Orbital Fractures Research Articles

Case Report: Facial fracture sequelae: the importance of using a specific customized implant (PSI) for orbital reconstruction

The reconstruction of orbital fracture sequelae is a major challenge due to concerns regarding surgical approach and implant stability. Few anatomical sites of such minute size have presented with as much variation in treatment as the orbital floor fractures and related sequelae. Our patient developed sequelae of an orbital fracture over the last 3 years, presenting with dystopia, ophthalmoplegia, and diplopia in the supra- and lateroversion and aesthetic impairment. The variety of implant materials for reconstruction after orbital fractures is extensive, and the decision as to which material to use continues to be debated. The continuing development of computer-aided diagnosis and management and the construction of stereolithographic models offer comparable reproduction of anatomical detail. This technology is described in relation to the planning of trauma surgery and sequelae and the planning of ablative surgery for malignant neoplasms of the head and neck. The use of specific 3D printed titanium implants for bone defects was first reported in cranial reconstruction in 2012, and several studies have reported their use in orbital fractures. The advantages of this implant were increased stiffness, preventing shape loss during placement, a precise fit, and decreased surgical time. However, in the existing literature, the one-piece implant done in this way was a precise fit; therefore, it is possible that navigation between intraoperative anatomical landmarks is lost. However, in cases where reconstruction is difficult, such as extensive orbital wall fractures and large orbital sequelae, the 3D printed implant has been helpful in decreasing surgical time and can be accessed by a limited surgical approach with a precise fit. Our clinical case involved a 37-year-old male patient who experienced severe physical aggression in 2020, amid the COVID-19 pandemic. At the time, due to the overwhelming healthcare demands and resource constraints imposed by the pandemic, immediate surgical intervention for the correction of the fracture was not feasible. As a result of this delay, the patient developed sequelae of the orbital fracture over the last 3 years.

Traumatic Optic Neuropathy Treatment Trial 2 (TONTT-2): evaluating the efficacy of different doses of erythropoietin – a multicentre, randomised, double-blind clinical trial

AimThe aim is to compare the efficacy and safety of three different weight-adjusted intravenous erythropoietin (EPO) doses in patients with indirect traumatic optic neuropathy (TON).MethodsThis study is a multicentre, randomised,...

Intraoperative navigation in craniofacial surgery

Craniofacial surgery requires comprehensive anatomical knowledge of the head and neck to ensure patient safety and surgical precision. Over recent decades, there have been significant advancements in imaging techniques and the development of real-time surgical navigation systems. Intraoperative navigation technology aligns surgical instruments with imaging-derived information on patient anatomy, enabling surgeons to closely follow preoperative plans. This system functions as a radiologic map, improving the accuracy of instrument placement and minimizing surgical complications. The introduction of first-generation navigation systems in the early 1990s revolutionized surgical procedures by enabling real-time tracking of instruments using preoperative imaging. Initially utilized in neurosurgery, intraoperative navigation has since become standard practice in otolaryngology, cranio-maxillofacial surgery, and orthopedics. Since the 2000s, second-generation navigation systems have been developed to meet the growing demand for precision across various surgical specialties. The adoption of these systems in craniofacial surgery has been slower, but their use is increasing, particularly in procedures such as foreign body removal, facial bone fracture reconstruction, tumor resection, and craniofacial reconstruction and implantation. In Korea, insurance coverage for navigation in craniofacial surgery began in 2021, and new medical technologies for orbital wall fracture treatment were approved in August 2022. These technologies have only recently become clinically available, but are expected to play an increasingly important role in craniofacial surgery. Intraoperative navigation enhances operative insight, improves target localization, and increases surgical safety. Although these systems have a steep learning curve and initially prolong surgery, efficiency improves with experience. Calibration issues, registration errors, and soft tissue deformation can introduce inaccuracies. Nonetheless, navigation technology is evolving, and the integration of intraoperative computed tomography data holds promise for further enhancements of surgical accuracy. This paper discusses the various types and applications of navigation employed in craniofacial surgery, highlighting their benefits and limitations.

