Challenges in management of congenital enophthalmos due to anomalous accessory orbital extraocular muscle bands.

INTRODUCTION: Congenital enophthalmos is a rare condition characterized by posterior displacement of the globe, often associated with bony orbital anomalies or whole globe development defects. The purpose of this report is to present two unrelated cases of congenital enophthalmos secondary to anomalous accessory orbital bands and to describe characteristics of orbital imaging that differentiate this condition from the other causes. METHODS: The case records of two patients who presented with congenital enophthalmos and were discovered to have anomalous accessory orbital extraocular muscle bands were reviewed. The clinical features, initial diagnosis, high resolution magnetic resonance imaging (MRI) findings, and surgical outcomes were noted. A 3-dimensional reconstruction model was used to understand the approach and surgical management in one of the cases. RESULTS: Both patients presented with unilateral severe enophthalmos, globe retraction, and restricted ocular motility in all directions since birth. High-resolution MRI of the orbits revealed a short anomalous band, isointense to the muscle, arising from a rectus muscle belly and attaching to the posteroinferior part of the globe adjacent to the optic nerve. The caliber of the extraocular muscles and ocular motor nerves was normal. In one patient, surgery was not pursued due to the extreme posterior location of the band with proximity to the optic nerve. In the other patient, the deviation did not improve, despite successfully severing the accessory band, due to extensive scarring. CONCLUSION: Anomalous accessory orbital extraocular muscle bands are a rare and often overlooked cause of congenital enophthalmos when associated with limited ocular motility. Imaging the orbit can aid in diagnosis and help differentiate it from other causes. Safe surgical approaches to address the problem are limited, and available approaches may not be effective. These two cases highlight that the management of accessory extraocular muscle bands causing enophthalmos can be extremely challenging and difficult to improve even with intensive surgical intervention.

Delayed onset enophthalmos and hypoglobus mimicking silent sinus syndrome following midface trauma.

Craniomaxillofacial trauma is primarily diagnosed and managed by oral and maxillofacial surgeons. Among the cases encountered, midface fractures involving orbital walls are highly prevalent. In these fractures, involvement of the orbital walls, particularly floor of the orbit, can lead to considerable aesthetic and functional limitations. From a maxillofacial perspective, indications for surgical repair of orbital floor encompass marked decrease in ocular motility, fracture affecting more than 50% of surface area, an increase in orbital volume exceeding 18% and enophthalmos greater than 2 mm. In the absence of these discernible signs, surgical intervention is not generally indicated. However, in this case, an early adolescent with a history of midface trauma and minimal orbital floor fracture 8 months earlier presented with progressively delayed onset enophthalmos and hypoglobus closely resembling features of silent sinus syndrome. The enophthalmos and hypoglobus were corrected by placing custom-made non-resorbable high-density polyethylene implant in the orbital floor. Postoperative follow-up demonstrated aesthetically and functionally satisfactory outcomes.

Ten-Year Follow-Up of Orbital Volume Augmentation With Calcium Hydroxyapatite Filler in Postenucleation Socket Syndrome.

PURPOSE: To describe the efficacy and persistence of injectable calcium hydroxyapatite (CAHY) to correct orbital volume deficit in postenucleation socket syndrome. METHODS: An observational study was conducted as a clinical review of all patients in the authors' practice who received injectable CAHY placed in the extraconal and intraconal space to increase orbital volume with a 10-year follow up. The amount of CAHY to be injected was defined according to the degree of orbital volume deficit. Patients previously treated with radiotherapy or with a conjunctival fornix insufficient to accommodate the external prosthesis were excluded. All the patients with at least 10 years of follow up were included in the study. RESULTS: Thirty-one postenucleation socket syndrome patients received injectable CAHY for orbital volume augmentation, with a 10-year follow up. The mean amount of preoperative relative enophthalmos measured by Hertel's exophthalmometry was 14.16 ± 2.15. An increase in the mean orbital volume of 3.35 ± 0.91 at 6 months and 2.97 ± 1.35 at 10 years was obtained. The mean follow-up was 219 ± 18 months (range, 184-240). Patients demonstrated clinical and cosmetic improvement that was observed to continue for 10 years. The complications were peribulbar ecchymosis, 2 extrusions of the internal prosthesis, and 2 ptosis. CONCLUSIONS: Injectable CAHY provides safe, simple, repeatable, and cost-effective technique to treat volume deficiency in the enophthalmic orbit in the long term. The volume augmentation obtained with this semipermanent filler demonstrated a lasting effect in the orbit with negligible loss of volume at 10 years.

