Orbital Wall Fracture Research Articles

Customized and Navigated Primary Orbital Fracture Reconstruction: Computerized Operation Neuronavigated Surgery Orbital Recent Trauma (CONSORT) Protocol.

Combined orbital medial wall and floor fractures and large isolated orbital floor fractures commonly require surgical treatment due to the high probability of diplopia and enophthal-mos. Primary reconstruction of these orbital fractures requires a high-level surgeon with a great amount of technical surgical skill. The use of novel technology can greatly improve the accuracy of reconstruction and achieve satisfactory clinical outcomes. Hence, the authors aimed to present our findings and overall experience with respect to extensive floor and medial wall orbital fracture reconstruction according to the Computerized Operation Neuronavigated Surgery Orbital Recent Trauma (CONSORT) protocol, a workflow designed for the primary reconstruction of orbital fractures with customized mesh and intraoperative navigation. A total of 25 consecutively presenting patients presenting with unilateral extensive orbital floor fractures and orbital floor and medial wall fractures were treated following the CONSORT workflow from January 2017 to March 2020. Fractures were surgically treated with a customized implant and intraoperative navigation. Patients underwent surgery within 14 days of the trauma injury. Preopera-tive and postoperative functional and aesthetic outcomes are described herein. All fractures were successfully reconstructed. Postoperatively, all 19 patients with preoperative diplopia reported the resolution of diplopia. Enophthalmos resolved in 18/20 cases. No patients had major complications during follow-up. Thus, the authors conclude that the CONSORT protocol introduced by the authors is an adaptable and reliable workflow for the early treatment of orbital fractures and can clearly optimize functional and aesthetic outcomes, reduce costs and intensive time commitments, and make customized and navigated surgery more available for institutions.

Improving Clinical Outcomes of Orbital Volume Restoration Using Peri-Operative Diagnostic Tools in Management of Orbital Fractures - A Prospective Study

Introduction: Accurate evaluation of change in orbital volume occurring due to trauma is of paramount importance to achieve an optimal final outcome. Thus, the purpose of this study was to assess and evaluate the orbital volume both radiological and clinical means for accurate surgical correction. Aim: To assess the final surgical outcome using standardized clinical and radiological tools perioperatively to restore orbital volume in patients with orbital wall fractures. Materials and Methods: A prospective interventional study of patients with unilateral orbital wall fractures which was carried out for 24 months. A thorough clinical evaluation and ophthalmological assessments including visual acuity, field of vision was performed. All patients had HRCT for volumetric assessment and assessed clinically for enophthalmos using Hertel exophthalmometer. Based on the level of enophthalmos and orbital volume change, treatment plan was formulated. Intraoperatively Hertel exophthalmometer is used to correct the predetermined enophthalmos. Postoperatively the patients are followed-up at designated intervals to assess the surgical outcome. RESULT: Road Traffic Accident (RTA) was the common etiology of orbital fractures which accounts for 84.1% (n=53) and the most common clinical sign was enophthalmos which accounted for 76.2% (n=48). The mean and standard deviation of orbital volume is 35.20 ± 4.21 and change in orbital volume is 4.29±2.76. The mean and standard deviation were calculated for all patients in different time intervals. The result showed a statistically significant difference in pre-operative phase, intra-operative phase and it maintained throughout the postoperative phase. CONCLUSION: In our study we have found that meticulous preoperative and intraoperative tools to assess in orbital reconstruction gives a desired surgical outcome. Hertel exophthalmometer and HRCT based 3D reconstructed volumetric analysis can be an excellent tool to evaluate anteroposterior globe malposition and volume change.

A Case of Orbital Medial Wall Fracture, with Missing Rectus Sign, That Showed Postoperative Extraocular Muscle Paralysis

A Case of Orbital Medial Wall Fracture, with Missing Rectus Sign, That Showed Postoperative Extraocular Muscle Paralysis