A Case of Compressive Optic Neuropathy Caused by Orbital Emphysema

Purpose: We report a patient with compressive optic neuropathy (CON) in whom visual acuity (VA) was restored after removing conjunctival emphysema through the conjunctiva.Case summary: A 55-year-old man was transferred to emergency department complaining of decreased VA in the right eye after trauma to the right temporal side of the head. The best-corrected visual acuity (BCVA) was 0.6 in the right eye. We confirmed a relative afferent pupillary defect and limited eye movement inferiorly in the right eye. The patient had blown his nose several times while being transferred to the hospital. On silt-lamp examination, there was conjunctival emphysema of the right eye. Orbital computed tomography showed a medial wall fracture of the right orbit and orbital emphysema above the optic canal. The P100 wave was delayed in the visual evoked potential (VEP) exam, and there was a decreased peripheral visual field on the Humphrey visual field test. Based on these findings, we diagnosed CON and treated him accordingly. To decompress the intra-orbital area, we injected mannitol intravenously, applied intraocular pressure-lowering and antibiotic eye drops in the right eye, and removed part of the conjunctival emphysema through the conjunctiva. At the 3-week follow-up, the BCVA had improved to 1.0 in the right eye with a normalized P100 wave on the VEP exam.Conclusions: In a case of CON caused by orbital emphysema after trauma, it is important to decrease the intra-orbital pressure as soon as possible to enable a good prognosis for the VA.

Computed tomography of acute orbital trauma in children: a retrospective study

INTRODUCTION: Orbital injuries account for 36 to 64% of all blunt trauma to the facial bones. Diagnosis of orbital wall fractures is carried out using conventional radiography in several projections and computed tomography; magnetic resonance imaging is less commonly used. Often, due to the small displacement of orbital bone fragments, X-ray diagnosis is difficult. Multislice CT with reconstruction of sagittal, coronal projections and 3D in the bone window in such cases is the best visualization method. However, there are still no clear indications for the use of each method and there is no complete view of the CT characteristics of orbital damage.OBJECTIVE: To study the diagnostic value of computed tomography of orbital fractures in pediatric patients with acute trauma.MATERIAL AND METHODS: Retro- and prospectively analyzed the results of CT scans of 94 patients with facial fractures from 01/01/2023 to 09/01/2023 to assess combined orbital injuries. Orbital fractures were detected in 63 children (67.0%). There were 44 boys (69.84%), 19 girls (30.15%) aged from 7 months to 17 years 10 months (average age 10.3). Statistics: For statistical analysis, the method of calculating the nominal correlation using the Kramer coefficient (V) using the IBM SPSS Statistics software package was used.RESULTS: Concomitant injury was observed in 30 (47.6%); isolated 33 (52.36%). The number and frequency of fractures observed were as follows: superior wall of the orbit — 39 (61.9%); zygomatic complex — 19 (30.1%); lower wall of the orbit — 43 (68.2%); nasal bone — 17 (26.9%); lower jaw — 6 (9.5%); medial wall of the orbit — 28 (44.4%); upper jaw — 27 (42.8%); alveolar process — 6 (9.5%); isolated zygomatic arch — 14 (22.2%); Le Fort type I — 1 (1.5%); Le Fort type II — 2 (3.1%); and Le Fort type III — 0 (0%). Orbital hematomas were found in 25 patients (39.6%). It was revealed a strong correlation between the presence of contiguous skull fractures and multiple skull fractures (V=0.878, p<0.001), frontal sinus fractures and frontal sinus hemosinus (V=0.69, p<0.001).CONCLUSION: Orbital fractures are a frequent type of facial fracture occurring in children with blunt isolated and combined trauma. In children with blunt trauma, head CT combined with clinical examination is currently the optimal tool for diagnosing clinically significant orbital injuries. There is a strong correlation between orbital hematomas and orbital vault fractures, orbital hematomas and lattice fractures, adjacent skull and orbital vault fractures, and adjacent skull and lattice fractures. CT examination should include multiplanar (in coronal and sagittal planes) and 3D reconstructions, which help to assess the extent of the fracture, the presence of diastasis, the degree of muscle impingement. Based on the data obtained, the clinician determines the need for surgical intervention.

