Accuracy of surgical navigation for patient-specific reconstructions of orbital fractures: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to review the recent literature on the technical accuracy of surgical navigation for patient-specific reconstruction of orbital fractures using a patient-specific implant, and to compare surgical navigation with conventional techniques.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed (Medline), Embase, Web of Science, and Cochrane (Core Collection) databases on May 16, 2023. Literature comparing surgical navigation with a conventional method using postoperative three-dimensional computed tomography imaging was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy (angular accuracy, linear accuracy, volumetric accuracy, and degree of enophthalmos), preoperative and perioperative times, need for revision, complications, and total cost of the intervention. MINORS criteria were used to evaluate the quality of the articles.

RESULTS

After screening 3733 articles, 696 patients from 27 studies were included. A meta-analysis was conducted to evaluate volumetric accuracy and revision rates. Meta-analysis proved a significant better volumetric accuracy (0.93 cm3 ± 0.47 cm3) when surgical navigation was used compared with conventional surgery (2.17 cm3 ± 1.35 cm3). No meta-analysis of linear accuracy, angular accuracy, or enophthalmos was possible due to methodological heterogeneity. Surgical navigation had a revision rate of 4.9%, which was significantly lower than that of the conventional surgery (17%). Costs were increased when surgical navigation was used.

CONCLUSION

Studies with higher MINORS scores demonstrated enhanced volumetric precision compared with traditional approaches. Surgical navigation has proven effective in reducing revision rates compared to conventional approaches, despite increased costs.

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.

[Orbital trauma]

Orbital trauma can occur independently or in conjunction with other craniofacial trauma and can cause damage to bony and neurovascular structures as well as soft tissues. Appropriate interdisciplinary treatment of patients is essential to prevent long-term damage such as blindness or muscle dysfunction. Even complex fractures and soft tissue damage can be visualized using modern thin-layer computed tomography (CT), which is necessary for proper treatment.

Intraoperative computed tomography for orbital reconstruction: a systematic review

Orbital reconstruction is a common procedure with inherent challenges and important consequences. Intraoperative use of computed tomography (CT) is an emerging application that facilitates accurate intraoperative evaluation to improve clinical outcomes. This review aims to investigate the intraoperative and postoperative outcomes of intraoperative CT use in orbital reconstruction. PubMed and Scopus databases were systematically searched. Inclusion criteria were: clinical studies investigating intraoperative CT use in orbital reconstruction. Exclusion criteria were: duplicates; non-English publications; non-full-text publications; studies with insufficient data. Of the 1022 articles identified, seven eligible articles representing 256 cases were included. The mean age was 39 years. Most cases were male (69.9%). With regards to intraoperative outcomes, the mean revision rate was 34.1%, with plate repositioning being the most common type (51.1%). Intraoperative time was variably reported. With regards to postoperative outcomes, there were no revisions, and only one case that had a complication (transient exophthalmos). Mean volumetric difference between the repaired and contralateral orbits was reported in two studies. The findings of this review present an updated evidence-based summary of the intraoperative and postoperative outcomes of intraoperative CT use in orbital reconstruction. Robust longitudinal comparisons of clinical outcomes between intraoperative and non-intraoperative CT cases are required.

Management of Complications and Secondary Deformity After Fractures of the Midface, Orbit, and Upper Third of the Maxillofacial Skeleton

Craniomaxillofacial trauma is a challenging entity to manage effectively and often necessitates serial evaluation and treatment. A multidisciplinary team is best served to evaluate and treat these complex injury patterns with the use of necessary adjuncts, such as neuronavigation, intraoperative imaging, custom implant use, and virtual surgical planning. Complications of facial trauma can present at a spectrum of time points and manifest in a variety of manners and as such patients should be observed closely and longitudinally. Although not all complications and secondary deformities can be avoided, this article highlights some common pitfalls and our unique management strategies.

Complete transection of the inferior rectus following blunt trauma: a case report

This report describes a rare case of complete transection of the inferior rectus resulting from blunt trauma to the orbit. Only eight other cases were identified in the literature. Computed tomography scans should be examined carefully for potential extraocular muscle injury.

Risk factors for inpatient hospital admission following isolated orbital floor fractures

Orbital floor fractures are common injuries seen in the emergency department (ED). In this study, the National Trauma Data Bank (NTDB, 2016-2017) was used to identify patients presenting with isolated orbital floor trauma. Patient-specific factors were analyzed to determine associations with management. The sample comprised 912 patients; 285 (31.3%) of these patients were discharged from the ED, 541 (59.3%) were admitted to the hospital but did not undergo an operation, and 86 (9.4%) underwent operative treatment. Pediatric patients and older patients (<18 years and>55 years) were more likely to be admitted than those aged 18-55 years, and pediatric patients were more likely to undergo an urgent operative intervention than those in the other age groups (all P < 0.001). Patients with alcohol use disorder (P = 0.002) and hypertension (P = 0.004) had increased odds of admission. Private and Medicare insurance patients were more likely to be admitted, and self-pay patients less likely (P < 0.001). Older age and Medicaid payor status showed increased odds of a greater hospital length of stay. Biological sex, race/ethnicity, functionally dependent health status, myocardial infarction, steroid use, and substance use disorder were not associated with discharge disposition. There are non-injury related, patient-specific factors that may influence the management of orbital floor fractures.

Assessment of quality of life in patients treated for orbital fractures

PURPOSE

This study aimed to assess the quality of life (QOL), before and after surgery, of patients who underwent open reduction and internal fixation for orbital fractures.

STUDY DESIGN

A prospective study.

PARTICIPANTS AND SETTING

The self-report outcome measures of 50 patients treated at the Department of Oral and Maxillofacial Surgery of the Second Affiliated Hospital of Jiamusi University from January 2016 to June 2019 were prospectively collected.

MAIN MEASURES

The quality of life was assessed using four patient-reported outcome measures (PROMs): the 15D questionnaire, Oral Health Impact Profile-14 (OHIP-14), Hospital Anxiety and Depression Scale (HADS), and 36-item Short Form Survey (SF-36). Both descriptive and comparative data analyses were calculated.

RESULTS

Zygomaticomaxillary complex fractures were the most encountered (40.3%). The total OHIP-14 scores before and after treatment were 1.72 and 1.68, respectively. Vision, breathing, sleeping, eating, usual activities, discomfort and symptoms, and vitality showed minimal changes in the 15D questionnaire. The HADS scores were ranged from 0 to 7, indicating no anxiety or depression. The comparison of SF-36 scores after 3 months and after ≥6 months of treatment revealed no significant difference.

CONCLUSIONS

Patients' QOL was minimally impacted by orbital fractures and their treatments. The severity of the negative impact can be minimized if appropriate management strategies are taken.

