Orbital Roof Defect Research Articles

Successful Management of Post-Traumatic Residual Orbital Roof Defects with Cosmetic Disfigurement and Functional Deficits Using Innovative Titanium Plate Orbitoplasty.

Late presentations of post-traumatic residual orbital roof deformities ensuing from old, unaddressed orbital injuries, can be extremely challenging to manage and quite complicated to correct, owing to proximity of the brain and frontal sinus, malunion or bony fusion of the displaced, delicate orbital fracture fragments, necrosis of entrapped extraocular muscles and progressive intraorbital soft tissue fibrosis and adhesions. There exists a paucity in literature on delayed repair of displaced and comminuted orbital roof fractures and late reconstruction of the three-dimensional architecture of the orbital frame and internal orbit. To present an unusual case of severe post-traumatic residual orbital roof deformity, resulting in longstanding aesthetic disfigurement and persisting functional deficits, and its successful management. The patient had sustained orbital injuries sixteen months ago, on being punched in the face at a boxing tournament. The increased orbital volume produced by an impure blowout fracture of the left orbital roof, with comminution of the upper and lower orbital rims, had resulted in considerable cosmetic deformity, discomfort as well as functional debility, all of which were successfully and efficaciously managed by an innovative use of a Titanium Orbital Plate for orbital roof reconstruction. Overlooked, undetected or ignored derangements in intraorbital volume and contour, can lead to severe cosmetic disfigurement in the form of enophthalmos, hypoglobus, entropion, telecanthus, palpebral fissure width narrowing and ptosis; in addition to crippling functional deficits, such as diplopia, blurred vision, levator dysfunction, restricted ocular motility and reduced visual range and acuity. An innovative Titanium mesh orbitoplasty enabled achievement of both, the aesthetic and functional goals of reconstruction of the distorted bony orbit, with successful correction of severe functional and aesthetic deficits.

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.

Reconstruction of a Combined Frontal Bone and Orbital Roof Defect With Associated Meningoencephalocele Using 3D Modeling and 3D Navigation

Introduction: Orbital roof fractures are uncommon and normally associated with high energy trauma in which multiple other injuries are present. Most can be managed non-operatively with close observation. However, in a small proportion the defect is such that it permits the development of a meningoencephalocele, which can cause exophthalmos, a reduction in visual acuity and pain, all of which are unlikely to improve without surgical treatment. In light of their scarcity and the potential of serious risks with surgery that includes meningitis and visual disturbance (or even loss), thorough planning is required so that the meningoencephalocele can be reduced safely and the orbital roof adequately reconstructed. Methods: We report a case of a patient with a frontal bone defect, orbital roof fracture and associated meningoencephalocele that presented years after being involved in a road traffic accident in another country, who complained of a significant headache and orbital pain. The use of 3D modeling to help plan the surgery, and intraoperative 3D navigation to help negotiate the anterior skull base are described along with the reconstruction of the frontal bone and orbital roof using titanium mesh contoured on the 3D model. Conclusions: Although conservative management of orbital roof fractures predominates; those that are symptomatic, have associated neurologic symptoms or pose a risk to the eyesight warrant a surgical approach. The methods of repair, which center around separating the intracranial and intraorbital contents, are described in the context of this patient and previous cases, and a treatment algorithm is proposed.

Acute Monocular Blindness Due to Orbital Compartment Syndrome Following Pterional Craniotomy

We present a case of orbital compartment syndrome (OCS) leading to monocular irreversible blindness following a pterional craniotomy for clipping of an anterior communicating artery aneurysm. OCS is an uncommon but vision-threatening entity requiring urgent decompression to reduce the risk of permanent visual loss. Iatrogenic orbital roof defects are a common finding following pterional craniotomies. However, complications related to these defects are rarely reported. A 65-year-old female who underwent an anterior communicating artery clipping via a pterional approach 4 days before developed proptosis, ocular movement paresis, and irreversible visual impairment following an orthopedic surgery. Computed tomography images revealed an intraorbital cerebrospinal fluid (CSF) collection, which was evacuated via an acute recraniotomy. The next day, proptosis and intraorbital CSF collection on computed tomography images reoccurred and an oral and maxillofacial surgeon evacuated the collection via a blepharoplasty incision and blunt dissection. In addition, the patient was treated with acetazolamide and an external lumbar CSF drainage during 12 days. Hereafter, the CSF collection did not reoccur. Unfortunately, monocular blindness was persistent. We hypothesize the CSF collection occurred due to the combination of a postoperative orbital roof defect and a temporarily increased intracranial pressure during the orthopedic surgery. We plead for more awareness of this severe complication after pterional surgeries and emphasize the importance of 1) strict ophthalmologic examination after pterional craniotomies in case of intracranial pressure increasing events, 2) immediate consultation of an oral and maxillofacial surgeon, and 3) consideration of CSF-draining interventions since symptoms are severely invalidating and irreversible within a couple of hours.

Congenital Ocular Dystopia from Orbitofrontal Bone Dysplasia.

