Orbital blowout fractures: a ten-year survey

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified. Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records. Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent). When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms. The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance. Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.

The diagnosis and management of orbital blowout fractures: update 2001

A cogent update of orbital blowout history, anatomy, and management are included with a retrospective study of 59 pure orbital blowout fractures which occurred between 1994 and 1998. Our goal is to provide a better understanding of this frequently encountered entity and to help augment the confidence of nonophthalmologists who will often evaluate patients with suspected orbital blowout fractures.

Reconstruction of orbital fractures with dehydrated human dura mater

PURPOSE

The best method for reconstructing the fractured orbital floor remains controversial. This article evaluates the usefulness of dehydrated human dura mater for orbital floor reconstruction after facial trauma.

PATIENTS AND METHODS

A retrospective analysis of 55 patients who had undergone surgical repair of orbital fractures was performed. The dura mater was used when the disruption was less than 2 cm in diameter. Fractures were divided into 3 types: type I (blow-out), type II (orbitozygomatic fracture), and type III (midfacial fracture). The patients were followed-up at least 1 year after surgery, and the cosmetic and functional results were reviewed.

RESULTS

A 7% complication rate was noted. No implant migration or infection resulted. One year postsurgery, all patients showed a complete resolution of their diplopia.

CONCLUSION

The safety and biocompatibility of dehydrated human dura mater support its use in orbital defects less than 2 cm in diameter.

Isolated orbital blowout fractures: survey and review

The management of orbital blowout fractures is controversial. The continuing debate includes the use of antibiotics and steroids, imaging, the surgical approach, and the choice of implant material for repair of the bony defect.A cross-sectional study was undertaken to assess current practice in treating orbital blowout fractures in the UK, in the form of a tick-box questionnaire. The questionnaire contained 9 closed and 2 open questions, and was forwarded to 256 practising fellows of the British Association of Oral and Maxillofacial Surgery. The response rate to the questionnaire was 73% (187/256). There was no consensus about the use of prophylactic antibiotics. However, 91% prescribed post-operative antibiotics and over half the respondents prescribed steroids. The most common imaging techniques used were computed tomography (CT, 88%) and plain radiograph (83%), 60% routinely sought an ophthalmic opinion and 65% assessed visual acuity. The most common surgical approaches were the subciliary (41%) and the infraorbital (37%), over half the respondents preferred to operate 6-10 days after the injury, and silicone elastomer was the preferred implant material of 66%.

Correlation of preoperative computed tomography and postoperative ocular motility in orbital blowout fractures

PURPOSE

To determine a relationship between preoperative soft tissue disruption and postoperative ocular motility in orbital blowout fractures.

METHODS

This retrospective cohort study reviewed 30 patients who met all criteria: retrievable coronal computed tomography (CT) scans; internal fractures of the orbital floor, with or without medial wall extension; preoperative diplopia; repair by a single surgeon; complete release of entrapped tissues; and postoperative binocular visual fields (BVFs). Motility outcomes were quantified by one group of the authors, who measured the vertical fusion within BVFs. Other authors analyzed CT scans, designating each fracture as either A or B, based on lesser or greater soft tissue distortion relative to the configuration of bone fragments. The interval between trauma and surgery was also determined.

RESULTS

Among the 15 patients with a postoperative motility outcome poorer than the median (86 degrees or less), four (27%) had A fractures; 11 (73%) had B fractures. Among the 15 patients with an outcome better than the median (88 degrees or more), 10 (67%) had A fractures; five (33%) had B fractures. Differences were more defined away from the median. Among five patients with B fractures and better than the median result, three (60%) had surgical repair during the first week after injury. Among the 11 patients with B fractures and less than the median result, one (9%) had repair during the first week.

CONCLUSIONS

Postoperative motility is influenced by soft tissue-bone fragment relationships. Whether the outcome can be altered by earlier surgery in selected cases will be determined by prospective studies.

Does diplopia persist after blow-out fractures of the orbital floor in children?

