Medial Wall Fractures Research Articles

Primary reconstruction of extensive orbital fractures using two-piece patient-specific implants: the Helsinki protocol

PurposeWe present our experience of titanium-milled two-piece patient-specific implants (PSIs) for primary reconstructions of extensive orbital floor and medial wall fractures (EOFMFs) and evaluate their postoperative functional and aesthetic outcomes in relation to commercially available implants.MethodsWe included all patients with primary reconstructions (< 22 days from injury) of EOFMFs treated in our department between January 2011 and October 2020. Extensive orbital floor and medial wall fracture was defined as involvement of orbital floor, medial wall and maxilloethmoidal junction; a fracture defect 5 mm or more; defect size more than a third of both inferior and medial walls; and Jaquiéry classification III or more. Patient characteristics, details of fracture defects and surgeries, postoperative outcomes and implant positions were retrospectively evaluated and compared between study groups.ResultsNineteen patients were included: 5 with two-piece PSIs and 14 with commercial implants. Implant position was good in 4/5 patients with two-piece PSIs and 2/14 with commercial implants. Revision surgery, globe malposition (GMP) > 2 mm, significant diplopia and poor implant position were more frequent in patients with commercial implants than two-piece PSIs. None of the patients with a good overall implant position had any significant postoperative symptoms.ConclusionExtensive orbital fracture reconstructions are somewhat rare, and surgical treatment is associated with a high rate of complications and postoperative symptoms. Titanium-milled two-piece PSIs are well suited for primary reconstructions of EOFMFs, as they lead to more precise reconstructions and fewer postoperative symptoms than commercially available implants.

The Incidence and Risk Factors of Medial and Inferior Orbital Wall Fractures in Korea: A Nationwide Cohort Study.

Purpose: We aimed to investigate orbital wall fracture incidence and risk factors in the general Korean population. Method: The Korea National Health Insurance Service–National Sample Cohort dataset was analyzed to find subjects with an orbital wall fracture between 2011 and 2015 (based on the diagnosis code) and to identify incident cases involving a preceding disease-free period of 8 years. The incidence of orbital wall fracture in the general population was estimated, and the type of orbital wall fracture was categorized. Sociodemographic risk factors were also examined using Cox regression analysis. Results: Among 1,080,309 cohort subjects, 2415 individuals with newly diagnosed orbital wall fractures were identified. The overall incidence of orbital wall fractures was estimated as 46.19 (95% CI: 44.37–48.06) per 100,000 person-years. The incidence was high at 10–29 and 80+ years old and showed a male predominance with an average male-to-female ratio of 3.33. The most common type was isolated inferior orbital wall fracture (59.4%), followed by isolated medial orbital wall fracture (23.7%), combination fracture (15.0%), and naso-orbito-ethmoid fracture (1.5%). Of the fracture patients, 648 subjects (26.8%) underwent orbital wall fracture repair surgeries. Male sex, rural residence, and low income were associated with an increased risk of orbital wall fractures. Conclusions: The incidence of orbital wall fractures in Korea varied according to age groups and was positively associated with male sex, rural residency, and low economic income. The most common fracture type was an isolated inferior orbital wall fracture.

Isolated paediatric orbital fractures: a case series and review of management at a major trauma centre in the UK.

PurposePaediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis.MethodsThis retrospective study was conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to a major trauma unit in London between 2010 and 2020.ResultsThirteen patients with isolated orbital fractures presented to our unit in this period. The average age was 13 years. Surprisingly the predominant aetiology was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. One medial wall fracture case was missed in the emergency department.Eight patients required surgical intervention due to diplopia caused by muscular entrapment of extraocular muscles; the final patient had a large defect resulting in enophthalmos requiring a large titanium plate. A transconjuctival approach was preferred for surgical access and resorbable sheet was used in the remaining cases. Five patients had nausea, vomiting or bradycardia associated with the oculocardiac reflex. Surgical intervention occurred within 24–48 h of injury in 6 cases. Resolution of diplopia occurred in 7 patients within 6 months.ConclusionPaediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.

Endoscopic Endonasal Repair of the Orbital Medial Wall Fracture Utilising Nasal Septal Cartilage as the Reconstructive Material.