Clinical manifestations, management, and outcomes of primary silent sinus syndrome: a systematic review.

INTRODUCTION: Silent sinus syndrome (SSS) is a rare disorder of the maxillary sinus, which may present with orbital symptoms. Most reports of silent sinus syndrome are limited to small series or case reports. This systematic review comprehensively characterizes the various clinical presentations, management, treatment, and outcomes in patients with SSS. METHODS: A systematic literature search of the PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were studies describing the presentation, management, or treatment of SSS or chronic maxillary atelectasis. RESULTS: One hundred fifty-three articles were included in the final review (n=558 patients). Mean age at diagnosis was 38.8 +- 14.1 years, with a relatively even distribution among sexes. Enophthalmos and/or hypoglobus were the most frequent symptoms, along with diplopia, headache, or facial pressure/pain. Most patients (87%) underwent functional endoscopic sinus surgery (FESS), and 23.5% received orbital floor reconstruction. Post-treatment, patients had significant reductions in enophthalmos (2.67 +- 1.39 vs. 0.33 +- 0.75 mm) and hypoglobus (2.22 +- 1.43 vs. 0.23 +- 0.62 mm). Most patients (83.2%) achieved partial or total resolution of clinical symptoms. CONCLUSIONS: SSS has a variable clinical presentation, with enophthalmos and hypoglobus being most common. FESS with or without orbital reconstruction are effective treatments to address the underlying pathology and structural deficits.

Orbital Vascular Malformations: Relationship Between Enophthalmos and Clinically Apparent Distensibility with Valsalva.

PURPOSE: Determining the hemodynamic characteristics of an orbital vascular malformation is a critical step in management. The purpose of this study is to assess the relationship between enophthalmos and clinically apparent distensibility of orbital vascular malformations, to optimize imaging and treatment. METHODS: In this cross-sectional cohort study consecutive patients at a single institution were screened for study entry. Data extracted included age, sex, Hertel measurements, presence or absence of distensibility during the Valsalva maneuver, whether lesions were primarily venous or lymphatic based on imaging, and location of the lesion relative to the globe. Enophthalmos was defined as ≥ 2 mm difference from the opposite side. Parametric and nonparametric statistics were used, and linear regression was performed to examine factors predictive of Hertel measurement. RESULTS: Twenty-nine patients met the inclusion criteria. Relative enophthalmos ≥2 mm was significantly associated with distensibility ( p = 0.03; odds ratio = 5.33). Distensibility and venous dominant morphology were the 2 most important factors associated with enophthalmos on regression analysis. The relative position of the lesion anterior or posterior to the globe did not have a significant bearing on baseline enophthalmos. CONCLUSIONS: The presence of enophthalmos increases the likelihood that an orbital vascular malformation is distensible. This group of patients was also more likely to be characterized by venous dominant malformations. Baseline clinical enophthalmos may serve as a useful surrogate marker for distensibility and venous dominance, which may be useful in guiding the selection of appropriate imaging.

Assessing effectiveness of endoscope-assisted medial orbital wall fracture repair vs. no surgery using benefit-risk metrics and literature review.

