The impact of orbital floor defect ratio on changes in the inferior rectus muscle and prediction of posttraumatic enophthalmos - A cadaver study.

BACKGROUND: Orbital floor fractures result in critical changes in the shape and inferior rectus muscle (IRM) position. Radiological imaging of IRM changes can be used for surgical decision making or prediction of ocular symptoms. Studies with a systematic consideration of the orbital floor defect ratio in this context are missing in the literature. Accordingly, this study on human cadavers aimed to systematically investigate the impact of the orbital floor defect ratio on changes in the IRM and the prediction of posttraumatic enophthalmos. METHODS: Seventy-two orbital floor defects were placed in cadaver specimens using piezosurgical removal. The orbital defect area (ODA), orbital floor area (OFA), position and IRM shape, and enophthalmos were measured using computed tomography (CT) scans. RESULTS: The ODA/OFA ratio correlated significantly (p < 0.001) with the shape (Spearman's rho: 0.558) and position (Spearman's rho: 0.511) of the IRM, and with enophthalmos (Spearman's rho: 0.673). Increases in the ODA/OFA ratio significantly rounded the shape of the IRM (ß: 0.667; p < 0.001) and made a lower position of the IRM more likely (OR: 1.093; p = 0.003). In addition, increases in the ODA/OFA ratio were significantly associated with the development of relevant enophthalmos (OR: 1.159; p = 0.008), adjusted for the defect localization and shape of the IRM. According to receiver operating characteristics analysis (AUC: 0.876; p < 0.001), a threshold of ODA/OFA ratio ≥ 32.691 for prediction of the risk of development of enophthalmos yielded a sensitivity of 0.809 and a specificity of 0.842. CONCLUSION: The ODA/OFA ratio is a relevant parameter in the radiological evaluation of orbital floor fractures, as it increases the risk of relevant enophthalmos, regardless of fracture localization and shape of the IRM. Therefore, changes in the shape and position of the IRM should be considered in surgical treatment planning. A better understanding of the correlates of isolated orbital floor fractures may help to develop diagnostic scores and standardize therapeutic algorithms in the future.

Matrixmidface Preformed Orbital Implants for Three-Dimensional Reconstruction of Orbital Floor and Medial Wall Fractures: A Prospective Clinical Study.

Study Design: Prospective Interventional study. Objective: To evaluate the efficiency of Matrixmidface preformed Orbital plates for three-dimensional reconstruction of orbital floor and medial wall fractures. Methods: This prospective institutional clinical study was conducted on a group of 14 patients who underwent repair of orbital floor and medial wall fracture defects using Matrixmidface Preformed Orbital plates and open reduction and internal fixation of associated fractures. The following parameters were studied preoperative and postoperative enophthalmos, hypoglobus, orbital volume; correction of diplopia, intraoperative and postoperative complications. Results: All 14 patients were males aged between 19 and 42 years. The most common mode of injury was found to be road traffic accidents (RTAs) followed by self-fall and trauma at workplace. Orbital fractures were associated with other concomitant maxillofacial fractures in 12 patients (85.7%) while 2 patients (14.3%) had pure blowout fractures. Significant improvement of enophthalmos was noted from preoperative period to 1 week, 6 weeks, and 6 months postoperatively (P value .02, .01, and .01, respectively). Out of 11 patients with preoperative hypoglobus, 5 patients (45.45%) had persistent hypoglobus in the immediate postoperative period which reduced to 4 patients (36.36%) at 6 weeks postoperatively (p value .00). The postoperative orbital volume of fractured side ranged from 20.3 cm3 to 26.76 cm3 with a mean of 23.50 cm3 ± 1.74. The mean difference between the volumes of the repaired and uninjured sides was found to be .27 cm3 ± .39 (P value .02) denoting that the reconstruction of the orbit closely approximated that of the uninjured side. Conclusions: The Matrixmidface Preformed Orbital plate provides exceptional reconstruction of the orbital blowout fracture defects and ensures satisfactory results clinically and radiographically. The plate ensures an approximate recreation of topographical anatomy of the orbit and adequately restores the orbital volume. It provides adequate correction of asymmetry, hypoglobus, enophthalmos and attempts to restore eye movements, without causing any significant postoperative complication.

