Transcaruncular Approach Research Articles

Postoperative Changes in Isolated Medial Orbital Wall Fractures Based on Computed Tomography.

The treatment has been improved on the accurate reduction of blow-out fracture for many decades. But still, it has been limited to reduce completely when surgeons are approaching by conventional technique. The authors analyzed the postoperative results using computed tomography (CT) scans after conventional open reduction of isolated medial wall fracture. Thirty-seven patients with isolated medial wall fracture were reviewed. All patients underwent preoperative, immediate, and postoperative CT scans. Two surgeons have performed the surgery by conventional open reduction with transcaruncular approach and absorbable mesh insertion. The authors evaluated changing orbital volume and distance, comparing the immediate and 6 months postoperative outcomes with preoperative outcome. The differences between immediate postoperative and 6 months postoperatively data were statistically evaluated. The authors used the distant value to minimize bias of CT view selection. Significant differences from the 2 kinds of data were observed (P < 0.05 for volume, P < 0.01 for distance, Paired t test). Bone remodeling process after conventional open reduction of orbital wall has not been fully understood. Most popular technique is conventional open reduction and mesh insertion but it is not easy for surgeons to reduce fractured bones completely. The authors analyzed the bone remodeling after incomplete reduction. These results suggest that the decreased measurements might be caused from the scar contracture with fibrosis. This research is very limited to explain the change while bone remodeling is progressed. Further research should be continued to discover the understanding of the process.

Usefulness of a Transconjunctival Approach in the Reconstruction of the Medial Blow-Out Wall Fracture.

BackgroundA transcaruncular approach is typically used for reconstructions of medial wall fractures. However, others reported that a transconjunctival approach was conducive for securing an adequate surgical field of view. In this study, we aimed to examine the extent of repair of medial wall fracture via a transconjunctival approach.MethodsWe retrospectively reviewed the medical records of 50 patients diagnosed as having medial wall fracture via preoperative computed tomography and who underwent surgery between March 2011 and February 2014. The fracture location was defined by dividing each of the anterior-posterior and superior-inferior distances into three compartments.ResultsA transcaruncular approach was used in 7 patients, while the transconjunctival approach was performed in the remaining 43 patients. The transconjunctival approach enabled a relatively broad range of repair that partially included the front and back of the medial wall, and was successful in 86% of the entire study population.ConclusionIt is known that more than 50% of total cases of the medial wall fracture occur mainly in the middle-middle portion, a majority of which can be reconstructed via a transconjunctival approach. We used a transconjunctival approach in identifying the location of the fracture on image scans except for cases including the fracture of the superior portion in patients with medial wall fracture. If it is possible to identify the location of the fracture, a transconjunctival approach would be an useful method for the reconstruction in that it causes no damages to the lacrimal system and is useful in confirming the overall status of the floor.

Using the Endoscopic Transconjunctival and Transcaruncular Approach to Repair Combined Orbital Floor and Medial Wall Blowout Fractures.

To demonstrate the effectiveness of the endoscopic transcaruncular and transconjunctival approach in the repair of combined medial and inferior orbital wall fractures. A retrospective chart review was conducted on 160 patients with combined medial and inferior orbital wall fractures. All patients underwent surgery via an endoscopic transcaruncular and transconjunctival approach without lateral canthotomy, performed by a single surgeon. Porous polyethylene sheets (1.0 mm in thickness) were implanted to cover the orbital defects. The minimal postoperative follow-up period was 6 months. The authors evaluated enophthalmos, diplopia, and ocular motility pre and postoperatively and report surgical complications. A total of 160 patients were included, comprising 121 men and 39 women. The mean patient age was 33.9 ± 14.1 years, and the mean postoperative follow-up period was 12 months. The average enophthalmos was 3.20 mm preoperatively, and the mean improvement at 6 months after surgery was 2.82 mm. One patient suffered a canalicular laceration after surgery, and another retrobulbar hemorrhage; however, both of these complications resolved with appropriate management. Otherwise, there were no significant surgical complications including newly developed diplopia, decreased visual acuity, or cerebrospinal fluid leakage. The endoscopic transcaruncular and transconjunctival approach is a useful and promising technique to repair combined medial and inferior orbital wall fractures.

Reconstruction of Large Orbital Posterior Floor Wall Fracture Considering Orbital Floor Slope Using Endoscope.

