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 Canalicular Wall Dehiscence/Thinning Found in Adults: A Case Series.

We retrospectively reviewed the medical records of all patients diagnosed with lacrimal canalicular wall dehiscence/thinning from January 2020 to January 2024 and found three patients. Two patients were male, and the other patient was female. Patient ages ranged from 53 to 82 years. None of the patients had a history of ocular trauma, congenital anomaly, or other ocular diseases except for cataract. All patients complained of epiphora, and the duration of symptom ranged from 15 months to 10 years. Unilateral involvement of the lower canaliculus and isolated single wall involvement affecting only the canalicular roof were observed in all patients. The roof was dehiscent in one case and thinned out in the other two cases. The dehiscent canaliculus was closed by sutures, and the thinned-out canalicular wall of one patient was covered using a conjunctival flap. However, recurrences were noted at two and five months after surgery.

Incidence of Pure Orbital Fractures with Concomitant Lacrimal Drainage System Injury in the Japanese Population: A Retrospective Study.

PURPOSE: This study aims to determine the incidence of pure orbital fractures with concomitant lacrimal drainage system injuries. METHODS: A retrospective observational study involving 956 sides from 940 pure orbital blowout fracture patients was conducted in our institution. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded. RESULTS: A total of 13 sides (1.4%) from 13 patients were included in the study. Canalicular laceration, bony nasolacrimal canal fracture, and lacrimal sac wall laceration were found in 9, 4, and 1 patients, respectively (one overlapping). Majority of the injuries resulted from either sports or falls. Inferomedial orbital strut fracture (23.1% vs. 7.6%; p = .075) and orbital floor fracture occurring lateral to the infraorbital groove (30.8% vs. 9.9%; p = .035) tended to be higher in patients with lacrimal drainage system injuries. CONCLUSION: There is a 1.4% incidence rate of pure orbital fractures with concomitant lacrimal drainage system injuries among the Japanese population included in this study. Inferomedial orbital strut fractures and orbital floor fracture lateral to the infraorbital groove were found to have higher association with lacrimal drainage system injuries.

A Comparative Analysis of the Incidence of Pediatric Orbital Fractures Before and During the COVID-19 Pandemic in the Japanese Population.

INTRODUCTION:  The aim of this study is to compare data on the incidence of pediatric orbital fractures before the onset of the coronavirus disease 2019 (COVID-19) pandemic and during the period of the pandemic in the Japanese population. METHODS: This retrospective, single-center, observational study including 225 patients (226 sides) aged ≤ 18 years old diagnosed with orbital fracture was conducted in our institution from March 2017 to April 2023. The study compared the incidence of pediatric orbital fractures in the pre-pandemic period from March 2017 to March 2020 and during the pandemic from April 2020 to April 2023. RESULTS: The most common cause of injury was sports in both groups (137 sides, 60.6%), and the ratio of causes of injury (P = 0.610) or between outdoor and indoor sports (P = 1.000) was not statistically different between the groups. Although the daily rate of patient consults was lowest during the country's state of emergency with priority preventative measures, the difference between pre-pandemic and pandemic was not statistically significant (P = 0.911). CONCLUSION: Despite the restrictions mandated by the Japanese government during the COVID-19 pandemic, the physical activities of children did not significantly decline. Hence, the risk of pediatric orbital fractures remained the same.

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.

Thickness of the Medial Pretarsal Adipose Tissue in the Upper Eyelid among the Japanese Population.

