Delayed immediate surgery for orbital floor fractures: Less can be more

Orbital floor fractures can result in diplopia, enophthalmos, hypoglobus and infraorbital dysthesia. Currently, the most common treatment for orbital floor fractures is immediate surgical intervention. However, there are a number of well-documented cases of unoperated orbital floor fractures in the literature, culminating in diplopia or enophthalmos in few patients. Of these, none reported the diplopia or enophthalmos to be bothersome. As reported previously in the ophthalmology literature, most orbital floor fracture-induced diplopia resolves as the swelling settles, and the few patients with remaining diplopia can successfully be treated with surgery on the uninvolved eye. It has also been commented that most patients with enophthalmos are asymptomatic. The authors’ institution has more than 50 surgeon-years experience with delaying immediate surgery for two weeks to allow time for the swelling-induced diplopia to resolve. In the authors’ experience, true entrapment of the inferior rectus muscle is rare. The present article describes a study of late follow-up (average 945 days) of 11 nonoperated patients with orbital floor fractures. In the eight patients who initially presented with diplopia, there was resolution of functionally limiting double vision. Only one patient had asymptomatic, but measurably significant, enophthalmos at −3 mm. All patients had full restoration of extraocular movements and resolution of infraorbital dysthesia. None of the patients were exposed to the operative risks of ectropion, infection, implant extrusion, bleeding or blindness. The present study provides level IV evidence that delaying surgery up to two weeks after orbital floor fracture may avoid unnecessary surgical risks and inconveniences in many patients with orbital floor fracture.     

单纯型眶壁爆裂骨折晚期畸形的诊断及整复

目的：探讨眶壁爆裂骨折所致眶壁畸形、眼球内陷的发生机制及其整复手术。方法：应用三维CT影像学技术及计算机三维诊断系统，观察眶壁畸形特征，测量眶腔容积变化，分析眼球内陷和复视的发生机制。并采用自体骨或羟基磷灰石人工骨植人恢复眶腔容积的方法进行整复。结果本组11例，未出现植人骨感染、外露等并发症。其中10例眼球突出度、眼球运动功能恢复，复视得以矫正，眶、眼睑外形良好；1例复视未得到矫正，眼球运动功能恢复欠佳。结论：眶壁爆裂骨折眼球内陷的原因主要是眶腔容积增大、眶内容疝出，还纳眶内容后植骨恢复眶腔容积，是治疗此类畸形的有效方法。     

Endoscopic endonasal repair of blowout fractures of the orbital floor

Objectives: This study is to show the usefulness of the endoscopic endonasal approach in the surgical treatment of isolated blowout fractures of the orbital floor.Methods: Between 1997 and 2003 we operated on 65 patients complaining of diplopia due to isolated blowout fractures of the orbital floor, including 4 patients accompanied with enophthalmos. In 62 of the 65, only the endonasal approach with endoscope was used, while in the remaining 3 patients, we used the combined endonasal and transantral approach. To do the endonasal repair surgery smoothly under the endoscope, via the middle nasal meatus, septoplasty was supplemented in 13 patients and submucous conchotomy in 57. The bone fragments trapping the orbital content herniated into the maxillary sinus were carefully removed so as to keep the periorbita intact. Tampon gauzes or a balloon catheter for temporal fixation was placed in the maxillary sinus through the middle nasal meatus to support the orbital floor for 2 to 7 days. No permanent supporting material was used. Immediately following the repair and the fixation the eye traction test was respectively performed to confirm that the eyeball was freely moving.Results: Postoperatively diplopia disappeared in 50 of the 57 patients using only the endonasal approach, (87.7%) and enophthalmos improved 3 of 4 followed over 6 months.Conclusions: From this high success rate with respect especially to diplopia we conclude that the endoscopic endonasal approach is alternative to extranasal methods in view of cosmetics and the improvement of eye movement.     

