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.

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.

Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management.

OBJECTIVE: The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos. METHODS: In this retrospective institutional review board-approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair. RESULTS: Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93. CONCLUSION: Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

Pediatric Orbital Floor Fractures: Outcome Analysis of 72 Children with Orbital Floor Fractures.

BACKGROUND: Orbital floor fractures are uncommon in the pediatric population. The aim of this study was to review the presentation, management, and outcomes for children with these injuries. METHODS: A retrospective review was performed on 72 consecutive children with orbital floor fractures over a 21-year period. RESULTS: Seventy-two patients with 76 fractures were identified. Mean follow-up time was 14.2 ± 4 months. The majority (50 percent) of patients suffered minimally displaced fractures, whereas 17 percent (13 of 76) suffered blowout fractures and 5 percent (four of 76) suffered trapdoor fractures. Nineteen percent of children (14 of 72) presented with decreased visual acuity and 8 percent (six of 72) had enophthalmos on presentation. Thirty-three percent (24 of 72) underwent surgery. The most common indications for surgery were size of the fracture, followed by muscle entrapment. Fracture width and the defect width-to-orbital width ratios were significantly greater in the operative cohort versus their conservatively managed counterparts (20.7 mm versus 7.7 mm, p < 0.05, and 0.54 versus 0.32, p < 0.05, respectively). Surgery was not associated with improved visual outcomes (p < 0.05). However, patients who underwent reconstruction had a significantly lower adjusted risk of enophthalmos on follow-up (relative risk, 0.02; 95 percent CI, 0.00 to 0.49; p < 0.05). CONCLUSIONS: Operative intervention prevents enophthalmos in pediatric patients with pediatric orbital floor fractures, and patients who present with decreased visual acuity should be cautioned that surgical intervention does not improve visual outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Orbital, periorbital, and ocular reconstruction.

The repair and restoration of the eyelids and orbit can be a medical and surgical challenge. Inadequate orbital volume restoration could lead to poor functional and cosmetic defects. With advances in technology, our surgical techniques are constantly improving. This article focuses on ocular and orbital reconstruction following traumatic, iatrogenic, and acquired defects. Optimal outcomes can only be expected with appropriate diagnosis treatment planning in consultation with other specialists.

Computer-guided orbital reconstruction to improve outcomes.

OBJECTIVES: (1) To describe repair of complex orbital fractures using computer planning with preoperative virtual reconstruction, mirror image overlay, endoscopy, and surgical navigation. (2) To test the hypothesis that this technique improves outcomes in complex orbital fractures. METHODS: A series of 113 consecutive severe orbital fracture cases was analyzed, 56 of which were performed with mirror image overlay guidance, and 57 of which were repaired without. Data were collected on patient characteristics, fracture severity, diplopia and globe position outcomes, complications, and need for revision surgery. RESULTS: The mirror image overlay group showed decreased postoperative diplopia in all fracture types (P = .003); the effectiveness was maximal for fractures that involved 3 or 4 walls or the posterior one-third of the orbital floor (P < .001). The need for revision surgery was greatly reduced in this cohort (4% vs 20%; P = .03). CONCLUSIONS: The efficacy of mirror image overlay navigation and orbital endoscopy was studied in one of the largest series of complex orbital fractures in the literature. Based on statistically significant improved outcomes in postoperative diplopia and orbital volume, as well as the decreased need for revision surgery, we accept the hypothesis that mirror image overlay guidance improves outcomes in complex orbital reconstruction and recommend its use for complex orbital fracture repair.

Orbital floor reconstruction considering orbital floor slope.

Orbital floor fractures are among the more challenging injuries faced by plastic surgeons. Enophthalmos is defined as backward, usually downward, displacement of the globe into the bony orbit. We describe reconstruction of the orbital floor slope in orbital floor fractures that prevents postoperative complications, especially posttraumatic enophthalmos. Thirty-three patients with orbital floor fractures were treated using reconstruction of the orbital floor slope between April 2009 and July 2010. The patients ranged in age from 12 to 54 years. There were 31 males and 2 females. All patients were operated on using a transconjunctival approach under general anesthesia. The orbital floor was reconstructed with poly-l/d-lactide sheets in all cases. Preoperatively, 23 [Float1]patients (69%) had enophthalmos, and 12 patients (36%) had symptomatic diplopia. The enophthalmos was corrected in 20 patients (86%), and the diplopia resolved in 10 (83%). Extrinsic ocular movement was impaired preoperatively in 1 patient (3%), but resolved after surgery. No patient had impaired visual acuity preoperatively or postoperatively. The results suggest that orbital floor reconstruction considering the orbital floor slope is a safe, reliable method with fewer complications that is more effective at preventing posttraumatic enophthalmos.

