Orbital fractures are frequently encountered in maxillofacial trauma and can be associated with severe globe injuries (SGI). Accurate and timely diagnosis is critical to prevent long-term complications, yet subtle fractures and soft tissue injuries may be overlooked. Recent advances in artificial intelligence offer promising tools to support clinical decision-making in acute settings. We collected CT images from 250 eyes with orbital wall fractures treated at a single center between May 2020 and May 2023. From CT scans of included subjects, a dataset of 18,000 annotated orbital CT scan slices was used, with segmentation preprocessing based on a U-Net framework. Two supervised convolutional neural network (CNN) classifiers were trained on axial and coronal CT images of the orbit. The first model (FxDetectCNN) was trained to detect orbital fractures, while the second model (SGIDetectCNN) was trained to classify injury severity as non-severe or severe. The models' performance was compared with annotations by two experienced ophthalmologists. The fracture detection model achieved an overall accuracy of 81%, with 86% sensitivity and 76% specificity. The SGI estimation model achieved 64% accuracy, with a sensitivity of 80% and a specificity of 48%, compared with expert annotation, which reached a maximum accuracy of 59.5% for SGI estimation. Our study demonstrates the feasibility of CNN models in detecting fractures and classifying the severity of ocular injuries from CT scans. These tools can assist emergency physicians in triaging patients and may serve as valuable decision-support systems in emergency settings.

Factors Associated With Surgical Outcomes in Medial Orbital Wall Fracture Reconstruction With Absorbable Plates.

We reviewed the literature on the management of isolated medial orbital wall fractures to understand when patients are treated surgically or conservatively, and their postoperative complications. A comprehensive search was conducted in Cochrane, Medline, and Embase databases on 11/1/2020 with the date range of January 1960 to July 2019 to find published systematic reviews, case series, and clinical research articles. A total of 1321 articles were reviewed, of which 55 papers met our inclusion criteria, and the analyzed papers included 44 case series and 11 case reports. All statistical analyses were performed using R open-access statistical software with a P -value of <0.05. Medial rectus involvement upon initial presentation was statistically different between surgical and conservatively managed groups (1±0.4 versus 0±0, P =0.008). When analyzing postoperative symptom differences among 738 surgically treated patients and 214 conservatively treated patients, most experienced no symptoms (79.1% versus 85.0%, ns). Diplopia was the most common postoperative complaint for the surgically treated group (10.3%), whereas enophthalmos was the most common in the conservatively treated group (8.4%). Surgically managed patients had a higher incidence of diplopia (29.8%±6.7% versus 3.7%±2.3%, P <0.01) and concomitant injuries (15.2%±5.6% versus 0.0%±0%, P =0.01). Although surgical and conservative groups had similar postoperative courses, the initial presentation of these groups differed from each other. These differences in the presentation can help guide practitioners in making clinical decisions on whether to treat their patients surgically or conservatively.

Purpose: Literature regarding the effects of gunshot wounds (GSW) to the face in children is scarce. This study aimed to identify presenting features and clinical outcomes of pediatric patients with GSW to the face, with special attention to ophthalmic data. Methods: This is a retrospective cohort study of patients seen by oculoplastics at a Level I trauma center in the United States after a GSW injury to the face from May 2018 to September 2024. Relevant demographic and clinical data were collected through chart review. Categorical variables are described using percentages and numerical variables are described using median with interquartile range. Results: Nine patients were included with a median age of 16.6 (4.7) years; 67% were male. The most common bullet entry site was the orbit (44%) followed by cheek (33%). The bullet traversed the midline in 78% of cases. Common injuries included orbital wall fracture, open globe injury, optic nerve injury, and intra-ocular hemorrhages. 56% had concomitant intracranial hemorrhages. At least 2 patients presented with non-light perceiving (NLP) vision in at least 1 eye. At final ophthalmology follow-up, 2 patients were legally blind, and 4 were NLP or had undergone enucleation in at least 1 eye. The most common surgical intervention performed was fracture repair (56%) followed by enucleation (33%). Conclusion: This study highlights the devastating effect of GSW to the face in children, particularly with respect to the eyes and orbits. Further studies with larger sample sizes are warranted to identify optimal management patterns and risk factors for poor outcomes.

