Postoperative Improvement of Diplopia and Extraocular Muscle Movement in Patients With Reconstructive Surgeries for Orbital Floor Fractures

An overview of 3D printed metal implants in orthopedic applications: Present and future perspectives

With the ability to produce components with complex and precise structures, additive manufacturing or 3D printing techniques are now widely applied in both industry and consumer markets. The emergence of tissue engineering has facilitated the application of 3D printing in the field of biomedical implants. 3D printed implants with proper structural design can not only eliminate the stress shielding effect but also improve in vivo biocompatibility and functionality. By combining medical images derived from technologies such as X-ray scanning, CT, MRI, or ultrasonic scanning, 3D printing can be used to create patient-specific implants with almost the same anatomical structures as the injured tissues. Numerous clinical trials have already been conducted with customized implants. However, the limited availability of raw materials for printing and a lack of guidance from related regulations or laws may impede the development of 3D printing in medical implants. This review provides information on the current state of 3D printing techniques in orthopedic implant applications. The current challenges and future perspectives are also included.

Usage of Object Matching Algorithms Combined with Mixed Reality for Enhanced Decision Making in Orbital Reconstruction-A Technical Note

This technical note describes the usage of object matching to virtually compare different modes of reconstruction in orbital trauma and display the results to the surgeon and the patient pre-operatively via mixed reality devices for enhanced surgical decision making and immersive patient education. A case of an orbital floor fracture is presented for which surface and volume matching were implemented to compare orbital reconstruction utilizing pre-fabricated titanium meshes versus patient-specific implants. The results could be visualized by mixed reality devices to further enhance surgical decision-making. The data sets were demonstrated to the patient in mixed reality for immersive patient education and enhanced shared decision making. The advantages of the new technologies are discussed in view of the new possibilities of improved patient education and informed consent processes, as well as new ways of teaching medical trainees.

Is Surgery Needed for Diplopia after Blowout Fractures? A Clarified Algorithm to Assist Decision-making

Diplopia is a common symptom after blowout fractures, with an incidence of 43.6%–83%. Although there is some consensus toward surgical correction, diplopia is not always resolved by surgery. Thus, there is a clinical dilemma for surgeons with regard to performing surgery at a specific time. This review aimed to create an algorithm to support accurate and effective decision-making.

Modified Target Angle as a Predictor of Success in Strabismus Management after Orbital Fracture

Surgery for strabismus secondary to orbital fracture reconstruction surgery has had low success rates and high reoperation rates due to its incomitant nature and complex underlying mechanisms. There has been no consensus as to which of the various methods for improving the surgical results are best. We proposed a modified target angle criteria that combined the regular target angle and a favorable Hess area ratio percentage (HAR%) threshold to evaluate surgical results within the first postoperative week and conducted a retrospective chart review. According to the criteria of the modified target angle at the first postoperative week, a total of 63 patients were divided into two groups: Group 1, patients who fulfilled the criteria (49 patients); and Group 2, those who did not (14 patients). Sex, type of fracture, and the use of porous polyethylene sheets and titanium mesh during reconstruction surgery were significantly different between the groups. Group 1 showed a significantly higher percentage of patients who met the criteria of HAR% > 65% at the first week and >85% (i.e., a successful outcome) at the 6-month visit (p < 0.01). Additionally, Group 1 had a higher HAR% at the first postoperative week (p < 0.01). In conclusion, the patients meeting the criteria of the modified target angle at the first postoperative week had a favorable outcome at the 6-month visit in both ocular alignment and ocular movement.

Wraparound nylon foil implant for isolated orbital floor fractures

PURPOSE

There are a variety of implant materials available for orbital floor fracture repair. Implant selection is guided by surgeon experience, availability, and patient specific needs. The purpose of this study is to describe a "wraparound" technique for nylon foil implant placement for large, isolated floor fractures that provides excellent results with low incidence of enophthalmos or other complications.

