Orbital fractures: a review

Orbital fractures treated in a university hospital of southern Italy: epidemiology, outcomes and prognostic factors resulting from 538 retrospectively analyzed cases

PURPOSE

Orbital fractures are common injuries and represent an interesting chapter in maxillofacial surgery. This retrospective study analyses data collected from 528 patients surgically treated at the University Hospital "Magna Graecia", Catanzaro, Italy, from 1st January 2007 to 31st January 2021.

METHODS

The inclusion criteria were a diagnosis of orbital bone fracture, complete clinical and radiological records, and a minimum follow-up of 12 months. We analyzed gender, age, etiology, fracture type, treatment, timing of repair, and associated complications.

RESULTS

The most frequent cause of trauma was road accidents (37.88%), followed by domestic accidents (25.95%). The manifestation of diplopia (72.35%), infraorbital nerve hypoesthesia (53.41%), extrinsic eye movement limitation (51.70%), and enophthalmos (41.29%), determined the indication for surgery. Our trauma team preferred the sub-eyelid approach (79.36%). The study shows a statistical significance in the correlation between the severity of the herniation of the lower rectus muscle and the presence of preoperative diplopia (p-value = 0.00416); We found the same statistical significance for the post-postoperative diplopia (p-value = 0.00385). Patients treated two weeks after the trauma show a higher rate of diplopia and a greater limitation of long-term post-operative eye movements than those treated within two weeks (diplopia 23.08% vs. 15.56%; eye movements limitation 13.33% vs. 7.69%). Early surgical treatment (> 14 days) reduces the likelihood of functional and structural damage to the lower rectus muscle.

CONCLUSION

Our data will support future maxillofacial traumatology studies, and the education and prevention measures taken will reduce the incidence of orbital trauma.

Incidence of Orbital Mucocele following Orbital Floor Fracture Repair

Mucoceles can often present as a complication after prior sinus surgery or maxillofacial trauma when mucosal drainage is obstructed. Their presence in the orbit following orbital wall fracture and subsequent repair represent an exceedingly rare complication whose occurrence is limited to a few reported cases in the literature. In these patients, continuous cyst expansion and subsequent mass effect may lead to ophthalmic symptoms, including orbital pain, proptosis, diplopia, and globe dystopia. We report the discovery of an orbital mucocele after orbital floor fracture repair and its possible association with the nonporous reconstruction plate utilized for fixation. When a patient with history of orbital wall reconstruction presents with new-onset ocular symptoms, an orbital mucocele should be considered as a potential diagnosis.

Etiology and Characteristics of Patients Presenting with Eyelid Lacerations at a Level 1 Trauma Center

Purpose

To investigate the etiology and demographic associations of patients presenting with eyelid lacerations to a US level 1 trauma center emergency department (ED).

Patient and Methods

A retrospective chart review of all patients with eyelid lacerations presenting to the ED at a single level 1 trauma center was performed. Eyelid lacerations were categorized as simple eyelid lacerations, eyelid lacerations with eyelid margin involvement, and eyelid lacerations with nasolacrimal system involvement. Data on demographics and clinical characteristics were analyzed.

Results

A total of 303 eyelid laceration cases were identified, 56% were simple eyelid lacerations, followed by 24% with nasolacrimal involvement and 20% involving the eyelid margin. Sixty percent of animal bites/scratches resulted in a nasolacrimal system involving laceration, most commonly affecting children. Falls were the most common etiology in children and patients over the age of 60. Black patients, patients presenting with concomitant ophthalmic injuries, and those with Medicaid insurance were more likely to have an assault etiology (p < 0.05 for all).

Conclusion

Falls were the most common etiology for eyelid lacerations in children and the elderly, while assault was the most common in adults. Identifying the most common etiology by demographic factors can help raise awareness regarding targeted prevention strategies for high-risk populations.

Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update

A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded based on the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians.

A systematic literature review and narrative synthesis on the use of autologous cartilage in the repair of orbital fractures

Introduction

Fractures of the orbit are common injuries within the maxillofacial skeleton, and can often result in restrictions to ocular movement, diplopia, and enophthalmous if herniation of globe content occurs. Various studies have demonstrated the use of autologous cartilage grafts in the reconstruction of orbital fractures.

Methods

A systematic review protocol was registered with PROSPERO, and reported in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses. Comprehensive electronic search strategies of four databases were developed. Studies were screened according to the inclusion and exclusion criteria by two independent reviewers.

Results

Seven thousand one hundred seventy-one articles were identified following a comprehensive literature search. These articles were filtered for relevance and duplication, which reduced the number of articles to 16. A total of 259 patients underwent orbital reconstruction with the use of autologous cartilage. Conchal cartilage was harvested in 148 patients, auricular cartilage in 22 patients, nasoseptal cartilage in 72 patients, and costal cartilage in 17 patients. Thirty, seven, twelve, and four complications were observed in patients where cartilage was harvested from the concha, auricle, nasoseptum and rib, respectively. Most common complications included diplopia (n=23), infra-orbital para/anaesthesia (n=27), and enophthalmos (n=7). No failure of graft or donor site morbidity were observed in the studies.

