Delayed Orbital Hemorrhage around Alloplastic Implants after Blowout Fracture Reduction

Alloplastic implants have been used to repair orbital wall fractures in most cases. Orbital hemorrhage is a rare complication of these implants and has been reported rarely in Korea. The purpose of this article is to report a late complication case focusing on their etiology and management. A 20-year-old male patient underwent open reduction with Medpor (porous polyethylene) insertion for bilateral orbital floor fractures. The initial symptom occurred with proptosis in the right side as well as vertical dystopia, which had started 4 days earlier, 8 months after surgery. Any trauma history after the surgery was not present. We performed an exploration and removal of hematoma with Medpor titanium meshed alloplastic implant. A case of delayed orbital hematoma following alloplastic implant insertion was identified. It occurred within the pseudocapsule of the implant. One week after surgery, overall symptoms improved successfully, and no complications were reported during the 11-month follow-up period. Although rare, orbital hemorrhage is a potential complication of alloplastic orbital floor implants, which may present many years after surgery. As in the case presented, delayed hematoma should be included in the differential diagnosis of late proptosis or orbital dystopia.

Update in Treatment of Orbital Blowout Fractures / 대한이비인후과학회지

The orbital wall is commonly fractured and its incidence ranges from 18 to 50% of all craniofacial fractures.1,2) Numerous papers have been reported about the surgical indication, surgical timing, approach options, and reconstruction materials for orbital blowout fractures. However, there are still debates on the ideal surgical options. The choice of surgical approach and materials for reduction of orbital blowout fractures depends on the surgeon's experience and preference. Recently, use of endoscope for blowout fractures has been popular worldwide due to its advantages over open reduction surgeries. In this review, I will discuss new techniques and concepts of the treatment of orbital blowout fractures with particular references.

Severe Traumatic Intraocular Injuries Related to Blowout Fractures

PURPOSE: Blunt trauma can cause a wide range of ocular injuries. This study was performed to describe the prevalence of severe intraocular injuries (SIOI) and their correlation with the severity of blunt orbital trauma. METHODS: We retrospectively analyzed 117 eyes of 107 patients with orbital wall fractures who visited the emergency room at Konyang University Hospital from July 2006 to June 2008. Clinical features such as age, sex, causes of injury, revised trauma score (RTS), type of orbital wall fractures were recorded. The patients were divided into two groups: blowout fracture with severe intraocular injuries (SIOI) and blowout fracture without SIOI. We compared the clinical and the injury-related characteristics between two groups and analyzed the SIOS-related factors. RESULTS: Among the 107 patients (117 eyes) with blowout fractures, 29 (27.1%) patients with 32 eyes (25.6%) had complicated severe intraocular injuries. Retrobulbar hemorrhage (14.5%), hyphema (13.7%), traumatic optic nerve injury (4.3%), and sustained loss of visual acuity (4.3%) were the most common SIOI disorders. A logistic regression analysis revealed that loss of visual acuity (odds ratio = 4.75) and eyeball motility disorder (odds ratio=7.61) were significantly associated with SIOS. CONCLUSION: We suggest that blowout fracture patients with loss of visual acuity or eyeball motility disorder are mostly likely to have severe intraocular injuries, so they need an ophthalmologic evaluation immediately.

Effects of the site and the extent of blowout fracture on enophthalmos and diplopia

Orbital blowout fractures are common consequence to blunt periorbital trauma. Pure orbital blowout fractures first occur at the weakest point of the orbital wall. Computed tomography(CT) is recognized to be the best imaging technique to evaluate orbital fractures. The extent and location of a blowout fractures in the CT scan were noted to have an effect on the clinical outcome. In the early posttraumatic period, the presence of significant enophthalmos is difficult to detect because of orbital edema. Early surgical intervention may improve the ultimate outcome because open reconstruction becomes more difficult if surgery is delayed. In this study, we evaluated isolated blowout fractures of the orbital floor by region-of-interest measurements from CT scans and their relationship to ophthalmologic findings. Six patients of the medial orbital wall fractures, eleven patients of the inferior orbital wall fractures, nineteen of the medial and the inferior orbital wall fractures confirmed by CT scan, were evaluated. The area of fracture and the volume of the displaced orbital tissue were determined from CT scan using linear measurements. Each of the calculated values for the area and the volume were compared with the degree of the enophthalmos, the diplopia, and the eyeball movement limitation to determine whether there was any significant relationship between them. The fracture area and the volume of the herniated orbital tissue were significantly positively correlated with the enophthalmos and the ocular motility limitation and not correlated with the diplopia. For the enophthalmos of 2mm or greater, the mean fracture area was 3.55+/-1.25cm2 and the volume of the herniated orbital tissue was 1.74+/-0.97cm3 for less than 2mm enophthalmos, 1.43+/-0.99cm3 and 0.52+/-0.49cm3, respectively. The enophthalmos of 2mm can be expected with 2.92cm2 of the fracture area and 1.40cm3 of the herniated orbital tissue. In conclusion, the enophthalmos of 2mm or more, which is a frequent indication for surgery. It can be expected when area of fracture is 2.92cm2 or more, or the volume of herniated orbital tissue is 1.40cm3 or more. And the CT scan using linear measurements has an application in the assessment of patients with blowout fractures and provides useful information in the posttraumatic evaluation of orbital fractures.