Background/Objectives: The subciliary approach offers excellent exposure for orbital and zygomaticomaxillary complex fracture repair but is associated with a relatively high risk of postoperative lower eyelid ectropion. This study evaluated the preventive efficacy of an acellular dermal matrix (ADM; WITHderm®) spacer graft placed during subciliary incision repair. Methods: This prospective observational cohort study included 20 patients who underwent open reduction and internal fixation for orbital wall or zygomaticomaxillary complex fractures using a subciliary approach between June and December 2024. A human-derived ADM (WITHderm®) spacer graft was interposed between the orbital septum and the orbicularis oculi muscle during incision closure. Postoperative outcomes were assessed at three time points: ectropion grading at 1 month and scar outcomes at 3 and 6 months using the Patient and Observer Scar Assessment Scale (POSAS). Results: No patients developed postoperative lower eyelid ectropion at 1-month follow-up (0% incidence). Both patient-reported and observer-reported scar outcomes improved significantly over time. The mean total PSAS score decreased from 21.0 ± 2.85 at 3 months to 11.3 ± 2.13 at 6 months (p < 0.001), while the mean total OSAS score decreased from 21.35 ± 2.25 to 11.4 ± 1.67 (p < 0.001). Overall patient satisfaction and objective scar ratings also showed significant improvement. Conclusions: ADM (WITHderm®) spacer grafting during subciliary incision repair appears to be a safe and effective strategy for preventing early postoperative lower eyelid ectropion and achieving favorable scar outcomes. Further studies are warranted to confirm these findings.

Delayed Surgical Release of Medial Rectus Muscle Entrapment Following Medial Orbital Wall Fracture: A Case Report

We aimed to evaluate the clinical efficacy of primary bone restoration with transnasal balloon-assisted support for inferior orbital wall fractures and compared it with the efficacy of conventional alloplastic reconstruction. A total of 85 patients were included in this study. Of them, 25 underwent transconjunctival reconstruction with alloplastic implants (Group A), whereas the remaining 60 underwent primary bone reduction with transnasal balloon-assisted support (Group B). Postoperative outcomes were evaluated based on Hertel exophthalmometry, the orbital volume ratio (OVR) calculated from 6-month follow-up computed tomography (CT) scans, and a curvature analysis of the posterior orbital floor contour on sagittal CT images. Both groups showed significant postoperative improvements in OVR (from 109.23% to 103.07% in Group A; from 111.17% to 103.27% in Group B; p< 0.001). The mean change in the Hertel scale was -0.20 mm in Group A and -0.43 mm in Group B, with no statistically significant difference between the groups (p> 0.05). No significant difference was observed in the magnitude of volume reduction between Groups A (6.16%) and B (7.90%; p= 0.296). Curvature analysis demonstrated a significantly smaller absolute curvature difference between the operated and contralateral sides in Group B than in Group A (0.0136 vs. 0.0310; p< 0.001). Transnasal balloon-assisted primary bone restoration represents a reliable surgical alternative, facilitating the reconstruction of natural orbital floor contours while minimizing complications associated with conventional alloplastic implants.

BACKGROUND: Traumatic eye injuries are an important cause of visual impairment and can significantly affect patients’ quality of life. Accounting for approximately 7% of all bodily injuries and 10–15% of ocular diseases, traumatic eye injuries pose a substantial medical and socioeconomic burden. This study aimed to evaluate the clinical and radiological characteristics of traumatic open-globe injuries (OGIs) that resulted in either primary enucleation/evisceration or primary repair at a tertiary hospital in Mogadishu, Somalia. METHODS: This retrospective study was conducted at Mogadishu Somalia Turkey Training and Research Hospital and included 52 eyes of 51 patients treated for traumatic OGIs between January 2020 and June 2022. Twenty-four eyes underwent primary enucleation/evisceration, while 28 eyes underwent primary repair. Continuous variables were compared using independent sample t-tests, and categorical variables were analyzed with the Pearson Chi-square test. Hierarchical regression analyses were performed to assess the association between surgical approach and selected clinical and radiological parameters. Statistical significance was defined as p < 0.05. RESULTS: Initial regression analysis revealed that initial visual acuity, cause of injury, and concomitant orbital fracture significantly predicted the surgical approach [F(4,44) = 23.440, p < 0.001], accounting for 70.1% of the variability. Initial visual acuity (B = 0.306, p = 0.008), cause of injury (B = 0.269, p = 0.010), and orbital fracture (B=-0.508, p < 0.001) were significant predictors. A second regression model incorporating orbital wall fracture components explained 74.8% of the variability [F(8,40) = 13.600, p < 0.001], with orbital roof fracture (B=-0.343, p = 0.008) emerging as a key factor. CONCLUSIONS: Initial visual acuity, cause of injury, and the presence of orbital fractures were significantly associated with the choice of primary surgical approach in traumatic OGIs. In particular, orbital roof fractures were identified as an important radiological factor influencing surgical decision-making.