PURPOSES: To evaluate clinical usefulness of endoscope-assisted medial orbital wall fracture repair via the retrocaruncular approach (rc-EAMOWFR) vs. no surgery (NS), and to perform a narrative review of relevant literature. METHODS: This was a retrospective cohort study enrolling isolated medial orbital wall fracture (IMOWF) eyes presented to two German level 1 trauma centers during a 7-year interval. The predictor variable was treatment type (rc-EAMOWFR vs. NS), and the main outcomes were late enophthalmos (LE) and retrobulbar hemorrhage (RH) assessed at 9-15 posttraumatic months. Descriptive and bivariate statistics were computed at α = 95%. Binary adjustments enabled calculation of number needed to treat (NNT), to harm (NNH), and likelihood to be helped or harmed (LHH) for demonstrating benefit-risk tradeoffs. Moreover, a narrative review was also performed. RESULTS: The sample comprised 502 patients (28.3% females; mean age, 46.5±19.2 years) with 541 IMOWF eyes (5.9% NS; 7.2% LE; 1.3% RH). Operated eyes had significantly lower LE events than NS eyes (symptomatic IMOWF: P < .0001; 95% confidence interval [CI], .03 to .16; NNT = 2 [95% CI, 1.1 to 6.1]; asymptomatic IMOWF: P < .0001; 95% CI, .01 to .07; NNT = 2 [95% CI, 1.1 to 1.8]). There were 7 (1.5%) RH events following rc-EAMOWFR (P = .99; 95% CI, .06 to 17.4; NNH = 68 [95% CI, 38.3 to 254.2]). LHH calculations posited that rc-EAMOWFR was 34 times more likely to prevent LE than to cause RH, regardless of fracture symptoms. Our results conformed to those of other 15 studies. CONCLUSIONS: The results of this study suggest that all IMOWFs be treated. rc-EAMOWFR performed in every 68 IMOWFs would be at risk of one RH event, but prevent 34 eyes from LE due to untreated fractures. Nearly 72% of untreated IMOWFs develop LE after 9 months.

Orbital Index: A Novel Comprehensive Quantitative Tool for Prediction of Delayed Enophthalmos in Orbital Floor Fracture Management.

SUMMARY: Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. However, identifying those at risk for delayed enophthalmos and requiring subsequent repair has remained a challenge. This study aimed to validate the Orbital Index, a prediction tool using computed tomography to stratify risk for delayed enophthalmos and establish a threshold for repair. The Orbital Index stratifies fractures by size, location, and inferior rectus rounding (a surrogate for fascioligamentous sling disruption) on a scale 0 to 6. A 22-year (1998 to 2020) multi-institution analysis of unilateral isolated orbital floor fractures was performed. Index scores were assigned to each scan, unoperated patients invited for blinded Hertel exophthalmometry assessment, and enophthalmos measurements correlated with Index scores. Interobserver scoring reproducibility was assessed with weighted Cohen kappa. Preintervention and postintervention Likert scale surveys were administered to determine whether this tool improved understanding and communication. The Orbital Index demonstrated high fidelity and interobserver reproducibility and identified a score of four or greater as a surgical threshold. Of 1769 computed tomography scans, 395 met criteria and were included for analysis. Eighty of 395 were managed operatively (operative rate, 20.3 percent). Of 315 patients managed nonoperatively, 41 (13.0 percent) agreed to follow-up evaluation and 28 (68.3 percent) were found to have enophthalmos. Unoperated patients with an Orbital Index score of 4 or higher were more likely to have enophthalmos than those with a score of 3 or less ( p = 0.001). The mean weighted Cohen kappa was 0.73, corroborating reproducibility. Communication ( p = 0.0003) and ability to correctly identify surgical need ( p = 0.01) were improved with use of this tool. The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.

Symptomatic enophthalmos due to sphenoid wing dysplasia appearing over 12 years in a patient with neurofibromatosis type 1: a case report and literature review.

Sphenoid wing dysplasia (SWD) is a common orbital complication of neurofibromatosis type 1 (NF1). However, enophthalmos associated with SWD is extremely rare, and details of its natural history are unclear. We present the case of a 14-year-old boy with an early childhood diagnosis of NF1 presenting with left blepharophimosis and enophthalmos for several months. Imaging demonstrated enlargement of the left lateral SWD, progression of the posteromedial deviation of the orbital contents, and sphenoid/ethmoid sinus deformation due to left temporal lobe compression over 12 years. Two characteristic changes were revealed on imaging: enlargement of the middle cranial fossa and deformation of the sphenoid/ethmoid sinuses. The orbital contents were compressed by the intracranial pressure of the temporal lobe and were displaced posteromedially into the space created by the deformed sphenoid/ethmoid sinuses. Because orbital symptoms can gradually become apparent over years with the progression of SWD and skeletal growth, long-term follow-up of orbital symptoms is recommended in patients with NF1.

Bilateral Enophthalmos as an Unusual Presenting Feature of Non-Hodgkin's Orbital Lymphoma.

Lymphoma is the commonest orbital malignancy. The typical presentation is proptosis or swelling, which warrants imaging and confirmation by tissue biopsy. Enophthalmos is a much rarer clinical sign and if bilateral and symmetrical can often present late. We describe a patient who presented with bilateral enophthalmos and symptomatic, secondary entropion due to bilateral non-Hodgkin's lymphoma in which orbital fat was replaced by a monoclonal proliferation of small B cells. Low-dose orbital radiotherapy and entropion surgery relieved the patient's symptoms.

