Pure Orbital Blowout Fractures Research Articles

Sports-Related Pure Orbital Blowout Fractures in Japan: Differences in Demographic and Clinical Characteristics between Sports.

The aim of this study was to present the demographic and clinical characteristics of sports-related pure (rim-sparing) orbital blowout fractures and to analyze these differences by type of sport. Ten years of sports-related orbital fracture data were accumulated. Patients were classified into similar sports (i.e., soccer and futsal) wherein orbital blowout fractures were obtained, producing 14 groups. This study included 377 sides from 374 patients. The majority of patients were male (83.4%), and the mean population age was 20.9 ± 10.8 years. The most common sports causing injuries were baseball/softball, rugby/football, and martial arts. Single-wall fractures were found in 78.8% of patients, but baseball/softball had a higher frequency of multiple-wall fractures (p = 0.035). Concomitant ocular and periocular injuries occurred in 18.6% of patients, which were frequently caused by baseball/softball (p < 0.001). The field of binocular single vision (BSV) included primary gaze in 84.2% of patients. Surgical management was conducted in 52.1% of patients. This study showed that baseball and softball had the highest rate of multi-wall fractures and concomitant ocular and periocular injuries. The field of BSV measured during the first examination was acceptable in most cases.

Incidence of Pure Orbital Fractures with Concomitant Lacrimal Drainage System Injury in the Japanese Population: A Retrospective Study

ABSTRACT Purpose This study aims to determine the incidence of pure orbital fractures with concomitant lacrimal drainage system injuries. Methods A retrospective observational study involving 956 sides from 940 pure orbital blowout fracture patients was conducted in our institution. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded. Results A total of 13 sides (1.4%) from 13 patients were included in the study. Canalicular laceration, bony nasolacrimal canal fracture, and lacrimal sac wall laceration were found in 9, 4, and 1 patients, respectively (one overlapping). Majority of the injuries resulted from either sports or falls. Inferomedial orbital strut fracture (23.1% vs. 7.6%; p = .075) and orbital floor fracture occurring lateral to the infraorbital groove (30.8% vs. 9.9%; p = .035) tended to be higher in patients with lacrimal drainage system injuries. Conclusion There is a 1.4% incidence rate of pure orbital fractures with concomitant lacrimal drainage system injuries among the Japanese population included in this study. Inferomedial orbital strut fractures and orbital floor fracture lateral to the infraorbital groove were found to have higher association with lacrimal drainage system injuries.

Algorithm for pediatric orbital blowout fractures: a 20-year retrospective cohort study

ObjectivePediatric orbital blowout fractures can include pathologies that seem mild but require urgent release; serious sequelae can occur with standby surgery or conservative treatment. We sought to validate an algorithm for the treatment of pediatric orbital blowout fractures. MethodsThis retrospective cohort study included 61 pediatric patients, aged 18 years or younger, treated for pure orbital blowout fractures according to the algorithm from April 1, 2000, to August 31, 2020, at the Japanese Red Cross Asahikawa Hospital. ResultsThere were 52 males (85%). Median age was 14 years (range, 5–18 years). There were 9 patients categorized as needing urgent release, 16 as needing repair, and 36 as needing conservative treatment. Mean follow-up ocular movement was 98.0 (95% Confidence Interval [95% CI], 96.8–99.2). Postoperative diplopia was not observed in 96% (79.6%–99.9%) of patients, better than in previous studies. A higher proportion of patients aged 0–12 years needed urgent repair than those aged 13–18 years (Odds Ratio [OR] = 14.2; 95% CI 1.6–683.4; p = 0.0046). There were no differences in Hess area ratio by age group. ConclusionClinical results with the algorithm were satisfactory. The algorithm is suitable for treatment of pediatric orbital blowout fractures. Level of evidence4.

