Orbital Trauma Research Articles

The Frequency of Decreased Visual Acuity in Orbital Fractures.

The aim of this systematic review is to summarize and evaluate the effect of orbital fractures (blowout fractures and nonblowout fractures) on visual acuity. In PubMed search and Scopus search, the terms "orbital fracture OR maxillofacial injury OR facial trauma OR craniofacial fracture," and "visual acuity OR functional outcome OR visual outcome OR improving document of visual acuity OR blindness OR optic nerve neuropathy" were used, which resulted in 1634 and 1152 papers, respectively. Of the 2226 titles excluding 560 duplicated titles, 227 abstracts were reviewed. Of the 227 abstracts reviewed, the authors found 56 potentially relevant full-text articles, of which 5 studies met our inclusion criteria. The odds ratio and 95% confidence intervals from each study were abstracted. The statistical analysis was performed with review manager (The Nordic Cochrane Centre). A summary of 5 studies affirmed that 43 patients among 532 orbital fractures (8.1%) had decreased visual acuity. Twelve patients among 159 blowout fractures (7.5%) had decreased visual acuity. Thirty-one patients among 373 orbital fractures other than pure blowout fractures (8.3%) had decreased visual acuity. In orbital fractures other than pure blowout fractures, the frequency of decreased visual acuity was higher than pure blowout fractures (n = 532, odds ratio, 2.23, 95% confidence interval = 1.06-4.70). Surgeons should acknowledge this with patients before surgery.

A case series of rapid prototyping and intraoperative imaging in orbital reconstruction.

In Christchurch Hospital, rapid prototyping (RP) and intraoperative imaging are the standard of care in orbital trauma and has been used since February 2013. RP allows the fabrication of an anatomical model to visualize complex anatomical structures which is dimensionally accurate and cost effective. This assists diagnosis, planning, and preoperative implant adaptation for orbital reconstruction. Intraoperative imaging involves a computed tomography scan during surgery to evaluate surgical implants and restored anatomy and allows the clinician to correct errors in implant positioning that may occur during the same procedure. This article aims to demonstrate the potential clinical and cost saving benefits when both these technologies are used in orbital reconstruction which minimize the need for revision surgery.

Intraorbital haematoma during a commercial flight: a case report

BackgroundIntraorbital haematoma is a rare clinical entity which can be caused by orbital traumas, neoplasms, surgeries nearby sinuses and orbit, vascular malformations, acute sinusitis, systemic abnormalities, barotrauma and valsalva maneuver.Case PresentationA 74-year-old male presented with sudden onset of ocular pain, upper eye lid swelling, proptosis and diplopia after a commercial flight. After complete ophthalmic ocular examination including pupillary light reflexes and laboratory examinations; computed tomography and magnetic resonance imaging of orbit revealed a subperiostal mass-like lesion in the right retrobulbar-extraconal region which was compatible with intraorbital haematoma. Visual acuity was not compromised so we planned a conservative approach with close observation. We administered systemic corticosteroid and topical dorzolamide/timolol combination therapy. At the first month follow-up, intraorbital haematoma resolved without significant sequelae.ConclusionIntraorbital haematoma can be managed by conservative approach without any intervention if it does not threat visual acuity or optic nerve. We experienced a case of intraorbital haematoma during a commercial flight. We discussed the rarity of this condition and its management.

Ethmoid Osteoma as a Culprit of Orbital Emphysema

Orbital emphysema is generally recognized as a complication of orbital fractures involving any paranasal sinuses. The recognition about its etiology has extended beyond sole trauma, but few articles mentioned tumors to be a possible cause.In this case report, we present a patient with orbital emphysema associated with ethmoid osteoma without orbital cellulitis or trauma history. The patient developed sudden proptosis, eyelid swelling, and movement limitation of the left eye, peripheral diplopia, and left periorbital crepitus after a vigorous nose blowing.Complete surgical resection of ethmoid osteoma followed by repair of the orbital medial wall was performed with assistance of combined endoscopy and navigational techniques. Twelve-month follow-up showed no residual lesion or recurrence; the orbital medial wall was accurately repaired with good visual function and facial symmetry.Tumors should be considered for differential diagnosis of orbital emphysema, and combined endoscopy and navigational techniques may improve safety, accuracy, and effectiveness of orbital surgeries.

