Ophthalmologic Outcomes Following Fronto-Orbital Advancement for Unicoronal Craniosynostosis

Postoperative Orbital Morphology Observations Following Fronto-Orbital Advancement and Cranial Vault Remodeling in Patients With Unilateral Coronal Synostosis

OBJECT

Observations of preoperative and postoperative orbital morphology following fronto-orbital advancement and cranial vault remodeling (FOA and CVR) in patients with unilateral coronal synostosis (UCS).

METHODS

This retrospective cohort included patients diagnosed with unilateral coronal synostosis and treated with fronto-orbital advancement and cranial vault remodeling at the Children's Hospital of Fudan University. The orbital height, orbital width, and orbital volume were obtained from head 3-dimensional computed tomography of preoperation and postoperation. The DICOM data of CT were then imported into mimics research version 21.0. The authors measured OH and OW according to the bony landmarks, then reset the parameters of the soft tissue window, and conducted a 3-dimensional reconstruction of the orbital soft tissue to get OV. The preoperative and postoperative measurements of the intact side were compared with the affected side, respectively. Statistical analysis was performed using SPSS version 25.0 (Ρ=0.05).

RESULTS

Twelve patients with UCS (5 male, 7 female) meeting criteria were included in the study. There were 4 patients with UCS on the left and 8 on the right. The average age at initial surgery was 19.50 months. Before the operation, the data of the intact side and the affected side were compared, respectively, and the difference was found to be significant in OH (Ρ=0.005) and OW (Ρ=0.005), while the OV (Ρ=0.106) was not statistically significant. After procedures of FOA and CVR, the data of the intact side and the affected side were compared, respectively, the significant difference was found in OV (Ρ=0.002), while not in OH (Ρ=0.060) or OW (Ρ=0.066).

CONCLUSION

After undergoing the operation of FOA and CVR, the OH and OW of the ipsilateral and contralateral sides of patients with UCS were basically symmetrical, while the volume of the affected orbit was still relatively smaller.

Strabismus and refraction in non-syndromic craniosynostosis - A longitudinal study up to 5 years of age

PURPOSE

To evaluate the refractive outcome and strabismus at 5 years of age, in children operated for various types of non-syndromic craniosynostosis, and further analyse the refractive and strabismic development over time.

METHODS

Eighty-nine children, who had undergone operations for non-syndromic craniosynostosis, were examined at 5 years of age. These children also underwent ophthalmological examination preoperatively and up to 1 year after the operation. An age-matched control group including 32 healthy children was also recruited. Strabismus and eye motility were registered. Refraction was measured in cycloplegia.

RESULTS

There was a difference regarding the refractive outcome between the different types of craniosynostosis. Higher values of hypermetropia were found in the metopic craniosynostosis group on both eyes. In the unicoronal craniosynostosis group, high values of hypermetropia and a higher degree of astigmatism were found on the side contralateral to the craniosynostosis. Strabismus was found in 11/88 children of whom 10/11 had unicoronal craniosynostosis. A vertical deviation on the side ipsilateral to the fused suture was highly prevalent (6/10 cases). Ophthalmological dysfunctions were rare in children operated for sagittal craniosynostosis.

CONCLUSION

Ocular manifestations such as strabismus, astigmatism and anisometropia were highly prevalent in children operated for unilateral coronal craniosynostosis. Children operated for metopic craniosynostosis had higher rates of hypermetropia. The screening and follow-up protocols need to be tailored with regard to the type of craniosynostosis.

