Craniofacial CT Scans revealed linear frontal bone fractures with subdural hemorrhages and pneumocephalus in the frontal area, fractures of the calvarial bones, lateral orbital walls, inferior orbital rims and orbital floors (Figure 1). A mannitol drip was started for the hemorrhage.
 She developed a persistent headache and binocular vertical diplopia with monocular diplopia, OS on the left gaze accompanied by pain on lateral left duction. Visual acuity was 20/25 OU. On the 17th hospital day, she underwent open reduction and internal fixation of multiple facial fractures using titanium plates and screws with reconstruction of both orbital floors using conchal cartilage autografts. The right eye diplopia resolved on the third postoperative day while the diplopia on left lateral downward gaze in the left eye resolved from the ninth postoperative day until the day of discharge.
 There was complete resolution of diplopia and improvement in visual acuity to 20/20 OD and 20/25 OS on follow up at one year.
 DICUSSION
 Orbital floor fractures are relatively common midfacial injuries encountered in urban areas2 and were first described by Smith and Regan in 1957.1 Since then, many articles have been written about their diagnosis and treatment, including indications and optimal time for surgery as well as optimal surgical methods.1 Epidemiological studies reveal that despite different settings, the majority of cases involve the young male population with violent assault as the most prominent etiology accounting for 37.8% of orbital blowout fractures; motor vehicle accidents came in at second with 17.6%.; with the remaining fractures resulting from athletics (14.1%).2 To our knowledge, local reports have not been published but similarities in profile can be deduced.
 Orbital floor fractures, also known as blowout fractures, imply that the orbital rims have remained intact, whereas one or more walls of the orbit, typically the floor has fractured.3 Orbital floor fractures can be classified into pure and impure according to extent of bone involvement (Table 1). Pure blowout fractures are fractures of the floor not involving the rim while impure blowout fractures have rim extension.3 Pure orbital floor fractures are further classified as trapdoor or non-trapdoor. Trapdoor fractures are those in which either edge of the inferior orbital wall is attached to its original position, while non-trapdoor fractures are those in which the inferior orbital wall is completely separated from its original position and the periorbital tissue has prolapsed into the maxillary sinus1 (Figure 2). These fractures can be also be classified by location: anterior, posterior and anteroposterior1,4 (Figure 3). Our patient presented with non trapdoor type orbital floor fractures measuring 10 x 4 mm on the right and 10 x 5mm on the left.
 Patients with orbital floor fractures often complain of blurred vision and pain on eye movement. Physical examination also elicits diplopia, accompanying limitation of eye movement and enophthalmos on the affected side. These signs and symptoms are due to (1) herniation of orbital contents with concomitant partial atrophy of extraocular muscles and to (2) an increase in the volume of the orbital cavity with possible compression of the optic nerve.4 Because of these features, orbital floor fractures are classified as both Otorhinolaryngologic and Ophthalmologic emergencies that warrant immediate surgical treatment especially if the patient presents with blurred vision.3,5
 Confirmatory imaging studies help locate and assess the extent of orbital floor injury. These include radiographs and computed tomography of the facial bones. The commonly used radiograph is the chin-to-nose or Water’s view. This gives a view of the whole orbital area and may reveal a pathognomonic “tear drop” sign, seen as an elliptical opacity underneath the inferior orbital rim, that represents orbital contents, usually orbital fat, that herniated through the fracture.1,3 However, facial computed tomography is still the most useful imaging tool in assessing orbital floor fractures.1,2,3,4 It is usually requested without contrast using 3 different cuts: coronal, axial and sagittal. Coronal cuts reveal discontinuity of the inferior orbital rims with concomitant soft tissue sublaxation; axial cuts present the extent of areas involved while sagittal cuts help locate if the fracture is anterior, posterior or anteroposterior.1,4 
