Residual Diplopia Research Articles

Outcomes of Strabismus Surgery Following Teprotumumab Therapy

PurposeTo investigate the results of patients undergoing surgical treatment for strabismic diplopia in thyroid eye disease (TED) following teprotumumab. DesignMulticenter, retrospective, case series. MethodsWe report 28 patients who underwent extraocular muscle surgery for strabismic diplopia after treatment with teprotumumab at 7 different academic centers. Elapsed time from last teprotumumab dose to the date of surgery, previous orbital decompression, primary preoperative horizontal and vertical deviation, surgical procedure, and 2-month postoperative results were collected from the patient records. ResultsSixteen (57%) patients were diplopia-free after one surgery. Three (11%) chose prism spectacles to correct residual diplopia, 2 (7%) used compensatory head posture to resolve diplopia, and 1 (4%) had intermittent diplopia and was functionally improved (choosing no prisms or further surgery). These were considered treatment successes. Three (11%) patients required reoperation, and all were diplopia-free after their second procedure. ConclusionsMost patients requiring surgery for strabismic diplopia following teprotumumab achieve good outcomes with success rates comparable to series published before the availability of teprotumumab.

Impact of Diplopia and Ptosis From Lingering Third Nerve Palsy After Treatment of Cerebral Aneurysms.

Third nerve palsies (TNPs) may not resolve after intervention for intracranial aneurysms that have compressed the nerve. The disability related to this lingering condition has not been assessed with the support of patient self-report. A single-institutional retrospective study of patients with TNP who had undergone interventions for intracranial aneurysms. We used residual primary-position diplopia, a narrow zone of single binocular vision, and vision-obscuring ptosis to divide TNP recovery into complete, incomplete nondisabling, and incomplete disabling outcomes based on medical record documentation and patient self-report derived from telephonic interviews. In a cohort of 33 patients, 13 (39%) had complete TNP recovery. There were 11 patients (33%) with lingering visual disability from diplopia or ptosis present before ophthalmic interventions. Of the 6 patients who underwent ophthalmic interventions, visual disability was relieved in only 2 patients, leaving 9 patients (27%) with lingering impairment in instrumental activities of daily living. Telephonic interviews of 23 patients (70% of the cohort) confirmed that the outcome criteria we applied were accurate in assessing visual disability in 17 patients (74%). Univariate analysis using the Fisher exact test showed that aneurysmal clipping as a treatment modality was the only clinical feature associated with a favorable TNP outcome. In applying a novel method of assessing disability, this study showed that more than one-quarter of patients undergoing procedures for brain aneurysms had lingering disability from third nerve palsy-associated diplopia or ptosis, despite later ophthalmic interventions. Patient self-report gleaned from telephonic interviews was valuable in largely validating the assessment method derived from medical records and in revealing differences between physician and patient estimation of disability.

A case series of surgical outcomes for orbital blowout fracture with extraocular muscle entrapment.

Although early surgical intervention to avoid muscle degeneration in patients with blowout fractures (BOFs) and extraocular muscle entrapment is recommended, there is still no gold standard for the surgical timing of extraocular muscle release. This study aimed to present our 10-year experience with surgical outcomes in BOF patients with extraocular muscle entrapment to provide supporting data for determining the surgical timing for better outcomes. We conducted a retrospective study of patients with BOFs with extraocular muscle entrapment who underwent surgery at a tertiary hospital between December 2009 and October 2019. Their demographics, causes of injury and clinical features including limitation of extraocular movement (EOM) and diplopia were collected. Patients diagnosed with BOF with extraocular muscle entrapment accounted for 3.08% (21/681) of all cases of BOFs over a 10-year period. The patients comprised 20 males and 1 female, with a median age of 17.0 years (IQR, 13-25 years). All 21 patients had diplopia preoperatively, and 20 had EOM limitations. Nausea and vomiting were observed in 5 patients (23.8%). Surgery was performed within 48 hours after injury in 19 cases (within 24 hours in 13 cases), with a median of 17.0 hours (IQR, 11-27). The median operative time was 47.5 minutes (IQR, 31.2-73.7 minutes). The median follow-up period was 9.0 months (IQR, 7-12). At the last follow-up, 4 patients still had EOM limitations and 3 had residual diplopia; however, this did not interfere with their daily activities. Early diagnosis through facial computed tomography and physical examinations and early intervention showed successful surgical outcomes of BOF with extraocular muscle entrapment.

