Bony Orbit Research Articles

Reconstruction of Bony Orbit Using Endoscope and Polyethylene with Embedded Titanium for a Patient with Postoperative Enophthalmos

Enophthalmos means displacement of the globe into the bony orbit backward, and usually downward. In post-traumatic enophthalmos, the mechanisms that determine the globe position can be the enlargement of the orbital cavity, the herniation of orbital fat into the maxillary sinus, fat atrophy, loss of ligament support, and scar contracture. It can be reconstructed through several approaches such as transconjunctival, canthotomy, lower eye lid, coronal approach, and by using bone, cartilage, and alloplastic materials. The authors report a case of postoperative enophthalmos reconstructed through subciliary and transnasal endoscopic approaches using porous polyethylene with embedded titanium.

Primary Orbital Intraosseous Hemangioma

Primary orbital intraosseous hemangioma represents a rare, histopathologically benign, vascular tumor of the bony orbit. Only 41 cases have been documented in the literature to date. The authors present 4 new cases of the disease and review the relevant literature. Retrospective, multicenter case note analysis of 4 patients with histopathologically confirmed primary orbital intraosseous hemangioma and a systematic review of the English-language literature. Four new cases of cavernous haemangiomata are presented with varying clinical manifestations, radiologic appearances, and treatments. Literature review (including the present 4 cases) yielded 45 cases in total. Presentation is often in the fourth and fifth decades (42% cases), the frontal bone being most commonly affected, followed by the zygoma, sphenoid, and maxilla. Intracranial extension occurred in 4 cases. Median duration of symptoms before presentation was 12 months (range, 1 month to 15 years) and the most frequent presentation was a painless mass, often on the orbital rim. The radiologic findings are reviewed. Histopathologically, the lesions were cavernous in 80%, capillary in 17%, and mixed in 3%; the capillary subtype seemed to be associated with more aggressive disease. Treatment was mainly by surgical excision and occasionally complicated by significant blood loss; preoperative embolization of lesions may reduce bleeding. Primary orbital intraosseous hemangioma is a rare vascular tumor that typically presents with a mass effect in the orbits of patients in the fourth and fifth decades of life. Preoperatively, it is important to be cognizant of the possible diagnosis as surgery can be complicated by life-threatening hemorrhage.

Congenital Orbital Fibrosis: A Distinct Clinical Entity

Purpose: To describe congenital orbital fibrosis as a distinct clinical entity, and highlight its constellation of features. Material and Methods: Retrospective, noncomparative, interventional case series of 4 patients with congenital orbital fibrosis. One patient underwent exploration of the orbit, release and biopsy of scar tissue. Two patients underwent strabismus surgery. One of these also underwent upper eyelid lengthening. Blepharoptosis, eyelid retraction, enophthalmos, proptosis, presence of a diffusely infiltrating orbital mass with secondary involvement of extraocular muscles, and dysplasia of the affected bony orbit were identified. Results: One patient presented with eyelid retraction, 1 with ptosis, and the remaining 2 had normal eyelid height. Furthermore, one patient demonstrated true enophthalmos. Of the remaining 3, 1 had symmetrical exophthalmometry, and 2 presented with proptosis. The later 2 patients presented with ipsilateral facial hypoplasia, accompanying orbital wall dysplasia and decreased orbital volume, confirmed on computed tomography. In addition, all patients demonstrated an irregular, retrobulbar mass located medially within the orbit, incorporating the medial rectus muscle. Conclusion: Congenital orbital fibrosis is a nonfamilial, nonprogressive, unilateral, distinct clinical entity, characterized by the presence of a diffusely infiltrating orbital mass with secondary involvement of extraocular muscles resulting in variable symptomatology due to the cicatricial process.

