Inferior Orbital Wall Fracture Research Articles

Predicting late enophthalmos: Differences between medial and inferior orbital wall fractures

The purpose of this study was to compare the strength of the relationships between predictors and late-onset enophthalmos in medial and inferior orbital wall fractures and to determine the most significant predictive factor of enophthalmos in medial or inferior orbital wall fracture. Sixty-three adult patients with unilateral medial or inferior orbital wall fracture who had been left untreated for more than two months were enrolled in this study. Patients who had accompanying multiple orbital wall fractures and those with orbital-zygomatic fractures were excluded. Orbital defect area and herniated muscle and fat volumes were evaluated using computed tomography. The degree of enophthalmos was measured using a Hertel exophthalmometer. Herniated muscle and fat volumes were positively correlated with defect area in the medial orbital wall fracture but showed no positive correlation with inferior orbital wall fracture. In the medial orbital wall fracture group, enophthalmos was positively correlated with defect area and herniated muscle and fat volumes. Defect area was more highly related to enophthalmos than other analyzed metrics. The defect area predictive of enophthalmos was 1.98cm2. However, enophthalmos was positively correlated only with herniated fat volume in inferior orbital wall fracture. The herniated fat volume predictive of enophthalmos was 343.50mm3. Orbital defect area in medial orbital wall fracture and herniated fat volume in inferior orbital wall fracture were the most significant predictors of late-onset enophthalmos.

Ocular Motility After Repair of Combined Medial and Inferior Orbital Wall Fractures With Extended Conjunctival Incision With Inferior Oblique Reattachment.

To describe ocular motility and effectiveness of an extended conjunctival incision with reattachment of the inferior oblique muscle to repair combined orbital medial and inferior wall fractures. The authors retrospectively studied 20 eyes from 20 patients who underwent combined orbital medial and inferior wall fractures surgery with reattachment of the inferior oblique muscle from January 2007 to December 2011. Single large L-shaped implant was inserted into the fracture site. All patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months, by computed tomography, Hertel exophthalmometry, the Hess test of ocular motility, and the Goldmann diplopia test. Sixteen patients (80%) had no significant enophthalmos or diplopia after surgery. Inferior oblique motility was not changed in 12 patients (60%) after reattachment of the inferior oblique muscle. After 1 month, inferior oblique underaction was presented in 8 patients (40%) and in 4 patients (20%) after 6 months. Finally, only 2 patients (10%) had the inferior oblique underaction remained, it was not improved. The extended conjunctival incision with reattachment of the inferior oblique muscle for combined orbital wall fracture repair offers a wide surgical field and space for a single large implant insertion and corrects the enopthalmos. The reattachment of the inferior oblique muscle does not contribute to the development of inferior oblique underactions or diplopia that was resolved spontaneously within 6 months after surgery.

The clinical characteristics and therapeutic effect of "white-eyed" blowout orbital fracture in children

Objective To investigate the clinical characteristics and surgical efficacy of ( without obvious ecchymosis of conjunctiva and eyelid) blowout fracture in children. Methods The clinical data of 59 patients with blowout orbital fractures, aging 3-18 years old, were retrospectively analyzed. The follow-up time was 6-9 months after the repair surgery for fracture. Results Fifty-nine (54.1%) cases had blowout orbital fracture in 109 children with orbital fractures. The main causes were accidental tumble, assault and car accident. Diplopia was noted in 56 patients accounting for 94.9%, ocular-heart reflex including nausea and vomiting was in 30 patients accounting for 50.1% and ocular motility muscle limitation was in all the patients. There were statistically significant differences in the grading constituent ratios of ocular dyskinesia between the primary position and different scales of ocular motilities (P=0.00). Proved by CT scan, the inferior orbital wall fracture was the most type and occurred in 45 cases (76.3%). Children aging less than 14 years old were more likely to have the inferior orbital wall fracture accounting for 85.0%, which was more than that 57.9% of children aging 14-18 years old (P=0.02). The final visiting was at 6-9 months after the surgery. Twenty-five cases (42.4%) had full ocular motilities and no diplopia. Twenty-four cases (40.7%) had residual diplopia only in peripheral visual field. Ten cases (16.9%) remained diplopia in the primary and reading position though ocular movements improved a lot. There were statistically significant differences in the constituent ratios of binocular single vision among the cases who underwent the surgery at different surgical time (P=0.03). The patients (71.4%) who underwent prompt orbital surgeries within 5 days after initial trauma appeared to have better ocular movement and binocular single vision. Conclusion White-eyed blowout orbital fracture frequently occurs in children and mainly involves the inferior orbital floor. The most important characteristics of white-eyed blowout orbital fracture include symptomatic diplopia with restricted ocular movement, ocular-heart reflex and soft tissue entrapment confirmed by CT scan. The patients who underwent prompt surgeries within 5 days had better ocular movement and binocular single vision. Key words: Orbital fracture, blowout, white-eyed, children; Ocular-heart reflex; Ocular movement; Diplopia

