Orbital Wall Fracture Research Articles

Patterns and prognosis of commotio retinae in orbital wall fractures.

Purpose:Orbital wall fractures are a significant cause of ocular injury in trauma and are associated with posterior segment pathology. This study aims to characterize patterns and prognosis of commotio retinae following orbital wall fracture.Methods:This study is a retrospective analysis of 294 orbital wall fractures diagnosed by computed tomography imaging from August 2015 to October 2016 at a Level 1 trauma center. Dilated funduscopic exams were assessed for acute posterior segment pathology, focusing specifically on commotio retinae (N = 38). These were compared with patients with no traumatic retinal findings (N = 253) to indicate statistically significant differences in the mechanism of injury, fracture pattern, subjective symptoms, radiologic and exam findings, and acute interventions.Results:Commotio was most commonly associated with assault (60.5%, p = 0.004) in a younger patient population, whereas normal retinal exams were more likely after falls from standing (24.1%, p = 0.022). Half of all commotio was found inferiorly and most commonly occurred in medial or inferior wall fracture. Patients with commotio were more likely to have motility deficits (29.7%, p = 0.049) with clinical evidence of entrapment (13.2%, p < 0.001), requiring acute operative repair (15.8%, p = 0.005). Inferior wall fracture was associated with 19.4% surgical intervention in commotio as compared with those with normal funduscopic exams (6.1%, p = 0.012). All patients with follow-up had resolution of commotio and best-corrected visual acuity of 20/25 or better.Conclusion:Retinal pathology is not infrequent in orbital wall fractures. Inferior wall fracture was associated with 19.4% surgical intervention in commotio as compared to those with normal funduscopic exams (6.1%, p = 0.012). A high index of suspicion and thorough investigation is warranted in evaluating these patients.

Factors Affecting Persistent Diplopia after Surgical Repair of Isolated Inferior Orbital Wall Fracture

Factors Affecting Persistent Diplopia after Surgical Repair of Isolated Inferior Orbital Wall Fracture

Reduction and Fixation of Medial Orbital Wall Fractures via the Transconjunctival Endoscopic Approach Assisted by a Navigation System

Reduction and Fixation of Medial Orbital Wall Fractures via the Transconjunctival Endoscopic Approach Assisted by a Navigation System

A Case of Corneal Chemical Injury by High-dose Ethanol during Orbital Wall Fracture Repair

A Case of Corneal Chemical Injury by High-dose Ethanol during Orbital Wall Fracture Repair

New anthropometric data for preoperative planning in orbital wall fracture treatment: the use of eyelid drooping.

BackgroundThe presence of enophthalmos is an important determinant in the decision of orbital wall fracture surgery. We proposed eyelid drooping as a new anthropometric diagnostic measure and analyzed whether eyelid drooping is associated with enophthalmos.MethodsThis retrospective study was performed from January 2014 to December 2016. A total of 75 patients with blowout fractures were studied. One experimenter measured the degree of enophthalmos using a Hertel exophthalmometer at 1 week after trauma and at 3 months after surgery. The height change of the upper eyelid was measured using the marginal reflex distance (MRD) on both sides, and the degree of eyelid drooping was calculated by comparing the two lengths. We analyzed statistically the correlation between enophthalmos and eyelid drooping. ResultsWe found a highly significant correlation between the degree of enophthalmos and the reduction rate of MRD (RRM, as an indicator of eyelid drooping) at 1 week after trauma (r = 0.845). Approximately 2.0 mm of enophthalmos was associated with a 30.8% reduction in MRD on the affected side as compared with the normal side. At 3 months after surgery, patients showed improved eyelid appearance, with a moderate association between enophthalmos and RRM.ConclusionWe demonstrated that the degree of enophthalmos, measured using an exophthalmometer, is associated with a change in the height of the upper eyelid. Thus, upper eyelid drooping can be used as another indicator for orbital wall fracture surgery. Compared with conventional methods, measurements of eyelid drooping are easy to perform, offering a great advantage and understanding to the patient.

