Pearls of orbital trauma management
Forrest Roth
Charles Soparkar2010, Seminars in plastic surgery
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Abstract
Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.
Related papers
A comparative study of different approaches in the treatment of orbital trauma: an experience based on 274 cases
Oral and maxillofacial surgery, 2010
The aim of the study was to compare the aesthetic results, complications and surgical indications in patients treated for orbital trauma by one of three different approaches: subciliary, transconjunctival or transconjunctival with lateral canthotomy. In this retrospective study, 274 patients (169 men and 105 women aged 16-78 years) who had been treated for orbital trauma without soft tissue lacerations of orbital region and then returned for long-term follow-up (6-48 months) between 2000 and 2007 were evaluated in terms of aesthetics and function for the presence of a visible scar and lower-eyelid malposition (scleral show or ectropion). Of the 274 patients, 50 (18.2%) experienced complications. In the group of 219 patients treated with the subciliary approach, 41 experienced complications, whereas amongst the 32 patients treated with the transconjunctival approach, there was one complication (0.3%) and amongst the 23 patients treated with the transconjunctival approach and canthoto...
Orbital Fractures: Indications and Surgical Techniques
American Orthoptic Journal, 2004
IMPORTANCE OF INITIAL RECOGNITION AND MANAGEMENT IN ORBITAL TRAUMA: A LITERATURE REVIEW (ATENA EDITORA)
IMPORTANCE OF INITIAL RECOGNITION AND MANAGEMENT IN ORBITAL TRAUMA: A LITERATURE REVIEW (ATENA EDITORA), 2022
Purpose: To discuss the initial management of orbital trauma and its impact on possible complications, seeking to obtain a better prognosis at a functional and structural level. Methods: Narrative Bibliographic Review carried out between October and November 2022, through searches in the Scielo and PubMed databases. After applying the inclusion and exclusion criteria, 12 were selected to compose the collection of this study. Review: Orbital fractures correspond to 16% of fractures that affect the face, and their pathogenesis varies according to the trauma mechanism and resulting forces. The damage encompasses bone structures, soft tissues and neurovascular structures, and the lesions may be isolated, of extensive pattern or be part of the greater zygomaticomaxillary complex, which occurs most of the time. For the identification of ocular and/or neurological lesions, clinical and radiological evaluation of the patients is necessary, and they may be referred to an ophthalmologist and neurologist, according to the affected structure. The transconjunctival approach is considered an option in the management of fractures of the orbitomaxillomalar complex, with a high success rate. Primary repair, using reconstructive principles, presented relevant aesthetic and functional results for victims of orbital trauma. Final considerations: The initial management of orbital trauma has an impact on the reduction of complications and outcomes when properly applied. The evaluation of orbital and periorbital structures in trauma depends on their recognition and immediate decision making to avoid negligence.
Commentary - Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis
Journal of Oral and Maxillofacial Surgery, 2020
This month's featured article is a systematic review and meta-analysis of orbital fracture repair timing and the resultant outcomes by Jazayeri et al. 1 A basic understanding of orbital trauma is helpful when reading the article. The following discussion begins with several summary points about orbital floor fractures, with commentary on the article afterward. Trauma to the orbit and surrounding region accounts for approximately one third of all facial fractures. 2 Orbital injury most commonly results from assault, followed by motor vehicle collisions, falls, and sports injuries. 3 Such injuries typically occur in younger males in their second to fourth decade of life. The most common site for an orbital fracture is the floor, accounting for approximately 50% of all orbital trauma cases. The second most common fracture site is the medial wall (25% of all orbital trauma). 4 In young children, orbital roof fractures are also relatively common. Orbital wall fractures can be seen in isolation or in conjunction with other fractures, such as nasoorbital-ethmoidal, zygomaticomaxillary complex, frontal, and Le Fort II/III fractures. Isolated orbital floor or medial wall fractures are referred to as blowout fractures. The putative mechanisms include hydraulic (trauma to the globe transmits pressure to the walls, causing a fracture) and buckling (trauma to the infraorbital rim is transmitted, causing the floor to buckle and fracture). Trap-door fractures occur when the fractured segment displaces and then reduces; this can trap the orbital contents, which can lead to restriction in extraocular movements, oculocardiac reflex, and soft tissue damage. The evaluation and management of orbital fractures is often challenging, especially because not all fractures will require surgical intervention. Both functional and esthetic considerations are crucial when determining whether and when to repair an orbital fracture. Evaluation Evaluation of the maxillofacial trauma patient begins with the Advanced Trauma Life Support algorithm, followed by a complete history and physical examination, including a full facial trauma evaluation. Key items related to orbital trauma include the following: History B Mechanism and timing of injury B Ocular history, including corrective lenses, previous surgery, pre-existing disease B Altered sensation (often present in the infraorbital nerve distribution) B Eye pain (at rest or with movement)
Management of Orbital Floor Fractures: An Oculoplastic Surgeon’s View
Journal of Postgraduate Medicine Education and Research, 2014
Orbital fractures commonly occur in maxillofacial trauma causing enophthalmos and diplopia. The isolated orbital floor fracture often called as blow out fracture is a common presentation following blunt trauma. The floor fractures may also occur in combination with zygomatic arch fractures, Le Fort II or III or with fracture of other orbital bones. The cosmetic and functional problems can virtually become untreatable if floor fractures are not properly managed. In recent years, management of these fractures has been standardized with special emphasis on methods of treatment, timing and materials used for reduction. How to cite this article Arora S, Grover AK, Bageja S. Management of Orbital Floor Fractures: An Oculoplastic Surgeon's View. J Postgrad Med Edu Res 2014;48(2):75-80.