Blow-out fractures of the orbital floor are comparatively rare in children, particularly those less than 8 years old. Published reports have suggested that the long-term outcome in children is worse than that in adults with similar injuries. In this study, we examine this question in the light of data from 45 children from Birmingham and Glasgow who were divided into three age ranges: 0-9 years (n = 9), 10-12 years (n = 11) and 13-15 years (n = 25). Fourteen were treated conservatively and 31 were treated surgically. The 0-9-year-old group were more likely to have small- or medium-sized defects in the anterior part of the orbital floor, which were of a linear 'trapdoor' type. The 13-15-year-olds tended to have larger 'open-door' defects. More than half the 0-9-year-olds had persistent diplopia compared with just under a third of the two other age groups. This diplopia took twice as long to resolve in the younger group compared with the other two groups. Our results confirm the view that younger patients have more persistent problems than adults after blow-out fractures of the orbital floor.

Examination of the injured eye: single system injury

Eye trauma is common and all trauma doctors should receive instruction in ocular examination techniques. This article considers different elements of eye examination: facial asymmetry and orbital fractures, lacerations, eye movements, pupils, anterior segment, posterior segment, and the optic nerve. Emphasis is placed on paediatric patients and those who will be particularly difficult to examine, such as those patients with occult rupture of the eye or brain penetration. The eye should be examined as part of the secondary survey in all trauma patients once they have been stabilized as blinding injuries can be treated and sight saved.

Blindness after reduction of facial fractures

Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 2 to 5 percent. Blindness may also follow surgical repair of facial fractures. Many mechanisms, such as intraoperative direct nerve injury, retinal arteriolar occlusion associated with orbital edema, or delayed presentation of indirect optic nerve injury sustained at the time of the initial trauma, have been implicated in causing this blindness. In this article, four cases of visual loss after surgical repair of facial trauma are reported. In a review of the University of Maryland Shock Trauma experience with facial trauma over 11 years, we discovered that 2987 of the 29,474 admitted patients (10.1 percent) sustained facial fractures, and that 1338 of these fractures (44.8 percent) involved one or both of the orbits. One thousand two hundred forty of these patients underwent operative repair of their facial fractures. Three patients experienced postoperative complications that resulted in blindness, a total incidence of only 0.242 percent. Postoperative ophthalmic complications seem to be primarily mediated by indirect injury to the optic nerve and its surrounding structures. The most frequent cause of postoperative visual loss is an increase in intraorbital pressure in the optic canal. When our data were added to the summarized cases, blindness was attributable to intraorbital hemorrhage in 13 of 27 cases (48 percent). In addition, 5 cases in our review attribute the visual loss to unspecified mechanisms of increased intraorbital pressure, bringing the total cases of visual loss caused by intraorbital pressure or hemorrhage to 18 of 27 cases, or 67 percent. Within the restricted confines of the optic canal, even small changes in pressure potentially may cause ischemic optic nerve injury.

An experimental investigation of the safe distance for internal orbital dissection

PURPOSE

The purpose of this investigation was to determine the distance from the orbital rim to the important soft tissues of the orbital apex using eight reference points to provide clinically useful information for surgical decision making.

MATERIALS AND METHODS

Eight human cadavers were used in this investigation. After circumorbital incisions were made and the canthal ligaments were detached, a careful subperiosteal dissection was performed to the soft tissues of the orbital apex. Four reference lines were established. The first two were based on a horizontal line drawn through the medial and lateral canthal ligaments and a perpendicular to this through the infraorbital foramen. The other two were created at points 45 degrees from the first two. Depth measurements were made with a straight probe at the eight points where the lines crossed the orbital rim. Means, standard deviations, and ranges were derived, and statistical differences were calculated between right and left orbits using a paired-samples t-test. Because no right and left differences were noted (P < .05), the data were pooled.

RESULTS

The mean distance from the orbital rim to the soft tissues of the orbital apex was 44.1 +/- 1.4 mm medially, 38.3 +/- 3.0 mm laterally, 44.5 +/- 1.72 superiorly, and 39.4 +/- 2.9 mm inferiorly. The superomedial distance was 46.3 +/- 2.7 mm, the inferomedial distance was 44.1 +/- 1.4 mm, the inferolateral distance was 41.4 +/- 2.5 mm, and superolateral distance was 39.4 +/- 2.8 mm.