A cadaveric study of induced isolated orbital floor fractures and implications for surgical decision-making: comparison of two preoperative imaging modalities

Computed tomography (CT) is the gold standard for the diagnosis of isolated orbital floor fractures, while cone beam computed tomography (CBCT) is an alternative. The aim of this study was to compare the diagnostic accuracy of CT and CBCT for isolated orbital floor fractures. Forty-eight isolated orbital floor fractures were systematically induced in cadaver orbits. CBCT and CT scans of each cadaver head were performed and the image data imported into ProPlan CMF for analysis. The orbital floor area (OFA), orbital defect area (ODA), and peri-orbital tissue herniation were evaluated. Surgical decision-making differed significantly according to the imaging modality (P = 0.031). The odds of decision discrepancy between CBCT and CT were higher with increasing ODA/OFA ratios, when adjusted for peri-orbital tissue herniation and fracture localization (P = 0.026). An ODA/OFA ratio cut-off value of >36.25% had a sensitivity of 100% and specificity of 71% (area under the curve 0.83, P = 0.011) for predicting discrepancies between CBCT and CT in surgical decision-making. In this cadaveric study, CT and CBCT were diagnostically equivalent for isolated orbital floor fractures with an ODA/OFA ratio ≤36.25%. However, fractures exceeding this threshold may be better evaluated by CT to avoid discrepancies in surgical decision-making.

Clinical characteristics and outcomes of orbital fractures: a sex-based cohort analysis

PurposeThis study aims to identify clinical similarities and differences between males and females presenting with orbital fracture. MethodsPatient charts of adult orbital fracture cases diagnosed via computed tomography and referred by a level 1 trauma center to the McGill University Health Centre between August 2015 to January 2018 were examined and analyzed. Clinical parameters included age, sex, mechanism of injury, morphology of orbital fracture, symptoms and examination features, and rates of ocular pathology. Comparative analyses were performed via Student's t-test and chi-square to assess for sex-related differences. ResultsThe study included 176 males (mean age: 46.2 years) and 68 females (mean age: 58.5 years). The most common etiology of orbital fracture was assault among males (32%) and fall from own or standing height among females (38%). Males had a higher prevalence of bilateral fractures than females (17% vs 6%; p = 0.02) and had more orbital walls fractured per orbit than females (2.0 vs 1.5; p < 0.01). Males were more likely to have their orbital roof fractured (28% vs 15%; p = 0.03) and were more likely to be intubated after their trauma (22% vs 7%; p = 0.004). Post-traumatic ocular pathology occurred in 11% of males versus 9% of females (p = 0.56). ConclusionIn our cohort of adult orbital fractures, males were more prevalent, more likely to have bilateral fractures, more extensive fracture per orbit, and higher prevalence of orbital roof fractures and intubation. Despite these differences, rates of ocular pathology did not differ significantly between males and females, highlighting the importance of a careful assessment in both groups.

The Comparison Between Traditional Versus 3D Printing Combined With Computer Navigation Technique in the Management of Orbital Blowout Fractures.

Three-dimensional printing (3D printing) technology and computer navigation technology have been gradually applied in surgeries for orbital blowout fractures. This study compared the efficacy of traditional techniques (group I) and 3D printing combined with computer navigation technology-assisted techniques (group II) in the management of orbital blowout fractures. All patients treated for orbital blowout fractures in the Affiliated Hospital of Yangzhou University from March 2018 to February 2021 were reviewed. The primary predictive variable was surgical techniques used for orbital fractures (traditional techniques or 3D printing combined with computer navigation technology-assisted techniques). Outcome variables included diplopia, limitation of extraocular muscle movement, and enophthalmos orbital volume. All the surgeries were successfully performed without serious complications. Six months after the operation, the degree of diplopia and limitation of extraocular muscle movement in the traditional techniques group and 3D printing combined with computer navigation technology-assisted techniques group were significantly improved (the former Z= -2.670, P=0.008, the latter Z=-3.584, P<0.001 and the former Z=-4.852, P<0.001, the latter Z=-5.427, P<0.001, respectively). There were no significant differences in the degree of diplopia and limitation of extraocular muscle movement between the 2 groups before the operation (the former Z=-0.842, P=0.400; the latter Z=-0.567, P=0.571), and there were significant differences after the operation (the former Z=-2.773, P=0.006; the latter Z=-2.892, P=0.004), and the 3D printing combined with computer navigation technology-assisted techniques group showed an advantage over the traditional techniques group. The difference in bilateral enophthalmos and orbital volume in traditional techniques groups and 3D printing combined with computer navigation technology-assisted techniques groups was dramatically decreased (the former t=12.558, P<0.001, the latter t=12.659, P<0.001, and the former t=19.194, P<0.001, the latter t=17.770, P<0.001, respectively). There were no significant differences in bilateral enophthalmos and orbital volume between the 2 groups before the operation (the former t=-0.410, P=0.683; the latter t=0.311, P=0.756), and there were significant differences after the operation (the former t=4.081, P<0.001; the latter t=4.078, P<0.001). There were statistically significant differences in surgical time and cost between the traditional technology group and the 3D printing combined with computer navigation technology-assisted technology group (the former t=8.445, P<0.001, and the latter t=3.534, P<0.001); 3D printing combined with computer navigation technology-assisted techniques group spent more surgical time and money than the traditional techniques group. The application of 3D printing combined with computer navigation techniques in the management of orbital blowout fractures can significantly improve the accuracy and safety of the operation. 3D printing combined with computer navigation technology-assisted techniques group spent more surgical time and money.