Pre-Operative Ocular Findings and Long-Term Follow-Up in a Large Cohort of Non-Syndromic Unicoronal Craniosynostosis

(1) Background: Non-syndromic unicoronal craniosynostosis (UCS) is associated with a high prevalence of ocular anomalies. Currently, the etiology of this association remains obscure, however, it is presumed to be primarily attributed to their orbital malformations and/or secondary to craniofacial surgery. We assessed pre-operative ophthalmological examinations of non-syndromic UCS patients and compared them with their postoperative outcomes and long-term follow-up. (2) Methods: A retrospective case series was conducted on medical records of patients with non-syndromic UCS at Sophia Children's Hospital, Rotterdam. Ophthalmologic examinations were collected at different time periods: T1 (first visit), T2 (<1 year after cranioplasty), and T3 (long-term follow-up at last visit). The McNemar's test was used for statistical analysis. (3) Results: A total of 101 patients were included, for whom examinations were available at T1 and T3. Patients had a mean age of 2.8 years (±2.7) and 9.5 (±4.9) at T1 and T3, respectively. At T1, 52 patients (51.5%) were diagnosed with strabismus, and 61 patients (60.4%) at T3. Vertical strabismus increased significantly from 23 patients (22.8%) at T1 to 36 patients (35.6%) at T3 (p = 0.011). Followed by astigmatism, which increased significantly from 38 (37.6%) at T1 to 59 (58.4%) patients at T3 (p = 0.001). T1 was available in 20 patients prior to fronto-orbital advancement (FOA), therefore, a sub-analysis was conducted on these patients, which was followed shortly after FOA at T2. Prior to FOA, strabismus was present in 11 patients (55.0%) and in 12 patients (60.0%) at T2. After FOA, strabismus worsened in two patients. (4) Conclusions: This study showed the high prevalence of ocular anomalies in patients with non-syndromic UCS before and after cranioplasty and at long-term follow-up. The findings of this study show that ophthalmic and orthoptic examinations are an important part of the optimal treatment of patients with non-syndromic UCS.

Long-term aesthetic and photogrammetric outcomes in non-syndromic unicoronal synostosis: comparison of fronto-orbital distraction osteogenesis and fronto-orbital advancement and remodeling

BACKGROUND

Fronto-orbital advancement and remodeling (FOAR) is among the most common surgical approaches for unicoronal craniosynostosis (UCS), although some data demonstrate failure to achieve long-term aesthetic normalcy, leading some to seek alternative treatment paradigms such as fronto-orbital distraction osteogenesis (FODO). This study compares long-term aesthetic outcomes of patients with UCS treated with FOAR and FODO.

METHODS

Twenty patients (four males) with non-syndromic UCS presenting to our institution and undergoing distraction were compared to a matched cohort of 20 patients (six males) undergoing FOAR. Clinical photographs and ImageJ were used to quantify periorbital anatomy including palpebral fissures, pupil-to-brow distance (PTB), and margin-reflex distance (MRD₁) in pixels. Whitaker classification was blindly assigned by craniofacial surgeons.

RESULTS

Photogrammetric analysis and Mann-Whitney U tests demonstrated significantly improved postoperative symmetry in distraction patients for palpebral width (p = 0.020), MRD₁ (p = 0.045), and canthal tilt (p = 0.010). Average Whitaker classification scores between FOAR (1.94) and distraction (1.79) cohorts were similar (p = 0.374).

CONCLUSIONS

UCS patients demonstrated significant postoperative improvements in periorbital symmetry, with distraction patients demonstrating superior results in palpebral width and canthal tilt. FOAR and FODO patients achieved similar Whitaker classification scores. These cohorts will be followed until craniofacial maturity prior to making any definitive conclusions.

3-Dimensional Morphometric Outcomes After Endoscopic Strip Craniectomy for Unicoronal Synostosis

BACKGROUND

Endoscopic strip craniectomy with postoperative helmeting (ESCH) for unicoronal synostosis has shown to be a less morbid procedure when compared with fronto-orbital remodeling (FOR). We aim in this pilot study to report objective methods and quantitative morphologic outcomes of endoscopically treated unicoronal synostosis using 3-dimensional surface scans.

METHODS

Our electronic records were reviewed for ophthalmological, neurodevelopmental outcomes, and helmet-related complications. For morphologic outcomes, the following parameters were used: Cranial Index, Cranial Vault Asymmetry Index, Anterior Symmetry Ratio (ASR), and Root Mean Square between the normal and synostotic sides of the head. Three-dimensional stereophotogrammetry scans were evaluated at 3 time points preoperative, 6 months post-op, and at the end of the treatment, which was compared with age-matched scans of normal controls and FOR patients. Nonparametric tests were used for statistical analysis.

