Reconstruction of Orbital Wall Fractures with a Combination of Resorbable Plates and Antibiotic-Impregnated Collagen Sheets

(1) Background: Orbital wall fractures are common in maxillofacial trauma, and artificial implants are often used for reconstruction. However, there has always been concern about infection because implants are directly exposed to the airway. This study was conducted to determine the effectiveness of a combination of resorbable plates and antibiotic-impregnated collagen sheets in reconstructions of orbital fractures and to determine whether it had an effect in reducing postoperative antibiotic use. (2) Methods: The retrospective study was conducted on 195 patients who underwent orbital wall reconstruction from March 2019 to August 2022. The 176 patients in the control group underwent reconstruction using only resorbable plates and were administered postoperative antibiotics for 5 to 7 days. On the other hand, the 19 patients in the experimental group underwent reconstruction using a combination of resorbable plates and antibiotic-impregnated collagen sheets and only received antibiotics once before surgery. The occurrence of ocular complications, the length of hospitalization, the infection incidence rate, and the adverse effects of antibiotics were investigated. (3) Results: significant ocular complications were observed in the experimental group during a follow-up period of more than 1 year. Regarding postoperative infections, there were two cases of infection in the control group (infection rate: 1.14%), while no infection was found in the experimental group. The hospitalization period of the experimental group was significantly shorter than that of the control group (p < 0.01), and the incidence of total adverse effects of antibiotics, especially nausea, was lower in the experimental group (p = 0.02). (4) Conclusions: The combined use of resorbable plates and antibiotic-impregnated collagen sheets allows effective orbital wall reconstruction without infection, with a shorter hospital stay, and with fewer antibiotic adverse effects.

Primary Orbital Reconstruction with Selective Laser Melting (SLM) of Patient-Specific Implants (PSIs): An Overview of 96 Surgically Treated Patients

Contemporary advances in technology have allowed the transfer of knowledge from industrial laser melting systems to surgery; such an approach could increase the degree of accuracy in orbital restoration. The aim of this study was to examine the accuracy of selective laser melted PSIs (patient-specific implants) and navigation in primary orbital reconstruction. Ninety-six patients with orbital fractures were included in this study. Planned vs. achieved orbital volumes (a) and angles (b) were compared to the unaffected side (n = 96). The analysis included the overlay of post-treatment on planned images (iPlan 3.0.5, Brainlab®, Feldkirchen, Germany). The mean difference in orbital volume between the digitally planned orbit and the postoperative orbit was 29.16 cm3 (SD 3.54, presurgical) to 28.33 cm3 (SD 3.64, postsurgical, t = 5.00, df = 95.00; p < 0.001), resulting in a mean volume difference (planned vs. postop) of less than 1 cm3. A 3D analysis of the color mapping showed minor deviations compared to the mirrored unaffected side. The results suggested that primary reconstruction in complex orbital wall fractures can be routinely achieved with a high degree of accuracy by using selective laser melted orbital PSIs.

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.

Reliability of Modified Hertels Exophthalmometer as an Intraoperative Tool for Assessment of Relative Globe Position in Orbital/Zygomatic Fracture

INTRODUCTION

Axial globe position assessment is commonly carried out with Hertels Exophthalmometer. Hertels requires an intact lateral orbital rim for its placement, which is often fractured in zygomatic fractures. Hence, to overcome this problem, we have modified the instrument for its application in zygomatic/orbital fractures. Reliability of this Modified Hertels Exopthalmometer has been already validated in normal healthy patients. Therefore, the aim of this study is to assess the efficacy of the Modified Hertels Exophthalmometer in pateints with zygomatic/orbital fracture.

MATERIALS AND METHODS

This is a prospective study carried out between April 2015 and October 2017, including 20 patients with a mean age of 34 years. Enophthalmos was measured using Modified Hertels in patients with unilateral orbital/zygomatic fracture indicated for surgical intervention by a single observer. The data was collected and statistically analyzed. Paired sample t-test was done to compare the preoperative exophthalmometer reading with readings at different time points.

RESULTS

A statistically significant difference was noted (P = 0.031) among the variables of Modified Hertels. We believe this instrument to be of practical use in the assessment of enophthalmos/exophthalmos in patients with lateral orbital trauma, surgery or disease and also precludes the use of rim-based exophthalmometry and other modifications of same.

Review of Ocular Injuries in Patients with Orbital Wall Fractures: A 5-Year Retrospective Analysis

Purpose

The purpose of this study was to determine the incidence of minor and major ocular injuries in patients with orbital wall fractures at Loma Linda University Health, a level-one trauma center, to help determine the most appropriate setting for the initial dilated fundus examination by ophthalmologists.