Reconstruction of a large orbital fracture extending to the posterior wall of the maxillary sinus is difficult and challenging. In this study, the authors present transconjunctival or transcaruncular approach using endoscopy and layered porous polyethylene barrier sheets to manage large orbital floor wall fracture. A retrospective review of all patients who underwent reconstruction of large orbital floor wall fractures between June 2009 and July 2015 was conducted. Patient demographics, degree of enophthalmos, ocular motility and diplopia test results, and surgical complications were reviewed. This study included 53 eyes of 53 patients. The mean time from trauma to surgery was 34.1 days (range, 1-360 days). The average postoperative follow-up period was 6.1 months (range, 3-14 months). The degrees of enophthalmos preoperatively, and 1 week, 1 month, and 3 months postoperatively were -1.98 mm (range, -1.5 to -3 mm), 0.13 mm (range, -1.0 to +1.5 mm), -0.09 mm (range, -2.0 to +1.5 mm), and -0.43 mm (range, -2.0 to +1.0 mm), respectively. The mean improvement in enophthalmos at 3 months postoperation was 1.55 mm (P < 0.001). There was only 1 patient with residual 2 mm enophthalmos at 3 months postoperation. There were no definite surgical complications in any patient. Sufficient dissection to the posterior extent of the fracture and reconstruction of the orbital floor slope are the most important surgical factors to prevent residual enophthalmos. The authors believe using an endoscope and layered porous polyethylene are effective techniques in challenging patients with large orbital wall fracture.

MINIMALLY INVASIVE METHODS OF SURGICAL TREATMENT OF ENDOCRINE OPHTHALMOPATHY

“Balanced” bone decompression of the orbit was performed in a patient with endocrine ophthalmopathy, CAS3, OD=30 mm, OS=31 mm with the use of minimally invasive transconjunctival approaches and frameless neuronavigation. At the first stage the preoperative computed tomography of the orbits was imported into the navigation software, and then marked the area of the proposed resection of the orbit walls. Further, in the operating room, the patient was registered in the navigation system. To perform bone decompression of the orbit and lipectomy, we used preseptal, transcaruncular and lateral retrocanthal approaches. These approaches are transconjunctival and do not leave postoperative scars. Upon completion of the orbitotomy, its accuracy and dimensions were determined by the intraoperative pointer of the neuronavigation system. Results. The postoperative period was uneventful. In the early postoperative period there was a regression of exophthalmus OD=26 mm, OS=27 mm, closure of the eye gap, but retraction of the eyelids remained. When examined 3 months after the operation, the exophthalmic regression was OD=23 mm, OS=24 mm, retraction of the eyelids — 1 mm, with lead — finishing to the lateral adhesion. When examined after 6 months — the position of the eyeballs in orbit: ОD=21 mm, ОS=22 mm, retraction of the eyelids is not present, there is no violation of oculomotorics, complications were not recorded. A satisfactory result was obtained. Conclusion. Minimally invasive transorbital approaches allow the transconjunctival acces to all orbital walls to perform decompression of the orbit and lipectomy without cutaneous incisions, to achieve good cosmetic and functional results. And the intraoperative use of the neuronavigation system ensures the bone decompression of the orbit in full. The technique is promising and requires further randomized studies.

An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair.

Recent advancements in computed tomography have enabled the diagnosis of naso-orbito-ethmoid (NOE) fractures to be made in much greater detail. Surgical access to the upper nasofrontal buttress in NOE fractures, however, has remained unchanged over the past decades. All approaches to these fractures using skin incisions have individual drawbacks. The transcaruncular approach is free of the drawbacks of the cutaneous approaches. We further extended the transcaruncular approach for the treatment of NOE and Le Fort II fractures. Eight patients; six with Markowitz's Type I NOE fractures and two with Le Fort II fractures, underwent fracture repair using an extended transcaruncular approach to access the upper nasofrontal buttress. In all but one case, which required an additional small skin incision on the glabella, the fracture on the upper nasofrontal buttress was repaired through an extended transcaruncular approach without making any skin incisions. All showed excellent fracture re-alignment on post-surgical CT. Complications happened in three cases; those in two cases were attributed to the extended transcaruncular approach, whereas those in the other were not. The extended transcaruncular approach is a promising alternative to current conventional approaches for NOE and Le Fort II fractures, achieving accurate repair without the need for skin incision.

Secondary Reconstruction of Residual Enophthalmos Using an Endoscope and Considering the Orbital Floor and Medial Wall Slope.

