Orbital blowout fractures: a ten-year survey

The Impact of Surgical Timing in Orbital Fracture Repair: A New Paradigm

BACKGROUND

For decades, there has been an ongoing debate about the ideal timing of orbital fracture repair (OFR) in adults.

METHODS

The authors conducted a retrospective review of patients who underwent OFR at 2 centers (2015 to 2019). Excluded were patients younger than 18 years and those with follow-up less than 2 weeks. The study's primary outcome was the incidence/persistence of postoperative enophthalmos/diplopia at least 2 weeks following OFR. The association between surgical timing and postoperative ocular complications was assessed in patients with extraocular muscle (EOM) entrapment, enophthalmos and/or diplopia, and different fracture sizes.

RESULTS

Of 253 patients, 13 (5.1%) had preoperative EOM entrapment. Of these, patients who had OFR within 2 days of injury were less likely to develop postoperative diplopia compared with patients who had OFR within 8 to 14 days (1 of 8 patients [12.5%] versus 3 of 3 patients [100%]; P = 0.018). Patients who had OFR for nearly total defects within 1 week of injury were significantly less likely to have postoperative enophthalmos (0 patients [0.0%]) compared with those who had surgery after 2 weeks (2 patients [33.3%] after 15 to 28 days versus 8 patients [34.8%] after 28 days from injury; P < 0.001). Patients who had delayed OFR for large fractures smaller than nearly total defects, preoperative persistent diplopia, or enophthalmos were not at significantly greater likelihood of postoperative ocular complications compared with those who had early OFR.

CONCLUSIONS

The authors recommend OFR within 2 days of injury for EOM entrapment and 1 week for nearly total defects. Surgical delay up to at least 4 weeks is possible in case of less severe fractures, preoperative persistent diplopia, or enophthalmos.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Assessing the Adequacy of Orbital Reconstruction With Titanium Mesh Using Clinical and Radiological Measures

Background Orbital reconstruction aims to restore the original orbit volume and correct diplopia, enophthalmos, and ocular motility of the fractured orbit. This study aimed to assess the adequacy of orbital reconstruction using radiological and clinical factors. Methods In this retrospective study, patients with orbital blowout fractures meeting clinical or radiographic criteria underwent orbital reconstruction with titanium mesh. The orbital volume and anteroposterior displacement were calculated pre- and post-operatively using computed tomography. Diplopia, inferior orbital nerve examination, and ocular movement were also evaluated. Pre- and post-operative orbital volumes of the fractured and contralateral unfractured orbits were compared. Statistical analysis was performed using MS Excel (Redmond, USA) and STATA BE (Texas, US). Results There was a significant reduction in the difference in volumes between fractured and normal orbits postoperatively (p-value <0.001). The mean difference between the reconstructed orbital floor fracture and the contralateral normal orbit was 0.55 cm3, which is within the normal anatomic variation. Enophthalmos was corrected postoperatively in our patients per radiological parameters as a result of a reduction in the mean posterior displacement. Infraorbital nerve hypoesthesia was not resolved postoperatively. Conclusion Our study highlights the restoration of the normal anatomical variation in volume differences between the fractured and contralateral orbits post-surgery using CT-guided analysis, thereby improving clinical outcomes.

Dacryocystitis Secondary to Orbital Mesh Implant Impingement: A Rare Etiology

A 22-year-old male patient reported swelling in relation to the right eye and developed recurrent purulent discharge and epiphora following a reconstructive traumatic orbital floor fracture repair two years ago. Radiographic investigation and surgical exploration reveal obstruction of the lacrimal apparatus at the lacrimal sac level due to over-extension/migration of the orbital floor mesh. The migration of the mesh was probably due to the extension of the mesh medially into the paranasal region.

Are We Overoperating on Isolated Orbital Floor Fractures?

BACKGROUND

Orbital floor fracture defect size and inferior rectus (IR) rounding index are currently accepted indications for surgery to prevent late enophthalmos. The authors analyzed the positive predictive value (PPV) of these indications.

METHODS

Twenty-eight patients with orbital floor fractures presenting without enophthalmos underwent Hertel exophthalmometry at presentation and at weeks 1, 2, 3, 6, 13, 26, and 52 or more after injury. Orbital defect size and IR rounding index were measured from computed tomographic scans, and PPVs of defects of 1.5 to 2 cm 2 or larger and IR rounding index of 1 or higher for enophthalmos (≥2 mm) were calculated.

RESULTS

Nineteen patients had isolated orbital floor fractures (group A), three had noncontinuous orbital floor and medial wall fractures (group B), and six had continuous orbital floor with medial wall fractures (group C). Mean follow-up time was 440 days. Of all patients, 20 had a defect size of 1.5 cm 2 or larger, 12 had a defect of 2.0 cm 2 or larger, and 13 had an IR rounding index of 1 or higher. Of the 28 patients, only one from group A and two from group C developed enophthalmos of 2 mm only. The PPVs of orbital floor defect size of 1.5 cm 2 or larger and 2 cm 2 or larger (groups A and B only) for late enophthalmos were 6.7% and 0%, respectively. The PPV of IR rounding index of 1 or higher for late enophthalmos (all groups) was 0%.