Lateral Orbital Expansion and Gradual Fronto-Orbital Advancement

In some patients with severe syndromic craniosynostosis, bony orbits are so small and shallow that the eyeballs dislocate. Dry cornitis and conjunctivitis can be seen often. When conventional fronto-orbital advancement is attempted in these cases, side walls of the orbit cannot go forward, because the width of bony orbit is smaller than the eyeball. To expand bony orbits and cranial volume, supralateral rim of the orbit was expanded laterally at the time of operation and gradually advanced foward postoperatively. With a coronal skin incision approach, frontal bone was taken off. Supralateral orbital rim bone was detached and cut at the centers of the orbits. Lateral expansion, 5 to 10 mm, was made and fixed with polylactate plates. A pair of distraction devices was fixed between the orbital rim and the temporal bone. Frontal bone was let floating on the dura mater and tied loosely with the orbital rim. Advancement of 1 to 1.5 mm/d was carried out, and the devices were taken off after 1-month consolidation period. Five patients with Pfeiffer syndrome, 1 with Crouzon, and 1 with Beare-Stevenson cutis gyrata syndrome were treated with this method. Procedure, outcomes, and complications are discussed.

Complex Midfacial Reconstruction: A Combined Technique of Computer-Assisted Surgery and Microvascular Tissue Transfer

The human midface is a complex anatomic region. The maxilla is the structural support between the skull base and the occlusal plane, resisting the forces of mastication, anchoring the dentition, separating the oral and nasal cavities, supporting the globe, and supporting the face and its mimetic musculature. 1 Futran N.D. Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006; 7: 249 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar The midface region dominates our outward appearance, which is unique to each individual, and its esthetic restoration after loss of the maxilla is of major importance for quality of life. Destruction of the midface may result from trauma, infectious or malignant disease, as well as from rare disorders of the immune system. The morbidity associated with total maxillectomy potentially includes impairment of deglutition and nutrition, orbital function and vision, speech and communication, self-image and mental health, and maintenance of hygiene and social acceptability. 1 Futran N.D. Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006; 7: 249 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar Reconstruction of midfacial defects still remains a surgical challenge, especially in cases with total loss of the maxilla including the orbital floor and preservation of orbital contents. 2 Cordeiro P.G. Santamaria E. Kraus D.H. et al. Reconstruction of total maxillectomy defects with preservation of the orbital contents. Plast Reconstr Surg. 1998; 102: 1874 Crossref PubMed Scopus (128) Google Scholar The overall goal is to replace the form and function of native tissue. In addition to separation of oral and nasal cavities, the contours of the bony orbit and the zygomatic prominence should be exactly restored, preserving optical function and facial symmetry. The prevention of diplopia as a result of postoperative enophthalmos should be of major importance, especially when orbital contents are not affected. ErratumJournal of Oral and Maxillofacial SurgeryVol. 72Issue 4PreviewIn “Complex Midfacial Reconstruction: A Combined Technique of Computer-Assisted Surgery and Microvascular Tissue Transfer” (Kokemueller et al., J Oral Maxillofac Surg 66:2398-2406) the author Martin Rücker MD, DMD, PhD should be listed as “Martin Rücker, MD, DMD”. Full-Text PDF

Imaging of Orbital Trauma

Assessing traumatic orbital injuries is an important challenge for radiologists; this assessment is even more difficult when the orbital injury is associated with injuries involving multiple organs. Common posttraumatic orbital injuries include anterior chamber injuries, injuries to the lens, open-globe injuries, ocular detachments, intraorbital foreign bodies, carotid cavernous fistula, and optic nerve injuries. Radiographic examination of the orbits is rarely performed. Ultrasonography (US) can be very useful for evaluating the globe and its contents; however, US is contraindicated if a ruptured globe is suspected. Magnetic resonance imaging may be difficult to perform emergently; it is contraindicated if there is a possibility that a metallic intraorbital foreign body is present. Computed tomography (CT) is considered to be the top choice for evaluating orbital trauma. The best protocol is to obtain thin-section axial CT scans, then to perform multiplanar reformation. When evaluating a patient with an orbital injury, the radiologist should do the following: (a) evaluate the bony orbit for fractures, note any herniations of orbital contents, and pay particular attention to the orbital apex; (b) evaluate the anterior chamber; (c) evaluate the position of the lens (the lens may be displaced, and it may be either completely or partially dislocated); (d) evaluate the posterior segment of the globe, look for bleeds or abnormal fluid collections, and evaluate for radiopaque or radiolucent foreign bodies; and (e) evaluate the ophthalmic veins and the optic nerve complex, especially the orbital apex.