Quantitative analysis of diplopia following orbital fracture repair

Orbital fractures can result in devastating functional complications to sight and well-being, yet our understanding of functional sequelae post reconstruction is not well understood in the literature. This research retrospectively analysed the activity of a specialist orbital surgeon over five years to evaluate the incidence of, and risk factors for, debilitating complications such as diplopia and restriction of extraocular movement. Orbital fracture cases repaired between 1 January 2015 and 31 December 2019 were retrospectively analysed. Demographics, orthoptic assessment, injury classification, timing, operative details, outcomes, and complications were recorded. Preoperative and postoperative binocular single vision scores (BSV) were recorded to calculate the effect of orbital repair on residual diplopia. Of 582 patients undergoing orbital access, 472 cases of orbital wall reconstruction satisfied the inclusion criteria, of which 162 (34%) were Jaquiéry 4 or 5. Overall, 10.6% had complications, 4.9% had diplopia, and 5.7% were returned to theatre. All those with residual diplopia had had it preoperatively, and had evidence of an improvement in BSV score. Time to surgery, material, and pure orbital fractures had a significant impact on the incidence of diplopia. Defect size did not. Whilst complication rates were low we conclude that strict adherence to a defined surgical protocol, postoperative imaging, and objective assessment of postoperative function are central to maintaining these standards. Objective orthoptic analysis of patients before and after orbital repair is critical to our understanding of this pathology. Whilst preoperative prediction of the persistence of long-term diplopia currently eludes us, further research should target it.

Fleeting diplopia and wobbly feet: Miller-Fisher syndrome-presenting as bilateral abducent nerve palsy

A case report of a healthy young male, presented with binocular diplopia of sudden onset with mild bilateral abduction limitation, progressed rapidly to near total ophthalmoplegia. Rest of the ophthalmic examination, blood pressure, and magnetic resonance imaging of brain were normal. Basic blood work-up was normal except mildly raised serum triglycerides. He gave a history of mild giddiness and ataxia. Neurological evaluation done showed absent deep tendon reflexes and serum anti-GQ1b antibody was raised. A diagnosis of Miller-Fisher syndrome was made and he was given intravenous immunoglobulin. Post-treatment his ocular motility recovered well, with minimal residual diplopia noted for distance. In individuals with abducent nerve palsy, normal imaging, and no systemic risk factors, a careful history asking for subtle neurological symptoms and a complete central nervous system examination is warranted to rule out conditions like Miller-Fisher syndrome which may not be a familiar entity to many ophthalmologists.

Orbital Fractures With Concomitant Ocular Nerve Palsy: An Insidious and Potentially Misleading Association in Surgical Decision-Making