Real Time Navigation-Assisted Orbital Wall Reconstruction in Blowout Fractures.

Limitation in performing restoration of orbital structures is the narrow, deep, and dark surgical field, which makes it difficult to view the operative site directly. To avoid perioperative complications from this limitation, the authors have evaluated the usefulness of computer-assisted navigation techniques in surgical treatment of blowout fracture. Total 37 patients (14 medial orbital wall fractures and 23 inferior orbital wall fractures) with facial deformities had surgical treatment under the guide of navigation system between September 2012 and January 2015. All 37 patients were treated successfully and safely with navigation-assisted surgery without any complications, including diplopia, retrobulbar hematoma, globe injury, implant migration, and blindness. Blowout fracture can be treated safely under guidance of a surgical navigation system. In orbital surgery, navigation-assisted technology could give rise to improvements in the functional and aesthetic outcome and checking the position of the instruments on the surgical site in real time, without injuring important anatomic structures.

CT-Based Morphological Analysis of Isolated Inferior and Medial Blow-out Orbital Fractures in Korean Adults

Purpose: To evaluate morphologic differences in isolated inferior medial orbital wall fractures (OWF) based on computed tomography scans.Methods: This was a retrospective observational case study of 22 patients with an isolated inferior OWF and 32 patients with an isolated medial fracture between January 2008 and August 2010. We analyzed patient demographics and bony radiologic characteristics on CT scans, including the length and height of the lamina papyracea, the number of ethmoid air cell septa, the length of the anterior and posterior border of the orbital floor, the thickness of the orbital floor maxillary bone, and the axial length of the eyeball.Results: There were no significant differences in sex, laterality, or concomitant intraocular injury between the two groups. The anteroposterior length (p = 0.391), the number of ethmoid septa (p = 0.869), and the thickness of the orbital floor (p = 0.419) did not differ significantly. The anterior (p < 0.001) or posterior (p = 0.014) height of the lamina papyracea, the lamina papyracea area (p < 0.001), and the lamina papyracea area/ethmoid air cell septa (p = 0.024) were significantly higher in the medial OWF group, while the anterior (p = 0.026) or posterior (p < 0.001) border length of the orbital floor and the axial length (p = 0.047) and volume (p = 0.034) of the eyeball were longer and smaller, respectively, in the inferior OWF group.Conclusions: Patients with a longer anterior or posterior border of the orbital floor, a shorter axial length, and a smaller eyeball volume are more likely to incur an isolated inferior OWF than an isolated medial OWF.

