Orbital Trauma Research Articles

Outcomes in Orbital Floor Trauma: A Comparison of Isolated and Zygomaticomaxillary-Associated Fractures.

Orbital floor fractures are common sequalae of trauma to the orbit. These fractures present as an isolated orbital floor (I-OF) fracture or with other midface fractures, typically the zygomaticomaxillary complex. The authors sought to better understand the differences in patient presentation, surgical decision-making, and outcomes in I-OF fractures compared with those associated with zygomaticomaxillary complex fractures (Z-OF). A retrospective review of patients with orbital floor fractures was conducted to generate an I-OF fracture group and a Z-OF fracture group. Demographics, preoperative symptoms, surgical choices, and postoperative complications were assessed. Complications were assessed individually and as 2 composite groups consisting of orbital complications and eyelid complications. There were 156 patients that met inclusion criteria with 75 I-OF fractures and 81 Z-OF fractures. The most common mechanism of injury for I-OF fractures was assault (34.7%) and motor vehicle accidents (39.5%) for Z-OF fractures. The I-OF group presented more often with diplopia (P = 0.01) whereas the Z-OF group had more trauma symptoms (P = 0.01), which included subconjunctival hemorrhages, retrobulbar hemorrhages, and relative afferent pupillary defects. I-OF fractures had longer preoperative observational periods (P < 0.001). Postoperatively, I-OF fractures had more motility restrictions (P = 0.002) but Z-OF fractures had higher risk for eyelid complications (P = 0.03). There was no significant difference in reoperation rates (P = 0.93). Multivariate analysis showed Z-OF fractures had reduced a rate of postoperative motility defects by 72% (P = 0.03) but had 2.6 times higher risk of eyelid complications (P = 0.04). Z-OF fractures present differently, vary in surgical management, and have complications that differ from an I-OF fracture.

Ocular motility and diplopia measurements following orbital floor fracture repair

PurposeDiplopia and ocular motility restriction following orbital fracture repair are common complications. The reported rates in the literature differ greatly, in part due to varying definitions of diplopia and methods of measurement. The purpose of this study is to describe a practical and efficient in-office method for examining ocular motility and diplopia in orbital trauma patients and to report the outcomes in a series of patients who underwent orbital floor fracture repair. Materials and methodsA retrospective chart review from 2012 to 2019 was conducted in patients who underwent isolated orbital floor fracture repair within 3 weeks of trauma. All patients had examinations to assess extraocular motility and subjective diplopia using the described techniques. ResultsNinety-three patients underwent orbital floor fracture repair and had adequate follow-up. Preoperatively, 71 (76%) patients had some restriction in motility and 59 (63%) patients complained of diplopia. Postoperatively, only 1 patient (1.09%) had clinically significant diplopia. Five (5.4%) additional patients demonstrated mild restriction in supraduction upon detailed ophthalmic examination that was not discovered upon subjective history. No patients had worsening of diplopia or motility after surgery. ConclusionsDiplopia and motility restriction following orbital fracture repair can be a persistent problem for some patients. It is important to perform a careful ophthalmic examination to detect motility deficits and diplopia that can be significant to the patient. The true rate of restriction and diplopia may be higher using detailed ophthalmic diagnostic techniques compared to subjective patient history.

The possible impact of increased physical intimate partner violence during the COVID-19 pandemic on ocular health.

During the COVID-19 outbreak, sheltering at home has led to an increase in physical intimate partner violence cases. Intimate partner violence–sustained ocular injuries may be higher during the pandemic due to the increase in physical intimate partner violence. Left untreated, intimate partner violence–related ocular or orbital trauma can lead to permanent vision loss. Even with treatment, patients often lose vision from intimate partner violence–related traumatic ocular injuries. Eye care providers and eye care facilities should understand the community services available to intimate partner violence survivors to better care for these patients. Due to the potential lasting economic burden and social strain of this pandemic, eye care providers and facilities should stay vigilant as there may still be a sustained increase in intimate partner violence even after the global COVID-19 pandemic.