Orbital fractures (OFs) are common, but their association with concomitant traumatic ocular nerve palsy (TONP) is exceptional and may potentially cause confusing clinical pictures of oculomotor involvement. The purpose of the present study is to describe a series of patients with OFs and concomitant TONP following facial trauma and to evaluate clinical features, diagnostic pitfalls, and final functional outcome. The investigators designed and implemented a retrospective case series and enrolled a sample of patients with OFs and concomitant TONP who had been managed at the University Hospitals of Geneva between 2013 and 2020. The primary outcomes were clinical pitfalls (diagnosis of neurogenic vs restrictive ocular motility pattern at baseline) and final functional outcome (persistent symptomatic diplopia). Other study variables included demographic and injury related parameters. The sample was composed of 10 patients with a mean age of 40.7±12.3years (range 21 to 53years) and 80% were men. In all patients, the diagnosis of the neurogenic component accounted for the main diagnostic pitfalls associated to the baseline post-traumatic limitation of ocular motility and diplopia. Six patients (60%) had a full spontaneous recovery of their diplopia. Four patients (40%) had a partial recovery with residual diplopia. Of these 4 patients, 1 patient underwent corrective strabismus surgery, 2 had temporary occlusion of 1 eye, and 1 had Fresnel prisms. At the final follow-up visit none of the patients had persistent symptomatic diplopia. The present study has shown that OFs with concomitant TONP entail complex ocular motility patterns of neurogenic and/or restrictive origin; the diagnosis of the neurogenic component represents the main clinical pitfall that warrants a careful orthoptic evaluation to ensure the appropriate management; the final outcome was favorable with no persistent symptomatic diplopia in any of the patients.

Аналіз результатів реконструктивно-відновних операцій при посттравматичних дефектах орбіти за методами комп’ютерного моделювання

Treatment of patients with post-traumatic orbital defects is relevant problem of ophthalmology and maxillofacial surgery. Residual diplopia or dislocation of the eyeball leads to disability, social maladaptation and development of psychoemotional disorders in patients. In this paper, we present an evaluation of treatment of patients with posttraumatic orbital wall defects based on the retrospective comparative analysis of CT data by computer simulation before and after reconstruction. When comparing the volume of the injured orbits before and after the operation (average volume difference was 2.7 ± 0.9 cm3), a significant improvement was found in terms of recovery of the orbital volume. The factors influencing the treatment effectiveness were determined based on the calculation of the volume of the orbits on the healthy and injured side in the software environment before and after the reconstruction. The causes of the detected cases of incomplete recovery of the orbital volume were analyzed. The solution to the problem of restoring the orbital volume is in the plane of restoring the geometry of the orbit because previous adaptation of the shape of the standard plate to its anatomical structure with overlapping defect on the stereolithographic model provided the best end result. Conclusions. Personalized adaptation of the implants to the shape of the orbit or individual production thereof can increase the accuracy of the orbital volume restoration, which can increase the effectiveness of eliminating complications such as enophthalmos and diplopia. The effectiveness of treatment of post-traumatic orbital defects by traditional methods directly depends on the severity of the damage, the degree of which determines the magnitude of the change in the orbital volume. However, the greater is the volume of the orbit changes as a result of the injury, the worse is the prognosis for its recovery. Development of the ways to individualize implants and evaluate their effectiveness is an important area for further research. Keywords: post-traumatic orbital defects, reconstructive surgery, computer simulation.

Medial rectus disinsertion for management of chronic complete sixth nerve palsy.

To report the outcomes of the medial rectus (MR) disinsertion procedure for the management of refractory esotropia (ET) with or without Abnormal head posture (AHP) in chronic complete sixth nerve palsy. This is a retrospective case series of patients with sixth nerve palsy who suffered from residual ET and diplopia following the conventional strabismus surgeries and underwent MR disinsertion procedure between April 2017 and February 2020. This procedure was offered to the patients who declined to use prism and did not wish to perform surgery on the fellow eye. The demographic and clinical data, including sex, age, visual acuity, pre and postoperative angle of strabismus, duction limitations, results of forced duction and force generation tests, details of prior strabismus surgeries, orbital CT scan findings, and follow up duration were collected from the medical records. Six patients were enrolled in this study. Mean age was 35.0 ± 14.0 years, and mean follow-up was 15.3 ± 5.9 months. The ET at the Primary position (PP) was 35.0 ± 18.4 prism dioptre (PD) before MR disinsertion, which decreased to 14.2 ± 17.4 PD after MR disinsertion procedure. Four cases needed additional complementary surgeries to improve residual ET in PP. No case developed overcorrection. Abduction deficiency was -5.0 ± 1.3 before MR disinsertion, which improved to - 2.8 ± 0.5 units at last follow-up. The mean of induced adduction deficiency was - 2.9 ± 0.4 at last follow-up. MR disinsertion can be considered in patients with chronic complete sixth nerve palsy and refractory diplopia when the conventional methods have failed.

