Acessos cirúrgicos combinados para tratamento de fraturas em assoalho orbital e lâmina papirácea: relato de caso / Combined surgical accesses for treatment of fractures in the orbital floor and lamina papyracea: case repor

A região orbitária é bastante suscetível a traumas, visto que apresenta uma posição exposta, além de ser composta por ossos frágeis. Quando indicada, é preciso intervenção cirúrgica para preservar a função visual e harmonia facial do paciente. Os acessos transconjuntival e transcaruncular são descritos na literatura como formas seguras, rápidas, funcionais e esteticamente benéficas para a abordagem ao assoalho orbitário e lâmina papirácea. Sobre os materiais biocompatíveis utilizados, a placa de titânio é inabsorvível e permite fixação interna rígida, moldada às curvaturas naturais dos ossos, com baixo risco de infecção. As folhas de polietileno poroso são polímeros inertes e não absorvíveis que facilitam o crescimento de tecido e reduzem as chances de rejeição. Nesse relato de caso, evidencia-se paciente masculino, 28 anos, vítima de traumatismo facial após prática esportiva que apresentou fratura de assoalho e parede medial orbitária direita, com indicação de reconstrução orbitária com acessos transconjuntival e transcaruncular para fixação de placa de titânio em assoalho da órbita direita e de folhas de polietileno poroso em lâmina papirácea à direita, respectivamente (AU)

The orbital region is quite susceptible to trauma, since it has an exposed position, besides being com-posed of fragile bones. When indicated, surgical intervention is required to preserve the patient's visual function and facial harmony. Transconjunctival and transcaruncular accesses are described in the literatu-re as safe, fast, functional and with esthetic benefits for the approach to the orbital floor and papyraceous lamina. Among the biocompatible materials used, the titanium plate does not undergo resorption and allows rigid internal fixation, being shaped to the natural curvatures of the bones, with low risk of infec-tion. Porous polyethylene sheets are inert and nonabsorbable polymers that facilitate tissue growth an reduce the chances of rejection. In this case report, a 28-year-old male patient, a victim of facial trauma after sports practice presented a fracture of the floor and the right orbital medial wall, and orbital recons-truction was indicated with transconjunctival and transcaruncular accesses for fixation of titanium plate in the floor of the right orbit and porous polyethylene sheets in papyracea leaf on the right, respectively (AU)

Navigation-guided optic canal decompression for traumatic optic neuropathy: Two case reports

Two cases of traumatic optic neuropathy presented with profound loss of vision. Both cases received a course of intravenous corticosteroids elsewhere but did not improve. They underwent Navigation guided optic canal decompression via external transcaruncular approach, following which both cases showed visual improvement. Postoperative Visual Evoked Potential and optical coherence technology of Retinal nerve fibre layer showed improvement. These case reports emphasize on the role of stereotactic navigation technology for optic canal decompression in cases of traumatic optic neuropathy.

Endoscopic Transnasal versus Transcaruncular Reconstruction in Isolated Medial Orbital Wall Fractures

PURPOSE: To compare 2 surgical techniques, endoscopic transnasal reconstruction and transcaruncular reconstruction in isolated medial orbital wall fractures. METHODS: This study included 79 isolated medial orbital wall fracture patients from January 2011 to December 2012 of Department of Ophthalmology, Inha University Hospital. The authors compared computed tomographic scans, diplopia, extraocular muscle (EOM) movements, and Hertel's exophthalmometer exams pre- and post-surgery. Thirty-five patients received endoscopic transnasal reconstruction and 44 received transcaruncular reconstruction. RESULTS: The 2 surgical methods showed no significant differences in primary gaze diplopia (p = 0.50), restriction of EOM movements (p = 0.48), remaining enophthalmos of more than 2 mm (p = 0.99), and improvement in enophthalmos (p = 0.07) when compared 6 months after surgery. Statistically significant differences were observed in peripheral diplopia (p = 0.04) 6 months after surgery. CONCLUSIONS: The 2 surgical methods present similar effectiveness in postoperative primary gaze diplopia, EOM restriction, and enophthalmos. With respect to postoperative peripheral diplopia, endoscopic transnasal reconstruction method showed advantages. The surgical method should be selected by comparing advantages and disadvantages.

Reconstruction of Isolated Medial Orbital Wall Fracture Using a Transcaruncular Approach

PURPOSE: We present our results in the reconstruction of medial orbital wall fractures using a transcaruncular approach. METHODS: Forty-five patients with isolated medial orbital wall fractures underwent reconstruction by transcaruncular approach in our clinic between May 2003 and October 2007, and were followed up for 6 months or more. RESULTS: Thirty-three males and 12 females were included in this study, with a mean age of 34.9 years. The most common indication for reconstruction were large sized fractures more than 50%. Operations were performed at a mean 11.9 days after trauma. Among 18 patients who had diplopia before the operation, 16 (89%) patients had symptom relief or improvement, and in the 2 patients where diplopia persisted, it did not in primary and down gaze and offered no difficulties in daily activities. Among 34 patients who had enophthalmos before the operation, most (n=30) of the patients had minimal enophthalmos not more than 2 mm, 4 patients had enophthalmos that exceeded 2 mm. CONCLUSIONS: Transcaruncular approach in reconstruction of isolated medial orbital wall fracture shows more satisfying functional and cosmetic results and can be preferred to isolated medial orbital wall fracture.

