Mechanisms of extraocular muscle injury in orbital fractures

Orbital floor fracture (blow out) and its repercussions on eye movement: a systematic review

The aim of this systematic review was to investigate the relationship between fractures of the floor of the orbit (blow outs) and their repercussions on eye movement, based on the available scientific literature. In order to obtain more reliable results, we opted for a methodology that could answer the guiding question of this research. To this end, a systematic review of the literature was carried out, using a rigorous methodological approach. The risk of bias was assessed using version 2 of the Cochrane tool for the risk of bias in randomized trials (RoB 2). This systematic review was carried out according to a systematic review protocol previously registered on the PROSPERO platform. The searches were carried out in the PubMed (National Library of Medicine), Scopus, ScienceDirect, SciELO, Web of Science, Cochrane Library and Embase databases, initially resulting in 553 studies. After removing duplicates, 515 articles remained, 7 were considered eligible, of which 3 were selected for detailed analysis. However, the results of the included studies did not provide conclusive evidence of a direct relationship between orbital floor fractures and eye movement.

Nontraumatic oculomotor nerve palsy following endoscopic sinus surgery

The proximity of the paranasal sinuses to the orbit and its contents increases the chances of injuries during endoscopic sinus surgery (ESS). We present an extremely rare case of transient oculomotor nerve palsy with no direct injury following ESS, which has never been reported in the literature. The proper clinical approach and medical management are also discussed in this case report.

Outcome Analysis of Surgical Timing in Pediatric Orbital Trapdoor Fracture with Different Entrapment Contents: A Retrospective Study

Orbital trapdoor fracture occurs more commonly in pediatric patients, and previous studies suggested early intervention for a better outcome. However, there is no consensus on the appropriate timing of emergent intervention due to the insufficient cases reported. In the current retrospective study, we compared the outcomes of patient groups with different time intervals from injury to surgical intervention and entrapment content. Twenty-three patients who underwent surgery for trapdoor fracture between January 2001 and September 2018 at Chang Gung Memorial Hospital were enrolled. There was no significant difference in diplopia and extraocular muscle (EOM) movement recovery rate in patients who underwent surgery within three days and those over three days. However, among the patients with an interval to surgery of over three days, those with muscle entrapment required a longer period of time to recover from EOM movement restriction (p = 0.03) and diplopia (p = 0.03) than those with soft tissue entrapment. Regardless of time interval to surgery, patients with muscle entrapment took longer time to recover from EOM movement restriction (p = 0.036) and diplopia (p = 0.042) and had the trend of a worse EOM recovery rate compared to patients with soft tissue entrapment. Hence, we suggested that orbital trapdoor fractures with rectus muscle entrapment should be promptly managed for faster recovery.

Diplopia after Isolated Inferior Orbital Wall Fracture According to the Computed Tomography Findings

Purpose: To investigate the postoperative changes in diplopia and evaluate factors that affect diplopia after isolated inferior orbital wall fracture.Methods: A retrospective study was conducted on 200 patients who underwent reconstruction surgery for isolated inferior orbital wall fracture between March 2001 and December 2020. Diplopia was categorized into peripheral, central, and full-degree types based on the history and binocular single vision. The natural course of diplopia was analyzed pre-operatively and at 1 day, 6 weeks, and 6 months postoperatively. We analyzed the orbital computed tomography images to determine fracture size (small, medium, or large), fracture site (anterior, middle, posterior, or mixed), extraocular muscle (EOM) size (swelling or deformity), EOM site (incarcerated or prolapsed), and EOM tenting.Results: Diplopia was seen in 144 out of 200 patients (72.0%) before surgery; peripheral diplopia was seen in 57 patients (39.6%), central diplopia in 46 (24.3%), and full-degree diplopia in 20 (13.9%). Pre-operative diplopia differed according to the pre-operative limitation of range of motion (LOM) (p < 0.001) and EOM site (p = 0.022). Pre-operative diplopia type differed according to the LOM direction (p = 0.018) and EOM size (p = 0.020). Diplopia persisted in 33 patients (16.5%) 6 months after the surgery. Recovery was faster in patients with peripheral diplopia compared to those with central or full-degree diplopia.Conclusions: The presence of diplopia was associated with the pre-operative LOM and EOM site but the type of diplopia was associated with LOM direction and EOM size. These factors can be used to predict the progression of diplopia in patients with isolated inferior orbital wall fracture.

Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery

Introduction

Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete.

Methods

We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself.

Results

Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia.

Conclusions

Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis.

Influence of Radiographic Soft Tissue Findings on Clinical Entrapment in Patients With Orbital Fractures

INTRODUCTION

Radiographic assessment of facial fractures with computed tomography (CT) scanning has become standard of care. As imaging resolution has improved, findings such as herniation of extraocular muscles (EOM) have become a means of diagnosing conditions like orbital entrapment. However, the sensitivity and specificity of these findings has not been well-studied. We sought to evaluate the value of radiographic findings such as fat herniation, EOM contour irregularity, and EOM herniation in predicting orbital entrapment after orbital fracture. Secondary endpoints include diplopia, abnormal EOM motility, and the need for surgical fixation.

METHODS

A single institution, retrospective review at a regional level 1 trauma center was conducted. Patients with orbital fractures were identified by International Classification of Disease (ICD) codes and CT reports were queried for the terms "herniation," "herniated," "entrapped," and "entrapment." Four hundred records were analyzed.

RESULTS

Sixty-seven percent of radiology reports mentioned "entrapped" or "entrapment," while the incidence of clinical entrapment was 2.8%. The odds of entrapment, diplopia, and abnormal EOM motility were higher in those with EOM herniation; however, EOM herniation had a positive predictive value of 7.9% for clinical entrapment. Fat herniation alone and EOM contour irregularity had positive predictive values of 4.2% and 4.8%, respectively.

CONCLUSIONS

While the odds of entrapment appear higher in patients with EOM herniation, this imaging finding is not predictive of clinical entrapment. Fat herniation and EOM contour irregularity did not have higher odds of entrapment, nor were they predictive. Diagnosis of orbital entrapment should be based primarily on physical exam, with CT as an adjunct only. The assumption that radiographic findings indicate orbital emergencies may result in unnecessary interfacility transfers, subspecialist consultations, and emergency operative procedures.

Association Between Compensatory Overaction of the Non-Injured Eye, Measured by HESS Chart and Postoperative Diplopia in Blow-Out Fracture

In orbital floor fracture, diplopia often persists post-operatively. This study evaluated the association between pre-operative parameters concerning the extent of the injury and post-operative diplopia, using multivariate analysis. A retrospective computed tomography analysis and chart review was performed for patients with punched out orbital floor fracture, who underwent operations during the period from April 2011 to March 2018. Five parameters were evaluated: the number of upward arrows on the Hess chart (representing compensatory overaction of the non-injured eye), time interval to surgery, muscular subscores, fracture area, and swelling rate of the inferior rectus muscle. Of the 32 patients, 9 (28%) had post-operative diplopia; pre-operative diplopia was completely restored in 23 (72%) patients by 6 months after surgery. Univariate analysis found statistically significant differences in the number of upward arrows on the Hess chart, time interval to surgery, muscular subscores, and fracture area. Logistic regression analysis demonstrated that only the number of upward arrows displayed a significantly increased risk for post-operative diplopia (odds ratio, 15.3; 95% confidence interval, 2.0-117.0; P = 0.008). Excessive overaction of the non-injured eye predicted persistent diplopia by 6 months post-operatively. Surgical intervention may be insufficient to achieve full recovery from diplopia and disturbances of ocular motility in some patients.

Pure Orbital Trapdoor Fractures in Adults: Tight Entrapment of Perimuscular Tissue Mimicking True Muscle Incarceration with Successful Results from Early Intervention

Orbital trapdoor fractures (OTFs) entail entrapment of intraorbital soft tissues with minimal or no displacement of the affected bones and are almost exclusively seen in children. This article aimed to report the diagnosis and treatment of an OTF of the floor in an adult patient and to critically review the literature regarding the management aspects of this specific subset of orbital blowout fractures in adults. A 29-year-old man presented with limitations of vertical right eye movements owing to blunt orbital trauma. The patient mainly complained of double vision in upper gazes and some episodes of nausea. Neither floor defect nor significant bone displacement found on orbital computed tomography, while edema of inferior rectus muscle was apparent. The patient underwent surgical repair 5 days later; a linear minimally displaced fracture of the floor was recognized and complete release of the entrapped perimuscular tissues was followed. Within the first week postoperatively, full range of ocular motility was restored, without residual diplopia. This case was the only identified pure OTF over a 6-year period in our department (0.6% of 159 orbital fractures in patients >18 years). By reviewing the literature indexed in PubMed, a very limited number of either of isolated case reports or retrospective case series of pure OTFs has been reported in adults. Contrary to the typical white-eyed blowout fractures, the literature indicates that OTFs in adults seem to not always constitute absolute emergency conditions. Although such fractures need to be emergently/ immediately treated in children, in the absence of true muscle incarceration, adults may undergo successful treatment within a wider but either early or urgent frame of time. Adults frequently exhibit vagal manifestations and marked signs of local soft tissues injury.