 The goal of surgical repair in orbital floor fractures is two-fold: to reposition herniated orbital fat and tissue back in the orbit; and to reconstruct the traumatic defect.4 Approaches are via open surgery (subciliary or transconjunctival) or endoscopic (transantral), (Table 2). The open transorbital approach is currently regarded as the mainstream method for reduction of blowout fractures of the inferior orbital wall. It is useful for releasing incarcerated soft tissue, as dissecting all soft tissue around the fracture area is necessary.1 Post operative complications include ectropion and unsightly scars, but these rarely occur in the hands of experienced surgeons.5 Endoscopic repair, usually via a transantral approach, can provide surgeons with several advantages over conventional external repair. These include excellent visualization of the medial and inferior walls of the orbit; easy access to maxillary bone (avoiding or minimizing use of intraocular alloplastic implants); virtual elimination of significantly visible facial scarring and eyelid complications; and performing the procedure under local anesthesia, making intra-operative evaluation of ocular movements and diplopia possible.5,6 A transorbital approach has the advantage of releasing incarcerated orbital tissue, while, in contrast, simply lifting the orbital tissue upward in a transantral approach may aggravate the incarceration1 (Table 2). In this patient, the open approach was used because a mid-facial de-gloving was necessary to access other fractures.
 The repair of orbital floor fractures involves many techniques, and adequate knowledge and skill is needed to perform any of these techniques employing careful judgment and analysis in formulating a plan that will fit the patient’s needs. As a general principle, the orbital complex is reconstructed by aligning its fractured parts with adjacent stabilized or intact structures.10 Familiarity with the complex shape of the orbital walls is important in repair. In the case of the orbital floor, it gently concaves inferolaterally, turning convex medially to posteriorly, assuming an S-shape configuration. 1,3 The posterior part of the floor is farthest from the inferior orbital rim with the infraorbital nerve coursing thru it makes it vulnerable and weak to the extensive forces absorbed when applied into the orbital area.1,3,10 This explains why posterior orbital floor fractures occur as non-trapdoor types and are difficult to expose. The orbital contents are positioned accurately and precisely into the orbit making any change in volume affect eye function. It is important to assess eye function first as it may give the examiner an idea of the extent of injury to the orbital floor. Indications for repair include diplopia, nonresolving oculocardiac reflex with entrapment (bradycardia, heartblock vomiting, nausea and syncope), fracture involving >50% of the orbital floor, and early enophthalmos or hypoglobus causing facial asymmetry.11 These signs and symptoms elicited during physical examination with documentation of the location of fracture through diagnostic imaging warrant early repair since herniated soft orbital tissue can atrophy within 2-3 weeks post trauma.4
 The types of grafts/implants used to span the defects of orbital floor fractures are divided into alloplastic and autogenous implants7 (Table 3). Autogenous grafts include bone, cartilage, and fascia. Alloplastic implants can be divided into nonabsorbable types, such as those made of silicone, polytef, hydroxyapatite, tantalum mesh, or titanium, and absorbable types, including those made of polyglactin or gel film. Repair of the orbital floor defect is mandatory if the defect measures at least 50% of the size of the orbital floor bone. The ideal implant must be nonreactive, provide good structural support, be easily positioned, and be readily available.1,2,3,4 In this case the surgeon utilized conchal cartilage grafts. This graft can be used in repairing defects as large as 2 x 2mm. It advantages over other autogenous grafts include having a shape similar to the orbital floor, ease of harvest, malleability and limited morbidity at the donor site.4 
 Autogenous tissue grafts, i.e. bone or cartilage, are preferred over alloplastic grafts in the repair of isolated orbital fractures similar to this case.10 Grafts (especially bone) should be secured to avoid displacement or migration and improve graft survival. Complete dissection of the fracture is necessary to identity the intact bone on all side of the fracture since these will be used as alignments when placing the graft. In the case of an orbital floor fracture, the posterior portion of the intact bone will serve as a guide to internal orbital reconstruction. The graft should be placed in inclined position just behind the inferior orbital rim to reach the intact posterior bone.3,10 Placing the graft based on correct anatomic position during reconstruction is of more significance rather than using the globe position as basis in volume restoration.10 It is a must to perform duction tests following graft placements and compare these to baseline duction test prior to surgery.9,10 This will help the surgeon distinguish if the stiff duction test is caused by edema from impingement of the musculofibrous ligament system by the graft material.10
 .
 Acknowledgement
 The authors would like to thank Dr Natividad Almazan and Dr. Felix Nolasco for their encouragement and support; and the resident doctors of the Department of ORL-HNS for their help in making this paper.
 
