Retrocaruncular approach for the repair of medial orbital wall fractures: an anatomical and clinical study

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Prospective Evaluation of Two Wall Orbital Fractures Involving the Medial Orbital Wall: PSI Reconstruction versus PDS Repair—Worth the Effort?

Proper treatment of the two-wall fractured orbit is still controversial. Specifically, there is no consensus on the issue of the necessity of medial orbital wall repair. With anatomically critical structures at risk during the surgical approach, surgeons’ view on the necessity of medial orbital wall repair often is restricted and an aesthetically disturbing enophthalmos is more likely to be accepted. Therefore, treatment options range from leaving the medial wall without repair to reconstruction with autogenous tissue or alloplastic materials, which can lead to moderate to severe side effects. However, emerging technologies such as patient-specific implants (PSI) offer a reliable and anatomically correct reconstruction of the bony orbit. This study aimed to evaluate the outcome of full orbital reconstruction using PSIs compared to only orbital floor repair using PDS (bioresorbable polydioxanone) foils leaving the medial orbital wall untouched in traumatic two-wall orbital fractures. Of all patients treated at the University Hospital of Düsseldorf between 2017 and 2019 who suffered from traumatic orbital fracture, only patients with a two-wall orbital fracture involving both the orbital floor and the medial wall (n = 68) were included. Patients were treated either with a PSI (n = 35) or a PDS foil (n = 33). Primary outcome parameters were ophthalmological disturbances analyzed via clinical investigation and intra-orbital angles, volumes and implant position analyzed with radiological 3D-datasets. While a two-wall reconstruction using PSIs led to a significant improvement of the enophthalmos, the rate of postoperative enophthalmos was significantly increased in cases of only orbital floor repair with PDS foils. Radiologically, a significant reconstruction of the three-dimensional bony orbit succeeded with the simple use of PSIs leading to a significant reduction in the traumatically enlarged orbital volume. PSI also led to a significant reduction in the traumatically enlarged medial angle of the orbit. This was not the case for single-floor repair with PDS foil. The results of this study suggest that complex orbital fractures can be reconstructed at an even higher degree of accuracy with selective laser-melted PSIs than PDS foils. In order to achieve a true to original reconstruction of the bony orbit, surgical treatment of the medial orbital wall can be advocated for in the long term depending on the indication.

Three-Dimensional Diagnosis in Orbital Reconstructive Surgery

Introduction

Orbital floor fractures are common among mid-face fractures. The general aim of treatment is to restore orbital volume and anatomy with grafts or reconstructive materials. Malpositioning of the implants and inadequate volume restorations are common complications of these procedures. The aim of our study is to present the surgical outcomes of orbital reconstruction aided by our algorithm of patient-specific virtual planning.

Materials and Methods

The current study was performed on 77 patients with orbital wall fractures who were categorized into two groups: Group A - 42 patients (virtual planning) and Group B - 35 patients (traditional approach). Criteria of analysis included the presence of diplopia postoperatively and duration of surgical procedures.

Results

Diplopia was recorded right after surgery in 16 cases (38.1%) of Group A and in 12 cases (34.3%) of Group B. However, 6 months postreconstruction, residual diplopia was recorded in 4 cases (9.5%) of Group A and in 12 cases (34.3%) of Group B. Mean operation time in Group A for the patients with isolated zygoma fracture was 2.23 h; for isolated orbital wall fracture was 1.98 h; and for combined zygoma, orbital wall, and facial bone fracture was 3.07 h. In Group B, these indexes were 3.47, 2.05, and 3.31 h, respectively.

Conclusions

Application of virtual planning could significantly improve postoperative outcomes in orbital reconstruction. However, application of this technology could be limited by complicated defects of the orbital walls, which would require complex shape of the implant that might be difficult to be prevent virtually.

[Anatomical description of the retro-caruncular approach and its application in oculoplastics: A cadaveric study]

PURPOSE

To describe the anatomical landmarks of the retro-caruncular approach and its clinical applications based on a cadaveric study.

