Unilateral Orbital Fractures Research Articles

Assessment of the Correlation Between Types of Orbital Fractures and Ocular Symptoms, and the Effect of Manual Preformed and Patient-Specific Mesh Implants: A Retrospective Study.

Although certain orbital fractures are associated with specific clinical symptoms, these relationships should be reviewed comprehensively. The optimal choice between manual preformed mesh implants (MPIs) and patient-specific mesh implants (PSIs) for orbital reconstruction remains undetermined due to inconclusive evidence regarding their effectiveness. This retrospective study investigated 280 patients with unilateral orbital fractures to explore the correlation between clinical ocular symptoms, including diplopia, enophthalmos, limitation of ocular movement, blindness, and the specific type of orbital fracture. The effects on orbital volume (OV) and orbital volume ratio (OVR) of MPI and PSI with and without the use of navigation were also evaluated in this study. Patients were categorized into 4 groups: MPI, PSI, navigation-assisted MPI, and navigation-assisted PSI. After this categorization, alterations in OV and OVR were analyzed before and after surgical intervention. Significant correlations were observed between the orbital fracture type and diplopia, enophthalmos, and limitation of ocular movement (P < 0.05). Patients in the MPI group exhibited a notable difference in the postoperative OV between the injured and normal sides (P < 0.05), but no statistically significant difference was found in the postoperative OV between the injured and normal sides among the patients in the other 3 groups (P > 0.05). Moreover, the MPI group demonstrated significantly higher postoperative OVR than the other groups (P < 0.05). Notably, PSI remained effective with or without navigation, MPI combined with navigation technology achieved a reconstruction quality similar to that of PSI by rectifying positioning errors during surgery. The authors found significant correlations (P < 0.05) between orbital fracture type and diplopia, enophthalmos, and limitations of ocular movement. Patient-specific mesh implant plays an important role in orbital reconstruction. It is also a good method for reconstructing orbital fractures using MPI assisted by navigation technology.

Three-dimensional computer navigation in the reconstruction of complex unilateral orbital fractures: evaluation and review of applications.

The eyes are the central aesthetic unit of the face. Maxillofacial trauma can alter facial proportions and affect visual function with varying degrees of severity. Conventional approaches to reconstruction have numerous limitations, making the process challenging. The primary objective of this study was to evaluate the application of three-dimensional (3D) navigation in complex unilateral orbital reconstruction. A prospective cohort study was conducted over 19 months (January 2020 to July 2021), with consecutive enrollment of 12 patients who met the inclusion criteria. Each patient was followed for a minimum period of 6 months. The principal investigator carried out a comparative analysis of several factors, including fracture morphology, orbital volume, globe projection, diplopia, facial morphic changes, lid retraction, and infraorbital nerve hypoesthesia. Nine patients had impure orbital fractures, while the remainder had pure fractures. The median orbital volume on the normal side (30.12 cm3; interquartile range [IQR], 28.45-30.64) was comparable to that of the reconstructed orbit (29.67 cm3; IQR, 27.92-31.52). Diplopia improved significantly (T(10) = 2.667, p = 0.02), although there was no statistically significant improvement in globe projection. Gross symmetry of facial landmarks was achieved, with comparable facial width-to-height ratio and palpebral fissure lengths. Two patients reported infraorbital hypoesthesia at presentation, which persisted at the 6-month follow-up. Additionally, five patients developed lower lid retraction (1-2 mm), and one experienced implant impingement at the infraorbital border. Our study provides level II evidence supporting the use of 3D navigation to improve surgical outcomes in complex orbital reconstruction.

Presurgical Virtual Planning and Intraoperative Navigation with 3D-Preformed Mesh: A New Protocol for Primary Orbital Fracture Reconstruction.