Delayed Orbital Floor Reconstruction Using Mirroring Technique and Patient-Specific Implants: Proof of Concept.

Enophthalmos is a severe complication of primary reconstruction following orbital floor fractures, oncological resections, or maxillo-facial syndromes. The goal of secondary orbital reconstruction is to regain a symmetrical globe position to restore function and aesthetics. In this article, we present a method of computer-assisted orbital floor reconstruction using a mirroring technique and a custom-made titanium or high-density polyethylene mesh printed using computer-aided manufacturing techniques. This reconstructive protocol involves four steps: mirroring of the healthy orbit computer tomography files at the contralateral affected site, virtual design of a customized implant, computer-assisted manufacturing (CAM) of the implant using Direct Metal Laser Sintering (DMLS) or Computer Numerical Control (CNC) methods, and surgical insertion of the device. Clinical outcomes were assessed using 3dMD photogrammetry and computed tomography measures in 13 treated patients and compared to a control group treated with stock implants. An improvement of 3.04 mm (range 0.3-6 mm) in globe protrusion was obtained for the patients treated with patient-specific implants (PSI), and no major complications have been registered. The technique described here appears to be a viable method for correcting complex orbital floor defects needing delayed reconstruction.

Post-traumatic Sinus Syndrome, Proposal for a New Clinical Entity (CDR Syndrome) as Variant of the Silent Sinus Syndrome: Systematic Review and Case Series.

The diagnostic criteria for silent sinus syndrome (SSS) are still controversial, especially for the post-traumatic/surgery cases that are, nowadays, excluded from the diagnosis of SSS because lacking of spontaneously. We present a systematic review of the last 10 years and our case series of SSS associated to previous trauma/surgery, proposing a new interpretation of SSS. In this work, following the PRISMA guide lines for systematic reviews, we collected 86 articles published on PubMed, Cochrane Library and Medline Plus since 2013 to 2023 about SSS. We divided them in six groups forming the structure of the review: (1) epidemiology, (2) clinical presentation, (3) imaging, (4) etiopathogenesis, (5) sss and craniofacial trauma and (6) treatment. We reported two explicative clinical cases: two men of 34 and 37 years old, involved in motorcycle accident in 2020 and 2014, respectively, and underwent surgery. They came back in 2023 referring diplopia documented by Hess-Lancaster test. CT-scan reported two clear cases of SSS. Basing on what is reported in literature, and basing on our experience, the post-traumatic/surgery SSS are more frequent than the idiopathic ones. Our proposal is to considered them as two individual entities. We propose to adopt the name of Post-traumatic sinus syndrome, or CDR syndrome (Catalfamo-De Rinaldis), for all cases that respect four specific diagnostic criteria reported into the text.

Complete Preservation of Orbital Fat by Restoration of Attenuated Orbital Septa Using an Acellular Dermal Matrix in Lower Blepharoplasty.

BACKGROUND: We hypothesized that application of acellular dermal matrix (ADM) over the orbital septum overlying the herniated orbital fat to tighten and strengthen the attenuated orbital septum in lower blepharoplasty would allow successful repositioning of the herniated orbital fat within the bony orbit. METHODS: The author prospectively compared the cosmetic outcomes of lower blepharoplasty using ADM with standard blepharoplasty. We evaluated recurrence of eyelid bulging and tear trough deformity, volume of the lower periorbital region, and enophthalmos and eyelid droop 1 year after surgery. RESULTS: Twenty-two of the 24 enrolled patients completed the study. There was no significant difference in recurrence of eyelid bulging and tear trough deformity between standard blepharoplasty and blepharoplasty with ADM graft groups. In the standard blepharoplasty group, the volume of the lower periorbital region decreased significantly after surgery. In the blepharoplasty with ADM graft group, there was no significant change in the volume of the lower periorbital region after surgery. In the standard blepharoplasty group, there was no significant change in eyelid droop on either side after surgery. In the blepharoplasty with ADM graft group, the eyelid droop decreased significantly after surgery on the right side but showed no significant change on the left side. There was no significant change in enophthalmos after surgery for either group. CONCLUSIONS: This study demonstrated that ADM graft provided effective support for maintaining the replaced orbital fat in lower blepharoplasty. In the long-term, blepharoplasty with ADM graft might be effective in slowing development of age-related enophthalmos. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Acquired enophthalmos in idiopathic orbital inflammatory disease.