Automatic orbital segmentation using deep learning-based 2D U-net and accuracy evaluation: A retrospective study

The purpose of this study was to verify whether the accuracy of automatic segmentation (AS) of computed tomography (CT) images of fractured orbits using deep learning (DL) is sufficient for clinical application. In the surgery of orbital fractures, many methods have been reported to create a 3D anatomical model for use as a reference. However, because the orbit bone is thin and complex, creating a segmentation model for 3D printing is complicated and time-consuming. Here, the training of DL was performed using U-Net as the DL model, and the AS output was validated with Dice coefficients and average symmetry surface distance (ASSD). In addition, the AS output was 3D printed and evaluated for accuracy by four surgeons, each with over 15 years of clinical experience. One hundred twenty-five CT images were prepared, and manual orbital segmentation was performed in all cases. Ten orbital fracture cases were randomly selected as validation data, and the remaining 115 were set as training data. AS was successful in all cases, with good accuracy: Dice, 0.860 ± 0.033 (mean ± SD); ASSD, 0.713 ± 0.212 mm. In evaluating AS accuracy, the expert surgeons generally considered that it could be used for surgical support without further modification. The orbital AS algorithm developed using DL in this study is extremely accurate and can create 3D models rapidly at low cost, potentially enabling safer and more accurate surgeries.

Exercise rehabilitation for recurrent extraocular muscle movement limitation after pediatric blowout fracture surgery: a case report

White-eyed blowout fractures with extraocular muscle (EOM) entrapment necessitate emergency surgical intervention. However, even after surgery, diplopia or EOM motion limitations may persist due to the incomplete reduction of soft tissue herniation caused by inadequate dissection or unresolved muscle strangulation. In this report, we present a case of postoperative EOM movement limitation in a 5-year-old girl who experienced recurrent restriction in the upward gaze of her right eye 14 days after surgery. Instead of revision surgery, the patient was treated with targeted EOM exercises focusing on the inferior rectus muscle and inferior oblique muscle. The patient was instructed to slowly move her pupils from the central point to the upper and outer sides, then in a straight line from the central point to the lower and inner sides before returning to the center point. On the 28th postoperative day, 2 weeks after initiating the exercises, the patient's EOM motion fully recovered. This case highlights the effectiveness of EOM exercises as a non-surgical treatment approach for improving recurrent EOM movement limitations in the absence of soft tissue herniation following surgical management of blowout fractures in children.

Orbital wall restoration with primary bone fragments in complex orbital fractures

BACKGROUND

Complex orbital fractures are impure orbital fractures because they involve the orbital walls and mid-facial bones. The author reported an orbital wall restoration technique in which the primary orbital wall fragments were restored to their prior position in complex orbital fractures in 2020. As a follow-up to a previous preliminary study, this study retrospectively reviewed the surgical results of complex orbital wall fractures over a 4-year period and compared the surgical outcomes by dividing them into groups with and without balloon restoration.

METHODS

Data of 939 patients with facial bone fractures between August 2018 and August 2022 were reviewed. Of these, 154 had complex orbital fractures. Among them, 44 and 110 underwent reduction with and without the balloon technique respectively. Pre- and postoperative Naugle exophthalmometer (Good-Lite Co.) scales were evaluated. The orbital volume and orbital volume ratio were calculated from preoperative and 6 months postoperative computed tomography images.

RESULTS

Among 154 patients with complex orbital fractures, 44 patients underwent restoration with the balloon technique, and 110 patients underwent restoration without it. The Naugle scale did not differ significantly between the two groups, but the orbital volume ratio significantly decreased by 3.32% and 2.39% in groups with and without the balloon technique and the difference in OVR was significantly greater in patients in the balloon restoration group compared with the control group. Postoperative balloon rupture occurred in six out of 44 cases (13.64%). None of the six patients with balloon rupture showed significant enophthalmos at 6 months of follow-up.

CONCLUSION

The balloon rupture rate was 13.64% (6/44 cases) with marginal screw fixation, blunt screws, and extra protection with a resorbable foam dressing. Furthermore, we restored the orbital wall with primary orbital fragments using balloon support in complex orbital wall fractures.

Management of orbital floor fractures in France: Results of a national online survey

INTRODUCTION

Orbital floor fractures (OFF) are common facial trauma injuries, and there are no official guidelines for their medical and surgical management. The aim of this study was to provide an overview of the management of OFF in France.

MATERIALS AND METHODS

An online questionnaire was sent to 144 surgeons at the 88 French centers involved in the management of OFF (2019 data from the National Health Insurance Body). The questions related to the preoperative clinical and radiographic examinations, the criteria for surgical indication, the materials used, and the elements of the postoperative period.

RESULTS

Ultimately, 42 questionnaires were analyzed (32 from oral and maxillofacial surgeons (OMFS), 8 from ophthalmologists, and 2 from ENT or plastic surgeons). For 69% of the surgeons, a systematic ophthalmological examination was carried out, 3-7 days after the trauma, and based on a Lancaster test or visual acuity (97.6% and 83.3% of the responders, respectively). The most important criteria for the therapeutic decision were diplopia or oculomotor disorder that persisted for more than 7 days (76.2%), clinical enophthalmos (54.8%), a large fracture (52.4%), and ptosis of the orbital content on CT scan (38.1%). The mean surgical delay was 7-15 days for 54.8% of the responders. Resorbing sheets were the preferred materials to repair small fractures, while larger fractures required alloplastic implants (titanium mesh).

CONCLUSION

This survey confirms the diversity of practices in France regarding the management of OFF. Further studies are needed before guidelines can be developed.

[Midface traumatology: one focus-more than two specialist disciplines?]

Midface fractures are a common occurrence and may be associated with other injuries. It is important to perform diagnosis and treatment planning on an interdisciplinary basis. CT is the gold standard diagnostic modality. Classification according to the pattern of fracture is via the LeFort and other systems. Treatment objectives are anatomic repositioning to preserve the function of the eyes, the infraorbital nerve, and facial symmetry, as well as to preserve masticatory function. The number of surgical access routes should be minimized and incisions of the facial skin avoided wherever possible.

Treatment of a naso-orbito-ethmoid fracture using open reduction and suspension sutures: a case report

Naso-orbito-ethmoidal (NOE) fractures are complicated fractures of the mid-face. The treatment of NOE fractures is challenging and a comprehensive treatment strategy is required. We introduce a case of NOE fracture treated with open reduction and suspension sutures. A 28-year-old woman presented with a unilateral NOE fracture. To reduce the frontal process of the maxilla, a suspension suture was made by pulling the fragment using a double arm suture via a transcaruncular incision. The suture thread was placed in the horizontal plane. Another suspension suture on the inferior orbital rim assisted reduction procedure, and they passed through the overlying skin. The reduction alignment could be finely adjusted by tightening the transcutaneous suture threads while checking the degree of bone alignment through the subciliary incision. The two suture threads were suspended using a thermoplastic nasal splint. An additional skin incision on the medial canthal area, which would have resulted in a scar, could be avoided. Four months postoperatively, computed tomography showed an accurate and stable reduction. The patient was satisfied with her aesthetic appearance, and functional deficits were not present.

