Surgical treatment of diplopia caused by fractures of the orbital floor

Oculomotor disturbance resulting from orbital floor fractures have different etiologic factors, sometimes damage of one of the ocular motor nerves, caused by direct injury to the orbit; this damage occurs also to one or more of the extrinsic ocular muscles, especially the obliques; frequently, the diplopia is caused by prolapsed orbital tissues with or without muscle entrapment or by a muscle fibrosis; when the diplopia appears after orbital floor reconstruction there is often a palsy of the inferior rectus muscle in front of silicone implant or bone graft on the orbital floor. In oculomotor disturbance after orbital floor fracture, the first stage will be to recognize the mechanism of the diplopia by a clinical examination, motility in the nine positions, Hess Charts, binocular vision and field, forced duction, radiography and sometimes coronal computed tomography which also allow visualization of soft tissues densities, including all extraocular muscles. If there is an indication of orbital surgery, it will be done always in first; oculomotor surgery will be done if necessary at the second stage, if there is a permanent diplopia without evolution during six months. The purpose of the treatment is to obtain orthophoria in primary position and in down gaze. A series of cases of fracture of the orbital floor with resulting diplopia are described. The method, the time, and the indications of orbital or oculomotor surgery are discussed according the variety of cases.     

伴或不伴下直肌箝闭的trapdoor眼眶骨折的临床特征

目的　研究伴或不伴有下直肌箝闭的ｔｒａｐｄｏｏｒ眶底骨折的临床特征。方法　回顾性分析２００８年１月至２０１５年１２月在深圳市眼科医院确诊为ｔｒａｐｄｏｏｒ眶底骨折并行眼眶壁骨折整复术的２０例儿童和青年患者的临床资料,根据ＣＴ图像和术中所见将患者分为两组:伴或不伴有下直肌箝闭组。对两组术前术后的症状、ＣＴ图像、手术记录和随访结果进行比较。结果　不伴下直肌箝闭组的年龄、就诊时间和手术时间分别为（８．９１±５．３２）岁、（７．６４±８．２４）ｄ、（９．００±８．３９）ｄ,伴下直肌箝闭组分别为（１２．４４±４．６９）岁、（９．５６±６．６２）ｄ、（１０．７８±６．４４）ｄ,两组相比差异均无统计学意义（均为Ｐ＞０．０５）。但伴有下直肌箝闭的ｔｒａｐｄｏｏｒ眼眶骨折表现为严重的眼球上转受限－３．８９±０．３３、明显下转受限－２．４４±０．７３和严重的被动上转受限－４。而不伴有下直肌箝闭者表现为轻至中度上转受限－１．９１±０．３０、轻度被动上转受限－１．０９±０．３０。除了伴或不伴有下直肌箝闭外,二组其他ＣＴ图像相似。结论　伴有严重的眼球上转受限、中度及以上眼球下转受限,及严重的被动上转受限的ｔｒａｐｄｏｏｒ眼眶骨折提示有下直肌箝闭。轻至中度眼球上转受限和轻度被动上转受限,下转无明显受限者提示仅为脂肪结缔组织嵌顿。     

Inferior oblique underaction: a transient complication related to inferior orbital wall fracture in childhood

Purpose: To evaluate inferior oblique (IO) underaction related to orbital floor fracture and its management. Methods: We retrospectively assessed 137 patients with orbital floor fractures who had undergone surgical repair between July 2003 and August 2009. Review of clinical data, which included photographs and radiologic findings, was performed. IO underaction was diagnosed based on anomalous head position and which was confirmed with the Hess test and limitation of duction and version in the nine diagnostic positions of gaze. Results: Twelve patients demonstrated IO underaction pattern (8.8%); 3 patients presented preoperatively and 9 patients presented postoperatively. All the patients showed IO underaction pattern in the Hess test and head tilt position. The median age was 9.5 years (range, 6–24 years), and all the patients were male. Of 12 patients, 10 (85%) presented with nausea and vomiting symptoms, 2 (17%) infraorbital hypoesthesia, and 3 (25%) pupillary dilatation. On the basis of the CT scans, all patients had trap door fractures with soft tissue entrapment. The IO underaction recovered spontaneously within 2 months without any treatment. Conclusion: Head tilt towards the injured side can be a warning sign of IO underaction in orbital floor fracture, especially pre‐ or postoperatively in the paediatric population. Physicians managing paediatric orbital fracture should be aware of this transient complication.     