 
 
 
 
 
 
 

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Combined orbital medial wall and floor fractures and large isolated orbital floor fractures commonly require surgical treatment due to the high probability of diplopia and enophthal-mos. Primary reconstruction of these orbital fractures requires a high-level surgeon with a great amount of technical surgical skill. The use of novel technology can greatly improve the accuracy of reconstruction and achieve satisfactory clinical outcomes. Hence, the authors aimed to present our findings and overall experience with respect to extensive floor and medial wall orbital fracture reconstruction according to the Computerized Operation Neuronavigated Surgery Orbital Recent Trauma (CONSORT) protocol, a workflow designed for the primary reconstruction of orbital fractures with customized mesh and intraoperative navigation. A total of 25 consecutively presenting patients presenting with unilateral extensive orbital floor fractures and orbital floor and medial wall fractures were treated following the CONSORT workflow from January 2017 to March 2020. Fractures were surgically treated with a customized implant and intraoperative navigation. Patients underwent surgery within 14 days of the trauma injury. Preopera-tive and postoperative functional and aesthetic outcomes are described herein. All fractures were successfully reconstructed. Postoperatively, all 19 patients with preoperative diplopia reported the resolution of diplopia. Enophthalmos resolved in 18/20 cases. No patients had major complications during follow-up. Thus, the authors conclude that the CONSORT protocol introduced by the authors is an adaptable and reliable workflow for the early treatment of orbital fractures and can clearly optimize functional and aesthetic outcomes, reduce costs and intensive time commitments, and make customized and navigated surgery more available for institutions.

Orbital fractures: Timing of surgical repair

Background, Aim, and Objectives: Orbital floor blow out fractures are uncommon in children but can present with a dilemma in the Emergency department upon presentation. We collected case reports of 17 cases over a three-year period. The patients were selected from the age group six to 13 years of age with history of trivial blunt orbital trauma. The main complaint was mild pain in the eye upon presentation. Five patients were having clinical presentation of oculo-cardiac reflex. The suspected patients underwent Cone Beam CT of the midface with multiplanar cone beam reconstruction which confirmed the diagnosis of orbital floor fractures with trap door defect or minimal displacement and in a few cases inferior rectus entrapment. Orbital floor trapdoor fractures have oblivious features upon presentation and can easily be overlooked if not evaluated managed by expert healthcare providers which can lead to significant morbidity and even mortality in patients with oculocardiac reflex. Cone Beam CT of mid face with multiplanar reconstruction is the standard of care in the diagnosis and management of white eyed blow out orbital floor fractures in the provision of evidenced based healthcare practice. Methodology: This is a retrospective cohort study to evaluate the results of pediatric age group with trapdoor and blow out orbital floor fractures who underwent CBCT for the diagnosis and further management. Seventeen cases were selected who were in the age group between 6 to 13 years.12 cases underwent surgery for orbital floor exploration and nine were having inferior rectus muscle entrapment which was released. Five patients were managed non surgically. Result: One patient disappeared in this group during one-year post-operative follow up. No residual defect was found in the remaining sixteen patients. Cone beam Computer tomography with multiplanar reconstruction should be the standard of care for the diagnosis and treatment of blow out and trapdoor orbital fractures. Strength and limitations: Although this study is of a limited number of pediatric patients, but it highlights the significance of CBCT in the management of trapdoor and blow out orbital floor fractures in children. Further studies are needed to elaborate the utilization of CBCT in the treatment of orbital floor and medial orbital wall fractures. Conclusion: Our study suggests that CBCT has a higher value of specificity and less radiation exposure in the diagnosis of orbital fractures in pediatric age group when there is isolated orbital or mid face trauma, and CT brain is not recommended. Cone Beam CT with multiplanar reconstruction is considered the standard of care in the diagnosis of white eyed blow out orbital floor fractures in the provision of evidenced based healthcare practice. Perioperative CBCT and navigation should be universalized to achieve the best outcome.

