Orbital Reconstruction Surgery Research Articles

In-House Three-Dimensional Printing in Orbital Reconstructive Surgery: A Case Report and Future Perspectives

In-House Three-Dimensional Printing in Orbital Reconstructive Surgery: A Case Report and Future Perspectives

Guidelines for Orbital Defect Assessment and Patient-Specific Implant Design: Introducing OA2 (Orbital Assessment Algorithm).

This study presents a review of the evolutionary development in reconstructive orbital surgery over the past 3 decades. Additionally, it proposes the Orbital Assessment Algorithm (OA2) to enhance decision-making for intraorbital reconstruction of post-traumatic orbital deformities. The objective of this paper is to provide insights into modern post-traumatic orbital reconstruction from a surgeon's perspective, with a specific focus on adult patients. It aims to highlight the advancements in computer-aided design and manufacturing techniques, particularly in the field of reconstructive orbital surgery, and to introduce the OA2 as a tool for improved decision-making in this context. The study conducts a comprehensive review of the evolution of reconstructive orbital surgery, focusing on the integration of 3D technology into surgical practices. It also outlines the development and rationale behind the proposed OA2, emphasizing its potential to enhance the accuracy and efficacy of intraorbital reconstruction procedures for post-traumatic deformities. The review demonstrates the significant progress made in reconstructive orbital surgery, particularly in leveraging 3D technology for virtual modeling, navigation, and the design and manufacturing of patient-specific implants. The introduction of the OA2 provides a structured approach to assessing and addressing post-traumatic orbital deformities, offering potential benefits in decision-making and surgical outcomes. In conclusion, this paper underscores the pivotal role of computer-aided design and manufacturing in advancing reconstructive orbital surgery. It highlights the importance of integrating innovative design concepts into implant manufacturing processes and emphasizes the potential of the OA2 to guide surgeons in the management of post-traumatic orbital deformities, ultimately contributing to improved patient outcomes.

Orbital Fractures Treated in Auckland From 2016 to 2020: Review of Patient Outcomes

Orbital reconstruction is a complex procedure demanding accurate placement of implants to restore volume and anatomic shape to the orbits. Intra-operative computed-tomography (CT) and rapid-prototype (RP) biomodels have been recently introduced as surgical aids to improve outcomes. Investigation is required to determine if there is a reduction in post-operative ophthalmic complications. Study Design Retrospective cohort study. Objective To evaluate the impact of intra-operative CT and RP biomodels on the incidence of post-operative diplopia, paraesthesia, cosmetic issues and ability to return to work following orbital reconstruction surgery. Methods Adult (>18 years) patients treated at Counties Manukau District Health Board, Auckland, by the Department of Oral and Maxillofacial Surgery for isolated orbital fractures were retrospectively enrolled into this study. An audit of clinical records was undertaken to determine incidences of diplopia, altered sensation, cosmetic concerns and ability to return to work. These findings were compared against our previous audit which documented these findings in patients treated between 2010 and 2015, prior to the introduction of intra-operative CT and RP biomodels. Results Routine use of intra-operative CT and RP biomodels was associated with a reduced incidence of post-operative diplopia. No significant difference was observed with regards to paraesthesia and cosmetic deficits. Conclusions The relatively low radiation exposure and cost associated with intra-operative CT and RP biomodels is justified with improved outcomes in subjective diplopia. Titanium as a material for orbital reconstruction was confirmed to be associated with low complication rates.