To repair orbital medial wall fractures, otorhinolaryngologists often use the silicone sheet technique by inserting an inverted U-shaped silicone sheet into the middle meatus after the removal of fractured bones, and packing gauze inside the silicone sheet for several days to fix the shape of the medial wall. However, this method does not sufficiently reduce the orbital content. To describe the surgical procedure to repair medial wall fractures using nasal septal cartilage as the reconstructive material. First, endoscopic septoplasty is performed. Although the correction of the septal deviation is performed to secure the operative field, the nasal septal cartilage, except the L-strut is resected simultaneously. After septoplasty, the fractured bones of the lamina papyracea are removed from the herniated orbital contents, and then the orbital contents can be reduced without resistance by pushing laterally. Subsequently, the cartilage is inserted beneath the fracture edges of the orbital medial wall with great care to avoid entrapping the orbital soft tissue and extraocular muscles. The cartilage can be placed appropriately along the medial wall of the orbit. This technique enables to repair most cases of orbital medial wall fractures using the endoscopic endonasal approach alone without alloplastic implants.

Customized and Navigated Primary Orbital Fracture Reconstruction: Computerized Operation Neuronavigated Surgery Orbital Recent Trauma (CONSORT) Protocol.

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.

Evaluation of commotio retinae in orbital fractures.

This study aimed to evaluate the mechanisms of injury and types of orbital fractures and their relation to concurrent commotio retinae. This retrospective study evaluated the records of patients with orbital fractures whose diagnoses had been confirmed by computer tomography between July 2017 and September 2019. Patient demographics, the circumstances of injury, ophthalmic examination results, and radiological findings were tabulated. Statistical analysis of the data used two-tailed student's t-tests, chi-squared tests, and odds ratio calculations. Statistical significance was set at p<0.05. Of the 204 patients with orbital fractures included in this study, 154 (75.5%) were male. The mean age was 42.1 years. Orbital fractures involving one orbital wall (58.8%) were more common than those affecting multiple walls (41.2%). The majority of fractures affected the inferior wall (60.3%), with the medial walls being the next most frequently affected (19.6%). The most common cause of injury was assault (59.3%), and the second most common was falls (24%). Commotio retinae was observed in 20.1% of orbital fracture cases and was most associated with injuries caused by assault (OR=5.22, p<0.001) and least associated with those caused by falls (OR=0.06, p<0.001). Eye movement restrictions were more common in central than peripheral commotio (OR=3.79, p=0.015) and with medial wall fractures than fractures to other orbital walls (OR=7.16, p<0.001). The odds of commotio were not found to be higher in patients with multi-walled orbital fractures than in those with single-walled fractures (p=0.967). In the study population, assault was the most common cause of orbital fractures and resulted in commotio retinae than other causes. Ophthalmologists should be aware of the likelihood of commotio retinae in patients with orbital fractures resulting from assault, regardless of the extent of the patient's injuries.

Role Of Cbct In The Treatment Of Orbital Floor Blow Out Fractures In Children

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.

A Case of Orbital Medial Wall Fracture, with Missing Rectus Sign, That Showed Postoperative Extraocular Muscle Paralysis

A Case of Orbital Medial Wall Fracture, with Missing Rectus Sign, That Showed Postoperative Extraocular Muscle Paralysis

Do Patient-Specific Implants Decrease Complications and Increase Orbital Volume Reconstruction Accuracy in Primary Orbital Fracture Reconstruction?

Patient-specific titanium implants are increasingly used in orbital trauma as a means of achieving improved surgical outcomes as well as decreasing postoperative complications; however, the data to support their use remain limited. The purpose of this study is to compare the complication rates and accuracy of orbital reconstruction using preformed titanium mesh implants and patient-specific implants. The authors conducted a retrospective cohort study consisting of patients with orbital floor and/or medial wall fractures treated by reconstruction with either preformed or patient-specific implants from August 1, 2015 to December 31, 2020. The primary predictor variable was the implant type. Outcome variables were the percent volume difference between the reconstructed and uninjured orbital volume and complications. Statistical analysis was performed using Fisher exact test and Wilcoxon rank-sum test. Of the 85 patients in the study, 73% were male and the average age was 38.7±16.6years. Sixty-one patients (72%) were treated with preformed implants and 24 (28%) with patient-specific implants. Complications occurred in 8.3% of the patient-specific implant group and 26.2% of the preformed implant group (P=.08). Percent volume difference between the reconstructed and nontraumatized orbit was 4.2% and 6.8% in the patient-specific and preformed implant group, respectively (P=.03). Patient-specific implants improved orbital volume reconstruction accuracy but did not decrease complications when compared to preformed implants.

Prebending of Prefabricated Orbital Implants: Towards Improved Orbital Angle Symmetry Post Craniofacial Trauma Surgery.