Pediatric orbital wall fractures: Prognostic factors of diplopia and ocular motility limitation

OBJECTIVES

To investigate the factors affecting recovery of diplopia and limited ocular motility in pediatric patients who underwent surgery for orbital wall fracture.

DESIGN

Retrospective observational case series.

METHODS

In this retrospective observational case series, 150 pediatric patients (1-18 years old) who were diagnosed with orbital medial wall or floor fracture and underwent corrective surgery between 2004 and 2016 at Seoul National University Bundang Hospital were included. The medical records of patients with orbital medial wall or floor fracture were reviewed, including sex, age, diplopia, ocular motility, preoperative computed tomographic finding, and surgical outcomes. Factors affecting recovery of diplopia and ocular motility limitation were analyzed.

RESULTS

Of the 150 patients (134 boys; mean age, 14.4 years) who underwent corrective surgery for orbital wall fracture, preoperative binocular diplopia was found in 76 (50.7%) patients and limited ocular motility in 81 (54.0%). Presence of muscle incarceration or severe supraduction limitation delayed the recovery of diplopia. In case of ocular motility limitation, presence of muscle incarceration and retrobulbar hemorrhage were related with the delayed resolution. Multivariate analysis revealed supraduction limitation (Hazard ratio [HR] = 1.74, 95% confidence interval [CI] = 1.19-2.55), larger horizontal orbital floor defects (HR = 1.22, 95% CI = 1.07-1.38), and shorter time interval to first visit (HR = 0.73) as negative prognostic factors for the recovery of diplopia. In addition, muscle incarceration (HR = 3.53, 95% CI = 1.54-8.07) and retrobulbar hemorrhage (HR = 3.77, 95% CI = 1.45-9.82) were found as negative prognostic factors for the recovery of motility limitation.

CONCLUSIONS

Presence of muscle incarceration and retrobulbar hemorrhage, horizontal length of floor fracture, supraduction limitation, and time interval from trauma to first visit were correlated with the surgical outcomes in pediatric orbital wall fracture patients. These results strengthen that the soft tissue damage associated with bony fracture affects the orbital functional unit. When managing children with orbital wall fracture, meticulous physical examination and thorough preoperative computed tomography based evaluation will help physicians to identify damage of orbital functional unit.

[Application of bone grafts from chin of the mandible in the reconstruction of orbital fracture]

OBJECTIVE

To evaluate the clinical effects of bone graft from the mandible in repairing orbital floor defects.

METHODS

Bone grafts from the mandible were used to treat 11 cases of orbital floor defects and followed up for 6-12 months.

RESULTS

The surgical incisions healed primarily in all 11 patients. The orbital floor structure was restored. No vision loss, limited eye movement, implant infection, or resorption were observed postoperatively, and no complications occurred in the supply area.

CONCLUSIONS

Bone grafts from the mandible were an ideal material to repair orbital floor defects.

Diplopia secondary to orbital fracture in adults

OBJECTIVE

To evaluate the incidence and evolution of diplopia as a complication of orbital fractures in adults.

PATIENTS AND METHODS

A review was conducted on medical records of all consecutive adults with orbital fracture referred between January 2014 and December 2015. An analysis was made of the incidence of diplopia secondary to fracture in the acute phase and its evolution. A descriptive study was performed on the variables related to patients, fractures, and fracture and diplopia treatment.