Patient-Specific Implant for Primary Orbital Reconstruction: A Case Report

The main aim of orbital fracture reconstruction is to restore the functional and aesthetic components of the eye. However, it is known that surgery for complex three-dimensional anatomy of the orbit is always a challenge. With recent advancements in technology, surgical predictability and outcomes have greatly improved. Several methods for orbital reconstruction surgery have been documented such as virtual surgical planning, intraoperative navigation, intraoperative imaging, and the use of patient-specific implant (PSI). PSI made of titanium can be designed by using a computer-aided design process and manufacturing (CAD-CAM) of CT-scan routinely used during diagnostic imaging. With precise analyses in shape and size followed by personalised implant design, the surgical precision can be alleviated further and at the same time, the surgical duration could be reduced with anticipation of better surgical outcomes. However, meticulous planning needs to be done preoperatively, with the timing of the surgery being an important factor. In the present case, pure orbital blowout fracture primarily treated with a personalised-implant solution derived from 3D-printing technology is described. Both pre-surgical and surgical workflow of this computer-assisted surgical method is elaborated. PSI for primary orbital reconstruction can be regarded as a viable alternative surgical solution including its working timeframe and adherence to the surgical protocol or algorithm.

Oculocardiac reflex incidence in post-traumatic orbital reconstruction surgery

The oculocardiac reflex (OCR) is a well-recognised phenomenon characterised by cardiac arrhythmia precipitated by various electrical, physical or chemical stimuli to branches of the trigeminal nerve. The reported incidence rate varies widely and specifically following post-trauma orbital reconstruction in the adult population has not been clearly defined. We reviewed a continuous case series of 100 patients who underwent post-traumatic orbital reconstruction to investigate the incidence of OCR in this population. Variables recorded included age, gender, American Society of Anaesthesiologists physical status (ASA), regular medications of relevance, fracture subtype, number of intraoperative OCR events, intraoperative medical management, and primary surgeon experience level. The overall incidence of OCR in this cohort was 48.4%. Increasing fracture complexity was associated with an increased risk of OCR (OR 4.378, 95% CI: 1.023 to 18.730, p = 0.046). Age, gender, ASA, regular medications of relevance and primary surgeon experience did not have a statistically significant effect on the incidence of an OCR. Our study indicates that the OCR is a common phenomenon during post-trauma orbital reconstruction. Further studies may be warranted to further recognise at-risk patients, to identify ideal management strategies.

Modified Target Angle as a Predictor of Success in Strabismus Management after Orbital Fracture.

Surgery for strabismus secondary to orbital fracture reconstruction surgery has had low success rates and high reoperation rates due to its incomitant nature and complex underlying mechanisms. There has been no consensus as to which of the various methods for improving the surgical results are best. We proposed a modified target angle criteria that combined the regular target angle and a favorable Hess area ratio percentage (HAR%) threshold to evaluate surgical results within the first postoperative week and conducted a retrospective chart review. According to the criteria of the modified target angle at the first postoperative week, a total of 63 patients were divided into two groups: Group 1, patients who fulfilled the criteria (49 patients); and Group 2, those who did not (14 patients). Sex, type of fracture, and the use of porous polyethylene sheets and titanium mesh during reconstruction surgery were significantly different between the groups. Group 1 showed a significantly higher percentage of patients who met the criteria of HAR% > 65% at the first week and >85% (i.e., a successful outcome) at the 6-month visit (p < 0.01). Additionally, Group 1 had a higher HAR% at the first postoperative week (p < 0.01). In conclusion, the patients meeting the criteria of the modified target angle at the first postoperative week had a favorable outcome at the 6-month visit in both ocular alignment and ocular movement.

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.

The Management of Orbital Roof Fractures and Defects: A Review.

To explore the anatomy, etiopathogenesis, diagnosis and classification, current evidence on intervention and the surgical management of orbital roof fractures and defects (ORFD) for oculoplastic surgeons presented with such cases. A review of the current literature through the MEDLINE database using the following search terms: "orbital roof fracture (+treatment/management)," "orbital roof defect (+treatment/management)," "orbital roof erosion (+treatment/management)," "orbital roof repair," "orbital roof," "orbital fracture," "pediatric orbital roof (defect/fracture/erosion)," "orbital anatomy," and "orbital roof anatomy" was conducted. As relatively little has been published on this topic, inclusion criteria were broad and peer-reviewed articles judged to be of clinical importance, relevant to the aims of this review, were included. Non-English abstracts were also included if relevant. Year of publication was not a strict exclusion criterion, and older articles were judged for their suitability based on clinical importance and relevance to current practice. Additional references were obtained from citations in key articles and recommendations from the coauthors based on their areas of expertise. The etiopathogenesis of ORFD varies. Classification systems have been formulated to guide management decisions and can range from conservative management to complex neurosurgery. Eyelid approaches have also been described. This review provides a summary of the evidence for each and a management framework oculoplastic surgeons can use when presented with ORFD. Oculoplastic surgeons can be involved, either alone or as part of a multidisciplinary team, in the management of ORFD, and for some, conduct orbital approach reconstructive surgery.