Methods

A retrospective study was performed from January 2008 to January 2013 of patients diagnosed with orbital wall fracture secondary to trauma. Exclusion criteria included unknown mechanism of injury, the absence of ophthalmology consultation, or absence of imaging. Data collected included age, gender, mechanism of injury, visual acuity, and anterior/posterior segment findings. Ocular injuries were categorized as either minor or major.

Results

Of 567 charts reviewed, 460 met criteria and were included for analysis. In the analysis, 86.5% of patients were male, and 81.3% were Caucasian. The most common mechanism of orbital fracture was blunt injury. Visual acuity was better than 20/100 in 82.4% of patients. On chart review, 81.1% of patients were found to have either a minor injury, a major injury, or both. The most common injury was subconjunctival hemorrhage (53.5%). Globe rupture (2.9%) and vision-threatening posterior segment findings such as retinal tear and choroidal rupture (1.3%) were relatively rare. Only one retinal detachment (0.2%) was found, specifically in the setting of severe injury with concomitant globe rupture.

Conclusion

Knowledge of the common ocular injuries associated with orbital fractures will help emergency department (ED) physicians and ophthalmologists provide the dilated fundus exam in the most appropriate setting. The most frequent injuries identified were non-vision threatening, and visually significant posterior segment findings were relatively rare (1.3%). Thus, for the majority of patients presenting to the ED with orbital fracture, a dilated fundus exam can be performed at a later date in the outpatient clinic setting, unless urgent orbital fracture surgery is planned.

Introduction of pulsed radiofrequency cautery in infraorbital nerve block method for postoperative pain management of trauma-induced zygomaticomaxillary complex fracture reduction

Although various cases of neuralgia and its treatments have been reported, not enough evidence is present to recommend a single type of treatment as the most effective. The patient we have dealt with experienced significant interferences in his daily life due to chronic allodynia, but the symptom could not be resolved via previously reported treatments. We report a case of which a patient who presented infraorbital neuralgia after trauma was successfully treated by a novel treatment strategy. The patient was treated by applying infraorbital nerve block and pulsed radiofrequency cautery side by side. Through this report, we evaluate proper prevention and treatment strategies for patients who develop infraorbital neuralgia through similar etiologies.

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[Exophthalmometry with computed tomography]

Bone abnormalities of orbit seen in patients with trauma or radiolesion are accompanied by enophthalmos or exophthalmos. Conventional measurements of eyeball protrusion with Hertel's exophthalmometer or with computed tomography do not provide accurate and reliable data, especially in patients with asymmetry of lateral orbital rims.

PURPOSE

To develop a method of computed exophthalmometry that provides accurate and reliable measurements in patients with various orbital conditions.

MATERIAL AND METHODS

Medical records and computerized axial tomography scans of 25 patients' orbits without false enophthalmos or exophthalmos were analyzed posthoc. First group included 13 patients with trauma or radiolesion of the orbit at the different stages of plastic-reconstructive treatment. Second group consisted of 12 patients with lacrimal duct obstruction and without any orbital bone abnormalities. Eyeball protrusion was measured from a line joining styloid processes of temporal bones according to the developed method.

RESULTS

Comparison of the results of three independent measurements showed that in group 1 mean value varied from 0.40 mm to 10.13 mm and in group 2 - from 0.10 mm to 0.87 mm. Standard deviation (0.00-0.29 mm) and standard error in mean (0.00-0.17 mm) was the same in both groups.

CONCLUSION

The newly developed method of exophthalmometry with the use of computed tomography provides accurate and reliable data in patients with various orbital conditions including asymmetry of lateral orbital rims. Eyeball protrusion with asymmetry not exceeding 0.9 mm does not lead to functional and esthetical abnormalities and may be considered normal. The developed method is easy to setup and use, it can be applied in medical practice for diagnostics, surgery planning and evaluation of postoperative results in patients with various orbital conditions.

Complete inferior rectus muscle transection secondary to orbital blowout fracture

Complete extraocular muscle transection is uncommon in the setting of blunt trauma. We report a case of a 53-year-old male that developed diplopia after hitting his face directly on a concrete slab after a fall. On examination, he had a right hypertropia with a complete infraduction deficit. A CT scan of the face showed an orbital floor blowout fracture with complete inferior rectus transection. On surgical exploration, the distal and proximal ends of the muscle were identified and sutured together, and the floor fracture was repaired. At his post-operative visits, the patient had a persistent infraduction deficit, but subjectively had improved diplopia.