Comparison of the postoperative outcome in pure medial orbital fracture among three groups: using porous polyethylene or hydroxyapatite through subciliary approach and transnasal endoscopic correction

Many methods of surgical repair of pure medial orbital fractures have been reported. In this study, we discuss the outcome from the surgical corrections of hydroxyapatite (Biocoral) or porous polyethylene (Medpor) through subciliary approach, and the transnasal endoscopic corrections. Between March 1993 and July 2003, 63 patients were treated with porous polyethylene and 48 patients were treated with hydroxyapatite. Between August 2003 and December 2005, 50 patients were treated with transnasal endoscopic approach. Patients had at least 6 months' follow-up, and the records for diplopia, enophthalmos, and other postoperative complications were reviewed retrospectively. As a result, 1 patient from the group using porous polyethylene, 2 patients from the group using hydroxyapatite, and 1 patient from the endoscopic correction group had enophthalmos. Besides enophthalmos, no other complications were observed. There was no significant statistical correlation among 3 groups. In conclusion, a transnasal endoscopic correction may be considered a useful method for surgical repair of pure medial orbital fractures, with no external facial scar and excellent visualization and accuracy comparable to that of the subciliary approach.     

Analysis of the postoperative outcome in 405 cases of orbital fracture using 2 synthetic orbital implants

The purpose of this study was to analyze the postoperative complications according to the location (floor/medial wall/floor and medial wall) of the orbital fracture of 405 patients during the past 10 years and to investigate the possible alterative data in postoperative outcome in change with the application of 2 synthetic orbital implants: porous polyethylene (Medpor) and hydroxyapatite (Biocoral). The medical records of 405 patients were reviewed especially for enophthalmos, diplopia, sensory disturbance in the area of distribution of the infraorbital nerve, and postoperative complications originated from the implanted material itself, from March 1993 to July 2003. Of the 405 patients, 214 patients were operated with porous polyethylene and 191 patients with hydroxyapatite. The complication rate of the porous polyethylene group was 5.6%, which was not statistically different from that of the hydroxyapatite group (9.4%). Also by the location of fracture, the complication rate of both groups was similar statistically. In the comparative category, enophthalmos was more frequent statistically in patients treated with hydroxyapatite than those treated with porous polyethylene, and no other significant differences were in postoperative outcomes between the both groups. The information provided in this report should aid in using porous polyethylene or hydroxyapatite for reconstruction of the orbital fracture and in accomplishing better postoperative outcome.     

Cyanoacrylate fixed silicone sheet in medial blowout fracture repair

Indications for medial blowout fracture repair may include persistent diplopia due to entrapped orbital contents or enophthalmos. In such cases a barrier must be placed along the medial orbital wall to prevent recurrence of entrapment and to minimize enophthalmos. Firm fixation of these barriers may be technically difficult. In seven patients silicone sheets were fixed in place along the medial orbital wall with butyl-2-cyanoacrylate cement. These patients have done well postoperatively with a mean time since surgery of 21 months.     

高密度多孔聚乙烯植入修复眶壁爆裂性骨折继发眼球内陷畸形

目的 探讨眶壁爆裂性骨折继发眼球内陷畸形的修复方法。方法1996年12月～2004年3月，共治疗眶壁爆裂性骨折继发眼球内陷患者56例，男30例，女26例。年龄22～48岁，平均32．5岁。受伤至手术时间16d～5年，合并复视患者34例，视力较受伤前降低者35例。采用下睑缘切口，于下眶缘骨膜下沿内下眶壁向眶尖方向潜行剥离。充分暴露骨折部位和松解嵌入上颌窦的眼眶组织并使其复位，使之成为骨膜下间隙。依据眼球的内陷程度，采用高密度多孔聚乙烯(porous high-density polyethylene，PHDPE)Medpor修复眶内下壁及其他眶壁缺损，矫正眼球内陷畸形。结果术后所有患者经2个月～5年随访，眼球内陷程度均稳定在2mm以内，无畸形复发及其他并发症发生。术后眼球内陷畸形均得到明显改善。34例复视患者中27例恢复，35例视力下降患者中9例视力较术前有不同程度改善，无复视加重和视力下降现象。大多数患者外观改善明显，其他患者也有不同程度改善，患者对手术效果满意。结论眶壁骨折整复术安全有效，手术应及早进行。Medpor组织相容性好、塑形容易、硬度适中、吸收率低、并发症少及手术效果稳定持久，是首选植人物。为防止眼球内陷畸形矫正不足，术中一般需矫正超过对侧1～2mm，严重的内陷者，术中矫正应超过2mm以上。     