CONCLUSIONS

The distances from the orbital rim to the soft tissues of the orbital apex varied among the eight different reference points (range, 38.3 +/- 3.0 mm to 46.3 +/- 2.7 mm). No distance was less than 31.0 mm or exceeded 51.1 mm. There was no difference noted (P < .05) between the right and left sides for each of the corresponding reference points.

Orbital reconstruction with individually copy-milled ceramic implants

Diagnostic advances such as computed tomography and new surgical techniques have dramatically improved both the functional and aesthetic outcome of orbital reconstructions. Taking a further approach, we designed ceramic implants (Bioverit) on the basis of stereolithographic models. After copy milling a resin template with a commercially available dental unit (Celay), the prefabricated implants were inserted for reconstruction of the lamina papyracea (n = 1), zygomatic complex (n = 2), infraorbital floor (n = 5), and rim (n = 3). Intraoperatively, only slight modifications of the implants had to be performed. The results were encouraging, as all cases showed a good aesthetic and functional postoperative outcome. Preoperative evaluation of the osseous defect and prefabrication of the required implant reduced operating time and patient morbidity significantly.

Orbital trauma

The globe and orbit constitute a very small portion of the body; however, trauma to this region assumes critical importance due to the high value we place on vision. The evaluation of orbital trauma has progressed rapidly with the development and wide distribution of computer-assisted imaging. Plain radiography, angiography, computed tomography (CT), and magnetic resonance imaging (MRI), may all be used in the evaluation of orbital trauma and the search for foreign bodies.

Transantral endoscopic orbital floor exploration: a cadaver and clinical study

A cadaver and clinical study was performed to determine the value of transantral endoscopy in diagnosis and treatment of orbital floor fractures. Six fresh cadaver heads were dissected using a 30 degree, 4-mm endoscope through a 1 cm2 antrotomy. In the cadaver, the orbital floor and the course of the infraorbital nerve were easily identified. The infraorbital nerve serves as a reference point for evaluation of fracture size; three zones of the floor are described that are oriented relative to the infraorbital nerve. In the clinical study, nine patients with orbital floor fracture initially underwent endoscopy at the time of fracture repair: three patients had comminuted zygomatico-orbital fractures, five had monofragmented tetrapod fractures, and one had an isolated orbital blowout fracture. Endoscopic dissection of the orbital fractures revealed seven fractures with an area > 2 cm2 and two fractures with an area of < 2 cm2. The isolated orbital floor blowout fracture had entrapped periorbital tissue, which was completely reduced endoscopically. A separate patient with a < 2 cm2 displaced fracture also had stable endoscopic reduction. In the remaining seven patients, the endoscopic technique assisted with the floor reconstruction by identifying the precise fracture configuration as well as identifying the stable posterior ledge of the orbital floor fracture. There have been no complications in any of our patients to date. We conclude: (1) Transantral orbital floor exploration allows precise determination of orbital floor fracture size, location, and the presence of entrapped periorbita. The information obtained through endoscopic techniques may be used to select patients who would not benefit from lid approaches to the orbital floor and may possibly eliminate nontherapeutic exploration. (2) Transantral endoscopic orbital floor exploration assists the reduction of complex orbital floor fractures and allows precise identification of the posterior shelf for implant placement. (3) Transantral endoscopic techniques can completely reduce entrapped periorbital tissue caught in a trapdoor type of fracture.

Orbital floor fractures in young children

Isolated orbital floor fractures in children before the end of the 7th year of life are said to seldom occur. This is thought to be due to differences in anatomy from adults in that the maxillary sinus is developing and the orbit is still increasing in size. Two cases of isolated orbital floor fractures in children aged less than 8 years are reported, their management discussed, and the literature reviewed.