STRABISMUS MANAGEMENT AFTER ORBITAL BLOWOUT FRACTURE

Orbital floor fractures (OBF) account for 40% of mid-facial injuries and are therefore the most common of all trauma injuries in this region. The post-treatment complication that often follows orbital floor repair is residual diplopia or 1 persistent diplopia and is seen in 86% of the OBF cases. The causes for persistent diplopia can be varied and is often related to the degree of inflammation, trauma to 2 musculature, fat or nerves and surgical timing. Some of the common causes of the same are - malpositioning of the globe, fibrosis of the inferior fibro fatty muscular complex following trauma, direct damage to an extraocular muscle (commonly inferior rectus muscle), local injury to a motor nerve, ischemia (or compartment syndrome), iatrogenic damage during reconstructive surgery or entrapment under improperly placed alloplastic material. Our case report mentions a rare case of persistent vertical diplopia even after successful repair of orbital blowout fracture. A 15-year-old male patient following a road traffic accident presented with persistent headache and vertical diplopia. The patient was evaluated by a oral maxillofacial surgeon and a presumptive diagnosis of a case of large orbital floor fracture with entrapment of inferior rectus muscle was made which was confirmed on CT Scan. He was managed surgically by reduction of the fracture and fixation with a titanium mesh. 2 weeks post-surgery he reported to the squint clinic with complaints of persistent double vision. On comprehensive ocular examination, it was found that patient had vertical diplopia with limitation of infraduction in the left eye with negative FDT, on re-evaluation of MRI scans with 1 mm cuts, a partial left inferior rectus tear was seen and documented as the cause of persistent diplopia. Patient was treated conservatively by prescribing prismatic glasses with fusional exercises. After 6 months of follow up, the patient was relieved of diplopia in primary position but there was a residual hypotropia in downgaze for which he was prescribed prisms only for downgaze.

Effects of orthoptic training for residual diplopia after surgical repair of blowout fractures.

To investigate the effects of orthoptic training for residual diplopia after blowout fracture (BOF) surgery. We retrospectively reviewed the medical records of 14 (average age, 22.9 ± 13.1years) patients with residual diplopia, who had undergone orthoptic training after BOF surgery at the Department of Ophthalmology, Kindai University Hospital, between August 2013 and September 2019. The orthoptic training included exercises for eye movement, convergence, and fusional area expansion. We assessed the training effects by scoring patients' Hess screen (Hess) test results and fields of binocular single vision (BSV). The scores obtained before/after surgery and after training were compared. We also investigated the factors that influenced patients' BSV scores after training. p < 0.05 was considered statistically significant. The respective pre- and postoperative and after-training average scores were 7.0 ± 5.3, 5.4 ± 4.3, and 2.5 ± 3.2 points for Hess and 50.0 ± 41.3, 48.2 ± 35.9, and 89.4 ± 14.0 points for BSV. Neither Hess nor BSV score showed a significant difference before and after surgery (p > 0.05, the Steel-Dwass test). Compared to the postoperative (i.e., before training) scores, both Hess and BSV scores significantly improved after training (p < 0.05 for Hess, p < 0.01 for BSV; the Steel-Dwass test). Orthoptic training appeared effective in resolving residual diplopia after BOF surgery by improving patients' ocular motility and expanding the BSV field.

Does Early Treatment of Paediatric Orbital Fracture Offer Any Advantage in Terms of Post-Operative Clinical Outcomes.

Trapdoor fractures commonly occur in children below 6years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24h to greater than 2weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex. A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies. A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24h to more than 1month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48h. Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.

Surgical strategy for third nerve palsy with aberrant regeneration: Harnessing the aberrant power.