单纯型眶壁爆裂性骨折早期手术治疗的效果

目的 探讨单纯型眶壁爆裂性骨折早期手术治疗的方法和效果.方法 2007年1月至2013年7月,对33例（36只眼）单纯眶壁爆裂性骨折患者行修复手术治疗.应用三维CT扫描技术,明确眶壁骨折情况和特征,采用下睑睫毛缘下皮肤入路显露眶壁骨折的部位,回纳眶内容物后,采用自体骨或高密度多孔聚乙烯（Medpor）仔细填充修复眶壁缺损.结果 33例术后随访3～12个月,未出现植入骨感染、外露等并发症,眶、眼睑外形良好,眼球运动功能恢复,复视均消失.29例双侧眼球突度对称,4例患侧眼球轻度内陷.结论 眶壁爆裂骨折使眶腔容积增大、眶内容物疝出,还纳眶内容物后修复眶壁恢复眶腔容积,是治疗的最有效方法.早期CT检查是明确诊断的必要方法,对眶壁爆裂性骨折应尽早手术治疗,以避免发生并发症.     

Endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor.

The indications for and timing of surgical treatment of blowout fractures of the orbital floor remain controversial. We report good results with the endoscopic transmaxillary reduction and balloon technique for blowout fractures of the orbital floor in the early stage after trauma in a consecutive series of 29 patients treated over the last 3 years, based on the following criteria: 1) diplopia observed by ophthalmological examination, 2) entrapment of intraorbital tissue at the fracture site on diagnostic imaging, mainly using CT scans, and 3) no improvement of diplopia during the acute phase (within one week of injury). Even in the presence of eyelid swelling, this method allows reduction and fixation of the fracture and impacted tissues simply and in a short time. Disappearance of diplopia was reported by 27 patients (93 %) within three months after surgery, and all 20 patients with enophthalmos were cured. There were only 4 cases with transient minor operative complications. Re-entrapment at the fracture site or relapse of symptoms was not seen during follow-up for 5 to 39 months (mean: 23.4 months). The combination of endoscopic transmaxillary reduction and the balloon technique for blowout fractures of the orbital floor is an effective and minimally invasive treatment with a high rate of improvement, not just for disturbances of ocular movement, but also for enophthalmos, which is often a problem in the long term.     

Severe orbital floor fractures: repair with a titanium implant

Summary Fractures of the orbital floor which require exploration are usually treated with an alloplastic floor implant or an autogenous bone graft. When large portions of the orbital floor, together with the lower parts of lateral and medial walls, are destroyed there may be no possibility of providing a conventional orbital floor reconstruction. In this situation, a titanium orbital floor implant may well be required to support the globe. 4 cases of traumatic orbital floor blow-out fractures are described. Clinically, all patients had diplopia, enophthalmos and radiological evidence of extensive loss of the orbital floor. A titanium orbital floor implant was molded and secured to the infraorbital rim with miniscrews to reconstruct the orbital floor and to reconstitute the orbital volume. No additional bone grafting was performed. Complications were minimal. From this experience, in severe orbital floor fractures, good results are obtained by supporting the globe using only a titanium implant.     