Navigation-guided surgery in orbital trauma

There are times in an orbital surgeon's life when experience and instincts seem inadequate and there is a need for some extra guidance and technical support. High-velocity injuries with shattered orbits are one such instance. In these cases, the entire orbit is disrupted and there are no bony landmarks to guide placement of implants and restoration of volume. Orbital walls have complex curvatures and it is extremely difficult to reestablish and symmetrize this complex three-dimensional (3D) anatomy. Inadequate reductions and poor implant placements are common causes of postoperative persistent enophthalmos. Intraoperative navigation guidance has greatly aided in accurate localization of bony landmarks, in planning complex reconstructions and verifying adequate reconstruction and symmetry, and in planning patient-specific or customized 3D-printed implants. It has brought in a revolution in the treatment of orbital trauma in current times.

Functional multislice computed tomography of the orbits in diagnosis of incomitant strabismus

To study the value of functional multislice computed tomography (MSCT) of the orbits in examination of patients with complex incomitant strabismus. The study included 34 patients. In 8 (23.5%) out of 34 patients, strabismus occurred as the result of an orbital injury. In some patients, incomitant strabismus was a complication of: retrobulbar injection of drugs (4 cases (11.7%)); endoscopic sinus surgery (6 cases (17.6%)); reconstructive surgery of orbits (7 cases (20.6%)). In 9 cases (26.5%), incomitant strabismus was detected in patients with thyroid eye disease (TED), of them 5 (14.7%) had previously undergone balanced orbital decompression (BOD). All patients underwent functional MSCT of the orbits. Complete absence of the contractile function of the studied muscles was noted in 6 cases with loss of ocular motility in one or several directions of gaze. Contraction of the injured muscle and its fixation in the area of iatrogenic defect in the orbital wall was observed in 6 patients with severe limitation of ocular motility. limitation of the excursion of the inferior and/or medial rectus muscles due to their fixation in the fracture of the orbital wall was observed in 5 patients after orbital trauma. Signs of contracture of the inferior rectus muscle were revealed in 4 cases of strabismus that occurred after retrobulbar anesthesia. Pronounced increase in the lateral dimensions of the extraocular muscles was determined in 4 patients with TED, as well as in patients who had underwent BOD. Displacement of the lateral and medial rectus muscles into the formed bony windows with a change in the vector of their action was observed in patients who had underwent BOD. The data obtained with functional MSCT of the orbits in 34 patients allowed more accurate characterization of the oculomotor disorders and evaluation of the functional state of the extraocular muscles.

Retrospective Analysis of the Outcomes in Orbital Floor Fractures: Guidelines for Better Strategic Management

Aim: Orbital trauma is considered one of the most commonmaxillofacial traumas with functional and cosmetic impactto eye globe. The main objective is to establish a roadmap for the management of orbital floor fractures.Patients and Methods: One hundred and seventy-threepatients were selected from the database of Mansoura UniversityHospitals with orbital floor fractures who were treatedat the Department of Plastic & Reconstructive Surgery Departmentover past 4 years. Cases were retrospectively reviewedby preoperative clinical findings, management, surgical approaches,and sequelae. Authors evaluated timing and indicationof surgical intervention, surgical outcomes, complications,and materials used for orbital reconstruction.Results: In total, there were (173) cases of orbital fractureswith average age of (23.14) years. The leading cause of thesefractures was motor traffic accident (64.7%). Pure blow-outfractures represent 25% of cases while fractures of inferiororbital rim alone were 45% of cases. Inferior orbital rimassociated with orbital fractures were 30%. 57.2% of patientswere managed surgically while 42.8% patients were managedconservatively. Conchal graft was used in 19 cases for floorreconstruction while 15 cases were managed by titaniummesh. In the follow-up, 10 patients still complain of enophthalmos,while 7 patients still complain of diplopia.Conclusions: Better postoperative results were presentedin cases managed immediately or within two weeks surgically,A guideline for choice of effective protocol for managementwas developed.

THE EFFECTIVENESS OF ORBITAL VOLUMES CALCULATIONS AFTER TRAUMATIC INJURIES BASED ON CT DATA

To present a case of a 56 y.o. male with maxillo-facial trauma after falling from heights and the possibility to choice the treatment tactics based on CT volume calculation. Material and methods. Patient N., 56 years old, came to the clinic 3 days after the injury – a fall from heights. During the examination in the clinic, the patient did not have visual impairments and difficulties in eye movement. We performed MSCT of the maxillofacial region, which revealed radiological signs of fractures of the lower and lateral walls of the right orbit. In order to determine further treatment tactics for this patient (surgical treatment or conservative therapy), the authors performed additional processing of MSCT data in order to obtain clarifying diagnostic information. Results. The authors performed the calculation of orbital volumes and confirmed the possible minimal risk of post-traumatic complications such as enophthalmos and hypophthalmos. It was decided to treat the patient conservatively. The long-term follow-up MSCT study confirmed the correct management of a patient with orbital trauma in terms of restoration of the right orbit walls with minimal volumetric change. Conclusion. This case highlights the advantage of using new techniques of CT data processing in daily practice.