Computer-aided Volume Measurement of Posttraumatic Orbits Reconstructed With AO Titanium Mesh Plates: Accuracy and Reliability

To prospectively evaluate the accuracy and reliability of "freehand" posttraumatic orbital wall reconstruction with AO (Arbeitsgemeinschaft Osteosynthese) titanium mesh plates by using computer-aided volumetric measurement of the bony orbits. Bony orbital volume was measured in 12 patients from coronal CT scan slices using OsiriX Medical Image software. After defining the volumetric limits of the orbit, the segmentation of the bony orbital region of interest of each single slice was performed. At the end of the segmentation process, all regions of interest were grouped and the volume was computed. The same procedure was performed on both orbits, and thereafter the volume of the contralateral uninjured orbit was used as a control for comparison. In all patients, the volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 1.85 cm3 (7%). This preliminary study has demonstrated that posttraumatic orbital wall reconstruction using "freehand" bending and placement of AO titanium mesh plates results in a high success rate in re-establishing preoperative bony volume, which closely approximates that of the contralateral uninjured orbit.

MRI of the fetal eyes: morphologic and biometric assessment for abnormal development with ultrasonographic and clinicopathologic correlation

Currently ocular biometric measurements are defined by US and are measured from the orbital walls. These bony landmarks cannot be seen by MRI, and therefore these measurements cannot be directly applied. To define measurements of normal growth of the fetal eyes using MRI. Transorbital views were analyzed in 198 fetal MR examinations. The ocular diameter (OD) and interocular and binocular distances (IOD and BOD) were measured and were plotted against gestational age. Fetuses with abnormalities affecting the eyes were evaluated separately. Of 198 scans, 146 had suitable images, 35 of which were abnormal. Normal growth of BOD, IOD and OD were determined, and compared with the respective already established US data. Normal growth charts were derived from a cohort of 111 normal fetuses. Because the margins of the vitreous are inside the bony orbit, at the same gestational age measurements of the BOD and OD are always less than the corresponding measurements by US, and those of the IOD are always more. Normal growth charts for MRI can now be used to support suspected diagnoses of orbital and ocular pathologies and the syndromes that give rise to them, and many examples are demonstrated.

Non‐traumatic enophthalmos: a review

Enophthalmos can be defined as a relative, posterior displacement of a normal-sized globe in relation to the bony orbital margin. Non-traumatic enophthalmos has a wide variety of clinical presentations and may be the first manifestation of a number of local or systemic conditions. It may present with cosmetic problems such as deep superior sulcus, pseudoptosis or eyelid retraction; or functional problems such as diplopia or exposure keratopathy. There are three main pathogenic mechanisms: structural alterations in the bony orbit; orbital fat atrophy; and retraction. Evaluation of enophthalmos patients includes orbital imaging and a thorough ophthalmic and systemic examination. In this review, we discuss the presenting features of non-traumatic enophthalmos and include a brief description of the more important causes. An approach to the clinical evaluation of these patients is also discussed together with a brief overview of the principles of management.