Orbital bone fractures: 10 years' experience at the Rome trauma centre: retrospective analysis of 543 patients

Orbital fractures are among the most frequent facial traumas. This study retrospectively analysed patients treated in Umberto I Hospital Trauma-Centre, Sapienza University of Rome from 1 January 2010 to 31 December 2020. The inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological records, and a minimum 12-month follow up. Gender, age, aetiology, fracture type, treatment, and associated complications were analysed using IBM SPSS Statistics, and p values of <0.05 were considered significant. In total, 1393 patients presented with orbital trauma, 543 of whom met the inclusion criteria and underwent surgery (394 males (72.6%) and 149 females (27.4%); mean (range) age 39.2 (7-90) years). Assault (n = 165, 30.4%) was the most common cause of trauma, followed by road traffic accidents and sports-related incidents. Diplopia was the major symptom at diagnosis (n = 183, 33.6%). Open reduction and internal fixation via a sub-eyelid approach was the preferred treatment, achieving a significant reduction in the functional changes induced by fracture (p < 0.05). Our data will aid future studies of maxillofacial traumatology and suggest that education and prevention measures could reduce the incidence of this type of trauma.

Technical considerations of computer-aided planning in severe orbital trauma: A retrospective study

The aim of this study was to evaluate the clinical outcomes of linear and orbital volume measurements in severe orbital trauma. Patients with severe orbital trauma that involved more than two walls and entailed a marked degree of comminution were included in this retrospective analysis. However, patients with incomplete clinical records and a simple blowout or zygmatico-orbital fractures were excluded. All the cases underwent surgical correction guided by virtual surgical planning and 3D-printed templates. The measurement protocol depended on assessing orbital dimensions, orbital volumetry, and the zygomatic bone's position in the three-dimensional planes. All patients' preoperative 3D CT scans were obtained, and DICOM files were imported into a three-dimensional image processing software. Data were then converted for 3D reconstruction in the axial, coronal, and sagittal views. A total of 18 patients with a mean age was 39.28 ± 6.28 were included in this study. The results revealed a significant difference between the pre and postoperative differences in distances in relation to the FHP (Frankfurt Horizontal Plane) (P = 0.0014) and sagittal planes (P < 0.0001). The orbital width and height of the traumatized orbit were significantly decreased from 45.26 ± 6.72 mm and 45.30 ± 2.89 mm to 39.74 ± 3.91 mm (P = 0.0022), and 40.34 ± 0.86 mm (P < 0.0001), respectively. Clinically, there was a satisfactory degree of symmetry regarding the zygomatic bones' position and orbital dimensions postoperatively. Moreover, the mean orbital volume on the traumatized side decreased significantly from 23.16 ± 1.91 cm³ preoperatively to 20.7 ± 1.96 cm³ postoperatively (P < 0.0001). These findings were associated with a low incidence of complications. Within the limitations of the study it seems that the described methodology is a relevant addition to clinical treatment options. It incorporates all the latest technology to plan virtual reconstruction surgery in the treatment of complex orbital trauma and should be adapted accordingly in cases of severe displacement and comminution.

Sensory change and recovery of infraorbital area after zygomaticomaxillary and orbital floor fractures

BACKGROUND

To compare the sensory change and recovery of infraorbital area associated with zygomaticomaxillary and orbital floor fractures and their recoveries and investigate the factors that affect them.

METHODS

We retrospectively reviewed 652 patients diagnosed with zygomaticomaxillary (n= 430) or orbital floor (n= 222) fractures in a single center between January 2016 and January 2021. Patient data, including age, sex, medical history, injury mechanism, Knight and North classification (in zygomaticomaxillary fracture cases), injury indication for surgery (in orbital floor cases), combined injury, sensory change, and recovery period, were reviewed. The chi-square test was used for statistical analysis.

RESULTS

Orbital floor fractures occurred more frequently in younger patients than zygomaticomaxillary fractures (p< 0.001). High-energy injuries were more likely to be associated with zygomaticomaxillary fractures (p< 0.001), whereas low-energy injuries were more likely to be associated with orbital floor fractures (p< 0.001). The sensory changes associated with orbital floor and zygomaticomaxillary fractures were not significantly different (p= 0.773). Sensory recovery was more rapid and better after orbital floor than after zygomaticomaxillary fractures; however, the difference was not significantly different. Additionally, the low-energy group showed a higher incidence of sensory changes than the high-energy group, but the difference was not statistically significant (p= 0.512). Permanent sensory changes were more frequent in the high-energy group, the difference was statistically significant (p= 0.043).

CONCLUSION

The study found no significant difference in the incidence of sensory changes associated with orbital floor and zygomaticomaxillary fractures. In case of orbital floor fractures and high-energy injuries, the risk of permanent sensory impairment should be considered.

Primary reconstruction of combined orbital and zygomatic complex fractures with patient-specific milled titanium implants - A retrospective study

The aim of this retrospective study was to compare mid-facial symmetry and clinical outcomes between patients treated with patient-specific and standard implants in primary fracture reconstructions of combined orbital and zygomaticomaxillary complex fractures. Patients who underwent primary reconstruction of orbital and zygomaticomaxillary complex fractures during the study period were identified and background and clinical variables and computed tomography images were collected from patient records. Zygomaticomaxillary complex dislocation and orbital volume were measured from pre- and postoperative images and compared between groups. Out of 165 primary orbital reconstructions, eight patients treated with patient-specific and 12 patients treated with standard implants were identified with mean follow-up time of was 110 days and 121 days, respectively. Postoperative orbital volume difference was similar between groups (0.2 ml for patient-specific vs 0.3 ml for standard implants, p = 0.942) despite larger preoperative difference in patient-specific implant group (2.1 ml vs 1,5 ml, p = 0.428), although no statistical differences were obtained in symmetricity or accuracy between the reconstruction groups. Within the limitations of the study it seems that patient-specific implants are a viable option for primary reconstructions of combined zygomaticomaxillary complex and orbital fractures, because with patient-specific implants at least as symmetrical results as with standard implants can be obtained in a single surgery.

Quantitative analysis of soft tissue sagging after lateral midface fractures: A 10-year retrospective study

BACKGROUND

Lateral midface fractures occasionally require open reduction and internal fixation to restore function and facial symmetry. However, some patients retain facial asymmetry despite undergoing surgery due to hard tissue displacement or soft tissue sagging. This study aimed to determine the influence of soft tissue sagging on the postoperative facial symmetry.

METHODS

We examined the medical records of 590 patients who underwent planned plate removal after lateral midface or zygomatic bone fractures. After applying the inclusion and exclusion criteria, we analyzed 106 cases of lateral midface fractures for hard tissue displacement and soft tissue sagging using pre- and postoperative radiological imaging and postoperative face scanning.

RESULTS

We observed significantly larger soft tissue sagging (p &lt; 0.001) and hard tissue displacement (p = 0.006) on the fractured side than on the non-fractured side. There was no correlation between differences in the soft tissue sagging and those in the hard tissue displacement (|rho|=0). Linear regression analysis showed no statistical influence of sex or age group on the soft tissue sagging and hard tissue displacement.

CONCLUSION

Therefore, we recommend treating soft tissue sagging as a discrete aspect of midfacial fracture treatment to achieve optimal postoperative facial symmetry. From a clinical perspective, we recommend better soft tissue management during open fracture treatment than focusing mainly on the reduction of bony hard tissues.