Pattern And Occurrence of Orbital Fractures Associated with Midface Trauma – A Hospital Based Observational Study

Aims &amp; Objectives: To study the pattern and occurrence of orbital fractures associated with midface trauma and to assess the association of fracture pattern with etiology of orbital fracture. Methodology: All midface trauma patients treated at the Oral and Maxillofacial Surgery Department of Govt Dental College Calicut between June 2019 and June 2020 were included. Plain radiographs and available CT scans were assessed by a senior maxillofacial surgeon to diagnose and evaluate orbital fractures. The etiology of fractures was recorded, and its correlation with orbital fracture patterns was analyzed. Clinical evaluation included assessing eye movements, enophthalmos, hypoglobus, palpebral fissure length, and alignment, as well as the presence of telecanthus. Results: Out of 238 midface trauma cases, 147 had orbital fractures, comprising 139 males (58.40% of total, 94.56% of total orbit) and 8 females (3.36% of total, 5.44% of total orbit). Road traffic accidents were the primary cause (91 cases, 38.24%, 61.90%), followed by falls (35 cases, 14.71%, 23.81%). The most common fracture site was the lateral wall (105 patients, 71.43%), followed by the floor (55 patients, 37.42%). Conclusion: The lateral orbital wall was the most frequently fractured site, likely due to its prominent position and susceptibility to direct impact. Conservative management was predominantly utilized. No statistically significant association was found between the etiology of trauma and fracture patterns

Analysis of risk factors for patients with traumatic optic neuropathy and comparison of visual outcomes of management strategies

BackgroundTraumatic optic neuropathy (TON) is a rare complication of facial trauma that results in vision loss. Clinical diagnosis of TON is based on a history of head trauma and an ophthalmic examination; however, the risk factors for TON and the ideal treatment strategy remain undetermined. This study investigated the predictive risk factors for TON and analyzed the effectiveness of current treatments with respect to visual outcomes in patients with TON. MethodsThis study retrospectively enrolled patients with periorbital facial bone fracture between 2008 and 2019. Initial facial bone computed tomography, ophthalmic exam results, initial Glasgow Coma Scale, and Injury Severity Score (ISS) were recorded. This study classified patients into 4 intervention groups (i.e., medication, surgery, combination therapy, and observation) to compare the outcome of visual acuity. ResultsThis study enrolled 1168 patients with facial bone fractures, 93 (7.96%) of whom were diagnosed as having TON. Independent risk factors for TON included optic canal fracture, medial orbital wall fracture, retrobulbar hematoma, and head Abbreviated Injury Scale ≥ 4. Patients with TON who initially presented with no light perception tended to have poor final visual acuity (VA) outcomes. The results indicated no significant difference in VA improvement among patients receiving observation, mega-dose corticosteroid therapy, surgical decompression, or combined steroid therapy and decompression. ConclusionClinicians can achieve early prediction of TON in patients with an initial unconscious state and the determined risk factors. The results indicated that conservative observation yielded noninferior VA outcomes in patients with TON compared with those receiving medication or surgical treatment.