CONCLUSIONS

For patients with orbital floor fractures presenting without enophthalmos, defects of 1.5 cm 2 or larger and 2 cm 2 or larger, and IR rounding index of 1 or higher, are weakly predictive of late enophthalmos. Furthermore, patients who do not develop enophthalmos within 3 weeks of injury are unlikely to develop significant (>2 mm) late enophthalmos.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Orbital floor fractures in Taiwan: A 10-year nationwide population-based study

PURPOSE

To characterize the epidemiology, associated complications, and risk factors of orbital floor fractures in a nationwide longitudinal health insurance database.

MATERIALS AND METHODS

Claims data from a million randomly selected registered residents from the Taiwan National Health Insurance Research Database were analyzed between 2001 and 2011 as part of a retrospective cohort review. Patients were identified using the International Classification of Disease-9 diagnosis codes for orbital floor fracture (closed: 802.6; open: 802.7). The cases were categorized as surgical or nonsurgical based on the procedure codes and compared statistically.

RESULTS

From 2001 to 2011, 663 patients were diagnosed with orbital floor fractures out of a total population at risk of 9,836,431 person-years (average incidence: 6.78 persons/100,000/year) with overall increasing incidence. Surgical treatments were performed in 213 (32%) patients. Patients who received surgical treatment were younger than those who did not (mean age 25.3 ± 13.6 years vs. 34.2 ± 18.6 years, P < 0.001). The diagnosis with diplopia was a significantly associated factor for surgical treatment (2.2% in nonsurgery group vs. 6.6% in surgery group, P = 0.007). Male gender (adjusted hazard ratios [aHR] = 2.1, 95% confidence interval [CI]: 1.79-2.49) and low monthly income (aHR = 1.76, 95% CI: 1.16-2.67) were the risk factors for orbital floor fracture.

CONCLUSION

The incidence of orbital floor fractures increased in the Taiwanese population between 2001 and 2011. Men and low income patients were at increased risk of orbital floor fracture. More research is necessary to clarify what factors are driving the escalating incidence of orbital fractures in this national population.

The Dilemma of Reconstructive Material Choice for Orbital Floor Fracture: A Narrative Review

The aim of this study is to present a narrative review of the properties of materials currently used for orbital floor reconstruction. Orbital floor fractures, due to their complex anatomy, physiology, and aesthetic concerns, pose complexities regarding management. Since the 1950s, a myriad of materials has been used to reconstruct orbital floor fractures. This narrative review synthesises the findings of literature retrieved from search of PubMed, Web of Science, and Google Scholar databases. This narrative review was conducted of 66 studies on reconstructive materials. Ideal material properties are that they are resorbable, osteoconductive, resistant to infection, minimally reactive, do not induce capsule formation, allow for bony ingrowth, are cheap, and readily available. Autologous implants provide reliable, lifelong, and biocompatible material choices. Allogenic materials pose a threat of catastrophic disease transmission. Newer alloplastic materials have gained popularity. Consideration must be made when deliberating the use of permanent alloplastic materials that are a foreign body with potential body interactions, or the use of resorbable alloplastic materials failing to provide adequate support for orbital contents. It is vital that surgeons have an appropriate knowledge of materials so that they are used appropriately and reduce the risks of complications.

Orbital floor fractures: epidemiology and outcomes of 1594 reconstructions

Objective

The aim of this study was to retrospectively review the midface and orbital floor fractures treated at our institution with regard to epidemiological aspects, surgical treatment options and postoperative complications and discuss this data with the current literature.

Study design

One thousand five hundred and ninety-four patients with midface and orbital fractures treated at the Department of Oral, Cranio-Maxillofacial and Facial Plastic Surgery of the Goethe University Hospital in Frankfurt (Germany) between 2007 and 2017 were retrospectively reviewed. The patients were evaluated by age, gender, etiology, fracture pattern, defect size, surgical treatment and complications.

Results

The average patient age was 46.2 (± 20.8). Most fractures (37.5%) occurred in the age between 16 and 35. Seventy-two percent of patients were male while 28% were female. The most common cause of injury was physical assault (32.0%) followed by falls (30.8%) and traffic accidents (17.0%). The average orbital wall defect size was 297.9 mm² (± 190.8 mm2). For orbital floor reconstruction polydioxanone sheets (0.15 mm 38.3%, 0.25 mm 36.2%, 0.5 mm 2.8%) were mainly used, followed by titanium meshes (11.5%). Reconstructions with the 0.15 mm polydioxanone sheets showed the least complications (p < 0.01, r = 0.15). Eighteen percent of patients who showed persistent symptoms and post-operative complications: 12.9% suffered from persistent hypoesthesia, 4.4% suffered from post-operative diplopia and 3.9% showed intra-orbital hematoma.

Conclusion

Results of the clinical outcome in our patients show that 0.15 mm resorbable polydioxanone sheets leads to significantly less post-operative complications for orbital floor defects even for defects beyond the recommended 200 mm².

Incidence and management of retrobulbar hemorrhage after blowout fracture repair

BACKGROUND

Retrobulbar hemorrhage (RBH) is a rare complication after orbital surgery but associated with ocular complications including blindness. The aim of this study was to identify clinical characteristics of patients with RBH requiring emergent orbital decompression after blowout fracture repair.

METHOD

A retrospective review of 426 blowout fracture patients at a tertiary oculoplastic clinic provided data regarding demographics, physical examination findings, and computed tomography (CT) images. Extraocular motility had been recorded in patient charts on a scale from 0 to - 4. Patients requiring emergent orbital decompression due to RBH after surgery (RBH group) were compared with those who did not (Control group), using the Mann-Whitney U-test. Incidences of RBH according to primary or secondary surgery were also investigated, using Fisher's exact test.

