Late Posttraumatic Enophthalmos Research Articles

What CT Findings are Predictive of Post-Traumatic Enophthalmos in Orbital Fractures?

Enophthalmos is a surgical indication for orbital fracture repair. However, guidelines to predict enophthalmos in orbital fractures are ambiguous. We systematically reviewed the existing literature on utilizing CT findings to establish objective metrics to predict enophthalmos in asymptomatic patients during initial trauma work-up. PRISMA guidelines were followed. PubMed and Embase were used to identify studies of interest. The Quality in Prognosis Studies (QUIPS) tool was used for risk of bias assessment. Random effects model meta-analyses of orbital volume change and fracture area values were completed. Regression analyses were performed to determine thresholds that predicted 2 mm enophthalmos. Of the initial 2236 abstracts, 36 met inclusion criteria. Thirty retrospective studies evaluated a total of 2851 patients and 6 prospective studies evaluated 211 patients. All 36 studies had predominantly low risk of bias. Predictors of enophthalmos assessed were orbital volume change (21 papers), fracture surface area (13 papers), inferior rectus muscle (IRM) displacements (7 papers), and fracture location (4 papers). Studies reporting on orbital volume change offered values ranging from 0.69 to 4.26 cm3. Fracture area predictor values ranged from 1.50 to 3.38 cm2. Meta-analyses confirmed the validity of both predictors. Pooled regression analyses demonstrated that 3.33 cm3 of orbital volume increase or fracture area of 3.12 cm2 were predictors of 2 mm enophthalmos. Both orbital volume change and fracture area measured on CT scan are good predictors of late post-traumatic enophthalmos. Pooled data indicates 3.12 cm2 of fracture area or 3.33 cm3 of orbital volume increase are predictive of enophthalmos.

Efficacy and Safety of Expanded Polytetrafluoroethylene Implantation in the Correction of Long-Term Posttraumatic Enophthalmos.

Long-term enophthalmos is a common orbital fracture sequela. Various autografts and alloplastic materials have been studied in posttraumatic enophthalmos repair. However, expanded polytetrafluoroethylene (ePTFE) implantation in late enophthalmos repair has rarely been reported. The authors report novel use of ePTFE for late posttraumatic enophthalmos repair. This retrospective study included patients with posttraumatic long-term enophthalmos who underwent hand-carved ePTFE intraorbital implantation for enophthalmos correction. Computed tomography data were collected preoperatively and at follow-up. The volume of ePTFE, the degree of proptosis (DP), and enophthalmos were measured. Postoperative and preoperative DP and enophthalmos were compared using the paired t test. The correlation between ePTFE volume and DP increment was established using linear regression. Complications were identified by chart review. From 2014 to 2021, 32 patients were included, with a mean follow-up of 19.59 months. The mean volume of implanted ePTFE was 2.39 ± 0.89 mL. After surgery, the DP of the affected globe improved significantly, from 12.75 ± 2.12 mm to 15.06 ± 2.50 mm ( P < 0.0001). A significant linear correlation was found between ePTFE volume and DP increment ( P < 0.0001). Enophthalmos was substantially ameliorated from 3.35 ± 1.89 mm to 1.09 ± 2.07 mm ( P < 0.0001). Twenty-five patients (78.23%) had postoperative enophthalmos of less than 2 mm. Infection and implant dislocation were not observed. The authors concluded that ePTFE intraorbital implantation exhibited long-term efficacy and safety for late posttraumatic enophthalmos repair and represents an effective and predictable alternative. Therapeutic, IV.

Current Management of Late Posttraumatic Enophthalmos.

After studying this article, the participant should be able to: 1. Describe the orbital anatomy and completely understand the important components relevant to surgical correction of enophthalmos, including oculo-orbito relations. 2. Understand the pathophysiology and predictive factors for posttraumatic enophthalmos and identify the challenges associated with correction of enophthalmos in the late setting. 3. Develop a surgical plan for late enophthalmos repair and understand the value and utility of osteotomies, intraoperative navigation, and patient-specific implants. 4. Discuss the expected outcomes, possible complications, and adjunctive surgery as related to late enophthalmos repair. This article addresses the current management of late posttraumatic enophthalmos. In this article, the authors describe surgically relevant orbital anatomy and oculo-orbital relations, the pathophysiology of enophthalmos, clinical and radiologic findings, decision-making in management, and surgical treatment. The authors attempt to cover some of the main challenges and recent advances in the management of late posttraumatic enophthalmos, including intraoperative navigation and patient-specific implants.

