Periorbital Trauma Research Articles

Prediction of substantial closed-globe injuries in orbital wall fractures.

To determine risk factors for substantial closed-globe injuries in orbital fractures (SCGI) and to develop the best multivariate model for the prediction of SCGI. A retrospective study was performed on patients diagnosed with orbital fractures at Farabi Hospital between 2016 and 2022. Patients with a comprehensive ophthalmologic examination and orbital CT scan were included. Predictive signs or imaging findings for SCGI were identified by logistic regression (LR) analysis. Support vector machine (SVM), random forest regression (RFR), and extreme gradient boosting (XGBoost) were also trained using a fivefold cross-validation method. A total of 415 eyes from 403 patients were included. Factors associated with an increased risk of SCGI were reduced uncorrected visual acuity (UCVA), increased difference between UCVA of the traumatic eye from the contralateral eye, older age, male sex, grade of periorbital soft tissue trauma, trauma in the occupational setting, conjunctival hemorrhage, extraocular movement restriction, number of fractured walls, presence of medial wall fracture, size of fracture, intraorbital emphysema and retrobulbar hemorrhage. The area under the curve of the receiver operating characteristic for LR, SVM, RFR, and XGBoost for the prediction of SCGI was 57.2%, 68.8%, 63.7%, and 73.1%, respectively. Clinical and radiographic findings could be utilized to efficiently predict SCGI. XGBoost outperforms the logistic regression model in the prediction of SCGI and could be incorporated into clinical practice.

Retinal Changes in a Patient with a Traumatic Orbital Subperiosteal Hematoma and Superior Ophthalmic Vein Compression

Purpose: We describe a case with retinal alterations similar to those of nonischemic central retinal vein occlusion, but also with superior ophthalmic vein compression attributable to a traumatic, subperiosteal orbital hematoma.Case summary: A 13-year-old male presented with left periorbital edema, a decrease in vision, and diplopia after blunt periorbital trauma. In ophthalmological evaluations, the best-corrected visual acuity (BCVA) was 0.4 (20/50) and a severe supraduction limitation was apparent (grade -4). Fundus examination revealed optic disc swelling, retinal vein dilation/tortuosity, and an arteriovenous transit time delay of 26s. Fluorescein angiography evidenced optic disc leakage. Ocular sonography and orbital magnetic resonance imaging revealed a superior subperiosteal hematoma in the left orbit accompanied by superior ophthalmic vein compression. We scheduled emergency hematoma evacuation. One month later, the BCVA had increased to 1.0 (20/20) and ocular movement was no longer limited. Orbital computed tomography showed that the superior ophthalmic vein compression had resolved and that the abnormalities observed in the initial fundus examination and fluorescein angiography had improved.Conclusions: Retinal changes that resemble nonischemic central retinal vein occlusion including retinal venous dilation and tortuosity may develop after a traumatic, orbital subperiosteal hematoma. Compressive obstruction of the superior ophthalmic vein may then be in play. Early surgical intervention featuring hematoma evacuation may prevent irreversible visual deterioration.

Spontaneous Development of Unilateral Orbital Emphysema Following a Bout of Sneezing: Case Report

ABSTRACT Orbital emphysema is a known complication of periorbital trauma due to a fracture in the orbital walls. However, it is uncommon to come across a case of orbital emphysema in clinical practice due to sneezing or coughing. The case reported here involves the development of spontaneous orbital swelling in a 24-year-old male occurring following a bout of sneezing. The case merits discussion to emphasize the importance of appropriate workup in detecting definitive etiology and urgently deciding upon the correct course of management in a case of orbital swelling, as any delay can cause permanent vision loss and on the other hand unnecessary intervention can cause damaging complications.

White Eyed Blow out Fracture

“White-eyed blow out fracture (WEBOF)” is a term used for children who had periorbital trauma with mild signs of soft tissue damage. WEBOF can be easily missed, resulting in a lost opportunity for surgical intervention. A pediatric patient presented with vomiting and diplopia after sustaining trauma, she was referred to our institution 2 weeks after a suspected head injury. Examination showed marked limitation on upgaze and downgaze on the right eye with accompanying diplopia. CT scan of the orbits revealed a right orbital floor fracture, with herniation of orbital fat and a mildly thickened right inferior rectus muscle. Patient underwent repair of orbital floor fracture and release of muscle entrapment with silicone implant under general anesthesia. Although release of muscle entrapment and repair of floor fracture was achieved, EOM underaction on vertical gaze and diplopia persisted. Timely diagnosis and intervention of WEBOF is important, not only to reverse the oculocardiac reflex but also to minimize the possibility of permanent ischemic injury and contracture of the involved extraocular muscle, which could lead to long-term strabismus and diplopia. Because the first clinical presentation is similar to that of a head injury, it is often overlooked, resulting in a delay in diagnosis and permanent morbidity.