The transcaruncular approach of the medial orbital wall fracture

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.

Transcaruncular Approach to Blowout Fractures of the Medial Orbital Wall

Transcutaneous and transconjunctival approaches are still frequently used to repair orbital wall fractures. However, medial orbital wall fracture remains a challenging area for plastic surgeons due to technical difficulties and postoperative scars. The transcaruncular approach is described and we present our experience with this approach to access the medial orbital wall in 10 patients with blowout fracture in the medial orbital region. All patients were corrected satisfactorily without cutaneous scar. The transcaruncular approach is a useful technique to repair medial orbital wall fractures.

Transcaruncular Approach for Reconstruction of Old Medial Orbital wall Fracture

PURPOSE: The purpose of this study was to identify the therapeutic effect of orbital reconstruction by transcaruncular approach on old medial orbital wall fracture. METHODS: We performed retrospective study on 23 eyes of 23 patients, who underwent orbital reconstruction with transcaruncular approach over six weeks after injury from July 1999 to August 2001. RESULTS: Nineteen cases had enophthalmos, preoperatively; five cases; 2 mm, seven cases; 3 mm, six cases; 4 mm, and one case; 5 mm, respectively. Postoperatively, we obtained enophthalmos less than 1 mm in 17 cases(89%). The exophthalmometry revealed that enophthalmos improved from 3.2+/-0.9 mm, preoperatively to 0.9+/-0.7 mm, postoperatively. Twelve cases had diplopia on the primary and downgaze, preoperatively. However, ten cases of them(83%) disappeared diplopia, postoperatively. Of the remaining two cases, one had persistent diplopia on the downgaze and the other had paralytic strabismus. CONCLUSIONS: We believe that the medial orbital wall repair through transcaruncular approach was a good way to correct enophthalmos and diplopia on old medial orbital wall fracture.

Treatment of the Medial Orbital Wall Fracture using Transcaruncular Approach

Medial orbital wall fracture can easily be overlooked because typical clinical symptoms appear in only a few instances. However, if it is left untreated in case of no diplopia, cosmetically undesirable enophthalmos may develop. Various cutaneous approaches, previously used, may leave noticeable scar or provide a limited overview of the orbit medial wall fracture site. We used the transcaruncular approach in 36 cases of 35 patients for reconstruction of the medial orbital wall fracture. The incision was made at the junction of the medial 3/4 and lateral 1/4 of the caruncle, and extended along the conjunctival fornix superiorly and inferiorly to or beyond both puncta for 10 - 15 mm long respectively. After soft tissue was dissected, periosteum was incised at the posterior to the posterior lacrimal crest. Implants up to a height of 2.5 cm could be inserted.The diplopia was resolved in all cases after the surgery, and enophthalmos measured 0 to 2 mm in all patients. Postoperative computed tomographic scans showed favorable reduction of the herniated soft tissues and anatomic reduction of the medial wall without complication related to the surgical approach in all cases. Transcaruncular approach is a better alternative to transcutaneous incisions because it provides wide exposure of the medial orbital wall, no visible cutaneous scar, short operation time, and no damage of important internal structures.

Orbital Reconstruction via Extended Transconjuctival and Transpalpebral Approach

In case of blow-out fracture involving floor or inferomedial wall, the fracture site can be accessed by methods such as subcilliary incision, mid-lower eyelid incision, infra-orbital incision and transconjunctival incision. Meanwhile, in case of orbital fracture involving supero-medial wall or roof, above-mentioned methods have the limitation of fracture site exposure, and bicoronal incision is required to overcome the difficult approach. The authors exposed fracture site widely and executed accurate reduction through extended transconjunctival approach and transpalpebral approach, instead of the approach by bicoronal incision. We executed 118 cases of orbital reconstruction by above method among 96 patients who consulted doctors to reconstruct blow-out fracture and enophthalmos from September 1997 to May 2001. Among the 118 cases were 50 cases of orbital floor fracture, 4 cases of orbital roof fracture, 48 cases of orbital medial wall fracture, 13 cases of complex type and 3 cases of enophthalmos. The authors made wide dissection of antero-superial medial wall of orbit and roof fracture of orbit enabled by above methods, which allowed enough exposure and approach to orbital fracture site and prevented side effects such as post operative lower eyelid scar or ectropion and scleral show.

Repair of Orbital Wall Fracture Using Transcaruncular Approach

Transcutaneous and transconjunctival approaches are still the most frequently used techniques in repairing orbital wall fractures. However, medial wall fracture is still a challenging area to the oculoplastic surgeons due to technical difficulties and postroperative scars. Transcaruncular approach is an effective way to repair medial or combined medial and inferior orbital wall fractures without visible scars. Ten cases of orbital wall fractures are repaired using the transcaruncular approach alone or combined with transconjunctival approch. All patients were corrected satisfactorily without leaving any visible scar. We think transcaruncular approach is a useful technique to repair medial orbital wall fracture.