The effect of titanium mesh implantation for the treatment of enophthalmos secondary to inferior orbital wall fracture

Objective To evaluate the effect ofSshaped titanium mesh implantation on orbit floor for enophthalmos secondary to inferior orbital wall fracture. Methods The surgical effects of 17 eyes of 17 cases inferior orbital wall fracture who receivedSshaped titanium mesh implantation on orbit floor for orbital wall reconstruction were analyzed retrospectively. Preoperatively, there were 9 cases with enophthalmos between 2 to 3 mm, 8 cases with enophthalmos between 3.5 to 4.5 mm, 3 cases with diplopia, 2 cases with apparent vertical globe dystopia. For all the cases, an inferior subciliary approach was performed, aSshaped titanium mesh plate was implanted under the periosteum to cover the area of the inferior orbital wall fracture for reconstruction of the orbital cavity. Results Postoperatively, on the follow-up period of 6-12 months, the enophthalmos of all cases was corrected to less than 2mm successfully, the preoperative diplopia disappeared in all the 3 cases, the vertical globe dystopia of 2 eases disappeared, and no visual complication was observed. No complication of infection, extrusion, rejection or migration of the implants occurred, however mild low eyelid retraction occurred in 1 case and disappeared at 8 month postoperatively. Conclusion Sshaped titanium mesh plate implantation in orbital reconstruction for correcting enophthalmos secondary to inferior orbital wall fracture is safe and effective. Key words: Fractures, orbital, inferior wall; Enophthalmos; Titanium mesh,S shaped; Implantation

Comparison of Absorbable Mesh Plate versus Titanium-Dynamic Mesh Plate in Reconstruction of Blow-Out Fracture: An Analysis of Long-Term Outcomes.

BackgroundA blow-out fracture is one of the most common facial injuries in midface trauma. Orbital wall reconstruction is extremely important because it can cause various functional and aesthetic sequelae. Although many materials are available, there are no uniformly accepted guidelines regarding material selection for orbital wall reconstruction.MethodsFrom January 2007 to August 2012, a total of 78 patients with blow-out fractures were analyzed. 36 patients received absorbable mesh plates, and 42 patients received titanium-dynamic mesh plates. Both groups were retrospectively evaluated for therapeutic efficacy and safety according to the incidence of three different complications: enophthalmos, extraocular movement impairment, and diplopia.ResultsFor all groups (inferior wall fracture group, medial wall fractrue group, and combined inferomedial wall fracture group), there were improvements in the incidence of each complication regardless of implant types. Moreover, a significant improvement of enophthalmos occurred for both types of implants in group 1 (inferior wall fracture group). However, we found no statistically significant differences of efficacy or complication rate in every groups between both implant types.ConclusionsBoth types of implants showed good results without significant differences in long-term follow up, even though we expected the higher recurrent enophthalmos rate in patients with absorbable plate. In conclusion, both types seem to be equally effective and safe for orbital wall reconstruction. In particular, both implant types significantly improve the incidence of enophthalmos in cases of inferior orbital wall fractures.

The Successful Reduction of an Anterior Maxillary Fracture with Foley Catheter and Real-Time Ultrasonography

The maxillary sinus is frequently involved in facial bone fracture, because the maxilla is closely connected to other facial bones and it is composed of only a thin bony wall. Early detection, accurate recognition of maxillary trauma as well as its treatment are important, because it directly affects facial contour. Conventional treatment of maxillary fractures has been open reduction with plate fixation. Although the maxillary anterior wall is relatively easy to access, the problems following conventional treatment, such as incision lines, insertion of drainage tubes, postoperative pain, relatively high costs and lengthy operation times can be burdens to patients. Ultrasonography has been studied for the diagnosis and treatment for facial bone fractures. As an accurate, safe, portable, and real-time imaging modality, it has many advantages. Therefore, some authors have considered the use of ultrasonography during the intraoperative period. Various surgical approaches other than the conventional open reduction technique have been used to treat inferior orbital wall fractures, instead of open reduction. One of these, an endoscopic approach to inferior orbital wall through the maxillary natural ostium and Foley catheter inflation in the maxillary sinus, provides a safe and less invasive treatment. The authors report a case of an anterior maxillary fracture successfully treated by applying the endoscopic approach method with a Foley catheter and real-time ultrasonography. The Successful Reduction of an Anterior Maxillary Fracture with Foley Catheter and Real-Time Ultrasonography

