Clinical Significance of the Inferomedial Orbital Strut in Orbital Blowout Fractures: Incidence of Symptomatic Diplopia in a Fractured vs. Intact Strut.

Background/Objectives: This study aims to compare the clinical findings, particularly symptomatic diplopia, associated with an inferomedial orbital strut fracture versus intact strut and to determine the clinical significance of the inferomedial orbital strut in patients with orbital floor and medial orbital wall fractures. Methods: A 10-year retrospective observational study involving orbital blowout fracture cases was conducted in our institution. Patients with fractures of the orbital floor medial to the infraorbital groove and medial orbital wall, as seen on computed tomography (CT) scans, were included in this study. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded. Fracture of the inferomedial orbital strut was diagnosed via coronal CT images and patients were classified into those with an inferomedial orbital strut fracture and those without. Results: A total of 231 orbits from 230 patients was included in the study (fractured strut on 78 sides and intact strut on 153 sides). Approximately 2/3 of patients in both groups had the field of binocular single vision in primary position upon first examination (p = 0.717). Patients with strut fractures demonstrated only comminuted or open fractures, while those without strut fractures showed diverse fracture patterns (p < 0.001). Conclusions: Inferomedial orbital strut fracture does not automatically result in diplopia in patients with orbital blowout fractures. The integrity of the orbital periosteum plays a more essential role in hampering extraocular muscle displacement, thereby preventing symptomatic diplopia in these patients.

Sports-Related Pure Orbital Blowout Fractures in Japan: Differences in Demographic and Clinical Characteristics between Sports.

The aim of this study was to present the demographic and clinical characteristics of sports-related pure (rim-sparing) orbital blowout fractures and to analyze these differences by type of sport. Ten years of sports-related orbital fracture data were accumulated. Patients were classified into similar sports (i.e., soccer and futsal) wherein orbital blowout fractures were obtained, producing 14 groups. This study included 377 sides from 374 patients. The majority of patients were male (83.4%), and the mean population age was 20.9 ± 10.8 years. The most common sports causing injuries were baseball/softball, rugby/football, and martial arts. Single-wall fractures were found in 78.8% of patients, but baseball/softball had a higher frequency of multiple-wall fractures (p = 0.035). Concomitant ocular and periocular injuries occurred in 18.6% of patients, which were frequently caused by baseball/softball (p < 0.001). The field of binocular single vision (BSV) included primary gaze in 84.2% of patients. Surgical management was conducted in 52.1% of patients. This study showed that baseball and softball had the highest rate of multi-wall fractures and concomitant ocular and periocular injuries. The field of BSV measured during the first examination was acceptable in most cases.

Lacrimal Sac, Classified within the Orbital Tissue.

PURPOSE: To disclose that the lacrimal sac is classified within the orbital tissue. MATERIALS AND METHODS: Ten orbits of 9 Japanese cadavers aged 64 to 85 years at death were included. The attachment site of the orbital septum in the medial canthal area was grossly dissected. The relationship between the orbital septum attachment site and the location of the lacrimal sac was examined. RESULTS: In the upper region, the orbital septum was attached to the most superior area of the lacrimal fossa and the medial canthal tendon. In the lower region, the septum was attached to the anterior lacrimal crest and the medial canthal tendon. In both the upper and lower regions, none of the septa attached to the posterior lacrimal crest. The lacrimal sac was situated behind the orbital septum. CONCLUSION: The lacrimal sac, which is situated behind the orbital septum, is classified within the orbital tissue.

The lacrimal sac, which is situated behind the orbital septum attaching to the anterior lacrimal crest and the medial canthal tendon, is classified within the orbital tissue.

Orbital Trapdoor Fracture With Extraocular Muscle Entrapment in Adults: A Case Series.

PURPOSE: To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment. METHODS: We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision. RESULTS: We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed. CONCLUSION: Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility.

Late-Onset Traumatic Corneal Conjunctival Epithelial Disorders due to Granular Formation After Cosmetic Suture Blepharoplasty.