Medial orbital wall fractures: classification and clinical profile

This article reports our experience and proposes a clinical classification regarding medial orbital wall fractures. After a retrospective analysis of 2741 patients with facial fractures, we were able to evaluate 273 patients with 304 medial orbital wall fractures. The male-to-female ratio was 5:1, and most injuries involved the left orbit. Most fractures were caused by personal altercations, but more complex injuries were noted with automobile accidents and falls. Fractures were divided into types based on location and severity of injury: type I (confined to the medial orbital wall), type II (medial orbital wall continuous with floor), type III (medial orbital wall with floor-malar fractures), and type IV (medial orbital wall and complex midfacial injuries). Although visual loss (2%), diplopia (41%), and enophthalmos (12%) were seen, diplopia and enophthalmos were commonly observed with type II injuries. Imaging studies showed that about 52% of the fractures were associated with prolapse of orbital fat, but only 43% could be diagnosed with plain x rays. Type I fractures were generally explored through a frontoethmoid incision; other types were treated with subciliary or transconjunctival approaches. The usual treatment consisted of repositioning the fragments and repair of the wall with polyethylene mesh or cranial bone graft. Type I and type II fractures seemed best explained by the hydraulic mechanism of injury, whereas the type III and type IV fractures best fitted the buckling theory.

The use of silastic as an orbital implant for reconstruction of orbital wall defects: review of 311 cases treated over 20 years

PURPOSE

A retrospective review of silicone rubber (Silastic; Dow Corning, Midland, MI) implants placed in orbits was undertaken. These implants were used to reconstruct defects in the orbital floor and/or walls secondary to trauma, or those created during malar or orbital osteotomies. The purpose of the study was to determine the incidence of removal of these implants from the surgical site.

MATERIALS AND METHODS

The records of 311 patients treated over a 20-year period were reviewed. Of these, 302 had received silastic implants secondary to trauma.

RESULTS

Forty-one patients (13%) had their implant removed at a second operation. The reasons for removal included infection, migration of the implant, worsening eye sign such as diplopia, and others.

CONCLUSION

Because there was a clinically significant rate of removal of this material, consideration should be given to the use of other available materials.

Orbital marginotomies for treatment of orbital and periorbital lesions

Access osteotomies allowing temporary displacement of various segments of the orbital rim provide direct visualization of deep orbital and paraorbital regions. These marginotomies are classified, according to the orbital region involved, as lateral, medial, superior, or inferior, and they provide adequate exposure of the corresponding orbital wall and its surrounding structures. Since these procedures are without complications and cause no unpleasant cosmetic effects, they are highly recommended for the treatment of various lesions in this area as well as for correction of malformations.

Low-dose computed tomographic imaging in orbital trauma

We review the findings in 75 computed tomographic (CT) examinations of 66 patients with orbital trauma who were imaged using a low-radiation-dose CT technique. Imaging was performed using a dynamic scan mode and exposure factors of 120 kVp and 80 mAs resulting in a skin dose of 11 mGy with an effective dose-equivalent of 0.22 mSv. Image quality was diagnostic in all cases and excellent in 73 examinations. Soft-tissue abnormalities within the orbit including muscle adhesions were well demonstrated both on primary axial and reconstructed multiplanar images. The benefits of multiplanar reconstructions are stressed and the contribution of soft-tissue injuries to symptomatic diplopia is examined.

Diplopia caused by orbital floor blowout fracture

Diplopia caused by orbital floor blowout fractures is one of the major complications of orbital injuries. The records of 48 patients who had incurred orbital injuries were reviewed; 23 had a history of a pure orbital blowout fracture. Surgery was indicated when the vertical movement of the eye was impaired, and it was performed after complete resolution of orbital hemorrhage and edema. The maximal time before the first surgical procedure was 14 days. Two patients required a second procedure because of persistent diplopia and enophthalmos.

Orbital volume measurement in the management of pure blowout fractures of the orbital floor

With the recent advent of accurate orbital volume assessment by computed tomography, a retrospective analysis was made of 31 patients with 'pure' blowout fracture of the orbital floor, managed either surgically or conservatively, to determine whether orbital volume measurement could provide an additional parameter of use in the management of such fractures. There was a significant difference in orbital volume discrepancy between patients managed surgically or conservatively suggesting that this investigation may be of use in decision making on surgical intervention in patients with orbital blowout fractures.

