Removal of an intraorbital metallic foreign body following double-penetrating ocular injury: A case report

RATIONALE

Open eye injury is one of the commonest ophthalmic emergencies, and when accompanied by intraorbital foreign bodies, the condition carries a poor prognosis.

PATIENT CONCERNS

A 28-year-old man presented to the emergency department of our hospital complaining of sudden painful loss of vision in the left eye after he hammered an iron plate.

DIAGNOSIS

The ocular examination revealed a 4-mm full thickness scleral laceration with prolapsed uveal tissue, a traumatic cataract. Computed tomography (CT) demonstrated an orbital foreign body in the retrobulbar area.

INTERVENTIONS

The patient underwent emergency scleral suturing, severance of medial rectus muscle, and removal of the orbital foreign body. Twelve days after the emergency operation, pars plana lensectomy and pars plana vitrectomy were performed.

OUTCOMES

After 3 months of follow-up, there was no immune response. Visual acuity in the left eye was the perception of hand motion. The retina remained mostly attached with normal intraocular pressure, and good cosmetic appearance. The globe anatomy was maintained, but the vision could not be restored due to the grave nature of the trauma.

LESSONS

Transconjunctival approach extraocular muscle severance may thus be a suitable approach to the removal of intraorbital metallic foreign body.

Applicability of a sheep model for training in plastic surgery of eyelids and orbit

OBJECTIVE

To test the applicability of a fresh tissue model for teaching facial plastic techniques and approaches to the eyelids and orbit.

DESIGN

Observational animal experiments.

SUBJECTS

Ten prepubescent sheep heads harvested following humane euthanasia at the completion of unrelated live animal research.

METHODS

Young sheep were saline perfused at the end of an in vivo protocol. Head and neck tissues were harvested and refrigerated for 3-7 days. An experienced oculoplastic surgeon and an otolaryngologist explored the feasibility of common oculoplastic procedures in the ovine model.

RESULTS

The model has potential for teaching basic principles in eyelid surgery including upper lid blepharoplasty, aponeurotic ptosis repair, upper lid gold weight lid loading for facial paralysis, lateral canthotomy and inferior limb cantholysis, lower lid tightening, and transconjunctival approach to the orbital floor. Eye muscle advancement, optic nerve sheath fenestration, and enucleation also accurately simulated human surgery. Anatomic variations limit the sheep model for orbital floor reconstruction and lacrimal drainage procedures.

CONCLUSIONS

The sheep head and neck provide an inexpensive, safe model for developing skills in several oculoplastic procedures. Formal simulation testing is needed to confirm these expert opinions.

Clinical outcome following use of transconjunctival approach in reducing orbitozygomaticomaxillary complex fractures

Background:

The increasing emphasis on the open reduction and internal fixation of orbito-zygomatico-maxillary complex fractures has led to a more critical appraisal of the various surgical approaches to the orbital and zygomatic skeleton. Transconjunctival approach popularized by Tessier although credited to Bourquet in 1924 offer excellent exposure of the orbito-zygomatico-maxillary complex fracture especially the infra-orbital rim, frontozygomatic suture and the orbital floor. The argument against a transconjunctival access focuses primarily on concern about limited exposure that apparently makes accurate reduction and osteosynthesis of displaced fracture fragments difficult or impossible. Also, due to close association with eye and various ocular complications reported in the literature, most of the surgeons feel skeptical about using this approach.

Aim:

The aim of this study is to analyze the efficacy of transconjunctival approach in the treatment of orbito-zygomatico-maxillary complex fractures by evaluating the functional and esthetic results and its associated complications.

Material and Method:

We report a series of eight patients who have undergone fracture repair of the orbito-zygomatico-maxillary complex via a transconjunctival approach. Postoperative patient evaluation was performed with specific attention paid towards wound healing, functional stability, esthetic appearance and postoperative ocular complications. Postoperatively clinical examination along with radiographic examination was done to evaluate the position of the zygoma and determine the adequacy of fracture reduction.