RESULTS

None of the ESCH cases developed strabismus, major neurodevelopmental delay, or helmet complications. All morphologic parameters improved significantly at 6 months post-op except for the Cranial Vault Asymmetry Index. The ASR was the only parameter to change significantly between 6 months post-op and final scans. At end of helmet treatment, ASR and Root Mean Square differed significantly between the ESCH and both FOR and control groups.

CONCLUSIONS

Endoscopic strip craniectomy with postoperative helmeting for single unicoronal synostosis had excellent clinical outcomes. Most of the improvement in head morphology occurred in the first 6 months of treatment. Despite the normalization of the overall head shape, there was residual asymmetry in the frontal and temporal regions of the head.

Fronto-Orbital Advancement for Metopic and Unilateral Coronal Craniosynostoses

Fronto-orbital advancement remains a powerful technique for the correction of anterior cranial vault differences related to metopic (trigonocephaly) or unilateral coronal (anterior plagiocephaly) craniosynostoses. Traditional fronto-orbital advancement requires access to the forehead and superior 2/3 of the orbit via a coronal incision. The frontal bone and orbital segment (bandeau) are then separated from the skull and reshaped. In patients with metopic craniosynostosis, the bandeau and frontal bone will need to be advanced and widened. In patients with unilateral coronal craniosynostosis, the bandeau will need to be "untwisted" to address the supraorbital retrusion on the affected side, the affected orbit will need to be shortened and widened, and the frontal bone flap will need to be proportionately advanced on the affected side. Overcorrection of the affected dimension should be undertaken to account for growth and relapse.

Hypertelorbitism Corrected by Facial Bipartition Improves Exotropia

BACKGROUND

The purpose of this study was to detail perioperative ophthalmologic evaluations to characterize functional ocular outcomes after facial bipartition surgery.

METHODS

Patients with hypertelorbitism who underwent facial bipartition surgery were studied specifically for eye motility disorders by separating patients into rare craniofacial clefts (midline and paramedian) (n = 34) and craniofacial dysostosis (Apert, Crouzon, and Pfeiffer) (n = 74). Preoperative and postoperative (12 months) ophthalmologic examinations (with depth perception tests), computed tomography scans, and magnetic resonance imaging scans were analyzed.

RESULTS

Among craniofacial cleft patients, mean interdacryon distance was reduced from 39 ± 4 mm to 17 ± 2 mm, with strabismus improved from 88 percent (exotropia 82 percent) preoperatively to only 29 percent postoperatively. Depth perception improved to a lesser degree, with abnormal tests at a rate of 79 percent preoperatively to 56 percent postoperatively. Wider hypertelorbitism had a higher degree of strabismus. Among craniofacial dysostotic patients, mean interdacryon distance was reduced from 37 ± 3 mm to 17 ± 2 mm, and strabismus improved from 55 percent to only 14 percent. Depth perception improved to a lesser degree, with 68 percent abnormal tests preoperatively and 46 percent postoperatively. Apert patients had more V-pattern strabismus and exotropia (79 percent) than did other craniofacial dysostosis patients (42 percent).

CONCLUSIONS

The authors' data indicate that facial bipartition for hypertelorbitism-known to improve periorbital aesthetics-also improves eye motility disturbances. Thus, vision problems related to exotropia should be considered a functional indication for facial bipartition surgery in patients with hypertelorbitism.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ophthalmological findings in children with unicoronal craniosynostosis

INTRODUCTION

Among non-syndromic, single-suture craniosynostoses, unicoronal craniosynostosis (UCS) presents the highest rate of ophthalmic manifestations requiring a visual follow-up, due to the high risk of amblyopia. After birth or during childhood, children with UCS have a high risk to present an aniso-astigmatism and a strabismus. The aim of this study was to characterize clinical ophthalmologic findings associated with UCS in a paediatric cohort.