自体颅骨移植在眶底重建中的应用

目的 评价自体颅骨移植在治疗面部外伤致眶底缺损中的作用。方法 对34例面部创伤眶底爆裂骨折（以下简称眶底骨折）有骨质缺损者,采用冠状切口取自休遭受,结膜切口加外眦切开入路进行骨移植修复缺损。结果 所有病例术后创口愈合良好,无感染。供骨区无并发症发生。1例术后3个月内有轻微下睑外翻,通过自行按摩半年后已不明显,8例术前有眶下区麻木者,术后1-6个月全部恢复,4例有复视者术后消失,通过半年至5年（平衡11个月）的随诊,移植骨成活良好,供受骨区切口瘢痕不明显,均取得了满意的临床疗效。结论 自体颅骨移植并发症少,对眶底的重建有许多优点。是眶底重建的理想移植材料。     

PC机三维CT影像的建立及在放射性眼眶整形中的应用

目的:在PC上建立眼眶发育不良整形手术的三维CT影像测量和分析系统.方法:应用计算机图像处理技术,在PC机上完成CT标准数据(DICOM3.0)解读,完成眼眶三维图像的重组、分析和测量,并应用于放射性眼眶的整形手术治疗.结果:14例眼眶发育不全患者经手术后眼眶横径、纵径和眶缘到外耳道的距离等测量指标都接近正常侧.结论:PC机三维CT影像测量和分析系统的建立,可以便捷,有效的量化放射性眼眶畸形的程度,为术前设计和术后判断提供客观依据,提高手术的精确性.     

Subcaruncular approach for the reconstruction of blowout fractures of medial orbital walls

To obtain a wide and clean operative field for anatomic reconstruction of medial orbital blowout fractures, an alternative method called the subcaruncular approach has been performed. Between March 2008 and June 2010, this method was applied to the orbits of 41 patients with isolated pure medial orbital blowout fractures. A medial half conjunctival incision was made and extended meticulously to the subcaruncular area through preseptal plane under direct vision. Pre- and postoperative computed tomographic scans and ophthalmic examinations were performed, and clinical results were assessed. Postoperatively, computed tomographic scans revealed anatomic reduction of orbital soft tissues and the reconstructed medial orbital wall to be in proper position in all cases, and diplopia and eyeball motility limitation were resolved in most patients. There were no complications except severe chemosis in one case. We believe that this method can be a useful alternative option for the anatomic reconstruction of medial orbital blowout fractures.     

Verification of clinical precision after computer-aided reconstruction in craniomaxillofacial surgery.

OBJECTIVE: Computer-aided surgery (CAS) has proved to be useful in reconstructive craniomaxillofacial surgery. Preoperative creation of virtual models by segmentation of the computerized tomography (CT) dataset and mirroring of the unaffected side allows for precise planning of complex reconstructive procedures. The aim of this study was to evaluate the accuracy of the preoperative planning and the postoperative result regarding the skeletal reconstruction. STUDY DESIGN: In a first step, the symmetry of unaffected human skulls and faces were evaluated by 20 midface CT data of skulls and 20 surface-scan data of healthy individuals. By mirroring and adjusting the original and mirrored datasets using a 3-dimensional modeling software, an automatic measurement procedure could evaluate the mean and the maximal modulus of the distances between both datasets. In a second step, 18 consecutive cases were selected which had been treated with CAS support. Group 1 consisted of orbital floor and/or medial wall fractures (n = 12), group 2 consisted of zygomatic bone fractures (n = 4), and group 3 included 2 patients who were treated by secondary orbital reconstruction including reosteotomy of the zygomatic bone (n = 2). To verify the surgical result, the preoperative CT dataset including the virtual planning and the postoperative CT dataset were compared by using image fusion. Additionally, postoperative surface scans and the clinical symptoms of the patients were evaluated. RESULTS: No differences between the skull and face symmetry were found. Mean values for distances considering the skull symmetry were 0.83 mm for male and 0.71 mm for female and for the face symmetry 0.65 mm for male and 0.76 mm for female. Comparing the preoperative planning with the postoperative outcome, a mean accuracy of 1.49-4.12 mm with maximum modulus of 2.49-6.00 mm was achieved. Orbital true-to-original reconstructions and the secondary reconstructions were more precise than the reposition of the zygomatic bones. The postoperative acquired surface scans resulted in mean distances from 0.89 to 1.784 mm. Despite these deviations, all patients demonstrated satisfying clinical outcome. CONCLUSION: The natural asymmetry in humans influences the accuracy of preoperative planning procedure, when the mirroring tool is used. The accuracy transforming the preoperative planning to the surgical reconstruction using CAS depends on location, surgical approach, and matter of reconstruction.     