Role Of Cbct In The Treatment Of Orbital Floor Blow Out Fractures In Children

Background, Aim, and Objectives: Orbital floor blow out fractures are uncommon in children but can present with a dilemma in the Emergency department upon presentation. We collected case reports of 17 cases over a three-year period. The patients were selected from the age group six to 13 years of age with history of trivial blunt orbital trauma. The main complaint was mild pain in the eye upon presentation. Five patients were having clinical presentation of oculo-cardiac reflex. The suspected patients underwent Cone Beam CT of the midface with multiplanar cone beam reconstruction which confirmed the diagnosis of orbital floor fractures with trap door defect or minimal displacement and in a few cases inferior rectus entrapment. Orbital floor trapdoor fractures have oblivious features upon presentation and can easily be overlooked if not evaluated managed by expert healthcare providers which can lead to significant morbidity and even mortality in patients with oculocardiac reflex. Cone Beam CT of mid face with multiplanar reconstruction is the standard of care in the diagnosis and management of white eyed blow out orbital floor fractures in the provision of evidenced based healthcare practice. Methodology: This is a retrospective cohort study to evaluate the results of pediatric age group with trapdoor and blow out orbital floor fractures who underwent CBCT for the diagnosis and further management. Seventeen cases were selected who were in the age group between 6 to 13 years.12 cases underwent surgery for orbital floor exploration and nine were having inferior rectus muscle entrapment which was released. Five patients were managed non surgically. Result: One patient disappeared in this group during one-year post-operative follow up. No residual defect was found in the remaining sixteen patients. Cone beam Computer tomography with multiplanar reconstruction should be the standard of care for the diagnosis and treatment of blow out and trapdoor orbital fractures. Strength and limitations: Although this study is of a limited number of pediatric patients, but it highlights the significance of CBCT in the management of trapdoor and blow out orbital floor fractures in children. Further studies are needed to elaborate the utilization of CBCT in the treatment of orbital floor and medial orbital wall fractures. Conclusion: Our study suggests that CBCT has a higher value of specificity and less radiation exposure in the diagnosis of orbital fractures in pediatric age group when there is isolated orbital or mid face trauma, and CT brain is not recommended. Cone Beam CT with multiplanar reconstruction is considered the standard of care in the diagnosis of white eyed blow out orbital floor fractures in the provision of evidenced based healthcare practice. Perioperative CBCT and navigation should be universalized to achieve the best outcome.

Lateral and superior orbital wall autodecompression in a patient with thyroid eye disease

Orbital autodecompression was reported previously in thyroid eye disease (TED). The reports principally focused on spontaneous orbital wall fractures or medial and inferior orbital wall expansion. This report introduces a 66-year-old man, a known case of TED with distinctive signs of lateral and superior orbital wall autodecompression on preoperative imaging.

Clinical Profiles and Surgical Outcomes of Strabismus Following Orbital Wall Fractures: A Large Cohort From a Tertiary Eye Care Center.

To evaluate the demographic details, clinical presentation, and surgical outcomes in patients presenting with strabismus following orbital wall fractures. A retrospective review was conducted over a 6-year period on 347 consecutive patients with strabismus who presented after orbital wall fractures. The patients were evaluated for their demographic data, clinical presentation, and profiles, management, complications, and outcomes of strabismus. Strabismus following orbital wall fractures was noted in 347 patients: 87.03% were men (n = 302) and 12.97% were women (n = 45). Fracture of the orbital floor in isolation or in combination with other walls was more frequently noted in 72.3% of patients (n = 251). The resultant strabismus included paralytic, restrictive, or both etiologies. Exotropia was noted most frequently in 25.65% of patients (n = 89), followed by exotropia with hypotropia in 20.75% of patients (n = 72). Ten percent of patients with strabismus (n = 34), who were observed for at least 6 months after injury, underwent surgical correction for strabismus. Preoperative diplopia was observed in 79.41% of patients (n = 27) and persisted after strabismus surgery in 15% of patients (n = 6). A successful outcome regarding the postoperative angle of deviation of 10 prism diopters or less horizontal and/or 5 prism diopters or less of vertical deviation with elimination of diplopia was observed in 41.17% of patients. Strabismus following orbital wall fractures is complex and requires a tailored strategy. The current study found the orbital floor to be more frequently involved in orbital wall fractures. However, the resultant strabismus was a combination of paralytic and restrictive etiologies. [J Pediatr Ophthalmol Strabismus. 2022;59(3):172-179.].

Patient-specific Implants for Orbital Fractures: A Systematic Review.