Complications associated with alloplastic implants used in orbital fracture repair

BACKGROUND

The treatment of orbital wall fractures involves observation and/or surgical reduction with repositioning of herniated orbital tissues. To prevent reherniation of tissue and development of enophthalmos, the orbital floor or wall defect is commonly covered with an alloplastic implant. Complications associated with these implants are infrequent and generally appear as isolated case reports.

METHODS

The authors reviewed the files of four consultative oculoplastic surgeons and searched for individuals with complications secondary to their alloplastic implants used during orbital fracture repair.

FINDINGS

Seventeen patients were identified with a variety of complications related to their alloplastic implant.

CONCLUSION

Although these implants are relatively inert and develop a fibrous capsule walling them off from the surrounding orbit, they remain foreign bodies and are thus subject to possible complications at any time. The authors review the spectrum of complications occurring with various alloplastic implants.

Influence of age on the management of blow-out fractures of the orbital floor

This study concerns 50 patients with blow-out fractures of the orbital floor, including 15 children, and was designed to evaluate the influence of age on clinical presentation and postoperative results. Fourteen of the 15 children were found to have a trap-door fracture. This type of fracture was not found in adults, who usually present with a large "open-door" fracture. In trap-door fractures, orbital tissues are liable to become trapped and even strangulated. It is therefore suggested that young patients with severely restricted eyeball motility, an unequivocal positive forced duction test, and findings indicating blow-out fracture of the orbital floor on CT, should undergo operative treatment as soon as possible after injury. A "wait and see" policy, keeping the patient under observation, seems to be appropriate for blow-out fractures in adults. Surgical treatment is recommended only in those adult patients who demonstrate impairment of vertical eyeball motility within the mainfield of view after the haemorrhage and oedema have resolved and in whom change in motility is no longer seen and Hertel measurements have stabilized.

Diplopia following midfacial fractures

Over a period of 2 years, 363 patients who had sustained a total of 438 midfacial fractures due to blunt trauma received a full ophthalmological examination within 1 week of injury. Of these, 72 patients (19.8%) developed diplopia. Diplopia was most common following road traffic accidents (31%) and least common with simple falls (10%). Blow-out fractures of the orbit led to double vision in 58% of cases. Eighty two percent of patients recovered from diplopia within 6 months of injury; only 1 patient required squint surgery for double vision. The principal risk factors for diplopia comprise road traffic accidents, blow-out fractures and comminuted malar fractures. Early surgical reconstruction of midfacial fractures with conservative management of concomitant motility disorders has, in our series, resulted in very few patients having diplopia in the long term.

The characteristics of midfacial fractures and the association with ocular injury: a prospective study

Ocular injuries commonly occur in patients with facial fractures. This prospective study was set up to determine the incidence of ocular injuries, as assessed by an ophthalmologist, in patients who had sustained midfacial fractures. Over a 2-year period, a study of 363 patients who had sustained midfacial trauma sufficient to lead to a facial bone fracture (438 fractures) was undertaken and patients received a comprehensive examination by an ophthalmologist and an orthoptist within 1 week of injury. The characteristics of the eye injuries sustained were related to the aetiology of the fracture, the type of fracture, and the sex and age of each patient. Ninety percent of patients sustained ocular injuries of various severities. Sixty three percent of patients sustained only minor or transient ocular injuries, 16% suffered moderately severe ocular injury and 12% experienced severe eye injuries. Road traffic accident was associated with the highest incidence of severe ocular disorder (9/45 = 20%) whilst assaults had the second highest incidence at 11% (20/181). One third of all patients with comminuted malar fracture suffered a severe ocular disorder (9/27) whilst blow-out fracture came second at 16.7% (6/36). Fifty six patients (15.4%) had a decrease in their visual acuity and 9 patients (2.5%) had significant traumatic optic neuropathy. Decrease in visual acuity was the main clinical finding accompanying the majority of significant eye injuries. When ocular injuries were related to aetiology, it was apparent that road traffic accidents and assaults associated with alcohol abuse showed the highest incidence of major ocular dysfunction. It is suggested that all patients sustaining midfacial fracture associated with a significant decrease in visual acuity either pre- or postoperatively should have an early ophthalmological review.