MATERIALS AND METHODS

A retrospective chart review from 2012 to 2020 was conducted in patients who underwent isolated orbital floor fracture repair with the use of the "wraparound" nylon foil implant. The surgical technique is described. Preoperative CT scans were assessed, and the patients were divided into groups based on the size of the floor fracture. Postoperative data was collected including Hertel measurements and complications related to the implant.

RESULTS

There were eighty patients who underwent orbital floor fracture repair with the described technique and had adequate follow-up. There were 18 (22.5%) small-sized fractures, 32 (40%) medium-sized fractures, and 30 (37.5%) large-sized fractures in the study group. One patient (3.33%) in the large fracture group had clinically significant enophthalmos of 2 mm postoperatively. There were no other patients with clinically significant enophthalmos. There were no instances of any complications related to the implant, and no patients required implant removal.

CONCLUSIONS

The "wraparound" technique for a nylon foil implant provides excellent results for isolated orbital floor fractures. It provides more support and stability than traditional nylon implants for larger fractures and has minimal complication rates.

Detecting Binocular Diplopia in Orbital Floor Blowout Fractures: Superiority of the Orthoptic Approach

Background and Objectives: In patients with orbital floor blowout fracture (OFBF), accurate diagnosis of ocular motility disorder is important for decisions about conservative or surgical therapy. However, the accuracy of the traditional test for detecting binocular diplopia/ocular motility disorder using a moving pencil or finger (hereinafter, “finger test”) has been generally accepted as correct and has not been subject to scrutiny so far. Hence, its accuracy relative to full orthoptic examination is unknown. Materials and Methods: In this paper, the results of the “finger test” were compared with those derived from a complex examination by orthoptic tests (considered “true” value in patients with OFBF). Results: “Finger test” detected ocular motility disorder in 23% of patients while the full orthoptic examination proved much more efficient, detecting ocular motility disorder in 65% of patients. Lancaster screen test and test with color filters were the most important tests in the battery of the orthoptic tests, capable of identifying 97.7% and 95.3% of patients with ocular motility disorder, respectively. Still, none of the tests were able to correctly detect all patients with ocular motility disorder in itself. Conclusions: As the presence of ocular motility disorder/binocular diplopia is an important indication criterion for the surgical solution of the orbital floor blowout fracture, we conclude that a complex orthoptic evaluation should be always performed in these patients.

Ocular motility and diplopia measurements following orbital floor fracture repair

PURPOSE

Diplopia and ocular motility restriction following orbital fracture repair are common complications. The reported rates in the literature differ greatly, in part due to varying definitions of diplopia and methods of measurement. The purpose of this study is to describe a practical and efficient in-office method for examining ocular motility and diplopia in orbital trauma patients and to report the outcomes in a series of patients who underwent orbital floor fracture repair.

MATERIALS AND METHODS

A retrospective chart review from 2012 to 2019 was conducted in patients who underwent isolated orbital floor fracture repair within 3 weeks of trauma. All patients had examinations to assess extraocular motility and subjective diplopia using the described techniques.

RESULTS

Ninety-three patients underwent orbital floor fracture repair and had adequate follow-up. Preoperatively, 71 (76%) patients had some restriction in motility and 59 (63%) patients complained of diplopia. Postoperatively, only 1 patient (1.09%) had clinically significant diplopia. Five (5.4%) additional patients demonstrated mild restriction in supraduction upon detailed ophthalmic examination that was not discovered upon subjective history. No patients had worsening of diplopia or motility after surgery.

CONCLUSIONS

Diplopia and motility restriction following orbital fracture repair can be a persistent problem for some patients. It is important to perform a careful ophthalmic examination to detect motility deficits and diplopia that can be significant to the patient. The true rate of restriction and diplopia may be higher using detailed ophthalmic diagnostic techniques compared to subjective patient history.