This pilot study aims to evaluate the feasibility and effectiveness of computer-assisted surgery protocol with 3D-preformed orbital titanium mesh (3D-POTM), using presurgical virtual planning and intraoperative navigation in primary inferomedial orbital fracture reconstruction. Between March 2021 and March 2023, perioperative data of patients undergoing surgery for unilateral inferomedial orbital fracture treated with 3D-POTM were analyzed. Presurgical virtual planning with a Standard Triangle Language file of preformed mesh was conducted using the mirrored unaffected contralateral side as a reference, and intraoperative navigation was used. The reconstruction accuracy was determined by: correspondence between postoperative reconstruction mesh position with presurgical virtual planning and difference among the reconstructed and the unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were assessed. Twenty-six patients were included. Isolated orbital floor fracture was reported in 14 (53.8%) patients, meanwhile medial wall and floor one in 12 (46.1%) cases. The mean difference between final plate position and ideal digital plan was 0.692 mm (95% CI: 0.601-0.783). The mean volume difference between reconstructed and unaffected orbit was 1.02 mL (95% CI: 0.451-1.589). Preoperative diplopia was settled out in all cases and enophthalmos in 19 (76.2%) of 21 patients. The proposed protocol is an adaptable and reliable workflow for the early treatment of inferomedial orbital fractures. It enables precise preoperative planning and intraoperative procedures, mitigating pitfalls and complications, and delivering excellent reconstruction, all while maintaining reasonable costs and commitment times.

Clinical and radiographic assessment of patient-specific transantral reconstruction of orbital floor fractures: A case series

To clinically and radiographically evaluate patient-specific titanium meshes via a trans-antral approach for correction of enophthalmos and orbital volume in patients with recent unilateral orbital floor fracture.Seven patients with unilateral orbital floor fractures received patient-specific titanium meshes that were designed based on a mirror-image of the contralateral intact orbit. The patient-specific implants (PSIs) were inserted via a trans-antral approach without endoscopic assistance. The patients were evaluated clinically for signs of diplopia and restricted gaze as well as radiographically for enophthalmos and orbital volume correction. Diplopia was totally resolved in two of the three patients who reported diplopia in the upward gaze. Whereas enophthalmos significantly improved in all but two patients, with a mean value of 0.2229 mm postoperatively compared to 0.9914 mm preoperatively. CT scans showed excellent adaptation of the PSIs to the orbital floor with a mean reduction of the orbital volume from 29.59 cc to 27.21 cc, a mean of 0.6% smaller than the intact orbit.It can be concluded that the proposed PSI can offer good reconstruction of the orbital floor through an isolated intraoral transantral approach with minimal complications. It could of special benefit in extensive orbital floor fractures.

Характеристика множественной и сочетанной офтальмотравмы у детей на современном этапе

Aim: to identify the medical and epidemiological hallmarks of eye damage in children with complex and multiple injuries in a specialized surgical department. Patients and Methods: this study included 403 children aged 1 month to 18 years with eye injuries associated with multiple or complex injuries of varying severity on the day before hospital admission. All children were admitted between 2014 and 2020. The following data were evaluated: patient's age, gender, severity of complex trauma based on the ISS score, cause of trauma, combination of anatomical areas involved. Results: among children with mechanical complex eye injuries, 255 (63%) were boys and 148 (37%) were girls. The mean age of boys was 10.2±0.34 years, and the mean age of girls was 8.5±0.42 years. Furthermore, more than half (67.5%) of those included in the study were school-aged children and adolescents. The most common types of injuries were those resulting from falls from height, school, sports, gunshot/mine blast, and street incidents. In more than half of the children (n=227, 56.4%), orbital traumas affecting the walls and/or content were reported. The most common type of eye damage was a complex damage to the orbit and ocular adnexa (most often as a periorbital hematoma). The percentage of children with multiple fractures of the orbital walls increases with an increase in the severity of polytrauma. Conclusions: children most often received mechanical complex eye injuries as a result of road traffic accidents. The percentage of children with minor, moderate, and severe complex injuries (assessed by the ISS) was 47.1%, 18.4%, and 33.5%, respectively. Orbital fractures are the most common surgical entities in children with complex mechanical eye injuries. Unilateral orbital fractures were diagnosed in 56.4% of cases, while bilateral orbital fractures were diagnosed in 17.9%. In the majority of instances, mechanical complex eye injuries are associated with traumatic brain injury (99%). KEYWORDS: complex eye injuries, multiple injury, combined injury, mechanical complex eye injury, orbital fracture, orbital injury, morbidity pattern, damage to eye. FOR CITATION: Arzhimatova G.Sh., Karaseva O.V., Koroleva E.A., Chernakova G.M. Multiple and complex eye injuries in children. Russian Journal of Clinical Ophthalmology. 2024;24(2):78–82 (in Russ.). DOI: 10.32364/2311-7729-2024-24-2-6.