Reconstruction of the orbital wall using superior orbital rim osteotomy in a patient with a superior orbital wall fracture

BackgroundFractures of the orbital wall are mainly caused by traffic accidents, assaults, and falls and generally occur in men aged between 20 and 40 years. Complications that may occur after an orbital fracture include diplopia and decreased visual acuity due to changes in orbital volume, ocular depression due to changes in orbital floor height, and exophthalmos. If surgery is delayed too long, tissue adhesion will occur, making it difficult to improve ophthalmologic symptoms. Thus, early diagnosis and treatment are important. Fractures of the superior orbital wall are often accompanied by skull fractures. Most of these patients are unable to perform an early ocular evaluation due to neurosurgery and treatment. These patients are more likely to show tissue adhesion, making it difficult to properly dissect the tissue for wall reconstruction during surgery.Case presentationThis report details a case of superior orbital wall reconstruction using superior orbital rim osteotomy in a patient with a superior orbital wall fracture involving severe tissue adhesion. Three months after reconstruction, there were no significant complications.ConclusionIn a patient with a superior orbital wall fracture, our procedure is helpful in securing the visual field and in delamination of the surrounding tissue.

Clinico-radiological features and treatment outcomes in children with traumatic orbital subperiosteal hematoma

To study the clinical findings, imaging features, and treatment outcomes in children diagnosed with traumatic orbital subperiosteal hematoma (OSpH). The medical records of eligible OSpH children treated either via needle aspiration or open surgical drainage were reviewed retrospectively. Three anatomical factors (inferior globe displacement, superior orbital sulcus fullness, extraocular movements) and two functional parameters (visual acuity, pupillary reactions) were used to determine overall success. A total of 10 children (mean age, 6.8years; 8 males) were included. All had a history of blunt trauma, unilateral presentation, inferior globe displacement, fullness of superior orbital sulcus, and raised retrobulbar resistance. Diminution of vision and restricted elevation was noted in 7 children, and 4 had a relative afferent pupillary defect. Computed tomography (CT) revealed superior OSpH in all 10 children and, additionally, orbital wall fracture in 4. Needle aspiration of the OSpH was performed in 8 children; 2 underwent open surgical drainage. At a mean follow-up of 8.5months, all children showed satisfactory improvement in both anatomical and functional parameters:1 child had a persistent nebulomacular corneal opacity, and 1 had minimal upper eyelid edema. A high index of suspicion, appropriate radiology (CT of orbits), and early management through needle aspiration of OSpH may help in early and satisfactory anatomical and functional outcomes.

Orbital wall restoring surgery with resorbable mesh plate.

BackgroundOrbital resorbable mesh plates are adequate to use for isolated floor and medial wall fractures with an intact bony buttress, but are not recommended to use for large orbital wall fractures that need load bearing support. The author previously reported an orbital wall restoring surgery that restored the orbital floor to its prior position through the transnasal approach and maintained temporary extraorbital support with a balloon in the maxillary sinus. Extraorbital support could reduce the load applied on the orbital implants in orbital wall restoring surgery and the use of resorbable implants was considered appropriate for the author’s orbital wall restoring technique.MethodsA retrospective review was conducted of 31 patients with pure unilateral orbital floor fractures between May 2014 and May 2018. The patients underwent transnasal restoration of the orbital floor through insertion of a resorbable mesh plate and maintenance of temporary balloon support. The surgical results were evaluated by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values.ResultsThe OVR decreased significantly, by an average of 6.01% (p< 0.05) and the preoperative and postoperative Hertel scale measurements decreased by an average of 0.34 mm with statistical significance (p< 0.05). No complications such as buckling or sagging of the implant occurred among the 31 patients.ConclusionThe use of resorbable mesh plate in orbital floor restoration surgery is an effective and safe technique that can reduce implant deformation or complications deriving from the residual permanent implant.

Complex Orbital Fractures: Three-Dimensional Planning and Combined Surgical Approach.