Patient-Specific Implant for Primary Orbital Reconstruction: A Case Report

The main aim of orbital fracture reconstruction is to restore the functional and aesthetic components of the eye. However, it is known that surgery for complex three-dimensional anatomy of the orbit is always a challenge. With recent advancements in technology, surgical predictability and outcomes have greatly improved. Several methods for orbital reconstruction surgery have been documented such as virtual surgical planning, intraoperative navigation, intraoperative imaging, and the use of patient-specific implant (PSI). PSI made of titanium can be designed by using a computer-aided design process and manufacturing (CAD-CAM) of CT-scan routinely used during diagnostic imaging. With precise analyses in shape and size followed by personalised implant design, the surgical precision can be alleviated further and at the same time, the surgical duration could be reduced with anticipation of better surgical outcomes. However, meticulous planning needs to be done preoperatively, with the timing of the surgery being an important factor. In the present case, pure orbital blowout fracture primarily treated with a personalised-implant solution derived from 3D-printing technology is described. Both pre-surgical and surgical workflow of this computer-assisted surgical method is elaborated. PSI for primary orbital reconstruction can be regarded as a viable alternative surgical solution including its working timeframe and adherence to the surgical protocol or algorithm.

A Multi-Criteria Assessment Strategy for 3D Printed Porous Polyetheretherketone (PEEK) Patient-Specific Implants for Orbital Wall Reconstruction.

Pure orbital blowout fractures occur within the confines of the internal orbital wall. Restoration of orbital form and volume is paramount to prevent functional and esthetic impairment. The anatomical peculiarity of the orbit has encouraged surgeons to develop implants with customized features to restore its architecture. This has resulted in worldwide clinical demand for patient-specific implants (PSIs) designed to fit precisely in the patient’s unique anatomy. Material extrusion or Fused filament fabrication (FFF) three-dimensional (3D) printing technology has enabled the fabrication of implant-grade polymers such as Polyetheretherketone (PEEK), paving the way for a more sophisticated generation of biomaterials. This study evaluates the FFF 3D printed PEEK orbital mesh customized implants with a metric considering the relevant design, biomechanical, and morphological parameters. The performance of the implants is studied as a function of varying thicknesses and porous design constructs through a finite element (FE) based computational model and a decision matrix based statistical approach. The maximum stress values achieved in our results predict the high durability of the implants, and the maximum deformation values were under one-tenth of a millimeter (mm) domain in all the implant profile configurations. The circular patterned implant (0.9 mm) had the best performance score. The study demonstrates that compounding multi-design computational analysis with 3D printing can be beneficial for the optimal restoration of the orbital floor.

Comparison of Nasoseptal Cartilage Graft Versus Titanium Mesh in Reconstruction of Pure Orbital Blowout Fractures.

To compare the efficacy of nasoseptal cartilage grafts versus titanium mesh implants in pure orbital blowout fractures. A retrospective review was performed on 48 patients who had surgical repair of an orbital fracture. Patients who underwent pure orbital blowout fracture repair with either nasoseptal cartilage grafts or titanium mesh implants and at least 1 year postoperative follow-up were included in the study. The clinical features and treatment outcomes were analyzed. Twenty-five patients fulfilled our study criteria and were included in the analyses. Nasoseptal graft was used in 12 patients (48%) while titanium mesh was preferred in 13 patients (52%). Preoperative clinical features including age, size of the floor defect, and preoperative clinical findings (enophthalmos, diplopia, and restriction of ocular motility) were similar between 2 groups. Mean postoperative follow-up was 14.7 ± 2.3 months in the nasoseptal group while it was 16.1 ± 2.5 months in the titanium group (P = 0.84). Diplopia and ocular motility limitation were resolved in all patients at the last postoperative follow-up visit, while 1 patient in each group had enophthalmos (8.3% versus 7.6%, P = 1.0). No patient in the nasoseptal group experienced postoperative complications while 2 patients in the titanium group (15.3%) developed material-related complications (P = 0.48). Long-term clinical results of nasoseptal cartilage grafts and titanium mesh implants in pure orbital blowout fractures with preoperative floor defects smaller than 4 cm2 were comparable. Nasoseptal cartilage grafts may be preferred in patients with septal deviation and no spurs or turbinate hypertrophy.

Surgical treatment of enophthalmos in children and adolescents with pure orbital blowout fracture.