Sir: A 25-year-old Hispanic man presented after being struck in the right midface with a wooden bat. Examination revealed a large laceration over the right eye, 7 mm of right-sided proptosis, a dilated right pupil, subconjunctival hemorrhage, the inability to abduct the right eye, and bilateral decreased visual acuity. Intraocular pressures measured 17 mmHg in the right eye and 12 mmHg in the left eye (normal, 10 to 21 mmHg). A maxillofacial computed tomographic scan demonstrated a right medial orbital wall blowout fracture with 17 mm of edematous medial rectus herniating 7 mm through the lamina papyracea (Fig. 1), and a right-sided retrobulbar hematoma tracking along the optic nerve (Fig. 2, left).Fig. 1.: Maxillofacial computed tomographic (3-mm slice thickness) axial view (above) and coronal view (below) at patient presentation. There is a 17-mm defect in the medial orbital wall. The medial rectus is herniated through the wall into the ethmoid sinus and is clinically entrapped (see text). Compared with the contralateral medial rectus in other slices, the herniated muscle is enlarged and edematous. Also note the marked periorbital soft-tissue swelling.Fig. 2.: (Above) Maxillofacial computed tomographic axial view of the patient at presentation. The retrobulbar hematoma is visible as a collection of blood directly behind the globe. (Below) Maxillofacial computed tomographic axial view after operative repair of the medial orbital wall with a Silastic sheet and reduction of the medial rectus. The thin implant is visible layered over the remaining lamina papyracea.The clinical and radiographic evidence of medial rectus entrapment and retrobulbar hematoma warranted urgent surgical exploration and decompression. A lateral canthotomy with subsequent medial orbital wall repair using a Silastic sheet were performed. Postoperatively, forced duction testing was normal, and the patient was started on 5 days of 60 mg of prednisone. A postoperative maxillofacial computed tomographic scan showed good reduction of the medial rectus muscle (Fig. 2, right). After 1 week, the patient's extraocular movements resolved fully, showing no signs of muscle entrapment. Orbital fractures commonly occur with midface trauma and range from nondisplaced to complex fractures disrupting the orbit. Of the orbital walls, floor blowout fractures are most frequently seen, and medial wall (lamina papyracea) fractures follow in frequency, as a result of their inherently weak structures. The incidence of isolated medial wall fracture ranges from 0 to 10 percent of orbital fractures, and the incidence of concurrent medial wall and floor fractures ranges from 6.8 to 22 percent in larger case studies and up to 47 percent in one smaller case study.1–3 Medial orbital wall fractures are often difficult to diagnose, with findings including asymptomatic (termed “white eyed”) subconjunctival hemorrhage, abduction failure, adduction failure, combination extraocular movement deficit, globe retraction, or proptosis secondary to edema.1,4 Many case reports demonstrate that these fractures can cause medial rectus incarceration, ischemia, and permanent visual deficits.1,4 Potentially more serious, a retrobulbar hematoma may introduce an emergent threat of permanent blindness, and is also difficult to diagnose clinically.5 Retrobulbar hematomas are uncommon following craniofacial trauma, with reported incidences ranging from 0.45 to 0.6 percent in retrospective reviews of large facial trauma series.5 Clinical diagnosis of acute retrobulbar hematoma lies in assessment of painful proptosis, visual deficits, and loss of pupillary reflexes; however, thin-slice maxillofacial computed tomography is a standard diagnostic aid in orbital trauma. Visual deficits result from increased pressure within the orbit stretching the optic nerve. As in our case, an orbital fracture may decompress a hematoma, resulting in normal intraocular pressures. Although isolated medial orbital wall fractures and their combination with medial rectus incarceration and retrobulbar hemorrhage are rare events, they are important conditions for those managing trauma patients. Because medial orbital wall fracture and retrobulbar hematoma may be silent, early recognition of subtle examination findings, expeditious imaging studies, and rapid operative intervention are crucial for minimizing permanent visual impairment. Arthur Turko, B.S. Simon Talbot, M.D. Bohdan Pomahac, M.D. Division of Plastic Surgery Harvard Medical School, and Brigham and Women's Hospital Boston, Mass.

