Prosthetic guidelines for ocular rehabilitation in patients with phthisis bulbi: a treatment-based classification system.

Prosthetic rehabilitation of phthisis bulbi defects is the only treatment option for cosmetic rehabilitation of patients with such defects. Currently, there is no treatment-based classification for prosthetic rehabilitation of patients with phthisis bulbi. Phthisical ocular defects and/or prosthetic rehabilitation were evaluated in an attempt to establish prosthetic guidelines that could be organized into a classification system. Fifty patients who received rehabilitation for phthisis bulbi were reviewed. Phthisis bulbi defects were divided into 4 classes. All the patients had rehabilitation, depending upon the class to which they were assigned. The aim of this treatment-oriented classification system was to organize and define the complex nature of the restorative decision-making process for patients with phthisis bulbi.

Correlation between volume of herniated orbital contents and the amount of enophthalmos in orbital floor and wall fractures.

PURPOSE: To analyze the correlation between the volume of herniated orbital contents and the amount of enophthalmos in orbital floor and wall fractures. MATERIALS AND METHODS: Patients with secondary enophthalmos due to unilateral orbital floor and wall fractures were recruited. Computed tomography-assisted measurements of both orbits as well as of the amount of enophthalmos were performed. The following volumes were calculated: 1) the overall volume of both the healthy and fractured orbit, 2) the volume of herniated orbital contents at the orbital walls, 3) the volume of herniated orbital contents anterior and posterior to the vertical eyeball equator. The amount of enophthalmos was also measured by computed tomography. Multifactor linear regression analysis was performed to obtain correlations between the amount of enophthalmos and the measured volumes. RESULTS: Twenty-three patients were included. The average enophthalmos was 4.0 mm (SD = 1.49). Although correlation between volume differences of healthy and fractured sides was not statistically significant, the overall volume of the herniated orbital contents was significantly correlated (P < .05) with the amount of enophthalmos. Regarding the specific orbital sites of herniation, the orbital floor was detected to be most significantly correlated to the amount of enophthalmos (P < .05), although only the herniation posterior to the vertical eyeball equator. CONCLUSION: The overall volume of herniated orbital contents correlated significantly with the amount of enophthalmos. The orbital floor was detected to be the site most significantly correlated with the amount of enophthalmos (although only if herniation occurred posterior to the vertical eyeball equator). Only the volume of herniated soft tissues posterior to the eyeball equator showed correlation with the amount of enophthalmos.

[Enophtalmos of the anophtalmic socket: incidence of the orbital morphology and therapeutic implications. Clinical study of 86 cases]. / Énophtalmie de la cavité anophtalme : incidence de la morphologie orbitaire et implications thérapeutiques. Étude clinique de 86 cas.

AIM OF THE STUDY: From a light asymmetry to a sunken eye aspect, a great disparity between the results after anophtalmic socket rehabilitation is noticeable: what are the factors involved in the degree of residual enophtalmos following excision of the eye? The litterature's response is based on physiopathological considerations around intraorbital architectural disturbance. We propose a geometrical approach related to the existence of different morphological types of orbit. PATIENTS AND METHOD: Eighty-six records of eviscerated and enucleated patients have been studied and submitted to a statistical analysis. A preliminary study has defined four types of orbit depending on the shape and operture of the orbital "window": two opposite types IA and III, a type II intermediate and a particular one, the type IB. A classification of enophtalmos' degree allows to analyze the parameters chosen and to identify the predictive factors. RESULTS: The statistical analysis confirms the incidence of the orbital morphology on the degree of enophtalmos but do not support the theories based on the intraorbital septal architecture changes. Depending on the orbital shape and the container-content relation, the volume loss is more visible on the whole orbitopalpebral surface of opened and high orbit but remains centered on the anteroposterior position of the implant of a closed and lengthened orbit. At the contrary to the type III, the type IA is not favorable for the anophtalmic patient and predispose to a higher degree of enophtalmos. This new approach has therapeutic implications on primary and secondary surgery for volume loss replacement. CONCLUSION: The success of anophtalmic socket rehabilitation is influenced by the orbital morphological type that has to be considered in the therapeutic strategy.

Fractured orbital wall reconstruction with an auricular cartilage graft or absorbable polyacid copolymer.