METHODS

This retrospective study included children admitted in our unit between 2015 and 2021, with isolated UCS treated in our institution and complete ophthalmological assessment comprising visual assessment, refractive status and oculomotor examination. Children with associated craniofacial disorders were excluded.

RESULTS

A total of 28 children met the inclusion criteria. Median age was 62 [13-192] months with a large proportion of girls (86%) and 71% of right-sided UCS. The mean best corrected visual acuity was 0.07 (±0.13) LogMAR, including 10 (36%) children with an amblyopia or history of amblyopia. Astigmatism was significantly higher on the contralateral side of the UCS than on the ipsilateral side, with a refractive cylinder error of 0.97 (±1.06) vs 0.56 (±0.68) diopters, respectively (p = 0.03). Strabismus was observed in 20 patients (71%) with a main pattern of esotropia with a vertical component. A pseudo-superior oblique palsy was found in 13 children (65%) with a median cyclodeviation of 8.7° [-5,4°-20.6°].

CONCLUSION

Children with UCS experience a high rate of various visual manifestations. This study highlights their need for a strict ophthalmological follow-up, in order to early diagnose and prevent visual complications.

Objective Analysis of Fronto-Orbital Dysmorphology in Unilateral Coronal Craniosynostosis

ABSTRACT

Correction (and over-correction) of asymmetries of the orbital shape and brow position in unilateral coronal craniosynostosis (UCS) is critical to successful fronto-orbital advancement. Here we quantify and three-dimensionally assess fronto-orbital irregularities in UCS patients compared to controls.Twenty-three patients with UCS evaluated at the Children's Hospital of Pittsburgh between 2006 and 2016 were age and gender-matched to controls. Computed tomography scans were reconstructed and evaluated for orbital metrics. A three-dimensional heat map of orbital regions was generated and evaluated for shape differences.Brow protrusion of the orbit ipsilateral to the synostotic suture did not differ significantly from healthy controls. Orbital height was significantly increased while orbital width was decreased on the UCS ipsilateral side compared to the contralateral side and controls. The ipsilateral cornea was overprojected relative to the brow and the infraorbital rim, but similar to controls relative to the lateral rim. The contralateral orbit had increased brow protrusion with decreased orbital height. The cornea was underprojected relative to the brow, but overprojected relative to the lateral orbital rim and similar to controls at the infraorbital rim. Three-dimensional comparison demonstrated significant overprojection of the contralateral brow, with some more mild and inconsistent underprojection of the lateral aspect of the ipsilateral brow.Key orbital and brow differences exist between the affected and unaffected sides in UCS. This study provides quantitative data that further characterize the orbital dysmorphology observed in UCS and identifies unique aspects of the diagnosis that should be taken into consideration during surgical planning.

Impact of the Craniofacial Surgery Simulation in Anterior Plagiocephaly on Orbits and Oculomotor Muscles: Biomechanical Analysis With a Finite Element Model

PURPOSE

The aim of this study was to show the displacements and strain induced by the supraorbital band advancement during a craniofacial surgery for an anterior plagiocephaly on the orbital bones and the orbital content thanks to a numerical surgical simulation using the finite element method.

METHODS

A three-dimensional (3D) finite element model of a child with an anterior plagiocephaly was entirely created from a tomodensitometry of a patient followed by our Craniofacial Pediatric team. Data of the tomodensitometry were computed with Slicer 3D to re-create the orbit geometry. Mesh production, properties of the model, and simulations of the fronto-orbital advancement were conducted on Hyperworks software (Altair Engineering, Inc., Detroit, MI, USA).

RESULTS

The resulting 3D Finite Element Model was used to perform the supraorbital advancement simulation. Displacement and strain patterns were studied for orbital bones, oculomotor muscles, and eyeballs. Relative high strain in the both trochlear area and excycloration of the right orbit are among the most interesting results as torsional strabismus as V-pattern strabismus are often described in children with an anterior plagiocephaly.