Reconstruction of orbital floor with polydioxanone plate

The use of a polydioxanone (PDS) plate for orbital reconstruction was evaluated in 20 patients with various traumatic defects of the orbital floor. The follow-up time was 9 to 45 months (mean 20.4 months). A CT scan was obtained in 13 patients. Radiographic analysis showed that in 12 of the 13 patients there was new bone in the orbital floor. Clinically, most patients had transitory postoperative diplopia (lasting for a mean of 29 days) because of overcorrection. Only 2 patients, however, suffered from persistent diplopia. In one patient, abducens nerve paresis was the cause. It is concluded that PDS is suitable for orbital floor reconstruction, at least in cases in which defects do not exceed 1-2 cm in diameter. Overcorrection seems necessary. The material is well tolerated, is totally absorbed and appears to be replaced by bone in nearly all cases.

Ocular motor abnormalities from head trauma

Head injuries cause the hospitalization of 200-300 persons per 100,000 population per year. Ophthalmologists provide diagnostic and therapeutic care to those trauma victims with damage to the globe, optic nerve, orbit, and ocular motor system. Eye movements can be affected by damage at any level of the central nervous system or peripheral motor unit. Comprehensive ocular motor assessment of the trauma patient can substantially contribute to the understanding of the patient's injury, recovery, and rehabilitation. This review examines all aspects of head and face trauma that can lead to ocular motility disturbances.

Poly(L-lactide) implants in repair of defects of the orbital floor: an animal study

Because of the life-long presence of alloplastic, nonresorbable orbital floor implants and the complications of their use mentioned in literature, the use of a resorbable material appears to be preferable in the repair of orbital floor defects. A high-molecular-weight, as-polymerized poly(L-lactide) (PLLA) was used for repair of orbital floor defects of the blowout type in goats. An artificial defect was created in the bony floor of both orbits. Reconstruction of the orbital floor was then carried out using a concave PLLA implant of 0.4-mm thickness. At 3, 6, 12, 19, 26, 52, and 78 weeks postoperatively, one goat was killed. Microscopic examination showed full encapsulation of the implant by connective tissue after 3 weeks. After 6 weeks, resorption and remodeling of the bone at the points of support of the implant could be detected. A differentiation between the sinus and orbital sides of the connective tissue capsule was observed. The orbital side showed a significantly more dense capsule than the antral side, which had a loose appearance. At 19 weeks, a bony plate was progressively being formed, and at 78 weeks, new bone had fully covered the plate on the antral and orbital side. No inflammation or rejection of the PLLA implant was seen.

Optic nerve blindness following a malar fracture

Optic nerve blindness following a malar fracture is an uncommon and usually permanent complication. When the loss of vision is immediate and total, the prognosis is poor. The case of a patient who suffered immediate and complete loss of vision after a malar fracture is presented. Computed tomography revealed compression of the optic nerve by bony fragments. No improvement was observed after megadose steroids and surgical treatment. The incidence, pathogenesis, diagnostic approach and therapeutic possibilities are discussed and the importance of establishing precisely the moment of the loss of vision is stressed.

Cutaneous approaches to the orbital skeleton and periorbital structures

Multiple cutaneous approaches to both the superior and inferior orbit have been reviewed. Incisional choices are optimally based on both facial esthetics and orbital function, which are achieved by an understanding of the unique anatomy of this region. The superior orbit is best approached by a blepharoplasty (lid crease) incision in conjunction with a lateral extension if additional exposure is necessary. Almost all aspects of the bony orbit can be reached with the exception of the frontal bone superior to the supraorbital rim. When wide exposure of the orbital skeleton is necessary, a bicoronal scalp flap is most effective in a nonalopecic patient. The inferior orbit can be approached by a ciliary, blepharoplasty, or conjunctival incision with a lateral canthotomy. None has proven esthetic advantages over the others, with the exception of the conjunctival incision when used alone. The lid incisions must be used with the understanding that orbital function must be assessed both pre- and postoperatively and meticulous attention paid to protection and care of the anterior globe. In addition, because of the thinness of the tissues being manipulated, edema, bruising, and final settling of lid form may require more postoperative time than is typical of more peripheral approaches.