Combination of transconjunctival and endonasal-transantral approach in the repair of blowout fractures involving the orbital floor.

In the repair of orbital blowout fractures through eyelid or conjunctival incision, it is difficult to see the posterior edge of the fracture and the condition of the herniated tissue before reduction of the orbital contents. Prolapsed orbital tissue or infraorbital nerve and vessels may therefore be damaged in the reduction.The recently advocated combination of traditional transconjunctival approach and endoscopic transantral approach allows reduction and reconstruction under clear endoscopic vision without a facial skin incision. We modified this technique to make it less invasive and applied it to the repair of orbital blowout fractures involving the orbital floor. The use of a 70-degree straight endoscope through an enlarged ostium as for functional sinus surgery allowed clear sight of the roof of the antrum. During the repair of the orbital floor through a transconjunctival approach, reduction and reconstruction was assisted from the antrum.Twelve cases of fresh blowout fractures were treated with this approach. There were seven male and five female patients. Mean age was 23.5 years. Causes of injuries were fights, motor vehicle or bicycle accidents, and sports. Patients with concomitant fractures involving the orbital rim were excluded. Persistent diplopia was present in eight cases and enophthalmos of more than 2 mm was detected in five cases preoperatively. The average intervals from injury to surgery was 22.8 days.Exploration, reduction and reconstruction of the orbital floor fractures were precisely performed with this procedure. Large orbital floor defects were reconstructed with silicone sheets, thin iliac bone grafts or nasal septal cartilage. In all eight cases that showed diplopia, ocular movement recovered and symptomatic diplopia disappeared after surgery. Enophthalmos of more than 2 mm was also improved in all five cases. One early case showed temporary entropion. Transient numbness of the cheek appeared in five cases and temporary maxillary sinusitis recovered in one case. Postoperative infection was not observed.This method provides visualisation of posterior edge of the fracture and the condition of herniated orbital contents before initiation of reduction. Dual manipulation by two surgeons is also possible in reduction and reconstruction of the orbital floor.     

非单纯性眼眶骨折的手术治疗

目的回顾性分析总结手术治疗非单纯性眼眶骨折的临床经验。方法2010年1月至2017年12月,中国医科大学附属第一医院整形外科收治的587例眼眶骨折患者,男性455例,女性132例,年龄19~65岁。术前根据临床表现和3D-CT检查结果进行诊断和评估;术中充分松解还纳嵌顿的软组织、复位眼眶、放置置入体;术后比较眼眶外形、眼球功能及3D-CT等评价手术效果。结果本组587例,术后均获10个月至2年随访,所有患者术后外形和功能均得到整体的改善或恢复。12例术前眼球内陷明显,术后仍有轻度内陷;9例仍有轻度眼球运动受限、复视部分恢复;除眼球破裂摘除患者,其余患者视力较受伤前均无明显下降。结论眼眶骨折需严格依据临床表现和3D-CT检查结果进行诊断和评估,及早地进行精确复位、固定、修补,可提高治疗的效果。     

A retrospective study of treatment of orbital floor fractures with the maxillary sinus approach

