Strabismus in pediatric orbital wall fractures

Purpose: To assess the clinical profiles and outcomes of strabismus in pediatric patients with orbital wall fractures. Methods: A retrospective interventional study of all consecutive children of age ?16 years who presented with traumatic orbital wall fractures with and without resultant strabismus was conducted. The details of patient demographics, clinical features, interventions, and outcomes were obtained. Results: Forty?three children presented with traumatic orbital fractures to a tertiary care center. The mean age at presentation was 11 years and there was a male predominance (72.09%). Isolated floor fracture involvement was the most common (n = 24, 55.81%), and almost half of the children had a white?eyed or trapdoor fracture (n = 21, 48.83%). Twenty?six (60.46%) children had surgical repair of fracture(s). Manifest strabismus following orbital fracture was documented in 12 children (27.90%). Of these, an exotropia was noted in seven (58.33%), hypotropia in two (16.67%), hypertropia in one (8.33%), and esotropia in one patient (8.33%), while an exotropia with hypotropia was noted in one patient (8.33%). Restrictive nature of strabismus due to either muscle entrapment or local trauma was more commonly observed in 11/12 patients (91.66%). Primary position diplopia before orbital wall fracture repair was observed in four children and after repair was observed in two children with manifest strabismus. Four children underwent strabismus surgery post?fracture repair. Conclusion: An improvement in strabismus and ocular motility was noted in majority of the patients after fracture repair. The few that underwent strabismus surgery had a restrictive nature of strabismus. Trapdoor fractures and the nature of trauma in children vary compared to adults. Persistence of strabismus may be due to an excessive time interval between trauma and fracture repair or the extensive nature of trauma

A study of pattern of maxillofacial fractures and its complications

Background: Incidence of maxillofacial fractures is quite high worldwide. A very important aesthetic function is served by maxillofacial skeleton moreover the prominent position of maxillofacial skeleton makes it more susceptible to fracture.Methods: A prospective study was done to assess the main etiology and pattern of maxillofacial fractures of 60 patients who came to the emergency department of Sri Guru Ram Das Institute of Medical sciences and Research between January 2018 and June 2019.Results: Total number of patients taken for this study were 60. The number of male patients were 56 (93.33%) and number of female patients were 4 (6.66%) and male to female ratio was (14:1). The age range spanned from 11 years to 70 years with (mean age=37.30 years, SD=14.27). Primary etiologic factor for maxillofacial fractures was road traffic accidents (49, 81.66%), followed by fall (8, 13.33%), and assault accounted for (3, 5%). Total 229 fractures were present in 60 patients. Concerning the anatomical site of fractures, it was explored that most common site of fractures is orbit (59, 25.72%) followed by fractures of maxilla (55, 24%) and zygomatic complex (35, 15.28%). Infection was most common complication and was present in 2 (3.33%) of the patients during hospital stay. 21 (35%) of the patients had associated head injury and maximum patients 49 (81.66%) were treated by open reduction and internal fixation.Conclusions: It is concluded, that main etiology of maxillofacial trauma is road side accidents. Therefore, strict compliance of traffic rules can avoid such injuries.

Correction of post-traumatic enophthalmos with anatomical absorbable implant and iliac bone graft

BACKGROUND: Trauma is one of the most common causes of enophthalmos, and post-traumatic enophthalmos primarily results from an increased volume of the bony orbit. We achieved good long-term results by simultaneously using an anatomical absorbable implant and iliac bone graft to correct post-traumatic enophthalmos.METHODS: From January 2012 to December 2016, we performed operations on seven patients with post-traumatic enophthalmos. In all seven cases, reduction surgery for the initial trauma was performed at our hospital. Hertel exophthalmometry, clinical photography, three-dimensional computed tomography (3D-CT), and orbital volume measurements using software to calculate the specific volume captured on 3D-CT (ITK-SNAP, Insight Toolkit-SNAP) were performed preoperatively and postoperatively.RESULTS: Patients were evaluated based on exophthalmometry, clinical photographs, 3D-CT, and orbital volume measured by the ITK-SNAP program at 5 days and 1 year postoperatively, and all factors improved significantly compared with the preoperative baseline. Complications such as hematoma or extraocular muscle limitation were absent, and the corrected orbital volume was well maintained at the 1-year follow-up visit.CONCLUSION: We present a method to correct enophthalmos by reconstructing the orbital wall using an anatomical absorbable implant and a simultaneous autologous iliac bone graft. All cases showed satisfactory results for enophthalmos correction. We suggest this method as a good option for the correction of post-traumatic enophthalmos.