Purpose: To describe a rare case of acquired enophthalmos in a patient with idiopathic orbital inflammatory disease after treatment with systemic corticosteroids. Observations: Orbital socket contracture produces a non-traumatic enophthalmos and is most frequently reported as a consequence of orbital trauma or metastatic fibrosis. A previously healthy 64-year-old male presented with 3-month history of binocular diplopia and left proptosis, hypoglobus, supraduction deficit, and compressive neuropathy. Imaging techniques showed a left orbital mass; laboratory tests and biopsy of the mass lead to the diagnosis of idiopathic orbital inflammatory disease. Systemic corticosteroids were administered and, surprisingly, the patient developed left enophthalmos with eyelid retraction. Conclusions and Importance: Although extremely unusual, orbital socket contracture can cause enophthalmos and visual morbidity in patients with idiopathic orbital inflammatory disease treated with corticosteroids.

Successful Management of Post-Traumatic Residual Orbital Roof Defects with Cosmetic Disfigurement and Functional Deficits Using Innovative Titanium Plate Orbitoplasty.

Introduction: Late presentations of post-traumatic residual orbital roof deformities ensuing from old, unaddressed orbital injuries, can be extremely challenging to manage and quite complicated to correct, owing to proximity of the brain and frontal sinus, malunion or bony fusion of the displaced, delicate orbital fracture fragments, necrosis of entrapped extraocular muscles and progressive intraorbital soft tissue fibrosis and adhesions. There exists a paucity in literature on delayed repair of displaced and comminuted orbital roof fractures and late reconstruction of the three-dimensional architecture of the orbital frame and internal orbit. Aim & Objectives: To present an unusual case of severe post-traumatic residual orbital roof deformity, resulting in longstanding aesthetic disfigurement and persisting functional deficits, and its successful management. Material & Methods: The patient had sustained orbital injuries sixteen months ago, on being punched in the face at a boxing tournament. The increased orbital volume produced by an impure blowout fracture of the left orbital roof, with comminution of the upper and lower orbital rims, had resulted in considerable cosmetic deformity, discomfort as well as functional debility, all of which were successfully and efficaciously managed by an innovative use of a Titanium Orbital Plate for orbital roof reconstruction. Discussion: Overlooked, undetected or ignored derangements in intraorbital volume and contour, can lead to severe cosmetic disfigurement in the form of enophthalmos, hypoglobus, entropion, telecanthus, palpebral fissure width narrowing and ptosis; in addition to crippling functional deficits, such as diplopia, blurred vision, levator dysfunction, restricted ocular motility and reduced visual range and acuity. Results & Conclusions: An innovative Titanium mesh orbitoplasty enabled achievement of both, the aesthetic and functional goals of reconstruction of the distorted bony orbit, with successful correction of severe functional and aesthetic deficits.

Silent Sinus Syndrome Post Trauma: A Case Report and Literature Review.

Silent sinus syndrome (SSS) is a relatively rare clinical condition occurring in the maxillary sinus exhibiting progressive enophthalmos and hypoglobus. The communication between the orbit and maxillary antrum due to trauma further leads to changes in the maxillary sinus. This could lead to the development of negative pressure within the maxillary sinus, collapse of antrum walls, and sucking in of orbital contents. Here, we present a case of a delayed orbital trauma, which was not treated initially. The patient's complaint was a constant feeling of a sunken right eye along with restriction in eye movements. On examination, the clinical and radiographic features were consistent with SSS. Orbital floor reconstruction was performed with the help of a titanium mesh for the correction of hypoglobus and enophthalmos. During follow-up, the patient showed no recurrence of the presenting functional and esthetic complaints. This clinical entity needs prompt diagnosis and early intervention so as to prevent further complications.

Orbital administration of fillers for optimization of symmetry in patients with microphthalmos or acquired anophthalmic sockets: A review.