Endoscopic Endonasal Approach of Orbital Medial Wall Reconstruction using Septal Cartilage: A Rare Surgical Case Report

ABSTRACT Orbital fractures can cause facial disfigurement and disturbs vision. Medial orbital wall fractures are diagnosed with frequent use of computed tomography (CT) scans in the diagnosis of orbital trauma. Orbital reconstruction plays a challenging role for the surgeons as it comes in a multitude of different forms. We report a case of 45-year male with a history of assault presented with diminution of vision, restricted abduction and diplopia of the left eye. Computed tomography scan showed fracture of the left medial orbital wall fracture and the patient was treated by endoscopic endonasal approach of medial orbital wall reconstruction using septal cartilage. How to cite this article Rajasekar MK, Vivek M, Narendrakumar V. Endoscopic Endonasal Approach of Orbital Medial Wall Reconstruction using Septal Cartilage: A Rare Surgical Case Report. Clin Rhinol An Int J 2015;8(1):30-33.

The role of computerised tomography in predicting visual outcome in ocular trauma patients.

Ocular blast injuries in the military setting are particularly associated with significant maxillofacial trauma and/or brain injury. The opportunity to perform a comprehensive ophthalmic evaluation is frequently limited in the acute multiple trauma scenario. We aim to describe the relationship between the clinical effects of acute ocular and orbital blast trauma with the findings on computerised tomography (CT). This was a retrospective consecutive case series of all soldiers with facial and/or suspected ocular injuries. A total of 80 eyes that had suffered blast injuries of varying severity were studied. Assessment of orbital and ocular CT images were performed by military consultant radiologists. A comparison was made with actual clinical findings. Statistical analysis was performed using Fisher's exact test. No pathological findings were described in 37 of the 80 eyes imaged by orbital and ocular CT scans. Clinically, these eyes and orbits were all found to be intact, or had minor trauma. All foreign bodies and penetrating eye injuries were successfully diagnosed by CT. Absence of an orbital fracture did not rule out a globe injury. However, a corneal or scleral defect was less likely when an orbital fracture was absent. The eye is a delicate structure prone to injury that requires urgent repair if breached. It is difficult to assess thoroughly in the unconscious or distressed patient. In this context, CT imaging is invaluable to be able to make a relatively confident prediction of clinical findings and decide upon the necessity for acute ophthalmic surgical intervention.

3D-assisted quantitative assessment of orbital volume using an open-source software platform in a Taiwanese population.

Orbital volume evaluation is an important part of pre-operative assessments in orbital trauma and congenital deformity patients. The availability of the affordable, open-source software, OsiriX, as a tool for preoperative planning increased the popularity of radiological assessments by the surgeon. A volume calculation method based on 3D volume rendering-assisted region-of-interest computation was used to determine the normal orbital volume in Taiwanese patients after reorientation to the Frankfurt plane. Method one utilized 3D points for intuitive orbital rim outlining. The mean normal orbital volume for left and right orbits was 24.3±1.51 ml and 24.7±1.17 ml in male and 21.0±1.21 ml and 21.1±1.30 ml in female subjects. Another method (method two) based on the bilateral orbital lateral rim was also used to calculate orbital volume and compared with method one. The mean normal orbital volume for left and right orbits was 19.0±1.68 ml and 19.1±1.45 ml in male and 16.0±1.01 ml and 16.1±0.92 ml in female subjects. The inter-rater reliability and intra-rater measurement accuracy between users for both methods was found to be acceptable for orbital volume calculations. 3D-assisted quantification of orbital volume is a feasible technique for orbital volume assessment. The normal orbital volume can be used as controls in cases of unilateral orbital reconstruction with a mean size discrepancy of less than 3.1±2.03% in females and 2.7±1.32% in males. The OsiriX software can be used reliably by the individual surgeon as a comprehensive preoperative planning and imaging tool for orbital volume measurement and computed tomography reorientation.

Diagnosis and imaging of orbital roof fractures: a review of the current literature.

Isolated adult orbital roof fractures are uncommon, and the majority of them are typically associated with extensive craniofacial, ophthalmologic, and other body injuries. It is crucial to make an appropriate diagnosis of orbital roof fracture if present. Therefore, the aim of this article was to review the current literature about diagnosis and imaging of orbital roof fracture to obtain current indications. A systematic review of articles published between January 1990 and August 2013 was performed. Early diagnosis of orbital roof fractures can reduce the incidences of intracranial and ocular complications. CT scan still plays a major role in the assessment of acute orbital trauma. Careful assessment and reporting of the CT scan findings are important. In fact, the clinicians managing the patient with acute head and facial trauma should be familiar with the common findings of CT scan in case of an orbital roof fracture.

Malpractice in treatment of sinonasal disease by otolaryngologists: a review of the past 10 years.