RESULT

Five (1.2%) of the 426 patients who underwent blowout fracture repair developed RBH requiring emergent intervention. All RBH patients fully recovered after the decompression procedure or conservative treatment. Number of days to surgery was significantly longer in the RBH group (97.0 ± 80.1) than in the Control group (29.0 ± 253.0) (p = 0.05). Preoperative enophthalmos was also significantly greater in the RBH group (RBH vs. Control group, 3.6 ± 1.7 mm versus 1.2 ± 1.3 mm (p = 0.003)). The incidence of RBH was significantly higher in patients that underwent secondary surgery (odds ratio = 92.9 [95% confidence interval, 11.16-773.23], p = 0.001).

CONCLUSIONS

Surgeons should pay more attention to hemostasis and postoperative care in patients with a large preoperative enophthalmic eye, when time from injury to surgery is long and in revision cases. When RBH occurs, time to intervention and surgical decompression is critical for visual recovery and preventing blindness.

TRIAL REGISTRATION

The institutional review board of the Yeungnam University Medical Center approved this study ( YUMC 2018-11-010 ), which was conducted in accord with the Declaration of Helsinki.

Custom-Made Zirconium Dioxide Implants for Craniofacial Bone Reconstruction

Reconstruction of the facial skeleton is challenging for surgeons because of difficulties in proper shape restoration and maintenance of the proper long-term effect. ZrO₂ implant application can be a solution with many advantages (e.g., osseointegration, stability, and radio-opaqueness) and lacks the disadvantages of other biomaterials (e.g., metalosis, radiotransparency, and no osseointegration) or autologous bone (e.g., morbidity, resorption, and low accuracy). We aimed to evaluate the possibility of using ZrO₂ implants as a new application of this material for craniofacial bone defect reconstruction. First, osteoblast (skeleton-related cell) cytotoxicity and genotoxicity were determined in vitro by comparing ZrO₂ implants and alumina particle air-abraded ZrO₂ implants to the following: 1. a titanium alloy (standard material); 2. ultrahigh-molecular-weight polyethylene (a modern material used in orbital surgery); 3. a negative control (minimally cytotoxic or genotoxic agent action); 4. a positive control (maximally cytotoxic or genotoxic agent action). Next, 14 custom in vivo clinical ZrO₂ implants were manufactured for post-traumatologic periorbital region reconstruction. The soft tissue position improvement in photogrammetry was recorded, and clinical follow-up was conducted at least 6 years postoperatively. All the investigated materials revealed no cytotoxicity. Alumina particle air-abraded ZrO2 implants showed genotoxicity compared to those without subjection to air abrasion ZrO₂, which were not genotoxic. The 6-month and 6- to 8-year clinical results were aesthetic and stable. Skeleton reconstructions using osseointegrated, radio-opaque, personalized implants comprising ZrO₂ material are the next option for craniofacial surgery.

A retrospective study to compare the treatment outcomes with and without surgical navigation for fracture of the orbital wall

PURPOSE

To evaluate the outcomes with and without aid of a computer-assisted surgical navigation system (CASNS) for treatment of unilateral orbital wall fracture (OWF).

METHODS

Patients who came to our hospital for repairing unilateral traumatic OWF from 2014 to 2017 were included in this study. The patients were divided into the navigation group who accepted orbital wall reconstruction aided by CASNS and the conventional group. We evaluated the surgical precision in the navigation group by analyzing the difference between actual postoperative computed tomography data and preoperative virtual surgical plan through color order ratios. We also compared the duration of surgery, enophthalmos correction, restoration of orbital volumes, and improvement of clinical symptoms in both groups systemically. Quantitative data were presented as mean ± SD. Significance was determined by the two-sample t-test using SPSS Version 19.0 A p < 0.05 was considered statistically significant.

RESULTS

Seventy patients with unilateral OWF were included in the study cohort. The mean difference between preoperative virtual planning and actual reconstruction outcome was (0.869 ± 0.472) mm, which means the reconstruction result could match the navigation planning accurately. The mean duration of surgery in the navigation group was shorter than it is in the control group, but not significantly. Discrepancies between the reconstructed and unaffected orbital-cavity volume and eyeball projection in the navigation group were significantly less than that in the conventional group. One patient had remnant diplopia and two patients had enophthalmos after surgery in the navigation group; two patients had postoperative diplopia and four patients had postoperative enophthalmos in the conventional group.

CONCLUSION

Compare with the conventional treatment for OWF, the use of CASNS can provide a significantly better surgical precision, greater improvements in orbital-cavity volume and eyeball projection, and better clinical results, without increasing the duration of surgery.

Orbital Implants in Orbital Fracture Reconstruction: A Ten-Year Series

Study Design

Retrospective comparative interventional series of all patients who had undergone orbital fracture repair by 2 senior orbital surgeons in a single tertiary trauma center from January 2005 to December 2014.

Objective

To compare the outcomes of different implants used for various types of orbital fractures.

Methods

Patients were evaluated by age, gender, etiology of fracture, clinical findings, type of fractures, and implant used. Main outcome measures included restoration of premorbid state without morbidity and complications including enophthalmos, diplopia, infraorbital hypoesthesia, and ocular motility restriction 1 year after fracture repair. Implant-related complications were collected for analysis.