Silent Sinus Syndrome Secondary to Lymphoma: An Unusual Case With Radiological Evidence of Rapid Progression.

OBJECTIVE: To describe a case of silent sinus syndrome secondary to malignancy and discuss the pertinent clinical findings. Silent Sinus Syndrome (SSS) refers to a rare, asymptomatic condition whereby occlusion of the maxillary sinus ostium results in gradual resorption of air, creation of negative pressure and collapse of the maxillary walls. METHODS: Review of medical records and literature review using NCBI/PubMed. RESULTS: We describe a case of a 54-year-old gentleman presenting solely with enophthalmos. He had been diagnosed with stage IVa small lymphocytic lymphoma (SLL) 1.5 years prior to this, which was being managed with active surveillance. CT demonstrated severe bowing of the anterior and posterolateral wall, inferior displacement of the floor of the orbit and right enophthalmos, thus supporting a diagnosis of silent sinus syndrome. Compared to previous staging CT at the time of the lymphoma diagnosis these findings were entirely new, and soft tissue in the pterygomaxillary fissure was found to be enlarged. The patient underwent endoscopic sinus surgery and a right maxillary mega-antrostomy was performed to ventilate the maxillary sinus and prevent progression of eye symptoms. A biopsy was taken from the pterygopalatine fossa, which was confirmed to be chronic lymphocytic leukemia (CLL). CONCLUSION: This case is unique both in being secondary to malignancy, as well as being rapidly progressive given the presence of radiologically normal appearances 1.5 years prior to presentation. Although a rare condition, prompt recognition of SSS is vital to prevent ophthalmological complications. This report highlights malignancy as a potential cause in cases with focal bony remodeling.

Etiology, Early Diagnosis and Proper Treatment of Silent Sinus Syndrome Based on Review of the Literature and Own Experience.

PURPOSE: The authors' aim was to review the literature in terms of the etiology of the syndrome, the frequency of Silent Sinus Syndrome (SSS) and surgical procedure, as well as to present their own experience. METHODS: The authors used PubMed, Medline, and Science Direct websites to find and review the most significant papers related to SSS. The case reports of SSS published between 2010 and 2020 were reviewed. A retrospective case review of 8 patients with SSS treated at the authors' departments was done. RESULTS: The silent sinus syndrome has been reported in both children and adults. It is relatively rare and should be differentiated from congenital sinus hypoplasia or atelectasis. It most often affects the maxillary sinus. SSS is usually diagnosed when facial asymmetry or vision problems occur. Late diagnosis requires endoscopic sinus surgery, involving orbital wall reconstruction. The etiology of the syndrome, including the role of bacterial flora found in the sinuses, is unclear. CONCLUSION: Early diagnosis of SSS enables avoiding orbital complications and limits surgical intervention to endoscopic surgery. Further research into bacteriology may help to understand the pathophysiology of the silent sinus syndrome.

Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery.

BACKGROUND: Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation. METHODS: The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures. RESULTS: One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02). CONCLUSIONS: The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Self-centering second-generation patient-specific functionalized implants for deep orbital reconstruction.

Deep and complete reconstruction of the orbital cavity has been shown to be essential for preventing enophthalmos and hypoglobus in patients with orbital defects or deformities. Additively manufactured patient-specific titanium implants provide unlimited options in design. However, implant malpositioning can still occur, even when intraoperative imaging and navigation are used. In this study, we investigated novel orbital implants containing features facilitating self-centering. Accuracy of implant placement and reconstruction of the orbital dimensions were compared retrospectively between self-centering second-generation patient-specific functionalized orbital implants (study group) and CAD-based individualized implants (control group). Design features of implants in the study group included functionalization with navigation tracks, a preventive design, and flanges - so called stabilizers - towards opposite orbital walls. Implant position was evaluated by fusion of preoperative virtual plans and the post-therapeutic imaging. Aberrances were quantified by 3D heatmap analysis. 31 patients were assigned to the study group and 50 to the control group, respectively. In the study group, most implants were designed with either one (n = 18, 58.06%) or two (n = 10, 32.26%) stabilizers. Twice (6.45%), one stabilizer had to be shortened intraoperatively. Implant fit analysis revealed a significantly more precise (p < 0.001) positioning in the study group (n = 22/31) than in the control group (n = 42/50). Self-centering second-generation patient-specific functionalized orbital implants showed significantly more accurate implant positioning, facilitating the transformation of virtual plans into patient's anatomy. The presented design provides an additional instrument for intraoperative quality control besides intraoperative imaging and navigation.