Measurement of Fracture Size Using the Picture Archiving Communication System in an Outpatient Clinic for Factors that Influence Postoperative Enophthalmos in Adult Inferior Orbital Wall Fractures

This study aims to determine the relationships between postoperative enophthalmos, preoperative enophthalmos, and fracture sizes in adults with inferior orbital wall fractures. The records of 31 patients who had operations for pure orbital floor blowout fractures from March 2003 to February 2004 were retrospectively reviewed. Using the Picture Archiving Communication System, we measured fracture sizes according to the orbital computed tomography results. We calculated fracture sizes according to the supposition that the fracture was a 2-dimensional figure. Hertel exophthalmometry was performed on preoperative day 1 and 3 months postoperatively. Mean changes of enophthalmos were 2.80 mm (P < 0.05, paired t test). The mean fracture size was 6.11 cm(2) (range, 3.56-11.73 cm(2)). Fracture size was a more accurate predictor of postoperative enophthalmos than the degree of preoperative enophthalmos (Pearson correlation; with preoperative enophthalmos = 0.513, with fracture size = 0.743, P < 0.05). In linear regression analysis, preoperative exophthalmometry measurements contributed approximately 27.1% to postoperative enophthalmos, whereas fracture size contributed approximately 54.3% (P < 0.05). In multiple regression analysis, the equation was Y = 0.313X + 0.464X' - 0.684 (X is the size of fracture; X', preoperative exophthalmometry measurement). The above 2 factors explained 82.3% of the total postoperative enophthalmos variance. Other factors, which contribute approximately 18%, might include time between insult and corrective surgery. In our study, fracture size was a better predictive factor for postoperative enophthalmos than preoperative exophthalmometric measurement. With our method, postoperative enophthalmos can be predicted more conveniently in a clinical setting, and decisions regarding the timing of early surgical reduction were made easier.

‘White-eyed’ blowout fracture: a case series of five children

The ‘white-eyed’ blowout fracture is an orbital injury in children that is commonly initially misdiagnosed as a head injury because of predominant autonomic features and lack of soft-tissue signs. We...

A Three-Dimensional Computed Tomographic Measurement of the Location of Infraorbital Foramen in East Asians

The aim of the study was to examine the different anatomic variations of the infraorbital foramen (IOF) in relation to sex, side, and age using three-dimensional computer tomography in East Asians. Three-dimensional computer tomography scans of patients who were admitted to our institution without any facial abnormality or fracture were included. Two hundred forty patients (480 eyes; 120 male and 120 female patients) were evaluated for the location of the IOF according to sex and age group. For evaluation of the location, the distance of the foramen from the dacryon and that from the inferior orbital margin were measured. The location of the IOF differed statistically between sexes, and the foramen of males was located more inferotemporally, compared with the foramen of females. The location of the foramen changed rapidly during the first 3 years of life and at ages 10 to 12 years. The location change leveled off at after 20 years of age, and the location changed inferotemporally along with growth. This anatomic knowledge of the location of the IOF may suggest that age and sex be considered for infraorbital nerve block, midface lift, and incision of periosteum in inferior orbital wall fracture, especially in children.

Niezwykłe izolowane złamanie dna oczodołu typu „blow-out” powikłane rozległą rozedmą podskórną: opis przypadku i przegląd piśmiennictwa.