OBJECTIVE: The objective of the study was to compare the functional and aesthetic results of fractured orbital wall reconstruction with an auricular cartilage graft or absorbable polyacid copolymer. MATERIALS AND METHODS: Twenty patients with blow-out orbital fracture/orbital floor associated or not with the medial wall were assessed by the same craniofacial surgical group. All were evaluated preoperatively and postoperatively by an ophthalmologist for diplopia, enophthalmos, exophthalmos, sensitivity, ophthalmic reflexes, intraocular pressure, and visual field.The patients were subjected to a preoperative facial multislice computed tomographic scan, repeated 6 months after surgery. Eight patients underwent reconstruction with an auricular cartilage graft, and 12 patients, with blade absorbable polyacid copolymer. Subtarsal access was used for all patients. RESULTS: Two patients showed temporary ectropion, 1 in each group. All patients presented satisfactory ocular function, and all tests revealed good orbital delineation, orbital symmetry, periorbital sinus individualization, and reduction of blow-out. CONCLUSIONS: The blow-out orbital wall reconstruction can be performed with the use of an auricular cartilage or with a blade absorbable copolymer without differences regarding functional or aesthetic complications and sequelae.

Displacements of eyeball in orbital blowout fractures.

Thirty-two cases of orbital blowout fracture, excluding those of linear fracture with trap-door variety, were selected to study the changes of the eyeball position: posterior displacement or enophthalmos, medial and inferior displacement. Two-millimeter slices of computed tomographic scans were taken, and the eyeball positions were measured with the contralateral eye as a control. Intraorbital edema, if present, at least 10 days after injury had little effect on the position of the eyeball, nor was there any evidence to suggest the late onset of enophthalmos. Enophthalmos remains around 1 mm before total orbital enlargement reaches 2 ml in volume, thereafter increases proportionally with total orbital enlargement until 4 ml, then remains on a plateau. Enophthalmos increases proportionally with the increase of medial orbital wall enlargement when the inferior orbital wall enlargement is less than 2 ml. With inferior wall enlargement more than 2 ml, 3 to 4 mm of enophthalmos is seen irrespective of the increase of medial wall enlargement. The medial displacement of the eyeball increases proportionally with the increase of medial wall enlargement when inferior wall enlargement is less than 2 ml. The inferior displacement of the eyeball has little proportional relationship with medial or inferior wall enlargement when the former exceeds 2 ml. Relatively good proportional relationship is found between the enophthalmos and the medial displacement of the eyeball, but not between the enophthalmos and the inferior displacement of the eyeball.

Comparison of conchal cartilage graft with nasal septal cartilage graft for reconstruction of orbital floor blowout fractures.

Our aim was to compare autogenous nasal septal cartilage and conchal cartilage as grafts for reconstruction of orbital blowout fractures. Twenty-two patients with blowout fractures were randomly assigned to two groups for treatment with a graft of nasal septal cartilage or conchal cartilage. Patients were evaluated for the presence of enophthalmos, diplopia, dysfunction of the infraorbital nerve, and restriction of the ocular muscles. Patients with enophthalmos of more than 2 mm were included in the study, and were followed up postoperatively at 10 days, 1 month, and 3-6 months. The patients treated with a nasal septal cartilage graft had significantly better correction of enophthalmos than those treated with conchal cartilage (p=0.02) after 10 days (p=0.02), 1 month (p=0.004), and 3-6 months (p=0.001). There was significantly less residual enophthalmos in the nasal septal graft group after 1 month (0.91 compared with 1.72 mm, p=0.02), and after 3-6 months (1.0 compared with 2.54 mm, p=0.008). Correction of enophthalmos was considerably better in patients who were operated on within 4 weeks of injury. We think that nasal septal cartilage is a better graft than conchal cartilage for reconstruction of blowout fractures. The time to intervention (the earlier the better) is a critical point in the correction of enophthalmos.

When is enophthalmos "significant"?

PURPOSE: It is currently unknown how many measurable millimeters of enophthalmos may be noticeable to an observer. Identifying the amount of enophthalmos present may help to guide patients and clinicians in regard to surgical management of enophthalmos. METHODS: The Massachusetts Eye and Ear Infirmary Oculoplastics imaging database was used to select 12 photographs of patients with unilateral enophthalmos whose measurements ranged between 1 mm and 8 mm for the study group and 12 photographs of patients who did not have enophthalmos as the control group. Observers were asked to review each of the photographs from both groups and to comment on whether the appearance was normal or abnormal. RESULTS: There was no statistical difference found when observers reviewed photographs from the control group and patients whose measurements ranged between 1 mm and 2 mm (87%, 83% respondents identifying patients as normal, respectively). Twenty-eight percent of observers found patients with 3 mm and 4 mm of enophthalmos as having a normal appearance (P < 0.001). Ninety-seven percent of observers commented that patients with measurements of 5 mm and 8 mm had an abnormal appearance (P < 0.001). CONCLUSIONS: Patients with 2 mm and less of measurable enophthalmos had a normal appearance as frequently as those without enophthalmos. Nearly all patients with measurements of 5 mm and greater had abnormal appearances. The point at which enophthalmos becomes detectable lies between 3 mm and 4 mm.