Results:

In all the patients excellent surgical exposure has been achieved for reduction and rigid fixation of the fracture fragments. None of the patients had any form of complication related to the approach. There were no postoperative ocular complications. Only one patient had postoperative chemosis which was transient and subsided subsequently. All the patients had excellent esthetic outcome, with symmetry of malar prominence restored and without any evident post-operative complications.

Conclusion:

Superior esthetic results and direct simultaneous access to the orbital rim, orbital floor and lateral orbital wall, support the use of the transconjunctival approach as a frontline approach to access the orbito-zygomatico-maxillary complex.

Transconjunctival Approach Using Lateral Skin Extension for Reconstruction of Orbit Zygomatic Complex Fractures: Technique Description and a Case Series Analysis

Study Design

A descriptive-observational study of a series case report of patients diagnosed with orbito-zygomatic complex (OZMC) fracture with lateral wall involvement, was conducted. All patients were assessed in the Oral and Maxillofacial Surgery Service at Hospital El Carmen, Maipu, Santiago, Chile.

Objective

The purpose of this study was to evaluate a single-institution experience with the transconjunctival approach to the orbit, utilizing a lateral skin extension as unique approach to access to fronto-zygomatic suture, infraorbital rim and/or orbital floor.

Method

The authors identified 41 patients with OZMC fractures who underwent to surgical treatment over a 45 months period. Among this group, 21 patients needed fixation with osteosynthesis of the frontozygomatic suture, and 16 of whom were treated with the approach being studied. The authors assessed scleral exposure, eyelid position changes, ectropion, and entropion as outcome measures, and reported satisfactory outcomes at a minimum of 9 months follow-up.

Conclusions

This study concludes that in our experience, the transconjunctival approach utilizing a lateral skin extension allows a direct, easy, and quick access to the entire infra orbital rim, orbital floor, fronto-zygomatic suture and lateral wall of the orbit, up to spheno-zygomatic suture, with low associated morbidity and complications.

Efficacy of transconjunctival approach for the treatment of orbital fractures: A protocol for systematic review and meta-analysis

BACKGROUND

This study aims to assess the efficacy of transconjunctival approach (TCA) for the treatment of orbital fractures (OF) comprehensively and systematically.

METHODS

In this study, we plan to search electronic databases of Cochrane Library, MEDLINE, EMBASE, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and for relevant randomized controlled trials. All these databases will be searched from inception to the March 1, 2020 without limitations of language and publication status. Two independent authors will carry out study selection, data collection, and study quality assessment. Any disagreements will be resolved by discussion with another author if necessary. The study quality will be assessed using Cochrane risk of bias tool. Statistical analysis will be conducted using RevMan 5.3 software.

RESULTS

This study will be the first 1 to exert direct evidence to evaluate the efficacy of TCA for the treatment of OF.

CONCLUSIONS

The findings of this study will provide an exhaustive view of TCA for the treatment of OF.

STUDY REGISTRATION NUMBER

INPLASY202040154.

Lower eyelid entropion following transconjunctival orbital fracture repair: Case series and literature review

Lower eyelid malpositions following transconjunctival repair of the floor and the zygomaticomaxillary complex fractures are rarely observed. The case series includes three patients (mean age, 22 years; 3 males) who developed lower eyelid entropion following orbital fracture repair (two complexes, one isolated type) using titanium mesh (n = 2) or iliac bone grafting (n = 1) through the transconjunctival approach. Entropion repair was attempted with scar release and Jones procedure in one, and posterior lamellar lengthening with mucous membrane graft in two patients. At a median follow-up of 25 months (range, 3-24), two patients had symptomatic relief without any lash globe touch, and one patient had persistent entropion after multiple interventions including failed mucous membrane graft (n = 1), full-thickness blepharotomy with everting sutures (n = 1), and scleral spacer grafting for posterior lamellar lengthening (n = 1). The literature is inconclusive about the association between eyelid malpositioning and any specific implant material, type of fracture, or incision closure technique.