[Current developments in primary and secondary surgical treatment of midface and periorbital trauma]

Fractures of the periorbita and the midface are among the most common bony facial injuries. Aesthetic and functional reconstruction is a challenge in clinical routine. This article illustrates recent developments in the primary and secondary surgical treatment of midface and periorbital trauma. Resorbable patches and films increase the anatomic reconstructive capacity and enable treatment of extensive orbital fractures. Orbital fractures with involvement of supporting key structures are advantageously reconstructed using patient-specific implants (PSI), which are fabricated by computer-assisted manufacturing techniques and positioned by intraoperative navigation. If late complications such as bulbar malposition and enophthalmos have occurred after the initial procedure, they can be addressed by overcorrective restoration of orbital volume. The use of PSI for initial fracture restoration of the midface is not yet established but may be useful in re-osteotomies of misconsolidated fragments. Extensive midface defects with significant soft tissue involvement can be reconstructed using microvascular grafts. Consecutive reconstructive procedures may include orthognathic surgery and local flap reconstruction. In summary, the integration and advancement of computer-assisted techniques now offers individualized reconstruction procedures, which may be a viable alternative to conventional implants and compression miniplates. Future developments may focus on the search for innovative biomaterials, which can be integrated into computer-aided design and manufacturing processes.

Orbital reconstruction: a systematic review and meta-analysis evaluating the role of patient-specific implants

The purpose of this study is to execute an evidence-based review answering the following question (PICO): "Do patient-specific implants (PSI), manufactured or designed using computer-assisted technology, improve outcomes (orbital volume change, enophthalmos, diplopia, and operative duration) compared to conventional methods in orbital reconstruction following traumatic orbital injury in the adult patient population?" We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. Inclusion criteria included any comparative paper whereby computer-assisted technology was used in the prefabrication or design process of implants for use in post-traumatic orbital reconstruction. Paediatric patient populations were excluded. Eight databases were systematically searched for relevant studies. Risk of bias was assessed through the NOS and RoB2 tools. Random-effects models were used to identify differences in outcomes between groups where possible. Analysis was performed using R 4.0.0. Eleven of 4784 identified studies were included, comprising 628 adult patients, with 302 and 326 patients in the patient-specific and conventional groups, respectively. Weighted mean difference between unaffected and post-operative orbital volume was 0.32 ml (SD 0.75) and 0.95 ml (SD 1.03) for patient-specific and conventional groups, respectively. Significant improvement was identified in post-operative orbital volume reconstitution with the use of PSI, compared to conventional implants, in 3 of the 5 reporting studies. Equally, post-operative enophthalmos trended towards lower severity in the patient-specific group, with 11.2% of patients affected in the patient-specific group and 19.2% in the conventional group, and operative duration was significantly reduced with the use of PSI in 3 of the 6 reporting studies. Despite a tendency to favour PSI, no statistically significant differences in key outcomes were identified on meta-analysis. Although there is some encouraging data to support improved outcomes with the use of patient-specific orbital implants in post-traumatic reconstruction, there is, at present, no statistically significant evidence to objectively support their use over conventional implants based on the currently available comparative studies. Based on the results of this study, the choice of implant used should, thus, be left to the discretion of the surgeon.

Computed tomography in traumatic orbital emergencies: a pictorial essay-imaging findings, tips, and report flowchart

Computed tomography (CT) is considered the gold standard technique for the assessment of trauma patients with suspected involvement of the eye and orbit. These traumas can result in dramatic consequences to visual function, ocular motility, and aesthetics. CT is a quick and widely available imaging modality, which provides a detailed evaluation of the orbital bony and soft tissue structures, an accurate assessment of the globes, and is used to guide the patients’ treatment planning. For a timely and accurate diagnosis, radiologists should be aware of fracture patterns and possible associated complications, ocular detachments and hemorrhages, and different appearances of intraorbital foreign bodies. This educational review aims to describe all post-traumatic orbital abnormalities that can be identified on CT, providing a list of tips and a diagnostic flowchart to help radiologists deal with this complex condition.

Orbital floor fracture repair with implants: a retrospective study

Background

Although prompt surgery after an orbital fracture is preferable, the actual timing of surgery in real-world settings varies. Therefore, this study investigated the outcomes of implant surgery for inferior orbital wall fractures by comparing three groups according to the time interval between the injury and surgery.

Methods

A retrospective review was conducted of patients’ medical charts and initial computed tomography images from 2009 to 2020. The time to treatment was chosen by patients or their guardians based on the patients’ comorbidities and the physician’s explanation. The patients were divided into three groups according to the time of surgery (group 1: 3–7 days, group 2: 8–14 days, group 3: 15 or more days). Data were collected on age, the time interval until surgery, the dimensions of the defect, the operation time, the follow-up period, and the postoperative paresthesia score (ranging from 0 to 10). The outcomes were evaluated using a 4-point scale: 4= good (no complications), 3 = fair (no subjective symptoms), 2 = poor (remaining paresthesia), and 1 = very poor (strabismus and/or enophthalmos).

Results

The study included 85 patients with unilateral fractures who underwent surgery from 3 to 93 days after injury. The overall score distribution of the surgical outcomes was as follows: good= 63, fair= 7, poor= 6, and very poor= 9. The three groups showed no significant differences in the transverse dimension of the injury (p=0.110) or the anteroposterior dimension (p=0.144). In groups 1, 2, and 3, the postoperative outcome scores were 3.84± 0.37, 3.63± 0.87, and 2.93± 1.33 (p=0.083), and the percentage of patients with good outcomes was 84%, 81.25%, and 57.14%, respectively.

Conclusion

Performing surgery using an artificial implant within 2 weeks of the injury showed better outcomes and fewer postoperative complications than when treatment was delayed.

Use of custom fabricated surgical jig to improve surgical outcomes in open reduction internal fixation of unilateral orbital fractures: A prospective clinical study

PURPOSE

The aim of the study was to assess the efficacy of virtual planning and surgical guide jig to improve surgical outcomes of open reduction and internal fixation with restoration and correction of orbital volume (OV) in unilateral orbital wall fractures.

METHODS

Fifteen patients with unilateral orbital fractures were assessed with ophthalmologic and radiographic parameters. The orbit was divided into three zones on computed tomography to localize defects. Fractures were coded into Fx Mx Rx Lx (F = Orbital Floor, M = Medial Wall, L = Lateral wall, R = Orbital Roof) based on pattern and specific wall involved. 1-mm sections were used to make stereolithographic models, design the custom fabricated surgical jig for intraoperative use as a guide.

RESULTS

Pre- and postoperative ophthalmological parameters, OV, were compared with the contralateral normal orbit serving as the reference. Postoperative ophthalmological parameters showed significant improvement in terms of visual acuity, enophthalmos, dystopia, and traumatic optic neuropathy. OV changes were concentrated in Zones 2 and 3. OV showed adequate restoration postoperatively.

CONCLUSION

The surgical jig served as an efficient guide to improve surgical outcomes of open reduction internal fixation. Preplanned intraoperative positioning helped achieve adequate anatomical reduction and fixation with an adequate reconstruction of OV aiding the effective transfer of virtual surgical plan on the table with improved surgical outcomes in clinical performance and functional restitution.Clinical trial registration: The Clinical Trials Registry of India (CTRI) Registration No.: CTRI/2019/11/021929.