Results

There were a total of 274 patients with 307 orbits reconstructed. Thirty-three (12.0%) patients sustained bilateral injuries; 58.0% (n = 178) of orbits had simple fractures (isolated orbital floor, medial wall, or combined floor and medial wall). The distribution of implants used were bioresorbable (n = 117, 38.1%) and prefabricated titanium plates (n = 98, 31.9%) depending upon the nature of fracture. Bioresorbables, titanium plate, and porous polyethylene were used significantly more than titanium mesh for simple fractures, and prefabricated anatomic titanium implants were used significantly more than the other implants for complex fractures. There was a statistically significant improvement in diplopia, enophthalmos, ocular motility, and infraorbital hypoesthesia (p-value < 0.001) 1 year following orbital fracture reconstruction.

Conclusions

When used appropriately, diverse alloplastic materials used in orbital fracture repair tailored to the indication aid orbital reconstruction outcomes with each material having its own unique characteristics.

Repair of orbital floor fractures via the transantral approach with osteosynthesis plate

INTRODUCTION

The most common surgical access techniques employed in patients with orbital floor fractures are associated with a risk of complications, such as implant infection, migration, epiphora, lower eyelid retraction, ectropion, diplopia worsening, retrobulbar hematoma, emphysema, "white-eyed" syndrome, enophthalmia relapse, hypoglobus, and persistent diplopia due to periorbital atrophy. Consequently, alternative access techniques precluding these complications have to be found.

STUDY OBJECTIVE

To assess the efficacy of transantral approach in the surgical treatment of patients with orbital floor fractures based on results of retrospective analysis of our clinical experience.

MATERIALS AND METHODS

We performed a retrospective study of medical records and X-ray data of 52 patients with fractures of the floor of the orbit, 18 to 68 years old, treated using transantral approach as described in the article. Titanium plates of special shape were used for orbital floor reconstruction.

RESULTS

In 94.2% of the cases, adequate restoration of the floor of the orbit was achieved. It led to regression of the ocular signs. In 4 patients, diplopia remained in extreme gaze positions, which did not require surgical correction. The failed cases were related to incorrect positioning of the plate or fixing screws. No inflammatory complications were observed.

CONCLUSION

Transantral access approach may be a technique of choice in treating patients with orbital floor fractures; it is safe, minimally traumatic, and effective in the early posttraumatic period when the injured area is located in the posterior parts of the floor of the orbit.

Orbital wall restoring surgery with resorbable mesh plate

BACKGROUND

Orbital resorbable mesh plates are adequate to use for isolated floor and medial wall fractures with an intact bony buttress, but are not recommended to use for large orbital wall fractures that need load bearing support. The author previously reported an orbital wall restoring surgery that restored the orbital floor to its prior position through the transnasal approach and maintained temporary extraorbital support with a balloon in the maxillary sinus. Extraorbital support could reduce the load applied on the orbital implants in orbital wall restoring surgery and the use of resorbable implants was considered appropriate for the author's orbital wall restoring technique.

METHODS

A retrospective review was conducted of 31 patients with pure unilateral orbital floor fractures between May 2014 and May 2018. The patients underwent transnasal restoration of the orbital floor through insertion of a resorbable mesh plate and maintenance of temporary balloon support. The surgical results were evaluated by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values.

RESULTS

The OVR decreased significantly, by an average of 6.01% (p< 0.05) and the preoperative and postoperative Hertel scale measurements decreased by an average of 0.34 mm with statistical significance (p< 0.05). No complications such as buckling or sagging of the implant occurred among the 31 patients.

CONCLUSION

The use of resorbable mesh plate in orbital floor restoration surgery is an effective and safe technique that can reduce implant deformation or complications deriving from the residual permanent implant.

Use of Acellular Allogenic Dermal Matrix (MegaDerm) in Orbital Wall Reconstruction: A Comparison With Absorbable Mesh Plate and Porous Polyethylene

The selection of materials for orbital wall reconstruction has been a matter of debate. This study aimed to evaluate the effectiveness of an acellular allogenic dermal matrix (ADM) as an orbital wall reconstruction material and to compare the results of orbital wall reconstruction with the ADM to those of reconstruction with the more widely used absorbable mesh plate and porous polyethylene. We retrospectively reviewed the clinical charts and computed tomography images of 73 patients who underwent orbital reconstruction at 1 institution between March 2013 and February 2014. In the ADM group, the mean defect size of 29 patients was 2.89 cm. After orbital wall reconstruction with ADM, patients with preoperative enophthalmos (7 patients), limited range of eyeball movement (6 patients), and diplopia (12 patients) showed improvements. In the comparative study, the 3 groups showed no significant differences with respect to age distribution (P = 0.522), defect size (P = 0.455), and preoperative findings such as enophthalmos (P = 0.811), diplopia (P = 0.357), and limited range of eyeball movement (P = 0.795). All the preoperative symptoms improved in every group, and in the ADM group, no complication was observed during the postoperative follow-up. ADM is a biocompatible material that combines the flexibility and rigidity required to support the orbital soft tissue. Therefore, it could be an excellent alternative material for orbital wall reconstruction.