This study evaluated outcomes of surgical treatment for enophthalmos after pediatric orbital blowout fracture. Associations of fracture type, fracture site, time from injury to treatment, and type of surgical procedure with treatment outcomes were assessed. The medical records of 200 children and adolescents (38 girls and 162 boys) with orbital fractures treated in the authors' department from 1975 to 2015 were reviewed retrospectively. The main causes of injury were accidental blows to the orbit and sports injuries. This study included only patients with fracture of the floor and/or medial wall of the orbit, which is referred to in the English literature as pure, or internal, blowout fracture. Patients with fracture of the orbital rim, lateral wall, or roof were excluded. Surgical treatment was performed for 178 patients; the other 22 children were treated conservatively. In the surgically treated group, treatment outcomes did not differ in relation to the severity of post-traumatic enophthalmos. The setting of the eyeball improved in 83% of patients. The severity of post-traumatic enophthalmos was not associated with surgical outcome in children.

White-eyed blowout fracture

White-eyed blowout fracture is often found in pure orbital floor blowout fracture among pediatric patients. Unlike common orbital blowout fractures with apparent clinical signs, the diagnosis of white-eyed orbital blowout fractures is difficult because of minimal soft-tissue signs. This report describes an early missed-out diagnosis of a white-eyed blowout fracture in a 7-year-old child, due to negligible soft-tissue manifestation.

Predictors of enophthalmos among adult patients with pure orbital blowout fractures.

The aim of this study was to determine the predictors of post-traumatic enophthalmos (PE) in relation to the internal orbital changes following pure orbital blowout fractures. The design was a 10-year retrospective cross-sectional study analysing 629 medical records and computed tomography (CT) data of patients with orbital fractures from January 2008 to January 2017. Demographic, etiology, co-morbidity and clinical characteristics were obtained from the medical records. Assessment of the PE, fracture site and size, intraorbital structures and muscle change were performed using the Digital Imaging and Communications in Medicine (DICOM) viewer software, OsiriX v5.8.2. Of the 629 patients with orbital fractures, 87 were pure orbital blowout fractures. Demographic pattern showed that males outnumbered females in the series, with male: female ratio of 5.7:1. The mean age was 37.2 ± 14.7 and the main etiology was motor vehicle accident. Orbital floor fracture was the most common fracture location (67.8%). The involvement of the posterior ledge and inferior orbital fissure showed statistical significant difference with PE (Fisher’s exact test, p = 0.03). Binary logistic regression showed that after controlling for age, patients with fracture size of more than 150 mm2 had three times the odds of sustaining a PE, (adjusted odds ratio (AOR) = 3.01 (95% CI 1.17–7.92).Fracture size larger than 150 mm2 was a radiological predictor of PE. Additional research investigating further on the role of concurrent fracture of the posterior ledge and inferior orbital fissure is advocated.

Comparison of clinicoradiological findings between patients with recovering diplopia and those with residual diplopia after surgery for pure orbital blowout fracture

PurposeDiplopia is a common symptom of blowout fracture (BOF), and can persist after proper surgical management. We compared clinicoradiological findings between patients with recovering diplopia and those with residual diplopia after surgery for orbital BOF. Materials and methodsWe retrospectively evaluated the CT images of 170 patients with orbital BOF and preoperative diplopia. We reviewed the following factors: sex, age, mechanism of injury, presence of diplopia before surgery, presence of enophthalmos before surgery, presence of an ocular motility abnormality before surgery, time interval between the trauma and surgery, fracture type, fracture size, volume of herniated orbital soft tissue, ratio of the volume of herniated orbital soft tissue to fracture size, number of points of contact between the extraocular muscle (EOM) and bony edge, EOM swelling, EOM swelling ratio, EOM displacement, EOM circling, EOM tenting, and EOM entrapment.The associations between the presence of diplopia 6 months after surgical repair and various clinicoradiological findings were analyzed using Wilcoxon rank-sum tests, Student's t-tests, Fisher's exact tests for univariable analysis, and logistic regression analysis for multivariable analysis. A Kaplan–Meier curve and log-rank test were used to identify the recovery status from diplopia. ResultsThe following findings were significantly different between patients with recovering diplopia and those with residual diplopia on univariable analysis (p < 0.05 for each): patient age, EOM entrapment, EOM circling, and EOM tenting. Multivariable analyses showed that patients who were older or those who had EOM circling or tenting on CT images had a greater probability of residual diplopia after surgery [p-values: 0.006, 0.013, and <0.001, respectively; odds ratio (95% confidence interval): 1.035 (1.010–1.061), 14.809 (1.775–123.556), and 4.851 (2.069–11.375), respectively]. The recovery rate for diplopia was significantly different between patients with EOM tenting and those without (p = 0.02). Additionally, young patients (0–12 years) showed a shorter recovery time from diplopia compared with older patients (>24 years) (p < 0.05). ConclusionPatients with residual diplopia after surgical management have different clinicoradiological findings compared with patients with recovering diplopia. Patients who are older, or those who have circling or tenting of the EOM on CT scans, are more likely to have residual diplopia.

