Abordaje transconjuntival en comparación con abordaje subciliar para el tratamiento de fracturas orbitarias / Transconjunctival versus subciliary approach for the treatment of orbital fractures

RESUMEN: Introducción: Los abordajes transconjuntival preseptal y subciliar han sido ampliamente utilizados para el manejo quirúrgico de las fracturas orbitarias. Sin embargo, aún existe incertidumbre sobre las complicaciones asociadas a cada uno de estos abordajes. Métodos: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios. Realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Resultados y conclusiones: Identificamos seis revisiones sistemáticas que en conjunto incluyeron 21 estudios primarios, de los cuales cuatro corresponden a ensayos aleatorizados. Concluimos que el abordaje transconjuntival preseptal podría disminuir tanto la incidencia de ectropión como de un resultado estético insatisfactorio, pero la certeza de la evidencia es baja. Además, este abordaje probablemente disminuye el riesgo de complicaciones intra y postoperatorias, tales como diplopía, parestesia transitoria, equimosis, exposición escleral, laceración del plato tarsal y laceración palpebral inferior. Por otro lado, el abordaje transconjuntival podría aumentar el riesgo de entropión, pero la certeza de la evidencia también es baja.

ABSTRACT: Introduction: The preseptal transconjunctival and subciliary approach have been widely used for the surgical management of orbital fractures. However, there is still uncertainty about the complications associated with each of these approaches. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified six systematic reviews that included 21 primary studies, four of which correspond to randomized trials. We conclude that the preseptal transconjunctival approach could decrease the incidence of ectropion and an unsatisfactory aesthetic result, but the certainty of the evidence is low. Furthermore, this approach probably decreases the risk of intra and postoperative complications, such as diplopia, transient paresthesia, ecchymosis, scleral show, tarsal plate laceration and lower palpebral laceration. On the other hand, the transconjunctival approach could increase the risk of entropion, but the certainty of the evidence is also low.

Retrospective analysis of 79 patients with orbital floor fracture: outcomes and patient-reported satisfaction

BACKGROUND: The aim of our retrospective study is to evaluate the management of isolated orbital floor fractures considering the clinical, functional and aesthetic results according to the surgical approach and the type of materials used. METHODS: Retrospectively, clinical, radiological, surgical, and ophthalmological data from 79 patients were collected from January 2010 to December 2016. Furthermore, included patients were interrogated on functional and aesthetic satisfaction. RESULTS: The main causes of trauma were physical aggression followed by accidents. The median time between trauma and surgery was 4 days. The most common surgical approaches were the subciliary and the transconjunctival ones. Alloplastic materials were used in 75 patients. In two patients, we used a combination of two grafts. Patients experienced minor immediate complications. On follow-ups, none of our patients suffered from ocular movement restrictions. Patients treated by subciliary approach had higher risk of retractile scaring compared to other surgical approaches. In our study, patients agreed to complete a questionnaire assessing functional and aesthetic outcomes with a high satisfaction score. No association between the implant material used and the results has been assessed. CONCLUSION: This study describes the results of orbital floor reconstructions. Despite a variety of materials used and surgical approaches performed, we believe that the transconjunctival approach is the most suitable option with a high satisfaction score.

Delayed Onset Diplopia due to Minimal Orbital Floor Fractures 16 Months Previously / 대한이비인후과학회지

Ocular symptoms related to orbital fracture occur immediately after the fracture in most cases. However, authors experienced a delayed onset diplopia occurred 16 months after orbital floor fracture. A 19-year-old man, who had right orbital floor fracture 16 months ago, presented with diplopia of upward gaze. At the time of the fracture, no surgery was performed because the fracture was minimal and there were no particular symptoms. Physical examinations revealed a minor ocular motility restriction of upward gaze, but orbital floor showed no definite interval change on computed tomography. Severe adhesion between the orbital fat tissue and orbital floor was noted intraoperatively and the adhesion was dissected. After the operation, the patient showed remarkable improvement in diplopia and restriction of the ocular motility.