EDITOR: Blunt orbital trauma with need of surgical repair is common. Postoperative complications are rare but may include retrobulbar haematoma [1], which may be serious since it can evolve rapidly into visual impairment or even permanent loss of vision [2]. Anaesthetists implicated in the postoperative care of such patients should be aware of this problem and its symptoms in order to act rapidly in an adequate way. Isolated treatment of pain and nausea and vomiting may result in permanent loss of vision within hours. Acute retrobulbar haemorrhage can follow as a severe complication of trauma, retrobulbar injections [3], orbital surgery or even minor eyelid surgery [4] with potentially devastating consequences such as loss of vision. Being aware of this potential complication and a rapid computed tomography (CT) scan may prevent grave sequel. This case highlights the need for increased awareness after blunt orbital trauma and orbital surgery. Case report A 41-yr-old male was involved in a dispute and punched in the face. In the emergency room the patient was conscious, had amnesia for the event, a right periorbital ecchymosis and haematoma but no nausea, vomiting or any visual deficit. A CT scan of the skull and brain revealed a fracture of the right maxillary sinus, including a haematosinus and a medial and inferior orbital wall fracture with a minor enophtalmus. Clinically, the patient described a minimal infra- and supraorbital hypoesthesia. The patient was transferred to an intermediate care unit for neurological surveillance and a conservative treatment was planned for the orbital wall fracture. Routine blood tests, including coagulation studies, were within norm ranges. Over the next 7 days, the hypoesthesia did not improve and the decision for surgical intervention was taken. The plastic and reconstructive surgeons performed a neurolysis of the infraorbital nerve and introduced a poly-p-dioxanon plate (PDS plate, 0.5 × 40 × 50 mm; Johnson & Johnson, Spreitenbach, Switzerland) to correct the enophtalmus. The patient was instructed not to blow his nose within the next 2 weeks. Despite these instructions, the patient did blow his nose and massive pain and nausea and vomiting developed rapidly. This happened within 12 h after surgery; for this reason the plastic surgeons called the anaesthetist responsible for postoperative pain management demanding a better treatment for pain, nausea and vomiting. To the anaesthesiologist, the intensity of pain appeared excessive for the type of surgery performed a few hours ago and the sudden onset of severe nausea and vomiting also appeared unusual. Clinically, the patient had an exophthalmus, which was difficult to visualize due to postoperative swelling and dressings. For these reasons a CT scan of the skull and the orbit was performed. These images revealed (Fig. 1) a massive right retrobulbar haemorrhage with marked proptosis and tenting (deformation) of the globe by the stretched optic nerve. The right pupil was deformed, indicating an optic nerve compression (relative afferent pupillary defect (RAPD)) and vision was reduced to 0.4 (normal = 1.0). The proptotic eye was immobile (‘frozen globus').Figure 1.: Transaxial computed tomography (CT), showing the retrobulbar haematoma and exophthalmus on the right hand side with compression of the inferior rectus muscle and compression of the optic nerve.An emergency revision with evacuation of the haematoma and removal of the PDS implant was performed. At the end of this procedure the globe was back in its proper position with improved extraocular movement and reduced RAPD. A few weeks later, the vision of the right eye was restored to 0.9 with full visual field and minimal residual RAPD. No postoperative CT scan was performed. Discussion Loss of vision is a complication of maxillo-facial trauma occurring in 0.67–3% of cases [2]. In a retrospective study [5] an incidence of loss of vision of 0.24% was found as a complication of surgery for orbital fractures; in 48% of the cases a retrobulbar haematoma was identified as the cause