Retrospective Analysis of the Outcomes in Orbital Floor Fractures: Guidelines for Better Strategic Management
The Egyptian Journal of Plastic and Reconstructive Surgery, 2021
Aim: Orbital trauma is considered one of the most common maxillofacial traumas with functional and cosmetic impact to eye globe. The main objective is to establish a roadmap for the management of orbital floor fractures. Patients and Methods: One hundred and seventy-three patients were selected from the database of Mansoura University Hospitals with orbital floor fractures who were treated at the Department of Plastic & Reconstructive Surgery Department over past 4 years. Cases were retrospectively reviewed by preoperative clinical findings, management, surgical approaches, and sequelae. Authors evaluated timing and indication of surgical intervention, surgical outcomes, complications, and materials used for orbital reconstruction. Results: In total, there were (173) cases of orbital fractures with average age of (23.14) years. The leading cause of these fractures was motor traffic accident (64.7%). Pure blow-out fractures represent 25% of cases while fractures of inferior orbital rim alone were 45% of cases. Inferior orbital rim associated with orbital fractures were 30%. 57.2% of patients were managed surgically while 42.8% patients were managed conservatively. Conchal graft was used in 19 cases for floor reconstruction while 15 cases were managed by titanium mesh. In the follow-up, 10 patients still complain of enophthalmos, while 7 patients still complain of diplopia. Conclusions: Better postoperative results were presented in cases managed immediately or within two weeks surgically, A guideline for choice of effective protocol for management was developed.
Management of orbital fractures in adolescents. Review and case report of three different techniques
Research, Society and Development, 2021
The management of orbital fractures in children and adolescents is little reported in the literature, considering that orbital fractures can cause functional problems such as enophthalmia, diplopia and aesthetic deformities. The aim of this study is to review the literature and report three clinical cases, corroborating with professional experience, about the different management of orbital fractures in adolescents, approaching the advantages, disadvantages and complications. Among the different fractures of the orbital floor, the techniques of interposition of autograft of the anterior wall of the maxillary sinus, suture for anchoring the periosteum, and reduction and stabilization of the fracture by means of titanium mesh fixation were performed. The choice of material and technique depends on the surgeon's preference, access and availability of materials. Regardless of which technique and material is used, and complete removal of the herniated tissue is fundamental to obtain ...
Is the pure and impure distinction of orbital fractures clinically relevant with respect to ocular and periocular injuries? A retrospective study of 473 patients
Journal of Cranio-Maxillofacial Surgery, 2019
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Management of orbital blow-out fractures
Expert Review of Ophthalmology, 2008
Twenty-nine patients with orbital blow-out fractures are reviewed. The approach to management and the criteria for surgery are discussed and the results of surgical and nonsurgical treatments reported. Of the 16 patients treated surgically, 3 (18,75%) required a second operation, indicating failure of primary management. All 13 patients for whom surgery was thought not to be indicated, recovered without complications. The incidence of associated severe ocular injuries (31 %) is high and indicates the need for a full ophthalmological assessment. The potential role of computed tomography in the management of blow-out fractures is discussed.