115. Review of OMFS DCTs’ Ophthalmic Assessment of Peri-orbital Trauma

Preservation of vision following periorbital trauma (POT) is highly dependent on rapid assessment, thorough examination, and accurate diagnosis. Basic ophthalmic assessment is an essential component of quality care and is significant in avoiding the sight-threatening consequences of POT. All Dental Core Trainees (DCT’s) working within Oral and Maxillofacial Surgery (OMFS) units should be competent in a basic ophthalmic assessment. Despite this, literature reports that almost half of the surveyed trainees in OMFS posts felt out of their depth.

Functional and cosmetic outcome in oculofacial trauma at tertiary center- multidisciplinary approach

To assess the outcome of lid, adnexal and orbital injuries in poly trauma patients at multi specialty hospital. Papers of 104 consecutive patients with oculofacial injuries were retrospectively reviewed. Data were analyzed with respect to extent, severity, type and location of oculofacial injury. Treatment outcome assessed after surgeries performed by combined approach of ophthalmologist and plastic surgeon. Periorbital soft tissue trauma observed in 65 (62.5%), orbital and Periorbital fracture in 39 (37.5%) cases and Intraocular injuries were noted in 43 patients (41.35 %). Accompanying other injuries was managed properly for better final outcome. Goal of repair is to restore anatomical and cosmetic appearance of patients. In our series of patients, we achieved 95% cosmetic satisfaction with loss of 5 eyes vision with best of our care. The oculofacial trauma patients have tremendous fear of visual loss and aesthetic appearance. Functional and cosmetic outcome of oculofacial injuries depends on multiple factors, well planned, appropriate, early intervention by multidisciplinary approach provides best surgical outcome.

White Eyed Blow Out Fracture - A Case Report

“White-Eyed Blow Out Fracture (WEBOF)" is a term used for children who had periorbital trauma with mild signs of soft tissue damage. WEBOF can be easily missed, resulting in a lost opportunity for surgical intervention. A pediatric patient presented with vomiting and diplopia after sustaining trauma, she was referred to our institution 2 weeks after a suspected head injury. Examination showed marked limitation on upgaze and downgaze on the right eye with accompanying diplopia

Current developments in primary and secondary surgical treatment of midface and periorbital trauma

Fractures of the periorbita and the midface are among the most common bony facial injuries. Aesthetic and functional reconstruction is achallenge in clinical routine. This article illustrates recent developments in the primary and secondary surgical treatment of midface and periorbital trauma. Resorbable patches and films increase the anatomic reconstructive capacity and enable treatment of extensive orbital fractures. Orbital fractures with involvement of supporting key structures are advantageously reconstructed using patient-specific implants (PSI), which are fabricated by computer-assisted manufacturing techniques and positioned by intraoperative navigation. If late complications such as bulbar malposition and enophthalmos have occurred after the initial procedure, they can be addressed by overcorrective restoration of orbital volume. The use of PSI for initial fracture restoration of the midface is not yet established but may be useful in re-osteotomies of misconsolidated fragments. Extensive midface defects with significant soft tissue involvement can be reconstructed using microvascular grafts. Consecutive reconstructive procedures may include orthognathic surgery and local flap reconstruction. In summary, the integration and advancement of computer-assisted techniques now offers individualized reconstruction procedures, which may be aviable alternative to conventional implants and compression miniplates. Future developments may focus on the search for innovative biomaterials, which can be integrated into computer-aided design and manufacturing processes.

The Orbital Bones Protect the Globe From Sharp Periorbital Trauma Injuries.

The bones of the orbit hold the globe and periocular structures and protect it and other periocular contents. This has been shown in blowout orbital fractures, as well as in high-energy injuries to the periorbital region. However, there is little information regarding how the orbital bones protect the globe after periorbital trauma from sharp objects. This study reports 4 cases of traumatic injury from sharp objects to the periorbital area and eyelids to demonstrate the protective features of the orbital bones. The anatomy of the periorbital bones clearly protected the globe from direct trauma in all the 4 cases. There was no harm to the orbit or visual impairment after the successful treatment with definitive surgery.

