Orbital blowout fractures: a ten-year survey

Monocular blindness developing 7 days after repair of zygomaticomaxillary complex fracture. A clinical report

Blindness following zygomaticomaxillary complex (ZMC) fracture and surgical repair is an unfortunate and uncommon complication. A review of the literature reveals fewer than 25 cases of monocular blindness resulting from zygomaticomaxillary fracture or repair. The case presented here is that of a man who was assaulted with a baseball bat and suffered a mildly displaced ZMC fracture. On admission, the patient had light perception only in his left eye. During his convalescence, vision in his left eye gradually improved to the point of allowing him to read a newspaper without difficulty. Then, 9 days after the injury (7 days after surgical repair), the patient awoke with complete blindness of the left eye. The possible mechanisms for such loss of vision are discussed.

Blow-out fracture of the orbit in 4 children

4 cases of blow-out fractures of the orbit in children are presented. Four 6- to 12-year-old boys were successfully operated on via an orbital and transsinus approach. As material for restoration of the broken orbital floor, Silastic was used in 3 patients.

Orbital floor fractures and their treatment

Orbital floor fractures can occur with or without any associated fractures of the middle third of the facial skeleton. Fifty-one patients with a unilateral "black eye" after motor vehicle accidents were reviewed. The fractures involving the orbital floor were analysed. The clinical signs and symptoms, with results of radiological examination, are discussed. The various treatment modalities and their postoperative complications are discussed.

A retrospective study of treatment of orbital floor fractures with the maxillary sinus approach

The Cook County Hospital, Chicago, Illinois, protocol for the management of orbital fractures is presented. Diplopia which fails to resolve in 1 week or appears after oedema subsides, enophthalmos or radiographic depression of the orbital floor, associated tripod fracture deformity, or purulent maxillary sinusitis are indications for surgery. The surgical procedure is a modification of the maxillary sinus approach, which includes the use of iodoform gauze packing, nasal antrostomy, a double layer oral closure and prophylactic antibiotics. A review of 102 patients treated surgically over a 6-year period is presented. Post-operative diplopia was 9% and there were minor complications in 3%, which were significantly lower than previously reported series of orbital fractures treated either non-operatively, or through an orbital exploration approach. No patient treated non-operatively required surgery in the future. The protocol presented can eliminate unnecessary exploration and yields excellent results with a simple surgical procedure.

Unilateral orbital floor fractures

Ninety patients operated on, on suspicion of unilateral orbital floor fractures are described. Age, sex, and etiology are given. Operative indication is examined and related to the operative findings. Fifty-six of the patients had fractures requiring transplantation, 24 had fractures which did not. Ten patients had no fractures. Only autogenous bone graft was used. The patients were examined three months and one to 11 years postoperatively (questionnaire). Of 82 operated patients who answered the questionnaire diplopia was found in eight, enophthalmos in two, hypesthesia in 18, reduced mobility in four and sinuitis in four. Preoperative X-ray: Three patients showed false positive X-ray findings. In 19 patients with false negative X-ray findings 12 required transplantation. Twenty-five tomographed patients showed fractures, two of which proved to be false positives. In eight patients with negative tomographical findings, fractures were found, seven of which required transplantation. The frequency of complications assessed in relation to the time of operation shows no significant difference, if surgery takes place within seven days of injury. Surgery performed later than this seems to produce more cases of chronic sinuitis.

Bilateral orbital floor fractures

Nineteen patients operated on suspicion of bilateral orbital floor fractures are described. All of the patients had severe comminute midfacial fractures. Orbital floor deficiency requiring transplantation was found in 68% of the cases, demonstrating homolateral maxillary and zygomatic fractures. On the basis of their findings, the authors recommend acute reposition of the fractures and routine exploration of the orbital floor in the case of deficiencies requiring transplantation and in cases of homolateral combined maxillary and zygomatic fractures.

The versatility of modern therapy in mid-facial trauma

Modern trends in the therapy of mid-facial trauma, which include the use of miniplates, wire osteosynthesis, and suspension wiring, bone transplantation from the contra-lateral canine fossa for orbital floor reconstruction, as well as the use of lyophilised dura placed over bony defects, are briefly discussed. The versatility of the combined techniques used in therapy has been illustrated by a case.

Proplast augmentation for posttraumatic zygomatic deficiency

Facial deformities following fractures of the zygomatic complex are common. Included in this article are the indications, work-up, and surgical technique for placement of Proplast implant material to correct the deformity of the malunited zygomatic complex. Three cases are presented to illustrate this approach.