Blow-out fracture of the orbit is a common injury. However, not many cases are associated with massive subcutaneous emphysema. Even fewer cases are caused by minor trauma or are associated with barotrauma to the orbit due to sneezing, coughing, or vomiting. The authors present a case of blow-out fracture complicated by extensive subcutaneous and mediastinal emphysema that occurred without any obvious traumatic event. A 43-year-old man presented to the Emergency Department with a painful right-sided exophthalmos that he had noticed in the morning immediately after waking up. The patient also complained of diplopia. Physical examination revealed exophthalmos and crepitations suggestive of subcutaneous emphysema. The eye movements, especially upward gaze, were impaired. CT showed blow-out fracture of the inferior orbital wall with a herniation of the orbital soft tissues into the maxillary sinus. There was an extensive subcutaneous emphysema in the head and neck going down to the mediastinum. The patient did not remember any significant trauma to the head that could explain the above mentioned findings. At surgery, an inferior orbital wall fracture with a bony defect of 3×2 centimeter was found and repaired. Blow-out fractures of the orbit are usually a result of a direct trauma caused by an object with a diameter exceeding the bony margins of the orbit. In 50% of cases, they are complicated by orbital emphysema and in 4% of cases by herniation of orbital soft tissues into paranasal sinuses. The occurrence of orbital emphysema without trauma is unusual. In some cases it seems to be related to barotrauma due to a rapid increase in pressure in the upper airways during sneezing, coughing, or vomiting, which very rarely leads to orbital wall fracture. Computed tomography is the most accurate method in detecting and assessing the extent of orbital wall fractures.

Role of Inferior Orbital Wall Morphologic Properties in Isolated Orbital Blow-Out Fracture

Purpose: To compare inferior orbital wall morphology between isolated inferior and medial orbital wall fracture patients. Methods: The morphologic properties of patients with isolated blow-out fractures involving the medial wall or inferior wall treated from August 2004 to August 2009 were reviewed. The cross-sectional area, thickness, gradient, and curvature of the inferior wall were measured via orbital CT in the opposite non-traumatized eye. Results: Patients with isolated inferior wall fractures (n = 77) and isolated medial wall fractures (n = 78) evidenced no differences in sex, age, etiology of trauma, laterality of trauma, and associated concomitant intraocular injuries. The cross-sectional area, thickness, and gradient of the inferior wall did not differ significantly between the 2 groups. However, the coefficient of curvature was significantly greater in patients with inferior wall fracture than in patients with medial wall fracture (0.016 ± 0.006 vs. 0.006 ± 0.002, respectively; p = 0.000). Conclusion: Patients with more convex and steep inferior walls are more likely to incur isolated inferior wall fractures than isolated medial wall fractures.

Reduction of Inferior Orbital Wall Fractures Using a Foley Catheter and an Endoloop

Various surgical approaches have been used to treat orbital blowout fractures. Among them, the transnasal endoscopic approach avoids external scars and allows clear observation of the fracture site. We conducted a retrospective study of blowout fractures reduced using a Foley catheter and an Endoloop. Patients (n=24) who underwent endoscopic reduction of inferior orbital wall fractures were analyzed. They were diagnosed using 3-mm facial computed tomography, and the surgical treatment consisted of fracture reduction using Foley catheter and Endoloop. Postoperatively, they were followed up for at least 3 months. There was no significant intraoperative or postoperative complication. The symptoms in all but two patients resolved completely after surgery. The technique using Foley catheter and Endoloop to reduce inferior orbital wall fractures endoscopically is safe and efficacious.

Traumatic orbital emphysema: a case report

A 30-year-old male presented with sudden diminution of vision, orbital pain, diplopia, and swelling of the eyelid of the right eye after blowing his nose within three days after a blunt ocular trauma. His best-corrected visual acuities were 6/10 in the right eye and 10/10 in the left eye. Anterior segment and fundus examination were normal bilaterally. Limitation of upward ocular motility was noticed in the right eye. Diplopia was detected in both upward and downward motilities. Intraocular pressures were 21 mmHg in OD and 16 mmHg in OS. Hertel exophthalmometry measurements were 21 mm for the right eye and 19 mm for the left eye. The direct computerized tomography image displayed the inferior orbital wall fracture and orbital emphysema in the right orbit. Prophylactic antibiotherapy was applied. The patient was advised not to blow his nose. He had no complaints on the third day after the trauma. Follow-up examinations showed no ophthalmological complications.