Post-traumatic enophthalmos secondary to orbital fat atrophy: a volumetric analysis

ABSTRACT Purpose To investigate via volumetric analysis whether orbital fat atrophy occurs in late post-traumatic enophthalmos. Methods An IRB-approved retrospective cohort study identified patients with diagnoses of both orbital fracture and enophthalmos with a CT orbits >3 months after injury. Exclusion criteria were surgical repair, other orbital disease or surgery, adjacent sinus disease, and an abnormal contralateral orbit. Images were analyzed using OsiriX imaging software (v.9.0.2, Pixmeo, Switzerland). Total orbital volume and orbital fat volume for the fractured and normal contralateral orbits were measured via three-dimensional volume rendering assisted region-of-interest computation. Enophthalmos was measured radiographically. Paired samples t-tests were used to compare orbital fat and total orbital volumes between the fractured and normal contralateral orbits. Results Thirteen patients met the inclusion criteria. The numbers of patients with each fracture pattern were floor (4), medial wall (4), floor/medial wall (3), zygomaticomaxillary complex (floor+lateral wall) (1), zygomaticomaxillary complex+medial (inferior/medial/lateral walls) (1). Mean time from injury to CT scan was 21.8 ± 16.3 months. Comparing the fractured and normal contralateral orbits, there was a statistically significant decrease in orbital fat volume (mean difference 0.9 ml (14.2%), p = .0002) and increase in total orbital volume (mean difference 2.0 ml (7.0%), p = .0001). One ml orbital volume change was responsible for 0.83 mm enophthalmos. Conclusions In addition to an increase in total orbital volume, orbital fat loss occurs with late post-traumatic enophthalmos due to unrepaired fractures. This suggests correction of bony change alone may be insufficient in some cases, and the use of custom implants may compensate for fat atrophy.

Functional Outcomes of Late Posttraumatic Enophthalmos Correction.

Posttraumatic enophthalmos has debilitating functional consequences, resulting in restriction of ocular motility and diplopia. Surgical correction aims to restore the globe position and ultimately improve function. This study evaluates the functional outcome of posttraumatic enophthalmos repair. Patients included in this study had posttraumatic enophthalmos and diplopia requiring enophthalmos repair. Diplopia was graded from 0 (no diplopia) to 4 (constant diplopia) based on the Functional Diplopia Grading Scale. Limitations of eye movements were recorded in the vertical, horizontal, and torsional directions. Data were gathered prospectively at preoperative assessment, postenophthalmos repair, and final follow-up. Between 2002 and 2014, 41 patients fulfilled inclusion criteria. Substantial functional improvement, defined as a decrease of greater than or equal to 1 grade of diplopia, was achieved in 65.9 percent of patients (27 of 41) after all surgical interventions. Patients with residual diplopia (34 of 41) after enophthalmos surgery were managed with secondary strabismus surgery (10 of 34) and/or prism glasses (four of 34). After all interventions, vertical restrictions improved from -1.95 ± 1.13 to -1.06 ± 0.98. Horizontal restrictions improved from -0.88 ± 0.62 to 0.59 ± 0.6. Adequate clinical correction of enophthalmos to within 2 mm of the contralateral globe was achieved in 37 of 41. This is the largest case series evaluating functional outcomes of patients undergoing posttraumatic delayed enophthalmos repair. A multidisciplinary care approach resulted in improved globe position and eye movement, and improvement of diplopia. Further studies with larger sample sizes are needed to better understand and treat this important and challenging problem. Therapeutic, IV.