Inferior rectus rupture following blowout fracture

Background: Extra-ocular muscle rupture is uncommon, usually seen after penetrating trauma or surgery. It is a very rare cause of diplopia following blunt orbital trauma.
Methods: A patient who presented with no inferior rectus function after blunt orbital trauma is described.
Results: Computed tomography (CT) scans demonstrated a large orbital floor fracture and suggested that the inferior rectus muscle was ruptured. This was confirmed at operation. Despite anatomical repair, there was no postoperative improvement in ocular motility.
Conclusions: Traumatic rupture of the inferior rectus is rare. Forced duction and force generation testing and CT are important in diagnosing ocular motility defects following orbital trauma.     

儿童trapdoor眼眶骨折研究进展

trapdoor眼眶骨折是一特殊类型的爆裂性眼眶骨折。因儿童骨骼较成人更具弹性,故最常见于儿童。其发病机制、临床表现及治疗原则与成人爆裂性眼眶骨折均有明显区别。临床表现主要为眼球垂直位转动受限伴恶心、呕吐及眼球转动痛等。其眶部CT骨折不明显,常表现为线形骨折,眼外肌被箝闭于骨折处或下直肌走行路径发生变化。儿童trapdoor型眼眶骨折治疗应在确诊后早期手术治疗,避免因眼外肌被箝闭缺血导致永久性眼外肌功能障碍。     

Pediatric orbital floor fracture : direct extraocular muscle involvement

OBJECTIVE: To study the clinical presentation, operative findings, and postoperative results of a surgical series of isolated orbital floor fractures in children. DESIGN: Noncomparative, retrospective, consecutive case series. PARTICIPANTS: Thirty-four patients (34 orbits) less than 18 years of age with isolated orbital floor fractures. Indications for surgery were severe limitation of extraocular ductions, 22 of 34; enophthalmos, 8 of 34: or both, 4 of 34. INTERVENTION: Surgical repair. MAIN OUTCOME MEASURES: Cause of fracture, symptoms, clinical signs, radiographic data, operative findings, postoperative results, and complications. RESULTS: Children older than 12 years of age were more likely to sustain an orbital floor fracture as a result of interpersonal violence than were children less than 12 years of age (P: = 0.020). Sixty-two percent of patients (21 of 34) exhibited pain with eye movements and/or nausea and vomiting. Most had a trapdoor type fracture (21 of 34). The inferior rectus muscle was entrapped in the orbital floor fracture in 69% (18 of 26) of patients with a severe limitation of ocular ductions. Preoperative nausea and vomiting were immediately relieved after surgery. The median time for improvement of preoperative duction deficits and diplopia was 4 days for patients receiving surgery within 7 days and 10.5 days for those undergoing surgery after 14 days (P: = 0.030). Resolution of duction deficits or diplopia was not dependent on time of surgery if performed within 1 month of injury. Loss of vision, worsening of motility, or implant complications did not occur. CONCLUSIONS: Pediatric patients with isolated orbital floor fractures who had pain, nausea, vomiting, and severe limitation of extraocular motility often have direct entrapment of the inferior rectus muscle into the fracture site. Surgical repair rapidly relieved preoperative pain, nausea, and vomiting. For patients with severe limitation of ductions, early surgical repair within 7 days of injury resulted in more rapid improvement of ductions and diplopia than surgery performed later.     