Normative Orbital Measurement Based on Computed Tomography Imaging in Tertiary Care Hospital, Bangalore, Karnataka

Introduction: The orbit is an anatomically complex region. Clear idea of the normal orbital measurements is needed for the diagnosis and management of the various diseases that may affect the orbit like optic neuritis, optic nerve glioma, meningioma, proptosis and exophthalmos. Aim: To evaluate normative orbital measurement at tertiary care hospital in Bangalore, Karnataka in Indian population based on Non Enhanced Computed Tomography (NECT) imaging. Materials and Methods: A cross-sectional observational study of 100 patients referred to a tertiary care centre for NECT of the brain for diseases other than those of the orbits was conducted. Patients having any orbital disorder, surgery or trauma and having metallic implants were excluded from the study. The patients of all age groups and either sex were included. The horizontal orbital diameter, vertical orbital diameter, orbital index, optic nerve complex, globe position, interorbital diameter and interzygomatic line measurements were calculated for 100 patients, i.e., total of 200 orbits using both axial and direct coronal CT images. Mean measurements of these parameters were calculated. Scans were performed on Siemens Somatom Perspective 128 slice multi- detector CT scanner. All statistical analysis was performed using Statistical Package for The Social Sciences (SPSS) for windows software (SPSS Inc. Illinois, Chicago, USA). Results: The mean orbital index was 118.6 and 118.3 for right and left orbit, respectively. It was derived from mean horizontal orbital diameter of 32.5 mm and 31.7 mm of right and left orbit, respectively and mean vertical orbital diameter of 38.4 mm and 37.4 mm of right and left orbit, respectively. Mean optic nerve sheath complex diameter was 5.2 mm and 5.4 mm for right and left orbit, respectively, while mean globe position measurements 6.7 mm and 6.8 mm of right and left orbit, respectively. Average interorbital distance was 22.9 mm and average interzygomatic distance 97.1 mm. Conclusion: The present study has given normative mean measurements for various orbital structures that are essential to ophthalmologists and radiologists to differentiate normal from abnormal dimensions which is likely to be helpful in accurate assessment of various orbital pathologies.

Инородное тело орбиты у ребенка школьного возраста (клинический случай)

The article presents a clinical case of May 2020. An 11-year old girl turned to the admission department of the regional children’s hospital with a suspected eyelid abscess. The day before she was seen by an ophthalmologist, parents refused from suggested abscess opening. According to anamnesis data, the girl got a strike in the upper eyelid of the right eye with a pen from herself at home. The girl and her parents could not tell exactly what was the pen like and was it whole after the strike or not. Initially an upper eyelid abscess of the right eye was diagnosed. During examination an eyelid wound, exotropia and limited adduction on the affected side, pronounced diplopia were found. Previously, the child was healthy.Anti-inflammatory, antibacterial therapy was prescribed. According to orbital computer tomography, tissue swelling, and gas accumulation were found in the right orbit. After three days of antibacterial therapy exotropia and diplopia have decreased. Limitation of the right eye adduction persisted. Wound revision with metal probe was performed which revealed a foreign body deep in the orbit. The foreign body had a limited approach, its exact location and dimensions were unknown. The girl underwent MRI of the orbits. A foreign body in the right orbit which was a ballpoint pen cap located between the medial wall of the orbit and medial rectus muscle was. An operation was performed. Eyelid wound was enlarged, and a foreign body was removed which was a cap and corpus fragments of a ballpoint pen. During the following rehabilitation period, diplopia and exophoria have completely disappeared, eyeball mobility was restored, and the girl was discharged after recovery. Diagnostics was difficult due to lack of anamnesis data; search of the foreign body was also difficult because plastic is an found X-ray negative material. Key words: orbital trauma; foreign body.

The Quality of the Evidence in Craniomaxillofacial Trauma: Are We Making Progress?