Orbital fractures are common facial fractures that can be challenging to repair and require careful attention to avoid unacceptable ophthalmic complications. Customized implants that are unique to an individual patient, or patient-specific implants (PSIs), have been increasingly used to repair orbital wall fractures. This systematic review summarizes the current evidence regarding custom-made orbital wall implants. A keyword search of published literature from January 2010 to September 2021 was performed using Ovid MEDLINE, PubMed, and the Cochrane Library databases. Original articles that included more than 3 human subjects with an orbital fracture repaired with a PSI were included. The search results were reviewed, duplicates were removed and relevant articles were included for analysis. Fifteen articles meeting the inclusion criteria. The articles were categorized into 3 separate groups based on the method of PSI fabrication: manual molding of a PSI on a 3D-printed orbital model (53%), directly from a 3D printer (27%), or via a template fabricated from a 3D printer (20%). Three primary postoperative outcomes were assessed: rates of diplopia, enophthalmos, and orbital volume. Postoperative rates of diplopia and enophthalmos improved regardless of the PSI technique, and postoperative orbital volumes were reduced compared with their preoperative state. When PSIs were compared to conventional implants, patient outcomes were comparable. This review of existing PSI orbital implant literature highlights that while PSI can accurately and safely repair orbital fractures, patient outcomes are largely comparable to orbital fractures repaired by conventional methods, and PSI do not offer a definitive benefit over conventional implants.

Factor Influencing Postoperative Enophthalmos After Reconstruction of Orbital Wall Fracture.

To determine factors influencing postoperative enophthalmos after reconstruction of orbital wall fracture. Data of consecutive patients who were diagnosed with unilateral medial or inferior orbital wall fracture from March 2013 to February 2020 were retrospectively reviewed. Forty-three patients were included in this study (24 with medial orbital wall fracture and 19 with inferior orbital wall fracture). Their medical records including Hertel exophthalmometry, preoperative computed tomography (CT) scan, and postoperative CT scan were reviewed. The degree of enophthalmos developed was calculated by measuring exophthalmos before surgery and at 6 months after surgery. Patients were classified into 2 groups depending on whether reduction was good after surgery or not. Data (eg, age, gender, onset, fracture size, and so on) were then compared between these 2 groups. A total of 43 patients were included in the study. Their mean age was 40.1 years. There were 34 (79.1%) males. The mean onset from trauma to surgery was 8.1 days. Insufficient soft tissue reduction was found in 9 patients through postoperative CT scan. Preoperative mean enophthalmos was - 1.70 mm. Postoperative mean enophthalmos was -0.45 mm after 6 months. The mean fracture size was 213.74 mm2. There was no statistically significant difference in enophthalmos at 6 months after surgery regardless whether the reduction was good or not. Enophthalmos at 6 months after surgery was associated with preoperative fracture size and onset. Postoperative enophthalmos development might be associated with preoperative fracture size and onset. Delayed operation in case of large orbital wall fracture might lead to undesired result. Thus, surgeons should keep that in mind.

Initial Management of Orbital Trauma: Is an Ophthalmologic Evaluation Necessary?

BACKGROUND: Orbital fractures may be associated with globe injuries, resulting in delayed ophthalmic complications and visual disturbance. The debate regarding the necessity of ophthalmologic evaluation in the initial management of orbital trauma continues. Therefore, there is a need to establish the rate of ocular injuries associated with orbital fractures. METHODS: A retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed tomography scan analysis at a level 1 trauma center, from 2014 to 2020 was performed. The inclusion criteria were patients 18 years or older with confirmed computed tomography scan diagnosis of orbital fracture and ophthalmology consultation. Patient demographics, injuries, comorbidities, and surgical outcomes were collected. RESULTS: A total of 201 patients with 224 orbital fractures (11.4% bilateral) were included. The mean age at injury was 50.5 ± 25.2 years; 21.9% of patients had an associated neurologic injury at the time of ED evaluation. The most common mechanisms of injury were mechanical fall (41%), occupational injuries (26.9%), and motor vehicle accident (25%). The posterior segment of the eye was most affected (16.1%), followed by the anterior segment (13.4%) and ocular adnexa (13.4%). A significant ocular injury was present in 21.9% of orbital fractures. These included choroidal hemorrhage (6.1%), hyphema (5.4%), retinal hemorrhage (4.5%), retrobulbar hematoma (4%), globe rupture (3.6%), choroidal hemorrhage (1.4%), retinal detachment (1.3%), corneal laceration (0.9%), choroidal rupture (0.4%), macular hemorrhage (0.6%), and retinal tear (0.4%). The mechanism of injury was not associated with an increased risk for a serious ocular injury. The most common ophthalmologic findings on examination were diplopia (30.4%), reduced extraocular movement (9.8%), and periorbital laceration (8.9%). Of all patients, 53.1% presented with one orbital wall fracture, of which, the orbital floor was the most commonly involved (44.2%). Associated facial fractures were found in 68.8% of patients. computed tomography scans showed displaced fracture in 44.6% of orbits, comminution in 45.3% and herniation of orbital contents in 42.9%. On multiple variable analysis, motor vehicle accident (OR = 2.5 [1.4–4.7], P = 0.003) and injury to the posterior segment (OR = 2.6 [1.2–5.8], P = 0.045) were associated with the need of surgical treatment. However, injury to the anterior segment (OR = 3.4 [1.5–8.0], P = 0.028) and ocular adnexa (4.0 [1.6–10.1], P = 0.002) were associated with the need of medical treatment alone. CONCLUSIONS: Our retrospective series demonstrated a 22% incidence of ocular trauma in orbital fractures. There were no association between mechanism of injury and serious ocular trauma. This emphasizes that the management of orbital traumas requires a multidisciplinary approach, including the facial trauma team and ophthalmology.