[Use of constructions from porous titanium nikelide for treatment of fractures of lower wall of eye-socket].

Surgical reconstructive treatment was done in 45 patients with fractures of lower wall of eye-socket in the clinic of maxillofacial surgery of MMA (named after I.M. Sechenov) during the period from July 2007 to July 2008. All fractures were cured with constructions from titanium nikelide. Use of implants from porous titanium nikelide let to shorten the operation time, to decrease the risk of infection joining, to prevent fibrous capsule formation along implant periphery that was essential in prevention of scarring and enophthalmia.

Huge orbital teratoma with intracranial extension: a case report.

The authors present an unusual case of huge orbital teratoma extended to the cranial fossa in a newborn baby. The clinical features, radiologic findings, and surgical approach are described. Discussion will focus on the surgical technique and on the sparing of the affected eye, comparing the authors approach with other few cases described in literature. Finally, detailed histopathologic finding is provided.

Reconstruction of orbital floor fractures: comparison of individual prefabricated titanium implants and calvarial bone grafts.

We assessed fresh (< or = 2 weeks) and old (>2 weeks) orbital floor fractures and examined how selection of the implant affected the development of enophthalmos or the treatment of pre-existing enophthalmos. We conducted a retrospective review of 61 cases treated with calvarial bone grafting or individually prefabricated titanium mesh implants. The features of orbital floor fractures and orbital volume (OV) changes were analyzed by a 3-dimensional medical surface rendering image software system. The difference in OV before and after surgery was significant (P < 0.05) in fresh and old fractures treated with either calvarial bone or individually designed titanium mesh. The difference in OV between unaffected and postoperatively affected sides was not significant in the group that received the individually designed titanium mesh, but was significant in the group that received calvarial bone. Spearman rank correlation analysis indicated positive correlations between enophthalmos and postoperative OV changes after implantation of cranial bone in fresh fractures or titanium mesh in fresh and old fractures. The long-term degree of enophthalmos can be predicted with 3-dimensional medical surface rendering. Individual digitally designed titanium mesh is the proper choice of implant material to recover precise OV in fresh or older orbital fractures.

Combined transconjunctival and transcaruncular approach for repair of large medial orbital wall fractures.

OBJECTIVES: To describe the combined transcaruncular and transconjunctival approach in isolated large medial orbital wall fractures and to study the implications of uncorrected posterior orbital volume on postoperative enophthalmos. METHODS: A retrospective medical record review was performed of 23 consecutive patients who underwent reduction surgery for isolated large medial orbital wall fractures using the combined transcaruncular and transconjunctival approach between February 1, 2003, and October 31, 2007. The unaffected contralateral orbital volume was assumed to represent the pretrauma volume of the affected orbit, and the uncorrected posterior orbital volume after reduction was determined using a software program. RESULTS: The mean (SD) volume of the affected orbit changed from 26.00 (2.01) cm3 to 24.08 (2.06) cm3 after reduction, which was still larger than the contralateral unaffected orbit by 1.48 (0.83) cm3. Despite the uncorrected volume in the most posterior portion of the medial wall, the mean (SD) postoperative enophthalmos measured only 0.17 (0.29) mm using Hertel exophthalmometry at a mean follow-up of 8.5 months. CONCLUSIONS: The combined transconjunctival and transcaruncular approach results in excellent outcomes in terms of prevention of postoperative enophthalmos of the large medial wall fracture without substantial complications. The far posterior medial volume may not contribute significantly to the development of posttraumatic enophthalmos.

Early versus late repair of orbital blowout fractures.

BACKGROUND AND OBJECTIVE: To compare early and late surgical repair of orbital blowout floor fractures. PATIENTS AND METHODS: A retrospective, comparative interventional case series reviewed medical records of 50 consecutive patients who underwent unilateral orbital floor fracture repair in a 4-year period. Comparative analysis was performed between patients operated on within 2 weeks of injury and those operated on at a later stage. RESULTS: Assault, motor vehicle accidents, and sports injuries were the most common causes of injury. Surgery was performed due to inferior rectus muscle entrapment and limitations in up gaze in 20 (40%) patients or to prevent enophthalmos in cases with significant bony orbital expansion in 30 (60%) patients. After surgery, enophthalmos improved an average of 0.8 mm. Limitation in ocular motility improved after surgery but was statistically significant only in up gaze. Patients who underwent early repair (within 2 weeks) achieved less improvement in enophthalmos versus patients who underwent late repair (delta enophthalmos of 0.2 +/- 1.1 vs 1.3 +/- 1.9 mm, respectively; P = .02). CONCLUSION: In these patients, postoperative vertical ductions and postoperative enophthalmos improved after fracture repair. Surgery was associated with a low rate of postoperative complications. No apparent difference in surgical outcome was seen between early (within 2 weeks) and late surgical repair.