Traumatic injuries resulting in complex pan-orbital fractures, often accompanied by fractures of the skull base, calvarium, and midface, present a unique surgical challenge. These injuries are often difficult to address in a single operation due to the need for staged neurosurgical and orbital reconstruction. Neurosurgical repair of the dura and orbital roof fractures may need to be performed before addressing fractures of the medial orbital wall and orbital floor. Pushing orbital contents back into the orbit from below is especially difficult with swelling from a CSF leak, and the risk of damaging a newly repaired orbital roof and dura. Waiting for the orbital roof and dural repair to heal is an option, but delayed repair of the other orbital walls is difficult once there is scarring and fibrosis of the orbital contents to sinus mucosa. In ballistic injuries with near-total destruction of the orbit, reconstruction is further complicated by the loss of natural anatomical landmarks. We present a novel staged operative repair of complex pan-orbital trauma due to a gunshot wound. This patient suffered multiple fractures of the orbit, including right orbital roof and medial orbital wall fractures, and left orbital roof, floor, and medial orbital wall fractures. The patient also had bifrontal herniation, CSF leak, and suffered a left globe obliteration rendering that eye unsalvageable.

Orbital wall fractures are among the most common maxillofacial injuries and require precise reconstruction to restore orbital volume, prevent diplopia, and avoid long-term sequelae such as enophthalmos or facial asymmetry. Traditional reconstruction techniques have relied on autologous grafts and preformed alloplastic implants; however, these approaches are limited by intraoperative variability, imprecise contour restoration, and increased operative time. Over the past decade, the emergence of patient-specific implants (PSIs), designed through advanced three-dimensional (3D) imaging, computer-aided design, and computer-aided manufacturing, has transformed the field of orbital reconstruction. PSIs allow highly accurate anatomical restoration, reduce intraoperative manipulation, and improve clinical outcomes. This review provides a comprehensive overview of the evolution of orbital fracture reconstruction, design and fabrication principles of PSIs, clinical evidence supporting their use, limitations, and future directions, including bioactive materials, artificial intelligence-driven design, and point-of-care 3D printing.

Assessment and Validation of a Predictive Model for Severe Ocular Injuries Associated With Orbital Wall Fractures.

Zygomatic arch fractures are often managed conservatively, but may result in persistent functional limitations, including temporomandibular dysfunction (TMD). This case highlights the challenges associated with delayed surgical intervention in cases with conservative management failure. We present a 60-year-old man who sustained zygomatic arch and lateral orbital wall fractures after a fall. The initial fracture showed minimal displacement with no coronoid process impaction, and conservative treatment with NSAIDs, muscle relaxants, physiotherapy, and dietary modifications was instituted. Despite 45 days of follow-up, the patient experienced persistent pain, trismus, and progressive masticatory dysfunction. Open reduction and internal fixation (ORIF) using the Al-Kayat approach successfully restored mandibular function. Even after initial conservative management, persistent functional limitations should prompt reassessment. Late surgical intervention remains a safe and effective option, particularly when muscle-related dysfunction is present. The Al-Kayat approach provides excellent exposure with minimal complications, enabling full functional recovery.

