Does Orbital Volume Change Using the Mirror Technique Have a Correlation With Posttraumatic Enophthalmos?

An increase in orbital volume (OV) is an important factor in posttraumatic enophthalmos. The aim of this study was to evaluate the correlation of OV change using the mirror technique with posttraumatic enophthalmos.In this cross-sectional study, a 3-dimensional (3D) semi-automated volumetric method, using a 3D volume rendering tool, was applied to measure OV. The total orbital volume difference (TOVD), posterior orbital volume difference (POVD), and anterior orbital volume difference (AOVD) were measured as predictive factors in traumatic and intact orbits. Enophthalmos was also examined as the outcome, using a Hertel exophthalmometer.A total of 27 patients were examined in this study. The mean TOVD was 4.48 ±â€Š1.82 mm, the mean POVD was 1.91 ±â€Š0.31 mm, and the mean AOVD was 2.57 ±â€Š1.71 mm; also, the mean enophthalmos was 2.89 ±â€Š1.12 mm. Pearson's correlation test demonstrated a positive correlation between enophthalmos and TOVD, POVD, and AOVD (P <0.05). Based on the linear regression model, TOVD had a predictive power of 61.7% for enophthalmos. For every 1-mm volume change, a 0.38-mm enophthalmos was expected (R, 0.617; B, 0.38; P = 0.001).TOVD, POVD, and AOVD showed strong correlations with enophthalmos. However, it seems that POVD has the greatest effects on the occurrence of posttraumatic enophthalmos.

Differences in interpalpebral fissure measurement in patients with unilateral enophthalmos resulting from orbital wall fractures.

PURPOSE: To determine the correlation between the degree of enophthalmos and interpalpebral fissure (IPF) measurements in a group of patients with unilateral orbital wall fractures. MATERIALS AND METHODS: The medical charts of 45 patients diagnosed with unilateral enophthalmos resulting from an orbital wall fracture were reviewed. Demographic characteristics were investigated, including patient age, sex, medical history, and type of orbital wall fracture. The correlation between the degree of enophthalmos and IPF was determined, adjusting for confounding demographic factors. RESULTS: In the group with orbital wall fractures, the correlation between the degree of enophthalmos and the IPF measurements was positive and significant (R = 0.299, p = 0.046, Pearson's correlation). The correlation coefficient increased after adjusting for age, sex, medical history, and type of orbital wall fracture (R = 0.316, p = 0.044). CONCLUSION: The patient group with more severe enophthalmos tended to have lower IPF values.

Is there a correlation between the clinical findings and the radiological findings in chronic maxillary sinus atelectasis?

OBJECTIVE: Silent sinus syndrome (SSS) is a clinical syndrome that occurs as a result of chronic maxillary sinus atelectasis (CMA) and is seen with progressive enophthalmos and hypoglobus. The aim of this study was to investigate the correlation between radiological findings and clinical findings in patients with radiologically asymmetrical reduced maxillary sinus volume. MATERIAL AND METHOD: A comparison was made of patients with CMA through evaluation of paranasal sinus computed tomography, magnetic resonance imaging examination of maxillary sinus volume of the CMA side and the contralateral side, thickness of the retroantral fat tissue, infraorbital bone curve, uncinate process lateralisation measurement, middle concha diameter, and calculation of the change in location of the inferior rectus muscle. RESULTS: The study included 16 patients. Although a statistically significant difference was determined between the healthy and the pathological sides in respect to maxillary sinus volume, thickness of the retroantral fat tissue, infraorbital bone curve, uncinate process lateralisation measurement, and middle concha diameter (p = 0.00, p = 0.002, p = 0.020, p = 0.020, p = 0.007), no significant difference was determined in respect to the change in location of the inferior rectus muscle (p = 0.154). A positive correlation was determined between the increase in sulcus depth and maxillary sinus volume and inferior orbital bone curve (p < 0.05). CONCLUSION: In CMA patients suspected of having SSS, radiological maxillary sinus volume analysis, determination of retroantral fat thickness, measurement of the infraorbital bone curve, and measurement of the uncinate process lateralisation can be used as objective tests. However, it should be kept in mind that radiological findings may not always be compatible with the ophthalmological examination findings.

Silent sinus syndrome an acquired condition and the essential role of otorhinolaryngologist consultation: a retrospective study.