Silent sinus syndrome in children.

INTRODUCTION: Silent sinus syndrome (SSS) is defined as a progressive enophthalmos and hypoglobus associated with maxillary sinus atelectasis. There is extremely limited literature describing SSS in children. The goals of this study are to characterize SSS in children through an IRB approval retrospective chart review of cases identified through a large health system-wide imaging database and to compare the presentation and outcomes of patients who underwent surgery versus those who were observed. METHODS: A radiology database of over 26 million reports from 2003 to 2017 was searched to identify children aged 1-18 years diagnosed with maxillary sinus hypoplasia or SSS on CT scan. Chart review was performed on the identified children including clinical presentation, eye symptoms, surgical treatment, and outcome. RESULTS: Eighty-three children were identified to have maxillary sinus hypoplasia. Eighty-one patients had maxillary sinus opacification and 57 patients had hypoglobus or enophthalmos characteristic of SSS. Thirty-two patients (47%) were seen by a specialist and 19 had surgery. The majority of patients (55%) had headache as their presenting symptom. There were no statistically significant differences in the clinical presentation between those who received surgery and those who were observed clinically. CONCLUSIONS: Silent sinus syndrome can present at any age. The majority of cases of maxillary sinus hypoplasia will have the orbital floor changes characteristic of SSS. Headaches are a common presenting symptom. Close follow up of pediatric patients is advised and early intervention may be favorable to prevent long term orbital changes and complications.

[Computer technologies in diagnostics and treatment of worsening post-enucleation socket syndrome]. / Komp'iuternye tekhnologii v diagnostike i lechenii progressiruiushchego anoftal'micheskogo sindroma.

Enucleation with primary orbital implantation and the use of ocular prosthesis does not exclude the risk of post-enucleation socket syndrome (PESS). Correction of such conditions requires modern visualization methods and software for calculation, modelling and control of the surgery. PURPOSE: To demonstrate the capabilities of modern computer technologies in diagnostics and treatment of patients with worsening post-enucleation enophthalmos. MATERIAL AND METHODS: The retrospective study included 6 patients (4 male and 2 female) aged 29-68 years who exhibited signs of PESS in 2017-2018. To define the orbital condition, patients underwent multispiral computed tomography (MSCT) and magnetic resonance imaging (MRI) followed by image analysis with computed exophthalmometry and step-by-step computed exophthalmometry. Results of these examinations helped construct 3D-models of patients' orbits, which were then used to calculate the parameters of the silicone implants. Patient-specific silicone implants were implanted into their orbits during surgery under general anesthesia. RESULTS: Implantation of the patient-specific silicone implant resulted in increase of the volume behind orbital prosthesis and correction of post-enucleation enophthalmos in all patients allowing them to use thinner, more mobile ocular prosthesis, and restore normal eyelid position. The patients also noted better appearance of the eye and personal comfort. CONCLUSION: Modern visualization methods along with computer analysis and modelling, as well as technologies to produce medical products enable creation of the best suitable patient-specific orbital implants. This allows achieving better clinical results and better quality of life for patients with monolateral anophthalmos.

Navigation-Assisted Isolated Medial Orbital Wall Fracture Reconstruction Using an U-HA/PLLA Sheet via a Transcaruncular Approach.