The treatment of facial asymmetry in patients with microphthalmos or acquired anophthalmic sockets usually requires aggressive reconstructive surgeries. In recent years, studies have been published on the use of fillers to optimize orbital tissue symmetry, as minimally invasive techniques. For this reason, we performed a systematic review of the literature published to date on the use of fillers for the treatment of volume loss in acquired anophthalmic or microphthalmic cavities. Fourteen articles were reviewed in which the material used, the injection technique, the anatomical study of the patients before the procedure and the presence of associated complications were analyzed. Various materials have been used as fillers, including autologous fat, calcium hydroxyapatite, collagen, hyaluronic acid, or polyacrylamide gel. Standard peribulbar and retrobulbar injection techniques were applied, with few associated complications, the most serious being the development of vasovagal symptoms. Patient follow-up is usually limited in most studies to 12 months. In Conclusion, the use of fillers seems to be a safe practice, with good results and few complications, although studies with longer follow-up times than those published to date would be required.

Silent sinus syndrome: A case report.

A 65-year-old patient was referred to the Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran, with left facial pain and numbness in the upper lip. Based on clinical examinations and radiographic investigations, the patient was diagnosed with silent sinus syndrome. This study discusses oral findings associated with silent sinus syndrome.

Factors Influencing Outcome of Orbital Floor Reconstruction.

Introduction Orbital floor fractures are routinely encountered in facial trauma. Many factors influence the final outcome of the orbital floor surgery, time interval and the extent of other facial bone fractures are the two factors which can significantly influence the postoperative outcome following orbital floor reconstruction. Our study aims to find the ideal time for intervention and the association of other factors in the final outcome of orbital floor reconstruction. Methods A retrospective and prospective cohort study of patients who were operated at Pondicherry Institute of Medical Sciences for orbital floor fractures, between 2011 January and 2017 July. All the data were entered on an Excel work sheet and statistically analyzed. Results In our study 8 patients (8/29, 27.58%) had diplopia prior to surgery, 5 patients (5/29, 17.24%) had complete recovery following surgery and 3 patients (3/29, 10.34%) had persistence of diplopia postoperatively. Patients with diplopia operated prior to 7 days were found to have significant improvement in postoperative diplopia. Patients with 5 or more facial fractures were found to have persistence of diplopia, infraorbital numbness, and enophthalmos postoperatively. Conclusion Our study suggests that early intervention, before 7 days improves the outcome in patients with diplopia and provides a better result postoperatively. In our study preoperative diplopia and infraorbital numbness and postoperative persistence of enophthalmos, diplopia, and paresthesia were found more in patients with 5 or more facial bone fractures. Our study suggests a poor postoperative outcome when 5 or more facial bones are fractured.

The Usefulness of the Navigation System to Reconstruct Orbital Wall Fractures Involving Inferomedial Orbital Strut.

BACKGROUND: Little attention has been paid to combined orbital floor and medial wall fractures with the involvement of the inferomedial orbital strut. Managing this particular fracture can prove challenging. However, various innovative techniques have been introduced to assist with the process. Our study focuses on sharing our approach to orbital wall reconstruction using navigation guidance and titanium-reinforced porous polyethylene plates, specifically cases involving the inferomedial orbital strut. We believe that implementing a navigation system can effectively lead surgeons to the fracture site with utmost safety. Also, we hypothesized that this navigation system is beneficial to use singe fan titanium-reinforced porous polyethylene plates with orbital wall fractures involving IOS while minimizing possible complications. METHODS: We retrospectively reviewed 131 patients with medial orbital wall and orbital floor fractures with or without combined other facial bone fractures who underwent orbital wall reconstruction by a single surgeon from May 2021 to May 2023. Amongst, we identified fourteen orbital wall fractures involving the inferomedial orbital strut. We used a subciliary incision as the only approach method for performing titanium-reinforced porous polyethylene plates for navigation-guided orbital wall reconstruction. Patients were followed up for at least three months. RESULTS: All cases were effectively resolved using titanium-reinforced porous polyethylene plates. There were no complications during the patient's complete recovery, confirmed clinically and radiologically. Based on the serial CT results, it was discovered that implanted titanium-reinforced porous polyethylene plates successfully covered the defect. CONCLUSION: Based on our retrospective analysis, it has been determined that among the 131 recorded cases of orbital fractures, 14 of them (or 10.7%) involved the inferomedial orbital strut. Navigation-guided reduction using titanium-reinforced porous polyethylene (TR-PPE) plates can lead to predictable, reliable, and excellent outcomes for treating orbital fractures involving the inferomedial orbital strut without complications.