The silent sinus syndrome (SSS) is a rare clinical entity characterized by painless spontaneous enophthalmos, hypoglobus, and facial deformities secondary to chronic maxillary sinus atelectasis. The aim of this study was to present an SSS diagnostic feature and evaluate the relationship between nasal septum deviation and maxillary sinus volume. A retrospective chart review of the clinical characteristics of 20 patients diagnosed with SSS between January 2013 and July 2014 were analyzed by the Department of Otorhinolaryngology of University Hospital Complex of Santiago de Compostela. 14 patients were females and six males. The mean age was 43 years (range 28-67 years). The right maxillary sinus was involved in 12 patients and the left maxillary sinus in eight patients. There was no statistical difference between gender and the presence of SSS. Maxillary sinus sizes were significantly smaller on the same side as the deviation (p < 0.01). 14 patients were treated with functional endoscopic sinus surgery (FESS) with maxillary antrostomy. We concluded that patients with SSS usually present with facial asymmetry, and the best approach to document and show all facial asymmetries for these patients are the frontal and craneo-caudal photographs. The present study demonstrates that, in adult patients, SSS generally presents a septal deviation to the affected maxillary sinus. We recommend performing a paranasal sinus CT scan when the patient has a deviated nasal septum, retraction of the malar eminence (evidenced from the viewpoint cranio-caudal facial) and hypoglobus. FESS performing postero-anterior uncinectomy and enlargement of the maxillary ostium is recommended to restore sinus pressure and prevent progression of the enophthalmos, hypoglobus and facial deformities.

Mechanical resistance of the periorbita and the orbital floor complex--are isolated orbital floor fractures only a soft tissue problem?

The primary aims of orbital floor reconstruction are to prevent enophthalmos and herniation of the orbital contents in order to achieve correct globe position. Theoretically, the mechanical load of the orbital floor is approximately 0.0005N/mm(2) (30g orbital content onto 600mm(2) of orbital floor area). Therefore, low mechanical stress from orbital floor reconstruction materials is expected. The periorbita and orbital floor complex (bony orbital floor with periorbita) of 12 human cadavers were investigated for their mechanical resistance to distortion and compared to different absorbable pliable reconstruction materials after modification with pores (Bio-Gide, Creos, and PDS). The human periorbita resistance (approximately 1.4N/mm(2)) was comparable to that of the absorbable membranes (Creos, Bio-Gide), and the resistance of PDS (approximately 2.3N/mm(2)) was comparable to that of the orbital floor complex. The periorbita has a higher stability than the bony orbital floor. Therefore, in isolated orbital floor fractures with a traumatized bony orbital floor and periorbita, reconstruction of the soft tissue as a periorbita equivalent with a resorbable membrane appears to be adequate to prevent enophthalmos and herniation of the orbital contents.

Volumetric analysis of chronic maxillary atelectasis.

BACKGROUND: The relationship between orbit and maxillary sinus volumes in patients with chronic maxillary atelectasis (CMA), commonly known as silent sinus syndrome if enophthalmos is present, is poorly understood. METHODS: A retrospective review of 22 patients who underwent endoscopic sinus surgery (ESS) for CMA from 2005 to 2013 was performed. Computed tomography (CT) images were analyzed using OsiriX 5.8.2 software for volumetric analysis of the orbit and maxillary sinus at presentation and after surgical treatment with ESS. RESULTS: Pretreatment mean orbit volumes on the diseased side (DS) and the contralateral side (CS) were 29.22 and 26.50 mL, respectively (p < 0.001); mean sinus volumes on the DS and CS were 8.51 and 17.20 mL, respectively (p < 0.001); and pretreatment mean midorbit heights (MOHs) on the DS and CS were 3.39 cm and 3.07 cm, respectively (p < 0.001). The percent decrease in sinus volume on the DS compared to that on the CS did not correlate significantly with the percent orbit-volume increase. Enophthalmos was present in nine (41%) patients, and diplopia was present in three (14%) patients. The measured degree of increased orbit volume and decreased sinus volume secondary to CMA did not significantly predict the presence of enophthalmos at presentation. Seven patients underwent sinus CT more than 6 months after ESS. In these patients, orbit volume on the DS decreased from 29.67 to 27.52 mL (p = 0.005), and sinus volume on the DS increased from 9.78 to 11.84 mL (p = 0.08). CONCLUSIONS: Volumetric analysis is a powerful and novel method for objectively demonstrating the degree of orbit expansion and maxillary sinus contraction seen with CMA. Spontaneous maxillary sinus expansion and a decrease in orbit volume can occur after ESS, but post-ESS volumes do not return to the normal volume of the CS.