The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?

The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant. Out of 260 patients' files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type. There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated. 1Introduction.

Biomechanical assessment of orbital fractures using patient-specific models and clinical matching

INTRODUCTION

Orbital wall fractures consider one of the most common fractures in the maxillofacial trauma. These fractures caused by two mechanisms, the buckling mechanism and hydraulic mechanism. This study aims to compare between the two mechanisms in terms of intensity and extension using the finite elements method.

MATERIAL AND METHODS

Three-dimensional model of the skull was generated using computed tomography data of young male patient. Virtual loads were applied on the eyeball and the infra-orbital rim separately. Von Mises stresses were examined in each simulation.

RESULTS

The simulation predicted fractures on the infra-orbital rim and orbital floor when simulating the hydraulic mechanism, and on the orbital floor and mesial wall when simulating the buckling mechanism.

CONCLUSION

Biomechanical studies are essential part in understanding maxillofacial fractures mechanisms. The results confirmed and ascertained what is seen clinically, and explained clearly the two mechanisms of orbital fractures.

A prospective study of resolution of post-traumatic orbital complications using PRECLUDE® MVP: A randomized controlled trial

Orbital fractures alone represent 10% up to 25% of all facial fractures, but when they are associated with other fractures of the middle-third of the face, their incidence can increase up to 55%. This study aimed to identify whether the size of the orbital defect based on the classification by Jaquiéry et al. influenced the resolution of post-traumatic complications after orbital wall reconstruction using PRECLUDE®MVP alone or in combination with a titanium mesh or autogenous bone graft. Thirty-five orbits were categorized into four groups on the basis of the size of the defect and the operative techniques: group 1 contained 16 Jaquiéry class I orbits treated only with PRECLUDE®MVP; group 2 included eight class II orbits treated with PRECLUDE®MVP along with autogenous bone graft harvested from the calvaria or a titanium mesh; group 3 included five class III orbits and group 4 included six class IV orbits that were treated the same way as those in group 2. Spearman correlation showed that the use PRECLUDE®MVP didn't improve the post traumatic complications for big orbital defects due to the three-dimensional anatomical changes that occurred by neurologic lesions and lipolysis of the orbital contents.

Oculocardiac reflex in an adult with a trapdoor orbital floor fracture: case report, literature review, and differential diagnosis

Orbital floor blowout fractures can result in a variety of signs and symptoms depending on the severity of the bone defect. Large defects often result in enophthalmos and restriction of ocular movement; yet the timing of surgery can be delayed up to two weeks with good functional outcomes. In contrast, an orbital trapdoor defect with entrapment of the inferior rectus muscle usually elicits pain with marked restriction of the upward gaze and activation of the oculocardiac reflex without significant dystopia or enophthalmos. When autonomic cardiac derangement is diagnosed along with an orbital floor fracture, it has been suggested that the fracture should be treated immediately. Otherwise, it will result in continued hemodynamic instability and muscular injury and may require a second surgery. This article reports the management of an unusual presentation of a trapdoor blowout orbital floor fracture surgery with oculocardiac response in an adult, with emphasis on its pathophysiology, management, and differential diagnosis.

Endoscopic slide-in orbital wall reconstruction for isolated medial blowout fractures

Background

This study evaluated the efficacy of the endoscopic medial orbital wall repair by comparing it with the conventional transcaruncular method. This surgical approach differs from the established endoscopic technique in that we push the mesh inside the orbit rather than placing it over the defect.

Methods

We retrospectively reviewed 40 patients with isolated medial orbital blowout fractures who underwent medial orbital wall reconstruction. Twenty-six patients underwent endoscopic repair, and 14 patients underwent external repair. All patients had preoperative computed tomography scans taken to determine the defect size. Pre- and postoperative exophthalmometry, operation time, the existence of diplopia, and pain were evaluated and compared between the two methods. We present a case showing our procedure.

Results

The operation time was significantly shorter in the endoscopic group (44.7 minutes vs. 73.9 minutes, <i>p</i>= 0.035). The preoperative defect size, enophthalmos correction rate, and pain did not significantly differ between the two groups. All patients with preoperative diplopia, eyeball movement limitation, or enophthalmos had their symptoms resolved, except for one patient who had preexisting strabismus.

Conclusion

This study demonstrates that endoscopic medial orbital wall repair is not inferior to the transcaruncular method. The endoscopic approach seems to reduce the operation time, probably because the dissection process is shorter, and no wound repair is needed. Compared to the previous endoscopic method, our method is not complicated, and is more physiological. Larger scale studies should be performed for validation.

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.

Surgical indication analysis according to bony defect size in pediatric orbital wall fractures

Background

Orbital fractures are the most common pediatric facial fractures. Treatment is conservative due to the anatomical differences that make children more resilient to severe displacement or orbital volume change than adults. Although rarely, extensive fractures may result in enophthalmos, causing cosmetic problems. We aimed to establish criteria for extensive fractures that may result in enophthalmos.

Methods

We retrospectively reviewed the charts of patients aged 0–15 years diagnosed with orbital fractures in our hospital from January 2010 to February 2019. Computed tomography images were used to classify the fractures into linear, trapdoor, and open-door types, and to estimate the defect size. Data on enophthalmos severity (Hertel exophthalmometry results) and fracture pattern and size at the time of injury were obtained from patients who did not undergo surgery during the follow-up and were used to identify the surgical indications for pediatric orbital fractures.

Results

A total of 305 pediatric patients with pure orbital fractures were included–257 males (84.3%), 48 females (15.7%); mean age, 12.01± 2.99 years. The defect size (p= 0.002) and fracture type (p= 0.017) were identified as the variables affecting the enophthalmometric difference between the eyes of non-operated patients. In the linear regression analysis, the variable affecting the fracture size was open-door type fracture (p< 0.001). Pearson’s correlation analysis demonstrated a positive correlation between the enophthalmometric difference and the bony defect size (p= 0.003). Using receiver operating characteristic curve analysis, a cutoff value of 1.81 cm² was obtained (sensitivity, 0.543; specificity, 0.724; p= 0.002).

Conclusion

The incidence of enophthalmos in pediatric pure orbital fractures was found to increase with fracture size, with an even higher incidence when open-door type fracture was a cofactor. In clinical settings, pediatric orbital fractures larger than 1.81 cm² may be considered as extensive fractures that can result in enophthalmos and consequent cosmetic problems.

