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.

Outcomes of Isolated Medial Orbital Wall Fracture Reconstructions

PURPOSE: To evaluate surgical results after the reconstruction of isolated medial orbital wall fractures. METHODS: We performed a retrospective chart review of patients with isolated medial orbital wall fractures who underwent reconstruction using the transcaruncular approach from March 2012 to October 2013. Computed tomography (CT) was performed before and after surgery. Postoperative follow-ups were conducted at 1 week, 1 month, and 3 months. Diplopia, ocular motility, postoperative complication, and exophthalmometry were recorded at each follow-up visit. Preoperative and postoperative enophthalmos was quantified using Hertel exophthalmometry and a quantitative method for the area of the circular sector under the chord (CA)/orbital area (OA) ratio at the CT scan. Patients were divided into either the incomplete or complete reduction groups based on the degree of reduction observed on postoperative CT. RESULTS: We evaluated 55 patients (42 males, 13 females) with an average age of 36 years. Five of 55 patients with preoperative enophthalmos of more than 2 mm obtained good symmetry after surgery. Diplopia at primary gaze was resolved in 9 of 9 patients and 2 patients had residual diplopia on lateral gaze. The difference of exophthalmometry and CA-to OA ratio between before and after reconstruction was not significantly changed in either the incomplete or complete groups. CONCLUSIONS: Enophthalmos and diplopia were well corrected in all subjects. If reduction was successfully performed in the anterior portion of medial orbital wall fracture, clinically significant enophthalmos might be preventable even if complete reduction was not obtained.

A Case of Pseudo-Duane's Retraction Syndrome With Old Medial Orbital Wall Fracture

We report a case of pseudo-Duane's retraction syndrome with entrapment of the medial rectus muscle in an old medial orbital wall fracture presenting identical clinical symptoms as Duane's retraction syndrome. A 15-year-old boy presented with persistent limited right eye movement since a young age. Examination showed marked limited abduction, mildly limited adduction, and globe retraction accompanied by narrowing of the palpebral fissure during attempted adduction in the right eye. He showed a right esotropia of 16 prism diopters and his head turned slightly to the right. A slight enophthalmos was noted in his right eye. A computed tomography scan demonstrated entrapment of the medial rectus muscle and surrounding tissues in an old medial orbital wall fracture. A forced duction test revealed a marked restriction of abduction in the right eye. A 5 mm recession of the right medial rectus muscle was performed. Postoperatively, the patient's head turn and esotropia in the primary position were successfully corrected, but there was still some limitations to his ocular movement. The importance of several tests such as the forced duction test and an imaging study should be emphasized in making a diagnosis for limitation of eye movement.

Inlay Grafting for the Treatment of the Posterior Comminuted Fracture of Medial Orbital Wall

PURPOSE: For blowout fracture of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomic reconstruction of the wall without surgical complications. Surgeons frequently worry about damage to the optic nerve from the dissection, when the part over the posterior ethmoidal foramen was fractured. The authors performed small incision and inlay grafting for reconstruction of medial orbital wall fracture. METHODS: Between January 2007 and April 2008, 15 out of 32 patients were included in an analysing the outcome of corrected medial orbital wall fracture. In 15 patients of posterior comminuted fracture of medial orbital wall, insertion of porous polyethylene(Medpor(R) channel implant, Porex, USA) to ethmoidal sinus was performed in multiple layer, through the transconjunctival approach (inlay grafting). RESULTS: In all cases, the orbital bone volume was reconstructed in its normal anatomical position. The associated ocular problems disappeared except for mild enophthalmos in 2 patients and there were no surgical complications associated with inlay grafting. CONCLUSION: The advantage of inlay grafting include anatomical reconstruction of the orbital wall; the avoidance of optic nerve injury; the simplicity of the procedure; and consequently, the absence of surgery-related complications. This technique is presented as one of the preferred treatments for posterior comminuted fracture of medial orbital wall.

Advantage of Middle Meatal Antrostomy in Transnasal Endoscopic Reconstruction of Medial Orbital Blow-out Fracture

PURPOSE: Blowout fracture is an outward fracture of the orbital wall. That usually occurs at inferior or medial wall of the orbit. The main pathophysiology is high intraocular pressure derived from impact of trauma. Among the four orbital wall, the medial wall is thinnest and most vulnerable to trauma. Many kinds of methods were introduced for correction of medial orbital wall fracture. Recently, transnasal endoscopic reconstruction methods were widely used. Endoscopic methods had many advantages. However, we experienced some cases of postoperative maxillary sinusitis. This study was planned to find out the effectiveness of middle meatal antrostomy after endoscopic reconstruction of medial orbital wall fracture. METHODS: This study was retrospective analysis of 28 patients who underwent transnasal endoscopic repair of medial orbital wall fracture. The 18 male and 10 female patients were ranged from 17 to 57 years of age(mean, 30.9 years). Among 28 patients, randomly selected 17 patients underwent middle meatal antrostomy as additional procedure by the same surgeon. After at least 12 months of follow-up period, we examined the nasal symptom, endoscopic and CT findings. RESULTS: One patient complained of nasal obstruction in middle meatal antrostomy group and four patients complained nasal symptoms in non middle meatal antrostomy group. On the endoscopic findings, three patients of non middle meatal antrostomy group had continuous nasal discharge. But middle meatal antrostomy group had no abnormal endoscopic findings. The abnormal CT finding(abnormal mucosal hypertrophy) were detected in four patient of non middle meatal antrostomy group. There were no abnormal CT findings in middle meatal antrostomy group. The data were statistically significant at comparative study. CONCLUSION: Authors think that the middle meatal antrostomy has some advantages as a additional procedure of endoscopic reconstruction of medial orbital wall fracture. Especially, it is good at preventing post- operative maxillary sinusitis. But, more larger group and strict application of disease entity are need for correct evaluation of middle meatal antrostomy effect.