Aplicação da lipoenxertia nas deformidades craniofaciais: experiência do INTO-RJ / Application of fat grafting in craniofacial deformities: an INTO-RJ experience

INTRODUÇÃO: O enxerto de gordura, atualmente, é usado amplamente na cirurgia plástica estética e reparadora como um preenchimento natural. Na cirurgia crânio-maxilofacial há uma diversidade de pacientes com deformidades congênitas e adquiridas que podem ser muito beneficiados com a lipoenxertia. MÉTODOS: Os pacientes foram submetidos à lipoenxertia para reconstrução e correção de defeitos da face no INTO em 2012 e 2013 utilizando uma técnica padronizada. Nossa avaliação foi clínica e subjetiva, levando em conta a opinião do paciente. Especificamente nos pacientes com enoftalmo tardio secundário à sequela de trauma, realizamos exoftalmometria com o exoftalmômetro de Hertel e tomografia no pré e no pós-operatório para avaliar objetivamente nossos resultados. RESULTADOS: Vinte e dois pacientes receberam tratamento. A maioria foi do gênero feminino (77%). O volume do gordura aplicado variou de 1 ml até 37 ml, com média de 15 ml por sessão. A quantidade de sessões variou de 1 a 4. A lipoenxertia foi usada como tratamento único em apenas 30% dos casos. Fizemos lipoenxertia retrobulbar variando de 6 a 10 ml o volume enxertado, sendo que em um paciente realizamos duas sessões. Houve um ganho de 3 a 7 mm de projeção do globo ocular. Na avaliação tomográfica constatamos também aumento da projeção ocular de 4 mm e 2,2 mm. O resultado clínico foi pobre. CONCLUSÃO: A lipoenxertia é um procedimento simples, barato e reprodutível que deve fazer parte do armamentário do cirurgião plástico e do cirurgião craniofacial. Pode ser uma alternativa nos difíceis casos de enoftalmo tardio.

INTRODUCTION: The fat graft is currently widely used in aesthetic plastic and reconstructive surgery as a natural filler. In cranio-maxillofacial surgery, fat grafting can be very beneficial for patients with various congenital and acquired deformities. METHODS: We included patients who had undergone fat grafting for reconstruction and correction of defects in the face during 2012 and 2013 by using a standard technique. Our assessment was both clinical and subjective, taking into account the patient's opinion. In patients with late enophthalmos secondary to trauma sequelae, we conducted exophthalmometry with an exophthalmometer (Hertel) and preoperative and postoperative CT to objectively evaluate our results. RESULTS: Twenty-two patients were treated. Most were female (77%). The volume of fat grafted varied from 1 ml to 37 ml, with a mean of 15 ml per session. The number of sessions ranged from 1 to 4. Fat grafting was used as a single treatment in only 30% of cases. We performed retrobulbar fat grafting ranging from 6 to 10 ml in volume; in one patient, the grafting was carried out over two sessions. There was a gain of 3 to 7 mm in projection of the eyeball. In tomographic evaluation, an increased eye projection of between 2.2 mm and 4 mm was found. However, the clinical outcome was poor. CONCLUSION: Fat grafting is a simple, inexpensive and reproducible procedure that should be part of the plastic and craniofacial surgeons' inventory. It may be an alternative in difficult cases of late enophthalmos.

Intra-operative navigation for orbital reconstruction to correct diplopia and enophthalmos with endoscopic assisted technique: first case report in Thailand.

BACKGROUND AND OBJECTIVE: In an orbital fracture involving diplopia, enophthalmos is a major problem to be corrected because ofsoft tissue swelling and limited incision, which causes inaccurate restoration oforbital anatomy and reestablishing orbital volume. Pre-operative computerized planning combined with intra-operative navigation and endoscopy are used to create the accurate anatomical orbital position and effectively correct the posttraumatic diplopia and enophthalmos. CASE REPORT: An 18-year-old Thai male with diplopia and enophthalmospresented aposttraumatic left orbital fracture two months prior Three-dimensional CTscan of the facial bone confirmed the fracture. The patient required surgical treatment for correction of the orbital fracture. The intra-operative navigator and endoscopy-assisted technique were used. Pre- and post-operative pictures were compared, indicated the successful correction of enophthalmos and clinical correction of diplopia. CONCLUSION: Intra-operative navigator combined with endoscopy-assisted technique were a new surgical procedure that could correct the orbital deformity problem involving enophthalmos and diplopia more effective.