Surgical instrument to improve implant positioning in orbital reconstruction: a feasibility study

Adequate positioning of an orbital implant during orbital reconstruction surgery is essential for restoration of the pre-traumatised anatomy, but visual appraisal of its position is limited by the keyhole access and protruding soft tissues. A positioning instrument that attaches to the implant was designed to provide feedback outside the orbit. The goal of this study was to evaluate the accuracy of placement with the instrument and compare it with the accuracy of placement by visual appraisal. Ten orbits in five human cadaver heads were reconstructed twice: once using visual appraisal and once using the instrument workflow. No significant improvement was found for the roll (5.8° vs 3.4°, respectively, p=0.16), pitch (2.1° vs 1.5°, p=0.56), or translation (2.9 mm vs 3.3 mm, p=0.77), but the yaw was significantly reduced if the instrument workflow was used (15.3° vs 2.9°, p=0.02). The workflow is associated with low costs and low logistical demands, and may prevent outliers in implant positioning in a clinical setting when intraoperative navigation or patient-specific implants are not available.

Surgical Management of Orbital Fractures Using X-ray Film Plate: a Retrospective Case Series

Purpose: Orbital trauma is associated with orbital blowout fractures, with associated globe injuries and loss of vision. Orbital reconstruction can be done with various implant materials. The aim of this study is to identify the safety and postoperative outcomes of using X-ray films as orbital implants during orbital reconstruction surgery.&#x0D; Study Design: An interventional case series.&#x0D; Place and Duration of Study: Ophthalmology departments of Lahore General Hospital and Mayo Hospital, Lahore from June 2001 to May 2017.&#x0D; Methods: Retrospective data of all the patients who came for orbital reconstruction surgeries from June 2001 to May 2017 was retrieved. All patients had undergone CT scan prior to surgery. Orbital reconstruction was done by a single surgeon, by bridging bony defect with sterilized X-ray film. All patients received post-operative antibiotics for 1 week.&#x0D; Results: Twenty three male patients were included in the series, with a mean age of 28 ± 2.47 years. Assault and sports injuries with a ball were the commonest form of trauma. Diplopia was the major presenting complaint in 91% of the patients. All patients underwent surgical reconstruction of the orbital floor of orbit with sterilized X-ray film using a lateral canthotomy approach. Only mild postoperative diplopia was recorded in 7 of the cases, with uneventful recovery in the majority.&#x0D; Conclusion: Sterilized X-ray film is a safe, cost effective, and durable material for reconstruction after orbital blowout fracture, especially in developing countries.&#x0D; Key Words: Orbital fracture, X-ray film, Diplopia.

Early Hypoglobus in Orbital Floor Reconstruction With Resorbable Implants.

Among the variety of materials developed for facial bone surgery, resorbable implants are widely used in orbital wall reconstruction. There are many advantages in selecting resorbable implants, such as minimal foreign body reaction and adjustability within the damaged orbital floor. Resorbable implants are supposed to remain in place over 1 to 2 years to hold the structure of immature healing tissue surrounding the bony defects. However, some patients who have undergone orbital wall reconstruction surgery with resorbable implants suffer from early hypoglobus. This retrospective study was performed from January 2014 to August 2019 and follows 39 patients with unilateral pure orbital floor fractures. All orbital floor reconstruction was performed using resorbable implants via the transconjunctival approach. Exophthalmometer measurements and CT scans showing the degree of implant sagging were used to provide an index of hypoglobus. Most patients showed hypoglobus over 3 to 4 months follow-up. The size of bony defect in the orbital floor showed positive correlation with follow-up exophthalmometer measurement and degree of implant sagging. Orbital floor reconstructed with resorbable implant tends to lose load-bearing strength gradually, especially in large bony defects. Therefore, surgeons should be cautious about using resorbable implants for the maintenance of reconstructed orbital floor, especially in large bony defects.