Orbital blowout fractures: manifestations and missed diagnoses in 207 surgically treated patients.

We aimed to retrospectively measure the incidence of missed orbital blowout fracture diagnosis in primary examinations of patients with surgically treated fractures, to identify the causes of the diagnostic oversight, and to describe the clinical manifestations of the fractures. A retrospective cohort of all patients with unilateral orbital blowout fractures who underwent subsequent surgical fracture reduction at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, from January 2011 to July 2021, was gathered. Demographics, fracture type, associated injuries, clinical manifestations, reconstruction indication, diagnostic delay, and causes of fractures were analysed. For statistical analysis, Fisher's exact test, unpaired t-test, and the Wilcoxon Rank Sum were used. Significance was set at P˂0.05. Fracture diagnosis was missed in 26 (13%) of 207 patients: in 40% of patients aged under 18 years and in 10% of patients aged 18 years or over (P=0.005). Suboptimal eye examination was found in 62% of patients with missed fracture and in 13% of those with timely diagnosis (P<0.001). Adjusted odds ratios for missed diagnosis in patients aged under 18 years versus patients aged 18 years and over was 9.3 (95% CI 2.4-35) and in patients with suboptimal versus sufficient eye examination 13.6 (95% CI 5.1-37). More common clinical manifestations in patients aged under 18 years were diplopia or restricted eye movements (P=0.005), pain in eye movements (P=0.010), nausea and/or vomiting (P<0.001), and bradycardia (P=0.014); periorbital haematoma was rarer (P<0.001). Suboptimal eye examination was involved in 62% and misinterpretation of computed tomography images in 50% of missed fractures, together explaining 85% of cases. Orbital blowout fractures are often missed in primary examination, especially in children and adolescents, who also present with subtler clinical manifestations. While the diagnosis can be difficult, appropriate clinical and radiological examination will reveal most cases.

Correlation between Orbital Computed Tomography Scan Measurements and Clinical Enophthalmos in Acute Isolated Orbital Floor Fractures

Abstract Purpose: To analyze the correlation between orbital computed tomography (CT) scan measurements including the fracture area (FA), the fracture location, the soft-tissue herniation volume (HV), the fractured orbital volume ratio (OVR) to the normal orbit, and the clinical enophthalmos in acute isolated orbital floor fractures. Methods: We enrolled 100 patients with acute isolated unilateral orbital floor fractures from May 2017 to January 2021. Based on the CT scan findings, we measured the FA, HV, OVR, and fracture site. We assessed enophthalmos using both clinical (CE) and radiographic (RE) measurements. Additionally, we investigated the correlation between CE and the measured parameters, along with the relationship between the pattern of diplopia and the fracture site. Results: We identified enophthalmos in 81% and diplopia in 78% of the patients with an acute blowout orbital floor fracture. CE was moderately correlated with the FA (R 2 = 0.4341, P &lt; 0.001). CE was weakly correlated with the HV (R 2 = 0.2861, P = 0.04). Anterior fractures caused diplopia in both vertical gazes, but posterior fractures were mostly associated with diplopia in the up gaze. OVR was strongly associated with RE (R 2 = 0.663, P &lt; 0.0001) and moderately associated with CE (R 2 = 0.4378, P &lt; 0.0001). The univariate regression analysis also showed that OVR could significantly predict CE and RE. Conclusions: OVR surpasses other CT scan measurements such as FA and HV in the prediction of clinical enophthalmos. Thus, OVR could be utilized to estimate clinical enophthalmos at the time of presentation, especially when the acute clinical setting prohibits the proper clinical evaluation.

Comparison of the Fractured and Non-Fractured Orbit Before and After Surgery Using a Titanium Implant or a Resorbable Poly-d,l-lactic Acid (PDLLA) Implant: A Study from a Single Center in Niš, Serbia of 58 Patients with Unilateral Orbital Floor Fracture Using Volumetric Measurement.

