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.

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.

Neumomediastino secundario a fractura aislada de piso de órbita / Pneumomediastinum secondary to isolated fracture of orbit floorx

Resumen Introducción: El neumomediastino se define como la presencia de aire o gas dentro de los planos fasciales del mediastino. Por lo general, es un fenómeno secundario a perforaciones traumáticas del tracto aerodigestivo. El neumomediastino secundario a una fractura orbitaria es un evento raro. Se asocia a complicaciones potencialmente mortales como el neumotórax, el neumopericardio y la mediastinitis. Objetivo: Describir un caso de neumomediastino secundario a una fractura aislada de piso orbitario y su manejo médico-quirúrgico. Caso clínico: Paciente de sexo femenino de 42 años que sufre traumatismo en regiones facial, cervical y torácica desarrollando secundariamente un enfisema subcutáneo panfacial y un neumomediastino, el cual se resuelve exitosamente. Discusión: El neumomediastino secundario a una fractura aislada de piso orbitario es un evento muy raro. El aire puede descender a lo largo de los espacios fasciales hasta el mediastino. En este sentido, sonarse la nariz es un factor de riesgo para desarrollar esta pa-tología. Conclusión: Ocurrido un trauma maxilofacial puede presentarse enfisemas de espacios profundos de la cabeza, cuello e incluso el mediastino.

Introduction: Pneumomediastinum is defined as the presence of air or gas within the fascial planes of the mediastinum. It is usually a phenomenon secondary to traumatic perforations of the aerodigestive tract. Pneumomediastinum secondary to an orbital fracture is a rare event. And it is related to life-threatening complications such as pneumothorax, pneumopericardium and mediastinitis. Aim: To describe a case of pneumomediastinum secondary to an isolated orbital floor fracture and its medical-surgical management. Clinical case: A 42-year-old female patient who suffers trauma to the facial, cervical and thoracic regions, secondary development of a subcutaneous panfacial emphysema and pneumomediastinum, which resolves successfully. Discussion: Pneumomediastinum following an isolated orbital floor fracture is a very rare event. The air can descend along the fascial spaces to the mediastinum. In this sense, blowing your nose is a risk factor to develop this pathology. Conclusion: After a maxillofacial trauma, emphysema of the deep spaces of the head, neck and even the mediastinum can occur

Nonlinear dynamic analysis of the pure "buckling" mechanism during blow-out trauma of the human orbit.

Considering the interplay between orbital bones and intraorbital soft tissues, commonly accepted patterns of the blow-out type of trauma within the human orbit require more thorough investigation to assess the minimal health-threatening impact value. Two different three-dimensional finite element method (FEM) models of the human orbital region were developed to simulate the pure "buckling" mechanism of orbital wall fracture in two variants: the model of orbital bone elements and the model of orbital bone, orbit and intraorbital tissue elements. The mechanical properties of the so-defined numerical skull fragment were applied to the model according to the unique laboratory tensile stress tests performed on small and fragile specimens of orbital bones as well as using the data available in the literature. The nonlinear transient analysis of the contact problem between bodies that differ substantially in terms of the Young's modulus was carried out to investigate the interaction of different bodies within an instant injury. Potential damage areas were found within the lower orbital wall as well as the destructive load values for both FEM skull models (7,660 N and 8,520 N). Moreover, numerical simulations were validated by comparing them with computed tomography scans of real injuries.

Efficacy of transconjunctival approach for the treatment of orbital fractures: A protocol for systematic review and meta-analysis.

BACKGROUND: This study aims to assess the efficacy of transconjunctival approach (TCA) for the treatment of orbital fractures (OF) comprehensively and systematically. METHODS: In this study, we plan to search electronic databases of Cochrane Library, MEDLINE, EMBASE, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and for relevant randomized controlled trials. All these databases will be searched from inception to the March 1, 2020 without limitations of language and publication status. Two independent authors will carry out study selection, data collection, and study quality assessment. Any disagreements will be resolved by discussion with another author if necessary. The study quality will be assessed using Cochrane risk of bias tool. Statistical analysis will be conducted using RevMan 5.3 software. RESULTS: This study will be the first 1 to exert direct evidence to evaluate the efficacy of TCA for the treatment of OF. CONCLUSIONS: The findings of this study will provide an exhaustive view of TCA for the treatment of OF. STUDY REGISTRATION NUMBER: INPLASY202040154.