Management of simultaneous ocular elevation and depression deficit in patients after reconstruction surgery for orbital floor fracture

PurposeTo present and examine the results of surgical correction of simultaneous ocular elevation and depression deficit in patients who underwent reconstruction surgery for orbital floor fracture.MethodsA retrospective analysis of medical records of patients who had undergone surgical correction for diplopia associated with orbital fracture which persisted after orbital reconstruction surgery. All patients underwent orthoptic evaluation before surgery and postoperatively with various times of follow-up.ResultsEight cases of blow-out fracture of the orbital floor were identified. Surgical plan varied from case to case. It included thorough revision of inferior rectus/oblique complex with or without recession of the former or flap tear repair and additional procedures. Postoperatively 4 patients (50%) were diplopia free, 3 (37.5%) presented diplopia in extreme upgaze and 1 (12.5%) in mid-upgaze and adduction. None of the patients reported diplopia in the primary position neither downgaze.ConclusionDiplopia persisting after reconstructive surgery of a fractured orbital floor may be corrected surgically. Our results suggest that at least two surgical procedures are necessary to achieve satisfying outcomes. Contralateral inferior rectus recession combined with superior oblique recession and superior rectus posterior fixation appears to be effective procedures for use.

Expert Consensus on Navigation-guided Unilateral Orbital Fracture and Orbital Floor Reconstruction Techniques.

Orbital fracture and orbital floor reconstruction surgery is characterised by limited surgical exposure and high risks. Before the advent of digital technology, the design and implementation of the surgical scheme for orbital floor reconstruction surgery mainly depended on the intuitive understanding of imaging and the clinical experience of surgeons, with strong unpredictability and experience dependence. Surgical navigation systems with real-time positioning and imaging functions, when used in orbital reconstruction surgery, can detect the real-time intraoperative position, avoid risks, and assist in locating the reconstruction position to ensure the accuracy of orbital reconstruction, with the help of a preoperative surgical plan. Many studies have confirmed its effect. Unilateral orbital fracture and orbital floor reconstruction surgery is one of the earliest and most widely used surgical techniques in maxillofacial surgery. Experts from the Society of Oral and Maxillofacial Surgery, Chinese Stomatological Association have fully discussed and formulated this expert consensus on navigation-guided unilateral orbital fracture and orbital floor reconstruction techniques to standardise the clinical surgical procedures and promote its application.

The Effects of Intraoperative Tarsorrhaphy on Conjunctival Chemosis During Orbital Fracture Repair Surgery

We employed intraoperative tarsorrhaphy depending on the degree of edema to treat moderate conjunctival chemosis during orbital fracture repair surgery. This is a retrospective case review of 1367 patients (1384 eyes) who underwent orbital fracture repair surgery by a transconjunctival approach. All cases of moderate conjunctival chemosis during surgery were included and were divided into 2 groups. In one group, intraoperative tarsorrhaphy was performed immediately the chemosis reached a moderate degree and the conjunctiva was incarcerated by the lower eyelid margin; once severe chemosis developed, stitches were added to cover all of the prolapsed conjunctiva with a palpebral margin. In the second group, moderate chemosis was treated with bandage pressure without stitches even after appearance of severe chemosis. The time course of conjunctival edema was recorded. The incidence of moderate conjunctival chemosis in orbital reconstruction surgery by the transconjunctival approach was 9.4%. The average time for resolution of moderate chemosis in the tarsorrhaphy group (3.5 ± 1.4 days) was obviously shorter than in the bandage group (6.2 ± 1.9 days). The incidence of severe chemosis in the intraoperative tarsorrhaphy group (14.1%) was significantly lower than in the bandage group (31.8%). Overall, the total duration of severe chemosis in the tarsorrhaphy group was obviously shorter than that of the bandage group. Intraoperative tarsorrhaphy was a highly effective method of treating moderate chemosis and preventing severe conjunctival chemosis during orbital fracture repair surgery.