A recent algorithm for management of orbital floor fractures with the application of a novel minimally invasive endoscopic surgery

Orbital floor (OF) fractures present a dilemma, with controversies surrounding surgical indication, approach, and ideal material for reconstruction. Our study was conducted on cases of OF fracture admitted to a tertiary referral centre. Cases of OF associated with zygomaticomaxillary complex (ZMC) fracture were managed as follows: those with ophthalmological problems were subjected to endoscopically assisted transorbital reconstruction of the floor; cases without ophthalmological problems were subjected to reduction and fixation of the ZMC fracture only. The recently developed endoscopic endonasal transmaxillary approach was used to manage cases with pure OF fracture, while the same approach with added endoscopic transethmoidal reconstruction of the medial orbital wall (MOW) was applied to cases with associated MOW fracture. Outcome measurements were the correction of diplopia and enophthalmos, along with the restoration of normal globe function. The study included 80 patients, who were divided into four groups according to the proposed algorithm. OF reconstruction was performed in 32 cases with either septal cartilage (n = 4), titanium plate (n = 11), or porous polyethylene mesh (n = 17). Our study presents the novel role of minimally invasive endoscopic surgery in the management of OF fracture, together with a recently developed management plan that could maximize positive outcomes and decrease morbidity.

Descriptive analysis of road traffic accidents in children aged 0-2 years

Aims: This study aims to investigate road traffic accidents (RTAs) involving infants and toddlers, defined as children from birth to 2 years old, focusing specifically on their epidemiology and outcomes. Methods: A retrospective, single-center, observational, and cross-sectional study was conducted in the Emergency Department of a university-affiliated training and research hospital. Data were collected from July 1, 2019, to January 1, 2024. Results: During the study period, 659 cases involved pediatric RTAs patients (individuals under 17 years old), with 41 cases specifically concerning infants and toddlers. These patients had a mean age of 12.98 ± 5.64 months, and 27 (65.9%) were boys. The median Pediatric Trauma Score for was 9 (range: 5-12) while the median pGCS score was 15 (range: 14-15). Motor vehicle accidents were the leading cause of injuries, accounting for 92.6% of cases, followed by motorcycle accidents (4.8%) and pedestrian-vehicle collisions (2.6%). Hospitalized patients exhibited various injuries, including femur fractures, subdural hematoma, orbital roof fracture, scalp hematomas, and lung contusion. Surgical intervention was required in only one case for a femur shaft fracture. Fortunately, no in-hospital deaths occurred among the study participants. Conclusion: This study underscores the importance of adult supervision to prevent RTAs and emphasizes the critical need for strict enforcement of child passenger safety laws to reduce the incidence of motor vehicle accidents involving infants and toddlers.

Efficacy of Nasal Septal Complex in the Endoscopic Reconstruction of Medial Orbital Wall.

The aim of this study is to investigate the efficacy of nasal septal complex reconstructing the medial orbital wall under some specific circumstances. The authors performed a study that included 10 patients who underwent isolated medial orbital wall fracture (blow-out fracture). All the reconstruction surgery of the patient included in this study fixed defect of medial orbital wall using autologous nasal septal complex (composed of nasal septal cartilage and perpendicular plate of ethmoid). The authors observed postoperative improvements of diplopia or ocular motility disorders of the affected orbit. The surgeries had gained satisfactory results, and without severe postoperative complications. After long-term follow-up, postoperative CT indicated the implant-covered defect of medial orbital wall, and there's no incarceration of the medial rectus. Meanwhile, the authors found there is no crack in the implant, and the surgery using nasal septal complex achieved premorbid orbital form. Autologous nasal septal complex provides a better complement to endoscopic reconstruction of medial orbital wall; this strategy allows nasal septum to reconstruct isolated medial orbital wall defects of various degrees, such as nasal septum fracture and dysplasia of perpendicular plate of ethmoid.

Assessment of the Correlation Between Types of Orbital Fractures and Ocular Symptoms, and the Effect of Manual Preformed and Patient-Specific Mesh Implants: A Retrospective Study.