CONCLUSIONS

This pediatric Finite-Element Model of both orbits of a child with an anterior plagiocephaly showed the impact of the fronto-orbital advancement on the oculomotor system. This model described the relationship between the craniofacial surgery and the strabismus in the unilateral coronal synostosis. The advantages of this model are the many opportunities for improvement, including postoperative period and additional surgical procedures.

A Cohort Study of Strabismus Rates Following Correction of the Unicoronal Craniosynostosis Deformity: Conventional Bilateral Fronto-Orbital Advancement Versus Fronto-Orbital Distraction Osteogenesis

BACKGROUND

The purpose of this prospective study is to compare perioperative morbidity and strabismus rates between traditional fronto-orbital advancement reconstruction (FOAR) and fronto-orbital distraction osteogenesis (FODO) in unicoronal craniosynostosis (UCS).

METHOD

A consecutive group of 15 patients undergoing FODO for isolated UCS were compared to a contemporaneous group of 15 patients undergoing traditional FOAR for UCS. Patient age, operative time, blood loss, blood replacement, technical details of the surgery, length of stay, complications, and strabismus rates were documented and compared statistically using chi-square and Student t test with a significance value of 0.05.

RESULTS

The 15 patients undergoing FODO were younger (6.3 and 9.8 months, P < 0.05), experienced less operative time for the initial procedure (111 versus 190 minutes, P < 0.01), less blood loss (26% versus 50% of total blood volume, P < 0.01), and less blood replacement (40% versus 60% of total blood volume, P < 0.05). One patient in the FODO group experienced a new-onset strabismus postoperatively compared with 5 in the FOAR group (P < 0.05). There were no complications requiring a return to the operating room in either group.

CONCLUSIONS

Fronto-orbital distraction osteogenesis for the treatment of isolated UCS is associated with a favorable perioperative morbidity profile and a decreased incidence of postoperative strabismus compared with traditional FOAR. These positive factors are tempered by the need for an additional procedure for removal of the device and lack of long-term outcomes data on the technique.

Orbital Volumetric Analysis in Patients With Unicoronal Craniosynostosis: A Comparison Between Distraction Osteogenesis and Fronto-Orbital Advancement

BACKGROUND

Unicoronal craniosynostosis is associated with orbital restriction and asymmetry. Surgical treatment aims to both correct the aesthetic deformity and prevent the development of ocular dysfunction. We used orbital quadrant and hemispheric volumetric analysis to assess orbital restriction and compare the effectiveness of distraction osteogenesis with anterior rotational cranial flap (DO) and bilateral fronto-orbital advancement and cranial vault remodeling (FOAR) with respect to the correction of orbital restriction in patients with unicoronal craniosynostosis.

METHODS

A retrospective review of all patients with a diagnosis of unicoronal craniosynostosis and treated with either DO or FOAR from 2000 to 2019 was performed. Preoperative and postoperative total orbital volumes, as well as quadrant and hemispheric volume ratios, were calculated from 3-dimensional head computed tomography scans. Selected preoperative and postoperative orbital measurements, including the maxillary length of the orbit (MLO; zygomaticofrontal suture to the top of zygomatic arch) and the sphenoid length of the orbit (SLO; the top of sphenoid suture to the top of zygomatic arch), were also obtained.

RESULTS

Data were available for 28 patients with unicoronal craniosynostosis. Mean preoperative total orbital volume was significantly smaller on the synostotic side compared with the nonsynostotic side (10.94 vs 12.20 cm3, P = 0.04). Preoperative MLO and SLO were significantly longer on the synostotic side compared with the nonsynostotic side (MLO: 20.26 vs 17.75 mm, P < 0.001; SLO: 26.91 vs 24.93 mm, P = 0.01). Distraction osteogenesis and FOAR produced significantly different changes in orbital quadrant and/or hemispheric volume ratios on the nonsynostotic side but not on the synostotic side.