Late treatment of malunited malar fractures

Malunited malar fractures are considered from the points of view of pathophysiology and anatomy. Clinical and radiographic approaches to assessment are described. Surgical techniques are presented in detail. Four representative cases are reported.

Orbital laceration caused by a blast of water: report of 2 cases

Two cases of orbital injuries caused by the jet of water from an irrigation sprinkler are described; they were of a type not previously reported. The jet of water, possessing high kinetic energy, stretched the orbital tissues and resulted in a rupture which followed the anatomical seams. Thus there was no bleeding, but oedema was present. The eyeball was also injured.

Traumatic enophthalmos

Traumatic enophthalmos, either following orbital floor fracture or enucleation, is caused by decreased orbital volume. Volume replacement, both surgical and/or nonsurgical, provides a direct treatment. Surgical treatment can increase orbital volume by reducing the herniated orbital tissue and/or implanting alloplastic or autogenous material. When a seeing eye is present, implant surgery may compromise vision; volume replacement must be judicious. Alternative surgical management creates the illusion that little or no enophthalmos exists by enlarging the palpebral fissure or changing orbital contour.

Blow-out fracture of the orbit. Diagnostic and therapeutic considerations, and results in 90 patients treated

On the basis of 90 patients with blow-out fracture of the orbit the authors present diagnostic methods, the treatment and follow-up results, mainly as regards visual function (diplopia) and aesthetics (enophthalmos). Surgery was performed in 77 cases, 6 patients were treated conservatively by eye muscle training, and 7 patients refused surgery. Surgery consisted in primary reconstruction of the orbit, exploration of the fracture site, freeing the entrapped soft tissues (periorbital tissues, eye muscles) and reconstruction of the defect with autogenous bone graft, followed by eye muscle surgery in cases of failure. After surgery no complications were observed. Results of treatment were evaluated by established methods elaborated by the authors, in the same order before and after surgery. Of 77 patients treated surgically recovery was obtained in 63.6%, marked improvement in 23.4%, slight improvement in 13.0%. In conclusion the authors state that: 1) in all cases ophthalmological examination is most important, 2) approach to the orbital floor or medial wall is best obtained by transconjunctival or subciliary incision, 3) in cases with a defect with a defect of the orbital floor the best material is autogenous bone graft. In linear fracture of the orbital floor and medial wall it is sufficient to free the entrapped tissues, 4) in all surgical patients eye muscle training proved effective.

Current treatment of blow-out fractures

Blow-out fracture repair and its timing have been controversial. Originally all x-ray proven fractures were repaired regardless of size or symptoms. Later a controversial report of a large series of cases indicated repair to be unnecessary. Today, x-ray proven fractures with enophthalmos justify surgery, but double vision alone is insufficient. Observation of improving diplopia for several days is suggested. Evaluation of x-rays, enophthalmos, diplopia with restriction, and facial anesthesia are recommended before surgery. Recognition of diagnostic signs and symptoms, as well as potential severe cosmetic and functional complications, have aided the approach to the decision for or against fracture repair.

The use of lyophilized dura in reconstruction of the orbital floor

The results and experiences with the use of lyophilised human dura in 52 cases are reported. Experimental work carried out on rabbits demonstrate that human lyodura is replaced by a layer of connective tissue. Both, the results of animal experiments as well as those experienced in 52 clinical cases suggest that lyodura is an excellent material for the reconstruction of defects of the orbital floor.

Lacrimal obstruction after migration of orbital floor implant

A 7-year-old girl developed epiphora, recurrent purulent conjunctivitis, and dacryocystitis 32 months after the repair of a traumatic orbital floor fracture. Dacryocystography and surgical exploration revealed that migration of the orbital floor implant had caused obstruction of the nasolacrimal duct at the sac. Migration of the implant was probably due to a failure to anchor the implant properly to bone.

Gelfilm and blowout fractures

A variety of alloplastic and natural substances have been utilized for support of the orbital floor following a blowout fracture. The employment of Gelfilm is herein recommended for the smaller floor defects. Sterile Gelfilm is manufactured from denaturated collagen, is 0.075 mm. thick, and is known to be tolerated well by ocular tissues. Complete absorbsion of Gelfilm occurs in two to three months, obviating the need for removal of a prosthetic material or the lifetime presence of an alloplast in the orbit. In contrast to autografts no additional surgery is required for its preocurement.