Purpose:Our study aimed to evaluate the outcome of contralateral eye (CE) fixation duress squint surgery (FDSS) in third nerve palsy (3rd NP) with aberrant regeneration and compare the postoperative ptosis correction with preoperative ptosis improvement on adduction.Methods:Patients of 3rd NP with aberrant regeneration who underwent CE FDSS between December 2012-July 2015 in a tertiary-care eye hospital with a follow-up period of 1-year were retrospectively studied to analyze preoperative and postoperative details. Surgical success was defined as the correction of ptosis within 1 mm of preoperative ptosis improvement during maximal adduction of the affected eye, postoperative alignment ≤10Δ, and resolution of subjective diplopia in primary position.Results:A total of 14 eyes in 14 patients (mean age 23.6 ± 13.6 years) were included. Mean preoperative exotropia and ptosis in primary position in 14 patients was 53.4 ± 20pd and 4.89 ± 2.9 mm, respectively, and mean hypotropia in 6 patients was 23.67 ± 5.89pd. The mean improvement of ptosis on adduction and supraduction in all patients was 4.07 ± 2.64 mm and 2.89 ± 2.22 mm, respectively (P = 0.213). All patients underwent large recession of CE lateral rectus (mean 12.4 ± 2.7 mm), 9 patients underwent CE medial rectus resection/plication (mean 6.0 ± 0.9 mm) and 6 patients underwent CE superior rectus recession (mean 6.6 ± 0.67 mm). Postoperatively, mean ptosis and exotropia correction was 3.7 ± 2.4 mm (P = 0.000) and 15 ± 9.6pd (P = 0.000), respectively, and mean hypotropia was 2.17 ± 4.02pd (P = 0.000). Surgical success was achieved in 6 patients. Postoperative ptosis correction showed strong positive correlation with preoperative improvement of ptosis on adduction (r = 0.87; P = 0.00).Conclusion:Preoperative lid excursion on adduction in 3rd NP can be regarded as a prognostic sign of the success of CE FDSS which can simultaneously correct both ptosis and squint.

Carotid-Cavernous Fistula Presenting With Bilateral Abducens Palsy.

Carotid-Cavernous Fistula Presenting With Bilateral Abducens Palsy.

Three-Dimensional Diagnosis in Orbital Reconstructive Surgery.

Introduction:Orbital floor fractures are common among mid-face fractures. The general aim of treatment is to restore orbital volume and anatomy with grafts or reconstructive materials. Malpositioning of the implants and inadequate volume restorations are common complications of these procedures. The aim of our study is to present the surgical outcomes of orbital reconstruction aided by our algorithm of patient-specific virtual planning.Materials and Methods:The current study was performed on 77 patients with orbital wall fractures who were categorized into two groups: Group A – 42 patients (virtual planning) and Group B – 35 patients (traditional approach). Criteria of analysis included the presence of diplopia postoperatively and duration of surgical procedures.Results:Diplopia was recorded right after surgery in 16 cases (38.1%) of Group A and in 12 cases (34.3%) of Group B. However, 6 months postreconstruction, residual diplopia was recorded in 4 cases (9.5%) of Group A and in 12 cases (34.3%) of Group B. Mean operation time in Group A for the patients with isolated zygoma fracture was 2.23 h; for isolated orbital wall fracture was 1.98 h; and for combined zygoma, orbital wall, and facial bone fracture was 3.07 h. In Group B, these indexes were 3.47, 2.05, and 3.31 h, respectively.Conclusions:Application of virtual planning could significantly improve postoperative outcomes in orbital reconstruction. However, application of this technology could be limited by complicated defects of the orbital walls, which would require complex shape of the implant that might be difficult to be prevent virtually.

An audit of residual diplopia following repair of midfacial fractures

Introduction Orbital fractures often result in diplopia. Surgical repair of such fractures can also often result in post-operative diplopia, a common surgical complication. This can be due to incomplete removal of extraocular muscles and orbital tissue from fracture sites or entrapment of orbital tissue by implant placement, neuromuscular trauma or Orbital Adherence Syndrome.