Purpose: We investigated the feasibility of isolated medial orbital wall fracture reconstruction using an unsintered hydroxyapatite particles/poly L-lactide (u-HA/PLLA) sheet implant with the assistance of intraoperative navigation via the transcaruncular approach. Patients and methods: Ten consecutive patients (5 males and 5 females; mean age, 57.5 years) were included based on the clinical and imaging criteria. All patients underwent surgical treatment of the isolated medial orbital wall fracture using transcaruncular incision and the u-HA/PLLA implant under navigation. The follow-up time was greater than 6 months. Preoperative and postoperative clinical data regarding the presence of diplopia, eye motility restriction, and enophthalmos were assessed. The orbital volumes of the injured and uninjured orbit were also evaluated using computed tomography images. Results: All patients had improved ophthalmologic functional and esthetic outcomes and were successfully treated without any long-term complications arising during follow-up. There was a significant difference between the preoperative and postoperative injured orbits due to herniation of the orbital contents. Moreover, the orbital volume of the postoperative injured side following surgery was the same as that of the unaffected side, indicating that anatomically good reconstruction had been obtained. Conclusions: Surgical treatment using the transcaruncular approach and u-HA/PLLA materials with intraoperative navigation is a safe, promising, and effective technique for isolated medial orbital wall fracture reconstruction.

Analysis of contemporary tools for the measurement of enophthalmos: a PRISMA-driven systematic review.

Enophthalmos has many causes, and serious post-traumatic cases indicate the need for operation. Such diagnoses should be made objectively, and a robust method for quantifying the degree to which the globe has been displaced is key. Current methods of measurement, however, have long been considered unreliable and inconsistent, in particular with regard to interobserver variability. The aim of this paper therefore was to review all these methods systematically, to analyse their reliability, and to compare them with others. The paper also includes a proposed protocol for the accurate and reliable measurement of protrusion of an eye, which aims to standardise the assessment of patients and to create a uniform approach that will enable the selection of those who are most likely to benefit from surgical treatment. Analysis of the data showed that computed tomographic (CT) exophthalmometry is the most reliable, followed by the Mourits' exophthalmometer, which performed better than the other clinical methods. In the acute phase of orbital blowout fractures, the measurement of herniated tissue through a fracture defect may give a good prediction of the degree of enophthalmos that is likely to occur without surgical correction. Measurement of the herniated volume and CT exophthalmometry should be the foundation for diagnosis and the planning of treatment. Three-dimensional imaging or Mourits' exophthalmometers (which are reliable non-radiological methods) could be used in a follow-up protocol.

A retrospective study of pure medial orbital wall fracture management.

PURPOSE: To describe the clinical presentation of isolated medial orbital wall fractures, the duration of symptoms and their management. METHODS: Retrospective study of 60 orbits of 60 patients over 18 years of age with isolated medial wall fractures of the orbit at the facial and trauma center of the Pitié-Salpêtrière university hospital of Paris between June 2012 and November 2015. Diplopia, enophthalmos and limitation of extraocular muscle movements were investigated. The location of the fractures was confirmed with three-dimensional computed tomography. Intraocular trauma was ruled out. Incomplete data were excluded. RESULTS: Eighty-three patients were identified (June 2012-November 2015). Sixty patients (39 males and 21 females) had a complete medical record. The mean age was 37 years, ranging from 18 to 75 years. Assault was the most common cause in 45 patients (75%), followed by sports accidents in 8 patients (13%), motor vehicle accidents in 6 patients (10%), and a fall in 1 patient. On presentation, 51 patients (85%) had no symptoms. Diplopia was present in 9 patients (15%). Four of them (6.7%) had associated enophthalmos. The diplopia resolved spontaneously in 5 patients (5.5%) and persisted more than 2 weeks in 4 patients (6.7%), for whom surgical intervention was recommended. Only 4 patients (6.7%) were managed surgically due to the presence of combined persistent diplopia and enophthalmos. The mean time from trauma to surgery was 18 days (15-45 days). At the 45-day postoperative follow-up, persistent diplopia was present in 1 patient out of the four treated surgically, with no residual enophthalmos. Fifty-six patients were managed conservatively. CONCLUSION: Asymptomatic fractures do not require surgical repair, and conservative management is adequate. Such fractures heal on their own without any consequences.

Bilateral Silent Sinus (Imploding Antrum) Syndrome.

Silent sinus syndrome, also termed imploding antrum syndrome, describes spontaneous enophthalmos arising from contracture of the maxillary sinus in the complete absence of any symptomatic sinonasal disease. The unusual nasal structure that probably causes the condition renders its occurrence almost exclusively unilateral. The authors describe a patient with left silent sinus syndrome, who presented 4 years later with right silent sinus syndrome; to the authors' knowledge, this is only the second case of bilateral sequential silent sinus syndrome. Each side was successfully managed with endoscopic antrostomy and secondary orbital floor repair.