Reconstructive surgery after craniofacial trauma aim to restore orbital anatomy for function and aesthetic reasons. The purpose of this study is to improve postoperative orbital symmetry with the use of prebent prefabricated titanium implants. In this retrospective study, patients with combined unilateral medial wall and floor fractures who underwent orbital reconstruction surgery were selected. The angle of inferomedial orbital strut (AIOS) was measured at 3 standard locations on preoperative facial computed tomography guided scans of the nonfractured orbit in the coronal view and used as a guide to bend the prefabricated titanium implants intraoperatively. The corresponding values were measured on the postoperative computed tomography and compared for symmetry. Out of 83 patients recruited for the study, 54 were in the prebent group while 29 were in the control group. All other demographics were similar among the 2 groups. Anterior AIOS has a difference of 4.9° between 2 orbits in the prebent group whereas a difference of 15.5° was noted in the nonprebent group. For middle AIOS, a difference of 4.7° was noted in the prebent group whereas nonprebent group had a difference of 14.1°. For posterior AIOS, the prebent group had a difference of 3.8° versus 14.1° in the nonprebent group. The difference in AIOS at all 3 points between the prebent and nonprebent group were significant. Anatomical prefabricated titanium plates are versatile implants that facilitate orbital reconstruction. Prebending of these implants according to the fellow orbit can achieve better surgical outcomes in a cost-effective manner.

Factor Influencing Postoperative Enophthalmos After Reconstruction of Orbital Wall Fracture.

To determine factors influencing postoperative enophthalmos after reconstruction of orbital wall fracture. Data of consecutive patients who were diagnosed with unilateral medial or inferior orbital wall fracture from March 2013 to February 2020 were retrospectively reviewed. Forty-three patients were included in this study (24 with medial orbital wall fracture and 19 with inferior orbital wall fracture). Their medical records including Hertel exophthalmometry, preoperative computed tomography (CT) scan, and postoperative CT scan were reviewed. The degree of enophthalmos developed was calculated by measuring exophthalmos before surgery and at 6 months after surgery. Patients were classified into 2 groups depending on whether reduction was good after surgery or not. Data (eg, age, gender, onset, fracture size, and so on) were then compared between these 2 groups. A total of 43 patients were included in the study. Their mean age was 40.1 years. There were 34 (79.1%) males. The mean onset from trauma to surgery was 8.1 days. Insufficient soft tissue reduction was found in 9 patients through postoperative CT scan. Preoperative mean enophthalmos was - 1.70 mm. Postoperative mean enophthalmos was -0.45 mm after 6 months. The mean fracture size was 213.74 mm2. There was no statistically significant difference in enophthalmos at 6 months after surgery regardless whether the reduction was good or not. Enophthalmos at 6 months after surgery was associated with preoperative fracture size and onset. Postoperative enophthalmos development might be associated with preoperative fracture size and onset. Delayed operation in case of large orbital wall fracture might lead to undesired result. Thus, surgeons should keep that in mind.

Comparison of Blowout Fracture Sites Observed in Young and Elderly East Asians.

The purpose of this study was to investigate the distribution of blowout fracture sites among age groups and compare clinical factors that can affect the fracture site. The authors reviewed 330 cases of blowout fracture surgeries and included 226 eyes of 226 patients aged between 20 and 29 years and between 50 and 59 years who underwent blowout fracture reconstruction between January 2017 and December 2020, in the Department of Ophthalmology at Korea University Hospital.Medical records including patient demography, trauma etiology, and preoperative computed tomography image were evaluated. Ethmoidal cell septa and fracture site position were compared between the 2 age groups. The causes of injury were categorized into 3 groups: focal trauma, gross trauma, and other causes. Orbital floor fracture was the most common type (40.00%) in the young group, followed by medial wall fracture (25.33%). in contrast, medial wall fracture accounted for the largest proportion (42.11%) in the older group, and orbital floor fracture accounted for only 26.67%. The major cause of blowout fracture in young patients was focal trauma, whereas gross trauma was the most common cause in the older group. The number of ethmoidal cells was 4.19 ± 0.831 (2-6) in the young group and 3.91 ± 1.022 (2-6) in the old group (P < 0.05). Distribution of blowout fracture site differed between age groups, and these differences can be explained by cause of injury and number of ethmoidal cells.

Blowout Fracture Assessment Based on Computed Tomography and Endoscopy: The Effectiveness of Endoscopy for Fracture Repair.