Congenital orbital fibrosis: report of two cases and review of literature.

A 7-year-old male child presented with complaints of lagophthalmos and lid retraction of the right eye since birth. Magnetic resonance imaging (MRI) showed diffuse thickening of right superior rectus and levator-palpebrae complex along with a hypointense, irregular, and ill-defined lesion in the adjoining fat abutting the lacrimal gland. Biopsy from the lesion showed diffuse orbital fibrosis. Another 3-year-old female child presented with complaints of her right eye appearing smaller and inability to move the right eye freely since birth. MRI showed thickening of right superior and medial recti with diffuse retrobulbar hypointense fibrotic strands. The findings were suggestive of orbital fibrosis. Congenital orbital fibrosis is an extremely rare orbital pathology with very few cases described in the literature. The most common clinical features are motility restriction, restrictive strabismus, upper lid retraction, enophthalmos, and proptosis. The diagnosis can be made on imaging but requires biopsy for confirmation. Management is mostly conservative in the form of refractive and amblyopia therapy.

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.

Patient Specific Implants for Orbital Reconstruction in the Treatment of Silent Sinus Syndrome: Two Case Reports.

Silent sinus syndrome is a rare disorder characterized by ipsilateral enophthalmos and hypoglobus following a collapse of the orbital floor, in the presence of asymptomatic long-term maxillary sinusitis. It results in enophthalmos, hypoglobus and deepening of the superior palpebral sulcus. A standardized treatment protocol for this infrequent syndrome has not yet been established. The management includes restoration of maxillary sinus ventilation with functional endoscopic sinus surgery and orbital reconstruction, either concurrently or separately. In this paper, the authors presented two patients successfully treated with patient-specific implants, and intraoperative navigation. These cases highlight the benefit of computer-assisted planning and titanium patient-specific implants in the management of silent sinus syndrome. To the best of our knowledge, this is the first report that described the use of PSI with titanium spacers performed with the aid of intraoperative navigation for SSS treatment. Advantages, drawbacks of this technique and treatment alternatives currently available in the literature were also discussed.

Complicaciones postoperatorias en fractura de órbita: experiencia en el Hospital del Trabajador de Santiago

Objetivo: Describir la experiencia del equipo de cirugía maxilofacial del Hospital del Trabajador en el manejo de las fracturas de órbita. Materiales y Método: Estudio retrospectivo de 42 pacientes consecutivos operados por fractura de órbita en el Servicio de Cirugía Maxilofacial del Hospital del Trabajador entre enero de 2016 y diciembre de 2017. Se tabularon datos demográficos, información del trauma, tipo de fractura, fracturas asociadas, tratamiento y seguimiento. Resultado: De los 42 pacientes, la mayoría eran hombres (73,8%) con edad promedio de 40 ± 12,24 años. Los principales síntomas al ingreso fueron equimosis (64,3%), edema periocular (54,8%), hemorragia subconjuntival (33,3%) y diplopía (26,2%). La pared orbitaria más frecuentemente afectada fue el piso de la órbita (85,7%). Las fracturas se presentaron de forma aislada en 35,7% de los casos y asociada a otra fractura de la cara en 64,3%. Post cirugía, la tasa de complicación fue de 16,7%, producto de diplopía y enoftalmos leves que solo requirieron tratamientos conservadores para su resolución. Discusión: La baja tasa de complicaciones se debe a la experiencia del equipo médico con un seguimiento a largo plazo, la medición de volúmenes orbitarios, imagenología intraoperatoria, utilización de malla prefabricada y asistencia endoscópica. Conclusiones: Un adecuado diagnóstico y evaluación son fundamentales para el tratamiento de la fractura de órbita. Los datos demográficos, las características de las fracturas y las complicaciones descritas fueron muy similares a lo reportado por otras experiencias, mientras que la tasa de complicaciones fue menor.