The trend of recovery period on postoperative eye movement in orbital blowout fractures

To investigate the trend of restoration of postoperative eye movements after orbital blowout fractures by analyzing the percentage of Hess area ratio (HAR%). This was a retrospective study of patients who underwent orbital blow out reconstruction surgery within 28-days post injury. Eye movements were measured preoperatively and 3, 6, and 12 months post operatively by Hess chart. Orbital fractures were classified into three shapes: trap-door fracture with muscle entrapment, trap-door fracture with incarcerated tissue, and depressed fracture. Correlations between fracture shapes, regions, reconstruction implant, age and HAR% were analyzed. This study involved 125 eyes (64 right eyes and 61 left eyes) of 125 isolated orbital fracture cases (95 males, 30 females, mean age: 27.2, range 4-85 years old). Of the total 125 cases, 96 patients had orbital floor fractures, 18 had orbital medial wall fractures, and 11 had combined orbital medial wall and floor fractures. Three had trap-door fractures with muscle entrapment, 42 had trap-door fractures with incarcerated tissue, and 80 had orbital depressed fractures. The overall mean HAR% improved significantly from 76.0 pre-operatively to 95.5 post-12 months (P < 0.01). The mean HAR% in orbital floor fracture improved significantly from 76.7 pre-operatively to 92.9 and 94.7 at 3, 6 months respectively. There was a non-significant improvement in the HAR% in medial wall fractures from 83.2 pre-operatively to 89.5 at 3 months and a significant improvement to 93.2 at 6 months (p < 0.05). Orbital fractures were reconstructed with either Unsintered hydroxyapatite particles/poly l-lactide composite sheet (u-HA/PLLA composite sheet) (91 patients), a silicone silastic sheet (20 patients) a combination of sheets (7 patients) or without an implant (7 patients). There was no significant difference in the HAR% improvement between the different implants. The HAR% improvement was significantly greater in patients <18 years old than in those aged 18 or over. The HAR% is an effective method of the objective assessment of recovery after orbital fracture. Patients and surgeons should be aware that the recovery after medial wall fractures is slower than after floor fractures and continues after three months post-surgery and that a longer period of observation without further intervention may be required for medial wall fractures, whilst floor fractures are likely to have achieved their maximal recovery by three months.

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.

Quantifying Eye Alignment in Orbital Fracture Patients: The Digital Hess Screen

Background: Quantifying diplopia to determine management and track outcomes for orbital fracture patients is vital for standardization between visits, physicians, and coordination among the multiple specialties that manage these patients. However, standardization is challenging, as diplopia is often reported subjectively. This study sought to describe the utility of the digital Hess screen in patients with orbital fractures compared with a control group. Materials and Methods: A prospective pilot study was designed in which adult patients who presented with orbital fractures between November 2017 and January 2019 without prior history of orbital pathology were recruited. Subjects underwent digital Hess screen testing, in which they wore anaglyph glasses and aligned targets on a computer screen to quantify static eye alignment. The degree of any eye misalignment was analyzed and compared with controls. Results: Ninety-one patients and 35 controls were enrolled. All participants were able to complete the digital Hess screen. Average cumulative deviation score of orbital fracture patients within 1 month of injury was 0.65°, compared with 0.28° in controls. This was a statistically significant difference (p < 0.01, 95% confidence interval -0.18 to 0.18). Conclusion: The Hess screen has been used to quantify phoria as a correlate of eye alignment and diplopia, but older versions were cumbersome and difficult to analyze. This study is the first to report on using the digital Hess screen to quantify phoria in orbital fracture patients and provides a more concise and standardized means to track clinical and surgical outcomes of eye alignment.

Management of simultaneous ocular elevation and depression deficit in patients after reconstruction surgery for orbital floor fracture

Purpose

To present and examine the results of surgical correction of simultaneous ocular elevation and depression deficit in patients who underwent reconstruction surgery for orbital floor fracture.

Methods

A retrospective analysis of medical records of patients who had undergone surgical correction for diplopia associated with orbital fracture which persisted after orbital reconstruction surgery. All patients underwent orthoptic evaluation before surgery and postoperatively with various times of follow-up.