Three-Dimensional Diagnosis in Orbital Reconstructive Surgery.

Introduction:Orbital floor fractures are common among mid-face fractures. The general aim of treatment is to restore orbital volume and anatomy with grafts or reconstructive materials. Malpositioning of the implants and inadequate volume restorations are common complications of these procedures. The aim of our study is to present the surgical outcomes of orbital reconstruction aided by our algorithm of patient-specific virtual planning.Materials and Methods:The current study was performed on 77 patients with orbital wall fractures who were categorized into two groups: Group A – 42 patients (virtual planning) and Group B – 35 patients (traditional approach). Criteria of analysis included the presence of diplopia postoperatively and duration of surgical procedures.Results:Diplopia was recorded right after surgery in 16 cases (38.1%) of Group A and in 12 cases (34.3%) of Group B. However, 6 months postreconstruction, residual diplopia was recorded in 4 cases (9.5%) of Group A and in 12 cases (34.3%) of Group B. Mean operation time in Group A for the patients with isolated zygoma fracture was 2.23 h; for isolated orbital wall fracture was 1.98 h; and for combined zygoma, orbital wall, and facial bone fracture was 3.07 h. In Group B, these indexes were 3.47, 2.05, and 3.31 h, respectively.Conclusions:Application of virtual planning could significantly improve postoperative outcomes in orbital reconstruction. However, application of this technology could be limited by complicated defects of the orbital walls, which would require complex shape of the implant that might be difficult to be prevent virtually.

Gradual oculomotor training in blow-out orbital fracture reconstruction recovery.

ObjectiveThis study compared the impact of gradual oculomotor training (GOT) in blow-out orbital fracture (BOF) reconstruction recovery with the impact of high-intensity trainings.MethodsIn total, 120 patients with BOF requiring orbital reconstruction surgery were randomly divided into four groups; all groups performed postoperative oculomotor training four times per day. Patients in Groups 1, 2, 3, and 4 performed 10, 20, 30, and 50 sets of all-direction movement per training on the first 3 days, respectively; they performed 10 additional sets per training on the following 4 days. Patients in all groups performed 50 sets per training from 8 days to 3 months postoperatively. Incision healing, pain, and satisfaction rate, as well as degree of diplopia, were recorded during follow-up.ResultsAt 7 days postoperatively, more patients in Group 1 had no/mild swelling and no/mild pain, compared with patients in Group 4. Patients in Groups 1 and 2 had higher satisfaction rates than patients in Group 4. The degree of diplopia did not significantly differ among the groups.ConclusionsFor patients with BOF, GOT after reconstruction surgery was more beneficial for wound healing, pain relief, and satisfaction; the degree of diplopia did not significantly differ, compared with high-intensity trainings.

Quantification of effective orbital volume and its association with axial length of the eye. A 3D-MRI study