Conclusion

Autogenous materials such as cartilage can be used as an alternative for orbital reconstruction. Cartilage was considered by the authors to provide adequate structural support to the orbital contents, and that it was easy to harvest, shape, and position.

Infection of a Nylon Foil Orbital Implant Due to Fusarium brachygibbosum and Lomentospora prolificans After Intranasal Methamphetamine Use

The authors describe a case of nylon foil implant infection caused by Fusarium brachygibbosum , and Lomentospora prolificans following medial orbital wall fracture repair in the setting of postoperative nasal methamphetamine use. A 61-year-old male presented with OS pain and swelling after a physical assault on his face. A CT of maxillofacial bones without contrast showed a moderately comminuted fracture of the medial wall of the left orbit with depression of fracture fragments into the left ethmoid air cells. Six days after repair of the medial wall fracture, the patient returned with a new onset headache, OS pain, and swelling to the left medial canthal area. He reported snorting methamphetamine approximately 48 hours before his current presentation. CT imaging showed fat stranding and soft tissue density in the extraconal space adjacent to the left medial rectus muscle and chronic fracture deformity of lamina papyracea with approximately 4 mm of medial displacement of the fracture fragments. The patient showed little clinical improvement after 48 hours of intravenous antibiotics, which led to the removal of the nylon foil implant by a left orbitotomy. Intraoperative tissue cultures grew coagulase-negative Staphylococcus , F. brachygibbosum , and Lomentospora (Scedosporium) prolificans . The patient was subsequently transitioned to oral clindamycin 600 mg three times daily and voriconazole 200 mg two times daily. To the authors' knowledge, this is the first case report to document an association between snorted methamphetamine and a fungal infection of an orbital implant.

Current Guidelines and Opinions in the Management of Orbital Floor Fractures

Orbital floor fractures are a common manifestation of facial trauma that is encountered by ophthalmology, otolaryngology, and oral maxillofacial specialists. Surgical intervention is required emergently in cases of tissue entrapment and less urgently in cases of presenting with persistent diplopia, enophthalmos greater than 2 mm, and/or fractures involving greater than 50% of the orbital floor. Surgical management is a debated topic with differing opinions among surgeons regarding timing of repair, type of implant, and surgical approach.

Accuracy of linear-probe ultrasonography in diagnosis of infraorbital rim fractures

BACKGROUND

Maxillofacial fractures are a common cause of visits to emergency department, accounting for more than 400,000 annual visits in the United States. Gold standard diagnostic tool is conventional computerized tomography (CT) or 3DCT reconstruction. However, the disadvantages of CT are radiation exposure, unavailable in some hospital and expensiveness. Whereas the bony structures overlap is a problem in diagnostic when using plain film X-ray. The objective of this study is to show the accuracy of a linear-probe ultrasound compared to computed tomography and plain film X-ray in diagnosis of infraorbital rim fracture.

METHODS

Patients clinically suspected of an inferior orbital rim fracture underwent linear-probe ultrasonographic investigation, plain film X-ray and CT. CT was used as gold standard in this diagnostic study. A radiologist and senior resident of plastic surgery were the examiner and interobserver for comparison.

RESULT

A total of 34 patients with suspected infraorbital rim fractures were investigated. Sensitivity of the linear-probe ultrasonography versus CT in the detection of infraorbital rim fracture was 92.9% (95% CI 66.1-99.8), specificity was 90.0% (95% CI 68.3-98.8), positive predictive value was 86.7% (95% CI 59.5-98.3), negative predictive value was 94.7% ( 95% CI 74.0-99.9), accuracy 91%.

CONCLUSION

Linear probe ultrasonography is a good diagnostic tool and has better reliability than the plain film X-ray and can be used as alternative to CT in inferior orbital rim fracture.

The outcome of conventional open reduction approach vs endoscopic approach for orbital floor repair

Introduction

Blunt trauma to the orbital rim is a frequent cause of both orbital fractures and damage to the surrounding facial bones and soft tissues. The inception of endoscopy and minimal invasive intervention has revolutionized the surgical treatment of blow out fracture of orbital walls. Thus, the present study was conducted to compare the outcome of conventional open reduction approach with endoscopic approach for orbital floor repair.

Materials and method

The study included 10 patients with clinical and radiographic evidence of orbital floor fracture, divided randomly into two groups: Group I-operated using endoscopic approach; and Group II- operated using conventional external approach. All the patients were evaluated clinically preoperatively, immediate post-operative and after 1 month for Diplopia, Extrinsic ocular motility, Enophthalmos and Hypoglobus.

Results

The study consisted of 40% females and 60% males, with mean age of Endoscopic and Conventional group being 27.20 ± 6.14 years and 27.60 ± 7.23 years respectively. In relation to diplopia, an insignificant difference was observed statistically. The mean change in enophthalmos and hypoglobus in endoscopic and conventional group showed a significant difference statistically (p < 0.001). Unrestricted ocular motility was present only in one case of each group and significantly increased to 5 cases in both the groups (p = 0.048). The mean duration of surgery in endoscopic and conventional group showed a significant difference statistically.