Results

Eight cases of blow-out fracture of the orbital floor were identified. Surgical plan varied from case to case. It included thorough revision of inferior rectus/oblique complex with or without recession of the former or flap tear repair and additional procedures. Postoperatively 4 patients (50%) were diplopia free, 3 (37.5%) presented diplopia in extreme upgaze and 1 (12.5%) in mid-upgaze and adduction. None of the patients reported diplopia in the primary position neither downgaze.

Conclusion

Diplopia persisting after reconstructive surgery of a fractured orbital floor may be corrected surgically. Our results suggest that at least two surgical procedures are necessary to achieve satisfying outcomes. Contralateral inferior rectus recession combined with superior oblique recession and superior rectus posterior fixation appears to be effective procedures for use.

Gradual oculomotor training in blow-out orbital fracture reconstruction recovery

Objective

This study compared the impact of gradual oculomotor training (GOT) in blow-out orbital fracture (BOF) reconstruction recovery with the impact of high-intensity trainings.

Methods

In total, 120 patients with BOF requiring orbital reconstruction surgery were randomly divided into four groups; all groups performed postoperative oculomotor training four times per day. Patients in Groups 1, 2, 3, and 4 performed 10, 20, 30, and 50 sets of all-direction movement per training on the first 3 days, respectively; they performed 10 additional sets per training on the following 4 days. Patients in all groups performed 50 sets per training from 8 days to 3 months postoperatively. Incision healing, pain, and satisfaction rate, as well as degree of diplopia, were recorded during follow-up.

Results

At 7 days postoperatively, more patients in Group 1 had no/mild swelling and no/mild pain, compared with patients in Group 4. Patients in Groups 1 and 2 had higher satisfaction rates than patients in Group 4. The degree of diplopia did not significantly differ among the groups.

Conclusions

For patients with BOF, GOT after reconstruction surgery was more beneficial for wound healing, pain relief, and satisfaction; the degree of diplopia did not significantly differ, compared with high-intensity trainings.

Clinical outcome after orbital floor fracture reduction with special regard to patient's satisfaction

PURPOSE

Primary reconstruction via transconjunctival approach is a standardized treatment option for orbital floor fractures. The aim of this study was to compare the findings of specific ophthalmologic assessment with the patient's complaints after fracture reduction.

METHODS

A retrospective medical chart analysis was performed on patients who had undergone transconjunctival orbital floor fracture reduction for fracture therapy with resorbable foil (ethisorb sheet or polydioxanone foil). A follow-up assessment including ophthalmological evaluation regarding visual acuity (eye chart projector), binocular visual field screening (Bagolini striated glasses test) and diplopia (cover test, Hess screen test) was conducted. Additionally, a questionnaire was performed to assess patients' satisfaction.

RESULTS

A total of 53 patients with a mean follow-up of 23 months (ranging from 11 to 72) after surgical therapy were included. Diplopia was present preoperatively in 23 (43.4%) and reduced in follow-up examination (n = 12, 22.6%). Limitations in ocular motility reduced from 37.7% to 7.5%. The questionnaire about the patient's satisfaction revealed excellent outcomes in relation to the functional and esthetical parameters.

CONCLUSION

Transconjunctival approach is a safe approach for orbital fracture therapy. Postoperative diplopia is nearly never perceptible for the individual and differs to pathologic findings in the ophthalmic assessment.

Surgical Correction of Diplopia in Orbital Fracture: Influence of Material and Design

Purpose

The purpose of this study is to compare the association of diplopia after orbital fracture repair using titanium mesh and high-density polyethylene-coated titanium mesh.

Materials and Methods

Retrospective review of records of consecutive patients who presented for primary/secondary correction of orbital fracture attending author's institute was done. Patients attending the institution between January 2013 and December 2017 (5 years' period) fulfilling the inclusion and exclusion criteria were included for this study.