Progress in reconstruction of orbital wall after fracture / 国际眼科杂志(Guoji Yanke Zazhi)

·At present, the orbital wall fracture is a very common facial trauma. The orbital contents are often incarcerated in the fracture cracks resulting in changes in the orbital eye position, then can bring a lifetime of diplopia and enophthalmos,which greatly affects the visual acuity and facial appearance. The purpose of repairing of orbital fracture is reconstructing orbital wall, repairing defect to correct eye position, avoiding enophthalmos and recovering visual function. The review will provide a comprehensive overview of orbital fracture reconstruction.

Orbital wall restoring surgery with resorbable mesh plate

BACKGROUND: Orbital resorbable mesh plates are adequate to use for isolated floor and medial wall fractures with an intact bony buttress, but are not recommended to use for large orbital wall fractures that need load bearing support. The author previously reported an orbital wall restoring surgery that restored the orbital floor to its prior position through the transnasal approach and maintained temporary extraorbital support with a balloon in the maxillary sinus. Extraorbital support could reduce the load applied on the orbital implants in orbital wall restoring surgery and the use of resorbable implants was considered appropriate for the author’s orbital wall restoring technique. METHODS: A retrospective review was conducted of 31 patients with pure unilateral orbital floor fractures between May 2014 and May 2018. The patients underwent transnasal restoration of the orbital floor through insertion of a resorbable mesh plate and maintenance of temporary balloon support. The surgical results were evaluated by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values. RESULTS: The OVR decreased significantly, by an average of 6.01% (p < 0.05) and the preoperative and postoperative Hertel scale measurements decreased by an average of 0.34 mm with statistical significance (p < 0.05). No complications such as buckling or sagging of the implant occurred among the 31 patients. CONCLUSION: The use of resorbable mesh plate in orbital floor restoration surgery is an effective and safe technique that can reduce implant deformation or complications deriving from the residual permanent implant.

Endoscopic and Transconjunctival versus Transcaruncular and Transconjunctival Reconstruction of Medial and Inferior Orbital Wall Fractures

PURPOSE: To compare two combined surgical techniques, endoscopic endonasal surgery with transconjunctival reconstruction and transcaruncular surgery with transconjunctival reconstruction, when used to treat both medial and inferior orbital wall fractures. METHODS: A retrospective review of 63 patients who were followed up from January 2011 to December 2014 at Inha University Hospital for surgical reconstruction of combined medial and inferior orbital wall fractures was undertaken. We compared between the patients the computed tomographic scans, diplopia, extraocular muscle (EOM) movements, and Hertel's exophthalmometer exams pre- and post-6 months surgery. A total of 29 patients received endoscopic transnasal surgery with trasconjunctival reconstruction, and 34 received transcaruncular surgery with trans-conjunctival reconstruction. RESULTS: There were no significant differences between the two combined methods in terms of the primary and peripheral gaze diplopia or the restriction of EOM movement 6 months after surgery. However, statistically significant differences were observed in exophthalmometer measurements 6 months after surgery. CONCLUSIONS: The two combined surgical methods showed similar results in terms of postoperative primary and peripheral gaze diplopia, EOM restriction, and enophthalmos. With respect to postoperative peripheral diplopia, endoscopic endosnasal surgery with transconjunctival reconstruction showed several advantages over the other method considered in this study. An appropriate surgical method should be selected by comparing the relative advantages and disadvantages.

The Transcaruncular Approach for the Reduction of Medial Orbital Wall Fracture

The evolution of surgical approaches to the medial orbit has been driven by the need to achieve safe, versatile, and direct access, while minimizing unwanted structural changes and scarring. Previous approaches such as medial skin incision or inferior transconjuntival incision have limited overview and may leave visible scar or lid retraction. Transcaruncular approach may successfully resolve such problems and maybe the first choice of method in reduction of medial orbit. The anatomy underlying the transcaruncular approach suggests that it offers the same excellent exposure of the medial wall as the Lynch approach. An incision through the caruncle and dense fibrous condensation passes along a natural plane between Horner's muscle and the medial orbital septum. So minimal bleeding occurs and can exposure the fracture site in the shortest time. We used this method in 22 patients for reduction of medial orbital wall fractures and it provides excellent surgical exposure, easy and rapid, and no visible scar remained.