Conclusion

Diplopia, hypoglobus and Enophthalmos correction was better achieved in endoscopic group as compared to conventional group. But duration of surgery was more in endoscopic group as compared to conventional group.

Detection of Abnormal Spontaneous Brain Activity Patterns in Patients With Orbital Fractures Using Fractional Amplitude of Low Frequency Fluctuation

Background

To date, no in-depth study has been conducted on the intrinsic pathological relationship between altered brain activity and related behavioral changes in patients with orbital fracture (OF).

Purpose

The present research aimed to explore the potential functional network cerebrum activities in patients with OF using resting state functional magnetic resonance imaging–fractional amplitude of low-frequency fluctuation (rsfMRI-fALFF). This technique can reveal dynamic functional changes in specific cerebrum areas.

Methods

Twenty patients with OF and 20 healthy controls (HCs) were included, closely matched in terms of gender, age, weight, and education level. To record spontaneous cerebral activity changes, the rsfMRI-fALFF tool was applied. Receiver operating characteristic (ROC) curves and Pearson's correlation analysis were used to analyze mean fALFF values in specific cerebrum regions and to explore changes of behavioral changes in patients with OF. The Hospital Depression and Anxiety scale was applied to reveal the relationship between emotional states and fALFF values of the right superior temporal gyrus in patients with OF.

Results

In comparison with HCs, significantly lower fALFF values were detected in the left anterior cingulate gyrus (LACG) and right superior temporal gyrus (RSTG) in patients with OF. ROC curve analysis showed excellent accuracy. The mean fALFF values of the RSTG negatively correlated with the depression score as well as the anxiety score.

Conclusion

The finding of abnormal spontaneous activities in cerebral regions may contribute to more comprehensive understanding of the potential neural network changes in patients with OF. The changes of fALFF value in patients with OF may help to gauge their emotional changes and clinical recovery levels.

The Incidence and Risk Factors of Medial and Inferior Orbital Wall Fractures in Korea: A Nationwide Cohort Study

Purpose: We aimed to investigate orbital wall fracture incidence and risk factors in the general Korean population. Method: The Korea National Health Insurance Service–National Sample Cohort dataset was analyzed to find subjects with an orbital wall fracture between 2011 and 2015 (based on the diagnosis code) and to identify incident cases involving a preceding disease-free period of 8 years. The incidence of orbital wall fracture in the general population was estimated, and the type of orbital wall fracture was categorized. Sociodemographic risk factors were also examined using Cox regression analysis. Results: Among 1,080,309 cohort subjects, 2415 individuals with newly diagnosed orbital wall fractures were identified. The overall incidence of orbital wall fractures was estimated as 46.19 (95% CI: 44.37–48.06) per 100,000 person-years. The incidence was high at 10–29 and 80+ years old and showed a male predominance with an average male-to-female ratio of 3.33. The most common type was isolated inferior orbital wall fracture (59.4%), followed by isolated medial orbital wall fracture (23.7%), combination fracture (15.0%), and naso-orbito-ethmoid fracture (1.5%). Of the fracture patients, 648 subjects (26.8%) underwent orbital wall fracture repair surgeries. Male sex, rural residence, and low income were associated with an increased risk of orbital wall fractures. Conclusions: The incidence of orbital wall fractures in Korea varied according to age groups and was positively associated with male sex, rural residency, and low economic income. The most common fracture type was an isolated inferior orbital wall fracture.

Biocompatible Materials for Orbital Wall Reconstruction-An Overview

The reconstruction of an orbit after complex craniofacial fractures can be extremely demanding. For satisfactory functional and aesthetic results, it is necessary to restore the orbital walls and the craniofacial skeleton using various types of materials. The reconstruction materials can be divided into autografts (bone or cartilage tissue) or allografts (metals, ceramics, or plastic materials, and combinations of these materials). Over time, different types of materials have been used, considering characteristics such as their stability, biocompatibility, cost, safety, and intraoperative flexibility. Although the ideal material for orbital reconstruction could not be unanimously identified, much progress has been achieved in recent years. In this article, we summarise the advantages and disadvantages of each category of reconstruction materials. We also provide an update on improvements in material properties through various modern processing techniques. Good results in reconstructive surgery of the orbit require both material and technological innovations.

Significance of subconjunctival hemorrhage in predicting ocular pathology for patients with orbital fracture

OBJECTIVE

Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture.

DESIGN

Retrospective chart review.

PARTICIPANTS

Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018.

METHODS

Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI.

RESULTS

Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ² analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%).

CONCLUSIONS

Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma.

Do Orbital Implants Differ in Complication Rates: A Retrospective Study of 88 Patients, and an Argument for Cost-Effective Practices in the Face of Rising Health Care Costs

Operative repair of orbital fractures utilizes implants constructed of a plethora of materials that vary in cost. Surgeon preference as well as fracture complexity may dictate the implant chosen. In this study, we retrospectively compared the complication rates of the four most common types of implants utilized at our institution. We found no significant difference in complication rates in our sample of 88 patients. Additionally, the least expensive implant was as effective as the most expensive implant in addressing isolated orbital blowout fractures. This situation is not unique to the field of oculoplastics. As evidenced from published literature in other areas of surgery, from orthopaedics to orthodontics, cheaper alternatives often afford similar outcomes as more expensive options. We herein argue that a cost-effective approach should be considered while still allowing for high quality of care, in the face of rising health care costs and health disparities in America.