Correction of Posttraumatic Enopthalmos: Still a Challenge

Orbital reconstruction is very challenging due to complex anatomy of the orbit and desirable functional and aesthetic results. Timing of intervention, indications for open reduction, choice of implant material, and placement play a very crucial role in the treatment protocol. Correction of posttraumatic enophthalmos and residual diplopia remain difficult to achieve and even sometimes need secondary revision. In the present case, we have discussed about the correction of posttraumatic enophthalmos and the challenges faced during and postsurgery and review about the management protocol for orbital reconstruction.

Pure Orbital Trapdoor Fractures in Adults: Tight Entrapment of Perimuscular Tissue Mimicking True Muscle Incarceration with Successful Results from Early Intervention

Orbital trapdoor fractures (OTFs) entail entrapment of intraorbital soft tissues with minimal or no displacement of the affected bones and are almost exclusively seen in children. This article aimed to report the diagnosis and treatment of an OTF of the floor in an adult patient and to critically review the literature regarding the management aspects of this specific subset of orbital blowout fractures in adults. A 29-year-old man presented with limitations of vertical right eye movements owing to blunt orbital trauma. The patient mainly complained of double vision in upper gazes and some episodes of nausea. Neither floor defect nor significant bone displacement found on orbital computed tomography, while edema of inferior rectus muscle was apparent. The patient underwent surgical repair 5 days later; a linear minimally displaced fracture of the floor was recognized and complete release of the entrapped perimuscular tissues was followed. Within the first week postoperatively, full range of ocular motility was restored, without residual diplopia. This case was the only identified pure OTF over a 6-year period in our department (0.6% of 159 orbital fractures in patients >18 years). By reviewing the literature indexed in PubMed, a very limited number of either of isolated case reports or retrospective case series of pure OTFs has been reported in adults. Contrary to the typical white-eyed blowout fractures, the literature indicates that OTFs in adults seem to not always constitute absolute emergency conditions. Although such fractures need to be emergently/ immediately treated in children, in the absence of true muscle incarceration, adults may undergo successful treatment within a wider but either early or urgent frame of time. Adults frequently exhibit vagal manifestations and marked signs of local soft tissues injury.

Early Experience With Nonporous Polyethylene Barrier Sheet in Orbital Fracture Repair.

The aim of this study was to evaluate the efficacy of the nonporous polyethylene barrier sheet as an alternative for nylon foil (SupraFOIL) implants in repair of orbital fractures. This is a prospective, case series using the Stryker 0.4-mm-thick nonporous polyethylene barrier sheet in all patients over the age of 18 years presenting with orbital fractures from December 2014 to June 2015. Patient's age, location of fracture, etiology of injury, presence of preoperative restriction and diplopia, and postoperative diplopia and/or enophthalmos was recorded. Institutional review board approval was received, and consent was obtained from all participants. Patients were followed for at least 6 months when possible. Scanning electron microscopy was used to compare the thickness, surface characteristics, and porosity of the nonporous polyethylene barrier and nylon foil implants. Beam deflection testing was also performed to compare the biomechanical properties of each implant. Forty-six patients who underwent repair of orbital fractures with the nonporous polyethylene barrier sheet were included in this series. Average age was 43.3 years (range: 18-84 years). Twenty-six of 46 patients (56.5%) were males, and 20 (43.4%) were females. The most common causes of injuries were assault (38.3%), falls (25.5%), motor vehicle accident (14.9%), and sports related (10.5%). Twenty of 46 patients (43.4%) had isolated orbital floor, and 2 patients (4.3%) had isolated medial wall fractures. Fifteen patients (32.6%) had combined floor and medial wall fractures involving the inferomedial orbital strut, and 9 (19.6%) had floor fractures associated with zygomaticomaxillary complex or lateral wall fractures. Twenty-eight patients (60.9%) had preoperative diplopia. Timing of surgery was between 3 and 55 days, with the median of 11.5 days. Five of 46 patients (10.8%) had residual diplopia at their 1-week postoperative visit, 4 of those patients' diplopia had resolved at 2 months postoperatively. One patient had residual diplopia at 6-month follow up. Electron microscopy showed that the 0.4-mm nonporous polyethylene barrier implant was thinner (0.33 mm) than expected and thinner than 0.4-mm SupraFOIL (0.38 mm). Scanning electron microscopy exhibited that the surface of the nonporous polyethylene barrier was smooth and nonporous. Beam deflection testing showed that for small forces (<100 mN), the 2 materials behaved nearly identically, but at higher forces, the nonporous polyethylene implant exhibited less stiffness. The use of nonporous polyethylene barrier sheet implant for orbital fracture repair is a safe and effective alternative to nonporous nylon foil implants. There were no complications and one case of residual diplopia (2.1%) in this case series.