Impact of surgical timing of postoperative ocular motility in orbital blowout fractures

PurposeTo investigate the surgical timing postinjury in regard to ocular motility in patients with orbital-floor blowout fractures.MethodsThis study involved 197 eyes (92 right eyes and 105 left eyes) of 197...

Can a Specific Computed Tomography-Based Assessment Predict the Ophthalmological Outcome in Pure Orbital Floor Blowout Fractures?

The aim of this study was to determine the predictive value of a specific computed tomography (CT)-based assessment for the final functional ophthalmological outcome in pure orbital floor blowout fractures. Data of 34 consecutive patients with pure blowout fractures who had undergone a period of at least 6 months of medical and ophthalmological follow-up were analyzed. The following 3 CT scan-based parameters were included: area ratio of the fractured orbital floor (RF), maximum height of periorbital tissue herniation (MH), and a 4-grade muscular subscore (MSS) describing the inferior rectus muscle displacement relative to the orbital floor level. The orthoptic complications (diplopia, enophthalmos, and ocular motility restriction) were evaluated by an experienced strabologist. The CT parameters' predictive value was analyzed using receiver operating characteristic curves and area under the curve (AUC), logistic regression, and Spearman correlation.The RF had a significant predictive value for enophthalmos appearance (AUC = 0.75, P = 0.02), and MH for diplopia (AUC = 0.80, P = 0.03). Among patients with complications, the relevance of MSS and MH as well as the severity of vertical deviation were also clinically strongly associated (rho = -0.52 and -0.56).Our study revealed the significantly predictive value of RF for occurrence of enophthalmos and of MH for diplopia persistence. Although statistically unable to predict the occurrence of ocular motility restriction, MH and MSS were clinically strongly correlated with the severity of ocular deviation limitations.

Prognostic CT findings of diplopia after surgical repair of pure orbital blowout fracture.

Diplopia is a common sequela of blowout fracture even after proper surgical management. We investigated the prognostic factors of diplopia after surgery of pure blowout fracture. We retrospectively reviewed CT images of 181 patients with pure orbital blowout fracture who underwent at least six months of postoperative follow-up. We evaluated the following CT factors: (1) fracture site (orbital floor, medial wall of the orbit, or both), (2) fracture type (closed flap, open flap), (3) fracture size, (4) volume of herniated orbital soft tissue, (5) ratio of volume of herniated orbital soft tissue to fracture size, (6) number of points of contact between extraocular muscle (EOM) and bony edge, (7) presence of EOM thickening, (8) EOM swelling ratio, (9) presence of displacement of EOM, (10) presence of deformity of EOM, (11) presence of tenting of EOM, and (12) presence of entrapment of EOM. The associations between diplopia at six months after surgical repair and various risk factors were analyzed using logistic regression models for univariable and multivariable analyses. EOM tenting and deformity and ratio of volume of herniated orbital soft tissue to fracture size were found to be statistically significant risk factors of diplopia at six months after repair on univariable analysis (all P<0.05). Patients who showed EOM tenting or deformity on CT images had 5.22 and 10.85 times greater probability of diplopia after surgery, respectively (P-value, <0.001 and 0.026; 95% confidence interval of odds ratio, 2.071-13.174 and 1.323-88.915, respectively). On the other hand, ratio of volume of herniated orbital soft tissue to fracture size was not significant on multivariable analysis (P=0.472). The prognosis of patients was predicted by CT evaluation. Patients who have tenting or deformity of EOM on CT scan are more likely to have postoperative diplopia.