Orbital blowout fractures--the influence of age on surgical outcome

We report the frequency of troublesome diplopia in 17 patients (11 patients less than or equal to 21 years) who underwent surgical repair of traumatic orbital blowout fractures. Thirteen patients had primary surgery performed within 21 days of injury, 2 patients at 4 and 6 weeks and 2 cases at 6 and 24 months. The latter continues to complain of diplopia. Contrary to previous studies, we found that young patients were no more likely to suffer from symptomatic post-operative residual diplopia than their adult counterparts.

The role of orbital wall morphological properties and their supporting structures in the etiology of "blow-out" fractures

The stiffness and strength of the orbital walls are proportionally dependent on the anatomical structures which support and strengthen these walls from the opposite side. The medial wall is therefore strong due to the support of ethmoid cells. The floor is stronger the less surface there is and the more supported it is by trabeculae of the maxillar sinus. The strength of the upper and lateral walls are proportional to their thickness. The orbital floor is on the average the weakest, followed by the medial and upper walls. The lateral wall is the stiffest and the most rigid. Computed tomography (CT) has improved structural analysis of the orbital contents and orbital walls enabling the visualisation of superficial and deep soft tissues and bone structures.

Custom orbital implant in the repair of late posttraumatic enophthalmos

We repaired late, posttraumatic enophthalmos in 21 patients by inserting a large, soft, Silastic block through a lower eyelid flap and transconjunctival approach to the orbit. These blocks were hand carved at the time of surgery to match bony defects as characterized by hypocycloidal tomographic biometry. Enophthalmos and hypo-ophthalmos were ameliorated with acceptable appearance in all cases. No implant rejections, migrations, or infections were found. Complications included upper eyelid blepharoptosis, lower eyelid retraction, and conjunctival prolapse. The improvements were stable over a median follow-up of 13 months.

A retrospective study of untreated orbital blow-out fractures

A retrospective study of 27 cases of untreated orbital blow-out fractures is presented. These patients were managed non-surgically because they presented with minimal ophthalmologic symptoms, or they sustained other injuries that prevented early repair. Twelve patients returned for follow-up examination and eight were contacted by telephone. In evaluating patients for diplopia, enophthalmos, hypesthesia, and restricted ocular movement, 85% showed complete resolution of symptoms. Based on these findings, surgical intervention is recommended only in those patients who demonstrate residual diplopia in primary gaze and restricted ocular motility that persist after 10 to 14 days, the presence of enophthalmos greater than 2 mm, and gross disruption of the orbital floor as confirmed by CT or tomography.

Ocular injuries associated with fractures involving the orbit

Ocular injuries often accompany periorbital fractures. The incidence reported by various authors varies greatly. The charts of 509 patients operated on because of a fracture involving the orbit were reviewed and the intra- and extraocular injuries were recorded. Subconjunctival haematoma, corneal abrasions and mild retinal oedema were not considered. It appeared that 26% of the injured suffered concomitant lesions of the eye and/or its adnexae. The incidence is discussed and certain hints are given, which can help non-ophthalmologists assess the severity of the trauma in cases where obvious signs are absent.

Medial orbital wall fracture with enophthalmos

An isolated blow-out fracture of the medial orbital wall is uncommon, whereas the incidence in conjunction with an orbital floor fracture is high. The most striking features of an isolated medial wall fracture are diplopia on medial and lateral gaze and/or enophthalmos. The cases of two patients with a fracture of the medial orbital wall with enophthalmos are presented. One patient had an isolated medial wall fracture, whereas the other had a combined medial and inferior orbital wall fracture. Treatment of the enophthalmos consisted of exposure of the medial wall fracture site using a bicoronal flap, freeing of the herniated soft tissues and reconstruction of the defect with an autogenous medial iliac bone graft. The incidence, aetiology, pathogenesis, signs and symptoms and surgical treatment of the isolated orbital medial blow-out fracture are discussed.