BACKGROUND A fracture of the orbital floor can lead to complications such as enophthalmos, impaired eye motility, or diplopia, which is why it is necessary to reconstruct the bony walls of the orbit. This study from a single center in Niš, Serbia, included 58 patients with unilateral orbital floor fracture and aimed to use volumetric measurement to compare the fractured and non-fractured orbit before and after surgery using a titanium implant or a resorbable poly-d, l-lactic acid (PDLLA) implant. MATERIAL AND METHODS From 2018 to 2022, a total of 58 patients with unilateral orbital floor fractures were treated at the Clinic of Dental Medicine, Niš. Computed tomography examination was used for volumetric measurement of the fractured and non-fractured (contralateral) orbit before and after the surgical procedure. A titanium implant was used in 31 patients, and a PDLLA implant was used in 27 patients. RESULTS Orbital volume ratio did not differ statistically significantly in relation to the type of implant (P=0.591). The postoperative volume did not differ statistically significantly from the volume of the contralateral side (titanium, P=0.212; PDLLA, P=0.232). There was a significant correlation between orbital volume and enophthalmos both before and after surgery (P=0.012, P=0.018, respectively). CONCLUSIONS Measuring the preoperative volume of the injured orbit is sufficient data for an indication because reconstruction depends primarily on the correlation between the volume and enophthalmos. The findings from this study showed that preoperative orbital volumetry using computed tomography evaluated enophthalmos and provide data to assist orbital floor reconstruction.

Comparison of Postoperative Enophthalmos Between Fresh and Delayed Unilateral Orbital Fractures After Orbital Reconstruction With Titanium Mesh Using Computer-Assisted Navigation.

This study compares postoperative enophthalmos between fresh and delayed unilateral orbital fractures after orbital reconstruction with titanium mesh using computer-assisted navigation. The sample was composed of 45 patients with post-traumatic unilateral enophthalmos who were divided into the fresh fracture group and the delayed fracture group. They underwent orbital reconstruction with standard preformed orbital implants and computer-assisted navigation system. The following parameters were measured with computed tomography images: the degree of enophthalmos, orbital volume, and fracture defect area. Patients were reviewed preoperatively (T0), 1 week postoperatively (T1), and 6 months postoperatively (T2). Computed tomography measurements showed that in both groups, the degree of enophthalmos decreased after surgery but increased significantly from T1 to T2 ( P <0.05). ΔE (difference in the degree of enophthalmos between T1 and T2) was similar in patients with fresh and delayed fractures. There was a significant difference in the degree of ΔE between patients with single-wall orbital fractures and those with two-wall orbital fractures. The findings indicate that postoperative enophthalmos is common in both the groups and is closely related to the degree of preoperative enophthalmos. Furthermore, the recurrence of enophthalmos is similar between the 2 groups, but it is higher in patients with orbital fractures involving 2 walls.

Effect of orbital volume in unilateral orbital fracture on indirect traumatic optic neuropathy.

This retrospective study aimed to analyze the relationship between the volume of the fractured and the normalorbitin patients with unilateral orbital fractures with and without indirect traumatic optic neuropathy (TON). Data of 25 patients with unilateral orbital fractures who underwent computer tomography between January 2016 and December 2020 were investigated. Emergency imaging was performed within 2hours of arrival at the emergency room.The subjects were categorized into two groups: unilateral orbital fractures with and without TON. The assessment of TON was performed during a comprehensive ophthalmologic examination by an ophthalmologist. The stereographic orbit was reconstructed, and the volume was calculated. Other variables examined included age, sex, and cause of orbital trauma.The variables were compared using paired t-tests. Statistical significance was set at p < 0.05. The orbital volume of the non-fractured orbit was27.50 ± 2.26 and 27.48 ± 2.64cm3 in the groups with and without TON, respectively.The average volume of the fractured orbit in the TON group was27.78 ± 2.56cm3, andthere was no significant volumetric difference between the fractured and non-fractured sides in this group. However, the average volume of the fractured orbit without TON was 28.76 ± 3.18cm3, larger than that of the non-fractured orbit (p = 0.016). Non-expansion of the fractured orbit was a risk factor for indirect TON in patients with unilateral orbital fractures. Volumetric analysis from primary imaging would expedite the diagnosis and treatment of TON, resulting in optimal outcomes.