PURPOSE: The purpose of this study was to report conjunctival granular formation as one of the causative factors of a traumatic corneal conjunctival epithelial disorder after plastic suture blepharoplasty. METHODS: Clinical charts of 7 patients who had visited Ohshima Eye Hospital with a symptomatic corneal epithelial disorder and history of suture blepharoplasty were reviewed. Clinical evidence of conjunctival granular formations was observed in all patients at the tarsal conjunctiva facing to corneal conjunctival traumatic epithelial disorders. The desired outcome was to alleviate the disorder. The assessment included tabulating results after the placement of a soft contact lens bandage and subsequent partial tarsal plate resection of the granular formation. RESULT: Seven women (mean age 45.0 ± 10.9 years) enrolled in this study had previously undergone suture blepharoplasty (mean 18.3 ± 6.9 years before). Soft contact lens bandages relieved all of the patients' complaints immediately. After resecting the granular formation, the traumatic corneal conjunctival epithelial disorder disappeared, and no recurrence was observed after surgery. CONCLUSIONS: The conjunctival granular formation within the tarsal conjunctiva after suture blepharoplasty caused the late-onset traumatic corneal conjunctival epithelial disorder. A complete cure was obtained after resection of the granular formation at the tarsal conjunctiva. To the best of our knowledge, this is the first report to identify the removal of granular formations in 7 patients with late-onset traumatic corneal conjunctival disorders many years after blepharoplasty. The resection of these lesions is a promising procedure to treat late-onset ocular epithelial disorder after suture blepharoplasty.

Surgical Outcomes of Bilateral Inferior Rectus Muscle Recession for Restrictive Strabismus Secondary to Thyroid Eye Disease.

This retrospective, observational study examined the surgical outcomes of bilateral inferior rectus (IR) recession in thyroid eye disease. Twelve patients who underwent bilateral IR muscle recession were included in the study. Surgical success was defined as patient achievement of the following conditions: (1) a postoperative angle of vertical ocular deviation of ≤3°; (2) a postoperative cyclotropic angle of ≤2°; (3) postoperative binocular single vision, including the primary position; and (4) postoperative enlargement of the field of binocular single vision. Linear regression analyses were performed to analyze the relationship between postoperative changes in the vertical and torsional ocular deviation angles and the amount of IR muscle recession and nasal transposition. Consequently, 9 out of 12 patients were deemed to have had successful surgical outcomes. There was a positive correlation between a change in the vertical deviation angle and a side-related difference in the amount of IR muscle recession in successful cases (crude coefficient, 2.524). A positive correlation was also found between a change in the torsional deviation angle and the amount of IR recession (crude coefficient, 1.059) and nasal transposition (crude coefficient, 5.907). The results will be helpful to more precisely determine the amount of recession and nasal transposition of the IR muscle in patients with thyroid-related bilateral IR myopathy.

Differences in patient characteristics between subconjunctival herniated orbital fat in the superotemporal quadrant and the other quadrants: An observational study.

Subconjunctival herniated orbital fat (SHOF) usually occurs in the superotemporal quadrant, and SHOF located in other quadrants is extremely rare. This study aimed to compare the patient characteristics between patients with SHOF in the superotemporal quadrant and those with SHOF in other quadrants. This is a retrospective study of 45 patients with SHOF who were referred to our institution between January 2015 and January 2023 and 14 previously reported patients in published case reports of SHOF that were not located in the superotemporal quadrant. Data on patient age, sex, affected sides, and body mass index were collected from the medical records of our institution and from previous reports. Patient age, male-to-female ratio, unilateral-to-bilateral ratio, and body mass index were compared between patients with SHOF in the superotemporal quadrant and patients with SHOF in the other quadrants. Of the 45 patients, only 1 patient showed SHOF in a location other than the superotemporal quadrant (inferonasal quadrant). Based on a comparison of 44 patients with SHOF in the superotemporal quadrant and 15 patients with SHOF in the other quadrants, the latter entity predominantly occurred in young, non-obese females (P < .050). Unilateral cases were more common in SHOF in the other quadrants (P = .003). Patient characteristics were found to be different between cases of SHOF in the superotemporal quadrant and those with SHOF in the other quadrants.

Orbital Langerhans Cell Histiocytosis: A Case Report.

An eight-year-old boy presented with a one-month history of left eyelid swelling. The patient was diagnosed with periorbital cellulitis at another clinic and was treated with oral antibiotics. However, the swelling did not subside. On initial consultation, the patient had left upper eyelid swelling with erythema. His extraocular muscle motility was normal, and the results of blood tests were unremarkable. A computed tomographic scan demonstrated a mass in the superior orbit with destructive changes in the left frontal bone. Histopathological examinations revealed a dense infiltrate of histiocytic cells. Immunohistochemical staining of the tumors for CD1a and Langerin was positive. A pathological diagnosis of Langerhans cell histiocytosis was made. Since orbital Langerhans cell histiocytosis has a high risk for central nervous system involvement, chemotherapy was the treatment of choice for any residual lesion to prevent sequelae to the central nervous system. At the six-month follow-up, the lesion did not recur, and the patient did not experience any central nervous system sequela.