Prediction of late enophthalmos using quantitative measures in isolated medial orbital wall fracture: Multiple regression analysis.

BACKGROUND: Enophthalmos is one of the most distressing complications of orbital fracture, and when faced with a blowout fracture, plastic surgeons often find it difficult to determine the need for surgical correction. Although a number of studies have been conducted on this topic, no study has yet been performed using a set of measurable parameters. METHODS: We quantitatively measured orbital fracture areas (OFA), volumes (OFV), and medial rectus muscle cross-sectional ratios in patients with an isolated medial orbital wall fracture defect during a 5-year period from 2014 to 2018. Only conservatively treated patients constituted the study cohort. Enophthalmos was measured by two plastic surgeons at ≥6 months after trauma. We analyzed correlations between various parameters and degrees of late enophthalmos in the study cohort. RESULTS: Significant correlations were observed between several parameters and late enophthalmos. Multiple regression analysis resulted in the following coefficients: -0.449 is constant (p = 0.017), 0.596 and 0.460 for OFA (p = 0.000) and OFV (p = 0.005), respectively. However, no significant relationship was observed between enophthalmos and medial rectus muscle cross-sectional ratios (p = 0.340). CONCLUSIONS: The results of this study enable the degree of late enophthalmos in conservatively treated patients to be predicted using OFV and OFA values. We suggest five indications that require surgical correction without long-term clinical follow-ups: (1) OFA ≥ 1.90 cm2, (2) OFV ≥ 1.00 cm3, (3) 1.30 OFA + OFV > 5.32, (4) signs of muscle incarceration, and (5) signs of severe retrobulbar hematoma. The more satisfactory the five indications are, the greater is the need for surgery.

Water balloon-induced orbital fracture in an aviator.

BACKGROUND: Orbital fractures are common injuries found in facial trauma. Typical etiologies of orbital fractures include motor vehicle collisions and assault. We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon. Additionally, we describe the aeromedical complications that may result from this injury. Finally, we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature. CASE PRESENTATION: A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit. Shortly afterwards, he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department. Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema. The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate. Four weeks later, he returned to flying status. CONCLUSIONS: Water balloons are thought to be safe and harmless toys. However, when coupled with slingshots, water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures. These injuries are concerning to aviators, as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses. At altitude, gases in the sinuses may expand and enter the orbit through these fractures, which may suddenly incapacitate the flyer. It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Does vertical incomitance predict the diplopia outcome in orbital fracture patients? A prospective study of 188 patients.

OBJECTIVE: To determine the predictive value of vertical incomitance for diplopia outcome in orbital fracture patients. PATIENTS AND METHODS: A prospective cohort study composed of patients with orbital fractures was designed. The predictor variable was vertical incomitance, and the primary outcome variable was diplopia. Incomitance was calculated in prism diopters (Δ) as the difference of the maximum absolute deviation between the upper and lower three gaze directions. Standard statistics for patient characteristics, the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were computed. RESULTS: The sample was composed of 188 patients grouped as follows: non-operated (n = 124) and operated (n = 64). Fifty-one patients showed vertical incomitance of whom 10 (19.6%) had persistent diplopia at the 1-year follow-up. The mean incomitance was 9.6Δ in the diplopia group versus 2Δ in the non diplopia group (OR = 1.13; p < 0.001). There was a statistically significant association between vertical incomitance of >2Δ and persistent diplopia at 1 year after adjusting for the surgery variable (OR = 1.07; p < 0.04). CONCLUSION: The present study has demonstrated that in orbital fracture patients, vertical incomitance was associated with (1) persistence of long-term diplopia, (2) the decision to perform surgery, and (3) the severity of the fracture.