Reconstruction of Two Wall Orbital Fractures: Experience With the 3D Titan Implant and Intraoperative Computed Tomography

Background: Orbital fractures are common in maxillofacial trauma and have varying anatomical deficits depending on the mechanism of injury. Orbital floor fractures are most common, but many patients suffer from two wall-floor and medial wall defects. Precise reconstruction and positioning of the orbital implant post traumatic injury can be technically challenging, especially in two wall fractures. We present our experience using the 3D Titan implant on a series of 7 patients with combined medial wall and orbital floor fractures. Methods: A retrospective chart review was performed of patients with combined medial wall and orbital floor fractures treated with 3D Titan between February 2016 and June 2020. The inclusion criteria were unilateral combined medial and orbital floor fractures due to traumatic etiologies, no previous history of orbital trauma, age older than 18 years, a contralateral healthy orbit, and a clinical follow-up of at least 1 month. Variables and outcomes included patient age, gender, mechanism of injury, visual defects, post-op infections, enophthalmos, proptosis, and diplopia. An O-arm intraoperative CT scanner was used to verify the implant position. Results: Ten patients presented with combined medial wall and orbital floor fractures, 3 were lost to follow-up. There were 6 men and 1 woman, and their ages ranged from 24 to 57 (mean age 38). Follow-up time ranged from 4 to 52 weeks, and a mean of 20 weeks. None of the patients experienced intraoperative complications such as hemorrhage, soft tissue incarceration, or acute optic neuropathy. No patients had postoperative infection or any change in visual acuity. All patients had satisfactory implant positioning as verified by intraoperative CT. Conclusions: The prefabricated design of the 3D Titan along with use of intraoperative CT guidance allows for efficient and precise reconstruction of combined medial wall and orbital floor fractures.

Prospective Evaluation of Intraorbital Soft Tissue Atrophy after Posttraumatic Bone Reconstruction: A Risk Factor for Enophthalmos.

Orbital fractures are a common finding in facial trauma, and serious complications may arise when orbital reconstruction is not performed properly. The virtual planning can be used to print stereolithographic models or to manufacture patient-specific titanium orbital implants (PSIs) through the process of selective laser melting. This method is currently considered the most accurate technique for orbital reconstruction. Even with the most accurate techniques of bone reconstruction, there are still situations where enophthalmos is present postoperatively, and it may be produced by intraorbital soft tissue atrophy. The aim of this paper was to evaluate the orbital soft tissue after posttraumatic reconstruction of the orbital walls’ fractures. Ten patients diagnosed and treated for unilateral orbital fractures were included in this prospective study. A postoperative CT scan of the head region with thin slices (0.6 mm) and soft and bone tissue windows was performed after at least 6 months. After data processing, the STL files were exported, and the bony volume, intraorbital fat tissue volume, and the muscular tissue volume were measured. The volumes of the reconstructed orbit tissues were compared with the volumes of the healthy orbit tissues for each patient. Our findings conclude that a higher or a lower grade of fat and muscular tissue loss is present in all cases of reconstructed orbital fractures. This can stand as a guide for primary or secondary soft tissue augmentation in orbital reconstruction.

Accuracy of the Application of 3-Dimensional Printing Models in Orbital Blowout Fractures-A Preliminary Study.

Application of 3-dimensional (3D) printing technology has grown in the medical field over the past 2 decades. In managing orbital blowout fractures, 3D printed models can be used as intraoperative navigators and could shorten the operational time by facilitating prebending or shaping of the mesh preoperatively. However, a comparison of the accuracy of computed tomography (CT) images and printed 3D models is lacking. This is a single-center retrospective study. Patients with unilateral orbital blowout fracture and signed up for customized 3D printing model were included. Reference points for the 2D distance were defined (intersupraorbital notch distance, transverse horizontal, sagittal vertical, and anteroposterior axes for orbital cavity) and measured directly on 3D printing models and on corresponding CT images. The difference and correlation analysis were conducted. In total, 9 patients were reviewed from June 2017 to December 2020. The mean difference in the intersupraorbital notch measurement between the 2 modules was -0.14 mm (P = 0.67). The mean difference in the distance measured from the modules in the horizontal, vertical, and anteroposterior axes of the traumatic orbits was 0.06 mm (P = 0.85), -0.23 mm (P = 0.47), and 0.51 mm (P = 0.32), whereas that of the unaffected orbits was 0.16 mm (P = 0.44), 0.34 mm (P = 0.24), and 0.1 mm (P = 0.88), respectively. Although 2D parameter differences (<1 mm) between 3D printing models and CT images were discovered, they were not statistically significant. Three-dimensional printing models showed high identity and correlation to CT image. Therefore, personalized models might be a reliable tool of virtual surgery or as a guide in realistic surgical scenarios for orbital blowout fractures.