RESULTS

The study included 39patients with a mean age of 48years (17-85). Of all the patients, 17 (43.6%) presented with diplopia in the acute phase. Differences were found between the groups with and without diplopia in relation to muscle entrapment diagnosed by orbital computed tomography, duction limitation, and fracture surgery ≤1week (P=.02, P=.00, P=.04, respectively). Out of the 17patients with diplopia, 12 had a mean follow-up of 18weeks (1-72), and in 10 (83.3%) diplopia was resolved in a mean time of 10weeks (1-72). There were spontaneous resolution in 4 (33.3%) patients, and resolution after fracture surgery in 4 (57%) of the 7 that underwent surgery. In 4cases (33.3%) prisms were prescribed, and 2 (16.6%) required strabismus surgery.

CONCLUSIONS

Diplopia secondary to orbital fracture in adults is frequent, but it is resolved in most cases spontaneously or after fracture surgery. A few patients will require prisms and/or strabismus surgery.

Incidence and Risk Factors of Inferior Rectus Muscle Palsy in Pediatric Orbital Blowout Fractures

The aim of this study was to evaluate the incidence, clinical features, and risk factors of sustaining inferior rectus (IR) palsy in a group of pediatric patients with orbital floor blowout fractures. We performed a retrospective case review of sequential cases of pediatric orbital floor blowout fractures (<18 years old) from 2000 to 2013 in a tertiary ophthalmic center in Singapore. A total of 48 patients were included in our study, of whom 5 had IR palsy (10.4%). Patients with IR palsy had a higher mean age (16.4 ± 1.5 years) compared with patients without IR palsy (12.4 ±3.3 years), had significantly ( p  < 0.05) worse preoperative motility, and had significantly greater proportion developing postoperative hypertropia (100%) compared with patients without IR palsy (4.7%). Our series of pediatric blowout fractures demonstrated IR palsy prevalence and clinical features for IR palsy which may be distinct to the pediatric group.

Orbital trapdoor fracture: can it occur also in adults?

We describe here a peculiar case of a 30-year-old woman presenting with an orbital trapdoor fracture. Preoperative and postoperative magnetic resonance images are provided to explain the mechanism of the injury.

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.

Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures

PURPOSE

To determine the role of fracture size and soft tissue herniation as measured by computed tomography in predicting the development of persistent diplopia in patients with isolated orbital floor fractures.

METHODS

A retrospective chart review identified patients presenting between March 2009 and 2012 with isolated orbital floor fractures. Computed tomographic scans were assessed for transverse fracture size and absence or presence of soft tissue herniation and rectus involvement. Presence of diplopia at 6-10 days, decision for surgical repair, and presence of diplopia were recorded.

RESULTS

Fifty-six patients fulfilled inclusion criteria. Eighteen of 56 patients (32%) had preoperative diplopia. In Type A fractures, 0/9 (0%) small, 1/8 (12.5%) medium, and 2/14 (14%) large fractures had diplopia. For Type B fractures, 3/4 (75%) small, 9/13 (69%) medium, and 4/8 (50%) large fractures had diplopia. Type B fractures were significantly more likely to cause diplopia than Type A fractures in the small (p = 0.003) and medium (p = 0.007) size groups but not in the large groups (p = 0.07).

CONCLUSION

Transverse fracture size and presence of soft tissue herniation on CT imaging can predict development of persistent diplopia in isolated orbital floor fractures. Small and medium sized fractures with soft tissue herniation are more likely to cause diplopia than large sized fractures. We recommend early repair or closer observation of small and medium sized orbital floor fractures with soft tissue herniation due to the high risk of diplopia.

Timing of operation for blowout fractures with extraocular muscle entrapment

Many authors have advocated early surgical intervention to avoid muscle degeneration in patients with blowout fractures with evidence of extraocular muscle entrapment imaged under computed tomography. However, there is still no golden standard with regard to the target timing of operations for releasing extraocular muscle. Between January 2002 and December 2011, the authors treated eight cases of blowout fracture with extraocular muscle entrapment. Notes from presumed cases of blowout fracture were retrospectively reviewed for information relating to surgical treatment and prognosis. In this series, a patient who was operated on 7 hours after injury showed the quickest recovery from diplopia. In contrast, a patient who was operated on 18 days after injury showed persistent diplopia for 2 years. Nevertheless, in patients who were operated on 3-11 days after injury, there was no obvious correlation between the outcome and the number of days between injury and the operation. It is concluded that, when emergency surgical intervention within several hours is not possible, it should be performed as soon after the injury as possible in order to prevent the increase of predictive fibrosis around the extraocular muscle.