Nowadays the development of diagnostic imaging, surgical techniques, alloplastic materials, and surgical instruments has made possible a more accurate management of orbital fractures. The aim of the present study was the management of orbital fractures and the solution of particular cases. The use of high-resolution computed tomography makes possible to gain a better understanding of the complex orbit anatomical structure. Also endoscopy is a valid alternative for medial orbital wall fractures treatment. It gives high control of the fracture site and its reduction. When this technology is combined with 3-dimensional (3D) reformatted images, it allows us to reconstruct more accurately the orbital defects. The authors present their experience in complex orbital fractures treated with the aim of the 3D navigation using a preformed orbital titanium plate. Endosopical approach was used to control plate positioning.

Combined Access for the Treatment of Medial Orbital Wall Fracture: Subciliary and Upper Eyelid Sulcus Incisions.

The present study presents a new surgical approach to treat medial orbital wall fractures, that is, the combined transcutaneous access through subciliary and upper eyelid sulcus incisions. The study performed the retrospective analysis of medical records belonging to 14 consecutive patients with medial orbital wall fracture, who were treated in the Plastic Surgery Division at Federal University of São Paulo, from 2005 to 2013, through the combination of subciliary and upper eyelid sulcus incisions to access the fracture foci. The mean age of the patients was 35.4 years, ranging from 8 to 66 years. Seven out of the 14 patients were women. Ten patients had fractures in the medial and inferior walls, whereas 4 patients had isolated medial wall fracture. Diplopia was found in all cases. Six patients had some type of extraocular muscle limitation. A computed tomography of the face was performed in the postoperative period to assess the orbital contour and the correct position of the grafts, whenever applicable. The patients were assessed for diplopia, enophthalmos, and scar quality. Four patients (28.6%) kept on showing diplopia at supraversion, whereas 2 patients (14.2%) evolved to enophthalmos. There was no need of reoperating the patients to reposition the grafts or the absorbable plaque. No patient evolved to ectropion or apparent scarring. The combined transcutaneous access through subciliary and upper eyelid sulcus incisions provides ample operative field, rapid exposure of the fracture foci, and adequate wall reconstruction. It can also present inconspicuous scar.

Reconstruction of medial orbital wall using a retrocaruncular approach

The purpose of the study was to analyze and describe the retrocaruncular approach to access medial orbital wall.A retrospective analysis was performed in patients referred for the treatment of orbital fractures between January 1st 2011 and July 31st 2017. The study included patients over 18 years old with isolated fractures of the medial orbital wall or combined with the orbital floor who underwent a transconjunctival approach with retrocaruncular extension and lateral canthotomy, and with a minimum follow-up of 6 months. Patients with fractures to the roof and/or lateral orbital wall were excluded.From a total of 319 orbits, 30 medial wall fractures were treated using a retrocaruncular approach, transconjunctival extension and lateral canthotomy. 7 of them were pure medial wall fractures and 23 were combined with orbital floor. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Only one patient developed a conjunctival granuloma in relation to the caruncle. No others patients had complications.This study concluded that this approach is a successful access for surgical treatment of medial orbital wall fractures because of their broad visibility without damaging structures, allowing adequate orbital reconstruction and excellent aesthetic results.

Antral Wall Approach for Reconstruction of Orbital Floor Fractures Using Anterior Maxillary Sinus Bone Grafts

Isolated orbital wall fractures account for 4% to 16% of all facial fractures. Even a modest change in the position of the bony walls can have a significant impact on orbital volume and globe position. Alloplastic materials or autogenous bone grafts such as the antral maxillary wall can be used to reconstruct small- to medium-size orbital fractures. The main advantage of an antral wall graft is the intraoral approach with minimal morbidity. Nine patients underwent repair of orbital floor fractures using the extraoral and the intraoral antral wall approach. The patients underwent preoperative computed tomography imaging and a minimum of 1 year follow-up. The size of the defects ranged from 0.5 to 1.4 cm. Two patients experienced minor immediate postoperative complications; infraorbital hypoesthesia. On follow-ups, none of our patients suffered from ocular movement restrictions or complications regarding the maxillary antral wall approach. The use of harvested bone grafts from the anterolateral wall of the maxillary sinus is a promising approach for the reconstruction of small- to mid-size orbital floor defects with minimal complications and excellent cosmetic and functional results.

Outer Table Frontal Bone Fracture: When Need Surgical Intervention?