Magnetic resonance imaging of the endophenotype of a novel familial Möbius-like syndrome

Möbius syndrome typically presents as a sporadic trait with congenital facial palsy and abduction impairment. We used high-resolution magnetic resonance imaging (MRI) and genetic analysis to examine a family with features of Möbius syndrome. We examined 3 related family members having congenital complete opthalmoplegia with ptosis and facial diplegia. Orbits were imaged in quasi-coronal and sagittal planes of 2 mm thickness. Subarachnoid cranial nerves were imaged in planes of 1 mm thickness. Linkage and mutation analysis were performed to determine whether the pedigree harbored mutations in 4 candidate genes. In affected subjects, MRI showed marked hypoplasia of extraocular muscles and intraorbital motor nerves. In the anterior orbit, rectus extraocular muscles were less hypoplastic but markedly curved toward insertion. Oblique extraocular muscles were hypoplastic and abnormally inserted. Posterior bony orbits were hypoplastic. Optic nerves were markedly straightened. Brainstems and cranial nerves III, VI, VII, and VIII were normal bilaterally. No pathogenic mutations were detected in affected individuals. Previous MRI studies have demonstrated brainstem hypoplasia and cranial nerve aplasia in Möbius syndrome. The current family had normal brainstems and subarachnoid portions of motor cranial nerves innervating the orbit but marked extraocular muscle hypoplasia. These clinical and MRI findings are atypical for Möbius syndrome and other congenital cranial dysinnervation disorders. Congenital facial weakness and complete ophthalmoplegia may occur despite MRI evidence of normal brainstem anatomy. The endophenotype appears to result from a genetic defect distinct from the congenital cranial dysinnervation disorders defined thus far, rather than a global brainstem insult.

A simplified approach to teaching medical students ocular movements and the rationale in testing the oculomotor, trochlear, and abducent nerves

The actions of the individual extraocular muscles are best explained to medical students in a lecture format by showing the relationship of each muscle to the axes of the globe and the walls of the bony orbit. The lateral and medial rectus muscles cross only the vertical axis, and consequently, cause only abduction and adduction, respectively. These muscles can be tested simply by asking the patient to abduct or adduct. Inability to do so indicates that the muscles and/or their innervation have been compromised. In contrast, the superior and inferior oblique and rectus muscles cross all three axes (vertical, horizontal, and anteroposterior) of the globe. Therefore, concentric contraction of each of these muscles results in three movements; abduction or adduction, elevation or depression, and intorsion or extorsion. These muscles must be tested with a sequence of two movements. Gaze can be either elevated or depressed by both an oblique and a rectus muscle. If abduction or adduction occurs first, one muscle of the pair becomes incapable of causing elevation or depression of the pupil. The rationale for abducting or adducting first is that either the oblique or rectus muscle of the pair will no longer cross the horizontal axis and will then be unable to effect the desired movement. Inability to elevate or depress gaze from the abducted or adducted position shows which muscle, the oblique or rectus, and/or its innervation has been compromised.

Surgical Anatomy of Retaining Ligaments in the Periorbital Area

The aim of this study was to elucidate an anatomic detail of ligamentous attachments in the periorbital areas of Korean cadavers. Sixty-one hemifaces of 35 Korean adult cadavers (age range, 43-101 years; 23 men and 9 women) were used. Fifty-five specimens were dissected, 12 used for tension measurement, and 6 for histologic study. Definite retaining ligaments were found in 42 (76.4%) of 55 dissected hemifaces. We named the retaining ligaments attached to the bony orbit periorbital ligament (PL). Periorbital ligament was in the medial and lateral orbital area. Medial PL (MPL) was curvilinear shaped and between an angle of +23.4 and -23.1 degrees on the horizontal at a midpupillary line. Lateral PL (LPL) was crescent shape and between an angle of +39.1 and -42.1 degrees. The MPL was vertical along the medical orbital rim just outer to the orbital septum. The width of MPL was 0.8 mm, and vertical length was 22.1 mm. The crescent-shaped LPL was located a few millimeters (up to 4 mm) lateral to the lateral orbital rim. The maximum width of LPL was 6.9 mm, and vertical length was 28.2 mm. The breaking strength of the LPL (14.2+/-11.1 N) was significantly higher (P=0.016) than that of the central lower eyelid (5.1+/-2.5 N). The breaking strength of the MPL (8.4+/-3.0 N) was also significantly higher (P=0.013) than that of the central lower eyelid. However, there was no significant difference between LPL and MPL (P=0.055). Knowledge of the retaining ligaments is conducive to performing the midfacial rejuvenating surgery.