Nylon foil "wraparound" repair of combined orbital floor and medial wall fractures.

PURPOSE: To evaluate a technique of implanting a single 0.4-mm-thick nylon foil (Supramid) continuously across combined medial wall and floor fractures within weeks of orbital trauma. METHODS: This retrospective, interventional case series includes patients with combined medial wall and floor fractures with or without external orbital and facial fractures, without prior surgery, and who were in the early posttrauma phase. One hundred two orbits in 98 consecutive patients were treated with a "wraparound" technique. The surgical technique is provided in detail. Comatose patients, those with cranial nerve palsies, severe globe injury, anophthalmia, or previous repair of the same fractures were excluded. Patients underwent surgery from 5 to 21 days after trauma. Postoperatively (average, 6.2 months), patients were evaluated for enophthalmos, extraocular motility, and diplopia. RESULTS: In 101 of 102 orbits, normal globe position, and full extraocular motility without diplopia was accomplished. One orbit had persistent enophthalmos, requiring a second procedure. This same patient had ipsilateral restriction in extreme upgaze, but no diplopia symptoms. This orbit had complete loss of inferomedial strut support. Overall, strut loss was not a risk factor for subsequent enophthalmos. No other patient had globe malposition, restrictive myopathy, or diplopia. Implant migration, hemorrhage, fistula, or infection was not observed. The transconjunctival and canthal wounds were hidden and tolerated by all patients with no eyelid cicatrization, webbing, or malposition. CONCLUSIONS: The "wraparound" technique for 0.4-mm nylon foil implantation continuously across orbital floor and medial wall fractures was associated with almost no enophthalmos and diplopia in this series.

Deep orbital Sub-Q restylane (nonanimal stabilized hyaluronic acid) for orbital volume enhancement in sighted and anophthalmic orbits.

OBJECTIVE: To describe a new technique of injecting Restylane Sub-Q (Q-Med, Uppsala, Sweden) into the intraconal and extraconal posterior orbit. METHODS: Retrospective review. Eight injections were performed in 5 patients using 2-mL Sub-Q in the intraconal and extraconal posterior orbit for orbital volume enhancement. Four injections were performed in sighted orbits and the remaining in anophthalmic orbits. The age range was 18 to 36 years; the follow-up time was 5 to 12 months. RESULTS: Orbital volume enhancement was achieved in all cases with an improvement in upper eyelid sulcus and skin fold. Enophthalmos reduction was 2 mm per 2-mL injection. The procedure was well tolerated. One patient experienced a vasovagal episode lasting 3 hours and 1 patient had postoperative pain. No such episodes occurred after I began injecting local anesthesia before performing the Sub-Q injection. One patient required hyaluronidase for migrating gel, which caused lower eyelid swelling. CONCLUSION: This small case series suggested the safety and tolerability of deep orbital Sub-Q. Injections are easily performed in the outpatient setting. The expected volume enhancement was achieved in all cases with no long-term adverse effects to date.

Orbital floor reconstruction with flexible Ethisorb patches: a retrospective long-term follow-up study.

OBJECTIVE: The purpose of the study was to investigate whether a flexible, biodegradable material (Ethisorb) shows better long-term results with regard to diplopia, bulbus motility, and exophthalmos/enophthalmos compared to the use of lyophilized dura-patches and polydioxanone (PDS) foils. METHODS: During a period of 6 years 435 patients with an orbital fracture were investigated retrospectively. Inclusion criteria were patients with fractures of the orbital floor with a maximum size of 2 x 2 cm. Bulbus motility, exophthalmos, enophthalmos, and diplopia were investigated during a period of 2 years. RESULTS: One hundred twenty orbital floors were reconstructed by lyophilized dura-patches, 81 by PDS, and 136 by Ethisorb. An exploration without an implantation was performed in 91 patients. The long-term investigation 12 to 15 months after surgery showed an exophthalmos and enophthalmos incidence of 1%, whereas a reduced bulbus motility and diplopia were found in 5% and 4%, respectively. Fifteen to 24 months after surgery 2% of the patients had an exophthalmos and 1% had an enophthalmos. A reduction of bulbus motility was found in 4% of the patients, and diplopia was found in 3%. The use of Ethisorb resulted in a significantly lower incidence of exophthalmos 3 months after surgery compared to PDS. CONCLUSION: The low rate of acquired bulbus motility demonstrates acceptable results in using Ethisorb in the floor of the orbit.

Orbital floor reconstruction with an alloplastic resorbable polydioxanone sheet.