Dynamic three-dimensional finite element analysis of orbital trauma

This study comprises a dynamic finite element (FE) analysis of the mechanisms of orbital trauma, specifically buckling and hydraulic theories. A digital model of the orbital cavity - including the eyeball, fatty tissue, extraocular muscles, and the bone orbit - was created from magnetic resonance imaging and computed tomographic data from a real patient. An impactor hit the FE model following two scenarios: one was a hydraulic mechanism for direct impact to the eyeball and the other a buckling mechanism for direct impact over the infraorbital rim. The first principal stress was calculated to determine the stress distribution over the orbital walls. The FE model presented more than 900,000 elements and time of simulation was 4.8 milliseconds (ms) and 0.6 ms, for the hydraulic and buckling mechanisms, respectively. The stress distribution in the hydraulic mechanism affected mainly the medial wall with a high stress area of 99.08 mm², while the buckling mechanism showed a high stress area of 378.70 mm² in the orbital floor. The presence of soft tissue absorbed the energy, especially in the hydraulic mechanism. In conclusion, the applied method of segmentation allowed the construction of a complete orbital model. Both mechanisms presented results that were similar to classic experiments. However, the soft tissue in the hydraulic mechanism absorbed the impact, demonstrating its role in orbital pathophysiology.

Orbital wall restoration with primary bone fragments in complex orbital fractures: A preliminary study

BACKGROUND

We have reported orbital wall restoration surgery with primary orbital wall fragment in pure blowout fractures using a combination of transorbital and transnasal approach in pure blow out fractures. However, this method was thought to be difficult to use for complex orbital wall fractures, since the sharp screw tip that fixate the maxillary wall increases the risk of balloon ruptures. In this study, we reviewed 23 cases of complex orbital fractures that underwent orbital wall restoration surgery with primary orbital wall fragment and evaluated the result.

METHODS

A retrospective review was conducted of 23 patients with complex orbital fracture who underwent orbital restoration surgery with primary orbital wall fragments between 2012 and 2019. The patients underwent orbital wall restoration surgery with primary orbital wall fragment with temporary balloon support. The surgical results were evaluated by the Naugle scale and a comparison of preoperative and postoperative orbital volume ratio. Complex fracture type, type of screw used for fixation and complications such as balloon rupture were also investigated.

RESULTS

There were 23 patients with complex orbital fracture that used transnasal balloon technique for restoration. 17 cases had a successful outcome with no complications, three patients had postoperative balloon rupture, two patients had soft-tissue infection, and one patient had balloon malposition.

CONCLUSION

The orbital wall restoration technique with temporary balloon support can produce favorable results when done correctly even in complex orbital wall fracture. Seventeen cases had favorable results, six cases had postoperative complications thus additional procedure seems necessary to complement this method.

Biodegradable implants for orbital wall fracture reconstruction

BACKGROUND

Due to the different handling properties of unsintered hydroxyapatite particles/poly-L-lactic acid (uHA/PLLA) and polycaprolactone (PCL), we compared the surgical outcomes and the postoperative implantation accuracy between uHA/PLLA and PCL meshes in orbital fracture repair.<br/>.

METHODS

Patients undergoing orbital wall reconstruction with PCL and uHA/PLLA mesh, between 2017 and 2019, were investigated retrospectively. The anatomical accuracy of the implant in bony defect replacement and the functional outcomes such as diplopia, ocular motility, and enophthalmos were evaluated.<br/>.

RESULTS

No restriction of eye movement was reported in any patient (n=30 for each group), 6 months postoperatively. In the PCL group, no patient showed diplopia or enophthalmos, while the uHA/PLLA group showed two patients with diplopia and one with enophthalmos. Excellent anatomical accuracy of implants was observed in 27 and 22 patients of the PCL and uHA/PLLA groups, respectively. However, this study showed that there were neither any significant differences in the surgical outcomes like diplopia and enophthalmos nor any complications with the two well-known implants.<br/>.

CONCLUSION

PCL implants and uHA/PLLA implants are safe and have similar levels of complications and surgical outcomes in orbital wall reconstruction.

[Advances in the research and application of orbital blowout fracture repair material]

Orbital blowout fractures can easily lead to defects of the orbital wall. In order to restore the continuity of the bone wall and avoid a series of clinical symptoms caused by orbital contents herniation or incarceration, the site of the defect should be reconstructed. The effect of reconstruction depends on the choice of surgical plan and repair material. The typical materials for bone wall defect repair include bone sheet, high density porous polyethylene, titanium mesh, absorbable polymer, bioactive ceramics and tissue engineering bone. This paper reviews the research findings and application of material for repairing of orbital blowout fracture. (Chin J Ophthalmol, 2019, 55: 876-880).

[Application of three-dimensional printing combined with surgical navigation and endoscopy in orbital fracture reconstruction]

Objective: To evaluate the clinical effect of three-dimensional printing combined with surgical navigation and endoscopy for orbital fracture reconstruction. Methods: A case series study. Twenty-eight patients (28 eyes) with orbital fractures (20 males and 8 females, aged 10-61 years, with simple orbital fractures in 22 patients and composite orbital fractures in 6 patients) were treated with three-dimensional printing combined with surgical navigation and endoscopy for orbital fracture reconstruction at Affiliated Eye Hospital of Nanchang University from July 2016 to June 2018. With the help of three-dimensional printed models and guides, navigation positioning guidance and endoscopic visualization performance, the soft tissue incarcerated in the orbital fracture area was loosened, and the repair material was implanted (video attached). Postoperative follow-up was conducted at 1 week and 3 months. The follow-up observation included the best corrected visual acuity, diplopia, dyskinesia of the eyes, enophthalmos, and orbital volume. The data were analyzed by the paired t-test, Wilcoxon and the Mann-Whitney U rank sum test. Results: The best corrected visual acuity before and 1 week after surgery was 4.714±0.400 and 4.732±0.377, respectively, and the difference was not statistically significant (t=1.724, P=0.096). The enophthalmos before and 1 week after surgery was 2.2 (2.0-5.0) mm and 0.3 (0.0-2.3) mm, respectively, and the difference was significant (Z=-4.604, P<0.01). The orbital volume before and 1 week after surgery was 2 008.10 (6.84-11 200.00) mm(3) and 478.76 (5.01-7 286.00) mm(3), respectively, and the difference was statistically significant (Z=-3.735, P<0.01).The preoperative diplopia degree was 0, Ⅰ, Ⅱ, and Ⅲ in 14, 11, 3, and 0 eyes, while the degree of diplopia 3 months after surgery was 0, Ⅰ, Ⅱ, and Ⅲ in 22, 6, 0, and 0 eyes, respectively. The difference was statistically significant (Z=-2.359, P=0.018). The preoperative dyskinesia degree of the eyes was 0, Ⅰ, Ⅱ, and Ⅲ in 11, 11, 3, and 3 eyes, while the dyskinesia degree of the eyes 3 months after surgery was 0, Ⅰ, Ⅱ, and Ⅲ in 23, 5, 0, and 0 eyes, respectively. The difference was statistically significant (Z=-3.456, P=0.001). No implant infection, displacement, and other serious complications were observed during the follow-up of 3 to 12 months. Conclusions: Three-dimensional printing technology combined with nasal endoscopy and surgical navigation, which is applied in the reconstruction of orbital fracture, can significantly improve the symptoms of diplopia, ocular dyskinesia, and ocular depression. It is a feasible assistant method. (Chin J Ophthalmol, 2019, 55: 658-664).