Residual Diplopia and Enophthalmos after Reconstruction of Orbital Wall Fractures

PURPOSE: We evaluated the risk factors and related results of residual diplopia and enophthalmos in patients who had orbital wall fracture repair. METHODS: 50 patients with orbital wall fracture who were followed up for at least 6 months postoperatively were included in this study. We analyzed effects of the patient age, timing of surgery, size and location of fracture on development of postoperative diplopia and enophthalmos. RESULTS: 32 patients had diplopia and 16 patients had enophthalmos greater than 2 mm. Among 32 patients with preoperative diplopia, 9 patients experienced postoperative diplopia. Among 16 patients with preoperative enophthalmos, 5 patients experienced postoperative enophthalmos. Delayed timing of surgery was a significant factor for development of postoperative diplopia and enophthalmos. Age of the patients and fracture size were not significant factors for development of postoperative diplopia and enophthalmos. CONCLUSIONS: Early surgical repair of orbital wall fractures decreases the incidence of residual diplopia and enophthalmos. Preoperative assessment of multiple variables could help to achieve cosmetical and functional better results.

The Analysis of Causes of the Postoperative Enophthalmos in Adult Blowout Fractures

PURPOSE: To evaluate clinical characteristics of adult blowout fractures who underwent orbital wall reconstruction and relationships between clinical factors and post operative complications. METHODS: The medical records of 29 patients with orbital blowout fractures who underwent orbital wall reconstruction were retrospectively reviewed from March, 2000 to November, 2001. Various clinical factors including cause of insult, fracture size, associated injuries, and preoperative enophthalmos were evaluated. Further factors which causes late postoperative enophthalmos were analyzed. RESULTS: Blowout fracture occurred most frequently between the ages of 20 and 29 years and was more common in male than female. The violence was the most common cause, and the most common fracture site was inferior wall combined with medial wall. After surgery extraocular movement limitation and diplopia were improved or eliminated. Preoperative mean enophthalmos was 2.83 mm and postoperative mean enophthamos was 1.27 mm. Fracture size was more predictable to late postoperative enophthalmos than the degree of preoperative enophthalmos measurement (Percent of Predication; with preoperative enophthalmos = 25%, with fracture size = 52%, p<0.05). CONCLUSIONS: In adult, the size of blowout fracture was large. Therefore enophthalmos was common complication after orbital wall reconstruction. The estimation of fracture size by using computed tomography was more predictable to late postoperative enophthalmos and easily accessible in clinic room as well as simple, therefore it is helpful to decide the early surgical reduction.

Prediction of Late Enophthalmos by Volumetric Analysis of Blowout Fractures using Orbital CT

The purpose of this study was to determine whether orbital volume assessment by CT could provide additional information for the initial evaluation of orbital blowout fractures and guide optimal treatment. The medical records of 26 patients with orbital blowout fractures, either surgically or conservatively managed, were retrospectively reviewed. Orbital volumetric analysis was then determined from digitized CT scans. Fracture-related volume expansion relative to the unaffected fellow orbit was correlated with degree of enophthalmos. Early Hertel's measurements[4 weeks] were obtained in 13 nonrepaired fractures and in 3 of 13 surgically repaired patients[late presentation;16 patients]. When seen at more than 4 weeks, 4[80%] of 5 patients with> OR =13% orbital volume expansion manifested significant enophthalmos[>2 mm] compared with 2[18.2%] of 11 patients with<13% orbital expansion[p<0.01]. CT measurements of orbital volume can predict the final degree of late enophthalmos and may facilitate the planning of surgical intervention.

Endonasal Endoscopic Reduction of Blowout Fractures of the Medial Orbital Walls / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Until recently, blowout fractures (BOFs) of the medial orbital walls were treated using external approach. With recent advances in endoscopy, many cases of BOFs of the medial orbital walls are now treated endonasaly using an endoscope. This article describes endonasal endoscopic reduction (EER) of BOFs of the medial orbital walls and reports the clinical results. MATERIALS AND METHODS: Twelve patients with BOFs of the medial orbital walls underwent EER. Their records were reviewed for surgical indications, operative techniques, operative results, and postoperative complications. RESULTS: Surgical indications were persistent diplopia, limitation of eye movement, and significant enophthalmos. Ten patients showed complete resolution of symptoms after the operation. One patient underwent medial wall reconstruction with transorbital approach after failure of EER, and is now free of symptoms. Another patient with both zygomatic fracture and BOF of the orbital floor remained enophthalmic after EER. There were no other significant complications postoperatively. CONCLUSION: The results indicate that EER is a safe and effective method of treating BOFs of the medial orbital walls.