CONCLUSIONS

Before correction, patients with unicoronal craniosynostosis have significantly smaller total orbital volumes on the synostotic side compared with the nonsynostotic side and significantly greater MLO and SLO on the synostotic side compared with the nonsynostotic side. There is no significant difference between DO and FOAR with regard to correcting the observed orbital restriction in these patients.

Ophthalmological findings in children with non-syndromic craniosynostosis: preoperatively and postoperatively up to 12 months after surgery

Aims

Craniosynostosis is a congenital condition characterised by premature fusion of one or more cranial sutures. The aim of this study was to analyse ophthalmic function before and after cranial surgery, in children with various types of non-syndromic craniosynostosis.

Methods

Children referred to Uppsala University Hospital for surgery of non-syndromic craniosynostosis were examined preoperatively. Visual acuity was measured with Preferential Looking tests or observation of fixation and following. Strabismus and eye motility were noted. Refraction was measured in cycloplegia and funduscopy was performed. Follow-up examinations were performed 6–12 months postoperatively at the children’s local hospitals.

Results

One hundred twenty-two children with mean age 6.2 months were examined preoperatively. Refractive values were similar between the different subtypes of craniosynostosis, except for astigmatism anisometropia which was more common in unicoronal craniosynostosis. Strabismus was found in seven children, of which four had unicoronal craniosynostosis.

Postoperatively, 113 children were examined, at mean age 15.9 months. The refractive values decreased, except for astigmatism and anisometropia in unicoronal craniosynostosis. Strabismus remained in unicoronal craniosynostosis. Two new cases with strabismus developed in unicoronal craniosynostosis and one in metopic, all operated with fronto-orbital techniques. No child had disc oedema or pale discs preoperatively or postoperatively.

Conclusion

Ophthalmic dysfunctions were not frequent in children with sagittal craniosynostosis and preoperative ophthalmological evaluation may not be imperative. Children with unicoronal craniosynostosis had the highest prevalence of strabismus and anisometropia. Fronto-orbital techniques used to address skull deformity may be related to a higher prevalence of strabismus postoperatively.

Ophthalmological outcomes of unilateral coronal synostosis in young children

BACKGROUND

To report refractive outcomes, describe types of strabismus and evaluate the outcomes of surgical intervention for unilateral coronal synostosis (UCS) in paediatric patients.

METHODS

This study retrospectively included 30 UCS cases. Patients aged from 3 months to 6 years (median: 1.8 years) were enrolled from January 2018 to December 2019 at Shanghai Children's Hospital. Sixteen patients had all types of strabismus; 15 of these patients underwent surgery.

RESULTS

Refractive errors of 30 cases were included. In 60% of patients, astigmatism of 1.00D or more existed in not less than one eye at last record. Twenty (66.7%) patients had the larger amount of astigmatism in the contralateral eye. Fifteen patients received strabismus surgery, of whom 6 patients with monocular elevation deficiency (MED) underwent the standard Knapp procedure, with or without a horizontal deviation procedure. Fifteen cases were horizontally aligned within 5 prism dioptres (Δ). Six patients with MED (100%) had attained ≥25% elevation improvement after surgery, and the vertical deviation decreased from 25.83 Δ ± 4.92 Δ (range, 20 Δ-30 Δ) to 0.83 Δ ± 4.92 Δ after surgery (range, 0 Δ-10 Δ), for an improvement of 26.67 Δ ± 4.08 Δ (t = 16 P < 0.05). In 1 patient with esotropia, the horizontal deviation decreased from + 80 Δ to + 5 Δ after surgery. One patient was diagnosed with trichiasis and one with contralateral lacrimal duct obstruction.

CONCLUSIONS

Contralateral MED was also the main type of strabismus in UCS. Superior oblique muscle palsy was still the most common, as previously reported. There is a risk of developing a higher astigmatism and anisometropia in the contralateral eye to synostosis. Other ophthalmic disorders should be treated in a timely manner.