Resolution of Diplopia in Late Repair of Enophthalmos Following Facial Trauma

Posttraumatic enophthalmos due to isolated or complex orbital fractures can contribute to diplopia. Current evidence recommends early repair. However, little is known about the outcome of enophthalmos correction when repair occurs beyond 30 days after trauma. In this systematic review, the authors aim to evaluate the current evidence on functional outcomes after delayed repair of posttraumatic enophthalmos.Two independent assessors undertook a systematic review of the literature using multiple databases. The authors' inclusion criteria identified studies involving patients at least 14 years of age who had surgical correction of persistent enophthalmos 30 days after initial trauma. Each eligible paper was included after critical appraisal using validated guidelines. Data on preoperative and postoperative enophthalmos and diplopia in each study was extracted. The pattern of fracture was also noted.The authors' search for the medical databases yielded 1053 articles, of which 6 eligible papers were included. Meta-analysis was performed. In patients with complex injuries involving orbital and mid-facial fractures, diplopia resolution was calculated to be 53%, and enophthalmos was corrected in 83% of the patients. In patients with isolated orbital fractures, 53% had resolution of their diplopia, and enophthalmos was corrected in 88% of the patients.Enophthalmos can be corrected to within 2 mm of the contralateral eye in both the isolated and complex orbital fractures in patients who present 30 days or greater after injury. Based on the studies reviewed, there is less predictability in diplopia resolution.

Comparison of Resorbable Mesh (Poly L-Lactide/Glycolic Acid) and Porous Polyethylene in Orbital Floor Fractures in an Experimental Model

BACKGROUND

Resorbable mesh and porous polyethylene are frequently used alloplastic materials for the treatment of the orbital blowout fractures. The literature lacks reports comparing their long-term effects on experimental models.

OBJECTIVE

Our aim was to radiologically and histologically evaluate the effectiveness and safety of porous polyethylene and resorbable mesh in a rabbit orbital blowout fracture model.

METHODS

Twelve New Zealand white rabbits (24 orbits) were randomized to 4 groups. In group 1, only orbital floor dissection was done. In group 2, following orbital floor dissection, a 10-mm defect was created without any extra procedure. In group 3, following a 10-mm defect creation, a 12-mm-round cut porous polyethylene was placed on the defect. In group 4, following a 10-mm defect creation, a 12-mm-round cut resorbable mesh was placed on the defect. Computed tomographic analysis was performed during follow-up period. Orbital floors were evaluated histologically at month 6.

RESULTS

No clinical complications were observed during follow-up period. In radiological evaluation, there was no statistically significant difference between groups regarding bone formation. In histological evaluation, the connective tissue was denser, and organized and better bone formation was observed in group 3 and 4 when compared with other groups.

CONCLUSION

Although no significant radiological changes were present, porous polyethylene and resorbable mesh performed better histologically. They were effective and well tolerated for reconstruction of the isolated orbital floor defects.

Customized Orbital Wall Reconstruction Using Three-Dimensionally Printed Rapid Prototype Model in Patients With Orbital Wall Fracture

BACKGROUND

It is difficult to restore original orbital contours because of their complex 3-dimensional structure. Moreover, slight implant malpositioning can result in enophthalmos or other complications. The authors describe our experience of using individualized prebent titanium-Medpor mesh implants and stereolithographic modeling in a series of patients who underwent orbital wall reconstruction.

METHODS

A consecutive series of 104 patients with orbital fractures received computer simulation-designed prebent titanium-Medpor mesh implants insertion. Preoperative computed tomography (CT) data were processed for each patient, and a rapid prototyping (RP) model was produced. The uninjured side was concurrently mirrored and superimposed onto the traumatized side to create a mirror image of the RP model. The authors fabricated the titanium-Medpor implants to intraoperatively reconstruct the 3-dimensional orbital structure. The prefabricated titanium-Medpor implants were inserted into the defective orbital wall and fixed. Postoperative CT images were immediately taken to evaluate the reconstructed contours and compare the preoperative and postoperative intraorbital volumes.

RESULTS

All reconstructions were successful without postoperative complications. The implants were correctly positioned in the sagittal, axial, and coronal planes relative to the original orbital contours. The mean preoperative intraorbital volumes of the uninjured and traumatized sides were 21.39 ± 1.93 and 23.17 ± 2.00 cm, respectively, and the postoperative mean intraorbital volume was 20.74 ± 2.07 cm.

CONCLUSIONS

Orbital reconstruction can be optimized using individually manufactured rapid prototype skull model and premolded synthetic scaffold by computer-aid of mirroring-reconstruction of 3-dimensional images and 3-dimensional printing techniques.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury

PURPOSE

Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described.

METHODS

This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded.

RESULTS

Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25-80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1-5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively.

CONCLUSION

Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Validation of a Novel Cognitive Simulator for Orbital Floor Reconstruction

PURPOSE

The increasing focus on patient safety in current medical practice has promoted the development of surgical simulation technology in the form of virtual reality (VR) training designed largely to improve technical skills and less so for nontechnical aspects of surgery such as decision making and material knowledge. The present study investigated the validity of a novel cognitive VR simulator called Touch Surgery for a core maxillofacial surgical procedure: orbital floor reconstruction (OFR).

MATERIALS AND METHODS

A cross-sectional study was carried out on 2 groups of participants with different experience levels. Novice graduate dental students and expert surgeons were recruited from a local dental school and academic residency programs, respectively. All participants completed the OFR module on Touch Surgery. The primary outcome variable was simulator performance score. Post-module questionnaires rating specific aspects of the simulation experience were completed by the 2 groups and served as the secondary outcome variables. The age and gender of participants were considered additional predictor variables. From these data, conclusions were made regarding 3 types of validity (face, content, and construct) for the Touch Surgery simulator. Dependent-samples t tests were used to explore the consistency in simulation performance scores across phases 1 and 2 by experience level. Two multivariate ordinary least-squares regression models were fit to estimate the relation between experience and phase 1 and 2 scores.