Several patients with ocular dystopia and craniofacial differences have been found to have orbital dysplasia and a frontal bone defect. This deformity is characteristically different from differential diagnoses of encephalocele, sphenoid dysplasia, craniofacial dysostoses, or atypical clefting. The authors retrospectively reviewed the craniofacial registries of two pediatric centers for patients presenting with ocular dystopia or orbitofrontal anomalies between 2000 and 2014. The features and treatment of these patients were analyzed. Four patients with congenital orbitofrontal bone dysplasia were identified, three with unilateral and one with bilateral frontal bone defects. Clinical signs of hypoglobus and vertical ocular dystopia of an average of 5.0 mm on the affected side were noted shortly after birth. The transversely oriented bony defect had an average surface area of 3.9 cm in unilateral cases and 10.7 cm in bilateral cases. Patients showed a characteristic orbital vertical elongation with an average orbital height-to-width ratio of 1.30-in excess of the average normal 1.14 by 14 percent-and inferior rim displacement. Cranial contour demonstrated frontal bossing and borderline dolichocephaly. Fronto-orbital reconstruction was performed in three patients, using cranial bone grafting to obliterate the orbital roof defect and elevate the orbital floor, which was successful in reducing ocular dystopia and preserving vision in each patient. One patient followed for 11 years postoperatively has a durable result with no surgical revision. Orbitofrontal bone dysplasia has not been previously reported, and includes a frontal bone defect and ocular dystopia. Single-stage fronto-orbital reconstruction appears to adequately correct it. Therapeutic, IV.

Porous polyethylene reconstruction of orbital floor and roof defects – clinical and radiological evaluation

Aim: The aim of this study was to evaluate clinically and radiologically the use of high porous polyethylene (Medpor) for reconstruction of post-traumatic orbital roof and floor defects. Patients: 37 patients had traumatic orbital wall defects were studied. Patients were classified into three groups. Group (A) included 22 patients had orbital floor defects. Group (B) included 10 patients had orbital roof defects. Group (C) included 5 patients had combined orbital roof and floor defects. All defects were reconstructed by medpor. Patients were followed by CT scan and by serial MRI. Results: Near all presentations improved in the immediate postoperative period and maintained in the postoperative follow-up period. Neither extrusion nor infection was recorded in any case. Enhancement was detected in the implants by MRI as early as one month post operative in 23 patients and 1.5 months postoperative in the remaining 14 patients. Conclusion: Porous polyethylene was found to be flexible, strong, porous and is highly biocompatible. Its porosity enables vascular and bony ingrowth leading to tissue adhesion and a reduced risk of infection. The current study is the first one described in humans to detect vascular ingrowth into medpor orbital sheets utilizing Gadolinium enhanced MRI. Porous polyethylene sheets was shown to have very favorable results in orbital wall reconstruction.

Orbital Dystopia Due to Orbital Roof Defect

We performed a retrospective review of patients who presented with delayed dystopia as a consequence of an orbital roof defect due to fractures and nontraumatic causes to search for a correlation between orbital roof defect size and surgical indications for the treatment thereof. Retrospective analyses were performed in 7 patients, all of whom presented with delayed dystopia due to orbital roof defects, between January 2001 and June 2011. The causes of orbital roof defects were displaced orbital roof fractures (5 cases), tumor (1 case), and congenital sphenoid dysplasia (1 case). All 7 patients had initially been treated conservatively and later presented with significant dystopia. The sizes of the defects were calculated on computed tomographic scans. Among the 7 patients, aspiration of cerebrospinal fluid, which caused ocular symptoms, in 1 patient with minimal displaced orbital roof and reconstruction with calvarial bone, titanium micromesh, or Medpor in 6 other patients were performed. The minimal size of the orbital roof in patients who underwent orbital roof reconstruction was 1.2 cm (defect height) x 1.0 cm (defect length), 0.94 cm(2). For all patients with orbital dystopia, displacement of the globe was corrected without any complications, regardless of whether the patient was evaluated grossly or by radiology. In this retrospective study, continuous monitoring of clinical signs and active surgical management should be considered for cases in which an orbital roof defect is detected, even if no definite symptoms are noted, to prevent delayed sequelae.

Orbital Roof Reconstruction Using Porous Polyethylene Sheet With Embedded Titanium

Calvarial defects, including the orbital roof defect that occurs after trauma or oncologic resection, require immediate reconstruction to avoid complications such as enophthalmos, diplopia, and transmission of the cerebral pulse to the eye. In these cases, autologous bone grafts or various alloplastic materials have been used.Between January 2010 and December 2010, 5 patients underwent surgery for orbital roof reconstruction using porous polyethylene sheet with embedded titanium, which was developed for reconstruction of inferomedial wall of the orbit. One patient underwent surgery because of tumor excision; the other patients, because of trauma. Two patients had intracranial hemorrhage and 3 patients had a defect in the supraorbital rim. We reconstructed the supraorbital rim and the orbital roof using a combination of calvarial bone graft and the porous polyethylene sheet with embedded titanium. The sheet was bended and trimmed according to the shape of the orbital defect, and it was fixed on the remaining adjacent bone using a microplate.There were no complications during the follow-up period. The patients were satisfied with the external appearance.In conclusion, the orbital roof reconstruction using porous polyethylene sheet with embedded titanium was an easy and a time-efficient procedure with satisfactory results.