PURPOSE: To investigate the medial pretarsal adipose tissue thickness of the upper eyelid in the Japanese population. METHODS: Sixty-two whole upper eyelids were harvested from 35 Japanese cadavers and fixed in paraffin. The samples were cut into 5 µm sagittal microsections and stained with hematoxylin and eosin, as well as Masson's trichrome. Data obtained from images and measurements were taken with Aperio ScanScope and ImageScope software and underwent statistical analysis. RESULTS: The samples were divided into 3 shapes sagittal cross-sections of the eyelid (triangular, rectangular, and flat) corresponding to the shape of the medial pretarsal adipose tissue. Type I (triangular shape, 48.4%) had a ratio of fat thickness at 1/2 tarsal height to peak fat thickness of <0.9, and type IIa (rectangular shape, 30.6%) and IIb (flat shape, 21.0%) had pretarsal adipose tissue thickness to tarsal height ratio of ≥0.2 and <0.2, respectively. The mean values of tarsal thickness at 1/2 tarsal height were 1021 µm for the type I group, 1100 µm for the type IIa group, and 764.4 µm for the type IIb group ( p = 0.01). The mean values of fat thickness at 1/2 tarsal height were 410.6 µm for the type I group, 303.3 µm for the type IIa group, and 242.6 µm for the type IIb group ( p = 0.26). CONCLUSIONS: The thickness of the medial pretarsal adipose tissue was different according to the shape of the sagittal cross-section of the eyelid. Awareness of the medial pretarsal adipose tissue thickness contributes to effective suture placement and safe suture depth during blepharoptosis surgery.

Lacrimal Gland Abscess: A Case Report.

Introduction: The aim of the study was to report a rare case of lacrimal gland abscess. Case Presentation: A 47-year-old woman noticed upper eyelid swelling on the right side 1.5 months before referral to our service. Oral antibiotics were administered, based on the diagnosis of acute dacryoadenitis at another clinic. The symptom had once subsided 20 days later but recurred. On the first examination, the right upper eyelid was swollen with tenderness. The right lacrimal gland was palpable. Blood tests revealed positive proteinase 3-anti-neutrophil cytoplasmic antibody. T2-weighted magnetic resonance and diffusion-weighted images showed a high signal intensity lesion in an enlarged right lacrimal gland, while apparent diffusion coefficient map demonstrated the lesion with a low signal intensity. We started administration of intravenous antibiotics. Abscess drainage and lacrimal gland biopsy were performed 4 days after the first examination. Culture test of the abscess showed only 1 colony growth of Cutibacterium acnes. The specimen harvested from the lacrimal gland showed proliferation of fibrous connective tissue and infiltration of inflammatory cells without vasculitis. After the drainage, the swelling gradually subsided. Administration of antibiotics discontinued at 22 days of follow-up. At 4-month follow-up, the patient did not have any symptom related to the lacrimal gland abscess. Conclusion: The diffusion-weighted images and apparent diffusion coefficient map are helpful for the diagnosis of lacrimal gland abscess when the culture tests provide poor results.

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.

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.

Dermolipoma in an Unusual Location: A Case Report and Literature Review.

A healthy nine-year-old Japanese male presented with a history of inferonasal conjunctival mass that was noted to increase in size in a few years' time. Initial examination revealed a 10-mm soft yellowish inferonasal conjunctival mass with a whitish surface. The rest of the examination findings were unremarkable. A computed tomographic scan was done and showed a conjunctival mass that was not connected posteriorly to the orbital fat but had the same density as the orbital fat. Complete surgical excision was performed, and pathologic evaluation of the excised specimen revealed a dermolipoma. The patient was subsequently followed up to monitor for any postoperative complications. Three months following the operation, there was no recurrence of the tumor, and the patient had an excellent cosmetic outcome.

Multiple CD34-Negative Orbital Solitary Fibrous Tumors in a Pediatric Patient.

A 12-year-old Japanese male presented with a 2-month history of headache that was later on associated with diplopia, painless proptosis of the OS, and left ophthalmoplegia. Initial examination revealed a 7-mm OS protrusion, which worsened to 9 mm in less than a month. Preoperative visual acuity worsened from 1.0 to 0.2 with the development of left afferent pupillary defect. Left ocular motility was severely restricted in all directions. Magnetic resonance imaging showed two well-defined lesions adjacent to one another in the left orbit. The patient underwent surgical excision of the left orbital masses. Histopathology findings were consistent with solitary fibrous tumor of the orbit. Immunohistochemistry findings revealed CD34-negative but signal transducer and activator of transcription 6-positive for both specimens. The patient was monitored postoperatively and there was no recurrence of the tumor even after 6 months.