Clinical characteristics and associated features of pure orbital roof fractures: A ten-year retrospective review.

PURPOSE: To present the demographics and clinical characteristics of pure (rim-sparing) orbital roof fractures. METHODS: This retrospective observational study used 10 years of data from a single institution. Patient age, sex, laterality, field of binocular single vision, associated injuries, and radiologic features were analyzed. Orbital roof fractures were categorized into four groups: comminuted/open, hinged, trapdoor, and linear. These were further subdivided into blow-in (-down) and blow-out (-up) fractures. Injury etiology was classified into fall, traffic accidents, sports injuries, assault, work-related, and others. RESULTS: Data documented a low incidence rate of 2.5% (27 patients) in 1074 patients. Most patients were male (81%). The most common cause of injury was fall (48%), followed by traffic accidents (22%). Comminuted/open fractures constituted the bulk of fracture types (54%), followed by hinged, and linear fractures. Blow-in and blow-out fractures had an incidence rate of 50% each. Concomitant fractures of the medial and inferior orbital walls were predominant. Low surgical intervention was noted owing to acceptable field of binocular single vision outcomes, and the field of binocular single vision included the primary position of gaze in 88% of patients. CONCLUSION: Pure orbital roof fractures occurred in 2.5% of patients with pure orbital fractures. Patients were predominantly male with trauma caused by high energy forces, which regularly caused comminution of the roof and fractures of the medial and inferior orbital walls. Most patients were managed conservatively.

Successful Management of Post-Traumatic Residual Orbital Roof Defects with Cosmetic Disfigurement and Functional Deficits Using Innovative Titanium Plate Orbitoplasty.

Introduction: Late presentations of post-traumatic residual orbital roof deformities ensuing from old, unaddressed orbital injuries, can be extremely challenging to manage and quite complicated to correct, owing to proximity of the brain and frontal sinus, malunion or bony fusion of the displaced, delicate orbital fracture fragments, necrosis of entrapped extraocular muscles and progressive intraorbital soft tissue fibrosis and adhesions. There exists a paucity in literature on delayed repair of displaced and comminuted orbital roof fractures and late reconstruction of the three-dimensional architecture of the orbital frame and internal orbit. Aim & Objectives: To present an unusual case of severe post-traumatic residual orbital roof deformity, resulting in longstanding aesthetic disfigurement and persisting functional deficits, and its successful management. Material & Methods: The patient had sustained orbital injuries sixteen months ago, on being punched in the face at a boxing tournament. The increased orbital volume produced by an impure blowout fracture of the left orbital roof, with comminution of the upper and lower orbital rims, had resulted in considerable cosmetic deformity, discomfort as well as functional debility, all of which were successfully and efficaciously managed by an innovative use of a Titanium Orbital Plate for orbital roof reconstruction. Discussion: Overlooked, undetected or ignored derangements in intraorbital volume and contour, can lead to severe cosmetic disfigurement in the form of enophthalmos, hypoglobus, entropion, telecanthus, palpebral fissure width narrowing and ptosis; in addition to crippling functional deficits, such as diplopia, blurred vision, levator dysfunction, restricted ocular motility and reduced visual range and acuity. Results & Conclusions: An innovative Titanium mesh orbitoplasty enabled achievement of both, the aesthetic and functional goals of reconstruction of the distorted bony orbit, with successful correction of severe functional and aesthetic deficits.

Pediatric Orbital Roof Fractures: A Ratio of Orbital Dimensions Correlated to Prevalence of Fracture.

Objective Orbital roof fractures are more likely to occur in younger children, specifically younger than 7 years. Cranium to face ratio decreases with age; however, there is no definition for measurement of the neurocranium or face. We propose using the length of the orbital roof as a measurement of the neurocranium and length of the orbital floor as a tool to estimate midface size. The purpose of this study is to test this measurement as a correlation rate of orbital roof fractures within the pediatric population. Design This is a retrospective study. Setting This study was done at the LeBonheur Children's Hospital. Participants Sixty-six patients with orbital roof fractures were identified and stratified by gender and age, specifically younger than 7 years and 7 years or older. Main Outcome Measures The main outcome measures were orbital roof length, floor length, and ratio thereof. Results Mean orbital roof length was 43.4 ± 3.06 and 45.1 ± 3.94 mm for patients <7 and ≥7 years, respectively ( p = 0.02). Mean orbital floor length was 41.3 ± 2.99 and 47.7 ± 4.19 for patients <7 and ≥7 years, respectively ( p < 0.00001). The mean roof to floor ratio (RTFR) for patients <7 years was 1.051 ± 0.039 and for patients ≥ 7 years was 0.947 ± 0.031 ( p < 0.00001). Conclusion As children age, the relative length of the orbital roof decreases when compared with the orbital floor. The RTFR was more than 1.0 in children younger than 7 years. These differences were statistically significant when compared with children 7 years and older. This measurement shift follows the differences noted in orbital fracture patterns during childhood.