Clinical Analysis of Internal Orbital Fractures in Children

In order to describe the demographics, etiologic and clinical factors, and outcomes of orbital fractures in children, we have reviewed a case series of 17 patients under 18 years of age with internal orbital fractures (i.e., without involvement of the orbital rim) presenting to the Ghil hospital between March 2000 and June 2001. For 15 of the patients, we performed orbital wall reconstruction with Medpor (R) barrier sheet implantation (thickness 1mm) through transconjunctival approach under endoscopic guidance, while maintaining mere observation on the other 2 patients. There were 14 male and 3 female patients. The most common cause of fractures was accident (7 cases). Inferior wall involvement was most commonly seen, and the trapdoor type fracture was the most common. Thirteen patients had extraocular muscle restriction, 9 had nausea/vomiting and 5 had bradycardia. Diplopia of 9 patients disappeared after 43+/-23 days. Nausea/vomiting and bradycardia disappeared rapidly after surgical intervention in all cases. These results suggest that trapdoor fractures with soft tissue entrapment are the most common in pediatric orbital wall fractures, and that most of them are associated with nausea/vomiting. We suggest that early diagnosis, and prompt surgical intervention are required for those patients with oculocardiac reflex.

Clinical Evaluation of the Associated Ocular Injuries of Orbital wall fracture Patients

PURPOSE: To describe the demographics, etiologic factors, clinical presentations, and associated ocular injuries in orbital wall fracture patients. MATERIALS AND METHODS: We retrospectively analysed 172 eyes of 144 patients with orbital wall fractures who visited emergency room & department of ophthalmology from 2000 to 2001. Clinical features such as age, sex, causes of injury, sites of orbital wall fractures, associated ocular injuries, number of associated injuries according to the site of orbital wall fractures, site of orbital wall fractures according to the associated injuries, associated injuries according to the number of orbital wall fractures. RESULTS:Total number of patients was 144 (172 eyes), 108 patients (75.0%) were men and 36 patients (25.0%) were women. Mostly, they were under 50 years of age. Traffic accidents (44.4%) was the most common cause of injury and medial wall (37.8%) was most common site of orbital wall fractures. Commotio retina (36.8%), Hyphema (8.8%), Eyelid laceration (19.3%), Traumatic optic neuropathy (5.7%) were most commonly associated injuries. The more number of wall fracture, the more occurred associated injuries. When more stronger force, such as lateral wall fracture, was accompanied, the associated injuries were more common. CONCLUSIONS: High prevalence of ocular and extraocular injury with orbital wall fractures emphasizes the need for a comprehensive ophthalmic evaluation and long-term follow-up.

Clinical Experience of Orbital wall Reconstruction using Medpor(R) Barrier Sheet Implant

PURPOSE: To evaluate surgical effect of Medpor(R) Barrier Sheet, by comparing with postoperative outcomes using Medpor(R) Barrier Sheet and Medpor(R) in orbital wall reconstruction. METHOD: We have retrospectively analyzed clinical features and postoperative outcomes in two groups. One group is 29 patients who had undergone orbital wall reconstruction using Medpor(R) Barrier Sheet, the other group is 26 patients who had undergone orbital wall reconstruction using Medpor(R). RESULTS: The violence was the most common cause of the orbital wall fractures, the most common fracture site was inferior wall in the two groups. There were no significant differences between the two groups in improvement of diplopia and limitation of extraocular movement(p>0.05). The mean amount of enophthalmic correction were 1.15 mm in Medpor(R) Barrier Sheet group and 1.39 mm in Medpor(R) group. Three cases of Medpor(R) Barrier Sheet group and two cases of Medpor(R) group caused the infraorbital hypoesthesia, but prolapse or dislocation of implant was not found in the two groups. CONCLUSIONS: In this study, Medpor(R) Barrier Sheet had similar surgical effect to regular Medpor(R); its advantages over regular Medpor(R) were easy intraoperative manipulation and less adherence of extraocular muscle in reconstruction of orbital wall fractures. But when cost- effectiveness is considered, Medpor(R) Barrier Sheet may be a good available implant in orbital wall reconstruction for the selective cases with extraocular muscle exposed.