Approach for naso-orbito-ethmoidal fracture

The purpose of this study is to discuss several approaches to addressing naso-orbito-ethmoidal (NOE) fracture. Orbital fracture, especially infraorbital fracture, can be treated through the transconjunctival approach easily. However, in more severe cases, for example, fracture extending to the medial orbital wall or zygomatico-frontal suture line, only transconjunctival incision is insufficient to secure good surgical field. And, it also has risk of tearing the conjunctiva, which could injure the lacrimal duct. Also, in most complex types of facial fracture such as NOE fracture or panfacial fracture, destruction of the structure often occurs, for example, trap-door deformity; a fracture of orbital floor where the inferiorly displaced blowout facture recoils to its original position, or vertical folding deformity; fractured fragments are displaced under the other fragments, causing multiple-packed layers of bone.

Trigeminal somatosensory evoked potential test as an evaluation tool for infraorbital nerve damage

Background

Neurosensory changes are frequently observed in the patients with mid-face fractures, and these symptoms are often caused by infraorbital nerve (ION) damage. Although ION damage is a relatively common phenomenon, there are no established and objective methods to evaluate it. The aim of this study was to test whether trigeminal somatosensory evoked potential (TSEP) could be used as a prognostic predictor of ION damage and TSEP testing was an objective method to evaluate ION injury.

Methods

In this prospective TSEP study, 48 patients with unilateral mid-face fracture (only unilateral blow out fracture and unilateral zygomaticomaxillary fracture were included) and potential ION damages were enrolled. Both sides of the face were examined with TSEP and the non-traumatized side of the face was used as control. We calculated the latency difference between the affected and the unaffected sides.

Results

Twenty-four patients recovered within 3 months, and 21 patients took more than 3 months to recover. The average latency difference between the affected side and unaffected side was 1.4 and 4.1 ms for the group that recovered within 3 months and the group that recovered after 3 months, respectively.

Conclusion

Patients who suffered ION damage showed prolonged latency when examined using the TSEP test. TSEP is an effective tool for evaluation of nerve injury and predicting the recovery of patients with ION damage.

Reconstruction of extended orbital floor fracture using an implantation method of gamma-shaped porous polyethylene

BACKGROUND

The conventional surgical method for reconstructing orbital floor fractures involves restoration of orbital continuity by covering an onlay with a thin material under the periorbital region. However, in large orbital floor fractures, the implant after inserting is often dislocated, leading to malposition. This study aimed to propose a novel implanting method and compare it with existing methods.

METHODS

Among patients who underwent surgery for large orbital floor fractures, 24 who underwent the conventional onlay implanting method were compared with 21 who underwent the novel γ implanting method that two implant sheets were stacked and bent to resemble the shape of the Greek alphabet γ. When inserting a γ-shaped implant, the posterior ledge of the orbital floor was placed between the two sheets and the bottom sheet was impacted onto the posterior wall of the maxilla to play a fixative role while the top sheet was placed above the residual orbital floor to support orbital contents. Wilcoxon signed-rank test and Mann-Whitney U test were used for data analyses.

RESULTS

Compared to the conventional onlay method, the gamma method resulted in better restoration of orbital contents, better improvement of enophthalmos, and fewer revision surgeries.

CONCLUSION

Achieving good surgical outcomes for extended orbital floor fractures is known to be difficult. However, better surgical outcomes could be obtained by using the novel implantation method of impacting a γ-shaped porous polyethylene posteriorly.

A useful additional medial subbrow approach for the treatment of medial orbital wall fracture with subciliary technique

BACKGROUND

To date, a variety of surgical approaches have been used to reconstruct the medial orbital wall fracture. Still however, there is still a controversy as to their applicability because of postoperative scars, injury of anatomical structures and limited visual fields. The purpose of this study was to introduce a useful additional medial subbrow approach for better reduction and securement more accurate implant pocket of medial orbital wall fracture with the subciliary technique.

METHODS

We had performed our technique for a total of 14 patients with medial orbital wall fracture at our medical institution between January 2016 and July 2017. All fractures were operated through subciliary technique combined with the additional medial subbrow approach. They underwent subciliary approach accompanied by medial wall dissection using a Louisville elevator through the slit incision of the medial subbrow procedure. This facilitated visualization of the medial wall fracture site and helped to ensure a more accurate pocket for implant insertion.

RESULTS

Postoperative outcomes showed sufficient coverage without displacement. Twelve cases of preoperative diplopia improved to two cases of postoperative diplopia. More than 2 mm enophthalmos was 14 cases preoperatively, improving to 0 case postoperatively. Without damage such as major vessels or extraocular muscles, enophthalmos was corrected and there was no restriction of eyeball motion.

CONCLUSION

Our ancillary procedure was useful in dissecting the medial wall, and it was a safe method as to cause no significant complications in our clinical series. Also, there is an only nonvisible postoperative scar. Therefore, it is a recommendable surgical modality for medial orbital wall fracture.

New anthropometric data for preoperative planning in orbital wall fracture treatment: the use of eyelid drooping

Background

The presence of enophthalmos is an important determinant in the decision of orbital wall fracture surgery. We proposed eyelid drooping as a new anthropometric diagnostic measure and analyzed whether eyelid drooping is associated with enophthalmos.

Methods

This retrospective study was performed from January 2014 to December 2016. A total of 75 patients with blowout fractures were studied. One experimenter measured the degree of enophthalmos using a Hertel exophthalmometer at 1 week after trauma and at 3 months after surgery. The height change of the upper eyelid was measured using the marginal reflex distance (MRD) on both sides, and the degree of eyelid drooping was calculated by comparing the two lengths. We analyzed statistically the correlation between enophthalmos and eyelid drooping.

Results

We found a highly significant correlation between the degree of enophthalmos and the reduction rate of MRD (RRM, as an indicator of eyelid drooping) at 1 week after trauma (r = 0.845). Approximately 2.0 mm of enophthalmos was associated with a 30.8% reduction in MRD on the affected side as compared with the normal side. At 3 months after surgery, patients showed improved eyelid appearance, with a moderate association between enophthalmos and RRM.

Conclusion

We demonstrated that the degree of enophthalmos, measured using an exophthalmometer, is associated with a change in the height of the upper eyelid. Thus, upper eyelid drooping can be used as another indicator for orbital wall fracture surgery. Compared with conventional methods, measurements of eyelid drooping are easy to perform, offering a great advantage and understanding to the patient.

About a pediatric facial trauma

Less-lethal weapon are more and more used in law enforcement to neutralize combative individuals and to disperse riot crowds. Even if this type of weapon has been created to be less damaging than classical firearms, it has been incriminated many times in cases of facial injuries with functional consequences, even death. In many countries, these guns can be possessed by average citizens. They could be extremely harmful when handled by inexperienced users and cannot be considered solely as defense weapons. Interestingly, little literature is available concerning facial injuries caused by the less-lethal weapons. We report the case of a ballistic wound on a 3-year-old child.

Choroidal volume changes following blow-out fracture repair

PURPOSE

To investigate the serial choroidal volume change following orbital blow-out fracture (BOF) repair.

METHODS

The choroidal volume was measured by optical coherence tomography in patients who underwent BOF repair, preoperatively and postoperatively at 1, 4, 12 and 24 weeks. The orbital volume ratio (OVR) was obtained by dividing the orbital volume of the traumatized orbit by that of the contralateral side using three-dimensional computed tomography imaging. The choroidal volume change was compared between both eyes using a linear mixed model.