Prevalence of Pediatric Periorbital Trauma at a US-Mexico Border Level 1 Trauma Center, 10 Year Retrospective Review

Introduction: Due to its location in the middle third of the face, the periorbital area is exposed to external forces that may cause blunt and/or penetrating trauma. This anatomical location houses important structures for vision, cosmesis, and upper and lower facial skeletal stability. Trauma in this area puts the patient at risk for injuries to important structures, that, when damaged at early age, may have permanent debilitating consequences. Methods: After obtaining IRB approval, we evaluated ER admissions at a Level 1 Trauma Center located in the US-Mexico border over a 10-year-period. Inclusion criteria included patients younger than 18 years old with diagnosis of trauma to the face involving the periorbital region. Results: From January 2009 to December 2018, 1192 pediatric patients were admitted to the Level 1 Trauma Center with trauma that involved the periorbital area amongst other injuries. Mean age was 8, STD 5.2. 61.4% were male patients. The most common mechanism of injury was fall (365) followed by blunt trauma (305) and motor vehicle accident (MVA) (108). 29.4% of patients required admission, and 18.8% required a surgical intervention. Conclusion: Periorbital trauma in the pediatric population may bring lifelong consequences due to deformity, dysfunction, or loss of the structures that are contained within this anatomical area. Further studies are warranted to assess risk factors and to provide prevention measures to avoid trauma and complications due to injury to these important structures.

PATTERN OF OCULAR TRAUMA AND VISUAL OUTCOME IN PATIENTS ATTENDING NATIONAL REFERRAL EYE HOSPITAL OF ERITREA

Background: Ocular trauma has been a significant disabling health problem and a leading cause of visual loss in lower-middle-income countries. These injuries have many diverse costs including human suffering, long-term disabilities, loss of productivity, and economic hardship. This study was aimed to describe the pattern of ocular trauma, its visual outcome, and the overall epidemiology of ocular trauma in all patients presenting to Berhan Eye Hospital, Asmara, Eritrea. Methods: A prospective observational study was conducted on ocular trauma patients who presented to Berhan Eye Hospital for the open globe, closed globe, and peri-orbital trauma from September – November 2018 after ethical approval from the Ministry of Health, Eritrea. Data on demography, initial and final visual acuity, type of injury as well as its outcome were collected using U.S Eye Injury Registry checklist. The types of injuries were classified according to Birmingham Eye Trauma Terminology System (BETTS), SPSS Version 22 was used. Results: Ocular trauma accounted for 1.94% of the total patients attending the outpatient department (OPD) and emergency during the studied period. Of the studied 280 participants, 218 (77.9%) patients were below 40 years of age. The male to female ratio was 2.4:1. Closed globe injuries accounted the highest 205 (73.21%) followed by the open globe injuries 75 (26.79%). Home and industrial premises were the main places where ocular injuries occurred in the participants. Conclusions: Ocular trauma affects mainly the younger age group. Blunt objects trauma in the eye are more common in low resource settings. Ocular trauma is an important cause of monocular blindness which can be prevented with early intervention and health promotion.

Periorbital Soft Tissue Trauma.

Eyelid trauma occurs across a broad spectrum of pathology, ranging from simple periorbital lacerations to severe, vision-threatening injuries requiring expert oculoplastic consultation. Any injury, no matter how benign, is also inherently cosmetically sensitive, further adding to the reconstructive challenge. In this review, we discuss the anatomy of the eyelid and develop an understanding of evaluating for signs of more serious, potentially occult, trauma. A framework is developed for approaching the patient with periorbital trauma to assess for injury and triage necessary treatments. Damage to the lacrimal drainage system, which can be particularly difficult to detect and repair, is specifically emphasized and explored.

Reconstruction of the Orbit

Orbital defects require careful consideration due to the need to protect globe position and visual function. The orbit’s unique geometry requires working within a confined space. When indicated, orbital rim fractures or segmental defects can be reconstructed using low-profile, titanium mini-plates. Multiple implant options are available to support the globe when defects involve the orbital floor or medial wall. These materials should be able to contour to match the concavity of the orbit, thereby avoiding changes in orbital volume. For complex defects, virtual surgical planning strategies, including intra-operative navigation or the use of anatomic models for pre-operative plate bending or cutting guides for secondary osteotomies, can improve precision and reduce operative time. This chapter will describe operative indications and practical management options for orbital defects. This review contains 7 figures, 1 video, 2 tables, and 38 references. Keywords: orbit anatomy, periorbital trauma, orbital reconstruction, craniofacial imaging, alloplastic implant, mini plate, surgical approach, virtual surgical planning

The Effect of Deep Vein Thrombosis Prophylaxis on Bleeding in Periorbital Surgery in Trauma Patients.