Objective: To measure the effective orbital volume (EOV) from magnetic resonance images, and investigate its relationship with axial length (AL) in those parameters. Methods: Cross-sectional, 3D-MRI study. 54 eyes of 54 patients (25 males) were included in this work. Patient weight, height and head circumference were also measured. Orbital and eyeball volumes were calculated after image segmentation. The difference between those values volume was assessed, estimating the EOV for each eye. Results: Mean eyeball volume was 7.83 ± 2.27 mm3, mean orbital volume 26.81 ± 0.59 mm3 and EOV 21.64 ± 0.19 mm3. The orbital volume was significantly higher in the male group (Wilcoxon signed-rank tests Z=-1.51, p<0.001; Z=-3.57, p<0.001 respectively). EOV was significantly correlated with AL in both males (r=-0.71, p<0.001) and females (r=-0.73, p<0.001), whereas it was also significantly associated with patient height (r=0.261, p=0.03). Associations between EOV and other age, axial and anthropometric characteristics were not statistically significant. Conclusions: Findings of this study could be of valuable importance in various clinical situations in which quantification of orbital volume is needed, such as orbital decompression in Graves' orbitopathy, volume restoration in orbital fractures or other orbital reconstructive surgery. In surgical interventions, clinical relationships should be carefully taken under consideration to avoid iatrogenic injury. Abbreviations: EOV = Effective orbital volume, AL = Axial length, ROI = Region of interest.

Use of sterile 5-cc spoon as an ophthalmological retractor in orbital roof and floor reconstruction surgery

Use of sterile 5-cc spoon as an ophthalmological retractor in orbital roof and floor reconstruction surgery

Clinical findings and surgical outcomes of patients with traumatic isolated inferior rectus muscle paresis

To evaluate clinical findings and surgical outcomes of patients with traumatic isolated inferior rectus muscle paresis. The medical records of patients with traumatic isolated inferior rectus paresis who underwent strabismus surgery at Farabi Eye Hospital between 2011 and 2018 were reviewed retrospectively. Clinical features, type of surgery, and surgical outcomes were extracted from the record for analysis. A total of 19 patients (14 males [74%]) were included. Mean patient age was 34.8±14.6years. Left eyes in 13 patients (68%) were involved. Thirteen cases (68%) underwent orbital reconstruction surgery for blow-out fracture. Preoperative limitation of duction in the gaze of the inferior rectus muscle was -2 to -3 in all cases. Four patients (21%) had a paradoxical contralateral compensatory head tilt. Inferior rectus muscle resection alone was the first surgical intervention in 12 patients (63%). At the final follow-up, 12 patients (63%) were orthotropic, without any deviation or diplopia in primary position and downgaze. Three patients (16%) had a residual hypertropia of 3Δ at distance and near without diplopia, and 4 patients (21%) required reoperation. In our patients with traumatic isolated inferior rectus paresis with persistent deviation at least 6months after trauma, a stepwise approach based on size of the vertical deviation was employed, with good outcomes: inferior rectus resection alone for hypertropia of 6Δ-20Δ and inferior rectus resection and superior rectus recession for hypertropia of ≥20Δ or significant hypertropia in the field of the superior rectus muscle.

Causes and Surgical Outcome of Orbital Wall Fractures in Mongolia

Objective: To determine causes, clinical manifestations of orbital wall blowout fractures, and evaluate surgical outcomes. Methods: A retrospective study with repeated measurements was conducted in 194 cases with orbital reconstructive surgery between 2002 and 2017 at Orbita Eye Hospital. The analyzed variables were patient age, sex, causes, and clinical manifestation of orbital wall fractures. Surgical outcomes, implant dependent, and surgical approach complications were prospectively analyzed in 60 patients up to 24 months after the initial surgery. Results: Orbital wall fractures were caused by assault in 82.7% of cases, household accidents 9.9%, car accidents 7.4%, and 0% by a sports injury. Diplopia was noted in 16.7%, extraocular movement limitation in 16.7%, enophthalmos in 23.3% for 24 months, or and more following surgery. In 4.2% of cases, prolapse of the orbital fat was noted using the transconjunctival approach, and 16.6% eyelid retraction with scarring in the subciliary approach. Implant displacement was noted 6.6% of cases in which a silicone sheet was used to reconstruct the fracture defect. Conclusions: Assault was the leading cause of orbital fractures, and this most often occurred in young males in Mongolia. Common signs and symptoms of orbital fractures were enophthalmos, diplopia, and extraocular movement limitation. The range of post-surgical enophthalmos, diplopia, and implant-related complications was consistent with those reported by other studies.