Assessing the precision of posttraumatic orbital reconstruction through "mirror" orbital superimposition: A novel approach for testing the anatomical accuracy.

Orbital reconstruction in cases of trauma is usually performed using the unaffected side orbital volume as a reference, but this measurement does not fully consider the anatomical characteristics of orbital surfaces. We propose a novel procedure based on the registration of 3D orbital segmented surfaces. Reconstructed orbits from 20 patients and healthy orbits from 13 control subjects were segmented from the post-operative CT-scans. The 3D orbital model from the unaffected orbit was "mirrored" according to the sagittal plane and superimposed onto the reconstructed one, with calculation of volumes, asymmetry index and point-to-point RMS (root mean square) distances. Inter- and intra-observer errors were tested through Bland-Altman plot. Differences in volume, asymmetry index and RMS value between the control group and the treated patients were assessed through two-way ANOVA and Student's t-test (p < 0.05). According to Bland-Altman test, intra- and inter-operator repeatability was respectively 87% and 89%. No significant differences in volume or asymmetry index between the control group and the treated patients were observed (p > 0.05), but the RMS value was significantly larger in the latter ones (on average, 0.90 ± 0.26 mm vs. 0.67 ± 0.17 mm, p < 0.05). Results show that the reconstructed orbits present a morphologically different surface from the unaffected ones.

Similarity in Bilateral Isolated Internal Orbital Fractures.

PURPOSE: In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma. METHODS: A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity. RESULTS: Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026). CONCLUSIONS: The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.

Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury.

OBJECTIVE: The detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI. METHODS: This retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients. RESULTS: A total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06-8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08-9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01-1.04; P = 0.002) were independent risk factors for concomitant intracranial injury. CONCLUSIONS: Emergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.

Comparison analysis of orbital shape and volume in unilateral fractured orbits.

Facial fractures often result in changes of the orbital volume. These changes can be measured in three-dimensional (3D) computed tomography (CT) scans for preoperative planning and postoperative evaluation. The aim of this study was to analyze the orbital volume and shape before and after surgical treatment of unilateral orbital fractures using semi-automatic image segmentation and registration techniques. The orbital volume in 21 patients was assessed by a semi-automatic model-based segmentation method. The fractured orbit was compared relative to the contralateral orbit. The same procedure was performed for the postoperative evaluation. Two observers performed the segmentation procedure, and the inter- and intraobserver variability was evaluated. The interobserver variability (mean volume difference ± 1.96 SD) was -0.6 ± 1.0 ml in the first trial and 0.7 ± 0.8 ml in the second trial. The intra-observer variability was -0.2 ± 0.7 ml for the first observer and 1.1 ± 0.9 ml for the second observer. The average volume overlap (Dice similarity coefficient) between the fractured and contralateral side increased after surgery, while the mean and maximum surface distance decreased, indicating that the surgery contributed to a re-establishment of size and shape. In conclusion, our study shows that the semi-automatic segmentation method has precision for detecting volume differences down to 1.0 ml. The combination of semi-automatic segmentation and 3D shape analysis provides a powerful tool for planning and evaluating treatment of orbital fractures.

Quantitative assessment of orbital fractures in Asian patients: CT measurement of orbital volume.

Enophthalmos is caused by an increase of orbital volume after blowout fracture and is one of the most critical complications of such fractures, but is often masked by swelling soon after injury. If surgery is performed after swelling resolves, it becomes more difficult to treat enophthalmos because of atrophy and fibrosis. Accordingly, it is important to estimate the severity of enophthalmos soon after injury. We developed a new criterion for determining whether orbital fractures are indicated for surgery in Asian patients using analysis of orbital volume. We retrospectively calculated the orbital volume of patients treated surgically or conservatively and analyzed the correlation between changes of orbital volume and the severity of enophthalmos. Regression analysis of the correlation between enophthalmos and increased orbital volume (y = 0.8x + 0.2; correlation coefficient: 0.92) showed that enophthalmos of 2.0 mm corresponded to an increase in orbital volume of 2.25 cm3. This result is similar to data reported previously for Caucasian patients - enophthalmos of 2.0 mm is a common surgical indication worldwide. Our results suggest that an increase of orbital volume of >2.25 cm3 could be a new criterion for surgical treatment of blowout fractures in Asians.