Aim: To describe the experience of the Maxillofacial Surgical team of Hospital del Trabajador de Santiago in the management of orbital fractures. Materials and Methods: Retrospective study of 42 patients operated consecutively between January of 2016 and November of 2017 at Hospital del Trabajador de Santiago by the Maxillofacial Surgery team due to orbital fracture. The demographic data was tabulated and then a comparison between isolated and combined orbital fractures was made. Results: Of 42 patients most were men (73.8%) with an average age of 40±12.24 years. At admission the main symptoms were ecchymosis (64.3%), periorbital edema (54.8%), subconjunctival hemorrhage (33.3%) and diplopia (26.2%). The most frequently affected orbital wall was the floor (85.7%). Isolated fractures accounted for 35.7% of the cases and those associated with other facial fractures for 64.3%. The postoperative complication rate was 16.7% due to diplopia and enophthalmos. Both complications were mild and only required conservative management. Discussion: The low complication rate might be due to the experience of the surgical team in the management of orbital fractures, long-term following, orbital volume measurements, intraoperative imaging, the use of prefabricated mesh and endoscopic guidance. Conclusión: An adequate diagnosis and evaluation are fundamental for orbital fracture treatment. Demographic data, fracture characteristics and the complications described were similar to those reported by other studies, while the rate of complications was lower than those experiences.

Outcome of Precontoured Titanium Mesh in the Reconstruction of Orbital Blowout Fractures.

Background Orbital blowout fractures are peculiar injuries causing disruption of both ocular function and symmetry. We present our experience with the use of a precontoured titanium mesh in orbital blowout fractures. Methods A retrospective study of patients undergoing correction of orbital blowout fractures with a precontoured titanium mesh was done at a tertiary care center in Mumbai. Data regarding demographics and pre- and postoperative clinical and radiological attributes were retrieved and compared. Results A total of 21 patients (19 males and 2 females) underwent correction of blowout fractures with a precontoured titanium mesh. The follow-up period ranged from 6 to 10 months. Road traffic accident (76%) was the most common etiology. Twenty (95%) patients had impure blowout fractures and 1 (5%) patient had a pure blowout. The orbital floor was most commonly fractured (16 [76%]). Associated fractures of the zygomaticomaxillary complex were found in 71% of patients. All patients were operated on within 3 weeks of trauma. A comparison of the operated and uninjured sides on coronal views of computed tomography (CT) scan in nine patients by Photopea application revealed a correction of the increased cross-sectional area in all cases. Enophthalmos was completely corrected in 94% patients, while 92% patients had complete correction of diplopia. One patient with a comminuted zygomatic fracture had persistent diplopia and mild enophthalmos. Infraorbital paresthesia persisted in 58% patients at 6 months of follow-up. No significant postoperative complications were noted. Conclusion The precontoured titanium mesh restores orbital wall anatomy and is safe, quick, fairly easy, and reproducible with a shorter learning curve. With proper patient selection and execution, prefabricated titanium mesh can serve as an excellent reconstructive option in blowout fractures of the orbit.

Corneal Perforation associated with "Silent Brain Syndrome" / Perfuração corneana associada à "síndrome do cérebro silencioso"

ABSTRACT This case report describes the clinical characteristics and ophthalmic management of a patient who developed corneal perforation due to severe enophthalmos consistent with "silent brain syndrome." A 27-year-old man with a history of congenital hydrocephalus and ventriculoperitoneal shunt was referred with complaints of "sinking of the eyeballs" and progressively decreasing vision in the left eye. Examination revealed severe bilateral enophthalmos in addition to superonasal corneal perforation with iris prolapse in the left eye. The patient underwent therapeutic keratoplasty the next day. Orbital reconstruction with costochondral graft and shunt revision of the intracranial hypotension were performed the next month to prevent further progression.

RESUMO Este relato de caso descreve as características clínicas e o manejo cirúrgico de um paciente que teve perfuração da córnea devido à enoftalmia grave consistente com a "síndrome do cérebro silencioso". Um homem de 27 anos com história de hidrocefalia congênita e derivação ventrículo-peritoneal foi encaminhado com queixas de "afundamento dos globos oculares" e diminuição progressiva da visão no olho esquerdo. O exame revelou enoftalmo bilateral importante, além de perfuração superonasal da córnea com prolapso iriano no olho esquerdo. A paciente foi submetida à ceratoplastia terapêutica no dia seguinte. Foi realizado no mês seguinte a reconstrução da órbita com enxerto costocondral e revisão do shunt para evitar progressão e piora do caso.