A STUDY OF PROFILE OF MULTIDETECTOR COMPUTED TOMOGRAPHY IN MAXILLO-FACIAL INJURIES IN A TERTIARY CARE CENTER

Maxillofacial injuries account for a large group of patients in the emergency department in tertiary care hospital, presenting as an isolated injury or a part of poly trauma. Road trafc accidents are the commonest cause of maxillofacial injuries. Such injuries are clinically important as they cause facial disgurement and thus imposing emotional, morbidity and cosmetic dependence. To observe these fractures and decide appropriate management lines, there is a need for imaging aid. The main purpose of imaging guidance is to nd and characterize the fractures and associated injuries. Aim:Study of prole of multi detector computed tomography in maxillo-facial injury in a tertiary care centre. Materials and methods: The cases coming to the emergency department and then forwarded to department of Radiology, MGM medical college and hospital, Aurangabad for CT scan formed the source of the data and were studied in detail. Detailed history of the cases was taken. Written and informed consent were taken for undergoing CT scan examination. Patients were scanned using 16 slice Toshiba acquilion machine. The data was tabulated and observed and conclusions were made. Results: Total 175 number of patient were included in the study and CT scan for maxillo-facial injuries were conducted. Diagnosis of the maxillofacial injuries were done and the fractures were classied according to age, gender, location and its subsets. According to our study 21-30 years of age group was the most common age group to be involved in maxillo-facial injuries. Frequency of maxillo-facial injuries was found to be more in male than female. Maxillo facial injuries occurred mostly due to road trafc accidents. Orbit was seen as the most common bone to be fractured followed by fracture of maxilla bone. Orbital wall fracture happen to be overall most common bone affected amongst all the other facial bones.

Diplopia after Isolated Inferior Orbital Wall Fracture According to the Computed Tomography Findings

Purpose: To investigate the postoperative changes in diplopia and evaluate factors that affect diplopia after isolated inferior orbital wall fracture.Methods: A retrospective study was conducted on 200 patients who underwent reconstruction surgery for isolated inferior orbital wall fracture between March 2001 and December 2020. Diplopia was categorized into peripheral, central, and full-degree types based on the history and binocular single vision. The natural course of diplopia was analyzed pre-operatively and at 1 day, 6 weeks, and 6 months postoperatively. We analyzed the orbital computed tomography images to determine fracture size (small, medium, or large), fracture site (anterior, middle, posterior, or mixed), extraocular muscle (EOM) size (swelling or deformity), EOM site (incarcerated or prolapsed), and EOM tenting.Results: Diplopia was seen in 144 out of 200 patients (72.0%) before surgery; peripheral diplopia was seen in 57 patients (39.6%), central diplopia in 46 (24.3%), and full-degree diplopia in 20 (13.9%). Pre-operative diplopia differed according to the pre-operative limitation of range of motion (LOM) (p < 0.001) and EOM site (p = 0.022). Pre-operative diplopia type differed according to the LOM direction (p = 0.018) and EOM size (p = 0.020). Diplopia persisted in 33 patients (16.5%) 6 months after the surgery. Recovery was faster in patients with peripheral diplopia compared to those with central or full-degree diplopia.Conclusions: The presence of diplopia was associated with the pre-operative LOM and EOM site but the type of diplopia was associated with LOM direction and EOM size. These factors can be used to predict the progression of diplopia in patients with isolated inferior orbital wall fracture.

