Does Intraoperative Navigation Improve Implant Position Accuracy in Orbital Fracture Repair?

Intraoperative Image Guidance in Orbital and Lacrimal Surgery: A Report by the American Academy of Ophthalmology

PURPOSE

To review the efficacy and safety of the use of intraoperative image guidance (IIG) in orbital and lacrimal surgery.

METHODS

A literature search of the PubMed database was last conducted in November 2023 for English-language original research that assessed the use of any image guidance system in orbital and lacrimal surgery that included at least 5 patients. The search identified 524 articles; 94 were selected for full-text analysis by the panel. A total of 32 studies met inclusion criteria. The panel methodologist assigned a level II rating to 2 studies and a level III rating to 30 studies. No study met the criteria for level I evidence.

RESULTS

Procedures reported on were as follows: fracture repair (n = 14), neoplasm and infiltrate biopsy or excision (n = 6), orbital decompression for Graves ophthalmopathy (n = 3), dacryocystorhinostomy (n = 1), and mixed etiology and procedures (n = 8). Four studies used more than one IIG system. One study that met level II evidence criteria compared the outcomes of orbital fracture repair with IIG (n = 29) and without IIG (n = 29). Borderline better outcomes were reported in the IIG group: 2% versus 10% with diplopia (P = 0.039) and 3% versus 10% with enophthalmos (P = 0.065). The other level II study compared the repair of fractures with navigation (n = 20) and without (n = 20). The group in which navigation was used had a measured mean volume reduction of 3.82 cm3 compared with 3.33 cm3 (P = 0.02), and there was a greater measured reduction in enophthalmos in the navigation group of 0.72 mm (P = 0.001). Although the remaining 30 assessed articles failed to meet level II criteria, all alleged a benefit from IIG. No complications were reported.

CONCLUSIONS

A small number of comparative studies suggest that there are improved outcomes when IIG is used in orbital fracture repair, but each study suffers from various limitations. No high-quality comparative studies exist for the management of lacrimal surgery, neoplastic disease, or decompression. Complications attributable to the use of IIG have not been identified, and IIG has not been analyzed for cost savings.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Secondary Correction of Posttraumatic Enophthalmos

Posttraumatic enophthalmos (PE) arises when the ocular globe is displaced posteriorly and inferiorly in the orbital cavity due to a mismatch in orbital volume and orbital content. This most commonly happens after orbital fractures. The resulting disruptions to aesthetic form and ocular functions often necessitate surgical correction for reconstruction and restoration. The purpose of surgical management of PE is to reconstruct orbital shape and volume as well as to restore any herniated orbital content. This can be particularly challenging in cases involving large defects that require complex orbital reconstruction. Recent advancements in computer-aided surgery have introduced innovative and important tools to assist surgeons with these difficult cases. The ability to create customized, patient-specific implants can facilitate reconstruction involving complicated anatomy. Additionally, intraoperative imaging and intraoperative navigation can serve as useful guides for surgeons to more accurately place implants, especially in cases with limited visualization, in order to achieve optimal outcomes.