Orbital Fractures

Orbital fractures are common in facial trauma and can be a challenge to treat. Understanding anatomy of the orbit, the clinical evaluation, indications for surgery, surgical approaches, complications, and postoperative are essential in providing appropriate treatment for patients who have sustained orbital fractures. In this article, the authors review the diagnostic evaluation, acute management, treatment options, and common complications of orbital fractures, as well as recent advancements in orbital fracture repairs.

[Applied anatomy of the medial orbital wall]

The article provides an overview of foreign and domestic studies on the anatomy of the medial wall of the orbit. Possible structural variants of the osseus structures of the medial wall and their applied clinical significance are indicated, including those having individual occurrence: additional lacrimal bone, morphological features of the structure of the fossa of the lacrimal sac, location, shape and size of the cells of the ethmoid bone, Onody cells, Haller infraorbital cell, the relative position of the anterior and posterior ethmoid foramina, the presence of additional ethmoid foramina, dysgenesis of the lacrimal bone and the orbital plate of the ethmoid bone. The anatomical prerequisites for the occurrence of intraoperative complications with surgical access to the medial wall of the orbit are described.

Risk of Dry Eye Syndrome in Patients with Orbital Fracture: A Nationwide Population-Based Cohort Study

This study aimed to investigate whether orbital fracture increases the risk of dry eye syndrome (DES) and identified the profile of prognostic factors. We studied a cohort from the Taiwan National Health Insurance Research Database (NHIRD). Overall, 46,179 and 184,716 participants were enrolled in the study and control groups, respectively. Each patient in the case group was age- and gender-matched to four individuals without orbital fracture that served as the control group. Cox proportional hazards analysis regression was used to estimate the risks of incident DES. During the follow-up period, the case group was more likely to develop incident DES (0.17%) than the control group (0.11%) (p = 0.001). Multivariate Cox regression analysis demonstrated that the case group had a 4.917-fold increased risk of DES compared to the controls. In the stratified age group, orbital fracture had the highest impact on patients aged 18–29 years. Furthermore, patients with orbital roof fracture have a greater risk of developing DES. Regardless of whether having received surgery or not, the patients with orbital fracture have higher risks of DES. Our study demonstrated that orbital fracture increases the risk of developing subsequent DES. Early recognition by thorough examinations with raised awareness in the clinical setting could preserve visual function and prevent further complications.

Traumatic enucleation of the left globe after a road traffic accident - A case report of an uncommon occurrence in maxillofacial trauma

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Sometimes the orbital mechanisms to protect the globe fail.

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Although rare, globe avulsion can occur after maxillofacial blunt trauma.

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Despite all efforts, permanent major sequels can occur after facial trauma.

Introduction

Serious injuries of the globe are uncommon in closed maxillofacial trauma, as the anatomical configuration of the orbit offers important protective mechanisms against external trauma. Thus, the objective of this work is to report a case of a rare traumatic enucleation of the globe resulting from maxillofacial blunt trauma.

Presentation of case

A 42-year-old man was hit by a car with a major complaint of facial pain. The patient had several facial fractures including: Le Fort I, naso-orbit-ethmoidal, anterior sinus wall and an exposed fracture of the orbit-zygomatic complex (OZC). The patient underwent to open reduction and internal fixation of facial fractures and enucleation of the left globe, however, evolved with postoperative infection and complications associated with, a so far unknown, type 2 diabetes. After secondary surgeries for removal infected bones and diabetes control, all injuries were fully healed, and the patient remained with major sequels.

Discussion

In this case, we hypothesized a high-energy trauma resulting in multiple facial fractures, especially involving the OZC, dislocated the thick lateral wall of the orbit within the orbital cavity and reduced the orbital volume. This resulted in an exaggerated increase in intraorbital pressure, which exceeded the capacity of all anatomical protective mechanisms of the globe, and pushed the globe outwards, causing a complete avulsion.

Conclusion

Besides all anatomical structures to protect the globe, rarely high energy maxillofacial trauma can cause severe damage to the globe resulting in loss of vision and globe avulsion.

Ophthalmology in Critical Care

Ophthalmic disease encountered in the intensive care unit (ICU) has a wide spectrum of prevalence and severity. Prolonged exposure of the cornea is common and preventable. Trauma, glaucoma, infection, vascular disease, and burns are among the potential causes of vision loss. Patients are predisposed to ocular complications by the ICU environment and critical illness itself. Critically ill patients require prioritization of life-sustaining interventions, and less emphasis is placed on ophthalmic disease, leading to missed opportunities for vision-saving intervention. It is therefore imperative for intensivists, nurses, and other providers to have an increased awareness and understanding of the broad range of ocular conditions potentially seen in the ICU.

Characteristics of Orbital Floor Fractures in the United States from 2006 to 2017

PURPOSE

To examine the incidence, characteristics, and economic burden of orbital floor fractures in the United States.