of this devastating complication. There is general agreement that the damage to the visual system caused by haematoma is the result of increased intraorbital pressure, which results in a decreased perfusion, representing a ‘compartment syndrome'. Bleeding frequently originates from the infraorbital artery or one of its branches. Owing to the anatomy of the orbit within inflexible walls, even a small haematoma may have catastrophic consequences. In fact, the orbital tissue seems to respond to fluid overload in such a way that once the hydraulic system of the orbit is exhausted, even small changes in volume can cause a dramatic increase in orbital pressure [1,6]. This pathology is also found in acute glaucoma. The pressure does not increase that dramatically when the haematoma finds its way into the periorbital sinuses via the orbital wall fracture. In this patient, however, this escape route was not possible because of the PDS plate in place. An orbital haematoma can cause complications ranging from vascular compression to acute stretching of the optic nerve resulting from proptosis. The accompanying retrobulbar oedema may additionally reduce retinal perfusion and compress the long and short ciliary vessels, leading to ischaemic damage to the optic nerve. In most cases the ischaemia occurs to the anterior part of the optic nerve [7]. The optic nerve provides some protection to the enclosed central retinal artery from direct compression. The higher systolic pressure of this artery also gives some added protection. Other vessels lying within muscle cones and entering the eye around the optic nerve do not have such protection. These include the prepapillary choroid and post ciliary arteries. Loss of vision can therefore occur without central artery occlusion and has been documented as anterior ischaemic neuropathy [8]. In some cases the vision is not at risk but displacement of the orbital structures by haematoma interferes with ocular motility and function. In the present case, the most critical aspect of orbital haematoma treatment is the rapidity of the diagnosis and the decision to perform immediate surgical drainage. Any delay between the onset of symptoms and orbital decompression can have a marked effect on functional recovery. It has been stated that if decompression is carried out within 2 h of the onset of symptoms it is likely to be successful in avoiding permanent damage [9]. Emergency lateral canthotomy with inferior cantholysis has been recommended as first-line treatment to reduce intraorbital and intraocular pressure while waiting for a CT scan and definitive surgery. It is a safe and often effective procedure to be performed even without any anaesthesia on a patient entering the emergency room with clinical suspicion of a retrobulbar haemorrhage [10]. Our patient was agitated, vomiting and ready to go to the operating theatre with a CT scan showing a major localized haemorrhage needing to be evacuated. Therefore no time was lost with a lateral canthotomy. Clinical diagnosis is based on a painful proptosis with or without visual deficit or loss of pupil reflex and nausea and vomiting. These symptoms are partially generated due to the rising intraocular pressure, which is ‘acute glaucoma' due to the impossibility that liquid can leave the front chamber of the eye. An emergency multi-slice CT scan is a fundamental diagnostic aid. The fundamental error that could have occurred in this case would have been to non-specifically treat pain with opioids and nausea and vomiting by central acting drugs such as serotonin antagonists, droperidol or dexamethasone. Symptoms would have been attenuated but the patient might have definitely have lost his vision on this eye. In conclusion, retrobulbar haematoma is a rare but severe complication of surgery for orbital fractures, with potentially devastating consequences such as loss of vision. Being aware of this potential complication and a rapid CT scan may prevent grave sequelae as well as the search of surgical complications in the immediate postoperative period.

