Ocular motility and diplopia measurements following orbital floor fracture repair

Development and validation of a risk calculator for postoperative diplopia following orbital fracture repair in adults

Postoperative diplopia is the most common complication following orbital fracture repair (OFR). Existing evidence on its risk factors is based on single-institution studies and small sample sizes. Our study is the first multi-center study to develop and validate a risk calculator for the prediction of postoperative diplopia following OFR. We reviewed trauma patients who underwent OFR at two high-volume trauma centers (2015-2019). Excluded were patients < 18 years old and those with postoperative follow-up < 2 weeks. Our primary outcome was incidence/persistence of postoperative diplopia at ≥ 2 weeks. A risk model for the prediction of postoperative diplopia was derived using a development dataset (70% of population) and validated using a validation dataset (remaining 30%). The C-statistic and Hosmer-Lemeshow tests were used to assess the risk model accuracy. A total of n = 254 adults were analyzed. The factors that predicted postoperative diplopia were: age at injury, preoperative enophthalmos, fracture size/displacement, surgical timing, globe/soft tissue repair, and medial wall involvement. Our predictive model had excellent discrimination (C-statistic = 80.4%), calibration (P = 0.2), and validation (C-statistic = 80%). Our model rules out postoperative diplopia with a 100% sensitivity and negative predictive value (NPV) for a probability < 8.9%. Our predictive model rules out postoperative diplopia with an 87.9% sensitivity and a 95.8% NPV for a probability < 13.4%. We designed the first validated risk calculator that can be used as a powerful screening tool to rule out postoperative diplopia following OFR in adults.

Considering the Interaction between Surgical Approach and Timing on Complication Rates of Complex Orbital Fracture Repair

OBJECTIVE

The optimal approach and timing of complex orbital fracture repair is an unresolved issue that is complicated by unique clinical presentations and patient-specific considerations. Early surgical repair in less than 14 days is associated with fewer complications; however, there are no guidelines addressing the optimal timing for surgical repair. This study assesses the time of surgical repair and surgical outcomes of complex orbital fractures.

METHODS

Retrospective chart review from 2010 to 2022. Adult patients with orbital fractures are treated with surgical repair.

RESULTS

In all, 94 patients presented with orbital fractures and were treated with 108 surgeries. Postoperative complications: vision disturbance 33/108 (30.6%), gaze restriction 12/108 (11.1%), lid malposition 10/108 (9.3%), globe complication 13/108 (12.0%), and hardware issues 14/108 (13.0%). Postoperative complications were not significantly associated with the surgical approach used for fracture repair or the time of surgical repair.

CONCLUSION

Postoperative complications following surgical repair of orbital fractures are not associated with surgical approach or time of repair following the initial injury.

Treatment of Persistent Post-traumatic Diplopia - An Algorithmic Approach to Patient Stratification and Operative Management

Study Design

Retrospective chart review of revisional orbital surgery outcomes in patients with diplopia from prior operative treatment of orbital trauma.

Objective

Our study seeks to review our experience with management of persistent post-traumatic diplopia in patients with previous orbital reconstruction and present a novel patient stratification algorithm predictive of improved outcomes.

Methods

A retrospective chart review was performed on adult patients at Wilmer Eye Institute at Johns Hopkins Hospital and at the University of Maryland Medical Center who underwent revisional orbital surgery for correction of diplopia for the years 2005-2020. Restrictive strabismus was determined by Lancaster red-green testing coupled with computed tomography and/or forced duction. Globe position was assessed by computed tomography. Seventeen patients requiring operative intervention according to study criteria were identified.

Results

Globe malposition affected fourteen patients and restrictive strabismus affected eleven patients. In this select group, improvement in diplopia occurred in 85.7% of cases with globe malposition and in 90.1% of cases with restrictive strabismus. One patient underwent additional strabismus surgery subsequent to orbital repair.

Conclusions

Post-traumatic diplopia in patients with prior orbital reconstruction can be successfully managed in appropriate patients with a high degree of success. Indications for surgical management include (1) globe malposition and (2) restrictive strabismus. High resolution computer tomography and Lancaster red-green testing discriminate these from other causes that are unlikely to benefit from orbital surgery.