小儿眶底骨折临床分析

目的 :探讨小儿眶底骨折的临床特点及治疗。方法 :回顾性研究 6 7例年龄小于 18岁的单纯眶底骨折患者 ,采用手术治疗眶底骨折 ,植入物为硅胶或羟基磷灰石。结果 :体育运动 (37 3% )和暴力伤 (2 3 9% )是造成小儿眶底骨折的主要原因 ;79 1%的病人有眼球运动疼痛和 /或恶心呕吐 ,复视 (79 7% ) ,严重的眼球运动障碍 (6 1 2 % )和眼球内陷 (2 5 4% )。小儿眶底骨折主要是陷阱型 (trapdoortype)骨折 (5 6 8% ) ,可伴有下直肌嵌顿。早期手术 (<1个月 )比晚期手术 (>1个月 )可以更有效地改善患者症状 (P <0 0 5 )。结论 :早期手术是治疗小儿眶底骨折的有效方法     

眶底爆裂性骨折致眼球运动障碍的上颌窦手术进路治疗

目的 观察上颌窦进路手术治疗眶下壁爆裂性骨折所致眼球运动障碍的临床效果.方法 对12例12只眼眶下壁爆裂性骨折伴复视及眼球运动障碍者,眼眶CT显示:眼外肌眶内软组织嵌顿于眶下壁骨折区,伤后观察2周,复视及眼球运动障碍无明显改善,采用上颌窦进路行眶下壁骨折复位术.术后随诊3～6个月.结果 12例患者术中开放上颌窦后可清晰观察到眶下壁骨折区各个边界及眶内软组织嵌顿情况,术中均将嵌顿在眶底骨折处的眶内组织推送回眶内,眶底骨折复位.术后12例患者中10例各方向眼球运动不受限,无复视,2例正前方及下方无复视,向上方运动轻度受限.术后1例并发上颌窦炎,经上颌窦冲洗治愈.结论 上颌窦进路早期治疗单纯眶下壁爆裂性骨折所致眼球运动障碍是有效的.     

The Oculocardiac Reflex in an Adult with a Non-Displaced Orbital Floor Fracture

Abstract

The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture. CT demonstrated the adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture. The patient's oculocardiac reflex resolved by early next morning, presumably from the tissue escaping from the orbital floor defect.     

Medial rectus muscle incarceration in pediatric medial orbital wall trapdoor fractures

PURPOSE: We describe two cases of orbital trapdoor fractures with medial rectus muscle incarceration. METHODS: Small interventional case series. RESULTS: This is a retrospective university based report of two healthy males (11 and 14 years old) who developed diplopia following blunt orbital trauma. Both patients had decreased horizontal ocular motility of the involved eye with minimal additional evidence of trauma. Computed tomography (CT) demonstrated no significant bony displacement; however, the left medial rectus muscle was located within the ethmoid sinus in the first and had an abnormal size and shape in the second case. In both cases, during urgent surgical repair, the incarcerated medial rectus muscle was gently released from linear non-displaced medial wall fractures and ocular motility normalized postoperatively. CONCLUSIONS: In pediatric patients sustaining blunt orbital trauma, medial rectus incarceration should be considered and managed accordingly.     

Inferior rectus muscle entrapped by Teflon implant after orbital floor fracture repair

A patient with a tripod fracture had entrapment of the inferior rectus muscle after reconstruction of an orbital floor defect with an alloplastic implant. Prior to insertion of the implant, the operating surgeon reported no motility disturbance. An orbital computed tomography scan suggested that the implant impinged on the inferior rectus muscle. Because of persistent diplopia, the orbit was reexplored. An intraoperative forced duction test prior to removal of the implant was positive in the field of action of the inferior rectus muscle. An intraoperative forced duction test after removal of the implant was negative in the field of action of the inferior rectus muscle. Motility was markedly improved after removal of the implant. These findings confirm that the implant was the cause of the entrapment. The surgical technique utilized to minimize complications after orbital floor reconstruction with the implant is outlined in this article.     

