Untreated ‘blow-in’ fracture of the orbital floor causing a mucocele: Report of an unusual late complication

Pure Orbital Floor Blow-In Fracture: An Extremely Rare Case

A 57-year-old man presented with left diplopia on an upward gaze and ophthalmalgia after hitting the left side of his head. CT revealed a fracture on the left side of the orbital floor without orbital rim fractures and the protrusion of a small bone fragment into the orbit. Hess charts indicated markedly limited vertical movement of the left eye. Based on these findings, the patient was diagnosed with a pure orbital floor blow-in fracture (BIF). Symptoms persisted after a two-week monitoring period; therefore, the bone fragment was removed by a transcutaneous surgical approach with the assistance of a navigation system and an endoscope. Symptoms resolved after surgery, and CT and Hess examinations six months after surgery showed a good outcome. A pure BIF is rare, particularly on the orbital floor. Only a few similar case reports have been published to date, and we herein describe the surgical procedures performed and the treatment outcome of our case.

Globe Compression by Bone Fragments in Orbital Blow-in Fractures: A Case Series and Systematic Review

PURPOSE

The purpose of this study was to describe the clinical characteristics, management, and outcomes of orbital blow-in fractures involving compression of the globe by bone fragments.

METHODS

A retrospective case series and systematic literature review were performed.

RESULTS

Three male patients (mean age 29 years) with orbital blow-in fractures causing globe indentation presented with extraocular movement restriction, choroidal folds, and B-scan ultrasonography demonstrating deformation of the globe contour by a hyperechoic bone fragment. All underwent surgical repair within 1 day of presentation resulting in improved visual outcomes. An additional 10 cases were identified in the literature review. The majority of patients were male (80%) with a mean age of 29 years. Fractures originated primarily from the lateral orbital wall (50%) or the orbital roof (40%). Globe compression was evident on CT of the orbit (100%) and ultrasonography (30%). Common presenting signs included decreased visual acuity (70%), restriction of supraduction (40%) or abduction (40%), choroidal folds (30%), brow laceration (40%), periorbital edema (40%), and hypoglobus (40%). Most patients underwent surgical intervention (80%) involving fracture reduction (50%) or fragment removal (38%). Reported postsurgical outcomes were excellent with resolution of diplopia, motility, and visual acuity.

CONCLUSION

Globe indentation from blow-in fractures are rare. Clinicians should be suspicious in cases of high-velocity trauma to the superolateral orbit with hypoglobus, motility limitation, and indentation of the globe upon dilated exam. Prompt diagnosis and early surgical removal of the compressive orbital bone fragments in a multidisciplinary fashion can lead to good visual, functional, and cosmetic outcomes.

Eyeball deviation by orbital mucocele after midface sinus injury

A mucocele is an epithelium-lined, mucus-filled cavity in the paranasal sinuses. Mucocele may develop due to scarring and obstruction of the sinus ostium caused by midface sinus trauma, such as orbital bone fracture or endoscopic sinus surgery. The authors report two cases of orbital mucocele as complications following midface sinus injury (endoscopic sinus surgery in one case, and orbital fracture repair in the other). In both cases, imaging studies showed a large orbital mucocele accompanied by bony erosion and orbital wall remodeling, compressing the ocular muscle. Using an open approach, the lesion was excised and marsupialized. The symptoms resolved, and the postoperative eyeball position was normal. Orbital mucocele may cause serious complications such as ocular symptoms, orbital cellulitis, osteomyelitis, and the formation of an abscess with the potential to invade the brain. Therefore, surgeons should consider the possibility of mucocele as a late complication of surgery and initiate an immediate work-up and surgical treatment if needed.