A case report of traumatic dislocation of eyeball

Complete dislocation of an intact globe into the maxillary sinus after an extensive blowout fracture is a rare occurrence. We report a case of pure blowout fracture of the floor of the orbit with intact orbital margins due to trauma resulting in complete dislocation of the globe into the maxillary sinus in a 42-year-old male. On ocular examination, the right eyeball was found to be absent from the orbit. Computerized tomography scan with contrast showed: (1) pure orbital blowout fracture; (2) intact eyeball in the right maxillary sinus; and (3) optic nerve seemed to be intact. Surgical exploration of the right maxillary sinus through Caldwell-Luc approach revealed a circular fracture which was just the size of the globe in the middle of the inferior orbital wall. The orbital contents were also found to be dislocated completely into the right maxillary sinus. The dislocated globe was repositioned into the orbit and the orbital floor fracture repaired with bone graft taken from iliac crest. The visual acuity in the right eye after the repositioning was no light perception. We are reporting this case because it is a rare condition and the various operative challenges.

Pure orbital blowout fractures reconstructed with autogenous bone grafts: functional and aesthetic outcomes

The purpose of this study was to investigate the ophthalmic clinical findings following surgical reconstruction with autogenous bone grafts of pure blowout fractures. A retrospective review of 211 patients who underwent surgical repair of an orbital fracture between October 1996 and December 2013 was performed. Following data analysis, 60 patients who were followed up over a period of 1 year were included. A solitary floor fracture was present in 38 patients and a floor and a medial wall fracture in 22 patients. Comparing preoperative findings between these two groups, preoperative diplopia and enophthalmos were almost twice as frequent in the group with additional medial wall fractures: diplopia 8% and 14% and enophthalmos 18% and 55%, respectively. One year following surgery there was no diplopia present in either group. In the solitary floor fracture group, 3% still had enophthalmos. It can be concluded that at 1 year following the repair of pure orbital floor fractures using autogenous bone, good functional and aesthetic results can be obtained. In the group with both floor and medial wall fractures, no enophthalmos was found when both walls were reconstructed. When the medial wall was left unoperated, 29% of patients still suffered from enophthalmos after 1 year.

Orthoptic Sequelae Following Conservative Management of Pure Blowout Orbital Fractures: Anecdotal or Clinically Relevant?

The aim of this study was to prospectively assess the prevalence of orthoptic anomalies following conservative management of pure blowout orbital fractures and to evaluate their clinical relevance. Clinical and radiologic data of patients with unilateral conservatively managed pure blowout orbital fractures with a minimum follow-up of 6 months were reviewed. Eligible patients were contacted and invited to undergo an extended ophthalmologic examination as follows: distance and near visual acuities, Hertel exophthalmometry, corneal light reflex (Hirschberg test), ductions and versions in the 6 cardinal fields of gaze, eye deviation with prisms and alternate cover test in all of the 9-gaze directions with Maddox rod, degrees of incyclo/excyclotorsion with right and left eye fixation, horizontal and vertical deviation with Hess-Weiss coordimetry, degree of horizontal/vertical and incyclo/excyclotorsion deviation with Harms wall deviometry, and vertical deviation with Bielschowsky head-tilt test. Of the 69 patients contacted, 49 declined to participate given that they were asymptomatic. Twenty patients agreed to undergo the examination. One patient complained of minimal double vision limited to the extreme downgaze. Four patients had asymptomatic ocular motility disturbances limited to the extreme gaze. Seven patients had asymptomatic horizontal heterophoria. These disturbances did not interfere with daily or professional activities in any of the patients. The current study demonstrated that conservative management of pure orbital blowout fractures can result in orthoptic anomalies. These sequelae were restricted to a very limited portion of the binocular field of the vision and were not found to be clinically relevant.

The influence of tissue herniation on diplopia and ocular motility in orbital blowout fractures

Aim The aim of the study is to determine the effect of orbital tissue herniation, as determined by computed tomography (CT) scan, on diplopia and ocular motility scores in blowout fracture patients. Materials and methods Patients who sustained pure orbital blowout fractures in the period 2000–2010, and for whom CT scan reports were available, were included in the study. Three levels of tissue herniation were reported: none, fat only, and fat and muscle. Orthoptic assessment included binocular single vision (BSV) and uniocular fields of fixation (UFOF) scores. Results One hundred and twenty-three patients were included in the study. Although mean BSV and UFOF scores decreased with increasing amounts of tissue prolapse, there was no significant difference between the BSV, UFOF scores of injuries with no tissue prolapse and those with only fat herniation (P > 0.05). A significant difference was noted between the BSV and UFOF scores of no/fat herniation and injuries with fat and muscle prolapse groups. Patients with muscle herniation had a tendency for an unfavourable outcome following surgical intervention. Conclusion We suggest that orbital fat herniation alone may not be an adequate indication for surgical intervention for correction of diplopia in orbital blowout fractures. Cases with orbital muscle herniation are more likely to have an unfavourable outcome in relation to diplopia.