The incidence of extraocular muscle and cranial nerve palsy in orbital floor blow-out fractures

The frequency of extraocular muscle (EOM) or cranial nerve (CN) palsy as the sole cause of diplopia in orbital floor blow-out fractures has not been previously determined. Of 40 blow-out fracture patients studied prospectively, seven had motility disturbances consistent with palsy of one EOM or CN. All seven patients had negative forced ductions, making entrapment, edema, or orbital hemorrhage unlikely causes of diplopia. The diplopia resolved in four patients in 1 year. Persistent diplopia is a common indication for repair of such fractures. If, however, diplopia is due only to EOM or CN palsy, orbital surgery should be deferred (in the absence of significant enophthalmos) in favor of observation and/or later strabismus surgery.

Reconstruction of orbital defects with autogenous bone from mandibular symphysis

Autotransplant bone is superior to other bone, cartilage, or alloplastic materials for the reconstruction of orbital floor defects. The bone used for filling orbital floor defects is taken from the symphysis of the lower jaw. The piece of bone, up to 3.5 X 1.5 cm in diameter is strong enough to support the orbital contents, while at the same time it is easily modelled and positioned. This method is indicated for reconstruction of the orbital floor, with or without rim defects. Taking of the transplant, while retaining the lower margin of the mandibular symphysis, preserves the contour of the chin.

Blowout fracture of the orbital floor with entrapment caused by isolated trauma to the orbital rim

There are two main theories on the cause of blowout fractures of the orbit: the "hydraulic" theory and the "buckling force" theory. Although both mechanisms have been shown responsible for experimental blowout fractures, the role of isolated rim trauma in producing clinical blowout fractures with entrapment of orbital soft tissues continues to be questioned. I examined a 69-year-old patient who developed a blowout fracture with clinical evidence of entrapment after isolated trauma to the orbital rim. Five days previously the patient had had a cataract extraction and implantation of an intraocular lens in the ipsilateral eye, which remained undisturbed by the trauma. This case supports the role of a buckling force to the rim in producing orbital blowout fractures. Review of the circumstances of injury in large series of blowout fractures suggests that this mechanism may be operative in the majority of cases.

Late reaction to silicone following reconstruction of an orbital floor fracture

This report presented the clinical and radiographic findings, the surgical management, and the histologic features of a chronic inflammatory lesion that developed in response to a Silastic orbital floor implant placed 13 years previously. A review of the literature supported the fact that implanted solid film polymers can precipitate a continuous, chronic inflammatory response that is dynamic and that may be exacerbated by numerous factors.

Posttraumatic enophthalmos and diplopia

Malposition of the globe and failure to fuse visual images are late-developing complications of orbital injury. This article reviews the causes of specific sequelae, such as enophthalmos, hypophthalmos, and diplopia, and describes a procedure of strategic implantation of autogenous bone grafts to correct the condition(s). Using quantifiable methods of assessing globe position and motility, the authors demonstrate improvement in 18 of 19 patients. Vision is reported unchanged or improved in 13 sighted patients. Several cases are presented with analyses of preoperative and postoperative photographs. Indications, contraindications, advantages, and disadvantages of the surgical procedure are described and compared to others.

Orbital blowout fractures. The prognostic significance of computed tomography

Nineteen patients with orbital floor fractures were examined and underwent computed tomography of both orbits. By evaluating the amount of orbital expansion and soft tissue herniation, we were able to identify a group of patients at high risk for developing enophthalmos (3/7 in the group with the largest amount vs. 0/7 and 0/5 in the two other groups). By studying the appearance of the inferior rectus muscle, we were also able to identify a group of patients at high risk for developing persistent diplopia (5/5 with entrapped muscles, 0/2 with hooked muscles and 0/12 of patients with free inferior rectus positions).