The aim of this study is to assess if there is an increase in postoperative venous thromboembolism (VTE) or bleeding complications in patients who received perioperative chemical thromboprophylaxis compared with patients in whom chemical thromboprophylaxis was held during periorbital trauma surgery. This is a retrospective chart review of patients undergoing periorbital surgery treated in three different city hospitals, by the Department of Oral and Maxillofacial Surgery, University of Texas, between August 2014 and December 2016. A total of 237 patients were included in this study. None of these patients suffered a postoperative VTE. A total of 102 patients received perioperative pharmacologic thromboprophylaxis in the form of enoxaparin or heparin. In this group, one patient suffered a buccal space hematoma. Chemical thromboprophylaxis was held in 135 patients preoperatively and for at least 24 hours postoperatively. In this group, one patient suffered a retrobulbar hematoma after repair of an orbital floor fracture. The rate of postoperative bleeding complications was compared by the chi-square test and was not statistically significant ( p = 0.8417).

Lower eyelid ectropion as a sequela of different underlying diseases in maxillo-facial surgery: Diagnostics and treatment approaches

PurposeThis study investigated the outcome of lower eyelid ectropion (LEE) treatment in patients with another primary periorbital or mid-facial pathology. Materials and methodsThis 18-year monocentric retrospective cohort study included patients admitted for various leading mid-facial pathologies and presenting with a LEE. The primary diagnosis, surgical pretreatment, ectropion type, ectropion severity score (ESS), and surgical techniques were recorded. The primary endpoint was the postoperative ESS score. ResultsOverall, 40 patients (female n = 16, male n = 24, average age 70.8 years), primarily with periorbital skin cancer (n = 21, 52.5%), facial palsy (n = 7, 17%), trauma (n = 6, 15%), or other pathologies (n = 6, 15%), were included. Surgical procedures mostly addressed a correction of anterior and posterior lamellae (n = 22, 55%), with isolated anterior lamellae in only a few cases (n = 10, 25%). The ESS score significantly decreased from 4.8 ± 1.8 to 1.3 ± 1.3 (paired t-test, p < 0.001) after a mean follow-up of 23.8 months. ConclusionLEE constitutes a relevant problem. Due to preexisting canthal ligament laxity in patients undergoing oncologic or traumatic midface surgery, the risk of ectropion has so far been underestimated. Bilamellar approaches in elderly patients are likely to be obligatory in any case.

Periorbital Trauma: A New Classification.

Overlooked injured structures in periorbital trauma could lead to aesthetic and functional deficits. As trauma may affect superficial, middle, and deep components, meticulous survey guided by a structured periorbital trauma classification is needed for proper management. Thus, a new classification for periorbital trauma is proposed to serve this purpose. Periorbital region was defined anatomically by anthropometric landmarks. The periorbital injuries were categorized according to anatomical and clinical basis. The new classification was used to study periorbital trauma cases received at Ain Shams University Hospitals between July 2013 and July 2016 retrospectively. The study included 260 patients: 196 (75.38%) males and 64 (24.62%) females. The type and severity of injury, time of primary intervention, type of surgery performed, and patients' visits to the outpatient clinic were evaluated. The status of the postinjury and postoperative (primary surgery) aesthetic status and functional status were evaluated. The periorbital region was identified. Anatomical categorization of periorbital injuries included periocular, frontal, temporal, and malar regions. Injuries/deficits were categorized into simple, composite, complex, and isolated bony injuries according to the depth and involved tissues. Subsequently, the classification was formulated. In the retrospective study, the incidence of extended simple injuries was the highest, while the least was the extended complex injuries. Functional deficits occurred in 24 patients (9.23%) and aesthetic deficits occurred in 55 patients (21.15%). Required secondary operations for this group included redo of fixation, correction of medial canthal ligament, repair of canalicular system, scar revisions, fat grafting, and creation of natural creases. The results of this study demonstrated that unsatisfactory aesthetic and functional results occurred when injuries of important structures were overlooked, aesthetic units were not respected, and when management was delayed. A three-dimensional, oriented, new classification of periorbital trauma based on anatomical and clinical categorization is proposed to help in identifying injured structures, stimulate the search for other injuries, structure preoperative evaluation, and recommend a surgical plan that would ultimately achieve precise primary repair with best aesthetic and functional outcome.