Results

In all, 44 patients, who fulfilled the inclusion and exclusion criteria, were included in the study. The mean age was 31.86 ± 9.1 years and the mean period of follow-up was 9.37 ± 2.1 months postoperatively, with a range of 6.5-24 months. There were 65.91% males, and the most common etiology was road traffic accident (50%). In all, 11 (25%) cases had postoperative diplopia. Of the 11 cases that had diplopia, 6 had Class 1 and 5 had Class 2 diplopia. Of these 11 cases, 8 cases had completion or partial resolution of diplopia by the end of 8 weeks' period, and in 3 cases, it persisted even after 3 months of care. The occurrence of diplopia was compared by demographic factor using Chi-square test, and the mesh type was only statistically significant (P = 0.026).

Discussion

The present study indicates that both types of mesh provide reliable, clinically better results. However, with passage of time, it was clinically observed that removing uncoated mesh poses extreme difficulty by the adherences and growth penetrating the meshes. In certain instances, clinically, it was observed that such adhesions may be a cause of compromise of eyeball movement.

Conclusion

Noncoated titanium orbital implants may lead to the adherence of orbital and periorbital structures, resulting in restrictive diplopia. High-density polyethylene-coated titanium mesh shows better performance as compared to noncoated mesh in preventing adherence situations.

Establishment of an acute extraocular muscle injury model in cats

AIM

To describe an acute extraocular muscle injury model in cats.

METHODS

Seventy-two cats were randomly divided into 6 groups (12 cats per group). Cats' left lateral recti were clamped using a surgical needle holder with a clamping strength of 2 (Groups A and D), 4 (Groups B and E) and 6 kg (Groups C and F). The right lateral recti were treated as controls. On the 4th and 7th days, hematoxylin eosin (HE) staining, immunohistochemical staining for proliferating cell nuclear antigen (PCNA), muscle force measurements and ocular alignment changes were performed to evaluate the extent of injuries.

RESULTS

The morphological changes were graded as mild, moderate or severe by HE staining in all experiment groups. PCNA immunohistochemical staining indicated repairment of muscle fibers in the damaged area. On the 4th and 7th days after clamping, the injured lateral muscle exhibited an elevated threshold for electric stimulation. The muscle forces among groups 2, 4 and 6 kg injury at 4d (Groups A, B and C) were statistically significant (P<0.05), but no significant differences were noted among groups 2, 4 and 6 kg injury at 7d (Groups D, E and F) (P>0.05), respectively. In addition, medial deviation in ocular alignment was also present to various degrees in all groups.

CONCLUSION

A cat model of acute extraocular muscle injury can be established by rectus clamping. Different clamping strengths can make different degrees of muscle injury. This model may help the future study in the acute extraocular muscle injury.

Factors Influencing Postsurgical Diplopia in Orbital Floor Fractures and Prevalence of Other Complications in a Series of Cases

PURPOSE

We conducted a review of orbital fractures treated in our hospital over a period of 4 years. We reviewed several complications of such fractures, especially the relationship of postsurgical diplopia with different presurgical variables: age, gender, type of fracture, fracture area, coronal and sagittal diameter of fracture, fractured floor area, time to surgery, presence of muscle herniation, and presence of muscle entrapment.

PATIENTS AND METHODS

Fractures involving the orbital floor remain a controversial issue in terms of surgical treatment and the time from trauma to surgery. Surgical indications are divided into esthetic and functional, and they greatly differ from one medical center to another. We observed that the variables that influence postoperative complications varied in the different studies reviewed. Postsurgical diplopia is one of the most important complications, and its relationship with presurgical variables was the focus of this study. For the purpose of this study, we performed bivariate and multivariate analyses, accepting P < .05 as significant.

RESULTS

According to the multivariate analysis, postsurgical diplopia was only associated with trapdoor fractures, regardless of all other variables, especially if these fractures were operated on after 48 hours. In addition, the bivariate analysis showed that fractures involving muscle herniation resulted in less diplopia and a better prognosis if operated on before 48 hours. However, these results were not statistically significant.

CONCLUSIONS

Surgery performed within 48 hours of trauma statistically improves fractures with true muscle entrapment and also, fractures with muscle hernation (although in this fractures, the improvement is not statistically significant).

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.