1619 Evaluation of Referrals to The Maxillofacial on Call Service Over A Seven-Year Period in A Busy Tertiary Trauma Centre and Teaching Hospital

Abstract Aim University Hospitals Plymouth is the only designated adult major trauma centre for the south west of England, also serving secondary care to a catchment of 450,000 patients. The on call maxillofacial service receives numerous referrals daily, which began to be recorded in a trauma database populated on a daily basis. Our study aims to evaluate these referrals with a view to classifying them and identifying service provision needs; improve support and training of the junior team; and understand patient demographics. Method There were 3717 referrals recorded between 7th January 2014 and 7th January 2021. All referrals were taken into account; from the emergency department; from primary care providers; from other hospital departments; and directly from patients themselves. Both adult and paediatric cases were included. Results Of these 3717 referrals, 2122 (57%) were pertaining to male patients. Adult patients accounted for 85% of the referrals and 1200 (32%) of all patients were referred for soft tissue injury. Around 20% of patients attended with facial swellings. 1090 (29%) patients were able to have treatment under a local anaesthetic, whilst 959 (26%) required admission. Most common fractures were nasal (8%), followed by orbital wall (6%) and mandibular fractures (4%). Conclusions Evaluation of the database shows a slight prevalence of male attenders, particularly in cases involving trauma. Management of soft tissue injuries under local anaesthetic is an important topic during the induction of new junior trainees to the department, in accordance with the expected service provision. Furthermore, the large sample has allowed for epidemiologic analysis and interventions.

Blowout Fracture Assessment Based on Computed Tomography and Endoscopy: The Effectiveness of Endoscopy for Fracture Repair.

The purpose of this study was to compare the configuration of blowout fracture observed through orbital computed tomography (CT) and endoscopy, then present the effectiveness of using an endoscope in reconstruction surgery of blowout fracture. We retrospectively reviewed the clinical records of 337 patients who underwent reconstruction surgery of blowout fracture between January 2017 and December 2020 in the Department of Ophthalmology at Korea University Guro Hospital. The patients were categorized into 3 groups based on preoperative CT findings as follows: combined orbital medial and floor wall fractures, trapdoor fractures, and large blowout fractures. The images obtained through CT and endoscopy were compared among the 3 groups. Endoscopy helped identify herniated soft tissue and posterior fracture margins, and it also provides better magnification and a brighter view of the posterior aspects of the fracture site. Furthermore, endoscopy can also provide educational opportunities to visualize the fracture site and help trainees understand the surgical procedure approach or orbital anatomy. Based on our results, we suggest using an endoscope during blowout fracture surgery as an effective approach to reduce postoperative complications due to endoscopy's advantages in clear visualization of the fracture site during operation.

Influence of fractures in different inferior orbital wall locations on ocular motility disorders.

Influence of fractures in different inferior orbital wall locations on ocular motility disorders.

A comparative study of porous polyethylene versus absorbable polydextro- and polylevolactic-lactide plate in reconstruction of isolated medial orbital wall fracture

Several materials for medial orbital wall reconstruction have been mentioned in the literature. Our main purpose was to investigate postoperative enophthalmos and diplopia after medial orbital wall reconstruction with polydextro- and polylevolactic (poly-L/DL) acid (P[L/DL]LA) mesh plates and porous polyethylene plates. Using a retrospective study design, we enrolled a cohort of isolated medial blowout fracture patients treated during a 58-month interval. The predictor variable was medial orbital wall reconstruction materials (P(L/DL)LA mesh plate and porous polyethylene plate. The main outcome variables included the occurrence of postoperative enophthalmos and diplopia at 1 week, 1, 3, 6, and 12 months post-surgery. Appropriate descriptive, uni- and bivariate statistics were computed, and P < 0.05 was considered significant. Three hundred-two isolated medial blowout fracture patients were included (24.5% females, 67% treated with P(L/DL)LA mesh plate). Exophthalmos measured highest in both groups 1 week after surgery and decreased steadily for 6 months postoperatively. Statistically significant differences were observed between both groups at 1 week, 1 month, and 3 months after surgery, with a higher incidence of exophthalmos observed in the P(L/DL)LA mesh plate group (P < 0.001). No significant differences were observed at 6 and 12 months after surgery. The occurrence of enophthalmos after medial blowout fracture reconstruction with P(L/DL)LA mesh plate is comparable with the use of porous polyethylene plate. Both P(L/DL)LA mesh and porous polyethylene plates are, therefore, reliable implants for medial orbital wall reconstruction.