Mucocele After Orbital Fracture Repair Masquerading as Optic Neuritis

The authors report a patient of mucocele formation after orbital wall fracture repair masquerading as optic neuritis.A 38-year-old man with a history of medial orbital wall fracture repair with an alloplastic implant 10 years previously, presented with left visual disturbance and mild ocular pain with movement of the left eye of 3-day duration, and a relative afferent papillary defect in his left eye. He reported having cold symptoms 2 weeks before presentation. His symptoms were typical of retrobulbar optic neuritis. Under suspicion of optic neuritis, computed tomography and magnetic resonance imaging were performed and revealed a large cyst in the sphenoid sinus and ethmoid sinus, just behind the alloplastic implant, that was compressing the medial rectus muscle and optic nerve of the left eye. The patient underwent endoscopic marsupialization of the cyst. Subsequent histologic examinations revealed a cyst lined with ciliated pseudostratified columnar epithelium. The patient had an uncomplicated postoperative course and the visual disturbance resolved. For patients who present solely with optic neuropathy after orbital fracture repair, it is important to be vigilant of potentially rare cause, mucocele formation.

Endoscopic-Assisted Removal of a Rare Mucocele Complicating From Alloplastic Medial Orbital Fracture Reconstruction

Orbital wall fracture reconstruction is usually recommended to prevent subsequent functional and esthetic complications. Mucocele development following such injuries or its management is recognized but rare sequelae. When they occur, they represent a diagnostic and management dilemma. The authors described a patient with orbital and ethmoidal mucocele. A 62-year-old female patient presented with progressive left exophthalmos 1 year following titanium mesh reconstruction of a medial orbital wall fracture. Computed tomography and magnetic resonance imaging demonstrated an encysted lesion encasing the mesh plate in the left orbit and extending into the ethmoidal sinus. The patient is treated surgically through endoscopic-assisted approach with complete removal of the lesion and lacrimal duct stenting. The patient improved immediately after surgery.

Diplopia due to maxillary sinus mucocoele

Mucocoeles are cyst-like lesions of the paranasal sinuses, which may rarely erode through the bony orbit and so displace or compress orbital contents. Such patients may present to ophthalmologists and other health care professionals with diverse problems including facial pain and swelling, proptosis, double vision, ptosis, infra-orbital anaesthesia, epiphora and optic nerve dysfunction with reduced vision. We present an illustrated interventional case report of an 81-year-old gentleman with a 2-week history of swelling around the left lower eyelid and malar region associated with double vision both in the primary position and particularly downgaze. We discuss the aetiology, diagnosis and contemporary management of maxillary mucocoeles and also the Caldwell-Luc procedure. The article serves as a reminder that maxillary mucocoeles may slowly and covertly invade the orbit and should be considered in the differential diagnosis in patients presenting with proptosis, globe displacement and an orbital or adnexal mass.

Anatomical 3-dimensional Pre-bent Titanium Implant for Orbital Floor Fractures

PURPOSE

This cadaver study evaluates the use of pre-bent 3-dimensional titanium mesh implants for orbital floor and medial wall reconstruction.

DESIGN

Nonrandomized comparative study.

PARTICIPANTS

Eight human cadaveric heads (n = 16 orbits).

METHODS

Transcutaneous incisions were used to expose both orbital floors in each cadaveric head. Unilateral orbital floor and medial wall fractures were generated in each specimen. The contralateral orbit remained uninjured. The fractures then were repaired with pre-bent titanium mesh fan plates molded from aluminum templates presenting different sizes. The templates were generated from topographical computed tomography (CT) data previously obtained from normal subjects. The accuracy of orbital reconstruction was evaluated with postoperative CT scans.

MAIN OUTCOME MEASURES

The mean value of the distances between the implant and the bony orbit was evaluated.

RESULTS

The mean distance between all 16 plates and their respective orbital floors/medial walls was 0.81+/-0.74 mm. Mean values were 0.68+/-0.63 mm for the unfractured side and 0.93+/-0.82 mm for the fractured side. No significant differences were found between orbits when evaluated for side of injury, gender, or size of defect.

CONCLUSION

Pre-bent 3-dimensional titanium mesh implants provide accurate reconstruction of orbital floor and medial orbital wall fractures. The mean implant error was <1 mm for all orbits studied.