Sinonasal disease is a common condition treated by otolaryngologists. Malpractice in this area is the most common litigation faced by otolaryngologists. This study analyzes malpractice in the treatment of sinonasal disease. Case series, review of legal records. Legal databases. Using 2 different computerized legal databases, the phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the past 10 years (2004-2013), yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement. Chronic sinusitis (42%) was the most common presenting symptom. Many cases included multiple types of alleged malpractice, with the most common being negligent technique (38%) and lack of informed consent (27%). The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting. Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease. Lack of informed consent continues to be a common allegation, and surgeons should ensure complete informed consent is obtained and well documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty-related claims.

An Approach to Some Aspects of Strabismus from Ocular and Orbital Trauma.

Strabismus caused by ocular or orbital trauma can be the result of localized acute soft tissue swelling or may follow orbital fractures, partial or complete loss of extraocular muscle (EOM) and/or cranial nerve function, or damage to surrounding tissues causing mechanical restriction. The strabismus is frequently incomitant and can be difficult, if not impossible to completely correct. The resulting diplopia can affect the individual's ability to function at work, in sports and in common tasks of daily living like driving. The preoperative evaluation should include an assessment of the degree of limitation, muscle function and the condition of the surrounding tissue. In most cases, high resolution computed tomography and/or surface coil dynamic magnetic resonance imaging are required to determine the extent and nature of suspected bony or EOM injury, as well as muscle contractility. If the scan reveals an intact but paretic muscle or only minor muscle injury, surgical intervention is based on the degree of muscle recovery 6 months after the initial insult. If a rectus muscle has been lacerated, and the proximal stump is functional, retrieval should be attempted, either by a direct conjunctival approach if located anteriorly, or by an anterior medial orbitotomy if located deep in the orbit. If a damaged muscle cannot be found, recovered or repaired at any time, then muscle transposition should be considered. If multiple muscles are damaged or scar tissue is excessive, a tether procedure may be indicated. This paper will present an approach to some aspects of strabismus in this setting.

'Sutureless' transconjunctival approach for infraorbital rim fractures.

Aim:To analyze the ease and surgical outcome of using sutureless transconjunctival approach for repair of infra-orbital fractures.Design:Prospective clinical case series.Materials and Methods:Totally 5 patients with infra-orbital rim or orbital floor fractures were selected and the fractures were accessed through a pre-septal transconjunctival incision. After reduction and fixation, the conjunctiva was just re-approximated and re-draped into position. Incidence of post-operative complications such as diplopia, lid retraction, eyelid dystopia, foreign body granuloma and poor conjunctival healing was assessed at intervals of 1 week, 15 days and a month post-operatively.Results:No complications were observed in any of the 5 patients. Healing was satisfactory in all patients.Conclusion:The sutureless technique appears to be a time saving and technically simpler viable alternative to multilayered suturing in orbital trauma with minimal post-operative complications.

Ophthalmic Features of Outpatient Children Diagnosed with Intracranial Space-Occupying Lesions by Ophthalmologists.

Introduction:Brain tumors in children often involve the visual system, but most retrospective series are by neurologists or oncologists. In this study we highlight the ophthalmic findings of outpatient children with visual complaints and/or strabismus who, based on ophthalmic examination, were suspected to and confirmed to harbor intracranial space-occupying lesions by magnetic resonance imaging (MRI).Materials and Methods:Retrospective case series of children (less than 18 years) who for visual complaints and/or strabismus underwent cranial MRI at a referral eye hospital (2005–2012), which revealed intracranial space-occupying lesions. Exclusion criteria were known preexisting orbital or ocular trauma, ocular tumor, or neurological disease.Results:For 26 patients (3 months-17 years; mean 7 years; median 9 years; and 14 boys), the most common clinical presentation was decreased vision with disc pallor (10) or swelling (three). Other presentations were strabismus with disc pallor or swelling (four; two of which were left sixth nerve palsies), acquired esotropia with diplopia (three; one bilateral and two left sixth nerve palsies), acquired exotropia (four; two of which were bilateral third nerve palsies, one of which was left partial third nerve palsy, and one of which was associated with headache), nystagmus (one), and disc swelling with headache (one). Most lesions were in the sellar/suprasellar space (10), posterior fossa (six), or optic nerve/chasm (four).Conclusions:The majority of outpatient children diagnosed by ophthalmologists with intracranial space-occupying lesions presented with disc swelling or pallor in the context of decreased vision or strabismus. Two strabismus profiles that did not include disc swelling or pallor were acquired sixth nerve palsy and acquired exotropia (with ptosis (third nerve palsy), nystagmus, or headache).

Imaging of the midfacial and orbital trauma.