Although certain orbital fractures are associated with specific clinical symptoms, these relationships should be reviewed comprehensively. The optimal choice between manual preformed mesh implants (MPIs) and patient-specific mesh implants (PSIs) for orbital reconstruction remains undetermined due to inconclusive evidence regarding their effectiveness. This retrospective study investigated 280 patients with unilateral orbital fractures to explore the correlation between clinical ocular symptoms, including diplopia, enophthalmos, limitation of ocular movement, blindness, and the specific type of orbital fracture. The effects on orbital volume (OV) and orbital volume ratio (OVR) of MPI and PSI with and without the use of navigation were also evaluated in this study. Patients were categorized into 4 groups: MPI, PSI, navigation-assisted MPI, and navigation-assisted PSI. After this categorization, alterations in OV and OVR were analyzed before and after surgical intervention. Significant correlations were observed between the orbital fracture type and diplopia, enophthalmos, and limitation of ocular movement (P < 0.05). Patients in the MPI group exhibited a notable difference in the postoperative OV between the injured and normal sides (P < 0.05), but no statistically significant difference was found in the postoperative OV between the injured and normal sides among the patients in the other 3 groups (P > 0.05). Moreover, the MPI group demonstrated significantly higher postoperative OVR than the other groups (P < 0.05). Notably, PSI remained effective with or without navigation, MPI combined with navigation technology achieved a reconstruction quality similar to that of PSI by rectifying positioning errors during surgery. The authors found significant correlations (P < 0.05) between orbital fracture type and diplopia, enophthalmos, and limitations of ocular movement. Patient-specific mesh implant plays an important role in orbital reconstruction. It is also a good method for reconstructing orbital fractures using MPI assisted by navigation technology.

Clinical and Surgical Results of Treatment Modalities in Orbital Roof Fractures: Single-Center Experience.

Orbital roof fractures are uncommon craniofacial fractures. Due to the location of the fracture and the mechanism of trauma, it is often associated with neuroophthalmological injuries. The authors aimed to evaluate the results of conservative and surgical treatments of patients with orbital roof fractures and present our clinical experiences regarding optimal treatment planning, especially in cases of moderate or severe head trauma. The authors retrospectively identified 145 patients who were treated for orbital roof fractures. Three colored silicone-injected cadaver samples and a dry skull were used to show the panoramic view of the anatomy of the orbital region. In this study, orbital roof fractures were classified under 4 types. The most common fracture type was type 1 (42%). Intracranial hemorrhage was observed in 60% of all cases and was most common in type 3 fractures (68%). Neuro-ophthalmological deficits were detected in 16% of all patients and were most common in Type 4 fractures (47%). Third cranial nerve deficit was the most common deficit (39%). Neuroophthalmological deficits were detected in 9.5 % of patients with mild head trauma and 32.5% in patients with moderate or severe head trauma. Moderate or severe head trauma was detected in 28% of the cases. Moderate or severe head trauma makes it difficult to detect neuro-ophthalmological complications, which are critical in determining the need for acute surgery. In patients with moderate or severe brain injury, treatment should be individualized according to the nature of the displacement and the relationship between concomitant fractures and intracranial hemorrhage.

Exploring 3D Printed Implants With Anti-Dropout Function to Overcome Time Constraints in Acute Orbital Fractures for Patient-Specific Implants.

Orbital wall reconstruction and implant insertion are crucial procedures for temporarily replacing the orbital walls in cases of significant fractures. Traditional methods using planar orbital implants have faced challenges owing to their flat shape, which increases the risk of dislocation from improper cuts and necessitates the use of screws in the orbital rim. This study aims to improve outcomes by employing customized 3-dimensional implants, thereby reducing complications and risk of dislocation resulting from external shock or implant weight postinsertion. This prospective study included 12 Korean individuals diagnosed with facial fractures (orbital wall injuries). Surgeries were performed on 12 patients, and follow-up CT scans were conducted on 10 of them. Therefore, the authors could only address the results for the 10 patients. The authors used bioactive glass ceramics and medical-grade poly-e-caprolactone to 3D print personalized implants, completing the manufacturing process in an average of 4.6 days. Computed tomography scans guided measurements of orbital volumes and exophthalmos. After surgery, we found that the difference values for bone orbital volumes (<0.1mL) and exophthalmos (<1mm except one) decreased compared with presurgery values. Independent t tests and Pearson correlation analysis revealed no significant changes between normal and affected sides in both phases. However, R-values increased in the postsurgery phase. Patients monitored postsurgery at 2 weeks, 3 months, and 6 months showed no complications. The 3D-printed patient-specific implants, customized to individual fracture shapes and featuring distinct implants and locking parts with notches, effectively restore bony orbital volumes and reduce exophthalmos. They have been proven feasible and applicable for reconstructing acute orbital wall fractures.