Augmentation of intraorbital volume with fat injection.

BACKGROUND: Enophthalmos is a challenging surgical problem to correct. Standard techniques to adjust orbital volume require invasive maneuvers such as osteotomies. Fat injection may provide a simple and less-invasive way of augmenting orbital volume to correct enophthalmos. METHODS: The right eye orbital volume of 10 New Zealand White rabbits was augmented with fat. Autologous fat was diced and injected into the retrobulbar space. Computed tomographic scans were evaluated for changes in globe position and retrobulbar volume. Visually evoked potentials were conducted to test the integrity of the optic tract. Rabbits were killed at 12 weeks after surgery. Orbital exenterations were performed to allow for gross and histologic evaluation. RESULTS: Right globe position showed a mean increase in eye proptosis of 3.4 mm at postoperative day 1 and 0.9 mm at 11 weeks postoperatively in comparison with the left globe position. No significant change was noted in the left globe position. Retrobulbar volume demonstrated an initial mean increase of 31 percent and a final mean increase of 9.8 percent at 11 weeks in the right eye compared with the left eye. Visually evoked potentials revealed intact optic pathways in all animals. Gross anatomical evaluation showed deposition of fat grafts. Histologic analysis showed both revascularized and necrotic areas of fat. No retinal or optic nerve damage was identified. CONCLUSIONS: Fat injection can augment orbital volume in an animal model and preserve visual function. Further investigation is necessary to document the clinical safety and value of this technique in humans.

Silent sinus syndrome: dynamic changes in the position of the orbital floor after restoration of normal sinus pressure.

BACKGROUND: Silent sinus syndrome is characterised by spontaneous enophthalmos and hypoglobus, in association with chronic atelectasis of the maxillary sinus, and in the absence of signs or symptoms of intrinsic sinonasal inflammatory disease. Traditionally, correction of the enophthalmos involved reconstruction of the orbital floor, which was performed simultaneously with sinus surgery. Recently, there has been increasing evidence to support the performance of uncinectomy and antrostomy alone, then orbital floor reconstruction as a second-stage procedure if needed. METHODS: We performed a retrospective review of 23 cases of chronic maxillary atelectasis managed in our unit with endoscopic uncinectomy and antrostomy alone. All patients were operated upon by the same surgeon. RESULTS: Twenty-two of the 23 patients had either complete or partial resolution. One patient had ongoing enophthalmos, and was considered for an orbital floor reconstruction as a second-stage procedure. CONCLUSION: Our case series demonstrates that dynamic changes in orbital floor position can occur after sinus re-ventilation. These findings support the approach of delaying orbital floor reconstruction in cases of silent sinus syndrome treated with sinus re-ventilation, as such reconstruction may prove unnecessary over time.

[Giant apocrine hydrocystoma of the internal canthus]. / Hidrocystome apocrine géant du canthus interne.

Hydrocystoma is a benign tumor whose development involves the sudoriferous eccrine or apocrine glands. We report the case of a giant apocrine hydrocystoma in a 70-year-old female diabetic patient. The tumor's natural progression over 10 years and its volume caused significant functional and aesthetic damage. This article discusses the radiological, clinical, anatomopathological, and therapeutic aspects of this tumor. The case is original in the tumor's location, size, and its double visual and lachrymal functional involvement as well as its aesthetic damage.

Silent sinus syndrome causing cyclovertical diplopia masquerading as superior oblique paresis in the fellow eye.

Silent sinus syndrome is an insidious maxillary sinus inflammatory disease causing a lowering, thinning, or even absorption of the orbital floor. Patients usually present with progressive enophthalmos and hypoglobus. We report a 41-year-old man with silent sinus syndrome who presented with cyclovertical diplopia masquerading as superior oblique muscle paresis in the fellow eye. Inferior oblique myectomy in the fellow eye resulted in excellent alignment.

Twist2: role in corneal stromal keratocyte proliferation and corneal thickness.