Pressure Onto the Orbital Walls and Orbital Morphology in Orbital Floor or Medial Wall Fracture: A 3-Dimensional Printer Study.

The purposes of this study were to compare the pressure onto the orbital floor and medial orbital wall between 3-dimensional printer skull models with unilateral orbital floor and medial orbital wall fractures and to compare the morphology of the orbital floor and medial orbital wall between patients with unilateral orbital floor and medial orbital wall fractures. The skull models were created based on computed tomographic (CT) data obtained from every 10 patients with unilateral orbital floor and medial orbital wall fractures. The orbital spaces of these models were filled with silicone, the silicone surface was pushed down, and pressures onto the orbital floor and the medial orbital wall were measured. On preoperative computed tomographic images taken in the same 20 patients, the superior and lateral bulges of the orbital floor and medial orbital wall were measured, respectively. The measurements were done on the unaffected sides. Consequently, the pressure onto the orbital floor was significantly higher in the orbital floor fracture models than in the medial orbital wall fracture models, although the pressure onto the medial orbital wall was not significantly different between the models. As for the morphologic study, the superior bulge of the orbital floor was higher in the orbital floor fracture group than in the medial orbital wall fracture group. The results of this study indicate that since the orbital floor with a high superior bulge receives high hydraulic pressure, patients with a high superior bulge have a greater risk of orbital floor fracture.

Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes.

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

The Usefulness of Diathermy Thermocoagulation in Chalazion Surgery.

Purpose: To investigate the usefulness of diathermy thermocoagulation in chalazion surgery. Methods: This prospective, observational study included 30 sides from 24 patients who underwent chalazion surgery using diathermy thermocoagulation. The eyelid was fixed with a chalazion clamp under local anesthesia. The skin or palpebral conjunctiva was incised, and the chalazion was partially curetted. The residual chalazion contents were coagulated with diathermy and detached from the surrounding tissues using forceps and scissors. Then, the residual chalazion contents were completely removed. Results: The chalazion was not palpable in all cases 1 week postoperatively. A small chalazion redeveloped close to the primary lesion 2 weeks postoperatively in one patient; however, it spontaneously improved. No other cases experienced recurrence or complication during the follow-up periods. Conclusion: Thermocoagulation of chalazion contents using diathermy facilitates grasp, dissection, and excision of chalazion contents.

Spontaneous regression of immunoglobulin G4-related dacryoadenitis and multiple organ involvement: A case report.

PURPOSE: Immunoglobulin G4 (IgG4)-related dacryoadenitis is rarely resolved spontaneously without steroids. Here, we report a case of IgG4-related dacryoadenitis and extra-ophthalmic lesions with spontaneous regression. METHODS: This is a clinical case report. A 56-years-old man had a 1-year and 7-month-old histories of neck and eyelid swelling, respectively. On the first examination, the lacrimal and submandibular glands were palpable bilaterally. Computed tomographic images showed enlargement of the lacrimal gland on both sides, right pulmonary hilar lymph node, and pancreas, and thickening of the abdominal aortic wall. Blood tests demonstrated elevated serum IgG4 level and positive hepatitis B surface antibody. Pathological examination of the biopsied lacrimal gland specimens revealed marked IgG4-positive plasma cell infiltration. RESULTS: The patient was monitored carefully without steroid administration. Serum IgG4 level had gradually decreased during follow-up period and reached the normal range 3 years after the biopsy. At 4-year follow-up, the lacrimal and submandibular glands were not palpable on either side. Computed tomographic images demonstrated no enlargement of the lacrimal gland, submandibular gland, or lymph nodes, and improvement of the enlarged pancreas and thickened abdominal aortic wall. CONCLUSION: Our case indicates that careful observation can be an option in selected cases with risks of steroid treatment or silent clinical course.

Changes in Lacrimal Punctum Position and Tear Meniscus Height after Correction of Horizontal Laxity in Involutional Lower Eyelid Entropion.