The purpose of this study is to evaluate the level of evidence in the craniomaxillofacial trauma literature. The secondary purpose is to determine if improvement in the quality of evidence has been made over the past 2 decades. This retrospective cohort study analyzed clinical articles published in select craniomaxillofacial surgery journals. Patient-focused articles were selected. The year of publication (1999, 2009, 2019) was the primary predictor variable. Secondary predictor variables included study funding status, anatomical facial region (eg maxilla, mandible, and so on), specific journal, and journal impact factor. The level of evidence was determined using the Center of Evidence-Based Medicine criteria, which served as the outcome variable. The statistical analysis included descriptive, bivariate, and regression analysis. The sample consisted of 469 craniomaxillofacial trauma articles, with 13.2% being published in 1999, 44.1% in 2009, and 42.6% in 2019. The majority of the studies (77.5%) were published in 4 journals. The impact factor varied among the journals with a significant improvement in the mean impact factor from (0.89 ± 0.29) in 1999 to (1.4 ± 0.47) in 2009 and a slight decline in 2019 (1.26 ± 0.71). Mandibular fractures (31.6%) and orbital trauma (26%) were the most investigated topics. Level 4 studies accounted for 67.4% of the sample, with level 3 evidence of 4.7%, level 2 of 22.6%, and level 1 of 5.3% of the included studies. Significant progress in the level of evidence has been made from 1999 but not since that time (P=.002). It is unclear why this may be but sheds light on the need for further development of high quality studies. Finally, a higher quality of evidence is associated with journal impact factor (odds ratio=1.9; P<.01) and funded research (odds ratio=4.69; P=.02). While there has been some improvement in the level of evidence in the craniomaxillofacial trauma literature over the past 2 decades, the current quality remains low, and further progress is needed to support the practice of evidence-based medicine.

Результаты комплексной реконструкции при сочетанной травме органа зрения, орбиты и придатков глаза. Клинический случай

Результаты комплексной реконструкции при сочетанной травме органа зрения, орбиты и придатков глаза. Клинический случай

A review of imaging used in the initial assessment of isolated orbital trauma in a sample of emergency departments in the Republic of Ireland

Introduction: Computed tomography (CT) facial bones is the radiological imaging of choice when investigating orbital trauma. However controversy still exists on the initial use of CT in the primary assessment of orbital trauma in the emergency department (ED). In cases of clinically suspected orbital trauma, initial plain radiographs are of limited value.

Is there an ideal time to repair orbital floor fractures?

Introduction: Orbital fractures often involve the orbital floor. They can be isolated or involve multiple orbital walls, also in conjunction with other facial fractures. Common symptoms include diplopia, enophthalmos, hypoglobus and cheek numbness. Repair of orbital trauma is believed by many specialists to be time sensitive, where outcomes can be significantly affected by timing and delays. We wanted to evaluate our outcomes in relation to timing.

Management of recurrent pneumo‐orbit secondary to post traumatic sino‐orbital fistula using a navigation‐guided customised 3D printed titanium implant: a case report and review of literature

ABSTRACTIntroductionChronic persistent pneumo‐orbital fistula is a rare complication of orbital trauma with only four previously reported cases in English literature, all of which were present after surgical repair of the orbital fracture and all of them were treated by removal of the orbital implant and cauterisation of the herniated tissues.Case presentationWe present an interesting case of recurrent left pneumo‐orbit secondary to untreated traumatic large inferomedial sino‐orbital fistula which was successfully repaired using a customised titanium Patient Specific Implant (PSI) inserted with assistance from a navigation system. The thin implant ensured there was no alteration of globe position or diplopia. To the best of the authors knowledge, this is the first reported case in the English literature to describe closure of active, persistent chronic pneumo‐orbital fistula using this novel technique.This article will explore this approach and discuss its limitations based on our experience and a review of the existing literature regarding different causes,presentations, complications,treatment and approaches for the management of pneumo‐orbitum.ConclusionThe use of a solid PSI is an effective and safe treatment for the closure of persistent sino‐orbital fistula and should be considered as a viable treatment option in this group of patients.