DESIGN

Retrospective, longitudinal study of the Nationwide Emergency Department Sample (NEDS).

PARTICIPANTS

Patients in the Emergency Department (ED).

METHODS

The NEDS, a representative sample of all hospital-based EDs in the US, was used to identify and describe ED visits with a primary diagnosis of orbital floor fracture from 2006 to 2017. Linear regression was used to estimate the trends in annual incidence and inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission.

MAIN OUTCOME MEASURES

Incidence, injury mechanisms, demographics, clinical characteristics, disposition, and economic burden.

RESULTS

From 2006 to 2017, there were an estimated 350 379 ED visits in the US with a primary diagnosis of orbital floor fracture. The incidence increased by 47% over the study period (P < 0.001): from 7.7 (95% confidence interval [CI], 6.9-8.5) to 11.3 (95% CI, 10.0-12.6) per 100 000 population. The majority were male (67%), aged 21 to 44 years (46%), and from low-income households (32%). The most common cause was assault (43%), which was most frequent in young adults (65%) and increased modestly over time (3.5 to 4.5 per 100 000 population; P = 0.02). The second most common cause was falls (26%), most frequent in patients aged ≥65 years (86%) and more than doubled over time (1.6 to 3.5 per 100 000 population; P < 0.001). The rate of inpatient admission was 14%, with a higher likelihood for patients aged ≥65 years (odds ratio [OR], 2.21; 95% CI, 1.99-2.46; P < 0.001) and falls (OR, 1.54; 95% CI, 1.27-1.86; P < 0.001). The total inflation-adjusted ED charges over the study period exceeded $2 billion, with the mean charge per visit increasing 48% (P < 0.001): from $5881 (95% CI, 5499-6263) to $8728 (95% CI, 8074-9382).

CONCLUSIONS

Orbital floor fractures are becoming an increasingly common and costly injury in the United States. Preventive strategies aimed at reducing assault and falls will be crucial to mitigate the burden of orbital floor fractures on the healthcare system.

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.

Reconstruction of Complex Cranial and Orbit Fractures with Associated Hemorrhages: Case Report and Review of the Literature

We present our experience following a unique case of coincident intracranial hemorrhage and comminuted fractures of both the squamous temporal bone and zygomaticofrontal orbit. Surgical techniques and outcome for this presentation have yet to be sufficiently described. A 55-year-old male presented following trauma with Glasgow Coma Scale score of 7. Radiographic evaluation revealed comminuted fractures of the squamous temporal bone with extension into the lateral orbit, along with zygomatic process fracture extending 2.5 cm medially into the orbital roof. Zygomaticofrontal orbital roof fragments reached superiorly into the middle cranial fossa and inferiorly into the orbit. Surgical intervention was deemed necessary to address underlying epidural hematoma, subarachnoid hemorrhage, correction of cranial bone defects, and decompression of the optic nerve and other intraorbital nerves. A frontotemporal approach was employed. Repair of temporal and orbital fractures was accomplished using a combination of wire mesh screws and titanium miniplates. Postoperative imaging demonstrated bony approximation and successful evacuation of traumatic hemorrhage. The patient remains functionally and neurologically intact apart from a sluggishly responsive left eye presumed to result from a left optic nerve or ciliary ganglion lesion. Although rapid reconstruction of complex cranial-orbital trauma and hematoma evacuation can permit acceptable gross functional neurological outcome following massive trauma, orbital fracture and subsequent hemorrhagic processes may be the nidus of neurological sequelae in this complex traumatic constellation. Thus, alterations in surgical approach and reconstruction are appropriate in order to maximize neurological function while supporting restoration of cosmetic space.

Blood Collection within the Maxillary Sinus following Orbital Fracture Repair: The Impact of Mesh Implants and Drains

This article aimed to assess the effects of (1) mesh (e.g., uncoated anatomic titanium plates) versus non-mesh (e.g., porous polyethylene-coated titanium sheets) implant materials and (2) drain placement on the accumulation of blood within the maxillary sinus following surgical repair of orbital floor fractures. Ninety-two patients who received orbital floor fracture repair between 2008 and 2014 were selected, with equal case numbers between categories: (1) non-mesh implant, without drain; (2) non-mesh implant, with drain; (3) mesh implant, without drain; and (4) mesh implant, with drain. Lesion-mapping software was used to measure blood and sinus volumes in postoperative computed tomographic images. Average postoperative maxillary sinus filling was 49% ± 29%. Average sinus filling was similar between mesh and non-mesh implant materials; this was true in cases with a drain (45 vs. 40%, respectively) and without (57 vs. 52%, respectively). Orbital drain placement was associated with a significant reduction ( p  = 0.048) in maxillary sinus filling of 12%. Mesh and non-mesh implant materials allow for similar drainage of orbital blood into the maxillary sinus postoperatively. In the majority of cases, space is available within the maxillary sinus to allow for drainage of orbital blood. Intraoperative drain placement is associated with reduced blood pooling within the maxillary sinus, suggesting it allows for drainage of orbital blood to the outside world.