Orbital Roof Encephalocele Mimicking a Destructive Neoplasm

The purpose of this case report is to report an orbital roof encephalocele mimicking a destructive orbital neoplasm. Orbital roof encephalocele is uncommon but can mimic neoplasm. One potential mechanism for the orbital roof destruction is a post-traumatic "growing orbital roof fracture." The growing fracture has been reported mostly in children but can occur in adults. Alternative potential etiologies for the encephalocele are discussed, including Gorham syndrome. Orbital roof encephalocele is uncommon in adults, and the findings can superficially resemble an orbital neoplasm. Radiographic and clinical features that might suggest the correct diagnosis include a prior history of trauma, overlying frontal lobe encephalomalacia without significant mass effect or edema, and an orbital roof defect. The "growing fracture" mechanism may be a potential explanation for the orbital roof destruction in some cases.

Pneumocele of the frontal sinus producing orbital roof defect: case report and review of literature

Type III frontal recess air cell as a cause of frontal sinus pneumocele has not been previously reported in literature. A 31-year-old woman with chronic history of sinusitis presented with pressure in the left eye on blowing the nose. Computed tomography examination of the orbits and paranasal sinuses with coronal and sagittal reformatted images showed abnormal collection of gas in the soft tissues at the superior aspect of the left orbit contiguous with the overlying left frontal sinus through a large defect in the orbital roof and a type III frontal recess air cell narrowing the left frontal recess.

Management of Diplopia Secondary to Neurosurgical Injury of the Orbital Roof

Diplopia related to neurosurgical procedures is often consecutive to oculomotor nerve lesions. We hereby report an oculomotor dysfunction secondary to an orbital roof effraction and its treatment. Following surgery for a left anterior communicating artery aneurysm, a 45-year-old woman reported vertical diplopia associated with a left orbital hematoma. The diagnosis of third cranial nerve palsy was excluded by orbital imaging which revealed an orbital roof defect with incarceration of the levator palpebrae and superior rectus. As neurosurgeons advised against muscle adhesiolysis, diplopia was corrected by a two-step procedure on the oculomotor muscles. We first corrected horizontal and torsional deviations by operating on the healthy eye, before correcting the vertical deviation on the fellow eye. This two-step extraocular muscle surgery allowed restoration of binocular single vision in a useful field of gaze. Diplopia can occur as a rare orbital complication during neurosurgical procedures. Surgery of extraocular muscles can provide good functional results.

The use of polyglactin 910-polydioxanon in the treatment of defects of the orbital roof

Purpose: This study evaluated the use of polyglactin 910-polydioxanon (PPP) for repair of orbital roof defects. Patients and Methods: Between 1988 and 1996, 144 patients treated in the Department of Neurosurgery, Christian-Doppler-Medical-Center Salzburg, were operated on transcranially for fractures of the orbital roof or intraorbital tumors. In 85 of these 144 patients, PPP was used for reconstruction of the orbital roof or closure of the periorbita. The postoperative results in patients in whom the PPP patch was used for reconstruction of the orbital roof were compared with the results of a group treated without PPP. Results: Even in severely injured patients, the reconstruction was judged to be very good in 71 patients (83.5%). Conclusion: PPP is a useful material for the reconstruction of the orbital roof.

Repair of traumatic orbital wall defects with nasal septal cartilage: Report of five cases

Purpose This article reports the use of nasal septal cartilage for the repair of traumatic orbital wall defects. Patients and Methods Five patients with disruption of the orbital wall after facial trauma were included in this retrospective review. All of the patients underwent open reduction with internal fixation of the fractures as well as repair of the orbital wall defect with autogenous septal cartilage. Results Nasal septal cartilage was used in four cases of orbital floor defect and one case of orbital roof defect. All of the cases were successfully treated by restoration of the orbital wall continuity. Conclusion Nasal septal cartilage is a readily accessible autogenous material that can be easily harvested with minimal donor site morbidity, and it should be considered when an autogenous orbital implant is needed for the repair of a traumatic orbital wall defect.

Cardiopulmonary Arrest After Retrobulbar Anesthesia in a Patient With an Orbital Roof Defect

Cardiopulmonary arrest developed after injection of bupivacaine hydrochloride, lidocaine, and hyaluronidase in a 78-year-old woman who had previously undergone ipsilateral transcranial orbital surgery with removal of the bone of the orbital roof. The patient required immediate cardiopulmonary resuscitation and intubation. Mechanical ventilation was necessary for 18 hours before spontaneous respirations resumed. The patient improved and was discharged on the fifth postanesthetic day. There were several possible mechanisms by which the local anesthetic could have entered the central nervous system. In patients with orbital roof defects, we recommend that retrobulbar anesthetic agents be used with caution.