Accuracy of free-hand positioned patient specific implants (PSI) in primary reconstruction after inferior and/or medial orbital wall fractures

BackgroundTo assess the accuracy with which CAD/CAM-fabricated patient-specific titanium implants (PSI) are positioned for inferior and/or medial orbital wall reconstruction without the use of intraoperative navigation. MethodsPatients who underwent a primary reconstruction of the orbital walls with PSI due to fractures were enrolled in this retrospective cohort analysis. The primary outcome variables were the mean surface distances (MSD) between virtually planned and postoperative PSI position and single linear deviations in the x-, y- and z-axis at corresponding reference points. Secondary outcome variables included demographic data, classification of orbital wall defects and clinical outcomes. ResultsA total of 33 PSI (orbital floor n = 22; medial wall, n = 11) were examined in 27 patients. MSD was on a comparable level for the orbital floor and medial wall (median 0.39 mm, range 0.22–1.53 mm vs. median 0.42 mm, range 0.21–0.98 mm; p = 0.56). Single linear deviations were lower for reconstructions of the orbital floor compared to the medial wall (median 0.45 vs. 0.79 mm; p < 0.05). There was no association between the occurrence of diplopia and the accuracy level (p = 0.418). ConclusionsFree-hand positioning of PSI reaches a clinically appropriate level of accuracy, limiting the necessity of navigational systems to selected cases.

Orbital floor fracture repair with implants: a retrospective study.

BackgroundAlthough prompt surgery after an orbital fracture is preferable, the actual timing of surgery in real-world settings varies. Therefore, this study investigated the outcomes of implant surgery for inferior orbital wall fractures by comparing three groups according to the time interval between the injury and surgery.MethodsA retrospective review was conducted of patients’ medical charts and initial computed tomography images from 2009 to 2020. The time to treatment was chosen by patients or their guardians based on the patients’ comorbidities and the physician’s explanation. The patients were divided into three groups according to the time of surgery (group 1: 3–7 days, group 2: 8–14 days, group 3: 15 or more days). Data were collected on age, the time interval until surgery, the dimensions of the defect, the operation time, the follow-up period, and the postoperative paresthesia score (ranging from 0 to 10). The outcomes were evaluated using a 4-point scale: 4= good (no complications), 3 = fair (no subjective symptoms), 2 = poor (remaining paresthesia), and 1 = very poor (strabismus and/or enophthalmos).ResultsThe study included 85 patients with unilateral fractures who underwent surgery from 3 to 93 days after injury. The overall score distribution of the surgical outcomes was as follows: good= 63, fair= 7, poor= 6, and very poor= 9. The three groups showed no significant differences in the transverse dimension of the injury (p=0.110) or the anteroposterior dimension (p=0.144). In groups 1, 2, and 3, the postoperative outcome scores were 3.84± 0.37, 3.63± 0.87, and 2.93± 1.33 (p=0.083), and the percentage of patients with good outcomes was 84%, 81.25%, and 57.14%, respectively.Conclusion Performing surgery using an artificial implant within 2 weeks of the injury showed better outcomes and fewer postoperative complications than when treatment was delayed.

The Incidence of Traumatic Optic Neuropathy Associated With Subtypes of Orbital Wall Fracture.

Traumatic optic neuropathy (TON) is a rare disease but leaves critical sequelae to patient. Purpose of this study is to evaluate the incidence of TON in each orbital wall fracture. Retrospective review of 2629 patients with orbital wall fracture was performed in from January 2010 to March 2019, based on diagnostic code, Korean Standard Classification of Diseases, 7th Revision. The orbital wall fractures were divided into 4 subtypes: superior, medial, inferior, and lateral wall. Incidence of TON is analyzed according to subtypes, single and multiple wall fracture. Among 2629 patients with orbital wall fractures, 27 patients were diagnosed with TON with an incidence of 1.02%. In single wall fracture, only lateral wall showed significantly high TON incidence, which only zygomatic fracture was included in single lateral wall fracture. In multiple wall fracture, it was statistically significant in the superior wall. Fracture on lateral and superior orbital wall showed a tendency to increase the incidence of TON. Based on the above results, radiologic evaluation and physical examination is necessary for patient who has lateral and superior orbital wall fracture.