Clinical findings, orbital imaging, and intraoperative findings in patients with isolated inferior rectus muscle paresis or underaction

PURPOSE

To present the clinical findings, orbital imaging, and intraoperative findings of patients with inferior rectus muscle underaction and to determine whether specific findings can help discern the underlying cause.

METHODS

A retrospective observational study was performed on patients presenting with isolated inferior rectus muscle underaction between January 2007 and October 2011. Patient history, ocular motility, fundus torsion, Lancaster red-green plots, and radiographic findings were analyzed. For patients who had surgery, intraoperative findings also were considered.

RESULTS

A total of 28 patients with inferior rectus muscle underaction were identified. Of these, 13 (46%) presented with inferior rectus muscle underaction after orbital trauma; 25 (89%) showed no increase in hypertropia >4(Δ) on head tilt to either side. Fundus intorsion was present in all patients. Of 15 patients evaluated by Lancaster red-green testing, 12 (80%) showed subjective intorsion. Twenty patients underwent orbital imaging via computed tomography or magnetic resonance imaging, and the results in 8 (40%) revealed obvious changes in the inferior rectus muscle. Nineteen patients underwent surgery; intraoperatively, the muscle appeared grossly normal in 8 patients (42%) and showed posterior muscle slippage in 4 (26%). Less common findings included stretched scar formation, flap tear, missing tissue, extensive muscle adhesions, or inability to identify the muscle.

CONCLUSIONS

Clinical findings in patients with inferior rectus muscle underaction are not sufficiently different to identify the cause, and orbital imaging identified a specific abnormality in only 40% of cases.

Longitudinal tear of the inferior rectus muscle in orbital floor fracture

We report a case of longitudinal avulsion of the inferior rectus muscle following orbital floor fracture and describe its clinical presentation, computed tomography (CT) features and management. A 53-year-old man felt vertical diplopia in all gaze immediately after the trauma. Orthoptic assessment showed left over right hypertropia of 20 prism diopters and left exotropia of 10 prism diopters in primary position. The left orbital floor fracture and the prolapse of orbital contents into the maxillary sinus were presented by CT. Exploration of the orbit was performed under general anesthesia. The displaced bone fragment was elevated and repositioned below the slastic implant. Diplopia continued in all directions of gaze, although the impairment of depression was reduced postoperatively. A residual left hypertropia of 10 prism diopters and exotropia of 10 prism diopters was present in primary position 1 month after surgery, though there were no enopthalmos or worsening of hypesthesia. Repeated CT revealed the muscle avulsion of inferior rectus at the lateral portion of the belly. The avulsion of a small segment of the inferior rectus and its herniation into maxillary sinus in more posterior views was detected by review of the preoperative images. Muscle avulsion should be considered in the management of orbital fracture if orbital tissue entrapment and nerve paresis are excluded as causes of reduction in ocular motility. A thorough review of the imaging studies for possible muscle injury is required before surgery in all cases of orbital fracture.

Pediatric craniofacial trauma: challenging pediatric cases-craniofacial trauma

The pediatric population, as well as the adult population, is subject to similar injuries and traumatic events involving the craniofacial skeleton. Although less frequent than adult injuries, the craniofacial injuries sustained by children are considered separately in textbooks and the literature because of the special unique problems associated with their treatment and the effects they might have on growth and development that can arise as a result of their management. Some of the more challenging cases that I have seen involve the very young with cranial bone fractures and cranial base fractures and those that involve the nasal and/or orbital-ethmoidal areas in young children and their secondary reconstruction. Some of these types of cases are not always clearly and thoroughly addressed in textbooks or articles because of their infrequent occurrence. Often, surgeons differ in approaches to treatment because of certain anatomic or physiological factors specifically related to childhood, facial growth, and the timing of treatment. Some of the cranial and facial developmental malformations seen in older children or adults can be attributed to trauma sustained in early childhood. This is because trauma may have a deleterious effect on the growth and development of facial structures in the postnatal life similar to that seen resulting from a genetic mutation.