Orbital Trauma

The orbit is contained within a complex bony architecture with overlying soft tissue that involves many important anatomical structures. Orbital trauma is a frequent cause of damage to these structures. The authors review the literature on reconstructive techniques focusing on fractures of the orbital rim, orbital roof, orbital floor, medial orbital wall, and naso-orbito-ethmoid complex. A thorough literature review was conducted using PubMed analyzing articles relevant to the subject matter. Various search terms were used to identify articles regarding orbital trauma presentation, diagnosis, management, as well as postoperative complications. Articles were examined by all authors and pertinent information was gleaned for the purpose of generating this review. Orbital trauma can result in a wide variety of complications in form and function. Not all orbital fractures require operative repair. However, bony disruption can cause enophthalmos, hypophthalmos, telecanthus, epiphora, cerebrospinal fluid leaks, orbital hematoma, and even blindness to name a few. Timing of operative repair as well as reconstructive method is dictated by the patient's individual presentation. Successful fracture management requires a detailed understanding of the anatomy and pathophysiology to ensure restoration of the patients' preoperative state. Orbital trauma encompasses a wide variety of mechanisms of injury and resulting fracture patterns. A variety of surgical approaches to the orbit exist as has been discussed allowing the surgeon access to all area of interest. Regardless of the fracture complexity, the principles of atraumatic technique, anatomic reduction, and stable fixation apply in all cases.

Exploring the effect of streamlining multidisciplinary care pathways on orbital trauma outcomes at a regional referral centre

Introduction

Complex orbital fractures require multi-specialty input. The United Kingdom currently has no agreed best practice guidelines. A systematic review and meta-analysis found a significantly increased adverse outcome of persistent diplopia in patients operated on more than 14 days after initial injury. At our tertiary centre, we felt patient outcomes may be affected by investigative and referral pathway limitations so evaluated to assess and attempt to improve these.

Methods

This was a two-stage service evaluation study of all orbital trauma patients requiring specialist oculoplastic and orbital input. The initial phase included all orbital trauma patients referred to our department in April–November 2014. We assessed relevant key performance indicators and then implemented changes to our referral system, educated referring departments and formed a multidisciplinary team clinic to manage complex trauma. We then re-evaluated, collecting data on all patients referred March–May 2015.

Results

Most patients were male and victims of assault. Following intervention, there was a significant reduction in the injury to eye clinic review time (3.45 weeks to 2.22 weeks, p = 0.01) and multidisciplinary team review time (3.86 weeks to 2.71 weeks, p = 0.04). Injury to discharge time was significantly reduced from 6.15 weeks to 3.36 weeks (p = 0.002).

Discussion

Our study shows that a multidisciplinary team approach and structured pathways can improve assessment and intervention times for orbital trauma patients. This may have a beneficial effect on patient outcomes. In the absence of guidelines in the United Kingdom, we believe similar improvements could be implemented by other national centres and outcomes evaluated to assist future guidance formation.

A simple method to estimate the linear length of the orbital floor in complex orbital surgery

BACKGROUND

The orbital floor (OrF) and infraorbital rim (IOR) repair in cases of complete destruction is challenging mainly due to the fact that the defect length cannot be measured. The aim of the current study is to develop a method of calculating the Orf length by using the gender and the lengths of the medial, superior and lateral orbital walls (OrW) of the same orbit.

MATERIAL AND METHODS

Ninety-seven (59 male and 38 female) European adult dry skulls were classified according to age: 20-39, 40-59 and 60 years and above. The length of each OrW was measured by using the direct distance between the optic foramen and a landmark in each orbital rim.

RESULTS

A side asymmetry was detected for the lengths of the inferior, superior and medial OrW. Although a gender dimorphism was detected, no correlation with the age was found. Using the Stepwise multiple regression analysis two formulas were developed, one for the right and one for the left OrF with coefficient of determination R² 0.43 and 0.57, respectively.

CONCLUSIONS

The proposed formulas represent a simple, applicable and individualized method to calculate the OrF linear length in cases of complete destruction of the IOR and OrF, with accuracy and without the use of expertise material. Such data may improve the surgery planning of orbital floor fractures and complex orbital reconstructions.

Implantation of Customized, Preshaped Implant for Orbital Fractures with the Aid of Three-dimensional Printing

Orbital floor fractures alone or in conjunction with other facial skeletal fractures are the most commonly encountered midfacial fractures. The technological advances in 3-dimensional (3D) printing allow the physical prototyping of 3D models, so creates an accurate representation of the patient's specific anatomy. A 56-year-old Caucasian man with severe hypoglobus and enophthalmos with an extensive blowout fracture was scheduled for reconstruction. First, 3D physical models were created based on the computed tomography scan datasets from patient. Then, this model was used as templates for preoperative trimming the implant. Surgical reconstruction with the aid of pre-shaped, customized prosthesis based on 3D anatomical model resulted in significant esthetic and clinical improvement. It is possible to build anatomical models on the basis of computed tomography scan datasets. It is relatively inexpensive and can be used in the repair of complex orbital floor fractures.