The Cook County Hospital, Chicago, Illinois, protocol for the management of orbital fractures is presented. Diplopia which fails to resolve in 1 week or appears after oedema subsides, enophthalmos or radiographic depression of the orbital floor, associated tripod fracture deformity, or purulent maxillary sinusitis are indications for surgery. The surgical procedure is a modification of the maxillary sinus approach, which includes the use of iodoform gauze packing, nasal antrostomy, a double layer oral closure and prophylactic antibiotics. A review of 102 patients treated surgically over a 6-year period is presented. Post-operative diplopia was 9% and there were minor complications in 3%, which were significantly lower than previously reported series of orbital fractures treated either non-operatively, or through an orbital exploration approach. No patient treated non-operatively required surgery in the future. The protocol presented can eliminate unnecessary exploration and yields excellent results with a simple surgical procedure.     

Correction of posttraumatic enophthalmos

Management of posttraumatic enophthalmos can present as a challenge to the reconstructive surgeon, particularly in cases of late presentation. This article reviews the pertinent anatomy of the orbit, diagnostic modalities, indications for surgery, and surgical approaches as they relate to the treatment of posttraumatic enophthalmos. Internal orbital reconstruction has evolved to an elegant procedure incorporating various biologic or alloplastic implants, including anatomical pre-bent implants. Successful repair of late enophthalmos has been demonstrated in multiple recent studies and is likely related to the precision with which orbital anatomy can be restored.     

Prospective study on ocular motility limitation due to orbital muscle entrapment or impingement associated with orbital wall fracture

IntroductionThe recommended urgent surgical management of ocular motility restriction due to orbital muscle entrapment or impingement associated with orbital wall fracture needs to be elucidated.AimTo evaluate the importance of the time from injury to surgery for the outcome in ocular motility and diplopia, the time lapse of ocular motility, diplopia and hypesthesia recovery.Material and methodsPatients with entrapment or impingement of orbital contents due to orbital wall fracture were followed up prospectively over 1 year regarding ocular motility, diplopia, hypesthesia and cosmetic deformity.Results21 patients (10 entrapments and 11 impingements) were included and treated surgically. The median time from injury to surgery was 36 (8–413) h for the entrapment group and 168 (48–326) h for the impingement group. The median time from study inclusion to surgery was 0 (0–1) days for the entrapment group and 1.0 (0.2–4.8) days for the impingement group. All the patients had ocular motility limitation and diplopia at the inclusion. Ocular motility improved gradually and was normal at final visit. Diplopia resolved gradually in all patients except in two with non-disturbing diplopia, at the final visit. Forced duction test was positive in 90% of the patients in the entrapment group and 70% in impingement group. At final visit, hypesthesia was found in none of the patients in the entrapment group but in 4 patients in the impingement group.ConclusionsIn this, the first prospective long term follow up of orbital wall fractures with ocular motility restriction, we did not find any significant correlation between the time from injury to surgery and the outcomes in ocular motility and diplopia. An entrapment requires surgery as soon as possible; however, the surgical reduction is at least as important as surgical timing. Surgery should be delayed until it can be performed by an experienced surgeon. Ocular motility restriction causing diplopia due to impingement is not an ophthalmologic emergency and surgery is recommended if the diplopia and ocular motility has not improved over time. Clinical examination of ocular motility and not CT scan findings is crucial to determine whether a limitation of ocular motility exists or not.     

眶颧复合骨折的综合手术整复

目的：评价眶颧复合骨折综合手术整复治疗的效果。方法：对眶颧复合骨折的患者施行早期骨折复位、钛钉钛板坚强内固定手术,部分眶容积增大的患者手术同期或术后2期行Medpor垫片眶内充填术矫正眼球凹陷。结果：25例眶颧复合骨折的患者接受了综合手术整复,均取得良好效果。结论：眶颧复合骨折伤后早期手术可以使眶颧骨折解剖学复位,眼球内陷患者通过Medpor垫片充填骨折区可减小眶容积,有效地矫正眼球凹陷。