PURPOSE: Twist2 is a member of a family of bHLH transcription factors critical for normal mesenchymal proliferation and differentiation. In this study, the authors analyzed the role of Twist2 in the eye and cornea through examination of a Twist2 loss-of-function mouse mutant. METHODS: Twist2 expression during eye development in the mouse was investigated using RT-PCR and mRNA slide in situ hybridization. Lineage tracing was performed using Cre reporter mice. Morphometric analyses were performed, and cell proliferation and cell death were investigated by immunohistochemistry using Ki67 and cleaved caspase 3 antibodies, respectively. RESULTS: In the mouse, Twist2 is expressed first in the periocular mesenchyme and subsequently in the corneal stroma and endothelium of the developing eye. Loss of Twist2 function leads to corneal thinning and a reduced population of stromal keratocytes. The reduction in the stromal cell population can be traced back to embryonic stages during which the proliferation of stromal progenitor cells is impaired and to the reduced number of proliferating cells in the corneal limbus postnatally. Adult Twist2-null mice display enophthalmia and blepharophimosis. Corneal thinning in mutant mice is not accompanied by glaucoma, an association reported in human patients. CONCLUSIONS: Twist2 is required for normal corneal keratocyte proliferation and eyelid morphogenesis in the mouse. Loss of Twist2 function leads to corneal thinning because of the reduction in stromal keratocyte proliferation.

Adjunctive use of hyaluronic acid gel (Restylane Sub-Q) in anophthalmic volume deficient sockets and phthisical eyes.

PURPOSE: This study aims to present the use of Restylane Sub-Q for orbital volume augmentation in patients with secondary volume deficiency either postenucleation or postevisceration or those with phthisical eyes. METHODS: This prospective case series reviews clinical, photographic, and radiologic records of 16 patients with anophthalmic or enophthalmic orbits who underwent volume augmentation by injection with hyaluronic acid gel in the intraconal and extraconal posterior orbit. The technique is discussed in detail. RESULTS: The volume of hyaluronic acid gel injected ranged from 2 to 4 ml (mean volume, 2.3 ml) per orbit, with a mean reduction of enophthalmos of 3.7 mm (71.4%) at 1 week, 2.8 mm (59.9%) at 6 months, and 2.5 (51.3%) at 12 months, with follow-up of 94.1%, 68.8%, and 50% of the patient group, respectively. Follow-up after 12 months consisted of subjective feedback from the patient. With the exception of one patient, the mean subjective follow-up period was 14.7 months (maximum, 22.4 months; minimum, 1.6 months). The procedure was well tolerated by 15 of the 16 patients who all experienced an improvement in cosmetic appearance. There was one possible complication of orbital cellulitis (although not examined by our clinic); this patient did not attend further follow-ups. One patient had full correction of her enophthalmos, which was maintained over 12 months. CONCLUSIONS: Hyaluronic acid gel injections in patients with enophthalmic sockets appear to be a safe, tolerable, and minimally invasive alternative for orbital volume augmentation in the outpatient setting. However, as predicted, its affects are temporary, and volume does begin to decrease within 12 months of injection.

Individual design and rapid prototyping in reconstruction of orbital wall defects.

PURPOSE: We examined the application of individual digital design and rapid prototyping in the reconstruction of orbital wall defects for different stages of orbital volume (OV) changes. PATIENTS AND METHODS: Patients with unilateral post-traumatic orbital defects underwent individual digital design and rapid prototyping to manufacture specific titanium mesh implants to create ideal OV recovery. Features of orbital wall fracture deformities and OV changes were analyzed and measured with 3-Dimensional Medical Surface Rendering image software system. RESULTS: Most cases involving enophthalmos and diplopia were rectified, except for 5 cases of enophthalmos and 2 cases of diplopia with fresh fractures and 11 cases of enophthalmos and 7 cases of diplopia cases with old fractures. Ocular movements and facial malformations were improved. The OV values between the uninjured and injured sides had a significant deviation (P < .05). The degree of enophthalmos had no significant deviation with OV changes pre- and postoperatively in the early fracture stages. The degree of enophthalmos in the old fracture stages had a significant deviation with OV changes pre- and postoperatively. CONCLUSIONS: This study showed that orbital wall fractures can be diagnosed in early fracture stages and that the degree of long-term enophthalmos can be predicted with 3-Dimensional Medical Surface Rendering software. Our results suggest that early-stage orbital wall fractures should recover OV as early as possible, and that advanced stage orbital wall fractures should overcorrect OV. The degree of accuracy and rational of OV reconstruction can be improved by appropriate individual digitalization design and rapid prototyping technology.