Differences in interpalpebral fissure measurement in patients with unilateral enophthalmos resulting from orbital wall fractures.

PURPOSE: To determine the correlation between the degree of enophthalmos and interpalpebral fissure (IPF) measurements in a group of patients with unilateral orbital wall fractures. MATERIALS AND METHODS: The medical charts of 45 patients diagnosed with unilateral enophthalmos resulting from an orbital wall fracture were reviewed. Demographic characteristics were investigated, including patient age, sex, medical history, and type of orbital wall fracture. The correlation between the degree of enophthalmos and IPF was determined, adjusting for confounding demographic factors. RESULTS: In the group with orbital wall fractures, the correlation between the degree of enophthalmos and the IPF measurements was positive and significant (R = 0.299, p = 0.046, Pearson's correlation). The correlation coefficient increased after adjusting for age, sex, medical history, and type of orbital wall fracture (R = 0.316, p = 0.044). CONCLUSION: The patient group with more severe enophthalmos tended to have lower IPF values.

Anatomical Study of the Infraorbital Nerve and Surrounding Structures for the Surgery of Orbital Floor Fractures.

The infraorbital nerve (ION) can easily be damaged by orbital trauma and periorbital surgical manipulations, due to its abutment to the orbital floor. Anatomic variability of the ION and surrounding structures has infrequently been documented. The aim of this study is to give precise anatomical knowledge about the ION with surrounding structures, to avoid iatrogenic injury of the ION during periorbital procedures.Forty orbits of 40 skull subjects (20 males and 20 females) were studied to analyze structures around the ION. The authors located the ION, infraorbital canal/groove (IOC/G), and infraorbital foramen (IOF), using several reference points. The various distances were also measured between those structures, and statistically analyzed. The authors compared the left and right sides, and analyzed the differences between both sexes. The IOF was also investigated regarding the shape and presence of the accessory IOF.Three different types of orbital floor osseous anatomy were made based on macroscopic analysis. Type 1 shows no groove, and the ION enters the canal covered by the roof (5 patients, 12.5%). Type 2 revealed a pseudocanal, which has a very thin, almost transparent roof (26 patients, 65.0%). Type 3 consists of the ION traveling in a true groove, before entering an IOC (9 patients, 22.5%). IOG/C complexes took the upward lateral course, until exiting via the IOF. The mean ±â€ŠSD length of the IOC was 12.86 ±â€Š3.79 mm, and of the IOG was 16.15 ±â€Š2.88 mm. The calculated combined mean length of the IOC/G complex was found to be 29.01 ±â€Š3.17 mm. An accessory IOF was found in 35% of the skulls (50% in male and 20% in female skulls), with a higher frequency on the left side in both male and female skulls.These results can increase the authors' knowledge of the anatomic variability of the infraorbital region, and help facial plastic surgeons during their surgical manipulations prevent any possible iatrogenic injury of the ION.

[Imploding antrum syndrome: three cases with different management approaches]. / Síndrome de implosión maxilar: tres casos y sus diferentes abordajes de tratamiento.