PATIENTS AND METHOD

A dissection of 8 orbits providing from 4 fresh cadavers was carried out at the anatomical laboratory of the University Hospital of Nice, France between October 2018 and January 2019.

RESULTS

Main anatomical relationships encountered are anteriorly the Duverney-Horner muscle and the lacrimal sac, posteriorly the anterior and posterior ethmoidal arteries, superiorly the pulley of the superior oblique muscle, inferiorly the lacrimonasal duct and the tendon of the inferior oblique muscle. The retro-caruncular approach allows a safe surgical access behind the lacrimal sac and Duverney-Horner muscle. Many oculoplastic surgical procedures can be performed through this approach: dacryocystorhinostomy, medial orbital fractures repair, "médial" orbital "décompression", biopsy of medial and extraconal tumours, medial periosteal fixation in third-nerve palsy.

CONCLUSION

The retro-caruncular approach is a safe procedure avoiding skin incision. It allows a wide surgical space even if it is reduced compared to a more conventional skin route. It requires a great anatomical knowledge and a longer surgical learning curve.

[Possible surgical approaches to the orbit]

For removal of tumors and foreign bodies from the orbit, for treatment of severe inflammatory diseases, and for repositioning of bone fragments following fractures or during reconstruction of the bony orbit, several different surgical approaches are available. During the past decade, improved understanding of the pathology and pathophysiology of particular orbital diseases, advancements in clinical endoscopy and microscopy, the introduction of modern imaging techniques for preoperative visualization of pathologic findings, modern approaches to orbital reconstruction, as well as developments in adjuvant therapy have led to a reduction in invasiveness and development of the modern minimally invasive surgical approaches to the orbit usually used today. This review article aims to describe several surgical approaches to the orbit that are nowadays commonly applied-frequently in the context of interdisciplinary therapy-as well as their indications and potential complications. Particular attention is paid to minimally invasive approaches. These different surgical approaches allow a 360-degree exposure of the internal orbital structures with the optic nerve at the center ("round the clock access to the orbit"). The review is complemented by hints and tricks for particular approaches, as well as by a review of the latest literature in the field.

Orbital Fracture Reconstruction Using Prebent, Anatomic Titanium Plates: Technical Tips to Avoid Complications

Orbital fractures are common. In patients where there is significant loss of the medial wall and orbital floor, anatomic prebent 3-dimensional plates allow efficacious restoration of orbital volume. However, the large size of these plates can result in technical difficulties with plate placement, especially in fractures with complete loss of 2 walls of the orbit. In this article, the authors review the pertinent anatomy of the bony orbit with respect to fracture and landmarks in fracture reduction. The authors also note the 3 most commonly encountered problems with the placement of anatomic plates: poor exposure, failure to identify the posterior ledge for the plate, and rotational issues with plate placement resulting in impingement. Technical tips are given to help overcome these issues intraoperatively.

Reconstruction of medial orbital wall using a retrocaruncular approach

The purpose of the study was to analyze and describe the retrocaruncular approach to access medial orbital wall. A retrospective analysis was performed in patients referred for the treatment of orbital fractures between January 1st 2011 and July 31st 2017. The study included patients over 18 years old with isolated fractures of the medial orbital wall or combined with the orbital floor who underwent a transconjunctival approach with retrocaruncular extension and lateral canthotomy, and with a minimum follow-up of 6 months. Patients with fractures to the roof and/or lateral orbital wall were excluded. From a total of 319 orbits, 30 medial wall fractures were treated using a retrocaruncular approach, transconjunctival extension and lateral canthotomy. 7 of them were pure medial wall fractures and 23 were combined with orbital floor. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Only one patient developed a conjunctival granuloma in relation to the caruncle. No others patients had complications. This study concluded that this approach is a successful access for surgical treatment of medial orbital wall fractures because of their broad visibility without damaging structures, allowing adequate orbital reconstruction and excellent aesthetic results.