RESULTS

Thirty-nine novices and 10 experts who were naïve to Touch Surgery were recruited for the study. Experts outperformed novices on phases 1 and 2 of the OFR module (P < .001), which provided the measurement of construct validation. Responses to the questionnaire items used to assess face validity were favorable from the 2 groups. Positive questionnaire responses also were recorded from experts alone on items assessing the content validity for the module. Participant age and gender were not relevant predictors of performance scores.

CONCLUSION

Construct, content, and face validities were observed for the OFR module on a novel cognitive simulator, Touch Surgery. Therefore, OFR simulation on the smart device platform could serve as a useful cognitive training and assessment tool in maxillofacial surgery residency programs.

The predictive factors of diplopia and extraocular movement limitations in isolated pure blow-out fracture

Purpose

To evaluate the predictive factors for development of diplopia and extraocular muscle movement (EOM) limitations in the patients with isolated pure blow-out fracture.

Methods

One hundred thirty-two patients with isolated pure blow-out fracture were included. The diagnosis was done with computed tomography scan. Possible predictive factors were analyzed with logistic regression. The cases that underwent surgery were assigned in the surgical group, and other cases were assigned in the non-surgical group. Receiver operating characteristic (ROC) curve analysis was used in the surgical group to evaluate the power of time interval from trauma to the surgery to predict persistence of 6 months postoperative diplopia and EOM limitation.

Results

At the first visit, 45 of 60 cases (75%) in the surgical group and 15 of 72 cases (20.8%) in the nonsurgical group had diplopia. After 6 months follow-up, 7 cases (11.7%) in the surgical group and 1 case (1.4%) in the nonsurgical group had persistent diplopia. Type of fracture was significantly associated with first visit diplopia (P = 0.01) and EOM limitations (P = 0.06). In the surgical group, type of fracture (P = 0.02 for both) and time interval from trauma to the surgery (P = 0.006 and 0.004, respectively) were significantly associated with 1 month diplopia and EOM limitations. Only time interval from trauma to the surgery (P = 0.04) was significantly associated with 3 months EOM limitation. In the ROC curve analysis, if the surgery was done before 4.5 (sensitivity = 87.5% and specificity = 61.3%) and 7.5 (sensitivity = 87.5% and specificity = 66.9%) days, risk of 6 months postoperative diplopia and EOM limitation was reduced, respectively.

Conclusions

In the early postoperative period, a higher rate of diplopia was observed in the patients with combined inferior and medial wall fractures and longer time intervals from trauma to the surgery. The best time for blow-out fracture surgery was within 4.5 days after the trauma.

Eye Inside Out: Endonasal Endoscopic Reposition of Eye from Nose with Complete Vision Regainment

Faciomaxillary and ocular trauma is a common entity in most emergency and trauma units. We came across a 68-year-old female patient with a history of bull horn injury over the right eye. Examination revealed an empty orbital socket with unreliable perception of light present. Imaging showed that the eye had displaced posteroinferomedially to be lying in the ethmoid air cells in the nasal cavity. Under nasal endoscopic guidance, the eye was reposited back into the orbital socket and conjunctival sutures were taken to stabilize the position. The patient had vision of counting fingers at 1.5 m on the first postoperative day which improved to 6/24 on last follow-up. Such is the rarity that never before has such a case been described in literature where traumatic displacement of eyeball into the nose has been successfully repositioned by an endonasal endoscope with appreciable regaining of vision. It also further promotes endonasal endoscopic approach in the management of orbital blow out injuries.

Delayed Periorbital Abscess after Silicone Implant to Orbital Floor Fracture

There is a lack of consensus regarding preferred implant materials for orbital floor fracture reconstruction, leading to surgeon- and institution-dependent preferences. A variety of implants are used for orbital floor fracture reconstruction, each with their own complication profile. Knowledge of different implant materials is critical to identifying complications when they present. We report a delayed periorbital abscess 5 years after orbital floor reconstruction using a silicone implant.

Reversible Blindness Following Orbital Fracture Repair

The authors report a case of a 72-year-old woman with unilateral, complete, reversible blindness (no light perception) immediately after uncomplicated repair of an orbital floor fracture. In this case, vision loss was reversed with prompt surgical intervention with removal of the orbital floor implant. The authors review the etiology of vision loss after orbital fracture repair and hypothesize as to the cause of blindness in this case. Given the frequency with which orbital fracture repair is performed by a variety of surgical subspecialists, it is imperative for surgeons to be familiar with the ophthalmic complications and be aware of the multiple causes of postoperative vision loss. The authors propose that immediate postoperative assessment of visual function be performed on all patients undergoing orbital fracture repair.