Combined transconjunctival and transcaruncular approach with multiple sheet implantation for three-dimensional reduction of concomitant medial and inferior orbital wall fracture.

Repairing fractures of the orbital wall and floor remains a complex challenge due to the intricate anatomy of the orbit and the limited visibility during surgery. With the advancement of digital technologies, tools such as DICOM (Digital Imaging and Communications in Medicine) now allow the creation of virtual mirrored models of the unaffected orbit, which can greatly assist in surgical planning and reconstruction. This study aimed to evaluate the accuracy of orbital wall reconstruction using patient-specific implants (PSIs) versus prebent titanium mesh. A single-blind randomized controlled clinical trial was carried out on 28 patients with unilateral orbital fractures, who were randomly divided into two equal groups. Group I underwent orbital wall reconstruction using prebent titanium mesh, while Group II received titanium PSIs. Clinical and radiographic evaluations were carried out at 1 week, 1 month, and 3 months postoperatively to evaluate enophthalmos, ocular motility, diplopia, and the precision of orbital volume restoration. The mean postoperative orbital volume was 27.48 ± 1.324 cm³ in Group I and 25.62 ± 1.492 cm³ in Group II. The difference in orbital volume between the reconstructed and intact orbit was significantly smaller in the PSI group (0.6543 ± 0.2767 cm³) compared to the pre-bent mesh group (1.666 ± 0.3884 cm³; p < 0.05). Patient-specific titanium implants significantly improved the accuracy of orbital volume restoration, particularly in cases involving large defects. Compared to pre-bent titanium mesh, PSIs reduced the need for revision surgery and offered superior volumetric outcomes. In contrast, prebent titanium mesh still provided satisfactory results for isolated single wall fractures and is likely to be cost-effective. This trial was retrospectively registered at ClinicalTrials.gov on March 05, 2024, under the registration number NCT06294535.

ABSTRACTTransorbital penetrating intracranial injury (TOPI) is a rare form of traumatic brain injury, often caused by high‐velocity projectiles. However, non‐missile penetrating injuries, particularly from wooden foreign bodies, are uncommon and pose diagnostic and therapeutic challenges due to their radiolucency and high risk of infection. We report the case of a 58‐year‐old Nepali male who sustained a TOPI after falling from a tree, with a wooden foreign body penetrating his right orbit and extending intracranially. The patient presented 6 days post‐injury with persistent pain and bleeding but no neurological deficits. Imaging revealed a comminuted fracture of the superomedial orbital wall with intracranial extension, an intraorbital foreign body, and vascular compromise in the anterior cerebral artery (ACA) territory. Given the intracranial extension and vascular involvement, a multidisciplinary approach involving neurosurgery and ophthalmology was employed. The foreign body was successfully removed via a medial orbitotomy, and the patient was managed with broad‐spectrum antibiotics. His postoperative course was uneventful, with no long‐term complications. TOPI involving wooden foreign bodies presents diagnostic difficulties due to their variable CT attenuation and potential to mimic pneumocephalus. MRI is often required for definitive diagnosis, but in resource‐limited settings, a combination of clinical evaluation and CT with angiography can guide management. Early surgical removal and infection control are critical for a favorable outcome. Various surgical approaches, including orbitotomy, transcranial, and transnasal endoscopic techniques, should be considered based on foreign body location and extent. This case underscores the importance of early recognition, multimodal imaging, and timely surgical intervention in managing TOPI. Despite the high‐risk nature of such injuries, meticulous planning and prompt treatment can lead to excellent functional and neurological recovery.