The purpose of this study was to compare the configuration of blowout fracture observed through orbital computed tomography (CT) and endoscopy, then present the effectiveness of using an endoscope in reconstruction surgery of blowout fracture. We retrospectively reviewed the clinical records of 337 patients who underwent reconstruction surgery of blowout fracture between January 2017 and December 2020 in the Department of Ophthalmology at Korea University Guro Hospital. The patients were categorized into 3 groups based on preoperative CT findings as follows: combined orbital medial and floor wall fractures, trapdoor fractures, and large blowout fractures. The images obtained through CT and endoscopy were compared among the 3 groups. Endoscopy helped identify herniated soft tissue and posterior fracture margins, and it also provides better magnification and a brighter view of the posterior aspects of the fracture site. Furthermore, endoscopy can also provide educational opportunities to visualize the fracture site and help trainees understand the surgical procedure approach or orbital anatomy. Based on our results, we suggest using an endoscope during blowout fracture surgery as an effective approach to reduce postoperative complications due to endoscopy's advantages in clear visualization of the fracture site during operation.

A comparative study of porous polyethylene versus absorbable polydextro- and polylevolactic-lactide plate in reconstruction of isolated medial orbital wall fracture

Several materials for medial orbital wall reconstruction have been mentioned in the literature. Our main purpose was to investigate postoperative enophthalmos and diplopia after medial orbital wall reconstruction with polydextro- and polylevolactic (poly-L/DL) acid (P[L/DL]LA) mesh plates and porous polyethylene plates. Using a retrospective study design, we enrolled a cohort of isolated medial blowout fracture patients treated during a 58-month interval. The predictor variable was medial orbital wall reconstruction materials (P(L/DL)LA mesh plate and porous polyethylene plate. The main outcome variables included the occurrence of postoperative enophthalmos and diplopia at 1 week, 1, 3, 6, and 12 months post-surgery. Appropriate descriptive, uni- and bivariate statistics were computed, and P < 0.05 was considered significant. Three hundred-two isolated medial blowout fracture patients were included (24.5% females, 67% treated with P(L/DL)LA mesh plate). Exophthalmos measured highest in both groups 1 week after surgery and decreased steadily for 6 months postoperatively. Statistically significant differences were observed between both groups at 1 week, 1 month, and 3 months after surgery, with a higher incidence of exophthalmos observed in the P(L/DL)LA mesh plate group (P < 0.001). No significant differences were observed at 6 and 12 months after surgery. The occurrence of enophthalmos after medial blowout fracture reconstruction with P(L/DL)LA mesh plate is comparable with the use of porous polyethylene plate. Both P(L/DL)LA mesh and porous polyethylene plates are, therefore, reliable implants for medial orbital wall reconstruction.

Acetabular Fractures with Central Hip Dislocation: A Retrospective Consecutive 50 Case Series Study Based on AO/OTA 2018 Classification in Midterm Follow-Up.

Introduction Management of acetabular fractures is challenging, especially when a medial acetabular fracture is complicated by central hip dislocation. We retrospectively investigated the clinical outcome and risk factors of secondary hip osteoarthritis requiring total hip arthroplasty after the surgical treatment of acetabular fractures with central hip dislocation. Materials and Methods The medical records of all patients who had acetabular medial wall fractures with central hip dislocation treated with open reduction and internal fixation by a single surgeon between January 2015 and June 2017 were reviewed. Surgical reduction was performed with the modified Stoppa with/without the Kocher-Langenbeck (KL) approach. Patients were followed for a minimum of three years, and the Majeed scoring system was used for functional evaluation. Multivariate logistic regression analysis was used to assess the association of patients' characteristics with the likelihood of advanced posttraumatic arthritis developing with conversion to total hip arthroplasty. Results Fifty patients were included in this study, with disease classified as AO/OTA 2018 62B/62C. Thirty-five patients (70%) had good or excellent Majeed pelvic scores. Eleven patients (22%) eventually received total hip arthroplasty because of end-stage posttraumatic arthritis. Three risk factors identified for total hip arthroplasty were male sex, initial marginal impaction, and sciatic nerve injury. Kaplan-Meier survivorship analysis estimated that the cumulative probability of free-from-end-stage arthritis was 78% (95% confidence interval, 73%–90%) at the 5-year follow-up. Conclusion Surgical fixation with the modified Stoppa and the KL approach for acetabular medial wall fractures with central hip dislocation is an effective approach with a satisfactory functional outcome. A prodromal factor was marginal impaction concomitant with articular damage. The trauma of high axial loading and the occupational distribution (males performing heavy manual labor and heavy lifting) with preoperative sciatic nerve injury increased the odds of developing end-stage arthritis.