Linear-type orbital floor fracture with or without muscle involvement

The indications for surgical repair of the orbital blowout fracture are controversial. One reason may be case variation among fracture types. We therefore focused on linear-type blowout fractures in this study. The study included 22 consecutive patients with linear-type floor fractures. Demographics, clinical and computed tomographic (CT) findings, surgical timing, postoperative course, and outcome were evaluated. Surgery was performed in 14 patients with diplopia but not enophthalmos. Five patients with severe vertical diplopia were defined as "missing rectus" by CT findings. Residual diplopia remained in 2 patients with "missing rectus," whereas the other 20 patients completely recovered eye motility. In the 9 patients without muscle entrapment, diplopia disappeared within 4 weeks after operation. However, recovery in patients with "missing rectus" took more than 1 month. Thus, the CT finding with or without muscle involvement was crucial for the linear-type blowout fractures. A comprehensive and timely decision based on clinical and radiologic findings is indispensable for satisfactory management as well as postoperative rehabilitation.

Linear trapdoor or "white-eye" blowout fracture of the orbit: not restricted to children

The management of orbital blowout fractures remains controversial, particularly in patients with a white-eye or trapdoor-type injury. We report our experience with 10 such cases (mean age 19.6 years, range 4-53) and show, unlike previous reports, that this pattern of injury is not restricted to children. Although most patients had a white eye (70%), the presence of subconjunctival haemorrhage and periorbital bruising did not exclude this injury, and the patients often (60%) had serious autonomic symptoms such as nausea and vomiting. A high index of suspicion and cross-sectional imaging is required to confirm the diagnosis. Early intervention (less than 7 days) seems to be associated with better outcome, but patients benefitted from intervention up to 41 days after injury. The mechanism underlying this pattern of injury and the rationale behind early intervention is also discussed.

Surgical management of orbital trapdoor fracture in a pediatric population

PURPOSE

Orbital trapdoor fractures are pure orbital floor fractures with herniation and entrapment of the orbital contents, leading to restricted eye movement and diplopia. Trapdoor fractures in children have been discussed widely in published reports; however, the treatment policy and outcome remain controversial, although early treatment has been advocated. Our retrospective study analyzed the long-term results of pediatric patients undergoing surgery for trapdoor fractures to determine the outcome in relation to the type of fracture and the timing and technique of intervention.

PATIENTS AND METHODS

The present study included 24 patients (age range 6 to 16 years) who underwent surgery for trapdoor fractures from 1998 to 2007. The demographic, etiologic, radiologic, and surgical findings, interval between trauma and surgery, surgical techniques, and complications were recorded. Diplopia, ocular motility, dysesthesia, and scar quality were recorded at follow-up.

RESULTS

The follow-up duration averaged 36 months. At follow-up, 1 (8.3%) of 12 patients who underwent surgery within 24 hours (urgent treatment) had residual diplopia. In contrast, 3 (37.5%) of 8 patients who underwent surgery 24 to 96 hours (early treatment) and 4 (100%) of 4 who underwent surgery after 96 hours (late treatment) had diplopia. No sensory deficit of the skin or unesthetic eyelid scar was noted.

CONCLUSIONS

We found a correlation between the outcome and the timing of surgery for trapdoor fractures in the pediatric population. The success rate was significantly better when the fractures were treated within 24 hours of the injury. The results of the present study have strengthened the assertion that trapdoor orbital fractures pose a true surgical emergency.

A consecutive case review of orbital blowout fractures and recommendations for comprehensive management

BACKGROUND

The orbital blowout fracture is a common facial injury, but full consensus has not been reached regarding its optimal management. The authors retrospectively explored consecutive cases of blowout fractures and proposed new recommendations for treatment.

METHODS

Two hundred eight newly registered patients were selected from the database of Nagasaki University Hospital over the past 5 years. One hundred nine patients in the authors' department were then reviewed regarding computed tomographic classification of fracture types, preoperative complaints, and outcomes.

RESULTS

Of the 208 patients reviewed, 43 underwent surgical repair: 37 for diplopia and 14 for enophthalmos, including eight patients who were treated for both conditions. Regarding floor fractures, the punched-out type fracture was the most common, but the burst type was associated with the highest likelihood of undergoing surgery. For medial wall fractures, the punched-out type dominated, but the overall operative incidence was lower than that observed for the floor fractures. For diplopia, more than half of the operations were performed within 2 weeks, but only two cases were performed within 3 days. For enophthalmos, over 60 percent of operations were carried out after 1 month. Two cases, later discovered to involve muscle strangulation, continued to demonstrate residual diplopia in ordinary use, and two patients continued to show enophthalmos. However, overall outcomes were considered satisfactory.