To present a transconjunctival and transcaruncular endoscopy approach involving layered porous polyethylene barrier implants to manage residual posttraumatic enophthalmos and to evaluate the effectiveness of this technique. The authors performed a retrospective review of all patients who underwent secondary reconstruction of orbital wall fractures because of residual enophthalmos between June 2008 and July 2015. Patients' demographics, degree of enophthalmos, ocular motility, diplopia test results, and surgical complications were reviewed. This study included 16 eyes (4 right eyes and 12 left eyes) of 16 patients (14 males and 2 females). The mean time interval from trauma to surgery was 7.1 months (range, 1-18 months). The average postoperative follow-up period was 6.4 months (range, 3-18 months). The degree of enophthalmos preoperatively and at 1 week, 1 month, and 3 months postoperatively was -2.47 mm (range, -2 to -3 mm), 0.5 mm (range, -0.5 to +2.5 mm), -0.06 mm (range, -0.5 to +1.5 mm), and -0.44 mm (range, -1.5 to +1.0 mm), respectively. There were no definite surgical complications in any patients. Dissection to the posterior margin of the fracture and reconstruction of the orbital floor slope are the most important surgical factors to prevent residual enophthalmos and scarring with recurrent diplopia. Demonstration of slight exophthalmos of the corrected side of about 1 to 2 mm at the end of the operation is also necessary. The authors believe that surgery using an endoscope and layered porous polyethylene is very useful for secondary reconstruction.

Considerations for the Management of Medial Orbital Wall Blowout Fracture.

Recently, diagnoses of and operations for medial orbital blowout fracture have increased because of the development of imaging technology. In this article, the authors review the literature, and overview the accumulated knowledge about the orbital anatomy, fracture mechanisms, surgical approaches, reconstruction materials, and surgical methods. In terms of surgical approaches, transcaruncular, transcutaneous, and transnasal endoscopic approaches are discussed. Reconstruction methods including onlay covering, inlay implantation, and repositioning methods are also discussed. Consideration and understanding of these should lead to more optimal outcomes.

Transcaruncular Approach for Treatment of Medial Wall and Large Orbital Blowout Fractures.

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm(2); the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm(2). Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).

Benefits of the Retrocaruncular Approach to the Medial Orbit

Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

Correction of Medial Blowout Fractures According to the Fracture Types.

Regarding the issue of blowout fracture, a variety of approaches and surgical techniques have been reported to improve postoperative results. However, there are no extant guidelines for the selection of these various methods. The current authors classified the medial blowout fracture into 3 different types and adapted to suitable surgical techniques. Between October 2010 and March 2013, 89 patients who had medial blowout fracture were included in this study. We classified the study patients into 3 different categories: greenstick, simple, and complex. The greenstick type used the transnasal endoscopic approach and was reduced with packing after applying a silastic sheet. The simple type used an onlay covering technique. The complex type was treated using the transcaruncular approach and inlay implanting technique. After surgery, the continuity of orbital wall was checked by computed tomography. Patients were then examined for the following conditions: diplopia, eyeball movement, and enophthalmos. The greenstick category consisted of 12 cases, most cases were satisfied. One case relapsed after removal of the packing. In the simple category, a total of 9 cases were treated by onlay covering technique. In all 68 cases of the complex type, we could obtain suitable anatomical reconstruction with inlay implanting technique. Only 2 cases complained of transient diplopia and moderate enophthalmos. Appropriate clinical classification, depending on the type of fracture and selection of optimal treatment methods, could obtain the satisfactory result and improve the treatment outcomes in the correction of medial orbital wall fracture.

Evolution of the surgical approach to the orbitozygomatic fracture: From a subciliary to a transconjunctival and to a novel extended transconjunctival approach without skin incisions

In the last 20 years, surgical approach to the orbitozygomatic fracture has evolved to limit skin incisions and minimize external scars. The treatment approach to the orbitozygomatic fracture was evaluated by a retrospective chart review from 1992 to 2012, and advantages, disadvantages, and complications were studied. Surgical approach to the orbitozygomatic fracture has evolved from a subciliary to a transconjunctival approach and to a novel extended transconjunctival approach without skin incisions in the last 20 years. The greatest advantage of using an extended transconjunctival approach is the wide exposure of the inferior orbital rim, orbital floor, lateral orbital wall, and the frontozygomatic suture in an unobstructed operative field without any skin incisions. Precise assessment of the reduction at the sphenozygomatic suture is possible with a wide exposure of the lateral orbital wall. As the dissection plane in a transconjunctival approach is entirely posterior to the lacrimal apparatus, the medial incision can be placed medially beyond the lacrimal punctum and by combining this approach with the transcaruncular approach, a wide operative field for the medial orbital wall can be obtained, which is the most advantageous point for choosing a transconjunctival approach over a subciliary approach. The complication rate was comparable to a subciliary approach. The author advocates an extended transconjunctival approach for orbitozygomatic fractures to avoid skin incisions and to precisely assess the reduction status.