Pure superior orbital wall Blowout fracture: an uncommon case

Blowout fractures are the most interesting orbital wall fractures. Although pure blowout fractures are most common seen at medial and inferior orbital wall, pure orbital roof blowout fractures are quite rare. A pure blowout orbital roof fracture is presented in this case report. Then we discussed the mechanism of superior orbital wall blowout fractures, the methods of radiologic evaluation and treatment options.

Measurement of Fracture Size Using the Picture Archiving Communication System in an Outpatient Clinic for Factors that Influence Postoperative Enophthalmos in Adult Inferior Orbital Wall Fractures

This study aims to determine the relationships between postoperative enophthalmos, preoperative enophthalmos, and fracture sizes in adults with inferior orbital wall fractures. The records of 31 patients who had operations for pure orbital floor blowout fractures from March 2003 to February 2004 were retrospectively reviewed. Using the Picture Archiving Communication System, we measured fracture sizes according to the orbital computed tomography results. We calculated fracture sizes according to the supposition that the fracture was a 2-dimensional figure. Hertel exophthalmometry was performed on preoperative day 1 and 3 months postoperatively. Mean changes of enophthalmos were 2.80 mm (P < 0.05, paired t test). The mean fracture size was 6.11 cm(2) (range, 3.56-11.73 cm(2)). Fracture size was a more accurate predictor of postoperative enophthalmos than the degree of preoperative enophthalmos (Pearson correlation; with preoperative enophthalmos = 0.513, with fracture size = 0.743, P < 0.05). In linear regression analysis, preoperative exophthalmometry measurements contributed approximately 27.1% to postoperative enophthalmos, whereas fracture size contributed approximately 54.3% (P < 0.05). In multiple regression analysis, the equation was Y = 0.313X + 0.464X' - 0.684 (X is the size of fracture; X', preoperative exophthalmometry measurement). The above 2 factors explained 82.3% of the total postoperative enophthalmos variance. Other factors, which contribute approximately 18%, might include time between insult and corrective surgery. In our study, fracture size was a better predictive factor for postoperative enophthalmos than preoperative exophthalmometric measurement. With our method, postoperative enophthalmos can be predicted more conveniently in a clinical setting, and decisions regarding the timing of early surgical reduction were made easier.

Can Systematic Computed Tomographic Scan Assessment Predict Treatment Decision in Pure Orbital Floor Blowout Fractures?

To describe and evaluate the reliability and the accuracy of a specific computed tomography-based assessment in predicting treatment decisions for pure orbital floor blowout fractures (BOFs). In this retrospective cohort study, the charts of all patients presenting with isolated BOFs from January 2009 through April 2011 at the University Hospital of Geneva were reviewed. The systematic computed tomographic assessment included the following 3 parameters: 1) ratio of the fractured orbital floor; 2) maximal height of periorbital tissue herniation, and 3) a 4-grade muscular subscore describing the position of the inferior rectus muscle relative to the level of the orbital floor. The parameters' predictive value regarding the treatment decision (conservative vs surgical) was assessed by logistic regression and relative operating characteristic curves. Forty-eight patients (24 male) were included. The patients' mean age was 49.5 years. The ratio of the fractured orbital floor, the maximal height of periorbital tissue herniation, and the muscular subscore were significant predictors in univariate analysis (P = .02, P = .006, P = .001, respectively), whereas, in a multivariate analysis, only muscular subscore remained a significant predictor (P = .003) and reached a similar predictive ability as the 3 parameters together. The present study showed that the severity of inferior rectus muscle displacement is the most important independent predictive radiologic factor in the treatment decision-making process for pure BOFs. This systematic computed tomographic assessment is a valuable tool for a better understanding of BOF management overall. Further studies are needed to establish its clinical relevance.