Clinico-Radiologic Findings of Entrapped Inferior Oblique Muscle in a Fracture of the Orbital Floor

A 51-year old man presented with vertical and torsional diplopia after reduction of a blowout fracture at another hospital one year ago. He had no anormalies of head position and 14 prism diopters (PD) right hypertropia (RHT) in the primary position. In upgaze no vertical deviation was found, and hyperdeviation on downgaze was 35PD. Bielschowsky head tilt test showed a negative response. Distinct superior oblique (SO) and inferior rectus (IR) underaction of the right eye was noted but IO overaction was mild on the ocular version test. Double Maddox rod test (DMRT) revealed 10-degree extorsion, but fundus extorsion was minimal in the right eye.Thin-section coronal CT scan showed that there was no fracture line on the anterior orbital floor, but a fracture remained on the posterior orbital floor. Also, the anterior part of the right inferior oblique muscle was vertically reoriented and the medial portion of the inferior oblique muscle was not traced on the coronal CT scan. The patient underwent 14 mm right IO recession and 3 mm right IR resection. One month after the surgery, his vertical and torsional diplopia were eliminated in the primary position.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

“Inverted Brown pattern”: A tight inferior oblique muscle masquerading as a superior oblique muscle underaction—clinical characteristics and surgical management

PURPOSE: To characterize, and evaluate the surgical management of, patients with unilateral deficiency of depression in adduction, suggesting superior oblique muscle underaction, without significant ipsilateral inferior oblique muscle overaction. METHODS: Such patients were identified who also had received either ipsilateral inferior oblique (IO) muscle weakening or contralateral inferior rectus muscle recession. Their histories, motility patterns, intraoperative findings, types of strabismus surgery, and postoperative results were analyzed. RESULTS: Twelve patients were identified with unilateral deficiency of depression in adduction, with no or minimal ipsilateral IO muscle overaction. Three of these patients (25%) had previously had surgery for Brown syndrome. Four (33%) had prior orbital floor trauma. On exaggerated forced duction testing recorded for nine patients, a tight IO muscle was recorded in 78%, with no laxity of the superior oblique tendon. Four patients (33%) underwent contralateral inferior rectus muscle recession, but in all four the deficiency of depression in adduction recurred. The other eight (67%) had an IO muscle weakening procedure and achieved overall improvement of ocular alignment. Nine subsequent patients with a similar pattern of misalignment were each managed with an IO weakening procedure, with good results. CONCLUSIONS: This motility pattern, which we are calling an "inverted Brown pattern," is caused by a tight or inelastic IO muscle. In such cases, IO muscle weakening yields better results than contralateral inferior rectus muscle recession, even though there is no significant IO muscle overaction preoperatively.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

Localized inferior orbital fibrosis associated with porcine dermal collagen xenograft orbital floor implant

We describe the clinical features, treatment, and histologic changes of a case of severe localized orbital inflammation associated with the use of porcine dermal collagen xenograft (Permacol) as an orbital floor implant in a 14-year-old boy. After uneventful blowout fracture repair with normal forced duction testing after insertion of a Permacol implant, progressive elevation and depression deficit developed in the postoperative period. There was no improvement after removal of the Permacol implant. Exploratory surgery revealed gross fibrosis of the inferior rectus muscle accounting for the abnormal ocular motility. Biopsy of the inferior rectus muscle showed chronic granulomatous inflammation suggestive of foreign body reaction. Although porcine dermal collagen xenograft has been suggested as an implant for orbital floor repair because of its reported high strength, ease of handling, and high biocompatibility, we believe that further studies are necessary before it can be recommended for this use.     

Diplopia following porous polyethylene orbital rim onlay implant

An 81-year-old man with ocular irritation associated with lower eyelid retraction, horizontal laxity of the lower eyelids, and hypoplastic inferior orbital rims underwent bilateral placement of porous polyethylene orbital rim onlay implants. Two weeks after surgery, he developed vertical binocular diplopia on downgaze. Examination of extraocular motility demonstrated limited infraduction OD. Surgical exploration revealed scarring in the anterior orbit between the inferior rectus pulley and the orbital implant. The orbital implant was found to lie higher than the inferior orbital rim. After surgical lysis of the scar and reduction of the vertical height of the implant, the patient's diplopia resolved. Orbital connective tissues critical to ocular motility may be abnormally superficial in orbital rim hypoplasia. Onlay grafts must be carefully placed so that they do not interfere with these tissues.     