CONCLUSIONS

If computed tomographic findings disclose a linear fracture with muscular strangulation, urgent surgery must be performed. However, for linear fractures without impaction of the muscle, or punched-out or burst type fractures, close observation for days may be appropriate. In addition, surgical intervention can be performed electively when diplopia persists for several days of observation.

A simple technique for the treatment of inferior orbital blow-out fracture: a transantral approach, open reduction, and internal fixation with miniplate and screws

PURPOSE

Infraorbital blow-out fracture (IOBF) is an uncommon midfacial trauma, and impairs eyeball function and causes esthetic problems. The extraoral approach can lead to some complications such as scarring, ectropion, and entropion. The intraoral approach, such as a transantral approach, has advantages such as no visible scaring, it can be used to simultaneously treat a zygomaticomaxillary complex fracture (ZMCF), and the procedure is relatively easy.

PATIENTS AND METHODS

IOBFs were reduced from the maxillary sinus, and fixated internally using miniplates and screws with/without Medpor (Porex, Newnan, GA) via a transantral approach. We used this technique in 11 patients who had an inferior blow-out fracture. Patient's records and CT scans were reviewed.

RESULTS

The mean age of the patients was 37 years (ranging between 15 years and 68 years). The mean follow-up period was 9.8 months, which ranged from 1 to 24 months. Before the operation, the patients had orbital symptoms: diplopia in 3 patients; enophthalmos in 4; and gaze limitation in 3. All the patients showed periorbital swelling and ecchymosis. After surgery, none of the patients had diplopia, gaze limitations, and enophthalmos. There were no orbital symptoms or sinus symptoms due to an infection or allergic reaction after surgery except in 1 patient. In 1 patient, maxillary sinusitis developed at 4 months after surgery which subsided with antibiotic therapy after plate removal.

CONCLUSION

We think this technique offers an easy approach, and produces reliable, satisfactory results in IOBF.

Urgent rescue of 'missing rectus' in blowout fracture

Because guidelines for the treatment of blowout fractures have not been defined for urgent-care surgery, some patients retain a sight-threatening strabismus after surgery. The authors present a case involving the immediate operation of a blowout fracture based on CT findings and symptoms, demonstrating that early intervention may restore the full range of motion in the affected eye. The CT image showing the absence of the inferior rectus muscle on the orbital floor and no apparent fracture indicates the muscle strangulation. Immediate surgery must be performed to prevent irreversible muscular degeneration in such cases, rather than delaying the procedure by several days.

Orbitozygomatic fracture management

Orbitozygomatic fractures are frequently encountered in plastic surgery. Management depends on a thorough preoperative physical examination, with attention to the ophthalmologic assessment. Coronal and axial computed tomography is essential for identifying fracture extent and orbital involvement. Adequate exposure and mobilization of fracture segments is essential for successful anatomical reduction. Failure to perform effective fixation may lead to subsequent complications, such as enophthalmos and diplopia. The authors illustrate the appropriate management of orbitozygomatic fractures in an effort to reduce complications and attain aesthetically satisfying results.

Oculomotor nerve palsy after functional endoscopic sinus surgery

We report an unusual case of partial oculomotor nerve palsy occurring after functional endoscopic sinus surgery, without anatomical disruption of the extra-ocular muscles. The clinical course and possible pathogenic mechanisms are also presented.

Orbital Fractures Complicated by Late Enophthalmos: Higher Prevalence in Patients With Multiple Trauma

PURPOSE

To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma.

METHODS

Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period.

RESULTS

Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance.

CONCLUSIONS

The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

Clinical recommendations for repair of orbital facial fractures

PURPOSE OF REVIEW

Orbital facial fractures are a common result of facial trauma. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are debated.

RECENT FINDINGS

The timing and treatment indications for orbital facial fractures are evolving. For orbital floor fractures, nonresolving oculocardiac reflex, the "white-eyed" blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures, which may cause latent enophthalmos or hypo-ophthalmos. For midfacial, lateral, supraorbital, medial wall, and nasoethmoidal fractures, repair within 2 weeks is indicated to avoid difficult repair from immediate posttraumatic wound healing.

SUMMARY

Orbital facial fracture management is germane to ophthalmologists, plastic surgeons, otolaryngologists, and others who treat patients.

