J Erik Kulenkamp, Asim V. Farooq, Javeneh Abbasian, Hassan Shah
A 16-year-old male with no significant medical history presented with blunt trauma to the right orbit from an elbow while playing basketball 1 week earlier. On that day, he presented to a pediatric ophthalmologist with the complaint of intermittent diplopia in primary gaze, which did not improve or worsen in upgaze or downgaze. On examination, visual acuity was 20/20 OU. There was a 5 prism diopter (PD) right-sided hypertropia that resolved in upgaze and increased to 10 PD in downgaze. Extraocular movements were full bilaterally, except for minimally decreased infraduction in the right eye (Fig.
Siwei Zhou, Katherine Duncan & S. Tonya Stefko
Silent sinus syndrome was first described as spontaneous enophthalmos and hypoglobus associated with subclinical maxillary sinusitis without prior trauma or surgery. This clinical entity has later been described after trauma in which damage to the ostiomeatal complex leads to atelectasis of the maxillary sinus. We report a case of a 14-year-old boy who presented 4 years after sustaining a non-operative orbital floor fracture with enophthalmos and transient diplopia. Computed tomography (CT) demonstrated enlargement in size of the original orbital floor fracture and bilateral maxillary sinus disease. Bilateral chronic sinusitis suggested an anatomical predisposition to sinusitis unrelated to the prior trauma. The authors propose that, in this case, negative pressure in the maxillary sinus and chronic inflammation led to bone resorption and failure of the orbital fracture to heal. This differs from prior reports of silent sinus syndrome in that there was complete resorption of bone of the orbital floor and no decrease in volume of the maxillary sinus given the open communication of the sinus and the orbit, making this a unique presentation of pseudo-silent sinus syndrome in a pediatric patient.
Mehta, Viraj J.; Chelnis, James G.; Chen, Qingxia; Mawn, Louise A.
Purpose: To evaluate the relationship between time to surgical intervention and extraocular motility outcomes in children following repair of an orbital floor fracture with inferior rectus entrapment.
Methods: After institution review board’s approval, a retrospective, consecutive case series of 28 children with unilateral orbital floor fractures entrapping the inferior rectus muscle was conducted. Clinical examinations and CT images were performed on all children. The main outcomes measures were postoperative motility measurements.
Results: Eleven patients underwent surgery within 24 hours of reported injury, while 17 patients underwent surgery after 24 hours. There was no statistically significant difference in average age at the time of surgery (p = 0.47) or average preoperative motility scores (p = 1.0) between the 2 groups. Patients who underwent surgery within 24 hours of reported injury had an improved likelihood of recovery (log hazard ratio = 0.469; 95% confidence interval, −0.42 to 1.36).
Conclusions: Our exploratory study suggests that surgical reduction of inferior rectus entrapment in pediatric orbital floor fractures within 24 hours from the time of injury shows an improved, but nonstatistically significant, likelihood of recovery in motility deficits with earlier surgical intervention.
Erin M. Shriver, George B. Bartley
Jacobs et al address the most feared complication of orbital surgery: vision loss. The authors conducted a 20-year retrospective review of all orbital operations resulting in significant visual decline at 2 tertiary academic medical centers. Although the study reports an overall incidence of 0.84%, the risk is significantly higher in orbital floor fracture repair with a combined approach (6%), endoscopic trans-sinus orbital apex surgery (10%), and intracranial orbital roof and apex surgery (18%).
Robert C. Kersten, M. Reza Vagefi, George B. Bartley
With the exception of pediatric trapdoor floor fractures (the so-called white-eyed blowout), which warrant immediate repair to prevent sequelae of oculocardiac reflex and muscle fibrosis,1–3 the optimal management of so-called routine orbital blowout fractures remains controversial. Two issues lie at the heart of the debate: the indications for repair and the timing of repair. Unfortunately, there are no prospective, randomized clinical trials to guide decision making.
Stephanie Ming Young, Yoon-Duck Kim, Sang Wook Kim, Han Byeol Jo, Stephanie S. Lang, Kyuyeon Cho, Kyung In Woo
To determine if conservatively treated blowout fractures of the orbit undergo spontaneous improvement based on radiologic findings.
Prospective, noncomparative series.
Patients with conservatively treated orbital blowout fractures in a single tertiary institution from 2012 through 2016 with initial and follow-up computed tomography (CT) scans.
Comparison of initial and follow-up CT to assess for smoothening of bony contour, joining of bony edges, reduction in herniation of orbital contents, and new bone formation. Orbital and fracture volumes were calculated using a 3-dimensional reconstruction software program (3D Workstation; TeraRecon, Foster City, CA).
Main Outcome Measures
Change in bony contour, new bone formation, and decrease in orbital and fracture volumes.