BLOW-IN FRACTURE OF ORBITAL ROOF. CASE REPORT.

Orbital fractures may be accompanied with severe damage of the eye bulb and other intraorbital tissues. Early clinical findings can be very mild, therefore it is vital to actively seek not only for any damage done to the soft tissues of the orbit, but also for extraorbital complications such as liquorrhea or meningitis. We report a relatively rare case of blow-in fracture of orbital roof in eleven years old boy. Patient was admitted to the emergency care after falling off a bicycle without impaired consciousness. During admission ophthalmologist evaluated the condition as severe contusion of the left bulb, with hemophthalmia and retinal comotosis. Due to significant swelling of eye lids and periorbital hematoma, it was not possible to perform specific tests to objectify possible oculomotor disorder and diplopia. CT scan findings show dislocated fracture of orbital roof with fragments reaching into the musculus rectus superior. For high risk of bulbus penetration and muscle damage a surgical intervention with bone fragments removal was performed using endoscopic assisted frontal orbitotomy. After operation patient had no signs of functional eye disorder.

Poor prognoses of open globe injuries with concomitant orbital fractures.

PURPOSE: Orbital trauma, particularly with open globe injury, can have a wide range of visual outcomes, which can be difficult to predict at presentation. Clinical features on presentation may provide insight into visual prognosis. We hypothesized that patients with open globe injuries and concomitant orbital fractures have poorer visual outcomes than patients without orbital fractures. METHODS: We reviewed the charts of 77 patients with isolated open globe injuries (OG) and 76 patients with open globe injuries and concomitant orbital fractures (OGOF). Multivariate regression analysis was performed to assess the relative influence of individual presenting historical and clinical features on visual outcome. RESULTS: OGOF patients were more likely to have sustained blunt trauma than a sharp, penetrating injury compared to OG patients. Ocular wound locations were more posterior and likely to involve multiple zones in OGOF compared to OG patients. Among OGOF patients, orbital floor fractures were the most common and roof fractures were the least common, but the latter was associated with presenting NLP vision and multiple zone involvement. The presence of an orbital fracture independently increased the odds of subsequent evisceration/enucleation (OR: 4.6, 95% CI 1.3-20.1, p = .0246) and NLP vision (OR: 6.81, 95% CI 2.42-21.85, p = .0005) when controlling for zone, mechanism of injury, uveal prolapse and demographic variables. CONCLUSIONS: The presence of an orbital fracture independently confers a worse visual and ocular prognosis in patients with open globe injuries. Patients with open globe injuries in this category should be appropriately counseled.

Traumatic Globe Displacement Into Anterior Cranial Fossa

@#A 64-year-old Malay gentleman alleged occupational injury when a malfunctioned metal hydraulic door hit on his face while unloading sand from his tipper-truck. Post-trauma, he complained of right eye (RE) pain and total loss of vision. On examination, noted RE visual acuity was unable to be assessed and left eye (LE) was 6/24 with pinhole 6/9. No eyeball could be seen in the right socket with superior orbital rim step deformity and left periorbital haematoma. Computed tomography scan of the brain and orbit confirmed displaced right eye globe into the right anterior cranial fossa with right and left multiple orbital wall fractures. He then underwent successful right eye globe repositioning. Traumatic orbital roof fracture is a rare condition. Repositioning of the eye globe was done to salvage the eye globe for a cosmetic reason and to avoid localised inflammatory reaction at the anterior cranial fossa.

Pulsatile Proptosis due to Intraorbital Meningocele.

We present a case of a 79-year-old man with a non-symptomatic pulsatile proptosis of the left eye. Magnetic resonance imaging revealed a meningocele into the left orbit due to an osseous defect in the orbital roof.

Traumatic orbital encephalocele: Presentation and imaging.

OBJECTIVE: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. METHODS: Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin. RESULTS: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. CONCLUSION: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.

An Unusual Transorbital Penetrating Injury by House-key (lock): A Case Report with a Small Review of Literature.

Penetrating injuries of the brain are quite uncommon, comprising approximately 0.4% of all head injuries. In our case, a four-year-old boy who fell forward on a house-key (lock) accidentally while playing with some other children sustained a left sided penetrating transorbital brain injury. After hospital admission, the patient had a Glasgow Coma Scale (GCS) score of 15/15, no visual loss but restriction of upward gaze (left eye) and profuse bleeding from the wound site. Firstly, the metallic key was removed in emergency operation theatre and haemostasis secured. Next day we did a combined surgical approach with neurosurgeons, Eye-surgeons and general surgeons after having CT scan report. We report this case because penetrating head injury is rare and transorbital penetrating head injury is even rarer and a predicament in emergency surgical practice with controversial management.

Treatment of Orbital Roof Blow-Up Fracture Using a Superior Blepharoplasty Incision.