Computed tomography based analysis of the lamina papyracea variations and morphology of the orbit concerning endoscopic surgical approaches

Introduction

Radiologic evaluation is mandatory to assess the type of endoscopic approach concerning sinonasal pathology and reconstruction of fractured defects before any treatment modalities are instituted related to medial wall of the orbit.

Objective

The goal was to provide improved understanding of the lamina papyracea variations and the relationship with the orbital morphometry.

Methods

This retrospective study was performed using computed tomography scans of 200 orbits and results were compared with respect to age, sex, laterality and LP variations.

Results

Lamina papyracea variations were categorized as type A, 80.5% (161/200); type B, 16% (32/200); type C, 3.5% (7/200). For medial wall the anterior and posterior lamina papyracea heights and angles were found as 17.14 mm, 147.88° and 9.6 mm, 152.72°, respectively. Also, the length of the lamina papyracea, the mean area of the orbital floor, medial wall, lamina papyracea and orbital entrance were 33.3 mm, 7.2 cm², 6.89 cm², 4.51 cm² and 12.46 cm² respectively. The orbital height and width were measured as 35.9 mm and 39.2 mm respectively. The mean orbital cavity depth was 46.3 mm from optic foramen to the orbital entrance and the orbital volume was 19.29 cm³. We analyzed the morphometric measurements tending to increase with aging and greater in men and the relationship of them with lamina papyracea types.

Conclusion

Precise knowledge of the lamina papyracea anatomy using computed tomography is essential for safer and more effective surgery and preforming the dimensions of an implant. In this way, the postoperative complications can be decreased and the best outcome can be provided.

Isolated Medial Orbital Wall Fracture Associated with Enophthalmos in a Paediatric Patient: An Unusual Presentation

Purpose

To report a case of isolated medial orbital wall fracture with enophthalmos in a paediatric patient and describe the clinical presentation and findings by means of computed tomography (CT) of the head and eyes.

Methods

We looked at the patient's medical and ophthalmologic history, and an ophthalmologic examination and a CT of the head were performed at baseline.

Results

A 14-year-old boy was admitted to the emergency department of our institution with ecchymosis of his right eyelids secondary to a sport accident. Physical examination revealed a moderate limitation of upgaze without diplopia. CT showed a medial orbital wall fracture without haemorrhage and a gross accumulation of air in the right eyelid with pressure exertion over the right globe and enophthalmos. The patient was treated conservatively with oral antibiotics and steroids showing dramatic improvement within 1 week. Enophthalmos and periorbital emphysema were completely resolved within 3 months after the accident as indicated by CT.

Conclusions

We conclude that surgical intervention and intravenous treatment are not warranted in similar cases of medial orbital wall fracture. Medical history, clinical and paraclinical evaluations, and a regular follow-up, including CT, are needed though to avoid complications such as painful abduction, horizontal diplopia, pseudo sixth nerve paresis, or pseudo Duane.

The influence of concomitant medial wall fracture on the results of orbital floor reconstruction

INTRODUCTION

Up to 35% of orbital floor fractures extend to the medial wall. This results in restriction of both abduction and adduction, leading to horizontal diplopia. The greater the defect, the more pronounced the enophthalmos.

AIM OF THE STUDY

The aim of the study was to determine the influence of concomitant medial wall defects on enophthalmos and diplopia, and the influence of intraoperative revision on the results of surgical reconstruction in patients with orbital floor fracture.

MATERIAL AND METHODS

78 cases of orbital floor fracture, with or without concomitant medial wall defect, were retrospectively analyzed. Reconstruction surgeries were performed in a similar fashion, but with variation in the alloplastic materials used. Careful investigation of the area was performed during the surgery.

RESULTS

Patients with associated medial wall defects had significantly more pronounced enophthalmos than those with isolated floor fracture, with no such difference after the orbital reconstruction. Postoperative vertical diplopia was more common in patients with an associated medial defect.

CONCLUSIONS

Associated medial wall defect leads to more severe enophthalmos at presentation. However, if the medial aspect of the orbital wall is revised properly, postoperative outcomes are not inferior to those in cases of isolated floor fracture.

Endoscopic endonasal repair with polyethylene implants in medial orbital wall fractures: A prospective study on 25 cases

The aim of the study was to assess the mid-term effectiveness and safety of an original technique consisting of reconstructing fractures of the medial wall of the orbit with porous polyethylene implants with an exclusive transnasal approach. Twenty-five patients were treated. Each patient underwent a pre-operative ophthalmologic evaluation and a CT scan. The surgery started with an anteroposterior ethmoidectomy of the fractured side; all the fractured bone fragments were removed and all usual landmarks of healthy bony margins were identified. A Medpor sheet was placed endoscopically to reconstruct the fractured wall. Each patient received an immediate postoperative CT scan, and was evaluated at day 1, 7, 30 and 6 months after surgery clinically and with an endoscopic examination. In all patients, preoperative enophthalmos and/or diplopia were corrected. The CT scans showed excellent reconstruction of the fractured bony walls. The immediate postoperative period was characterized by a very high degree of subjective comfort. No perioperative complications were detected. At the 6 months follow up, all meshes appeared covered by epithelialized mucosa at the endoscopic inspection, and clinical results were stable. Scars or lid complications are always prevented. The technique described has become the standard to treat medial wall fractures in our department.