Our study comprised 41 patients and 44 orbits, with 38 unilateral and 3 bilateral cases. Most were men (65.9%; n = 27), and the mean age was 34.3±13.5 years. The mean time from injury to follow-up scan was 4.6 months (range, 1–15 months). All orbits showed changes in bony contour from initial to follow up CT, including smoothening of the orbital contour (88.6%), joining of bony edges (90.9%), and reduction in herniation of orbital contents (65.9%). Most of the orbits (n = 41; 93.2%) showed features of neobone formation. Of the 44 orbits, 91.4% showed a decrease in orbital volume, whereas 94.3% showed a decrease in fracture volume. The reduction in volume was statistically significant for both orbital (from 23.7±4.0 to 21.8±3.9 ml) as well as fracture (from 1.2±0.8 to 0.7±0.6 ml) volumes from initial to follow-up scans, respectively (P < 0.001).
A large proportion of patients showed improvement in radiologic findings despite being treated conservatively. This highlights the spontaneous improvement that can occur in untreated blowout fractures not just clinically, but radiologically, in terms of soft tissue and bony findings.
Sirous Nekooei, Mahsa Sardabi, Mohammad Etezad Razavi, Amirhossein Nekooei, Mohammad Yaser Kiarudi
Orbital floor fractures alone or in conjunction with other facial skeletal fractures are the most commonly encountered midfacial fractures. The technological advances in 3-dimensional (3D) printing allow the physical prototyping of 3D models, so creates an accurate representation of the patient’s specific anatomy. A 56-year-old Caucasian man with severe hypoglobus and enophthalmos with an extensive blowout fracture was scheduled for reconstruction. First, 3D physical models were created based on the computed tomography scan datasets from patient. Then, this model was used as templates for preoperative trimming the implant. Surgical reconstruction with the aid of pre-shaped, customized prosthesis based on 3D anatomical model resulted in significant esthetic and clinical improvement. It is possible to build anatomical models on the basis of computed tomography scan datasets. It is relatively inexpensive and can be used in the repair of complex orbital floor fractures.
Yukito Yamanaka, Akihide Watanabe, Chie Sotozono, Shigeru Kinoshita
Purpose To investigate the surgical timing postinjury in regard to ocular motility in patients with orbital-floor blowout fractures.
Methods This study involved 197 eyes (92 right eyes and 105 left eyes) of 197 patients (154 males and 43 females, mean age: 29.0 years, range: 7–85 years) with pure orbital blowout fractures. All patients underwent surgical repair within 30 days postinjury and were followed up for 3 months or more postoperative (mean follow-up period: 8.4 months, range: 3–59 months). Orbital blowout fractures were classified into one of three shapes: (1) trap-door fracture with muscle entrapment, (2) trap-door fracture with incarcerated tissue and (3) depressed fragment fracture. Ocular motility was estimated by percentage of Hess area ratio (HAR%) on the Hess chart at the final follow-up examination. In addition, correlations between postinjury surgical timing and HAR% were analysed.
Results The mean postinjury surgical timing was 10.7±7.8 days (range: 0–30 days). The mean postoperative HAR% (92.9%±10.5%) was significantly improved compared with preoperative HAR% (73.5%±21.7%) (p<0.01). The mean postoperative HAR% (98.3%±4.4%) of the orbital-floor trap-door fracture patients with incarcerated tissue who underwent surgical repair within 8 days postinjury was significantly better than that of the patients who underwent surgical repair after 8 days (94.2%±5.8%) (p<0.01).
Conclusions Patients with orbital-floor trap-door blowout fractures with incarcerated tissue that were repaired within 8 days postinjury had better outcomes than those repaired after 8 days, and HAR% is a useful method to record orbital fracture surgical outcomes.
Ahsen Hussain, MBChB, FRCOphth, James Oestreicher, MD, FRCSC, Navdeep Nijhawan, MD, FRCSC
Nora Silverman, Jordan Spindle, Sunny X. Tang, Andrew Wu, Bryan K. Hong, John W. Shore, Sara Wester, Flora Levin, Michael Connor, Benjamin Burt, Tanuj Nakra, Todd Shepler, Eric Hink, Tarek El-Sawy & Roman Shinder
Orbital floor fractures (OFF) with entrapment require prompt clinical and radiographic recognition for timely surgical correction. Correct CT radiographic interpretation of entrapped fractures can be subtle and thus missed. We reviewed the clinical, radiographic and intraoperative findings of 45 cases of entrapped OFF to correlate pre- and intraoperative findings with radiography.
Retrospective review and statistical analysis of 45 patients with OFF using the chi squared and Kruskal–Wallis tests. Main outcome measures included patient demographics, clinical features, radiologic interpretation, intraoperative findings, and treatment outcomes. Twenty-one cases (47%) had radiologic evaluations of orbital CT scans that included commentary on possible entrapment. Intraoperatively, 16 (76%) of these patients had the inferior rectus muscle incarcerated in the fracture, while 5 (24%) patients had incarceration of the orbital fat. Possibility of entrapment was not commented on in the radiology reports of the remaining 24 (53%) cases. Intraoperatively, 13 (54%) of these patients had the inferior rectus muscle incarcerated in the fracture, while 11 (46%) patients had incarceration of the orbital fat. It is vital to assess the possibility of entrapment, especially in young patients, in the setting of OFF as a delay in diagnosis may lead to persistent diplopia, disfigurement, or bradycardia. Most radiology reports did not mention the possibility of entrapment in this cohort. A key concept is that entrapment occurs when any orbital tissue (muscle or fat) is trapped in the fracture site.