In orbital roof blow-up fractures, reduction can be achieved easily using an approach from the anterior cranial fossa but the procedure is highly invasive. In contrast, an orbital approach using a superior blepharoplasty incision is minimally invasive. However, if bone fragments are adhered to the dura mater, there is a risk of dura mater injury when fragments are moved for reduction. In blow-in fractures, reduction is performed by pushing the bone fragments against the anterior cranial fossa. In contrast, the procedure is difficult for blow-up fractures because bone fragments must be pulled out into the orbit through the anterior cranial fossa. Orbital blow-up fractures are often associated with intracranial injuries and frequently treated by an approach from the anterior cranial fossa. There has not yet been a report that discusses whether reduction of bone fragments should be performed in blow-up fracture without intracranial injury. In this report, we describe two cases of orbital roof blow-up fracture that did not require treatment for intracranial injury and that were treated using an orbital approach. The treatment involved only the release of orbital fat entrapped between bone fragments and did not involve reduction. The treatment outcomes were good in both cases.

Gunshot-like wound caused by sling shot injury - a case report.

We report a rare case of sling shot injury that presented with a gunshot-like wound with preseptal cellulitis, in a toddler. An 11-month-old Malay child presented with a gunshot-like wound over the forehead following sling shot injury. On examination, he had a deep circular laceration wound over the forehead, measuring 2.0 cm in diameter, with minimal bleeding. There was no obvious foreign body seen inside the wound and no palpable foreign body surrounding the wound. The gunshot-like wound was associated with left preseptal cellulitis. A skull X-ray showed a white opaque foreign body in the left frontal bone. Computed tomography (CT) scan of orbit and brain revealed a left comminuted fracture of the left orbital roof, and left frontal brain contusion with prelesional edema. Wound exploration was performed and revealed a 0.5 cm unshattered marble embedded in the left frontal bone. The marble and bone fragments were removed. The left preseptal cellulitis responded well to intravenous antibiotic and topical antibiotic.

Titanium mesh reconstruction of orbital roof fracture with traumatic encephalocele: a case report and review of literature.

Orbital roof fractures are rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 21 cases published to date. Orbital roof fractures are generally encountered in males between 20 and 40 years of age following automobile collision. We report a case of an orbital roof fracture with traumatic encephalocele into the left orbit. Early diagnosis and treatment are very important because the raised intraorbital pressure may irreversibly damage the optic nerve. Computed tomography with 3-D reconstruction, the imaging modality of choice, showed the displaced fracture fragment deep into the orbit. Reconstruction of the orbital roof should be performed in every case. We used an extracranial approach to elevate the fracture with titanium mesh to stabilize the fragment. The cosmetic results were excellent but delay in treatment was responsible for delayed recovery of vision. The case report is followed by a brief overview of orbital roof fractures including pertinent review of literature.

Clinical Manifestations, Management, and Ophthalmologic Complications of Orbital Roof Fractures and Zygoma Fractures

PURPOSE: To investigate the clinical manifestations, management, and ophthalmologic complications of orbital roof fractures and zygoma fractures. METHODS: A retrospective survey of 119 patients who visited Korea University Medical Center from June 2009 to June 2010 was performed. The sex, age, causes, fracture characteristics, neurologic injury, ocular injury, and combined facial bone fractures of patients who were diagnosed with orbital roof fracture and zygoma fracture were statistically analyzed. RESULTS: The mean age of patients with orbital roof fracture was 33.0 years old. The most common cause of orbital roof fracture was traffic accident (36.1%) with 6 patients receiveing surgical treatement (9.8%). Among the ophthalmologic diagnoses of the patients with orbital roof fracture, traumatic iridocyclitis was the most common (7 eyes) followed by eyeball rupture (2 eyes). The mean age of patients with zygoma fracture was 36.6 years old. The most common cause of zygoma fracture was traffic accident (32.8%), with 51 patients receiving surgical treatement (87.9%). Among the ophthalmologic diagnoses of the patients with zygoma fracture, traumatic iridocyclitis was the most common (6 eyes), followed by commotio retina (4 eyes). CONCLUSIONS: The present study regarding clinical characteristics and treatment of orbital roof fracture and zygoma fracture is helpful for ophthalmologists regarding the treatment of accompanying ophthalmologic complications.

A Case of Exophthalmos due to Traumatic Orbital Encephalocele

Exophthalmos after trauma may develop because of retrobulbar hemorrhage, carotid cavernous fistula and orbital roof fracture. The orbital roof is composed of two layers of strong bone that makes it the strongest among the orbital walls and reports of its case are hardly found. However, rarely strong impact such as in automobile accidents causes these fractures and exophthalmos may develop due to herniation of brain tissue through a traumatic defect in the roof of the orbit. The authors experienced gradually increasing exophthalmos in a 33-year old man who had developed a subdural hematoma, orbital roof fracture and anterior temporal skull fracture due to an automobile accident. We report a case of orbital roof fracture in which herniation of brain was shown in orbital computed tomography and exophthalmos disappeared after dural suture.