Aging of the Bony Orbit: A Three-Dimensional Computed Tomographic Study

Facial aging is a dynamic process involving the aging of soft tissue and bony structures. The shape, size, and volume of the bony orbit have all been shown to change with increasing age. In this study, we demonstrate how specific bony aspects of the orbit change with age in both male and female subjects and what impact this may have on the techniques used in facial cosmetic surgery. Facial bone computed tomography (CT) scans were obtained from 60 white subjects (30 female, 30 male). Our study population consisted of 10 male and 10 female subjects in each of 3 age categories. Each CT scan underwent three-dimensional (3-D) reconstruction with volume rendering. Orbital aperture width was measured as a line drawn from the posterior lacrimal crest to the frontozygomatic suture. This line was then used as the x-axis from which the distance to the superior and inferior orbital rim at nine equal increments (labeled 10 to 90) was obtained. The orbital aperture area was also measured on each 3-D model. The Student t test was used to identify any trends between age groups. The orbital aperture width and area in both our male and female subjects showed a significant increase with increasing age. There was a significant increase in height of the superior orbital rim medially in both genders, suggesting that the superior orbital rim receded with age in this region. The inferior orbital rim receded significantly laterally in our female population, while our male subjects had a recession of the entire inferior orbital rim. These results suggest that the bony elements of the orbit change dramatically with age, and this, coupled with soft tissue changes, can lead to the appearance of the aged eye and orbit.

An orbital depth guide for repair of the orbital floor

Repair of the orbit after injury is difficult and there are risks such as retrobulbar haemorrhage, and damage to critical structures of the superior orbital fissure, nasolacrimal apparatus, and the optic nerve that can lead to permanent blindness. The maximum depth of the socket is between 3.5–4.5 cm 1 Stassen L.F. Kerawala C.J. Peri and intraorbital trauma and orbital reconstruction. in: Ward-Booth P. Schendel S.A. Hausamen J.E. Maxillofacial surgery. 2nd ed. Churchill Livingstone, Edinburgh2006: 205-222 Google Scholar from the margin of the inferior orbit to the optic foramen and can be difficult to assess intraoperatively after injury. Recently Evans and Webb 2 Evans B.T. Webb A.A. Post-traumatic orbital reconstruction: anatomical landmarks and the concept of the deep orbit. Br J Oral Maxillofac Surg. 2007; 45: 183-189 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar highlighted important and reliable orbital landmarks that permit safe dissection within the bony orbit. To maintain a safe distance from deep structures within the orbit we suggest using a marked Howarth periosteal elevator as a guide. The orbital depth is marked on the elevator with a marking pen as shown in Fig. 1 and used as a guide during the operation.

Posttraumatic Enophthalmos

Enophthalmos is defined as a backward, and usually downward, displacement of the globe into the bony orbit. In posttraumatic enophthalmos, the mechanisms that determine globe position are: 1) the enlargement of the orbital cavity; 2) the herniation of orbital fat into the maxillary sinus; and 3) fat atrophy, loss of ligament support, and scar contracture. The aim of this article is to analyze the strategies to prevent enophthalmos and to correct late posttraumatic enophthalmos. In this study, 80 patients (52 cases of orbitozygomatic fractures and 28 late posttraumatic enophthalmos) were treated between January 1998 and January 2005. Fracture reduction in primary enophthalmos was performed. In enophthalmos as sequelae, the treatment consisted of orbital reconstruction in combination with bone grafts harvested from calvaria, iliac crest, and/or orbital osteotomies. In some cases, biomaterials were also used. All these techniques may also be combined depending on the severity of enophthalmos. The results were satisfactory in all cases. It is evident that a perfect correction of the deformity is difficult to achieve. Often soft tissue changes limit the aesthetic and morphologic results, despite adequate bony reconstruction.