Purpose: To examine changes in the position of the lower eyelid punctum and tear meniscus height (TMH) after correction of horizontal laxity of the lower eyelid in involutional lower eyelid entropion. Methods: This prospective, observational study included 42 sides of 36 patients with involutional entropion who underwent a lateral tarsal strip procedure or transcanthal canthopexy (+ lower eyelid retractor advancement). The horizontal distance from the medial margin of the lower lacrimal punctum to the medial canthus was measured using ImageJ software. TMH was measured using anterior segment optical coherence tomography. All measurements were performed preoperatively, at postoperative 3-month and at postoperative 6-month. Results: The lower lacrimal punctum significantly shifted laterally at 3-month follow-up and slightly returned toward its original position at 6-month follow-up (Friedman's test, P < 0.001). Although the differences did not reach statistical significance, TMH in the lower eyelid increased at 3-month follow-up and then slightly decreased at 6-month follow-up (Friedman's test, P = 0.076). Conclusions: The results of this study imply that lateral shift of the lower lacrimal punctum prevents effective drainage of tears accumulated in the lacrimal lake, resulting in increased TMH after correction of horizontal laxity of the lower eyelid in involutional entropion.

Lymphoproliferative disorders in the lacrimal caruncle: report of three cases and review of literature.

This report included three cases of lymphoproliferative disorders developing from the lacrimal caruncle. The first case was an 11-year-old boy with reactive lymphoid hyperplasia in the left lacrimal caruncle. The second case was an 80-year-old woman with reactive lymphoid hyperplasia in the right lacrimal caruncle. The third case was a 77-year-old man with follicular lymphoma in the left lacrimal caruncle. Our literature review of cases with lacrimal caruncular lesions showed 11 reported cases with reactive lymphoid hyperplasia and 17 with malignant lymphoma. There had been no previous report on follicular lymphoma in the lacrimal caruncle.

Severe corneal involvement secondary to congenital lower eyelid epiblepharon.

PURPOSE: The study aims to examine an incidence and risk factors of severe corneal involvement in patients with congenital lower eyelid epiblepharon. METHODS: This retrospective, observational study included 509 patients (933 eyes) with congenital lower eyelid epiblepharon. Data on age, sex, affected side, past history, past surgery, presence or absence of concomitant periocular/ocular diseases, body height and weight, astigmatic power, and corneal involvement were collected. Severe corneal involvement included corneal scarring, vascularization, and perforation. RESULTS: Severe corneal involvement was found in 30 patients (5.9%) (34 eyes, 3.6%). Corneal scarring and perforation with scarring were shown in 29 patients (33 eyes) and 1 patient (1 eye), respectively. Nine patients (12 eyes) demonstrated concomitant corneal vascularization with corneal scarring. Logistic regression analysis showed that body mass index had an odds ratio of 1.057 (P = 0.078). Age and sex did not affect occurrence of severe corneal involvement (P > 0.050). CONCLUSIONS: In this study, 5.9% of patients showed severe corneal involvement in congenital lower eyelid epiblepharon. Logistic regression analysis indicates that a high body mass index was a possible risk factor of severe corneal involvement caused by congenital lower eyelid epiblepharon.

Regression of Folliculosebaceous Cystic Hamartoma in the Palpebral Conjunctiva After Incisional Biopsy.

A 72-year-old man presented with a mass in the lower palpebral conjunctiva on the left side that recurred after biopsy at another clinic. On the first examination, a hard, yellow-white mass was located in the lower palpebral conjunctiva on the left side with some vessels running onto the tumor surface. A small piece of the tumor was removed for pathologic examination, and the results of the examination corresponded to folliculosebaceous cystic hamartoma. The patient noticed reduction in size of the residual tumor at 3 weeks postbiopsy. Slit-lamp examination revealed considerable regression of the tumor. At 6 months of follow-up, the tumor did not recur.

The relationship between orbital floor fracture patterns around the infraorbital groove and development of infraorbital nerve hypoesthesia: a computed tomographic study.

PURPOSE: To examine the relationship between patterns of orbital floor fracture around the infraorbital groove and development of infraorbital nerve hypoesthesia. METHODS: This retrospective, observational study included 200 patients (200 sides) of pure orbital floor fracture with or without medial orbital wall fracture. Data on the presence or absence of infraorbital nerve hypoesthesia were collected from medical records. Based on coronal computed tomographic images, patients were classified into 3 groups: a fracture extending medially to (medial group), into (in-groove group), and laterally to the infraorbital groove (lateral group). RESULTS: Infraorbital nerve hypoesthesia was found in 72 patients (36.0%). A fracture extended into or laterally to the infraorbital groove in 86.2% of patients with infraorbital nerve hypoesthesia, while a fracture was limited to the portion medial to the infraorbital groove in 77.3% of patients without infraorbital nerve hypoesthesia (P < 0.001). A logistic regression analysis demonstrated that patients in the lateral and in-groove groups were highly associated with development of infraorbital nerve hypoesthesia, with an odds ratio of 134.788 in the lateral group (95% confidence interval, 30.496-595.735; P < 0.001) and that of 20.323 in the in-groove group (95% confidence interval, 6.942-59.499; P < 0.001) with the medial group as the reference. CONCLUSIONS: This study indicates that patients with orbital floor fracture extending into or laterally to the infraorbital groove have a high risk of infraorbital nerve hypoesthesia, compared to those with orbital floor fracture limited to the portion medial to the infraorbital groove.