Spectrum of Ocular Findings in Closed Head Injuries, Correlation With Severity of Neurological Involvement, and Treatment Outcome: A Hospital-Based Cross-Sectional Study.

Purpose: To study the various ocular findings in patients with closed head injuries, to find any association with the degree of neurological involvement, and to analyze the treatment outcome after the necessary intervention.Setting: Tertiary referral hospital in Eastern India.Design: Prospective observational study.Methods: Patients with closed head injuries attending our Outpatient department as well as referred from the Neurosurgery department for ophthalmic evaluation between October 2017 and September 2019 were recruited for the study. All patients meeting the inclusion criteria were examined by an experienced ophthalmologist. The Glasgow coma scale (GCS) was applied to grade the neurological involvement by the neurosurgery team. Ocular findings were recorded and necessary imaging was requested. Appropriate neurosurgery consultations were done in patients with neurological findings. All ocular injuries were managed as per institutional protocol. Descriptive statistics were used for analysis with p< 0.05 taken as statistically significant.Results: A total of 207 patients (414 eyes) were included in the study. The mean age was 33.82 years, with the prevalence of male patients (82.12%). The most common cause of head injury was RTA (57.01%) followed by assault (11.59%). The majority of patients (53.14%) were classified as having moderate, 46.37% patients with mild, and 0.48% with severe neurological involvement as per GCS scoring. Isolated ocular findings were seen in 70.04% of patients while 29.95% of patients had both neurological and ophthalmic features. Ocular adnexal involvement was observed in 38.6%, anterior segment involvement in 86%, neuro-ophthalmic manifestations in 33.3%, and posterior segment involvement in 38.6% of patients. Ocular signs were resolved over due course of time in 48.8% of patients, completely resolved in 28%, while there was no improvement in 6.28% of patients. The final best-corrected visual acuity of >6/18 was achieved in 51.69% of patients. Statistical significance was observed in the correlation between the GCS scoring and general ocular findings (p= 0.02) as well as a relative afferent pupillary defect (p=0.003). The association between age > 50 years and neuro-ophthalmic features was not found to be statistically significant (p=0.56).Conclusion: Poor visual acuity at presentation, optic canal fractures, the presence of multiple fractures of orbital walls, no improvement in vision within 48 hours of starting intravenous corticosteroids, were indicators of a poor visual prognosis in this study. The GCS, neuro-deficit, and ocular signs contribute significantly to the prediction of outcomes. Prompt treatment and referral can lead to a good resolution of symptoms and signs.

Characteristics of Postoperative Anisocoria After Medial Orbital Wall Fracture Repair.

The purpose of this study was to present the clinical characteristics and etiology of patients with anisocoria after medial wall fracture repair. This study was a retrospective, noncomparative case series of postoperative anisocoria after medial orbital wall fracture repair. Data regarding patient demographics, laterality, signs and symptoms at presentation, interval between injury and surgery, fracture size using orbital computed tomography, pupil size of mydriasis, time of discovery of postoperative mydriasis, time of resolution of anisocoria, surgical outcomes, and complications were collected. Twelve patients were included in this study. The mean interval between injury and surgery was 19.17 ± 4.95 (range, 12-30) days. The mean fracture size of the anteroposterior meridian was 25.22 ± 2.15 (range, 21.8-28.4) mm and that of the horizontal meridian was 16.02 ± 2.02 (range, 12.5-21.2) mm. Postoperatively, unilateral pupil dilation was observed at a mean of 5.33 ± 1.61 (range, 3-8) hours after surgery, and mean pupil size was 5.13 ± 0.61 (range, 4-6) mm in the dilated eye and 3.29 ± 0.26 (range, 3-3.5) mm in the normal eye. The dilated pupils all recovered within a mean of 3.42 ± 1.08 (range, 2-5) days. Postoperative anisocoria after medial orbital wall blowout fracture surgery may occur in delayed repair of the posterior location of large fractures. Transient mydriasis caused by parasympathetic nerve injury returned to normal pupil size.