Longitudinal tear of the inferior rectus muscle in orbital floor fracture

We report a case of longitudinal avulsion of the inferior rectus muscle following orbital floor fracture and describe its clinical presentation, computed tomography (CT) features and management. A 53-year-old man felt vertical diplopia in all gaze immediately after the trauma. Orthoptic assessment showed left over right hypertropia of 20 prism diopters and left exotropia of 10 prism diopters in primary position. The left orbital floor fracture and the prolapse of orbital contents into the maxillary sinus were presented by CT. Exploration of the orbit was performed under general anesthesia. The displaced bone fragment was elevated and repositioned below the slastic implant. Diplopia continued in all directions of gaze, although the impairment of depression was reduced postoperatively. A residual left hypertropia of 10 prism diopters and exotropia of 10 prism diopters was present in primary position 1 month after surgery, though there were no enopthalmos or worsening of hypesthesia. Repeated CT revealed the muscle avulsion of inferior rectus at the lateral portion of the belly. The avulsion of a small segment of the inferior rectus and its herniation into maxillary sinus in more posterior views was detected by review of the preoperative images. Muscle avulsion should be considered in the management of orbital fracture if orbital tissue entrapment and nerve paresis are excluded as causes of reduction in ocular motility. A thorough review of the imaging studies for possible muscle injury is required before surgery in all cases of orbital fracture.     

Early treatment of secondary muscle restriction due to orbital blow-out fractures]

INTRODUCTION: Orbital blow-out fractures can result in chronic oculomotor restriction. This is the consequence of orbital fasciae or muscle trapped within the fracture. A delayed treatment usually results in incomplete repair. However, when the extrapped tissues are freed by reconstruction of the orbital floor, oculomotor sequelae can be prevented or at least limited. PATIENTS AND TREATMENT: Twelve adults and 2 children were treated for blow-out fracture in the past two years at the Eye Department of Geneva University Hospital. All of these patients had a non regressive oculomotor restriction, an enophthalmus and/or an infraorbital hypoesthesia with evidence of a blow-out fracture on the CT-scan. They were operated on between the second and the sixth week following trauma. Extrapped fasciae were freed under microscope and the orbital floor was reconstructed with a thin plate of biomaterial (PDS). RESULTS: Tissues could be entirely removed and kept separated from the underlying structures by the biomaterial used for reconstruction. Ocular motility returned to normal in 13 cases within 1 to 3 months, without further intervention. Only one patient had to wear a low grade prism with vertical action. DISCUSSION: In case of blow-out fractures, the long term prognosis of the ocular motility depends on immediate management following the trauma. Orbital floor reconstruction is indicated when consecutive oculomotor restriction is likely avoiding in the majority of the cases any residual oculomotor restriction. On the contrary when delayed, treatment is often difficult generally with limited mobility. CONCLUSION: From an ophthalmological point of view, microsurgical extraction of incarcerated orbital fasciae and reconstruction of the orbital floor is indicated for early treatment of oculomotor restriction.     

Internal orbital fractures in the pediatric age group: characterization and management

OBJECTIVE: To evaluate the specific characteristics and management of internal orbital fractures in the pediatric population. DESIGN: Retrospective observational case series. PARTICIPANTS: Thirty-four pediatric patients between the ages of 1 and 18 years with internal orbital ("blowout") fractures. METHODS: Records of pediatric patients presenting with internal orbital fractures over a 5-year period were reviewed, including detailed preoperative and postoperative evaluations, surgical management, and medical management. MAIN OUTCOME MEASURES: Ocular motility restriction, enophthalmos, nausea and vomiting, and postoperative complications. RESULTS: Floor fractures were by far the most common fracture type (71%). Eleven of 34 patients required surgical intervention for ocular motility restriction. Eight were trapdoor-type fractures with soft-tissue incarceration; five had nausea and vomiting. Early surgical intervention (<2 weeks) resulted in a more complete return of ocular motility compared with the late intervention group. CONCLUSIONS: Trapdoor-type fractures, usually involving the orbital floor, are common in the pediatric age group. These fractures may be small with minimal soft-tissue incarceration, making the findings on computed tomography scans quite subtle at times. Marked motility restriction and nausea/vomiting should alert the physician to the possibility of a trapdoor-type fracture and the need for prompt surgical intervention.