Delayed Orbital Hemorrhage around Alloplastic Implants after Blowout Fracture Reduction

Intraocular Migration of Porous Polyethylene Malar Implant Used for Treacher Collins Eyelid Reconstruction

Lower eyelid colobomas associated with Treacher Collins syndrome can be challenging to repair because of associated orbital and midfacial dysostosis. Alloplastic implants such as porous polyethylene have been advocated as readily available malar implants to help improve eyelid retraction. The authors report the first case of porous polyethylene implant insidious migration into the orbit with subsequent scleral penetration. A 14-year-old male with Treacher Collins syndrome, presented with a 3-week history of left eye pain, redness, and eyelid swelling unresponsive to topical treatment. He previously had bilateral lower lid coloboma repair with alloplastic implant placement and full-thickness skin grafts. On exam, he had left eye injection and chemosis, with left hypotropia and complete restrictive ophthalmoplegia. Imaging revealed displacement of implant into the orbit with adherence and impingement on the eye globe.

Chocolate Cysts Associated With Porous Polyethylene Orbital Implants

Late-onset orbital hemorrhage is a rare complication of alloplastic implant use in orbital wall reconstruction following trauma. The authors report 3 patients with chocolate cysts presenting 3 to 9 years after orbital fracture repair with porous polyethylene implants. All patients were managed by implant removal and evacuation of cyst contents. Complete excision of the cyst was performed in 1 patient, while partial excision of the capsule was performed in 2 patients. Improvement of symptoms associated with the mass effects of the cyst was noted after surgical intervention. The authors also report the first case of orbital volume expansion from a chocolate cyst associated with a nonbarriered porous polyethylene implant. Delayed hemorrhage with capsule formation, although extremely rare, is a possible complication following orbital fracture repair with porous polyethylene implants.

Warfarin-associated delayed orbital hemorrhage after orbital fracture repair with smooth nylon foil implant

The authors describe the first report in the literature of delayed orbital hemorrhage that may be partly caused by supratherapeutic anticoagulation. A 52-year-old man with supratherapeutic international normalized ratio (INR) presented with acute proptosis, orbital pain and diplopia 9 months after the floor and medial orbital wall fracture repair using nylon foil implant. He was found to have hemorrhaged into the capsule surrounding the orbital implant. Three weeks later, the patient underwent implant removal after warfarin was discontinued for 5 days and INR was normalized. His symptoms resolved postoperatively. This case describes a unique risk factor of delayed orbital hemorrhage in patients with previous orbital fracture repair, and highlights that coagulopathy should be investigated in patients presenting with acute proptosis with a history of orbital fracture repair. The authors also provide a comprehensive and up-to-date literature review on previously reported cases with delayed hemorrhagic complications from alloplastic orbital implants.

Permanent Versus Bioresorbable Implants in Orbital Floor Blowout Fractures

PURPOSE

To compare the outcomes of bioresorbable and permanent implants in the reconstruction of isolated orbital floor blowout fractures.

METHODS

Retrospective series of all patients who had orbital floor fracture repair in a single tertiary trauma center from January 2005 to December 2014. The authors reviewed the case notes and CT scans of patients with orbital floor fracture repair with either bioresorbable or permanent implants. Main outcome measures were enophthalmos, diplopia, and ocular motility restriction 1.5 years after fracture repair. Implant-related complications were collected for analysis.

RESULTS

There were a total of 88 patients in our study. Bioresorbable implants were used in 48 patients (54.5%) while 40 patients had permanent implants (45.5%). The authors analyzed the implants used in various sizes of orbital fractures: small (<13.3 mm), medium (13.3-20 mm), and large (>20 mm). One and a half years after fracture repair, both groups had comparable clinical outcomes (n = 2 and n = 0 for diplopia for permanent and bioresorbable implant groups, respectively, n = 0 for enophthalmos for both groups and n = 1 for ocular motility limitation for both groups) overall and across all fracture sizes.

CONCLUSION

Bioresorbable implants degrade after fracture healing through hydrolysis and promote the gradual transfer of functional forces to healing bone during its disintegration. The clinical outcomes of diplopia, enophthalmos, and ocular motility restriction associated with the use of resorbable implants are comparable to that of permanent implants for all fracture sizes. Their study shows that bioresorbable and permanent implants are equally safe and effective for the treatment of patients with isolated orbital floor blowout fractures.