Repair of the Orbital Wall Fractures in Rabbit Animal Model Using Nanostructured Hydroxyapatite-Based Implant

Cellular uptake and cytotoxicity of nanostructured hydroxyapatite (nanoHAp) are dependent on its physical parameters. Therefore, an understanding of both surface chemistry and morphology of nanoHAp is needed in order to be able to anticipate its in vivo behavior. The aim of this paper is to characterize an engineered nanoHAp in terms of physico-chemical properties, biocompatibility, and its capability to reconstitute the orbital wall fractures in rabbits. NanoHAp was synthesized using a high pressure hydrothermal method and characterized by physico-chemical, structural, morphological, and optical techniques. X-ray diffraction revealed HAp crystallites of 21 nm, while Scanning Electron Microscopy (SEM) images showed spherical shapes of HAp powder. Mean particle size of HAp measured by DLS technique was 146.3 nm. Biocompatibility was estimated by the effect of HAp powder on the adhesion and proliferation of mesenchymal stem cells (MSC) in culture. The results showed that cell proliferation on powder-coated slides was between 73.4% and 98.3% of control cells (cells grown in normal culture conditions). Computed tomography analysis of the preformed nanoHAp implanted in orbital wall fractures, performed at one and two months postoperative, demonstrated the integration of the implants in the bones. In conclusion, our engineered nanoHAp is stable, biocompatible, and may be safely considered for reconstruction of orbital wall fractures.

CT-Based Morphological Analysis of Isolated Inferior and Medial Blow-out Orbital Fractures in Korean Adults

PURPOSE

To evaluate morphologic differences in isolated inferior medial orbital wall fractures (OWF) based on computed tomography scans.

METHODS

This was a retrospective observational case study of 22 patients with an isolated inferior OWF and 32 patients with an isolated medial fracture between January 2008 and August 2010. We analyzed patient demographics and bony radiologic characteristics on CT scans, including the length and height of the lamina papyracea, the number of ethmoid air cell septa, the length of the anterior and posterior border of the orbital floor, the thickness of the orbital floor maxillary bone, and the axial length of the eyeball.

RESULTS

There were no significant differences in sex, laterality, or concomitant intraocular injury between the two groups. The anteroposterior length (p = 0.391), the number of ethmoid septa (p = 0.869), and the thickness of the orbital floor (p = 0.419) did not differ significantly. The anterior (p < 0.001) or posterior (p = 0.014) height of the lamina papyracea, the lamina papyracea area (p < 0.001), and the lamina papyracea area/ethmoid air cell septa (p = 0.024) were significantly higher in the medial OWF group, while the anterior (p = 0.026) or posterior (p < 0.001) border length of the orbital floor and the axial length (p = 0.047) and volume (p = 0.034) of the eyeball were longer and smaller, respectively, in the inferior OWF group.

CONCLUSIONS

Patients with a longer anterior or posterior border of the orbital floor, a shorter axial length, and a smaller eyeball volume are more likely to incur an isolated inferior OWF than an isolated medial OWF.

Ocular motility disturbances in orbital wall fracture patients

It is difficult to identify the exact cause of ocular motility disturbances in orbital wall fracture patients. By performing CT and ocular motility tests before and after surgery, this study analyzes the functions of the extraocular muscles and determines correlations between the results. Between February 2001 and January 2003, 45 eyes of 45 patients with orbital wall fractures, whose medical records could be traced back at least 6 months, underwent surgical repair in our hospital. All variables were analyzed using the independent t-test, paired t-test, and Chi-square test. There was no significant difference in the location and degree of fracture and the incarceration pattern of 6 patients who had moderate or severe diplopia, and of the remaining patients 6 months after surgery. However, in the case of diplopia, the sum of ocular motility limitation was 5.67 +/- 4.18, and the degree of extraocular motility disturbance was 3.67 +/- 2.42 before surgery. When there was no diplopia, the sum of ocular motility limitation was 1.13 +/- 1.38, and the degree of extraocular motility disturbance was 1.08 +/- 1.16 (p < 0.005, independent t-test). Ocular movement was successfully recovered by surgical reduction within 3 weeks from trauma. Postoperative ocular motility disturbance was more related to various ocular motility test results than CT findings. Ocular motility disturbances can remain after surgery if ocular motility limitation and extraocular motility disturbance are significant after trauma. Additional studies on the various tests to examine functions of extraocular muscles are required to identify and analyze the exact cause of ocular motility disturbance.