The severity of midfacial and orbital injuries depends on the one hand on cause, force vector, load point, or area and on the other hand on the bony and soft tissue resistance as well as individual anatomy. These variables result in a variety of possible injuries of the midfacial and orbital complex. The time critical choice of an adequate imaging modality of these injuries is influenced by the possible severity of concomitant injuries. Besides the confirmation of a clinical diagnosis, the need for high-resolution three-dimensional imaging for preoperative planning of facial reconstruction using intraoperative navigation has become more and more important in the past years. To achieve optimal functional and esthetic outcomes, the anatomical complexity of the midface has to be addressed and the adequate imaging modality has to be chosen keeping the upcoming surgical treatment in mind. The current imaging modalities for midfacial and orbital trauma are presented and critically evaluated depending on the indications. Furthermore, new strategies to support surgeons in achieving best possible midfacial reconstructions are discussed. An algorithm to choose the adequate imaging modality in midfacial and orbital traumatology is provided.

Use of copolymer polylactic and polyglycolic acid resorbable plates in repair of orbital floor fractures.

The fractures of the orbital floor are common after craniofacial trauma. Repair with resorbable plates is a viable reconstructive option; however, there are few reports in the literature. This study describes our experience using copolymer polylactic and polyglycolic acid (PLLA/PGA) orbital reconstruction plates (LactoSorb, Lorenz Surgical, Jacksonville, FL) in 29 cases of the orbital floor fracture repair. We conducted a retrospective review of 29 orbital floor fractures at a single institution repaired through transconjunctival, preseptal dissection using PLLA/PGA plates fashioned to repair the orbital floor defect. Associated fractures included zygomaticomaxillary, LeFort, and nasoethmoid fractures. There were six patients with complications. Four patients had transient diplopia with complete resolution of symptoms within 1 year. One patient had diplopia postoperatively, but was later lost to follow-up. Two patients have had persistent enophthalmos since 1 year. In each of these cases, the floor fracture was coincident with significant panfacial or neurotrauma. We did not encounter any adverse inflammatory reactions to the implant material itself. The study concluded that orbital floor fracture repair with resorbable plates is safe, relatively easy to perform, and in the majority of cases was effective without complications. In the presence of severe orbital trauma, more rigid implant materials may be appropriate.

Diagnosis and treatment of optic nerve trauma.

Decreasing visual acuity secondary to orbital trauma or orbital and anterior skull base surgery may be caused by either sudden space-occupying intraorbital lesions, including retrobulbar hemorrhage (RBH), or direct damage to the prechiasmatic pathway. Contrary to traumatic optic neuropathy, RBH must be diagnosed and treated immediately to prevent permanent damage to the visual system. Therefore, monitoring and handling of visual pathway damage are mandatory. Flash visual evoked potentials and electroretinograms can provide evidence of the status of conductivity of the visual pathway when clinical assessment is not feasible. Both are thus essential diagnostic procedures not only for primary diagnosis but also for intraoperative evaluation. In case of RBH surgical decompression is compulsory. However, traumatic optic neuropathy does not respond to either corticosteroids or optic canal surgery. Modern craniomaxillofacial surgery requires detailed consideration of the diagnosis and treatment of traumatic visual pathway damage with the ultimate goal of preserving visual acuity.

Effectiveness of Computed Tomography for Blow-out Fracture.

Purpose:This study assessed the association between eye symptoms (enophthalmos or diplopia) and site of damage, volume, deviated inferior rectus muscle (IRM) and type of fracture with computed tomography (CT). The intent is to anticipate the prognosis of orbital trauma at initial diagnosis.Methods:Forty-five patients were diagnosed with fractures of the inferior wall of one orbit. Fracture area, volume of displaced tissue, deviated IRM, and type of fracture were evaluated from coronal CT by one investigator. The association of those variables with the occurrence of eye symptoms (diplopia and enophthalmos) was assessed.Results:Of 45 patients, 27 were symptom-free (Group A) and 18 had symptoms (Group B) of enophthalmos and/or diplopia. In Group B, 12 had diplopia, one was enophthalmos, and five had both. By CT measurement, group A mean area was 192.6 mm2 and the mean volume was 673.2 mm3. Group B area was 316.2 mm2 and volume was 1,710.6 mm3. The volume was more influential on symptom occurrence. Each patient was categorized into four grades depending on the location of IRM. Symptom occurrence and higher grade were associated. Twenty-six patients had trap-door fracture (one side, attached to the fracture), and 19 had punched-out fracture (both sides detached). The punched-out fracture was more strongly associated with symptoms and had statistically significantly higher area and volume.Conclusion:In orbital trauma, measurement of fracture area and volume, evaluation of the deviated IRM and classification of the fracture type by coronal CT can effectively predict prognosis and surgical indication.