Delayed Retrobulbar Hemorrhage after Orbital Floor Reconstruction

PURPOSE: Retrobulbar hemorrhage is a rare complication followed by blepharoplasty, trauma, orbital reconstruction, and so on. Most of the cases occur within 24 hours, half of them in the first 6 hours. Some authors have reported delayed retrobulbar hemorrhage after blepharoplasty and trauma within 1 day to 9 days. However, there have been few reports of delayed retrobulbar hemorrhage resulting from the complication of orbital reconstruction. METHODS: A 22-year-old male underwent orbital floor reconstruction due to the orbital floor fracture. In 84 hours after the surgery, he complained sudden onset orbital pain and decreased visual acuity immediately after defecation. Intraocular pressure was unmeasurable due to the swelling at that time. Emergency computed tomography was performed. RESULTS: Computed tomography revealed subperiosteal hematoma on inferior orbital wall extended to the apex. Emergency decompressive surgery was performed within 1 hour. After evacuation of hematoma, orbital symptom was improved and visual acuity was restored. CONCLUSION: Delayed retrobulbar hemorrhage is rare but vision-threatening.Therefore early diagnosis and treatment of delayed retrobulbar hemorrhage is thought to be crucial. The cause of delayed hemorrhage was not clear, however, valsalva maneuver might be the cause of hemorrhage.

Immediate Operation in Pediatric White-eye Blowout Fracture

PURPOSE: 'White-eye blowout' fracture is often occur in young patients and defined as blow out fracture with little or no clinical sign of soft tissue trauma such as edema, ecchymosis, but with marked motility restrictions in vertical gaze. In this conditions, immediate operation is essential. We reported the clinical investigation study of these cases about clinical symptoms and radiologic findings and introduce our experiences about immediate operations in 'white-eye blowout' fractures. METHODS: From January 2008 to December 2009, nine pediatric patients who were diagnosed as pure white-eye blowout fractures were involved this study. Patients with other facial bone fractures or with poor general medical condition were excluded. In all cases, we performed immediate operation within 48 hours. RESULTS: All patients had diplopia, vertical gaze restriction or systemic symptoms. Six patients had nausea, vomiting and syncope caused by oculocardiac reflex. In all patients, preoperative symptoms were improved after immediate operation. There were no postoperative complications such as infection, hematoma or wound dehiscence. CONCLUSION: When we meet the young patients with history of periocular trauma, with little or no soft tissue trauma signs, but with marked vertical gaze restriction or general symptoms caused by oculocardiac reflex, we should immediately examine by facial bone computed tomography and refer the patient to ophthalmologist for ophthalmic evaluations. If patient is diagnosed as orbital floor fracture with entrapped muscle or soft tissue, the earlier surgical reduction get better clinical outcomes.

Internal Fixation of Medpor(R) Implant for Prevention of Enophthalmos in Posteriorly Extended Orbital Floor Fracture

PURPOSE: The purpose of this study is to evaluate the effectiveness of internal fixation method of Medpor(R) implant with BioSorb(TM)FX screw which is used for prevention of enophthalmos in posteriorly extended large orbital floor fracture. METHODS: From Jun. 1997 to Dec. 2007, 21 patients who were diagnosed with posteriorly extended large orbital floor fractures were classified into two groups. One group(n=11) had undergone reduction surgery with regular Medpor(R) sheets without any fixation method, while the other group(n=10) had their Medpor(R) sheets fixed with the BioSorb(TM)FX screws. The two groups were evaluated by comparison of their enophthalmos degree and effectiveness. RESULTS: In the non-fixation group, six patients had enophthalmos preoperatively and three of them showed persistent enophthalmos postoperatively. In postoperative CT examination, displacement of Medpor(R) implant with soft tissue impaction into maxillary sinus was observed in the patients. In the screw fixation group, three patients had enophthalmos preoperatively, but none of them suffer from complication such as residual enophthalmos, soft tissue impaction, muscle entrapment or optic nerve compression postoperatively. CONCLUSION: Internal fixation method of Medpor(R) implant with BioSorb(TM)FX screw on the medial surface of orbital floor provides firm stabilization of implants and surrounding soft tissues and can be an effective option especially when postoperative implant displacement or malposition was expected.