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

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

Evaluation of orbital volume in unilateral orbital fracture using computed tomography.

Aim and Objective:Our study was an observational and evolutional to analyze the significance of orbital volume calculation in predicting the probability or tendency of developing late enopthalmous on patients with unilateral orbital fracture with or without associated midface injury reported to our hospital.Materials and Methods:The subjects in our study included fifteen patients between18 and 60years. They were treated surgically and conservatively. Patients were exposed to series of examination from the day of injury or reporting for a consecutive period of up to six months following injury. CT was taken prior to treatment following management to evaluate the volume change in orbit. Its correlation and significance to treatment outcome were analyzed using MIMICS software by Materialise by comparing injured orbit to opposite side normal eye.Result:Conclusive of clinical examination and summary of statistical analysis patients were categorized into three groups: Low (with volume change of less than 2%), Medium (volume change between 2 to 20%) and High (volume change more than 20%) by comparing fractured orbit to uninjured orbit and a statistically significant mean value of 27.7 ± 2.6 cu. mm for fractures eye and 25.9 ± 2.6 cu. mm for normal eye was found (P ≤ 0.05).Conclusion:Orbital volume can be considered as useful criteria in evaluation of patients with orbital fracture. Evaluation and follow up in correlation with resultant volume assessment provide a better indicator for assessment of prognosis and enopthalmous. Unlike other methods for volume assessment MIMICS software by Materialise provide a better method and it can be incorporated to working station in hospital. Every CT assessment in orbital trauma should include orbital volume as a parameter and this software is easy and user-friendly software that does not require its technical knowledge for application.

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

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

Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures.

The study reports the correlation between surgical timing and postoperative ocular motility in orbital blowout fractures. This was a retrospective study of 191 patients that underwent surgical repair for unilateral orbital fractures. All patients included in the study had symptomatic diplopia from the fracture. Patients were classified into one of three groups according to the time of surgery after injury: (1) Early (within 14days of surgery), (2) intermediate (between 15 and 30days), and (3) late (greater than 30days). Ocular motility was measured presurgery and at 3 and 6months postsurgery by Hess chart with calculation of the Hess area ratio (HAR%). Surgery was conducted at a mean of 24.7 ± 45.0days (range: 1-283days) postinjury. There were 120 patients in the early surgery group (surgery at 6.8 ± 3.8days), 38 in the intermediate surgery group (20.7 ± 4.1days), and 33 in the late surgery group (95.1 ± 75.0days). Overall the HAR% improved significantly from a mean of 74.2% preoperatively to 90.8% at 6months postoperatively (p < 0.01). In the early and intermediate groups, the postoperative HAR% improved significantly with all fracture regions (orbital floor, medial wall, and combined orbital medial wall and floor) (p < 0.05). However, in the late groups, the postoperative HAR% only improved significantly with orbital floor fractures. Pre- and postoperative the HAR% give objective evidence of ocular motility improvement with early orbital floor fracture repair surgery. However, observation can be deployed, as a significant improvement in ocular motility can also be achieved with reconstructive surgery conducted 30days or more after depressed floor-fragment fractures. Early intervention should be prioritized for symptomatic medial wall fractures, as late surgery does not improve motility.

Functional and Cosmetic Outcome after Reconstruction of Isolated, Unilateral Orbital Floor Fractures (Blow-Out Fractures) with and without the Support of 3D-Printed Orbital Anatomical Models.