Practice patterns in the use of prophylactic antibiotics following nonoperative orbital fractures

Purpose

The purpose of this study was to analyze the practice management patterns of the current members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and to determine the use of oral prophylactic antibiotics in an attempt to prevent orbital cellulitis following nonoperative orbital fractures.

Patients and methods

A cross-sectional web-based survey was emailed to all the members of ASOPRS regarding their current management of nonsurgical orbital fractures and their experience with orbital cellulitis following nonoperative orbital fractures.

Results

The majority of practicing oculoplastic surgeon members of ASOPRS do not routinely prescribe prophylactic antibiotics for patients with nonoperative orbital fractures or patients with orbital fractures whom the physicians are observing and who might potentially need surgical intervention. Among the reported cases of orbital cellulitis following a nonoperative orbital fracture in this survey, more than a quarter of the patients had received prophylactic antibiotics. Furthermore, among physicians who have managed orbital cellulitis following nonoperative fracture, 75% (33 out of 44 physicians) report that <1% of patients develop orbital cellulitis.

Conclusion

Despite frequent recommendation for the use of prophylactic antibiotics after orbital fractures in commonly cited ophthalmic references, the majority of oculoplastic surgeons do not use prophylactic antibiotics for orbital fractures, including both nonoperative orbital fractures and orbital fractures that may potentially need surgery.

Influence of the volume of soft tissue herniation on clinical symptoms of patients with orbital floor fractures

INTRODUCTION

One of the most important complications of orbital floor fractures is diplopia and restricted ocular movement. The role of the volume of soft tissue herniation on these clinical symptoms after orbital floor fractures is unclear and potentially may predict development of persistent clinical symptoms. Therefore the aim of this study was to assess pre- and postoperative complications associated to the volume of soft tissue herniation, with special interest to diplopia and bulbus motility impairment.

MATERIAL AND METHODS

204 untreated patients with orbital floor fractures from 2009 to 2011 were included in this retrospective study. Contingency tables and χ²-test were performed to analyze associations between two qualitative variables. p-Values p < 0.05 were considered as significant. Volume measurement was performed in a semiautomatic segmentation method with the software "ITK-Snap".

RESULTS

The volume of soft tissue herniation correlated significantly with pre- and postoperative diplopia (p = 0.003; p = 0.002), persistent diplopia (p = 0.009) as well as pre- and postoperative bulbus motility impairment (both p < 0.001). Furthermore we found out significant associations between the volume of soft tissue herniation and pre- and postoperative complications depending on fracture type and reconstruction technique.

CONCLUSIONS

Volume measurement of soft tissue herniation may help to predict postoperative complications, particularly bulbus motility restriction and persistent diplopia. The risk for these symptoms rises with increasing volume of soft tissue herniation after orbital floor fractures. Therefore we recommend for these patients within indication an early repair and/or closer observation.

A comparable study of the diagnostic performance of orbital ultrasonography and CBCT in patients with suspected orbital floor fractures

OBJECTIVES:

To compare the diagnostic performance of ultrasonography and CBCT against CT in detecting orbital floor fractures.

METHODS:

A total of 120 orbits with clinical suspicion of isolated orbital floor fractures underwent multislice CT scanning with coronal reconstruction; orbital ultrasonography using a standard machine equipped with a 7- to 10-MHz linear transducer; and CBCT. Patients with severe head and face injuries were not included. The diagnostic performance of ultrasonography and CBCT was reported assuming conventional CT as the imaging method of choice.

RESULTS:

According to CT findings, fractures of the floor were present in 39 orbits. The sensitivity, specificity, positive-predictive value and negative-predictive value of ultrasonography in detecting orbital floor fractures were 87.2%, 100%, 100% and 94.2%, respectively. The corresponding values for CBCT were 97.4%, 97.5%, 95.0%, and 98.8%, respectively. Areas under the receiver operator characteristics curves of orbital floor fracture detection were 0.94 for ultrasonography and 0.98 for CBCT.

CONCLUSIONS:

When conventional CT cannot be performed in patients with clinically suspected orbital floor fracture and no severe or complex head and face injuries, CBCT could be used in detecting fractures as a reliable surrogate. Because of a lower sensitivity of ultrasonography, however, its use is limited in this regard.

Blowout fracture-orbital floor reconstruction using costochondral cartilage causing pain, warping, and diplopia

Orbital floor reconstruction is the most challenging component in the midfacial trauma management. Most often owing to the complexity of the fractures, the floor reconstruction requires grafts or other substitutes. Literature reveals several sources of autogenous sources of such grafts. Though most of the grafts are well taken and gives an ideal result, at certain instances, owing to the complex nature of the graft, its biochemical nature, reaction to the grafting, biochemical response, a reactionary change may result at late stages. The aim of this manuscript is to present a rare instance of warping of a costochondral graft that was used as a part of the orbital floor reconstruction giving rise to an ophthalmic emergency. The situation was immediately diagnosed and successfully managed. The situation, structural, and biochemical mechanisms behind such a phenomenon are discussed.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.