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.

Comparison of Computerized Tomography(CT) and Ultrasonography(US) in the Diagnosis of Nasal Bone Fracture and Medial Orbital Wall Fracture

For the diagnosis of nasal bone fracture and medial orbital wall fracture, plain radiography and computerized tomography(CT) have been utilized. But plain radiography is less reliable due to its low specificity. So CT has been given a preference to plain radiography in examining both fractures. However, CT has some disadventages; high expense, heavy radiation hazard, and coexistent injuries may restricted a patient,s positioning and so thus preventing or delaying the diagnosis. By comparison, ultrasonography(US) represents a safe, inexpensive, noninvasive, portable, and wide availability. This paper compares the relative values of CT and US in the diagnosis of both fractures. In nasal bone fracture, US proved to be more accurate than CT. Thirty-seven nasal bone fractures were diagnosed by US; whereas only thirty-two of these were revealed on CT. Compared with US, CT demonstrated 87% sensitivity. In examining medial orbital wall fracture, eight cases were diagnosed by CT; whereas seven of these were revealed on US. Compared with CT, US demonstrated 88% sensitivity. In medial orbital wall fracture, US was almost as accurate as CT. In this research, it is concluded that in the investigation of nasal bone fracture and medial orbital wall fracture, US is an accurate diagnostic modality and correlates well with CT.

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.

Surgical Treatment of Medial Orbital Wall Fracture According to Proper Indication

Compared with orbital floor fracture, the frequency and significance of medial orbital wall fracture has been relatively ignored because of the lack of proper diagnosis and the difficulty of surgical approach. The surgical delay results to the troublesome complications like enophthalomos, extraocular muscle movement dysfunction. For the reason, it is necessary to measure the exact fracture part and bone defect size with CT scan, the ophthalmologic evaluation and the proper treatment for the indication. We operated on 17 medial orbital wall fracture patients with transnasal endoscopic approach, open reduction through minimal medial canthus incision(6-7 mm), or both methods according to the fracture type. We classified them into three types according to the degree of periosteal injury, the size of the bone defect and the degree of comminution with CT scanning and ophthalmologic evalution. In the case of Type 1, there is no herniation of orbital contents and periosteum is intact despite fracture. The patients of Type 1 can be treated by packing with Foley catheter, Merocel(R) sponge, etc. after bone reduction with transnasal endoscope. In the case of Type 2, which has the herniation of orbital contents and bone defect of approximately 1 cm or less in diameter with periosteum injury, after the bone defect site can be confirmed with an endoscope, the medial wall can be reconstructed by Titanium Mesh, silastic sheet or autogenous bone graft through minimal medial canthus incision. In the case of Type 3, the bone defect is over 1 cm in diameter accompanying comminuted fracture. The fractured medial wall of type 3 can be reconstructed with bone graft through coronal incision or open sky incision. Minor complications occurred in 7 patients but all patients were successfully treated without patient's complaints during the follow-up period of 6-18 months. In addition, the scar by minimal medial canthus incision is imperceptible. The indicaions make the fracture reduction easy and accurate. Especially, it is proper to pediatric patients and young female patients because it corresponds to minimal invasive Technique.

Repair of Medial Orbital Wall Fracture

From March 1997 to August 2001, Titanium mesh screen 1.0 (SYNTHES(R)) were applied to the repair of 29 medial orbital fractures; 18 patients with orbital inferior wall fracture, 16 patients with nasal bone fracture and 6 patients with pure medial wall fracture. Clinically, the periorbital ecchymosis and subconjunctival hemorrage were sensitive indications of orbital wall fracture. Even though there are no sign of diplopia or enophthalmos, in cases of simple nasal bone fracture with periorbital ecchymosis and subconjunctival hemorage, the evaluations of medial orbital wall fracture were strongly recommended because the medial orbital wall fractures occurred frequently combined with simple nasal bone fractures. Titanium mesh screen 1.0 was used as onlay implant to fit the anatomical shape on the fracture portion needed to be reconstructed and 1.3mm microscrews (SYNTHES(R)) were used to fix titanium mesh screen. The patients were followed up for 18 months with no significant enophthalmos or diplopia.

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.