BACKGROUND: Silent sinus or imploding antrum syndrome is a very rare condition, consisting of a usually asymptomatic spontaneous collapse of the sinus walls and floor of the orbit. It is associated with negative pressures, and when this occurs, it presents with manifestations such as enophthalmos, hypoglobus, and tilt flow orbital floor. As its incidence is very low, it is frequently missed as a diagnosis, and in fact there are currently fewer than 150 cases reported in the literature. CLINICAL CASES: Three patients have been identified in our practice over a period of two years, with different symptoms that influenced the decision of the treatment modality, which were: watch and wait, endoscopic sinus surgery, or endoscopic sinus surgery plus orbitoplasty. CONCLUSIONS: Despite being a rare entity, it stills catches the attention of the ENT, OMF surgery and Ophthalmologist. The diagnosis is mainly radiological, due to the late clinical manifestations and symptomatology. The treatment should be individualised and based on the symptoms and the individual decision of each patient, firstly by Functional Endoscopic sinus surgery, and once sinus permeability is restored, it may require augmentation surgery of the orbital floor, either with autologous bone implant, titanium or other material. It is important to be aware of this pathology, to know and to suspect it, avoiding misdiagnosis.

Influence of the volume of soft tissue herniation on clinical symptoms of patients with orbital floor fractures.

INTRODUCTION: One of the most important complications of orbital floor fractures is diplopia and restricted ocular movement. The role of the volume of soft tissue herniation on these clinical symptoms after orbital floor fractures is unclear and potentially may predict development of persistent clinical symptoms. Therefore the aim of this study was to assess pre- and postoperative complications associated to the volume of soft tissue herniation, with special interest to diplopia and bulbus motility impairment. MATERIAL AND METHODS: 204 untreated patients with orbital floor fractures from 2009 to 2011 were included in this retrospective study. Contingency tables and χ2-test were performed to analyze associations between two qualitative variables. p-Values p < 0.05 were considered as significant. Volume measurement was performed in a semiautomatic segmentation method with the software "ITK-Snap". RESULTS: The volume of soft tissue herniation correlated significantly with pre- and postoperative diplopia (p = 0.003; p = 0.002), persistent diplopia (p = 0.009) as well as pre- and postoperative bulbus motility impairment (both p < 0.001). Furthermore we found out significant associations between the volume of soft tissue herniation and pre- and postoperative complications depending on fracture type and reconstruction technique. CONCLUSIONS: Volume measurement of soft tissue herniation may help to predict postoperative complications, particularly bulbus motility restriction and persistent diplopia. The risk for these symptoms rises with increasing volume of soft tissue herniation after orbital floor fractures. Therefore we recommend for these patients within indication an early repair and/or closer observation.

Orbital Fat Prolapse Into the Nasal Cavity in Orbital Blowout Fracture.

In this study, the authors describe the first report of 2 patients of fat prolapse into the nasal cavity by orbital blowout fracture. The patients were a 58-year-old male and an 86-year-old female. The patients could not attain binocular single vision in any eye position because of severe impairment of the extraocular muscle motility. Computed tomographic images of both patients revealed orbital blowout fractures with orbital fat prolapse into the nasal cavity. The fractures were reduced under transconjunctival/transcaruncular and endonasal endoscopic approaches. Six months postoperatively, the patients attained a binocular single vision field, including in the primary eye position.

How reliable is the visual appraisal of a surgeon for diagnosing orbital fractures?

PURPOSE: The aim of this study was to evaluate the usefulness of intra-operative visualisation, endoscopic assistance, and CT measurements for estimating the orbital fracture size and complexity. METHODS: Ten human cadaver heads were subjected to thin-slice computed tomography (CT). Standardised fractures were created using piezoelectric surgery in accordance with the Jaquiéry classification system. Four surgeons and one anatomist used six different observation methods to visualise and describe the orbital defects. RESULTS: The intraclass correlation coefficients (ICCs) for the fracture length measurements were relatively low for all observation methods (range, 0.666-0.883). CT measurements of width showed high consistency (ICC, 0.910). The surface area of the defect was highly overestimated by all methods (range, 121-184%). None of the observers was able to accurately estimate the length or width of 95% of the defects within an error range of ±0.75 cm. CONCLUSION: CT measurements are the most consistent and accurate tool for estimating the critical size of orbital factures. In daily practice, a measurement tool in a DICOM viewer could be used, although software packages that allow manual adjustments are advisable. Direct intraoperative visualisation and surgeon experience are of limited value in the estimation of fracture size and complexity, and endoscopy provides no additional advantages.