Frontal bone fracture is a common facial bone fracture which commonly involved the outer table part. Most of the time outer table fracture is treated conservatively. However, when there is involvement of orbital wall fracture, as well as entrapment of extraocular muscle, surgical intervention via open reduction and internal fixation is needed. We described a case of outer table frontal bone fracture with left orbital roof fracture complicated with superior rectus muscle entrapment which was successfully treated via open reduction and internal fixation.International Journal of Human and Health Sciences Vol. 02 No. 03 July’18. Page : 167-169

Preforming of polydioxanone sheets for orbital wall fractures – A technical note

IntroductionPolydioxanone (PDS) sheets are commonly used in the treatment of orbital wall fractures. A potential drawback of PDS is that it may be difficult to adapt to the anatomy of the orbital walls. Therefore a study was conceived to test the feasibility of preforming PDS sheets. Material and methodsPDS sheet material was water-heated and preformed using a template based on a statistical anatomical model. Then the deformed sheet was cooled, stored and compared to the original model to investigate post-deformation changes. ResultsPDS sheet material could easily be deformed using a mould. No significant post-cooling shape changes were noticed. ConclusionsPDS sheet material can be preformed into complex geometric shapes. This could be a benefit in the treatment of orbital wall fractures.

Endoscopic repair of medial and inferior orbital wall

IntroductionOrbital fractures are common in facial and orbital trauma, with orbital floor and medial wall commonly affected. ObjectiveThe aim of this study was to evaluate the outcomes of endoscopic repair of medial and inferior orbital wall fracture. DesignA case series with chart review (observational study), the study was conducted in academic tertiary care medical centers. MethodsNine patients underwent endoscopic repair of medial and inferior orbital wall fracture between the years May 2013 and August 2016. ResultsSignificant changes in preoperative eye lid ecchymosis, diplopia, enophathalmus, emphysema and facial hypoesthesia. Other postoperative complication of nasal endoscopy (blandness, hemorrhage, infection, exposure, and extrusion of the graft) were absent in all patients. ConclusionsEndoscopic repair of medial and inferior orbital wall fracture using porous polyethylene was an easy and fast approach with satisfactory outcomes with avoiding the external incision.

Immediate and long-term results of unsintered hydroxyapatite and poly L-lactide composite sheets for orbital wall fracture reconstruction

Bone defect reconstruction in orbital wall fractures with absorbable alloplastic such as the unsintered hydroxyapatite and poly L-lactide composite (u-HA/PLLA) system is gaining popularity. The u-HA/PLLA material has osteoconductive and osteosynthetic properties. However, quantitative, long-term outcome data after the use of u-HA/PLLA for orbital wall fractures are lacking. We retrospectively analyzed 115 patients who underwent surgical repair of orbital wall fractures with a u-HA/PLLA sheet from 2011 to 2016. A chart review was performed, and the time-dependent changes at fracture sites were assessed by imaging. The immediate postoperative and the latest follow-up bony orbital volumes of the affected side were compared. Seventy patients were eligible for this study (mean age, 44.6 ± 22.1 years; 48 men and 22 women; mean follow-up period, 29.7 ± 12.8 months). Except for one case of hematoma, there were no postoperative wound complications. Of the 70 patients, 10 had postoperative diplopia and 2 had enophthalmos; these conditions were presumably caused by the extension and severity of the fracture. Satisfactory reduction in the entire orbital wall, without pathological changes, was demonstrated. There were no significant differences in the mean bony orbital volumes of the affected side immediately after surgery (24.774 ± 3.092 cm3) and at the latest follow-up (24.749 ± 3.205 cm3) (p = 0.756). The u-HA/PLLA sheet is useful for orbital wall fracture reconstruction because of its desirable handling characteristics, initial mechanical strength, long-term maintenance of structural stability, radiopacity, and few associated complications. Future randomized controlled trials need to be performed to compare u-HA/PLLA with other conventional materials.