Medpor Implant Fixation Using Fibrin Glue in the Treatment of Medial Orbital Wall Fracture.

The optimal treatment modalities are determined based on the symptoms and degree of the bone defects in patients with medial orbital wall blowout fracture. Most of the patients in this series underwent implant surgery. However, there are many patients whose implants were not fixed during surgery. Therefore, some patients who had implant migration occurred had been reported. We have therefore used methods for applying fibrin glue (Tisseel, Baxter Healthcare, Norfolk, United Kingdom) for the fixation of implant. Between 2007 and 2013, a total of 168 patients underwent porous polyethylene orbital implant (Medpor) surgery with the application of Tisseel. All the patients underwent surgical treatments via a transcaruncular approach, for which the Medpor was used. Postoperative complications include 6 cases of the limitation of extraoccular movement, 10 cases of diplopia, and 7 cases of enophthalmos. However, there were no specific complications caused by Tisseel. All the patients were satisfied with the treatment outcomes. In this study, we report the usefulness of Tisseel in the fixation of the medial orbital wall fracture using the Medpor implant with a review of literatures.

Surgical Treatment of Dysthyroid Optic Neuropathy: Long-Term Visual Outcomes with Comparison of 2-Wall versus 3-Wall Orbital Decompression

ABSTRACTPurpose: To compare the long-term visual outcomes after 2-wall (medial-lateral) versus 3-wall (medial-lateral-inferior) orbital decompression combined with fat removal in patients with dysthyroid optic neuropathy (DON).Methods: Records of 68 eyes of 42 patients were retrospectively reviewed. Two-and 3-wall decompression was performed in 41 and 27 eyes, respectively. Transcaruncular approach was used for medial wall decompression. Lateral canthotomy combined with upper eyelid crease incision was used for lateral wall removal, and combined with transconjunctival lower eyelid incision if floor decompression performed. Outcome measures were visual acuity (VA), color vision, Hertel measures, visual field mean deviation (MD) and pattern standard deviation (PSD)Result: The mean follow-up time was 39.3 months (range, 12–72 months). All indicators of visual function significantly improved after 2-and 3-wall decompression. The improvement in VA and color vision was similar between groups. (logMAR VA: 2-wall: 0.52 ± 0.68 versus 3-wall: 0.71 ± 0.86, p = 0.335); (color vision on Ishihara plates: 2-wall: 10.1 ± 8.1 versus 3-wall: 11.6 ± 7.8, p = 0.447). The improvement in MD and PSD were higher after 3-wall decompression (MD: 2-wall: 10.0 ± 5.5 versus 3-wall: 14.3 ± 7.5 dB, p = 0.020); (PSD: 2-wall: 3.5 ± 1.9 versus 3-wall: 4.8 ± 3.0 dB, p = 0.045). Proptosis reduction was higher after 3-wall decompression (2-wall: 5.1 ± 1.3 versus 3-wall: 7.2 ± 1.9 mm, p = 0.0001). New onset diplopia was seen 20% and 28.5% of cases in 2-and 3-wall decompression, respectively. No adnexal/orbital complications were seen in 2-wall group, however orbital hematoma (1 case) and persisting eyelid edema (1 case) were encountered in 3-wall group.Conclusion: Both 2-and 3-wall orbital decompressions are safe and effective for management of visual dysfunction in DON. Although 3-wall decompression provide better improvement in the parameters of visual field analysis and Hertel measures, new onset diplopia, adnexal/orbital complications are more common with this technique.

White-eyed medial orbital wall fracture with oculocardiac symptoms.

White-eyed medial orbital wall fracture with oculocardiac symptoms.

Three-dimensional pre-bent titanium implant for concomitant orbital floor and medial wall fractures in an East asian population.