Objectives: Orbital wall fractures constitute approximately 85% of orbital traumas requiring hospitalization and nearly 40% of all craniofacial injuries. These fractures are typically classified according to the anatomical structures involved. This study aimed to assess the incidence and morphological patterns of orbital fractures in patients with head injuries, using computed tomography (CT) imaging to enhance diagnostic precision. Materials and Methods: This prospective observational study was conducted at a tertiary care institution and included 508 patients presenting with head injuries. The study focused on the frequency and types of orbital fractures as visualized through CT imaging, along with associated ocular and intracranial injuries. High-resolution CT scans (1.5–3 mm slice thickness) of the orbit and brain were obtained. Comprehensive ocular examinations were performed using slit lamp biomicroscopy and indirect ophthalmoscopy. Fractures were anatomically categorized based on CT findings, and traumatic brain injury (TBI) was evaluated in relation to the Glasgow Coma Scale. Results: Of the 508 patients, 80.4% were male. Road traffic accidents (RTAs) were responsible for 99% of the orbital fractures. The most frequently affected age group was 20–30 years, accounting for 38% of cases. Orbital fractures were identified in 153 patients (30%), with multiple wall fractures showing a strong association with TBI, present in 86% of those cases. The naso-orbito-ethmoid region was the most commonly involved fracture site. Subconjunctival hemorrhage was the most prevalent ocular finding. Zygomatico-orbital complex fractures were the most frequently observed isolated fractures, especially among patients with concurrent TBIs. Conclusion: Orbital fractures continue to represent a substantial source of morbidity among patients with head trauma, particularly in the setting of high-velocity mechanisms such as RTAs. Our study reinforces the strong association between multi-wall orbital fractures and the concomitant occurrence of both ocular injury and TBI, highlighting the intricate anatomical and functional interdependence of the orbit and neurocranial structures. Our study findings suggest that naso-orbito-ethmoid region fracture, due to their anatomical complexity and frequency, may serve as a clinical marker for more severe concomitant injuries. These findings underscore the necessity of a multidisciplinary management paradigm – one that brings together the expertise of neuro-ophthalmologists, neurosurgeons, maxillofacial surgeons, and neurologists – to ensure timely diagnosis, risk stratification, and coordinated care. Early recognition and intervention are paramount, not only to preserve visual function but also to mitigate the long-term neurological and esthetic sequelae inherent to complex craniofacial trauma.

Objective: To analyze the clinical features of patients with traumatic optic neuropathy (TON) and to explore its clinical patterns and treatment outcomes. Methods: A retrospective analysis was conducted on data from 323 patients (334 eyes) with TON, who were treated in the Department of Otorhinolaryngology Head and Neck Surgery, the Affiliated Hospital of Qingdao University from April 1999 to October 2024. Among these patients, 288 were male and 35 were female, with ages ranging from 4 to 70 years. All patients were followed up for a period of 6 to 24 months, with the final follow-up visual acuity recorded as the ultimate visual outcome. The visual acuity evaluation criteria were classified into five levels: no light perception, light perception, hand movement in front of the eye, counting fingers at 1 meter, and "chart-visible acuity". A treatment outcome was deemed effective if the post-treatment visual acuity improved by one level or more compared to pre-treatment, or if the chart-visible acuity improved by two lines or more on the logMAR chart. The clinical characteristics of patients, causes of injury, complications, treatment methods, and changes in visual acuity before and after treatment were summarized. Logistic regression analyses were performed to identify the influencing factors affecting treatment efficacy. Results: TON occurred mostly in young (215/323, 66.56%) males (288/323, 89.16%), the majority of patients came from villages and towns (236/323, 73.07%). Traffic accidents (232/323, 71.83%) remained the main etiology. Most patients had craniofacial injuries and other bodily injuries. The effective rate of vision improvement was 50.30% (168/334). Multiple logistic regression analyses identified that residual vision (light perception or better) at presentation (OR=3.26, P<0.001) and receiving treatment within 7 days after injury (OR=2.04, P=0.008) were protective factors on visual acuity recovery, while the presence of orbital wall fracture was a risk factor for visual acuity recovery (OR=0.26, P<0.001). Additionally, undergoing surgical treatment was a protective factor for visual improvement in patients with no light perception (OR=2.94, P=0.007). For patients with residual vision at presentation, orbital wall fracture was a significant risk factor (OR=0.28, P=0.009). Conclusions: TON is more prevalent in young males and is primarily caused by traffic accidents, leading to a poor prognosis. Timely medical intervention following injury significantly influences prognostic outcomes. Early surgical intervention (within 7 days) is recommended, particularly for patients with no light perception at presentation.