Correction of Late Posttraumatic Enophthalmos Using an Antral Balloon

Enophthalmos is the posterior displacement of the ocular globe within the bony orbit. Correction of late posttraumatic enophthalmos is one of the most challenging surgical procedures. We have performed a corrective procedure for late enophthalmos using an antral balloon, with or without minimal bone grafting. All orbital contents were separated from the bone fragments, infraorbital nerve, and mucosa of the maxillary antrum. The remaining orbital floor was fractured by the surgeon's digital pressure from the maxillary antrum. The antral balloon was placed in the maxillary antrum and inflated under direct vision from inside the orbit. After a consolidation period, the patient underwent antral balloon removal. A total of 5 patients underwent repair of late enophthalmos using this antral balloon technique. The median time from initial injury was 14 months (range, 6-90 months). The median antral balloon placement duration was 76 days (range, 53-106 days). Satisfactory symmetries were achieved in 4 patients. Mild residual enophthalmos remained in 1 patient, who had an orbital framework deformity and was missing the entire orbital bony floor preoperatively and who required simultaneous bone grafting. The ideal indication for our technique was the need for orbital floor reconstruction, without an orbital framework deformity. This technique could avoid autogenous bone grafting or permanent alloplastic implantation, which may cause a foreign body reaction, chronic inflammation, and migration. We believe that our new technique is one of the least invasive corrective procedures for late posttraumatic enophthalmos.

Evaluation of the Application of Computer-Aided Shape-Adapted Fabricated Titanium Mesh for Mirroring-Reconstructing Orbital Walls in Cases of Late Post-Traumatic Enophthalmos

Computer-aided individually shape-adapted fabricated titanium mesh for the mirroring-reconstruction of the orbit is a promising method for the correction of post-traumatic enophthalmos. The purpose of this study was to evaluate the application of this technique and assess the treatment outcomes. Twenty-one patients with delayed treatment of unilateral impure orbital fracture and post-traumatic enophthalmos were included in this study. Computed tomography-based mirroring-reconstruction images of the orbit were obtained for each individual to fabricate anatomically adaptive titanium mesh by computer-aided design and computer-aided manufacturing techniques. After exposing the areas of orbital defect and reducing the herniated soft tissue, the titanium mesh was inserted to reconstruct the internal orbit with a mean deep extension of 29.33 mm. Measurements were performed to assess the change in the degree of enophthalmos and orbital volume before and after surgery. Paired samples t test and Pearson correlation coefficient were employed for statistical analysis. Follow-up examinations revealed that the degree of enophthalmos decreased to less than 2 mm in 11 patients, 2 to 4 mm in 9 patients, and remained greater than 7 mm in 1 patient. Statistical analysis revealed that post-traumatic enophthalmos in this series was 4.05 +/- 2.02 mm, which was associated with an orbital volume increment of 6.61 +/- 3.63 cm(3), with a regression formula of enophthalmos = 0.446 x orbital volume increment + 2.406. Orbital reconstruction effected a orbital volume decrease of 4.24 +/- 2.41 cm(3) and enophthalmos correction of 2.01 +/- 1.46 mm, the regression formula being enophthalmos = 0.586 x orbital volume decrease + 0.508. After surgery, the degree of unresolved enophthalmos was 2.03 +/- 1.52 mm, and the retained orbital volume expansion was 2.23 +/- 2.86 cm(3), and the regression formula was enophthalmos = 0.494 x orbital volume expansion + 1.415. Application of the individual fabricated titanium mesh for orbital reconstruction reduced the trauma-induced orbital volume increment by 65% and corrected 50% of severe late enophthalmos. Additional augmentation of orbital contents was required for further correction. The related treatment parameters were suggested.

Evaluation of Computer-Assisted Shape-Adapted Fabricated Ti-Mesh Applied to Mirroring-Reconstruct Orbital Walls in Correction of Late Post-Traumatic Enophthalmos