RESULTS

We analyzed the choroidal volume of 11 patients. Choroidal volume showed a trend of slight increase during the immediate postoperative period, and then, choroidal volume decreased abruptly between postoperative 1 to 4 weeks (β-coefficient - 0.22, P < 0.001). Choroidal volume also showed gradual decrease between postoperative 4 to 24 weeks (β-coefficient - 0.02, P < 0.001). During the study period, there were no significant differences in choroidal volume change between BOF and contralateral unaffected eyes (β-coefficient - 0.20, P = 0.711). The hyperopic refractive errors (β-coefficient 0.27, P = 0.028) and the larger preoperative OVR (β-coefficient 10.37, P = 0.013) were associated with larger choroidal volume.

CONCLUSIONS

Choroidal volume showed a similar decreasing change following BOF repair between the BOF and the contralateral unaffected eyes. Moreover, choroidal volume of both eyes was associated with the degree of orbital volume expansion due to BOF, suggesting that choroidal volume change after BOF repair was affected not only by trauma-associated local hemodynamic changes but also by systemic influences such as inflammatory response.

Reconstruction of medial orbital wall using a retrocaruncular approach

The purpose of the study was to analyze and describe the retrocaruncular approach to access medial orbital wall. A retrospective analysis was performed in patients referred for the treatment of orbital fractures between January 1st 2011 and July 31st 2017. The study included patients over 18 years old with isolated fractures of the medial orbital wall or combined with the orbital floor who underwent a transconjunctival approach with retrocaruncular extension and lateral canthotomy, and with a minimum follow-up of 6 months. Patients with fractures to the roof and/or lateral orbital wall were excluded. From a total of 319 orbits, 30 medial wall fractures were treated using a retrocaruncular approach, transconjunctival extension and lateral canthotomy. 7 of them were pure medial wall fractures and 23 were combined with orbital floor. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Only one patient developed a conjunctival granuloma in relation to the caruncle. No others patients had complications. This study concluded that this approach is a successful access for surgical treatment of medial orbital wall fractures because of their broad visibility without damaging structures, allowing adequate orbital reconstruction and excellent aesthetic results.

[Orbital emphysema: radiologic and ophthalmologic findings]

Orbital emphysema, or the presence of air in orbital tissues, is normally associated with an injury although it can arise when a Valsalva maneuver causes an increase in upper airway pressure. This potential complication of an orbital wall fracture, usually in the ethmoid bone, occurs in 50% of such cases. On fracture, air passes from the nasal fossa, sinuses, or subcutaneous tissue. The condition is benign and transient in most cases, and loss of vision is rare. No protocol for treating orbital emphysema with serious complications in which vision is affected has been established. We report 9 cases of orbital emphysema, describing events leading to the fractures, radiologic findings, and treatments.

Usefulness of indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture associated with orbital blowout fracture

BACKGROUND

Nasal fracture and orbital blowout fracture often occur concurrently in cases of midface blunt trauma. Generally, these multiple fractures treatment is surgery, and typically, the nasal bone and orbit are operated on separately. However, we have found that utilizing a transconjunctival approach in patients with concurrent nasal bone fracture and orbital blowout fracture is a useful method.

METHODS

The participants in the present study included 33 patients who visited the Plastic Surgery outpatient department between March 2014 and March 2017 and underwent surgery for nasal fracture and orbital blowout fracture. We assessed patients' and doctors' satisfaction with surgical outcomes after indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture with associated orbital blowout fracture.

RESULTS

According to the satisfaction scores, both patients and doctors were satisfied with transconjunctival approach.

CONCLUSION

We presented here that our method enables simultaneous operation of nasal fracture accompanied by orbital blowout fracture, rather than treating the two fractures separately, and it allows precise reduction of the nasal fracture by direct visualization of the fracture site without any additional incisions or difficult surgical techniques. Also, by preventing the use of excessive force during reduction, this method can minimize damage to the nasal mucosa, thereby reducing the incidence of nasal bleeding.

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.

Reconstruction of Medial Orbital Wall Fractures without Subperiosteal Dissection: The "Push-Out" Technique

Background

Various surgical methods for repairing medial orbital wall fractures have been introduced. The conventional technique requires total separation of the displaced orbital bones from the orbital soft tissues. However, subperiosteal dissection around the fracture can cause additional damage. The aim of the present study is to introduce a method of reconstructing medial orbital wall fractures without subperiosteal dissection named the “push-out” technique.

Methods

Six patients with post-traumatic enophthalmos resulting from an old medial orbital wall fracture and 10 patients with an acute medial orbital wall fracture were included. All were treated with the push-out technique. Postoperative computed tomography (CT) was performed to assess the correct positioning of the implants. The Hertel scale and a comparison between preoperative and postoperative orbital volume were used to assess the surgical results.

Results

Restoration of the normal orbital cavity shape was confirmed by examining the postoperative CT scans. In the old fracture group, the median orbital volume of the fractured side was 29.22 cm³ preoperatively, and significantly improved postoperatively to a value of 25.13 cm³. In the acute fracture group, the median orbital volume of the fractured side was 28.73 cm³ preoperatively, and significantly improved postoperatively to a value of 24.90 cm³. Differences on the Hertel scale also improved, from 2.13 mm preoperatively to 0.25 mm postoperatively in the old fracture group and from 1.67 mm preoperatively to 0.33 mm postoperatively in the acute fracture group.

Conclusions

The push-out technique can be considered a good alternative choice for old medial orbital wall fractures with posttraumatic enophthalmos, acute medial orbital wall fractures including large fractured bone segments, and single-hinged greenstick fractures.

Facial and Orbital Fractures: A Fifteen Years Retrospective Evaluation of North East Sicily Treated Patients

Background:

Orbital fractures are classified as diseases usually related to common midface trauma. It represents the most challenging treatment due to the complex anatomy, physiology, and aesthetic role. A midface trauma involves also the zygomatic complex and the nose, however the orbit fracture seems to be a more frequent disease due to its anatomical features.

Objective:

The purpose of this work is to retrospectively evaluate and record the frequency of the midfacial traumas and orbital fractures observed in the North Eastern Sicily. The results of the present data may be useful for the clinicians in order to recognize the kind of fracture just from the first general visit having a quick diagnosis and management.

Methods:

In the years between 2001 and 2016, about 1200 patients with midfacial trauma and about 100 patients involving the orbital floor have been evaluated. All those patients underwent the surgical fracture reduction and a CT scan follow up control at one month, three months, six months and one year.

Results:

Data showed high percentage of orbital floor, nose and mandibular body and ramus fractures; moreover the most frequent causes of fractures seem to be related to motor vehicle accident, followed by assaults, work and fall.

Conclusion:

The results have highlighted the changing trends in the causes of facial injuries, particularly the increasing incidence of assaults and the falling incidence of motor vehicle accidents in developed countries. The quick diagnosis and management proved fundamental for the successful treatment. Clinicians should be able to recognize the first symptoms in order to avoid possible complications.