Comparison of preseptal and retroseptal transconjunctival approaches in patients with isolated fractures of the orbital floor

Preseptal transconjunctival approach in orbital floor fracture repairs to prevent postoperative lower eyelid malposition

PURPOSE

Lower eyelid malposition can be a complication following orbital floor fracture surgeries. We present our incidence of lower eyelid malposition from a large case series of orbital floor fracture repairs using the 'swinging eyelid' approach and 'hang back' technique.

METHODS

A retrospective review of all orbital fracture surgeries at our institution from November 2011 to March 2021 was performed. Primary outcomes included the incidence of lower eyelid malposition by category, the average time to presentation after primary surgery, and reoperation rates among cases with lower eyelid complications.

RESULTS

A total of 438 cases that involved repair of the fractured orbital floor were identified. Six patients (1.37 %) developed lower eyelid malposition following primary orbital floor repair. Two patients (0.46 %) developed reverse ptosis of the lower eyelid. Two patients (0.46 %) returned with lower lid cicatricial ectropion. One patient (0.23 %) had postoperative lower eyelid retraction. One patient (0.23 %) had postoperative lower eyelid cicatricial entropion. No cases of lower lid flattening, lower eyelid fat flattening, or eyelid notch was noted. All patients with lower eyelid malposition underwent additional surgeries except one patient with reverse ptosis (83.3 %). The average time to the presentation of postoperative complications from the surgery date was 292.8 days (range = 49 days to 3.5 years).

CONCLUSION

Lower eyelid malposition after orbital floor repair is a known complication that can be decreased by employing the 'swinging eyelid' with a preseptal approach and closure by the 'hang back' technique.

Orbital Fractures

Orbital fractures are common in facial trauma and can be a challenge to treat. Understanding anatomy of the orbit, the clinical evaluation, indications for surgery, surgical approaches, complications, and postoperative are essential in providing appropriate treatment for patients who have sustained orbital fractures. In this article, the authors review the diagnostic evaluation, acute management, treatment options, and common complications of orbital fractures, as well as recent advancements in orbital fracture repairs.

Experience of orbital floor fractures in a UK level one trauma centre: a focus on the surgical approach and lid-related complications

The two surgical approaches to access orbital fractures are transconjunctival and transcutaneous. The aim of this study was to assess the outcomes of orbital repairs with a focus on lid-related complications and their management. A retrospective analysis was carried out over a five-year period (January 2015 to January 2020) to assess all consecutive orbital repairs in our unit. Data were collected for variables including demographics, fracture pattern, surgical approach, and details of postoperative complications. A total of 111 patients were included in the study, 94 were male (85%), the majority being between 16 and 45 years of age. A total of 46 (41%) had isolated orbital floor fractures, 31 (28%) zygomaticomaxillary complex, and 18 (16%) Le Fort pattern fractures. Eighty per cent (n = 91) received a transconjunctival approach as first choice. In the transconjunctival group, six (6.6%) had entropion and increased scleral show, four (4.4%) had ectropion, and none had canthal malposition. In the transcutaneous group (n = 20) there was a higher rate of ectropion (25%, n = 5), a lower rate of entropion (n = 1, 5%) and higher rate of increased scleral show (n = 2, 10%). Factors associated with a higher rate of complications included complex fractures, use of conjunctival sutures, and increased length of time to surgery. Seventy-two per cent of patients who suffered entropion required further surgical treatment. The most common complication of the transconjunctival approach was entropion, and clinicians should have a low threshold for early surgical management. We feel that this should be part of the consenting process, especially in high-risk cases.

Loss of Malar Bags in Lower Eyelid in Orbital Blow Out Fracture Reconstruction Following Pre- or Retro-Septal Transconjunctival Incision

An isolated orbital blow out fracture may require surgical correction by accessing the infraorbital rim through a transconjunctival incision and inserting an orbital plate. The risk for aesthetic complications due to the incision has previously been well described. Sixty patients surgically treated using pre- or retro-septal transconjunctival incisions for isolated orbital blow out fractures were recruited and examined with regards to lower eyelid asymmetry. Forty-seven controls with conservative treatment were recruited and underwent a similar examination. A grading system for malar bags in the lower eyelids was set up to compare the 2 groups. All patients with moderate or severe malar bags on the nonoperated eyelid lost the malar bags on the operated side and developed asymmetry in the lower eyelids. No difference was found between the pre- and retro-septal approach. In this study we describe a new complication related to the transconjunctival incision and highlight the importance of informing patients in need of reconstruction of the orbital walls about the risk of postoperative asymmetry in the lower eyelids.

Analysis of the effect of repair materials for orbital blowout fracture on complications

AIM

To investigate the effect of repair materials for orbital blowout fractures on the occurrence of postoperative complications.

METHODS

The clinical data and follow-up data of 54 subjects with orbital blowout fractures were retrospectively analyzed. The study was divided into three groups according to the used repair materials: titanium mesh (16 cases), Medpor (12 cases), and Medpor titanium mesh (26 cases). All test data were analyzed using the SPSS version 23.0 statistical software. The mean age and duration of disease between the groups were compared through one-way analysis of variance. The Chi-square (χ ²) test was used to compare the number of males and females, different fracture types, and different surgical approaches among groups. The χ ² test was used to compare the frequencies for complications in each group.

RESULTS

The baseline characteristics of age and gender in each group were matched (F=1.763, P=0.172; χ ²=0.026, P=0.987). In addition, there was no difference in the type of fracture and surgical approach (χ ²=0.460, P=0.977; χ ²=0.691, P=0.952), or the incidence of complications (χ ²=0.081, P=0.960) between the three groups.

CONCLUSION

Although there is no difference in effect of various repair materials on the incidence of complications, the effect of repair materials on postoperative complications of orbital blowout fractures should not be ignored.

What surgical approach has the lowest risk of the lower lid complications in the treatment of orbital floor and periorbital fractures? A frequentist network meta-analysis

PURPOSE

Evidence on the best surgical approach with the lowest lower lid complications (LLCs) in the treatment of orbital floor (OF) and periorbital fractures (POFs) is limited because of the absence of head-to-head studies. We performed this network meta-analysis (NMA) to compare various surgical approaches in treatment of OFs and POFs, with respect to LLCs.

MATERIALS AND METHODS

This NMA based on PRIMSA guidelines studied the incidence of the LLCs among various surgical approaches in the treatment of the OFs and POFs. We searched several databases from 1970 to March 2018. All clinical studies comparing different surgical approaches in treatment of OFs and POFs were included. Outcome variables were ectropion, entropion, scleral show and other complications. Predictor variables were transconjunctival approach (TCA), subciliary approach (SCA), subtarsal approach (STA) and infraorbital approach (IOA). Frequentist NMA was performed using STATA software.

RESULTS

A total of 47 studies with 5267 cases of the OFs and POFs received ORIF using 4 surgical approaches with 6 comparisons were included. TCA significantly reduces the prevalence of ectropion than SCA (OR = 3.54, CI1.28-9.84), but no significant difference was found between TCA and, STA or TCA and IOA. SCA and STA significantly reduce the prevalence of entropion than TCA (OR = 5.02, CI, 1.79-14.06, OR = 0.11, CI, 0.02-0.57) respectively. We found no significant difference between the 6 comparisons with respect to other complications.

CONCLUSION

This NMA shows that the application of various surgical approaches leads to different incidences of LLCs. While TCA appears to have the lowest overall LLCs rate, STA has lowest rate among the transcutaneous approaches. The choice of an appropriate surgical approach for a given fracture should take these among other factors into consideration. Owing to the limitations of this study, we suggest that the results be interpreted with caution.