Prediction of late enophthalmos by volumetric analysis of orbital fractures.

The purpose of this study was to determine whether orbital volume assessment by computerized tomography (CT) could provide additional information for the initial evaluation of orbital blowout fractures and guide optimal treatment. The medical records of 30 patients with orbital blowout fractures, either surgically or conservatively managed, were retrospectively reviewed. Orbital volumetric analysis was then determined from digitized CT scans. Fracture-related volume expansion relative to the unaffected fellow orbit was correlated with motility deficits and location and degree of enophthalmos. Early Hertel's measurements (< 4 weeks) were available in 21 patients and did not correlate with the computer volumetric values or with subsequent late enophthalmos. Late Hertel's measurements (> 4 weeks) were obtained in 13 of 15 nonrepaired fractures and in 5 of 15 surgically repaired patients (late presentation; 18 patients). When seen at more than 4 weeks, 11 (92%) of 12 patients with > or = 13% orbital volume expansion manifested significant enophthalmos (> 2 mm) compared with 1 (17%) of 6 patients with < 13% orbital expansion (p = 0.004). Fractures presenting with enophthalmos on initial examination had extensive medial wall involvement in addition to the floor fracture (p = 0.003). CT measurements of orbital volume can predict the final degree of late enophthalmos and may facilitate the planning of surgical intervention.

Granulomatous idiopathic orbital inflammation.

One category of idiopathic orbital inflammation (IOI) displays a granulomatous inflammatory pattern that mimics sarcoidosis, although this has not been extensively addressed in most published series of IOI. We analyzed the clinicopathologic features of patients with biopsy-proven noninfectious granulomatous inflammation of the orbit. Review of surgical pathology records from January 1988 to May 1992 identified 12 patients with a diagnosis of sarcoidosis or other noninfectious granulomatous process involving the orbit. Clinical records were reviewed, and the patients' physicians contacted to determine if the diagnosis of sarcoidosis was confirmed. Five cases in which the systemic diagnosis was not established despite thorough evaluation are reported here. We report five cases of noninfectious IOI in which sarcoidosis was suspected clinically and histologically. In these, however, further systemic evaluation at 15 to 32 months (mean 22.4) failed to reveal evidence of systemic involvement. A spectrum of histopathologic patterns was seen, including non-necrotizing foreign body type granulomas, lipogranulomatous inflammation, and variable sclerosis. Patients with solitary orbital noncaseating granulomatous inflammation should be thoroughly evaluated before a diagnosis of sarcoidosis is made. Practitioners should be aware of the existence of granulomatous IOI not associated with systemic sarcoidosis as a distinct clinicopathologic entity.

Nasolacrimal disorders and their treatment.

Dysfunction of the excretory part of the nasolacrimal system may be congenital in otherwise normal infants or associated with congenital facial anomalies. It may also occur as a result of soft-tissue trauma to the face and naso-orbital fractures. Dacryocystorhinostomy and conjunctivodacryocystorhinostomy are discussed as treatment techniques.

Steroids and orbital blowout fractures--a new systematic concept in medical management and surgical decision-making.

Thirty-eight patients with computed tomography (CT)-proven orbital fractures and diplopia were studied prospectively to determine the efficacy of steroids in the medical management of orbital fractures. The protocol is based on double-blind assignments to steroid (ST) and non-steroid (NT) treatment groups. Outcome analysis was based on sorting fractures into three CT classes: I-without soft tissue prolapse (n = 15); II-with soft tissue prolapse (n = 14); and III-CT evidence of inferior rectus entrapment (n = 9). Results included resolution of diplopia without surgery in both ST and NT groups in CT classes I and II. Median time course of resolution was compressed to less than 5 days in the ST treatment group, however, versus 13 days in the nontreatment group. All fractures in class III had residual diplopia with five of nine patients having surgical results that were enhanced in the ST treatment group. In addition, enophthalmos was unmasked in the ST treatment group within 1 week of treatment versus 5 months without treatment. A protocol for medical management and surgical decision-making in blowout fracture is presented.

Medial wall fractures.

Medial wall blowout fractures may accompany orbital floor fractures or may occur as isolated fractures after blunt facial trauma. A "Z-plasty"-type incision over the medial orbital region allows the best exposure and cosmetic result following the repair of an isolated medial wall fracture.

Isolated neurofibroma of the orbit.

In a 66-year-old woman, a large solitary neurofibroma arising in the right infraorbital nerve extended into the maxillary antrum and the orbit. Following extirpation of this rare tumor, bony defects of the right orbital floor and inferior orbital rim were repaired with a biplanar supramid implant.