Unilateral isolated frontosphenoidal craniosynostosis causing frontal plagiocephaly

Synostotic frontal plagiocephaly is most commonly caused by frontoparietal (unicoronal) synostosis, but may be caused by other fusions along the coronal hemiring. Frontosphenoidal synostosis is a rare cause of frontal plagiocephaly, with only five previously reported cases. We present the case of an 8-month-old male infant with frontal plagiocephaly caused by unilateral isolated frontosphenoidal synostosis mimicking frontoparietal (unicoronal) synostosis. The clinical and radiological features included flattened ipsilateral forehead, retruded ipsilateral maxilla, a midline chin, contralateral deviation of the nasal root and endocranial base, and anomalies of the bony orbit. Unilateral isolated frontosphenoidal synostosis may be misdiagnosed as unicoronal synostosis. Careful physical and radiological assessment is necessary to recognise this synostotic disorder of the coronal hemiring.

Linear scleroderma as a rare cause of enophthalmos: a case report

IntroductionEnophthalmos is an important physical sign which can be easily missed.Case presentationA 64-year old female presented with painless and progressive shrinking of her right eye. Visual acuity was 6/6 in both eyes. The main clinical findings included exophthalmometry readings of 14 mm in the right eye and 22 mm in the left eye and a linear scar on her right forehead. This scar is a feature of linear scleroderma and called "en coup de sabre". She was referred to a dermatologist for further assessment.ConclusionEnophthalmos is defined as the relative recession of the globe into the bony orbit and if measuring greater than 2 mm can give a noticeable cosmetic deformity. Scleroderma is a systemic or localised disease. Linear scleroderma has the following features-localised fibrosis of the skin, blood vessels, subcutaneous fat, muscle and sometimes bone. Histology shows an inflammatory and a sclerotic phase. Ophthalmic effects include enophthalmos, lash loss, lid induration or tightening and periorbital oedema.

Choice of proper time for orbital implant in anophthalmia children

From birth to adulthood, craniofacial development is dependent on the normal orbital growth. The increase of orbital volume is related to the growth of eyeball. Debates are ongoing as to when should be the appropriate age to remove abnormal globes and place orbital implants before puberty. Some articles suggested that the earlier to place of orbital implants the better, however, some considered that static orbital implants make invalid for stimulating the bony orbit to a full-developed volume, which will result in more than once implantation procedures. This article will focus on the growth of the orbit and the eyeball, retard of orbital development caused by soft tissue absence, as well as the selection of proper time for the placement of orbital implants during childhood.

Age-Related Changes of the Orbit and Midcheek and the Implications for Facial Rejuvenation

Aging of the midface is complex and poorly understood. Changes occur not only in the facial soft tissues, but also in the underlying bony structure. Computed tomography (CT) imaging was used for investigating characteristics of the bony orbit and the anterior wall of the maxilla in patients of different ages and genders. Facial CT scans were performed for 62 patients ranging in age from 21 to 70 years, who were divided into three age groups: 21-30 years, 41-50 years, and 61-70 years. Patients also were grouped by gender. The lengths of the orbital roof and floor and the angle of the anterior wall of the maxilla were recorded on parasagittal images through the midline of the orbit for each patient. The lengths of the orbital roof and floor at their midpoints showed no significant differences between the age groups. When grouped by gender, the lengths were found to be statistically longer for males than for females. The angle between the anterior maxillary wall and the orbital floor was found to have a statistically significant decrease with advancing age among both sexes. Bony changes occur in the skeleton of the midcheek with advancing age for both males and females. The anterior maxillary wall retrudes in relation to the bony orbit, which maintains a fixed anteroposterior dimension at its midpoint. These changes should be considered in addressing the aging midface.

A new treatment based classification system for fractures of the bony orbit

Introduction: Orbital fractures are common and may be isolated or associated with other injuries of the facial skeleton and soft tissues. The floor is often fractured in isolation but orbital fractures can involve all walls. To date there has not been report of a classification system based on treatment algorithm, only on anatomical location of injury.