TRIAL REGISTRATION

The study was approved by the Institutional Review Board of Shanghai Children's Hospital (approval No. 2020R023-E01) and adhered to the tenets of the Declaration of Helsinki. Ethics approval was procured on March 30, 2020. This was a retrospective study. Written informed consent was sought from the patients' parents or legal guardians. Clinical Trials Registry number: ChiCTR2000034910 . Registration URL: http://www.chictr.org.cn/showproj.aspx?proj=56726 .

A 24-month cost and outcome analysis comparing traditional fronto-orbital advancment and remodeling with endoscopic strip craniectomy and molding helmet in the management of unicoronal craniosynostosis: A retrospective bi-institutional review

Introduction

Endoscopic strip craniectomy with helmeting (ESCH) has been shown to be a safe and efficacious alternative to fronto-orbital remodeling (FOR) for selected children with craniosynostosis. In addition to clinical factors, there may be economic benefits from the use of ESCH instead of FOR.

Methods

A retrospective review of 23 patients with nonsyndromic unicoronal craniosynostosis (UCS) treated with FOR was carried out at Great Ormond Street Hospital (GOSH) for Children in London, UK. Secondary data were used for the ESCH cohort from a paper published by Jimenez and Barone (2013). Data were collected on surgical time, transfusion rates, length of hospital stay, adverse event rates, reintervention rates, and overall costs. Costs were categorized and then assigned to the appropriate data sets.

Results

The mean age of patients undergoing FOR (vs. ESCH) was 17.4 mo (vs. 3.1 mo) with a mean surgical time of 234 min (vs. 55 min), mean transfusion volume of 221.6 mL (vs. 80.0 mL), mean transfusion rate of 14/23 (vs. 2/115), and a total immediate overnight stay of 3.13 days (vs. 97% next-day discharge). The FOR group had a higher adverse event rate (5/23 vs. 4/115, p=<0.005) and a higher number requiring extraocular muscle surgery (4/23 vs. 7/109, p=0.16). There was a substantial difference in overall costs between the two groups. Total variance cost for the FOR group was £7436.5 vs. £4951.35, representing a cost difference of £2485.15 over the 24-month study period.

Conclusion

ESCH, in comparison to FOR, appears as a more economical method in the management of USC patients, as well as having clinical benefits including reduced adverse event rate and improved ophthalmic outcomes.

Strabismus in Unicoronal Craniosynostosis: Effect of Orbital Dysmorphology and Fronto-Orbital Advancement and Remodeling

BACKGROUND

The purpose of this study was to determine what craniometric changes occur to both orbits of unicoronal craniosynostosis patients undergoing fronto-orbital advancement and remodeling, and which of these changes are associated with new onset of postoperative strabismus.

METHODS

A retrospective analysis was performed of the preoperative and postoperative orbits of 24 unicoronal craniosynostosis patients and the orbits of 24 control subjects, totaling 144 orbits. Eight parameters were evaluated using multivariate logistic regression analysis. One of the parameters was modified orbital index, an indicator of severity of harlequin deformity.

RESULTS

Significant differences in orbital dimensions and angles were present bilaterally in unicoronal craniosynostosis orbits when compared to controls. Fronto-orbital advancement and remodeling increased the ipsilateral unicoronal craniosynostosis orbital volume from 13,184 ± 2003 mm to 16,220 ± 2323 mm (p < 0.001). Ipsilateral horizontal cone angles were increased from 48 ± 5 degrees to 54 ± 7 degrees (p = 0.004). Ipsilateral vertical cone angles were decreased from 73 ± 8 degrees to 66 ± 10 degrees (p = 0.003). Ipsilateral modified orbital index improved from 0.83 ± 0.06 to 0.88 ± 0.06 (p = 0.003). Three of the 19 unicoronal craniosynostosis patients developed transient postoperative strabismus. Logistic regression analysis displayed a strong significant association between new-onset strabismus and a change in modified orbital index with a coefficient of 30.84 ± 14.51 (p < 0.05).