Introduction: The aim of the study was to report 5 cases of concomitant traumatic macular hole (TMH) and orbital fracture and discuss its incidence. Methods: This was a retrospective, observational study including all patients with orbital fracture who were referred to us from May 2013 to December 2023. Axial and coronal orbital computed tomographic images with bone and soft tissue window algorithms and optical coherence tomographic images were obtained from all patients. Results: Among 1,171 sides from 1,152 patients with pure orbital blowout fractures, we found 5 sides from 5 patients (0.4%) with concomitant TMH. All trauma was caused by baseball/softball injury. One patient had a medial orbital wall fracture with TMH stage 1b. Two had orbital floor fracture with TMH stages 2 and 3. The other two had both orbital floor and medial orbital wall fractures with TMH stages 3 and 4. Orbital fracture was reduced in 3 patients. Two had spontaneous closure of TMH with no improvement in visual acuity, while one improved with pars plans vitrectomy and internal limiting membrane peeling. Conclusion: The incidence of concomitant TMH and orbital fracture is only 0.4%. The rarity of this association supports the protective role of orbital fractures in blunt trauma. Specific mechanisms of trauma, such as impacts from baseballs and softballs, may increase the risk of such injuries.

This Issue At A Glance

To describe a series of orbital fractures and associated ophthalmic and craniofacial injuries in the pediatric population. A retrospective case series of 312 pediatric patients over a 9-year period (2002-2011) with orbit fractures diagnosed by CT. Five hundred ninety-one fractures in 312 patients were evaluated. There were 192 boys (62%) and 120 girls (38%) with an average age of 7.3 years (range 4 months to 16 years). Orbit fractures associated with other craniofacial fractures were more common (62%) than isolated orbit fractures (internal fractures and fractures involving the orbital rim but without extension beyond the orbit) (38%). Roof and medial wall fractures were most common (30% and 28%, respectively), followed by orbital floor (24%) and lateral wall (18%) fractures. Orbital roof fractures are the most common fracture in patients <8 years old, whereas orbital floor fractures are the most common fracture in patients older than 8 years. Eighty-seven patients (28%) underwent surgical repair. There is an increasing incidence of surgery in older patients (p = 0.02). Associated neurologic injuries were more common (23%) than associated ophthalmic injuries (20%). Pediatric orbit fracture patterns are dictated by the age of the patient with respect to their craniofacial morphology and mechanism of injury. Orbital roof fractures are more likely to occur in younger patients and not require surgery, whereas orbital floor fractures are more common in older patients and are more likely to require surgery.