restrained, 8 (5%) were restrained with air bag and belt, and 9 (6%) were restrained with air bag only. Of the patients sustaining a fracture requiring surgical intervention, there were 64 (41%) patients with mandible fractures, 52 (33%) with nasal fractures, 59 (38%) with orbital fractures, 50 (32%) with ZMC fractures, 10 (6%) with frontal sinus fractures, 12 (8%) with NOE fractures, 26 (17%) with Le Fort I fractures, 2 (1%) with Le Fort II fractures, and 3 (2%) with Le Fort III fractures. Upon evaluation of seat position, there were no significant differences in total number or severity of maxillofacial fractures between drivers and passengers (p 0.08 and p 0.17 respectively). There were significantly more facial fractures in the unrestrained group versus all other restraint device groups (p 0.001). Of the overall patients requiring surgical intervention to repair their facial fractures, 92 (3%) of the 2796 had no restraint; 47 (1.6%) out of 2969 had 3 point restraints; 8 (1.1%) out of 698 had air bag and belt; and 9 (1.8%) out of 497 had air bag only. Therefore the lack of restraint device patients suffering a motor vehicle collision will double the incidence of facial fractures requiring surgery (3%) versus any other restraint device (1.5%) (p 0.001). Conclusion: At our institution, 3% of unrestrained patients in motor vehicle collisions suffer maxillofacial fractures severe enough to require surgical intervention while only 1.5% of restrained patients require surgery. Therefore, the use of any restraint system results in a significant decrease in the total number and severity of maxillofacial fractures.

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.

Correction of Late Post-Traumatic Enophthalmos Using a Tissue Expander

Correction of Late Post-Traumatic Enophthalmos Using a Tissue Expander

O.366 The classification and management of late post-traumatic enophthalmos

A new ‘FE-Meshfree’ three-node triangular element (Trig3-RPIM) is developed based on the partition of unity (PU) concept. The Trig3-RPIM element employs the shape function of classical three-node triangular element (Trig3) to construct the PU and the radial-polynomial basis function which is free from the possible singularity of the moment matrix to construct the nodal approximation. The Trig3-RPIM element synergizes the individual strengths of finite element method and meshfree method. Moreover, it is free from the linear dependence problem which otherwise cripples many of the PU based finite elements. Several linear, nonlinear and free vibration test problems are solved and the performance of the element is compared with those of the well-known three-node triangular element (Trig3) and four-node iso-parametric quadrilateral element (Quad4). The results show that, for regular meshes, the performance of the element is superior to those of Trig3 and Quad4 elements. For distorted meshes, the present element has better mesh-distortion tolerance than Trig3 and Quad4 elements.

A Surgical Treatment of Severe Late Posttraumatic Enophthalmos Using Sliced Costal Cartilage Chip Grafts

The efficacy of sliced costal cartilage chip grafts for the treatment of late posttraumatic enophthalmos was investigated. Surgery was conducted based on the method reported by Matsuo et al. in 1989. After making an incision in the lower eyelid, dissecting the subperiosteum of the medial orbital wall, orbital floor and lateral orbital wall was performed to the posterior of the orbit, and then costal cartilage chips were gradually grafted in a step-like configuration to the subperiosteum from a location posterior to the equatorial plane of the eyeball. At this time, as well as to the area of concave depression in the orbital bone caused by the fracture, grafts were made to the subperiosteum of the non-deformed medial and lateral orbital wall, to move all of the orbital tissue, including the eyeball, forward. This was performed for five cases of severe late posttraumatic enophthalmos. Among the five cases, there were four cases of severe orbital fracture and one case for which malignant orbital tumor extirpation and radiation therapy had been performed. Following surgery, although mild enophthalmos remained in three of the five cases, esthetically satisfactory results were obtained for all cases. Costal cartilage chip grafts were shown to be an effective method for the treatment of late posttraumatic enophthalmos.

Correction of Late Post-Traumatic Enophthalmos Using a Tissue Expander

We described a new technique to correct late post-traumatic enophthalmos using volume augmentation with a tissue expander. A 47-year-old male requiring enucleation with an implant replacement following orbital fracture with the globe injury had been complaining of persistent enophthalmos and cosmetic defect. Computed tomography scan demonstrated significant enophthalmos resulting from a volume discrepancy between an orbita and the orbital contents. To prevent worsening of the prosthesis motility with correction of enophthalmos, projection of the prosthetic globe was postoperatively adjusted by gradual inflation of an expander placed behind the enucleation implant. As a result enophthalmos was appropriately corrected without any change of the prosthesis motility.