Risk factors for development of superior limbic keratoconjunctivitis in thyroid eye disease in Japanese.

PURPOSE: To analyse risk factors for the development of superior limbic keratoconjunctivitis (SLK) in thyroid eye disease (TED). METHODS: This prospective, observational study included 638 eyes/sides from 319 patients with TED. The eyes were classified into two groups, based on the presence and absence of SLK. Multivariate logistic regression analysis was performed to evaluate potential risk factors, including sex, patient age, past treatment history (steroid, orbital radiotherapy and radioiodine therapy), smoking, clinical activity score, margin reflex distance (MRD)-1 and -2, Graefe sign/lid lag, Hertel exophthalmometric results, Schirmer's test results, tear break-up time (TBUT) and tear meniscus height (TMH). RESULTS: SLK was found in 198 eyes (31.0%) from 121 patients. Young age (OR, 0.977; P = 0.006), smoker (OR, 1.785; P = 0.009), presence of Graefe sign (OR, 2.912; P < 0.001), absence of lid lag (OR, 0.485; P = 0.031), high Hertel exophthalmometric values (OR, 1.125; P = 0.002), shorter Schirmer's test results (OR, 0.962; P < 0.001), shorter TBUT (OR, 0.815; P = 0.002) and high upper TMH (OR, 1.003; P = 0.013) were associated with the development of SLK. A high MRD-1 measurement value also tended to be associated with a risk of SLK, with an OR of 1.187 (P = 0.056). CONCLUSION: The present study proposed several risk factors in relation to the development of SLK in TED.

Epidemic Keratoconjunctivitis-Associated Acute Dacryoadenitis in an Adult.

A 39-year-old man presented with a five-day history of swelling of the right upper eyelid and ocular irritation in the right eye. On the first examination, the patient showed conjunctival injection, conjunctival chemosis, swollen upper eyelid, and palpable lacrimal gland with tenderness on the right side. Magnetic resonance images showed an inflamed right lacrimal gland. Blood test demonstrated negative results for immunoglobulin M of Epstein-Barr, mumps, herpes simplex, and herpes zoster viruses. We administered oral prednisolone (30 mg/day) based on a possible diagnosis of idiopathic dacryoadenitis. One week after steroid treatment, the periocular inflammation reduced to some extent although the inflammation substantially persisted. Four weeks after the steroid treatment, the patient informed us that he had met his friend 10 days before the onset, and that friend had conjunctival injection at that time which was subsequently diagnosed as an epidemic keratoconjunctivitis. The periocular inflammation subsided, but two corneal white spots were observed on slit-lamp examination. Although immunochromatographic test for adenovirus was negative, the blood test showed a positive result for immunoglobulin M of adenovirus serotype 3. In eight weeks of follow-up, the number of corneal opacities increased to five spots, but the acute dacryoadenitis did not recur.

Positional relationship between lacrimal sac and skull base: implication of risk of cerebrospinal fluid leakage during dacryocystorhinostomy.

Cerebrospinal fluid (CSF) leakage is a rare but severe complication during dacryocystorhinostomy (DCR). Understanding the details of the anatomy of the lacrimal drainage system and skull base is essential to avoid this complication. We examined the positional relationship between the lacrimal sac and skull base using 16 cadavers (22 sides) and using computed tomographic images taken in 81 patients (81 sides). Consequently, the frontal sinus intervened between the lacrimal sac and skull base in 81.8-90.1% of cases. The lacrimal sac fundus and posterior lacrimal crest were far from the skull base/cribriform plate, and the skull base above the lacrimal sac was considerably thick. These results indicate that the risk of skull base injury and consequent CSF leakage during DCR is extremely low. However, surgeons should be cautious of this complication by indirect injury due to a twisting movement of a bone rongeur applied to the maxillary bone during creation of a bony window in patients with no interposition of the frontal and ethmoid sinuses between the lacrimal sac and skull base.