BACKGROUND: Craniofacial injuries contribute substantially to morbidity after blunt trauma, with orbital fractures seen in approximately 10–25% of all traumatic facial fractures. Orbital blow-out fractures occur when an orbital wall is fractured with an intact orbital rim, and usually occurs after significant blunt trauma from an object larger than the orbital aperture. The aim of this study is to determine the impact of age, injury severity, and mechanism of injury on orbital blow-out fracture patterns. METHODS: We retrospectively reviewed all patients admitted to a regional Level 2 Trauma Center, who sustained blunt orbital fractures, over an 11-year period, from January 2006 to December 2016. We excluded all patients who had orbital rim fractures and all penetrating trauma. Only patients who had a computed tomography scan of their face on presentation were included. There were 825 patients who met inclusion criteria. Individual charts were reviewed for demographics, length-of-stay(LOS), mechanism of injury(MOI), injury severity score(ISS), and mortality. Individual facial CT scans were reviewed along with the formal radiologist report to determine fracture locations. Statistical significance was set at a p value ≤0.05. This study was approved by our Institutional Review Board. RESULTS: Our cohort consisted of 825 patients, with 42 mortalities (5.1%). The mean age was 40.4 years old (range 1–97) and there was an approximate 4:1 male:female ratio. The mean LOS was 5.4 days (range 0–78) and the mean ISS was 14.7(range 1–50). The most common MOI was motor vehicle collisions(MVC) in 211 patients, followed by assault, ground-level mechanical falls, All-Terrain Vehicle(ATV) accidents, motorcycle collisions(MCC), and other mechanisms in 171, 151, 112, 53, and 127 patients, respectively. Overall, the most common orbital blow-out fracture involved the orbital floor in 567 patients (68.7%), followed by the lateral, medial, superior(roof), and posterior walls in 310(37.6%), 183(22.2%), 160(19.3%), and 16(1.8%) patients, respectively. The most common fracture pattern combination was orbital floor and lateral wall fractures in 202 patients (24.5%). The mean number of orbital blow-out fractures per patient in the entire cohort was 1.50. Orbital floor fractures remained the most common blow-out fracture in all age groups, accounting for 72.4% in pediatrics (1–17 years old), 66.4% in adults (18–64 years), and 77.7% in the elderly (age ≥65 years). Patients with ISS <15 were significantly more likely to have an orbital floor fracture when compared to patients with ISS ≥15, with fractures present in 81.1% and 56.9% of patients, respectively(p<0.05). MCC resulted in the highest mean number of orbital blow-out fractures per patient (1.83), which was significantly higher than other mechanisms(p<0.05). Patients who had ground-level mechanical falls were most likely to have orbital floor blow-out fractures (90.0%) compared with other mechanisms(p<0.05). CONCLUSION: Orbital blow-out fractures are a common injury after significant blunt craniofacial trauma. The orbital floor is most frequently involved, and patients who have mechanical falls seem particularly prone to this injury. Patients with lower ISS in our cohort likely had more concentrated craniofacial injuries, explaining their worse fracture patterns. MCC appears to confer the greatest craniofacial trauma with the most severe orbital blow-out fracture patterns. Age did not independently predict fracture patterns.

Assessment of a Consecutive Series of Orbital Floor Fracture Repairs With the Hess Area Ratio and the Use of Unsintered Hydroxyapatite Particles/Poly l-Lactide Composite Sheets for Orbital Fracture Reconstruction

The purpose of this retrospective study was to investigate treatment options for orbital floor fractures at a Level 1 Trauma Center in Southern California. A review of 45 cases of isolated orbital floor fractures treated at the University of California at Irvine between February 2004 and April 2007 was done. Patients were retrospectively analyzed for gender, age, mechanism of injury, associated facial injuries, presenting symptoms, method of treatment, and postoperative complications. Thirty-six male patients and nine female patients were treated. Motor vehicle collision (26/45) was the most common cause of injury, and the mean age of the patients was 35.5 years (range: 15-81 years). Ecchymosis surrounding the orbital tissue was the most common presentation (38/45). Diplopia was present in 8 of 45 patients, with 1 patient requiring urgent decompression for retrobulbar hematoma. Forty-three patients underwent surgical repair; 40 underwent transconjunctival approach with lateral canthotomy; 17 underwent reconstruction with porous polyethylene Medpor (Porex Surgical, Inc., College Park, GA.); and 26 underwent reconstruction with a titanium mesh plate. Immediate postoperative complications included 12 patients with infraorbital numbness, 3 with diplopia, 1 with cellulitis, and 1 with ectropion with a subcilliary approach. Average timing of surgery of our study was 4.94 days (range, 1-20 days). Orbital floor fracture management has changed significantly over the past few decades with the introduction of new internal fixation methods and new materials for reconstructing orbital floor defects. Recommendations for surgical intervention on orbital floor fractures mostly depend on clinical examination and imaging studies. Consequences of inadequate repair of orbital floor fractures can lead to significant facial asymmetry and visual problems. Both porous polyethylene and titanium plates are effective tools for reconstructing the orbital floor. Our review demonstrates that orbital floor fractures can be repaired safely with minimal postoperative complications and confirms that transconjunctival approach to orbital floor is an effective way for exposure and prevention of ectropion that can be seen with other techniques.

The trend of recovery period on postoperative eye movement in orbital blowout fractures