BackgroundThe objective of this article is to evaluate clinical outcomes of combined orbital floor and medial wall fracture repair using a three-dimensional pre-bent titanium implant in an East Asian population.MethodsClinical and radiologic data were analyzed for 11 patients with concomitant orbital floor and medial wall fractures. A combined transcaruncular and inferior fornix approach with lateral canthotomy was used for the exposure of fractures. An appropriate three-dimensional preformed titanium implant was selected and inserted according to the characteristics of a given defect.ResultsFollow-up time ranged from 2 to 6 months (median, 4.07 months). All patients had a successful treatment outcome without any complications. Clinically significant enophthalmos was not observed after treatment.ConclusionsThree-dimensional pre-bent titanium implants are appropriate for use in the East Asian population, with a high success rate of anatomic restoration of the orbital volume and prevention of enophthalmos in combined orbital floor and medial wall fracture cases.

Efficacy of endoscopic transcaruncular approach to reconstruct isolated medial orbital fracture

To study the efficacy of endoscopic transcaruncular approach in the repair of isolated medial orbital fracture. It was a retrospective case series study.Retrospective chart was reviewed in 21 patients (21 eyes) receiving endoscopic transcaruncular approach to reconstruct isolated medial orbital fracture at Quzhou People's Hospital from May 2011 to May 2012. of visual acuity, diplopia, protrusion degree of both eyes and the movement of eye balls was recorded for analysis. All patients were followed up for 8-20 months. There was no extrusion, rejection, infection or other complications of Medpor surgical implant during follow-up. There was no instance of decreased visual acuity at post-operation. The post-operative protrusion degree of both eyes was almost identical at less than 2 mm. The movement of eye balls was satisfactory in all directions. Diplopia disappeared in 13 cases, 1 case improved. Endoscopic transcaruncular approach is a safe and effective treatment in the repair of isolated medial orbital fracture.

Transcaruncular Approach to the Isolated Medial Orbital Wall Fracture

With technologic progress in imaging for patients with trauma, isolated medial orbital wall fractures have become an increasingly appreciated injury. Given that these injuries may cause deformity and functional deficit, reconstruction is warranted in some cases. Surgical approaches to the medial orbit have evolved, and there are particular benefits of the transcaruncular approach. This approach was used to reconstruct isolated medial orbital wall fractures for 9 patients over a 33-month period. A cadaver dissection demonstrating the approach combined with skull images is presented to illustrate anatomic details and technical points of the dissection.

Transient and Isolated Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction

Neurogenic blepharoptosis related to orbital surgery is very rare and only 1 report was published in the literature. This report presents 1 case of transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction. A 12-year-old male patient who suffered from periorbital trauma visited our hospital with right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported; however, there were no signs of either limitation of ocular motion or anisocoria. On the orbital CT images, a 17 mm × 20 mm-sized medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. After the operation, he had right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and there were no signs of anisocoria. He did not receive any additional medication for blepharoptosis and was discharged 3 days postoperation. By the ninth day of postoperative recovery, the patient still suffered from right blepharoptosis with no levator palpebrae superioris muscle function. We prescribed a low dose of oral corticosteroid and the patient was monitored on a weekly basis. Finally, he recovered completely with normal symmetric eyelid position and levator function.

Orbital Tumors Excision without Bony Marginotomy under Local and General Anesthesia.

To present our experience of removing middle to deep orbital tumors using a combination of minimally invasive soft tissue approaches, sometimes under local anesthesia. Methods. In this retrospective case series, 30 patients (13 males and 17 females) underwent tumor removal through eyelid crease (17 eyes), conjunctival (nine eyes), lateral canthal (two eyes), and transcaruncular (two eyes) approaches. All tumors were located in the posterior half of the orbit. Six cases were removed under monitored anesthesia care with local block, and 24 were under general anesthesia. Results. The median (range) age and follow-up duration were 48.5 (31–87) years old and 24.5 (4–375) weeks, respectively. Visual acuity and ocular motility showed improvement or no significant change in all but one patient at the latest followup. Confirmed pathologies revealed cavernous hemangioma (15 cases), pleomorphic adenoma (5 cases), solitary fibrous tumor (4 cases), neurofibroma (2 cases), schwannoma (2 cases), and orbital varix (1 case). None of the patients experienced recurrence. Conclusions. Creating a bony marginotomy increases intraoperative exposure of the deep orbit but adds substantial time and morbidity. Benign orbital tumors can often be removed safely through small soft-tissue incisions, without bone removal and under local anesthesia.