A clinical analysis of bilateral orbital fracture

Although bilateral orbital fracture can cause serious eyeball and facial skeletal problems, few reports have been issued on the topic. We analyzed the clinical features of bilateral orbital fracture by reviewing the medical records of 147 patients and compared bilateral and unilateral fractures by reviewing the literature.Bilateral orbital fracture was most common in men aged between 50 and 59 years. A traffic accident was the leading cause of trauma, and average time between trauma and surgery was 12.2 days. Bilateral medial fracture accompanied by nasal fracture accounted for the overwhelming majority, and impure blowout fracture in at least 1 eye occurred in 69.4% of the 147 patients. Associated ocular injuries seemed to be similar for bilateral and unilateral fracture. Thirty-five patients (23.8%) had other multiple traumas affecting other than the eyes, and this significantly increased the need for surgery (P < 0.05). Of the 48 patients who underwent surgery, including 4 cases of bilateral surgery, 21 patients who had ocular motility restriction with central diplopia within 30 degrees almost completely recovered. No significant relation between the timing of surgery and improvement was found. Although unilateral surgery was performed in most cases, facial asymmetry related to enophthalmos was unclear at 6 months postoperatively.In summary, bilateral orbital fracture was found to be clinically distinguishable from unilateral fracture in several aspects. We hope these findings provide a reference guide to the approach and management of bilateral orbital fracture.

Transantral Orbital Floor Fracture Repair Using a Folded Silastic Tube

OBJECTIVES

The purpose of this study was to evaluate the advantages and limitations of using a silicon tube to support the fractured orbital floor by a transantral approach.

METHODS

A retrospective study was conducted from January 2000 to December. 2011 in 51 patients with pure orbital floor fractures. The patients underwent reduction surgery via a transantral approach for inserting a folded silastic tube to support the fractured orbital floor in the maxillary sinus. A chart review of preoperative and postoperative ocular symptoms, operation records, and complications was maintained.

RESULTS

In 18 out of 25 patients with diplopia, postoperative improvement was seen. In 13 out of 15 patients with extraocular muscle limitation, postoperative improvement was seen. Enophthalmos resolved postoperatively in four of five patients. Postsurgical complications occurred in three patients: an overcorrection, an infection in the maxillary sinus, and an implant extrusion, all of which were resolved by revision surgeries.

CONCLUSION

During the course of the study, we sensed reduction using a folded silastic tube via a transantral approach as an easy and effective technique with good postoperative results, and minimal implant related complications. This novel procedure is recommended as a surgical option for the reduction of orbital floor fractures.

A case of blowout fracture of the orbital floor in early childhood

There are few reports of blowout fractures of the orbital floor in children younger than 5 years of age; in a search of the literature, we found only six reported cases which revealed the exact age, correct diagnosis, and treatment. We herein report the case of a 3-year-old boy with a blowout fracture of the orbital floor. Computed tomography showed a pure blowout fracture of the left orbital floor with a slight dislocation of the orbital contents. The patient was treated conservatively due to the absence of abnormal limitation of eye movement or enophthalmos. The patient did not develop any complications that necessitated later surgical intervention. Computed tomography at 6 months after the injury showed the regeneration of the orbital floor in the area of the fracture and no abnormalities in the left maxillary sinus. We herein present our case and the details of six other cases reported in the literature, and discuss their etiology, diagnosis, and treatment methods.

Predictability in orbital reconstruction: A human cadaver study. Part I: Endoscopic-assisted orbital reconstruction

In the treatment of orbital defects, surgeon errors may lead to incorrect positioning of orbital implants and, consequently, poor clinical outcomes. Endoscopy can provide additional visualization of the orbit through the transantral approach. We aimed to evaluate whether endoscopic guidance during orbital reconstruction facilitates optimal implant placement and can serve as a convenient alternative for navigation and intra-operative imaging. Ten human cadaveric heads were subjected to thin-slice computed tomography (CT). Complex orbital fractures (Class III/IV) were created in all eligible orbits (n = 19), which were then reconstructed using the conventional transconjunctival approach with or without endoscopic guidance. The ideal implant location was digitally determined using pre-operative CT images, and the accuracy of implant placement was evaluated by comparing the planned implant location with the postoperative location. There were no statistically significant differences (p > 0.05) in the degree of implant dislocation (translation and rotation) between the transconjunctival orbital reconstruction and the endoscopic-assisted orbital reconstruction groups. Endoscopic-assisted orbital reconstruction may facilitate the visualization of orbital defects and is particularly useful for training purposes; however, it offers no additional benefits in terms of accurate implant positioning during the anatomical reconstruction of complex orbital defects.

Reconstruction of orbital floor blow-out fractures with autogenous iliac crest bone: a retrospective study including maxillofacial and ophthalmology perspectives

This is a 10-year retrospective study of patients with an isolated unilateral orbital floor fracture reconstructed with an autogenous iliac crest bone graft. The following inclusion criteria applied: isolated orbital floor fracture without involvement of the orbital rim or other craniofacial injuries, pre-/post-operative ophthalmological/orthoptic follow-up, pre-operative CT. Variables recorded were patient age and gender, aetiology of injury, time to surgery, follow-up period, surgical morbidity, diplopia pre- and post-operatively (Hess test), eyelid position, visual acuity, and the presence of en-/or exophthalmos (Hertel exophthalmometer). Twenty patients met the inclusion criteria. The mean age was 29 years. The mean follow up period was 26 months. No patient experienced significant donor site morbidity. There were no episodes of post-operative infection or graft extrusion. Three patients had diplopia in extremes of vision post-operatively, but no interference with activities of daily living. One patient had post-operative enophthalmos. Isolated orbital blow-out fractures may be safely and predictably reconstructed using autogenous iliac crest bone. The rate of complications in the group of patients studied was low. The value of pre- and post-operative ophthalmology consultation cannot be underestimated, and should be considered the standard of care in all patients with orbitozygomatic fractures, in particular those with blow-out fractures.