Antibiotic Prophylaxis' Effect on Enophthalmos in Orbital Floor Fracture with Chronic Maxillary Sinusitis

PURPOSE: Orbital floor fracture has open wound to maxillary sinus and if the patient has chronic maxillary sinusitis, it may be have more risk of infection, complications. The purpose of this comparative study is to be the effectiveness of prophylactic antibiotics in orbital floor fracture with chronic maxillary sinusitis. METHODS: We studied 20 patients who diagnosed as orbital floor fracture with chronic maxillary sinusitis from march, 2005 to may, 2006. Among them 16 were male, 4 were female and age was ranged from 15 to 68, average was 42. A day before operation, Prophylactic antibiotics were used to 10 patients. Prophylactic antibiotics were not used to 10 patients. We defined control group as prophylactic antibiotics injection group a day before operation. After surgery, we confined use of same antibiotic for 7 days in both group. After 6 month from surgery, we compare the degree of enophthalmos from healthy side to legion side with hertel exopthalmometry(Inami, Japan) in control group and non-prophylactic antibiotics injection group. RESULTS: In control group, comparison of discrepancy between enophthalmic eyeball and normal eyeball with Hertel exophthalmometer was 1.1mm and non-prophylactic antibiotics injection group was 2.1mm. In independent sample t-test, control group was showed statistically significant difference with non-prophylactic antibiotics injection group(p=0.007). CONCLUSIONS: In orbital floor fracture with chronic maxillary sinusitis, bacteria in maxillary sinus can increase post-operative complication by infecting infraorbital soft tissue, and it is thought to be antibiotic prophylaxis is play a role in decrease in degree of enophthalmos. We feel the need to further study of prophylactic antibiotics in orbital floor fracture with chronic maxillary sinusitis.

Usefulness of Sagittal CT in Orbital Floor Fracture

Optimal diagnostic tool of facial bone fractures is computed tomography(CT). When we diagnosed the facial bone fracture, we routinely used axial & coronal view of CT. But, development of software related CT enabled the application of various views recently. The purpose of this study is to evaluate about usefulness of sagittal view of the CT. Group I was the axial & coronal views about 15 patients with orbital floor fracture. Group II was the axial, coronal & sagittal views about same 15 patients. We asked 4 senior residents of department of plastic reconstructive surgery & ophthalmology, Yeungnam university hospital question about their confidence and usefulness. Compared with group II to group I, group II was more useful result. Using Pearson's chi-square test, statistical significance was checked (p<.05) about almost questions. It means that sagittal view is useful tool for orbital floor fracture.

The 'White-eyed Blowout' Fracture

Blow-out fractures of the orbital floor are comparatively rare in children. They have some characteristics. We have come across a group of young patients(less than 16 years of age) with little or no clinical evidence "White-eyed" of soft tissue trauma(e.g., edema, ecchymosis), diplopia with restriction of vertical gaze, lack of enophthalmos and radiologic signs of minimal bone displacement. Some investigators advocate 2-week waiting period has been found to be of little benefit in these persons and possibly harmful to their motility, so surgery within the first few days after injury as it may help to avoid permanent motility restriction in "white-eyed blowout". This paper reviews our experience of six "White-eyed blowout" patients. One of the six patients has continued mild extraocular movement restriction by 7 months. But, in one patient, symptoms resolved rapidly by 1 month after surgery. We suggest that "White-eyed blowout" can be the new categories of blowout fracture.