Risk Factors for Ocular Complications Following Orbital Fractures: A Large–Scale Multivariate Analysis

Background: Orbital fractures are common in maxillofacial trauma and have varying anatomical deficits depending on the mechanism of injury. Orbital floor fractures are most common, but many patients suffer from two wall-floor and medial wall defects. Precise reconstruction and positioning of the orbital implant post traumatic injury can be technically challenging, especially in two wall fractures. We present our experience using the 3D Titan implant on a series of 7 patients with combined medial wall and orbital floor fractures. Methods: A retrospective chart review was performed of patients with combined medial wall and orbital floor fractures treated with 3D Titan between February 2016 and June 2020. The inclusion criteria were unilateral combined medial and orbital floor fractures due to traumatic etiologies, no previous history of orbital trauma, age older than 18 years, a contralateral healthy orbit, and a clinical follow-up of at least 1 month. Variables and outcomes included patient age, gender, mechanism of injury, visual defects, post-op infections, enophthalmos, proptosis, and diplopia. An O-arm intraoperative CT scanner was used to verify the implant position. Results: Ten patients presented with combined medial wall and orbital floor fractures, 3 were lost to follow-up. There were 6 men and 1 woman, and their ages ranged from 24 to 57 (mean age 38). Follow-up time ranged from 4 to 52 weeks, and a mean of 20 weeks. None of the patients experienced intraoperative complications such as hemorrhage, soft tissue incarceration, or acute optic neuropathy. No patients had postoperative infection or any change in visual acuity. All patients had satisfactory implant positioning as verified by intraoperative CT. Conclusions: The prefabricated design of the 3D Titan along with use of intraoperative CT guidance allows for efficient and precise reconstruction of combined medial wall and orbital floor fractures.

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

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.

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

Little attention has been paid to combined orbital floor and medial wall fractures with the involvement of the inferomedial orbital strut. Managing this particular fracture can prove challenging. However, various innovative techniques have been introduced to assist with the process. Our study focuses on sharing our approach to orbital wall reconstruction using navigation guidance and titanium-reinforced porous polyethylene plates, specifically cases involving the inferomedial orbital strut. We believe that implementing a navigation system can effectively lead surgeons to the fracture site with utmost safety. Also, we hypothesized that this navigation system is beneficial to use singe fan titanium-reinforced porous polyethylene plates with orbital wall fractures involving IOS while minimizing possible complications. We retrospectively reviewed 131 patients with medial orbital wall and orbital floor fractures with or without combined other facial bone fractures who underwent orbital wall reconstruction by a single surgeon from May 2021 to May 2023. Amongst, we identified fourteen orbital wall fractures involving the inferomedial orbital strut. We used a subciliary incision as the only approach method for performing titanium-reinforced porous polyethylene plates for navigation-guided orbital wall reconstruction. Patients were followed up for at least three months. All cases were effectively resolved using titanium-reinforced porous polyethylene plates. There were no complications during the patient's complete recovery, confirmed clinically and radiologically. Based on the serial CT results, it was discovered that implanted titanium-reinforced porous polyethylene plates successfully covered the defect. Based on our retrospective analysis, it has been determined that among the 131 recorded cases of orbital fractures, 14 of them (or 10.7%) involved the inferomedial orbital strut. Navigation-guided reduction using titanium-reinforced porous polyethylene (TR-PPE) plates can lead to predictable, reliable, and excellent outcomes for treating orbital fractures involving the inferomedial orbital strut without complications.

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.

Orbital Emphysema

Orbital fractures: Timing of surgical repair

Objective To observe the clinical efficacy of porous polyethylene titanium mesh implants for orbital blowout fractures. Methods The data of 20 eyes of 20 cases of blowout orbital fracture were retrospectively analyzed, including 6 cases of orbital medial wall fractures, 6 cases of orbital floor fractures, and 8 cases of orbital floor and medial wall fractures. There were 6 cases with diplopia, 6 cases with enophthalmos more than 3 mm, 2 cases with apparent downward globe dystopia, 6 cases of the fracture area over 20mm×20mm with herniation of large amount of orbital contents. Orbital fracture repair surgery was performed in all cases. The diorthosis of orbital fracture with an incision at inner canthus to implant porous polyethylene titanium mesh was performed in 6 cases of orbital medial wall fractures. Diorthosis of orbital fracture with an incision at lower palpebral margin to implant prefabricated mesh was performed in the rest 14 cases. Results All patients were followed up for 3 to 6 months.Diplopia was completely disappeared in 5 cases, and improved in 1 case. The 6 cases of enophthalmos was successfully corrected to less than 2 mm of enophthalmos. The vertical globe dystopia of the 2 cases disappeared. 6 cases of the fracture area more than 20 mm×20 mm had not showed enophthalmos. No visual acuity impairment was observed.No complications such as limited eyeball movement, rejection or migration of the implants occurred. Conclusion Porous polyethylene titanium mesh implants for orbital blowout fractures is safe, effective and stable. Key words: Fractures, orbital, blowout; Titanium mesh, porous polyethylene

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.

Negative orbit vector is defined as the most anterior globe portion protrudes past the malar eminence. The aim of the study was to evaluate the relationship between negative orbit vector and blow-out fracture location analyzing the distance between the anterior corneal surface and orbital bone with facial soft tissue in medial and orbital floor blow out fractures using orbital computed tomography (CT). Seventy-seven patients diagnosed with blow-out fractures involving the medial or orbital floor were included. Distances from the anterior cornea to lower lid fat, inferior orbital wall, inferior orbital rim, and anterior cheek mass were measured using orbital CT scans. The proportion of negative orbit vector and measured distanced were compared between medial wall fracture and orbital floor fracture. Medical records including age, sex, concomitant ophthalmic diagnosis, and nature of injury were retrospectively reviewed. Forty-three eyes from 43 patients diagnosed with medial wall fracture and 34 eyes from 34 patients diagnosed with orbital floor fracture were included. There was no significant difference in the distance from the anterior cornea to lower lid fat (P = 0.574), inferior orbital wall (P = 0.494), or orbital rim (P = 0.685). The distance from anterior cornea to anterior cheek mass was significantly different in medial wall fracture (-0.19 ± 3.49 mm) compared with orbital floor fracture (-1.69 ± 3.70 mm), P = 0.05. Negative orbit vector was significantly higher in orbital floor fracture patients (24 among 34 patients, 70.6%) compared with those with medial wall fractures (19 among 43 patients, 44.2%) (P = 0.04). Patients presenting with a negative orbit vector relationship when the most anterior portion of globe protruded past the anterior cheek mass and malar eminence were more likely to develop orbital floor fracture than medial wall fracture.

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm(2); the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm(2). Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).

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. &#x0D; We present a case of bilateral orbital floor fractures with diplopia repaired with conchal auricular cartilage graft in a 22 year old female.&#x0D; &#x0D; CASE REPORT&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; DICUSSION&#x0D; 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.&#x0D; 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.&#x0D; 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&#x0D; 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 &#x0D; 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.&#x0D; 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 &gt;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&#x0D; 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 &#x0D; 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&#x0D; .&#x0D; Acknowledgement&#x0D; 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.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

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.