The orbital floor is frequently reconstructed after blow-out fractures or midface fractures to avoid a relapse of the repositioned orbital tissue and to prevent enophthalmos. A total of 31 patients underwent reconstruction of internal orbital wall fractures with a resorbable 0.25 mm or 0.5 mm-thick polydioxanone implant (PDS). Skeletal and functional outcome was evaluated retrospectively with regard to fracture size. Fracture size was graded as small, moderate or large by CT scans and operating records. Two of the 25 patients with small or moderate defects showed an enophthalmos of 2-3 mm. Five of the six patients with large defects or two orbital wall fractures had enophthalmos. The scar that formed after implant resorption was to weak to provide adequate support of the globe or to compensate the enlarged orbital volume. Endoscopic follow-up examination of 12 patients showed yielding of the scar in the orbital floor already in moderate defects. Eight patients had diplopia in extreme gaze and two had significant diplopia. Blow-out and midfacial fractures with small to moderate defects in the orbital floor (up to a size of 2.5 cm2) can be reconstructed by polydioxanone sheet to avoid enophthalmos. Polydioxanone implants should only be used in cases without massive orbital fat herniation. The scar formed after implant resorption may influence functional outcome.

The use of titanium mesh in the management of orbital trauma--a retrospective study.

This study examines the use of titanium mesh in the reconstruction of internal orbital defects. The goals of reconstruction when treating orbital fractures include restoration of internal wall continuity and provision of support to the orbital contents. In this way the untoward sequelae of post-traumatic enophthalmos and disturbance of visual acuity are avoided. Autogenous grafts have been the material of choice for most surgeons involved with treatment of these injuries. The major disadvantages of using autologous tissue are the need for a graft donor site, with attendant increases in operative time, prolonged hospitalization, increased postoperative discomfort and problems intrinsic to the donor site wound. The purpose of this report is to present the author's experience with the use of titanium alloplasts in the early repair of traumatic orbital wall fractures. Patients treated at the Townsville General Hospital from July 1, 1997-March 1, 2000 with injuries involving the orbit repaired with titanium mesh or micro-mesh were included in the study.

Volumetric determination of enucleation implant size.

PURPOSE: To determine whether volumetric calculation of enucleation implant size improves the results of the enucleation procedure. METHODS: The volume of the enucleated globe was measured in 33 eyes of 33 patients, allowing intraoperative calculation of implant size. The degree of postoperative anophthalmic volume deficit was evaluated by determining the relative enophthalmic position of the implant using Hertel exophthalmometry. These results were compared with those obtained from two groups of historical control patients who had previously undergone enucleation with the insertion of standard size 18-mm or 20-mm implants. RESULTS: There was significant variability in the volume of "normal" size globes (range, 7.0 to 9.0 ml; mean, 7.9 ml; standard deviation [SD], 0.7), resulting in the placement of implants between 18 to 22 mm in diameter. Study patients undergoing volumetric determination of implant size demonstrated less implant enophthalmos (mean, 5.9 mm) than historical control patients who received 18-mm (mean, 8.5 mm; P =.0001) or 20-mm (mean, 6.8 mm, P = .0332) implants. CONCLUSIONS: Volumetric determination and individualization of enucleation implant size appears to reduce postoperative anophthalmic volume deficit.

Orbitozygomatic craniotomy. Technical note.

The orbitozygomatic approach provides wide, multidirectional access to the anterior and middle cranial fossae, as well as to the upper third of the posterior fossa and clivus. The authors describe technical details of the surgical approach as it has evolved over 3.5 years of experience in 83 consecutive cases. This modified technique eliminates the need for bone reconstruction of the orbital walls to prevent enophthalmos and minimizes the risk of injury to the frontal branch of the facial nerve. At a follow-up evaluation after a period averaging 14 months, all patients were pleased with the cosmetic results of this approach.

Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid fat pads.

We describe in detail the anatomy and function of the "Lockwood suspensory ligament" and the interrelated function of the orbital contents responsible for the intraorbital position of the eyeball and fat. With age, or because of genetic disposition, the eyeball descends, reducing the space between it and the floor of the orbit. This will inevitably cause forward projection of the extraconical orbital fat, creating herniated fat pads and resulting in enophthalmia. Based on the volume of the bony orbit and its contents, it is likely that relocating, rather then removing, herniated fat pads will greatly improve and prevent the enophthalmia of aging and give the globe a position and a projection of youth. Based on the results of surgery using the capsulopalpebral flap, it is likely that a descended Lockwood suspensory ligament, rather than a weakened orbital septum, is the cause of herniated fat pads and enophthalmia. We feel neither a weakened orbital septum nor an overabundance of orbital fat nor a shallow orbit is responsible for either of these conditions. We give a detailed description of how to raise the globe, preserve and relocate herniated fat pads, and manage and prevent enophthalmia and obtain a beautiful, youthful looking eye.