Accuracy of free-hand positioned patient specific implants (PSI) in primary reconstruction after inferior and/or medial orbital wall fractures

BackgroundTo assess the accuracy with which CAD/CAM-fabricated patient-specific titanium implants (PSI) are positioned for inferior and/or medial orbital wall reconstruction without the use of intraoperative navigation. MethodsPatients who underwent a primary reconstruction of the orbital walls with PSI due to fractures were enrolled in this retrospective cohort analysis. The primary outcome variables were the mean surface distances (MSD) between virtually planned and postoperative PSI position and single linear deviations in the x-, y- and z-axis at corresponding reference points. Secondary outcome variables included demographic data, classification of orbital wall defects and clinical outcomes. ResultsA total of 33 PSI (orbital floor n = 22; medial wall, n = 11) were examined in 27 patients. MSD was on a comparable level for the orbital floor and medial wall (median 0.39 mm, range 0.22–1.53 mm vs. median 0.42 mm, range 0.21–0.98 mm; p = 0.56). Single linear deviations were lower for reconstructions of the orbital floor compared to the medial wall (median 0.45 vs. 0.79 mm; p < 0.05). There was no association between the occurrence of diplopia and the accuracy level (p = 0.418). ConclusionsFree-hand positioning of PSI reaches a clinically appropriate level of accuracy, limiting the necessity of navigational systems to selected cases.

Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures.

The study reports the correlation between surgical timing and postoperative ocular motility in orbital blowout fractures. This was a retrospective study of 191 patients that underwent surgical repair for unilateral orbital fractures. All patients included in the study had symptomatic diplopia from the fracture. Patients were classified into one of three groups according to the time of surgery after injury: (1) Early (within 14days of surgery), (2) intermediate (between 15 and 30days), and (3) late (greater than 30days). Ocular motility was measured presurgery and at 3 and 6months postsurgery by Hess chart with calculation of the Hess area ratio (HAR%). Surgery was conducted at a mean of 24.7 ± 45.0days (range: 1-283days) postinjury. There were 120 patients in the early surgery group (surgery at 6.8 ± 3.8days), 38 in the intermediate surgery group (20.7 ± 4.1days), and 33 in the late surgery group (95.1 ± 75.0days). Overall the HAR% improved significantly from a mean of 74.2% preoperatively to 90.8% at 6months postoperatively (p < 0.01). In the early and intermediate groups, the postoperative HAR% improved significantly with all fracture regions (orbital floor, medial wall, and combined orbital medial wall and floor) (p < 0.05). However, in the late groups, the postoperative HAR% only improved significantly with orbital floor fractures. Pre- and postoperative the HAR% give objective evidence of ocular motility improvement with early orbital floor fracture repair surgery. However, observation can be deployed, as a significant improvement in ocular motility can also be achieved with reconstructive surgery conducted 30days or more after depressed floor-fragment fractures. Early intervention should be prioritized for symptomatic medial wall fractures, as late surgery does not improve motility.

Characteristics of Postoperative Anisocoria After Medial Orbital Wall Fracture Repair.

The purpose of this study was to present the clinical characteristics and etiology of patients with anisocoria after medial wall fracture repair. This study was a retrospective, noncomparative case series of postoperative anisocoria after medial orbital wall fracture repair. Data regarding patient demographics, laterality, signs and symptoms at presentation, interval between injury and surgery, fracture size using orbital computed tomography, pupil size of mydriasis, time of discovery of postoperative mydriasis, time of resolution of anisocoria, surgical outcomes, and complications were collected. Twelve patients were included in this study. The mean interval between injury and surgery was 19.17 ± 4.95 (range, 12-30) days. The mean fracture size of the anteroposterior meridian was 25.22 ± 2.15 (range, 21.8-28.4) mm and that of the horizontal meridian was 16.02 ± 2.02 (range, 12.5-21.2) mm. Postoperatively, unilateral pupil dilation was observed at a mean of 5.33 ± 1.61 (range, 3-8) hours after surgery, and mean pupil size was 5.13 ± 0.61 (range, 4-6) mm in the dilated eye and 3.29 ± 0.26 (range, 3-3.5) mm in the normal eye. The dilated pupils all recovered within a mean of 3.42 ± 1.08 (range, 2-5) days. Postoperative anisocoria after medial orbital wall blowout fracture surgery may occur in delayed repair of the posterior location of large fractures. Transient mydriasis caused by parasympathetic nerve injury returned to normal pupil size.