A Non-missile Orbitocranial Wooden Trajectile Extracted by Trans-conjunctival Approach: Exploring an Unconventional Avenue

A middle-aged female presented with drooping of the eyelid and loss of vision in her left eye (LE) following a fall at her residence 20 days back. On examination, in LE, vision was no light perception, with severe ptosis, ocular movements were restricted in all directions of gaze, and the fundus showed optic disc pallor. The right eye (RE) examination was normal. MRI of the brain and orbit showed a linear foreign body traversing between the medial and inferior recti, coursing through the superior orbital fissure close to the optic nerve. The posterior limit of the foreign body bordered on the left cavernous sinus. An urgent surgical extraction of the foreign body was done under general anaesthesia in conjunction with the neurosurgeon. A 7 cm long wooden twig was removed through a medial trans-conjunctival approach. This case report elaborates on the comprehensive management of an orbitocranial wooden foreign body in a middle-aged patient.

Comparison of Transconjunctival versus Subtarsal Approach in Orbital Reconstruction with Respect to Post-Operative Complications and Aesthetic Outcome - A Systematic Review

Background

Limited evidence exists regarding the optimal surgical approach for orbital floor reconstruction, resulting in uncertainty regarding the choice of approach with the best aesthetic outcomes and lowest post-operative complications.

Objectives

This systematic review aimed to compare the transconjunctival and subtarsal approaches (STA) in orbital reconstruction in terms of post-operative complications and aesthetic outcomes.

Data Sources

The systematic review was conducted following PRISMA guidelines. PubMed, Google Scholar and Cochrane databases were searched from January 1, 2000 and December 31, 2021.

Study Eligibility Criteria

Eligible studies included clinical studies comparing the transconjunctival and STA approaches in orbital reconstruction. The outcome variables assessed were aesthetic scar, hyperaesthesia, entropion, ectropion, enophthalmos, epiphora and other complications. A total of 346 articles were initially identified, and after evaluation using Mendeley software, 292 articles were reviewed. Finally, five articles that met the inclusion criteria were included in this systematic review.

Study Appraisal and Results

The transconjunctival approach demonstrated superior aesthetic outcomes compared to the STA approach. However, the STA approach had a lower incidence of post-operative complications, including hyperaesthesia, entropion, ectropion, enophthalmos and epiphora.

Limitations

The main limitation of this systematic review is the limited availability of literature directly comparing these two approaches, which precluded the inclusion of randomised controlled trials. Furthermore, the search strategy was restricted to specific databases, namely PubMed/Medline, Google Scholar and the Cochrane Collaboration Library.

TRANSCONJUNCTIVAL APPROACH FOR SURGICAL REPAIR OF INFRAORBITAL RIM FRACTURES AND ORBITAL FLOOR FRACTURES

AIMS

The aim of this study is to retrospectively evaluate the use of a transconjunctival surgical approach in maxillofacial surgery on the fractures of the infraorbital rim and the orbital floor by analyzing the operating time, the incidence of perioperative and postoperative complications, as well as the functional and aesthetic outcomes of transconjunctival surgical treatment.

MATERIALS AND METHODS

All the patients on whom we used a transconjunctival approach from December 2017 to December 2021 were included in this retrospective study. The epidemiological causes of fractures of the midface skeleton were analyzed. The length of the operating time of the transconjunctival approach with lateral canthotomy was compared with a control group in which the supraorbital eyebrow approach was performed. In addition, we analyzed the incidence of perioperative and postoperative complications in comparison with publications from other centers.

RESULTS

We used the transconjunctival approach 103 times on 89 patients (in 14 patients the transconjunctival approach was performed bilaterally). In cases where the lateral canthotomy was used to extend the transconjunctival approach, there was no prolongation of the operating time. Perioperative complications included the perforation of the lower eyelid in 2 patients. In the postoperative period we recorded complications in 3 patients. Ectropion of the lower eyelid was present in one patient and entropion of the lower eyelid was observed in two patients. The percentage of perioperative and postoperative complications does not exceed the incidence of complications in transcutaneous approaches on the infraorbital rim.

CONCLUSION

Based on the results of our study, we can consider the transconjunctival approach, either alone or in combination with lateral canthotomy.