Household Orbital Trauma that Nearly Cost Life

This is a clinical case of a child who was the victim of a domestic orbital-cerebral trauma which almost cost him his life, admitted urgently to the operating room after a clinical and radiological check-up and treatment with antibiotics, analgesia and antitetanus, it has benefited from an extraction of the foreign body with a good evolution

Facial and Dental Trauma

Dental and facial trauma are very common in a daily routine radiology practice. Knowledge of the functional anatomy of the mandibulofacial and maxillofacial regions forms the cornerstone of a thorough full radiologic evaluation of the patient with a dental and/or facial trauma. Cone beam computed tomography and multidetector computed tomography are currently considered the imaging modalities of choice. There are several patterns and classification systems for the various subtypes of mandibulofacial and maxillofacial fractures. They are discussed separately in this article with special attention to the types of dental trauma and orbital trauma.

Dynamic three-dimensional finite element analysis of orbital trauma

This study comprises a dynamic finite element (FE) analysis of the mechanisms of orbital trauma, specifically buckling and hydraulic theories. A digital model of the orbital cavity - including the eyeball, fatty tissue, extraocular muscles, and the bone orbit – was created from magnetic resonance imaging and computed tomographic data from a real patient. An impactor hit the FE model following two scenarios: one was a hydraulic mechanism for direct impact to the eyeball and the other a buckling mechanism for direct impact over the infraorbital rim. The first principal stress was calculated to determine the stress distribution over the orbital walls. The FE model presented more than 900,000 elements and time of simulation was 4.8 milliseconds (ms) and 0.6 ms, for the hydraulic and buckling mechanisms, respectively. The stress distribution in the hydraulic mechanism affected mainly the medial wall with a high stress area of 99.08 mm2, while the buckling mechanism showed a high stress area of 378.70 mm2 in the orbital floor. The presence of soft tissue absorbed the energy, especially in the hydraulic mechanism. In conclusion, the applied method of segmentation allowed the construction of a complete orbital model. Both mechanisms presented results that were similar to classic experiments. However, the soft tissue in the hydraulic mechanism absorbed the impact, demonstrating its role in orbital pathophysiology.

Nonlinear dynamic analysis of the pure \u201cbuckling\u201d mechanism during blow-out trauma of the human orbit

Considering the interplay between orbital bones and intraorbital soft tissues, commonly accepted patterns of the blow-out type of trauma within the human orbit require more thorough investigation to assess the minimal health-threatening impact value. Two different three-dimensional finite element method (FEM) models of the human orbital region were developed to simulate the pure “buckling” mechanism of orbital wall fracture in two variants: the model of orbital bone elements and the model of orbital bone, orbit and intraorbital tissue elements. The mechanical properties of the so-defined numerical skull fragment were applied to the model according to the unique laboratory tensile stress tests performed on small and fragile specimens of orbital bones as well as using the data available in the literature. The nonlinear transient analysis of the contact problem between bodies that differ substantially in terms of the Young’s modulus was carried out to investigate the interaction of different bodies within an instant injury. Potential damage areas were found within the lower orbital wall as well as the destructive load values for both FEM skull models (7,660 N and 8,520 N). Moreover, numerical simulations were validated by comparing them with computed tomography scans of real injuries.

Primary care assessment of orbital trauma at a level 1 trauma centre

ObjectiveWith increasing constraints on our publicly funded health care system, appropriate triage of trauma patients is becoming pivotal, making the primary care assessment (PCA) invaluable. Our study aims to compare the initial assessment of patients with orbital fractures with that conducted by the ophthalmology service. DesignRetrospective chart review. Participants243 patients with 277 fractured orbits presenting to a level 1 trauma centre seen between August 2015 and January 2018. MethodsKey elements of the PCA, including subjective vision loss, visual acuity, intraocular pressure, pupil examination, and extraocular movements, were documented and compared with the assessment by the ophthalmology service as the control. The primary outcome was inter-rater reliability as estimated by Cohen's kappa (κ) coefficient. Secondary outcomes included the sensitivity and specificity, as well as the rate of completion of examination components. ResultsPCA examination findings agreed with the ophthalmology service on most components of the examination with the highest agreement with relative afferent pupillary defects and detection of hyphemas (κ = 1). Primary care physicians less often performed most aspects of the assessment. Among performed components of the examination, the average sensitivity was 60.6%, and the average specificity was 84.2%. ConclusionsOur results show good inter-rater reliability of the PCA compared with the ophthalmology examination but low rate of completion of examination components, suggesting a potential overdependence on the ophthalmology assessment. Given the limited resources of the public health care system, our study may highlight the PCA as a potential focus to improve effective and safe patient management.

Middle aged male with blurry vision following blunt orbital trauma.

Middle aged male with blurry vision following blunt orbital trauma.