Blowout fracture in a 3-year-old

A 3-year-old patient was referred to the oral and maxillofacial department with a fracture of the orbital floor. Due to the lack of clinical symptoms, a conservative approach was chosen. After 3 weeks, an enophthalmos developed. The orbital floor reconstruction was successfully performed through a transconjunctival approach. This case highlights the rarity of pure blowout fractures in young children. The specific presentation and diagnostics of orbital floor fractures in children and the related surgical planning and intervention are discussed.

Biomaterials for reconstruction of the internal orbit

Orbital floor injuries, alone or combination with other facial fractures, are one of the most commonly encountered midface fractures. Techniques for orbital reconstruction have migrated away from autogenous bone grafts to well-tolerated alloplasts, such as titanium and Medpor. Material for reconstructing the orbit can then be selected based on requirements of the defect matched to the mechanical properties of the material. Material selection is largely and ultimately dependent upon surgeon preference.

Derivation of a clinical risk score for traumatic orbital fracture

BACKGROUND

Given that orbital fractures are found in only one of every eight patients receiving computed tomography for acute orbital trauma, we sought to prospectively identify clinical predictors of orbital fracture that may obviate the need for exposing low-risk patients to ionizing radiation.

METHODS

Prospective cohort study conducted from July 2007 through October 2009 at two urban emergency departments. Consecutive patients undergoing computed tomography for acute blunt orbital trauma were evaluated on 15 clinical findings before imaging. The primary outcome of interest was presence of any acute orbital fracture. The secondary outcome was a fracture requiring emergent operative intervention. Multivariable logistic regression analysis with multiple imputation was used to derive a predictive risk score.

RESULTS

A total of 2,262 patients with acute orbital trauma were enrolled. Median age was 38 years with male predominance (68.3%). Acute orbital fractures were found in 360 patients (15.9%). The derived risk score included orbital rim tenderness, periorbital emphysema, subconjunctival hemorrhage, pain with extraocular movement, impaired extraocular movement, and epistaxis. Across 10 multiply imputed data sets, a mean of 660 patients (29.2%) lacked all six equally weighted predictors, of which 6.3% (95% confidence interval, 4.3-8.2) experienced an acute orbital fracture and only 0.5% (95% confidence interval, 0.0-1.0) required emergent operative intervention.

CONCLUSION

Six clinical predictors identify patients with blunt orbital trauma at increased risk for acute orbital fracture. A risk score of 0 identifies patients at very low risk for emergent operative intervention. Multicenter studies are needed to validate these findings and derive a clinical decision instrument to reduce orbital imaging without compromising patient safety.

LEVEL OF EVIDENCE

Diagnostic study, level II.

Functional outcome after non-surgical management of orbital fractures--the bias of decision-making according to size of defect: critical review of 48 patients

The treatment of mild and moderate fractures of the orbital wall is controversial. Apart from clinical signs, the size of the defect is often used to aid the decision about treatment. We hypothesised that variables would be present that had an impact on the position and motility of the globe but were independent of the size of the defect, and prevented a balanced judgement of the outcome of conservative treatment. Between January 2000 and December 2007, 48 of 127 patients were included in this retrospective study to analyse the functional outcome of orbital fractures managed without operation. Selection was dependent on the availability of complete clinical records, post-traumatic computed tomographic (CT) scans (axial and coronal sections) and ophthalmic examination. All 48 defects were analysed and allocated to categories of a semiquantitative classification. The area of fracture of each defect was calculated with an integral calculus or geometrical formula and correlated with the associated category. Category A included all orbital walls as a single unit (A1) and combined fracture patterns (A2 and higher). Category B described isolated fractures of the medial wall. There was a significant correlation between classes A1 and A2 (p<0.01) and absolute area of the fracture (0.98 (0.4)cm(2) and 2.42 (0.8)cm(2)). Diplopia was most often seen in fractures in category B1 (the anterior third of the medial wall) and the post-traumatic position of the globe significantly correlated with the area of the fracture (p=0.04). The degree of diplopia was less severe in fractures of the posterior portion of the orbit (zones 2 and 3) compared with fractures of the anterior orbit, even if the defect was larger. The conservative management of category A1-3 and B1-3 fractures up to 2.42 (3.15)cm(2) showed no functional impairment, provided that enophthalmos was less than 2mm and there was no entrapment of periorbital tissue or extraocular muscles. We found good correlation between enopthalmos and the size of the fracture, but not for diplopia or motility of the eye. We conclude that conservative management of an orbital fracture in which the defect is less than 3cm(2) has a low risk of permanent functional damage if enophthalmos is less than 2mm and entrapment of soft tissue or muscles is excluded.

The importance of accurate, early bony reconstruction in orbital injuries with globe loss

Patients who sustain facial fractures frequently suffer from visual disturbance. Additionally, orbital fractures often involve ocular injury, which, not infrequently, may require enucleation. Yet an anophthalmic orbit does not obviate the need for aggressive orbital fracture treatment. In fact, treatment of the sequelae of the anophthalmic orbit can be difficult and require multiple surgeries. Intraoperative use of a conformer after accurate bony reduction and orbital reconstruction with bone grafts or orbital implants are essential steps to allow for prosthetic rehabilitation of the anophthalmic orbit.