The advantages of advanced computer-assisted diagnostics and three-dimensional preoperative planning on implant position in orbital reconstruction

ObjectiveAdvanced three-dimensional (3D) diagnostics and preoperative planning are the first steps in computer-assisted surgery (CAS). They are an integral part of the workflow, and allow the surgeon to adequately assess the fracture and to perform virtual surgery to find the optimal implant position. The goal of this study was to evaluate the accuracy and predictability of 3D diagnostics and preoperative virtual planning without intraoperative navigation in orbital reconstruction. MethodsIn 10 cadaveric heads, 19 complex orbital fractures were created. First, all fractures were reconstructed without preoperative planning (control group) and at a later stage the reconstructions were repeated with the help of preoperative planning. Preformed titanium mesh plates were used for the reconstructions by two experienced oral and maxillofacial surgeons. The preoperative virtual planning was easily accessible for the surgeon during the reconstruction. Computed tomographic scans were obtained before and after creation of the orbital fractures and postoperatively. Using a paired t-test, implant positioning accuracy (translation and rotations) of both groups were evaluated by comparing the planned implant position with the position of the implant on the postoperative scan. ResultsImplant position improved significantly (P < 0.05) for translation, yaw and roll in the group with preoperative planning (Table 1). Pitch did not improve significantly (P = 0.78). ConclusionThe use of 3D diagnostics and preoperative planning without navigation in complex orbital wall fractures has a positive effect on implant position. This is due to a better assessment of the fracture, the possibility of virtual surgery and because the planning can be used as a virtual guide intraoperatively. The surgeon has more control in positioning the implant in relation to the rim and other bony landmarks.

Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury

ObjectiveThe detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI. MethodsThis retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients. ResultsA total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06–8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08–9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01–1.04; P = 0.002) were independent risk factors for concomitant intracranial injury. ConclusionsEmergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.

Is there more to the clinical outcome in posttraumatic reconstruction of the inferior and medial orbital walls than accuracy of implant placement and implant surface contouring? A prospective multicenter study to identify predictors of clinical outcome

PurposeReconstruction of orbital wall fractures is demanding and has improved dramatically with the implementation of new technologies. True-to-original accuracy of reconstruction has been deemed essential for good clinical outcome, and reasons for unfavorable clinical outcome have been researched extensively. However, no detailed analysis on the influence of plate position and surface contour on clinical outcome has yet been published. Materials and methodsData from a previous study were used for an ad-hoc analysis to identify predictors for unfavorable outcome, defined as diplopia or differences in globe height and/or globe projection of >2 mm. Presumed predictors were implant surface contour, aberrant implant dimension or position, accuracy of reconstructed orbital volume, and anatomical fracture topography according to the current AO classification. ResultsNeither in univariable nor in multivariable regression models were unfavorable clinical outcomes associated with any of the presumed radiological predictors, and no association of the type of implant, i.e., standard preformed, CAD-based individualized and non−CAD-based individualized with its surface contour could be shown. ConclusionThese data suggest that the influence of accurate mechanical reconstruction on clinical outcomes may be less predictable than previously believed, while the role of soft-tissue−related factors may have been underestimated.

Clinical analysis of complications of contusion of eyeball and coexisted orbital blowout fracture

Objective To analyse the clinical features of ocular complications due to contusion of eyeball and coexisted orbital blowout fracture caused by ocular contusion. Methods The data of 134 eyes of 132 patients of ocular contusion were retrospectively analyzed.The age, gender, cause and ocular complications were recorded. The patients received CT, according to whether combind with orbital wall fracture they were divided into two groups: the contusion of eyeball group and the orbital blowout fracture group. Results The ratio of male to female was 4.74∶1, the most age was 21-50 years.The ocular complication occurred in 67 eyes (73.63%) in the contusion of eyeball group and 18 eyes (41.86%) in the orbital blowout fracture group.The ocular complications in the ocular contusion of eyeball group were more than those in the orbital blowout fracture group (P=0.000). Traffic accident was the highest incidence of ocular complication in 38 eyes of 51 eyes (74.51%). Conclusion The ocular contusion are mainly young and middle-aged males. Ocular complications in the simple contusion of eyeball group are more than those in the orbital blowout fracture group, and traffic accident is the main cause of ocular complication. Key words: Contusion, ocular; Complications, ocular; Contusion, eyeball; Orbital blowout fracture