Entrapment of the lateral rectus muscle with associated oculocardiac reflex in pediatric facial trauma: A case report

Background: Medial orbital wall fractures with extraocular muscle entrapment represent a significant but less common variant of orbital trauma compared to floor fractures. These injuries pose a diagnostic and management challenge, with the potential for severe, long-term functional deficits and life-threatening systemic complications if not addressed promptly. This report details a case of medial rectus muscle entrapment complicated by a concurrent posterior segment injury. Case presentation: A 21-year-old male presented to the emergency department following a motorcycle accident, sustaining blunt trauma to his left eye. He reported an acute onset of blurred vision and binocular diplopia. Ophthalmic examination revealed a visual acuity of 20/80 in the left eye. There was a manifest esotropia and a profound abduction deficit, with marked restriction of movement on attempted lateral, superolateral, and inferolateral gaze. The forced duction test was positive, confirming mechanical restriction. Funduscopy identified significant retinal hemorrhages. A maxillofacial computed tomography scan confirmed a comminuted fracture of the left medial orbital wall (lamina papyracea) with clear evidence of medial rectus muscle entrapment within the fracture fragments. The patient underwent urgent surgical intervention involving exploration of the medial orbit, careful release of the incarcerated medial rectus muscle, and anatomical reconstruction of the wall with a titanium mini-plate. Intraoperative forced duction testing confirmed complete resolution of the mechanical restriction. Postoperatively, the patient showed free passive ocular motility, although active movement was recovering, and the retinal injuries required continued observation. Conclusion: This case underscores the critical importance of maintaining a high index of suspicion for medial rectus entrapment in patients presenting with post-traumatic diplopia and an abduction deficit. A thorough clinical examination, particularly the forced duction test, is paramount and often more definitive than imaging alone. Urgent surgical decompression and reconstruction are imperative to prevent permanent strabismus from muscle ischemia and to mitigate the risk of the oculocardiac reflex. Furthermore, the presence of concomitant intraocular injuries, such as traumatic retinopathy, must be diligently assessed as they significantly impact the final visual prognosis.

Background:Pediatric ocular trauma is the leading cause of monocular blindness and comprises 7% of injuries. Prompt treatment is mandatory but may vary by facility type. This study investigates factors influencing treating facility, comparing level 1 and level 2 verified pediatric trauma centers (PTC) with other trauma centers (non-PTC).Methods:The National Trauma Data Bank 2019 was examined for ages 1 to 18 years with ICD10 ocular trauma diagnoses. Descriptive statistics compared patients of PTCs versus non-PTCs. Logistic regression was used to examine the association between treatment at PTC and type of ocular injury, adjusting for age, race, ethnicity, sex, socioeconomic status, injury severity score (ISS), and suspicion of child abuse. A second logistic regression model evaluated the association between direct transfer from emergency department (ED) to operating room (OR) and injury type, and adjusted for confounders. End points included surgical intervention and discharge disposition.Results:Of 645 patients with ocular trauma, 67.6% were male, 14% were Hispanic. Median age was 10 years at PTC versus 13 years non-PTC (P=0.001). Two hundred eighty-two (44%) were treated in PTC. There was no difference in proportion with ISS >15 or mechanism of ocular injury. One hundred forty-six patients were taken directly to OR from ED, with no difference between PTC and non-PTC. The most common diagnoses for patients taken directly to OR were eye or adnexa contusion and laceration, globe or adnexal open wound, and orbital wall fractures. There was no association between type of injury and treatment at PTC versus non-PTC. 71 abuse reports were noted, of which 23 (32.4%) were treated in PTCs, compared with 48 (67.6%) treated at non-PTCs (P=0.036). Logistic regression examination of direct to OR admission revealed only Hispanic ethnicity was significantly associated (P=0.03).Conclusions:Pediatric ocular traumas are treated at both PTCs and non-PTCs at a similar rate and level of severity. Younger children and more Hispanic children tended to be treated at PTCs. More abuse reports were noted in non-PTCs. Hispanic ethnicity was noted to be inversely associated with direct transfer to OR from ED. This study should form the background from which evaluation of outcomes can begin, to clarify the optimal treatment pathways for pediatric ocular trauma, and if there are disparities in outcomes.Type of study:Retrospective cross-sectional study.