CONCLUSIONS

The orbital dysmorphology in unicoronal craniosynostosis is bilateral in nature, and it is not wholly treated with conventional fronto-orbital advancement and remodeling. The severity of ipsilateral orbital dysmorphology is correlated with the incidence of postoperative strabismus following conventional fronto-orbital advancement and remodeling. Future research is needed to develop strategies to mitigate the risk of development of strabismus in this group of patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Age at Craniosynostosis Surgery and Its Impact on Ophthalmologic Diagnoses: A Single-Center Retrospective Review

BACKGROUND

Ocular abnormalities in craniosynostosis are a persistent concern for patients and providers, and some surgeons feel that early surgical intervention for synostosis alleviates the progression of ophthalmologic abnormalities. In contradistinction, the authors hypothesize that operating early will have no bearing on postoperative ophthalmologic outcomes.

METHODS

Single-suture craniosynostosis patients who underwent surgical correction between 1989 and 2015 were reviewed. Patients with multisuture craniosynostosis, syndromic diagnoses, no preoperative ophthalmology evaluation, and less than 2 years of follow-up were excluded. Logistic regression was used to determine odds of preoperative and postoperative ophthalmologic abnormalities by age, while controlling for patient-level covariates.

RESULTS

One hundred seventy-two patients met inclusion criteria. The median age at surgery was 10 months (interquartile range, 7 to 12.9 months). Increasing age at the time of surgery was associated with increased odds of preoperative ophthalmologic diagnoses (OR, 1.06; p = 0.037) but not postoperative diagnoses (OR, 1.00; p = 0.91). Increasing age at surgery was also not associated with increased odds of ophthalmologic diagnoses, regardless of timing (OR, 1.04; p = 0.08). Patients with coronal synostosis (OR, 3.94; p = 0.036) had significantly higher odds of preoperative ophthalmologic diagnoses. Patients with metopic (OR, 5.60; p < 0.001) and coronal (OR, 7.13; p < 0.001) synostosis had significantly higher odds of postoperative ophthalmologic diagnoses.

CONCLUSIONS

After reviewing an expansive cohort, associations of both overall and postoperative ophthalmologic diagnoses with age at surgery were not found. The authors' findings thus run counter to the theory that early surgical intervention lessens the likelihood of postoperative ophthalmologic diagnoses and improves ophthalmologic outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Relationship Between Ocular Protrusion and Craniofacial Structures

OBJECTIVE

This study aimed to evaluate the relationships between ocular protrusion and other craniofacial structures.

METHODS

The lateral cephalograms of 124 nonsyndromic white adults were assessed. Two orbital and 13 craniofacial parameters were measured. Subgroups were constructed according to sex, anteroposterior position of maxilla, and mandibular plane angle values.Anatomical parameters and their relationships were statistically analyzed by analysis of variance and multivariate stepwise regression analysis.

RESULTS

There were no significant differences in ocular protrusion distances between sexes, and between individuals with different maxillary anteroposterior position and mandibular plane angle values. Ocular protrusion distances, the distance between the eyeball apex and the lateral orbital margin (Eyeball apex-LOr: OP1) and inferior orbital margin (Eyeball apex-IOr: OP2), were found to be 20.6 ± 2.8 and 16.5 ± 3.1, respectively. However, regression analysis showed that the ocular protrusion distances had weak correlation with a few craniofacial structures. The OP1 had a low negative relationship with the maxillary anteroposterior position (N-Aperp) (r: -0.289) (P < 0.05). The OP2 had a low negative relationship with the palatal plane angle (FH/PP) (r: -0.291) (P < 0.01) but had a positive relationship with the cranial base angle (BSN) (r: 0.304) (P < 0.01) and posterior facial height (SGo) (r: 0.299) (P < 0.01).

CONCLUSIONS

Ocular protrusion distances did not differ by sex, maxillary anteroposterior position, and amount of mandibular plane angle and showed weak correlation with a few craniofacial structures. Ocular protrusion amounts can be used for diagnosis and treatment plan in craniofacial syndromic or nonsyndromic anomalies.