CT assessment of orbital volume in late post-traumatic enophthalmos

CT assessment of orbital volume in late post-traumatic enophthalmos

CT assessment of orbital volume in late post-traumatic enophthalmos.

The potential of CT to facilitate preoperative planning of reconstructive maxillofacial surgery by orbital volume quantification was analysed in 11 patients with traumatic enophthalmos as a late sequela of zygomatic fractures. We carried out biplanar CT examination of the orbits, and calculated total orbital and fat volumes for the healthy and enophthalmic sides. Displacement of the orbital floor and lateral wall was present in 11 and 7 cases respectively. Indentation of the medial wall was noted in 9 cases. Quantitative evaluation of the orbital cavity revealed a significant increase (P < 0.0188) in total volume on the enophthalmic side, the difference between the two sides ranging from 9.2% to 36.4%, mean 17.9%. The degree of enophthalmos, measured radiologically as 2.5-5 mm, correlated with the increase in orbital cavity volume (P = 0.000076). Enophthalmos was 2.5-3 mm in 7 cases (63.6%) and 3.5-5 mm in 4 (36.4%). This corresponded with a mean increase in orbital volume of 3.4 ml (12.3%) and 7.1 ml (27.8%) respectively. Fat atrophy was not an aetiological factor in the production of post-traumatic enophthalmos.

Transconjunctival approach vs subciliary skin-muscle flap approach for orbital fracture repair.

To compare the transcutaneous and transconjunctival approaches for repair of orbital rim and floor fractures. We conducted a retrospective study of the occurrence of eyelid retraction following the repair of 63 orbital fracture, 27 with the subciliary skin-muscle flap approach and 36 with the transconjunctival preseptal approach. Academic tertiary referral medical center. Fifty-nine patients underwent 63 orbital explorations. Of the 27 transcutaneous explorations, 24 were done early within the first 2 weeks of injury and three were performed for correction of late posttraumatic enophthalmos. Of the 36 transconjunctival explorations, 25 were done early and 11 were performed for correction of late posttraumatic enophthalmos. Clinically noted complications. We found a 12% rate of transient ectropion and a 28% rate of permanent scleral show with the subciliary skin-muscle flap approach compared with no transient ectropion and a 3% rate of permanent scleral show with the transconjunctival approach. We believe that the transconjunctival approach provides excellent exposure with less risk of postoperative eyelid retraction and ectropion.

Custom orbital implant in the repair of late post-traumatic enophthalmos : Putterman AM, Millman AL. Am J Ophthalmol 108:153, 1989

Custom orbital implant in the repair of late post-traumatic enophthalmos : Putterman AM, Millman AL. Am J Ophthalmol 108:153, 1989

Custom orbital implant in the repair of late posttraumatic enophthalmos : AM Putterman, AL Millman. Am J Ophthalmol 1989; 108:153–159

Custom orbital implant in the repair of late posttraumatic enophthalmos : AM Putterman, AL Millman. Am J Ophthalmol 1989; 108:153–159

Late posttraumatic enophthalmos corrected by dense hydroxylapatite blocks

Late enophthalmos caused by an unrepaired zygomatic or orbital blowout fracture can cause esthetic and functional impairment. The sunken appearance of the superior suicus and the depressed globe are obvious cosmetic defects. Functional impairment of the eye can also be troublesome, with restriction of motion and diplopia being common complaints. Early repair of surgically correctable fractures, prior to scar contraction or fat atrophy, is the most acceptable procedure. Even so, early repair is at times fraught with uncertainty, since the only parameter for measuring the adequacy of treatment is the late cosmetic and acceptable functional result. The various materials that have been used to treat orbital floor complications in the nonseeing eye include glass beads,’ tantalum,2 Teflon,3 polyethylene,4 polymethylmethacrylate,5 and Silastic6 In the seeing eye the placement of Silastic, cartilage,7 fascia,8 and bone,9,10 as well as osteotomy” have been used. Both the use of autogenous materials that resorb or move and osteotomy constitute only crude nonreproducible methods for the correction of late enophthalmos. This case report describes the use of hydroxylapatite in dense block form (Calcitek, San Diego, California) to correct late posttraumatic enophthalmos in a seeing eye.