Efficacy of Fat and Perifascial Areolar Tissue Graft in Refractory Esotropia: A Case Report

Purpose: This case report presents a novel approach for the management of refractory esotropia using adhesiolysis and fat and perifascial areolar tissue (PAT) transplantation.Case summary: A 62-year-old male presented with left eye strabismus fixus following iatrogenic medial rectus (MR) muscle injury and medial orbital wall fracture during endoscopic sinus surgery. One month later, he underwent MR laceration repair and orbital wall reconstruction. Despite three subsequent interventions for exotropia and its subsequent conversion to esotropia, the left eye esodeviation progressively worsened, culminating in strabismus fixus. Initial examination revealed significant left eye esotropia with fixed gaze and 5-mm enophthalmos. Surgery included implant removal, adhesiolysis between the eyeball and surrounding tissues, scar and MR recession, and placement of a fat and PAT graft on the medial aspect of the eyeball to prevent postoperative re-adhesion. Three years of follow-up demonstrated sustained orthophoria in primary gaze with improved extraocular muscle function and enophthalmos.Conclusions: Fat and PAT graft has potential in oculoplastics for preventing re-adhesion and augmenting orbital volume in patients with refractory restrictive strabismus due to multiple surgeries.

Serial Case of CT Scan Imaging in Fracture of Midface Region

Background: Fractures in the face region are frequently seen in motor vehicle accidents, as the face is highly exposed during such incidents. Motor vehicle accidents are common in Bali, with fracture of the face region is the 2nd most common injury found in radiologic examination. Computed tomography (CT) scans are crucial for assessing these fractures, allowing for an accurate evaluation of severity to plan the patient treatment. Case: We present serial cases CT scan images of complex midface fractures such as Le Fort, tripod, NOE and orbital wall fracture and its characteristic imaging on CT-imaging. Conclusions: CT scan may guide treatment plans aimed at minimizing disability and enhancing the patient's quality of life. Understanding the imaging characteristics of midface fractures is thus essential for effective diagnosis and management.

Atraumatic Release of Incarcerated Inferior Rectus Muscle in Trapdoor Fracture Can Lead to Better Functional Outcome.

Deciding the proper surgical approach for repairing blowout fractures with entrapped soft tissue are among one of the most challenging decisions for maxillofacial surgeons. This is due to multiple factors including the type and site of fracture, time elapsed from trauma. Tranconjunctival, subciliary, and/or transantral endoscopic has been described before. The authors report here a case of a young adult, presenting with diplopia, pain, and enophthalmos after being exposed to a blunt trauma on the left side. Computed tomography (CT) scan confirmed diagnosis of left orbital floor fracture with trapped inferior rectus in a trapdoor manner. Although presentation was later than 48 hours from trauma, yet incorporating, minimally traumatic dual, transconjunctival-transantral endoscopic approach the inferior rectus muscle was preserved and regained full range of movement, after <3 months postoperatively.

Assessing the Viability of Polycaprolactone Mesh in Bilateral Orbital Floor Reconstruction: Insights From Le Fort II Fracture Cases.

This study aims to evaluate the effectiveness of pure polycaprolactone (PCL) mesh in reconstructing complex bilateral orbital floor fractures associated with Le Fort II fractures. PCL mesh is traditionally viewed as less suitable for severe fractures due to its perceived weakness. This study challenges that perception by demonstrating the utility of PCL mesh in high-severity cases. Two patients with Le Fort II fractures and bilateral orbital floor fractures underwent orbital reconstruction using a 3D-printed PCL mesh. The mesh was molded and inserted through subciliary or transconjunctival incisions. Orbital volumes were analyzed preoperatively and postoperatively using CT scans and a 3D Analysis program. Both cases demonstrated significant correction of orbital volume differences postoperatively, leading to improved symmetry and successful reconstruction. For case 1, the preoperative orbital volume difference of 3.2cc was reduced to 1.1cc postoperatively. For case 2, the preoperative orbital volume difference of 1.18cc was reduced to 0.4cc postoperatively. The PCL mesh provided adequate structural support and facilitated effective tissue integration. Despite the radiolucency of the PCL mesh on CT scans, volumetric analysis confirmed stable and balanced orbital volumes. Pure PCL mesh is a viable alternative for orbital floor reconstruction in severe craniofacial fractures, offering a balance of structural support and biocompatibility. To validate these findings, further research with larger samples and long-term follow-up is recommended.