Three-Dimensional Computer-Aided Analysis of 293 Isolated Blowout Fractures – Which Radiological Findings Guide Treatment Decision?

Our study purpose was to clarify the extent of isolated unilateral orbital blowout fracture in relation to surgical treatment and other factors behind the treatment decision. The specific aim was to determine which computer-aided measurements based on radiological images associate with treatment choice. A retrospective cohort study was implemented on patients with an isolated unilateral orbital blowout fracture. Computer-aided measurement of fracture extent was performed. The study variables included treatment as primary outcome (surgical vs nonsurgical), post-traumatic orbital volume difference (mL) compared to contralateral orbit, fracture area (mm2), fracture depth (mm) as predictor variables, and age, sex, injury mechanism, side and site of orbital fracture and positions of recti muscles as explanatory variables. Postoperative outcomes were reported. Logistic regression analysis was used to determine the risk factors for surgery. The statistical significance level was set at P < .05. Of 293 patients, 28.0% received surgical and 72.0% nonsurgical treatment. Volume difference, fracture area and fracture depth predicted surgical outcome (P < .001). In adjusted univariate regression analyses, fractures with moderate and severe displacement of recti muscles were more likely to receive surgical treatment than fractures with mild or no displacement (OR 6.15 and 30.75, respectively, P < .001). Isolated medial wall fractures were significantly less often (OR 0.05, P = .006) and patients with older age (OR 0.97, P = .013) slightly less often treated with surgery. Patients with preoperative symptoms had more often persisting postoperative symptoms than patients without preoperative symptoms. Positions of the recti muscles are an independent radiological factor guiding orbital blowout fracture treatment decision. The bony fracture extent is a combination of volume difference, fracture area and fracture depth which are strongly correlated to each other. A computer-aided method significantly facilitates the systematic evaluation of bone fragments, and the extent of orbital fractures.

Orbital Infection Due to Medial Wall Fracture: Three Cases of Orbital Complications Caused by Paranasal Sinusitis Secondary to Medial Orbital Wall Fracture.

The aim of this study was to report 3 cases of orbital complications in patients with secondary sinusitis due to medial orbital wall fracture. We believe that sinusitis can be secondary to the fracture of the medial orbital wall when the sinus drainage orifice is blocked due to some fracture pieces or other blocking factors. We precisely show the direct evidence of the blocking factors through radiology. Retrospective, noncomparative, interventional case series. All patients had intraorbital complications and a history of traumatic orbital medial fracture as well as imaging findings of sinusitis. A medical record review of clinical history, imaging studies, and surgical and treatment outcomes were performed. Postoperative visual acuity, appearance, eye movement, surgical and imaging findings. Three patients (2 males and 1 female; average age 38.33 years [range, 11-65]) received endoscopic surgery for orbital complications related to sinusitis. All patients had evidence of paranasal sinusitis after the orbital injury. Two patients were treated with antibiotics before the operation, but there was no significant improvement. All patients underwent transnasal endoscopic sinotomy. Two patients received orbital abscess incision and drainage surgery and 1 patient underwent a cyst excision operation. The visual acuity of the 3 patients was improved after the operation, and the clinical examination was significantly improved. The anatomy of the orbit is closely related to the nasal cavity. The fracture of the medial orbital wall often causes abnormal anatomy of the sinus outflow tract. For the 3 of our patients, the blocking factors of sinus orifices were fracture fragment, orbital bone deformation, and the formation of giant nasal intraorbital mucocele. Sinusitis possibly occurs when drainage is not smooth. Infections develop due to the secretions retaining and accumulation of microorganisms. Inflammation from the sinus can be spread into the orbit in various ways. Our 3 patients indicate that a fracture of the inner orbital wall may cause sinusitis. When the patient is injured again or sneezing or in other conditions when the pressure in the nasal cavity increases, inflammation of the sinuses enters the orbit, causing serious intraorbital complications. It is necessary to carefully follow-up on the medical history, combined with imaging examination, to prevent the misdiagnosis of intraorbital hemorrhage or hematoma from affecting the treatment.In recent years, more and more cases of intraorbital complications caused by sinusitis have been reported.1,2 Severe intraorbital inflammation can pose a threat to vision and even life. With the great tool of the endoscope, nasal-orbital problems can be well solved. For our 3 patients, we opened the paranasal sinus and removed the occlusion of the sinus orifice through transnasal endoscopy. All patients achieved good surgical and clinical results.