Chronic Maxillary Sinusitis Occurred after Reconstruction of Inferior Orbital Wall Fracture

A 27-year-old man presented with symptoms of chronic postnasal drip and nasal obstruction, which had begun one year earlier. He had undergone an ophthalmologic operation due to inferior orbital wall fracture 12 years ago. During physical examination, mucopurulent discharge was observed from the right middle meatus. On the paranasal sinus computed tomography, a sheet-like foreign material was observed inside the right maxillary sinus and haziness was found in the right maxillary, ethmoid, and frontal sinuses. Endoscopic sinus surgery was performed and a silastic sheet, which had been inserted during previous surgery, was removed. After surgery, the patient's symptoms disappeared gradually. We report a case of maxillary sinusitis that occurred after orbital wall reconstruction with a silastic sheet and discuss about the efficacy of the silastic implant.

Postoperative pain and vomiting after orbital wall surgery in trauma

Postoperative pain and vomiting after orbital wall surgery in trauma

Massive Orbital Emphysema-An Unusual Clinical Presentation of Isolated Medial Orbital Wall Fracture

Orbital emphysema is an unusual complication of orbital fractures which are the common sequelae of periorbital trauma. Most cases are due to inferior orbital wall fractures. Here we report a case with an unusual clinical presentation of isolated left medial orbital wall fracture complicated with massive orbital emphysema. Without ophthalmic or neurologic defect, conservative management with cold compression and analgesics was prescribed. He was also advised not to blow his nose. On follow-up at 1 and 4 months, the orbital emphysema subsided, and the patient remained free of any optic impairment. Relevant literature is also reviewed.

Resources: Internet Resources for the Independent Medical Evaluator – 2007

Abstract Rating patients with head trauma and multiple neurological injuries can be challenging. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 13.2, Criteria for Rating Impairment Due to Central Nervous System Disorders, outlines the process to rate impairment due to head trauma. This article summarizes the case of a 57-year-old male security guard who presents with headache, decreased sensation on the left cheek, loss of sense of smell, and problems with memory, among other symptoms. One year ago the patient was assaulted while on the job: his Glasgow Coma Score was 14; he had left periorbital ecchymosis and a 2.5 cm laceration over the left eyelid; a small right temporoparietal acute subdural hematoma; left inferior and medial orbital wall fractures; and, four hours after admission to the hospital, he experienced a generalized tonic-clonic seizure. This patient's impairment must include the following components: single seizure, orbital fracture, infraorbital neuropathy, anosmia, headache, and memory complaints. The article shows how the ratable impairments are combined using the Combining Impairment Ratings section. Because this patient has not experienced any seizures since the first occurrence, according to the AMA Guides he is not experiencing the “episodic neurological impairments” required for disability. Complex cases such as the one presented here highlight the need to use the criteria and estimates that are located in several sections of the AMA Guides.

Repair of Medial Orbital Wall Fracture: Transcaruncular Approach

The aim of this paper is to demonstrate the safety and the use of the transcaruncular approach as a surgical technique for managing a medial wall fracture. This approach was used in 40 patients with a isolated medial or a combined medial and inferior orbital wall fracture between September 1998 and September 2002. A computed tomographic scan was taken before and after surgery. The ocular motility and enophthalmos were checked before and after surgery. The transcaruncular approach provided the appropriate surgical exposure in all cases. Patients were followed up for a mean of 9.4 months (range, 5–24 months) after repairing the orbital wall fracture. Hertel exophthalmometry showed that among the 40 patients; 24 patients showed no enophthalmos. The enophthalmos ranged from 0.5–1 mm in 14 patients and 1.5 mm enphthalmos was noted in 2 patients. A clinically significant enophthalmos ≥2 mm was not found postoperatively. Preoperatively, 12 patients (30%) had a diplopia in the primary position of the gaze and 26 patients (65%) had a diplopia within 30° of the gaze. Postoperatively, all patients had an orthotropia in the primary position but 4 patients (10%) had a residual diplopia either on the lateral gaze (2 patients) or the upgaze (2 patients). There were 2 cases of an implant misplacement. The transcaruncular approach provides a safe, rapid, and cosmetically pleasing surgical approach for managing a isolated medial wall fracture. When combined with the inferior transconjunctival approach, a combined medial and inferior orbital wall fracture can be successfully repaired.