Clinical and radiological characteristics of Graves' orbitopathy patients showing spontaneous decompression

ObjectiveTo investigate clinical implications and radiological characteristics of spontaneous decompression in patients with Graves' orbitopathy (GO). MethodsThe medical records and images of GO patients showing spontaneous decompression in computed tomography (CT) scans without any other cause, such as orbital surgery or trauma were retrospectively reviewed. Clinical parameters, including clinical activity score (CAS), modified NOSPECS score, exophthalmometry results, extraocular muscle involvement, and the presence of optic nerve compression were evaluated. Paired orbit analyses of maximum recti muscle diameters, area of lamina papyracea, and number of ethmoid air cell septa were determined quantitatively in the unilaterally decompressed group. Results77 orbits of 55 patients were found to present spontaneous decompression, which was observed only in the medial orbital wall in all cases. In the paired orbit comparison, maximal diameters of medial (P = 0.009) and lateral recti muscles (P = 0.023) were significantly larger in decompressed orbits than in non-decompressed orbits. However, the incidence of optic neuropathy was not significantly different (P = 0.500). There was no difference in anatomic features of lamina papyracea or ethmoid air cells between decompressed and non-decompressed orbits. ConclusionsSpontaneous decompression occurred in the medial wall, associated with enlarged horizontal recti muscles, but not with structures of lamina papyracea or the ethmoidal sinus. Orbital bone remodeling by spontaneous decompression by lowering intraorbital pressure, might have provided a protective effect against the development of optic neuropathy.

Analysis of unilateral complex orbital fractures with a new treatment algorithm

The aim of this study is to investigate preoperative and postoperative properties, the management of unilateral complex orbital fractures, and to offer an algorithm for orbital fractures. For this research study, 248 patients with orbital trauma were evaluated according to an offered algorithm. Diplopia, enophthalmos, dystopia, infraorbital nerve dysfunction, and ocular movement limitations were documented for clinical assessment. Orbital rim displacement and an orbital volume check with computed tomography (CT) were used for indication of surgery. The injured orbital volume was compared with the healthy orbital volume in the preoperative and postoperative periods. In total, 58 patients required operations among the 248 patients, according to the algorithm. The preoperative mean injured orbital volume measurements of the operated patients were statistically different than the healthy orbital volume measurements (30.13 cm3 ± 2.69 cm3 and 27.15 cm3 ± 1.29 cm3, respectively). In the postoperative period, there was no difference between the injured and healthy orbital volume. In conclusion, an algorithm may facilitate the approach to unilateral complex orbital fractures. Ophthalmic examination, rim displacement, and the measurement of orbital volume using computed tomography are key points of orbital fractures with regard to management.

Reactivation of Thyroid Associated Orbitopathy Following Trauma with Intraorbital Foreign Body

A 63-year-old female with mild, bilateral, stable thyroid-associated orbitopathy sustained trauma resulting in glass foreign bodies embedded on the left ocular surface and left lateral orbital extraconal and intraconal space. After 2 orbitotomies including a failed attempt to remove the intraconal foreign body and poor response to oral steroids, she developed severe, progressive left periorbital edema and 9 mm of relative proptosis. Serial, post-operative imaging demonstrated worsening inflammatory changes along the surgical tract, which slowly improved over several months, with simultaneously worsening proptosis and enlargement of the left inferior and medial rectus muscles consistent with worsening thyroid orbitopathy. She subsequently underwent unilateral 3-wall orbital decompression with improvement in her symptoms. Periorbital trauma with orbital foreign bodies and related surgical trauma may result in reactivation of thyroid-associated orbitopathy.

Medical Malpractice in Sinonasal Disease: An Analysis of Litigation over the Last Ten Years

Objectives: (1) Review past literature on medical malpractice in rhinology and sinonasal disease in the Unites States of America. (2) Analyze otolaryngology malpractice litigation related to sinonasal disease in the last 10 years. (3) Discuss ways to prevent future malpractice litigation in this area of otolaryngology. Methods: The study is a case series with review of court records pertaining to litigation of otolaryngologic treatment of sinonasal disease using the Westlaw and Lexis Nexis legal databases. The phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the last 10 years, yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement. Results: Chronic sinusitis was the most common presenting symptom. Many cases included multiple types of alleged malpractice with the most common being negligent technique and lack of informed consent. The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of the 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting. Conclusions: Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease and ensure informed consent is obtained and well-documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty-related claims.