Polyester Urethane Implants for Orbital Trapdoor Fracture Repair in Children

The objective of this study was to present the surgical and clinical outcomes of polyester urethane implants in orbital trapdoor fracture repair in children. This is the first study reporting on the use of polyester urethane implants to repair orbital fractures. A retrospective review was performed of children with orbital trapdoor fracture who underwent surgical repair in the authors' medical center over 6years. The trapdoor fracture diagnosis was based on clinical and computed topographic findings. Eight patients with trapdoor fracture were identified. All cases were repaired by polyester urethane implant placement. Patients' mean age was 13.5years and mean follow-up was 13.6months. All patients had orbital floor fractures. Two fractures also involved the medial wall. Seven patients had inferior rectus muscle entrapment and 1 had medial rectus muscle entrapment. Three patients had residual diplopia on extreme upgaze after the surgical repair. No patient had enophthalmos or infraorbital paresthesia at the end of follow-up. No postoperative complications associated with the used material were reported. The polyester urethane implant is a reliable, safe, inexpensive, and effective implant for trapdoor fracture repair in children. It can serve as a promising alternative to implants fabricated from other synthetic materials for orbital floor fracture repair.

Functional Outcomes of Late Posttraumatic Enophthalmos Correction.

Posttraumatic enophthalmos has debilitating functional consequences, resulting in restriction of ocular motility and diplopia. Surgical correction aims to restore the globe position and ultimately improve function. This study evaluates the functional outcome of posttraumatic enophthalmos repair. Patients included in this study had posttraumatic enophthalmos and diplopia requiring enophthalmos repair. Diplopia was graded from 0 (no diplopia) to 4 (constant diplopia) based on the Functional Diplopia Grading Scale. Limitations of eye movements were recorded in the vertical, horizontal, and torsional directions. Data were gathered prospectively at preoperative assessment, postenophthalmos repair, and final follow-up. Between 2002 and 2014, 41 patients fulfilled inclusion criteria. Substantial functional improvement, defined as a decrease of greater than or equal to 1 grade of diplopia, was achieved in 65.9 percent of patients (27 of 41) after all surgical interventions. Patients with residual diplopia (34 of 41) after enophthalmos surgery were managed with secondary strabismus surgery (10 of 34) and/or prism glasses (four of 34). After all interventions, vertical restrictions improved from -1.95 ± 1.13 to -1.06 ± 0.98. Horizontal restrictions improved from -0.88 ± 0.62 to 0.59 ± 0.6. Adequate clinical correction of enophthalmos to within 2 mm of the contralateral globe was achieved in 37 of 41. This is the largest case series evaluating functional outcomes of patients undergoing posttraumatic delayed enophthalmos repair. A multidisciplinary care approach resulted in improved globe position and eye movement, and improvement of diplopia. Further studies with larger sample sizes are needed to better understand and treat this important and challenging problem. Therapeutic, IV.