The present study aimed to analyze if a preformed “hybrid” patient-specific orbital mesh provides a more accurate reconstruction of the orbital floor and a better functional outcome than a standardized, intraoperatively adapted titanium implant. Thirty patients who had undergone surgical reconstruction for isolated, unilateral orbital floor fractures between May 2016 and November 2018 were included in this study. Of these patients, 13 were treated conventionally by intraoperative adjustment of a standardized titanium mesh based on assessing the fracture’s shape and extent. For the other 17 patients, an individual three-dimensional (3D) anatomical model of the orbit was fabricated with an in-house 3D-printer. This model was used as a template to create a so-called “hybrid” patient-specific titanium implant by preforming the titanium mesh before surgery. The functional and cosmetic outcome in terms of diplopia, enophthalmos, ocular motility, and sensory disturbance trended better when “hybrid” patient-specific titanium meshes were used but with statistically non-significant differences. The 3D-printed anatomical models mirroring the unaffected orbit did not delay the surgery’s timepoint. Nonetheless, it significantly reduced the surgery duration compared to the traditional method (58.9 (SD: 20.1) min versus 94.8 (SD: 33.0) min, p-value = 0.003). This study shows that using 3D-printed anatomical models as a supporting tool allows precise and less time-consuming orbital reconstructions with clinical benefits.

Anatomical implication of less occurrence of inferior oblique muscle entrapment in orbital floor trapdoor fracture

To examine the anatomy of the inferior oblique (IO) muscle and its surrounding structures to clarify why IO muscle entrapment develops less in orbital floor trapdoor fractures. Computed tomographic (CT) images on the unaffected sides were obtained from 64 patients with unilateral orbital fractures. On coronal planes, presence or absence of an infraorbital groove below the IO muscle was confirmed. At the level of the medial margin of the infraorbital groove/canal, the distance from the orbital floor to the IO muscle (IO-floor distance), the thickness of the orbital floor, and the shortest distance from the inferior rectus (IR) muscle to the orbital floor (shortest IR-floor distance) were measured. On quasi-sagittal planes, the distances from the inferior orbital rim to the inferior margin of the IO muscle (IO-rim distance) and the most anterior point of the infraorbital groove (groove-rim distance) were measured. The infraorbital groove was found below the IO muscle in eight patients (12.5%), and the IO-rim and IO-floor distances were significantly longer than the groove-rim and shortest IR-floor distances, respectively (p < 0.001). The orbital floor below the IO muscle was significantly thicker than that below the IR muscle (p < 0.001). Although the medial margin of the infraorbital groove is the most common fracture site, the IO muscle was not located above the groove in most cases. A longer IO-floor distance and thicker orbital floor below the IO muscle may also contribute to less occurrence of IO muscle entrapment in orbital floor trapdoor fractures.

Three-Dimensional Computer-Aided Analysis of 293 Isolated Blowout Fractures – Which Radiological Findings Guide Treatment Decision?

Our study purpose was to clarify the extent of isolated unilateral orbital blowout fracture in relation to surgical treatment and other factors behind the treatment decision. The specific aim was to determine which computer-aided measurements based on radiological images associate with treatment choice. A retrospective cohort study was implemented on patients with an isolated unilateral orbital blowout fracture. Computer-aided measurement of fracture extent was performed. The study variables included treatment as primary outcome (surgical vs nonsurgical), post-traumatic orbital volume difference (mL) compared to contralateral orbit, fracture area (mm2), fracture depth (mm) as predictor variables, and age, sex, injury mechanism, side and site of orbital fracture and positions of recti muscles as explanatory variables. Postoperative outcomes were reported. Logistic regression analysis was used to determine the risk factors for surgery. The statistical significance level was set at P < .05. Of 293 patients, 28.0% received surgical and 72.0% nonsurgical treatment. Volume difference, fracture area and fracture depth predicted surgical outcome (P < .001). In adjusted univariate regression analyses, fractures with moderate and severe displacement of recti muscles were more likely to receive surgical treatment than fractures with mild or no displacement (OR 6.15 and 30.75, respectively, P < .001). Isolated medial wall fractures were significantly less often (OR 0.05, P = .006) and patients with older age (OR 0.97, P = .013) slightly less often treated with surgery. Patients with preoperative symptoms had more often persisting postoperative symptoms than patients without preoperative symptoms. Positions of the recti muscles are an independent radiological factor guiding orbital blowout fracture treatment decision. The bony fracture extent is a combination of volume difference, fracture area and fracture depth which are strongly correlated to each other. A computer-aided method significantly facilitates the systematic evaluation of bone fragments, and the extent of orbital fractures.