Ophthalmic complications of endoscopic sinus surgery

The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.

The management of orbitozygomatic fractures

Orbitozygomatic injuries are among the most common fractures encountered by the plastic surgeon. Appropriate management depends on an accurate diagnosis, focusing on the physical examination and data from computed tomography scans. One must pay particular attention to the orbital component of this injury, as it is from this that so much of the morbidity relating to these fractures is incurred. As with all facial fractures, accurate reduction is paramount to a successful outcome. As many buttresses as are necessary should be visualized to ensure an anatomic reduction. The amount and location of fixation depend on the fracture anatomy.A successful outcome may be expected if these basic principles are followed.

The effects of airbags on orbital fracture patterns in frontal automobile crashes

PURPOSE

To investigate orbital fractures that occurred in frontal automobile crashes and to determine the effects of frontal airbags on injury incidence and severity.

METHODS

The National Automotive Sampling System database files from 1993 to 2000 were examined. Frontal crashes were selected that included drivers and front-seat passengers only and excluded ejected occupants and rollover crashes. Orbital fractures could be closed, open, displaced, or any combination of these and were identified by using the Abbreviated Injury Scale codes.

RESULTS

The analysis included 12,429,580 front-seat occupants from 25,464 cases. Of all occupants who were exposed to an airbag deployment, 0.09% sustained an orbital fracture. In contrast, occupants who were not exposed to an airbag deployment were more than twice as likely to sustain an orbital fracture (0.22%). In addition to reduction in incidence, airbags were also shown to decrease the severity of orbital fractures that occupants sustained. Occupants exposed to airbag deployment mostly sustained closed, less severe fractures (61.9%), whereas occupants not exposed to airbag deployment sustained the majority as more severe, open, displaced, or comminuted fractures (61.3%).

CONCLUSIONS

This article presents the most comprehensive study of orbital fractures in automobile crashes to date. It is shown that both the incidence and the overall severity of orbital fractures decreases considerably with exposure to airbag deployment. This is accomplished because the airbag minimizes occupant contact with the windshield and steering wheel, which are the two leading sources of orbital fractures for occupants not exposed to airbag deployment.

Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis

PURPOSE

To assess the quality of information in the literature and suggest guidelines for repair of isolated orbital floor fractures.

CLINICAL RELEVANCE

Orbital floor fractures are a common result of orbital injury. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are still controversial.

LITERATURE REVIEWED

A MEDLINE literature review was performed using PubMed. Articles published from 1983 to the present were retrieved using the key words, "orbital floor fracture, orbital trap-door fracture, and orbital blow-out fracture." Suggested indications and timing for repair of isolated orbital floor fractures were extracted from selected articles. Each recommendation was rated according to its importance in the care process and strength of evidence supporting the given recommendation.

RESULTS

No prospective randomized clinical trials on the treatment of orbital floor fractures have been performed. Despite this, most recommendations were rated as most important to patient care (A) and had strong support for treatment (level I).

CONCLUSIONS

The timing and treatment indications for orbital floor fractures are evolving. Nonresolving oculocardiac reflex, the "white-eyed" blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures that may cause latent enophthalmos or hypo-ophthalmos.

Trapdoor fracture of the orbit in a pediatric population

Orbital-floor blowout fractures of the trapdoor variety, first described by Soll and Poley, have also appeared in the French and Japanese literature. The trapdoor fracture is described as a pure orbital-floor fracture, linear in form and hinged medially, which allows herniation of orbital contents through the fracture and then entraps these herniated contents. A review of the orbital-floor fracture literature reveals a high incidence of persistent diplopia associated with ocular-muscle entrapment, which may later necessitate corrective surgery of extraocular muscles. Recent publications in the ophthalmologic literature have stressed the importance of early surgical intervention. This article reports a retrospective series of 19 pediatric patients (age range, 5 to 16 years) who presented to two institutions. All patients had radiographic confirmation of a trapdoor fracture. Physical examination demonstrated a high association between these fractures and restricted ocular motility (17 of the 19 patients). In the cases with trapdoor fracture and restricted ocular movement, early intervention was associated with better postoperative function. It is thus recommended that the symptomatic trapdoor orbit fracture be considered an urgent indication for surgical intervention. Practitioners therefore must have a high index of suspicion for these injuries. Prompt diagnosis is critical to maximize clinical outcome.