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

Management of Persistent Diplopia and Epiphora in Mismanaged Orbital Blowout Fracture - A Case Report

ABSTRACT

A 31-year-old male with a history of right zygomaticomaxillary complex (ZMC) fracture presented with aesthetic concerns, continuous tearing, and double vision. The patient had undergone multiple surgeries post accident, resulting in an asymmetrical cheek bulge, persistent diplopia, and epiphora. Investigations revealed abnormal placement of an orbital mesh and damage to the lacrimal sac. A surgical plan was devised to remove the plates, reposition the muscles, secure the floor, correct the epiphora, and provide the desired aesthetics. The surgery involved removal of the mesh and a long plate, refracturing of the zygoma, approximation and securing of the fractured zygoma with plates, and creation of an osteum on the lateral wall of the nose. Post-operatively, the patient's healing was uneventful and he was satisfied with the outcome. This case underscores the importance of a proper surgical technique and patient-centered care in managing complex facial fractures.

'Frozen eye' - Post blowout fracture surgical correction - A case report

The Rationale

"Frozen Eye" is a very uncommon sequel after treatment of orbital blowout fractures requiring implant placement.

Patient Concerns

The implant may faultily impinge on the ocular and extra-ocular muscle(s), causing the abnormality in the movement of the eye.

Diagnosis

We present a 56-year-old male whose ocular implant impinged on muscle, causing "frozen eye" and had an infected implant.

Treatment Outcomes

The same was removed and surgically corrected. The manuscript describes the details and discusses the possible mechanism that led to the "Frozen Eye".

White-Eyed Orbital Blowout Fracture With Oculocardiac Reflex Secondary to Extraocular Entrapment in a Pediatric Patient

White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are attributed to the tendency of younger bone to break and reapproximate owing to greater elasticity. This phenomenon, commonly referred to as the greenstick fracture, increases the risk of entrapment of surrounding soft tissue structures in orbital floor fractures. Further concern arises in the presence of an oculocardiac reflex, which requires urgent intervention to prevent serious bradycardia. Prolonged entrapment can go unnoticed and result in irreversible ischemic damage to entrapped tissues. This case discusses the presentation 16-year-old female who sustained a left sided, white-eyed blowout fracture from a face-first ground level fall. On admission, she displayed restrictive strabismus and mild periorbital edema around the left eye. Vertical gaze was restricted when looking inferiorly on the affected side. With sustained upward gaze, her heart rate decreased from 99 to 81 beats per minute. High-resolution non-contrast computed tomography scans of the head showed entrapment of the inferior rectus muscle and periorbital fat. Liberation of entrapped tissues with reduction of bony segments was performed urgently, utilizing a MEDPOR® Titan 3D orbital floor plate and secured with two screws. The patient had an uneventful postoperative period and showed considerable improvements in periorbital edema, duction, and ophthalmalgia on the affected side. In addition, the oculocardiac reflex could no longer be elicited on prolonged upward gaze. Mild and improving paresthesia was noted in the maxillary distribution of the left trigeminal nerve. Sensory deficits like this are the result of fracture communication with the infraorbital canal, which may cause irritation of the infraorbital nerve responsible for sensation by the maxillary division. By postoperative week 7, she had complete resolution of periorbital edema, indiscernible duction abnormalities, and complete healing of surgical incision sites, and an oculocardiac reflex could not be elicited.

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.

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.

Orbital Bony Reconstruction With Presized and Precontoured Porous Polyethylene-Titanium Implants

PURPOSE

Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous polyethylene-titanium implants (Medpor Titan 3D Orbital Floor Implant) are designed to reestablish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. This is the first study to report clinical outcomes with this implant.

METHODS

This retrospective case series reviewed clinical data and outcomes for patients undergoing orbital reconstruction with a presized and precontoured porous polyethylene-titanium orbital implant from January 2016 to June 2018.

RESULTS

A total of 34 orbits of 33 patients were identified (mean age: 43 ± 16 years, 70% men). Most bony defects were a result of trauma and included large orbital floor deformities (100%), medial wall defects (74%), disrupted inferomedial struts (68%), and broken posterior ledges (82%). Symptomatic diplopia (73%) and enophthalmos (89%, mean: 3.7 ± 2.1 mm) were common preoperatively. Many cases were revisions (44%). Mean follow up was 7.8 ± 6.7 months. All patients had improved globe positioning, enophthalmos, and hypoglobus. Seven patients had persistent postoperative diplopia: 6 responded to prism therapy and 1 required strabismus surgery. One patient required retrobulbar hematoma drainage and 1 patient required implant explantation due to chronic infection.

CONCLUSIONS

Commercially available presized and precon toured porous polyethylene-titanium implants are useful for complex orbital bony defects and can achieve functional improve ments in diplopia, enophthalmos, and extraocular motility with a low incidence of postoperative complications or revisional surgery.

Repair of orbital floor fractures via the transantral approach with osteosynthesis plate

INTRODUCTION

The most common surgical access techniques employed in patients with orbital floor fractures are associated with a risk of complications, such as implant infection, migration, epiphora, lower eyelid retraction, ectropion, diplopia worsening, retrobulbar hematoma, emphysema, "white-eyed" syndrome, enophthalmia relapse, hypoglobus, and persistent diplopia due to periorbital atrophy. Consequently, alternative access techniques precluding these complications have to be found.

STUDY OBJECTIVE

To assess the efficacy of transantral approach in the surgical treatment of patients with orbital floor fractures based on results of retrospective analysis of our clinical experience.

MATERIALS AND METHODS

We performed a retrospective study of medical records and X-ray data of 52 patients with fractures of the floor of the orbit, 18 to 68 years old, treated using transantral approach as described in the article. Titanium plates of special shape were used for orbital floor reconstruction.

RESULTS

In 94.2% of the cases, adequate restoration of the floor of the orbit was achieved. It led to regression of the ocular signs. In 4 patients, diplopia remained in extreme gaze positions, which did not require surgical correction. The failed cases were related to incorrect positioning of the plate or fixing screws. No inflammatory complications were observed.

CONCLUSION

Transantral access approach may be a technique of choice in treating patients with orbital floor fractures; it is safe, minimally traumatic, and effective in the early posttraumatic period when the injured area is located in the posterior parts of the floor of the orbit.