Pathomechanism of optic nerve avulsion

Optic nerve avulsion following peri-orbital trauma is an enigmatic clinical entity. Several mechanisms and ideas have been put forward to derive a logical conclusion, however, each factor independently does not appear to explain the mechanism in a logical way, therefore, here we elaborate the probable chain of events responsible for this complication. During isolated blunt trauma to the orbital framework, the globe continues to move anteriorly without any active resistance, in contrast to the globe, the optic nerve with more delicate bony and soft tissue relations, likely to remain relatively static. Thus the junction between the optic nerve and ocular coat suffers the maximum distractive injury due to anteroposterior tractional forces. In addition to this, physiological Bell’s phenomenon may induce torsional tension at this junction leading to further worsening of distractive forces and violent separation of optic nerve from the globe.

The Reliability of the Transconjunctival Approach for Orbital Exposure: Measurement of Positional Changes in the Lower Eyelid.

BackgroundLower eyelid incisions are widely used for the orbital approach in periorbital trauma and aesthetic surgery. In general, the subciliary approach is known to cause disposition of the lower eyelid by scarring the anterior lamella in some cases. On the other hand, many surgeons believe that a transconjunctival approach usually does not result in such complications and is a reliable method. We measured positional changes in the lower eyelid in blowout fracture repair since entropion is one of the most serious complications of the transconjunctival orbital approach.MethodsTo measure the positional changes in the lower eyelids, we analyzed preoperative and postoperative photographs over various time intervals. In the analysis of the photographs, marginal reflex distance 2 (MRD2) and eyelash angle were used as an index of eyelid position. Statistical analyses were performed to identify the significance in the positional changes. All patients underwent orbital reconstruction through a transconjunctival incision by a single plastic surgeon.ResultsIn 42 blowout fracture patients, there was no statistical significant difference in the MRD2 and eyelash angle. Furthermore, there were no clinical complications, such as infection, hematoma, bleeding, or implant protrusion, during the follow-up periods.ConclusionThe advantages of the transconjunctival approach for orbital access include minimal scarring and a lower risk of eyelid displacement compared with other approaches. Based on these results, we recommend the transconjunctival approach for orbital exposure as a safe and reliable method.

Orbitocranial penetrating injury by a metallic foreign body. Case report and anatomical considerations

Abstract Orbitocranial penetrating injuries (OPI) represent a rare type of head injuries encountered in clinical practice. These appear after falls or motor vehicle accidents and are more frequent among children. We present the case of a male patient with OPI, associated with large frontal hemorrhagic contusion, with minimal periorbital trauma findings related to brain injury. Knowing and understanding the clinical anatomy of the orbit and the patterns of injuries in OPI are mandatory, since failure in detecting intracranial complications may lead to the increase of the neurological morbidity, visual loss and death.

Clinical Decision Rule to Identify Orbital Wall Fracture Among Children: Retrospective Derivation and Validation Study.

Head and face injuries are leading causes of emergency department visits in children. There is yet no clinical decision rule on face CT such as pediatric head CT rules. The goal was to develop and validate a clinical decision rule for identifying orbital wall fractures in children with periorbital trauma in the emergency department. This was a retrospective derivation and validation study. Children younger than 18 years who underwent orbit CT after periorbital trauma were included between January 2011 and December 2013 in 3 emergency centers. Among 16 candidate clinical variables, 13 clinical signs and symptoms were selected as clinical predictors. For the fracture model, these clinical predictors were analyzed by 3-fold cross-validation. Diagnostic performance was assessed using the area under the receiver operating characteristic (AUROC) curve in both cohorts. Four variables (orbital rim tenderness, periorbital ecchymosis, painful extraocular movement, and nausea/vomiting) had the best predictive model with the highest AUROC value. The AUROC values for fracture prediction were 0.793 (95% confidence interval, 0.741-0.844) and 0.809 (95% confidence interval, 0.742-0.877) in the derivation cohort and validation cohort, respectively. The sensitivity and negative predictive values were 96.4% and 93.4%, respectively, in the derivation cohort, and 97.8% and 98.1%, respectively, in the validation cohort. The sum of these scores ranged from 0 to 4. Patients with a sum of scores of 1 or higher showed significantly increased risk for fracture. The 4-variable predictive model can be useful for finding clinically important orbital wall fractures in children.