Orbital fracture repair outcomes with preformed titanium mesh implants and comparison to porous polyethylene coated titanium sheets

BACKGROUND

Restoration of orbital volume after internal orbital fractures can prevent enophthalmos. A variety of allografts are commonly used including titanium mesh with and without porous polyethylene coating. Some controversy exists over the use of uncoated titanium mesh in the orbit. Newer products contoured to the three dimensional orbital anatomy aim to improve reestablishment of the complex orbital shape though studies of outcomes with their use are limited.

METHODS

A retrospective chart review was performed to evaluate surgical outcomes in all patients who underwent orbital fracture repair with DePuy/Synthes titanium MatrixMIDFACE prefabricated implants (PFTi) as compared with porous polyethylene/titanium hybrid implants (PPETi) including Stryker Medpor Titan, MTB, and BTB implants. Incidence of reoperation, diplopia, and movement restriction between PFTi and PPETi groups and the risk ratio of the above outcomes between implant types were compared.

RESULTS

A total of 464 orbital implants were reviewed. Patients were divided by implant type with 195 patients receiving a PFTi implant and 269 patients receiving PPETi implant. (PFTi) and 269 had placement of a porous polyethylene/titanium hybrid implant. Despite statistically significant increased probability of utilization in more complex and delayed fractures, the PFTi implant showed no significant difference in complication profile or reoperation rate compared to the more commonly used PPETi.

CONCLUSIONS

PFTi implants, designed to replicate the native orbital shape, have similar surgical outcomes and no difference in complication profile compared to standard porous polyethylene/titanium implants hybrid plates.

Treatment of Orbital Medial Wall Fractures with Titanium Mesh Plates Using Retrocaruncular Approach: Outcomes with Different Techniques

Surgical management of medial wall orbital fractures should be considered to avoid diplopia and posttraumatic enophthalmos. Treatment of these fractures remains a challenge for the maxillofacial surgeon because of complex anatomy and limited vision. This article aims to retrospectively evaluate the outcomes in the repair of medial orbital wall fractures using a retrocaruncular approach and titanium meshes, comparing the placement of the titanium mesh with three different techniques: (1) conventional free hand under direct vision, (2) with the assistance of an endoscope, and (c) with the assistance of a navigation system. Eighteen patients who underwent surgery for orbital medial wall fracture were enrolled in the study. On the basis of the implant placement technique, three groups were identified: group 1 (CONV), conventional free hand under direct vision; group 2 (ENDO), endoscopically assisted; group 3 (NAVI), a navigational system assisted (BrainLab, Feldkirchen, Germany). The postoperative quality of orbital reconstruction was assessed as satisfactory in 12 cases, good in 4 cases, and unsatisfactory in 2 cases. Particularly in group 1 (CONV) in four patients out of eight, the posterior ledge of the fracture was not reached by the implant and in one patient the mesh hinged toward the ethmoid. In group 3 (NAVI), in one patient out of five, the posterior ledge of the fracture was not reached. In conclusion, titanium orbital mesh plates and retrocaruncular approach are a reliable method to obtain an accurate orbital medial wall reconstruction. The use of endoscopic assistance through the surgical incisions improves accuracy of treatment allowing better visualization of the surgical field. Navigation aided surgery is a feasible technique especially for complex orbital reconstruction to improve predictability and outcomes in orbital repair.

Computer-Assisted Three-Dimensional Planning for Orbital Decompression

Thyroid-associated orbitopathy is the most common cause of unilateral or bilateral proptosis in adults. A mainstay of surgical treatment is orbital decompression utilizing osteotomies to increase the size of the affected bony orbit to accommodate the larger soft tissue volume. Over the past several decades, numerous approaches have been described for orbital decompression. However, given the intricate osseous and soft tissue anatomy within the orbit, orbital decompression is a potentially hazardous intervention. With advances in three-dimensional imaging and virtual planning, extensive orbital decompressions can be performed safely and efficiently. In this report, we describe two cases of three-wall orbital decompressions using three-dimensional planning.