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Ophthalmologic Repercussions of Orbital Fractures
Open Journal of Ophthalmology
Orbital fractures refer to all continuity solutions involving the wall of the orbit. They are responsible for serious complications, particularly ophthalmological. Objective: To identify the epidemiological, anatomical and clinical aspects as well as the possible ocular complications of orbital fractures in the Gbêkê region. Methods: Prospective study from July 1, 2020, to October 31, 2020, i.e., a duration of 4 months. It took place in the ophthalmology department of the University Hospital of Bouaké. Patients with orbital fractures with ocular repercussions received during the study period were included. Results: Out of 27 cases of orbital floor fracture received, 20 had ocular complications, i.e., a prevalence of 74.07%. The average age was 32 years with extremes of 18 and 48 years. The male gender predominated with 80%, i.e. a sex ratio of 4. Subconjunctival hemorrhage was the most frequent reason for consultation (70%). The etiology was dominated by road traffic accidents (85%). The average consultation time was 24 hours. 80% of the patients had a distance visual acuity (DVA) between 3/10 and 10/10.) Diplopia was observed in 60% of patients. Blow out fracture (70%) was the most prominent orbital lesion. At the paraclinical level, 80% of the patients had performed a CT scan of the orbit. Evisceration was the predominant ophthalmologic surgical management (4 patients). At the bone level, reconstruction of the orbital floor with a polydioxanone plate (PDS) was performed in 50% of patients. Conclusion: The risk of ocular injury in orbital fractures is frequent because of the close relationship between the orbit and the eyeball.
Management of old naso-orbital fractures with ocular involvement and associated complications caused by facial trauma
Medical Journal of Indonesia
A 14-years-old boy came with chief complaint of epiphora and history of globe rupture repair surgery due to facial trauma one year ago. Patient got complications from the trauma, including nasolacrimal duct obstruction, phthisis bulbi, enophthalmos, facial deformities, and ptosis. Multidisciplinary approach was performed simultaneously in one session surgery which included oral mucosal graft for non-irritative phthisis bulbi, silicone block implant for blowout fracture, external dacrycystorhinostomy for obstructed nasolacrimal duct, fascia lata brow suspension/frontalis sling for ptosis, and septorhinoplasty for nasal augmentation. After the surgery, symptoms of epiphora had resolved and aesthetical improvement of facial deformities was also prominent. Management of old orbital fracture poses additional challenges due to the complications that have occurred over time. Loss of functionality may seem impractical to manage because no function can be pertained. Nevertheless, it is impor...
Orbital Fractures
Otolaryngology online Journal, 2014
This article attempts to review the role of Otolaryngologist in managing patients with orbital trauma. There is a high incidence of orbital injury in facio maxillary trauma. Trauma to orbit can be blunt / penetrating in nature. Commonest bony injury to orbit involves the floor and medial wall. Both these walls can be easily accessed by otolaryngologist. It is very important for otolaryngologist to be competent in handling these problems.
The transconjunctival approach for treating orbital trauma
Journal of oral and maxillofacial surgery, 1991
Functional outcome after non-surgical management of orbital fractures—the bias of decision-making according to size of defect: critical review of 48 patients
British Journal of Oral and Maxillofacial Surgery, 2013
Please cite this article in press as: Kunz C, et al. Functional outcome after non-surgical management of orbital fractures-the bias of decision-making according to size of defect: critical review of 48 patients. Br J Oral Maxillofac Surg (2012), http://dx.
Retrospective survey of 150 surgically treated orbital floor fractures in a trauma referral centre
European Journal of Plastic Surgery, 2008
We present the epidemiology associated with 150 cases of orbital floor fractures surgically treated at a trauma centre. A 3-year analysis of patients surgically treated for orbital floor fractures at the University Hospital Virgen del Rocio, Sevilla, Spain, was conducted. Data regarding patient demography, signs and symptoms of presentation, cause and nature of injury, associated facial fractures, surgical approaches, materials used for orbital floor reconstruction and ocular damage were collected. Statistical analyses were conducted, including chi-squared and Fisher tests, odds ratios and confidence intervals. Men comprised 66.7% of the patients, and those aged 20-39 years were the most frequently affected. Male patients outnumbered female patients by a 2:1 ratio and were involved in a wider range of behavioural patterns resulting in orbital floor fractures. Motor vehicle accidents were the main cause, followed by physical assaults. The most common signs and symptoms associated with orbital floor fractures were periorbital ecchymosis and diplopia. Corneal abrasion was the most frequent positive ocular finding. This was followed in frequency by traumatic ocular globe rupture. However, most ocular injuries were of minor character. The ratio of impure to pure orbital floor fractures approached 3:1. We report results from one of the current largest series of surgically treated orbital floor fractures in a trauma referral centre. The most susceptible population included young men, and motor vehicle accident was the predominant mechanism. Further analysis of impure and pure orbital floor fractures revealed important differences in several demographic aspects such as mechanism of injury and signs and symptoms of presentation.
Functional outcome after surgical treatment of orbital floor fractures
Clinical Oral Investigations, 2012
In the present article, the authors want to present the results of a retrospectively evaluated consecutive series of patients with surgically treated isolated orbital floor fractures (OFF; "blow-out fractures") concerning the functional outcome after OFF and give detailed recommendations based on the clinical and radiological findings. A series of 60 patients with isolated OFF over a 5-year period needing surgically repair at the same institution were evaluated. Patient data were analysed in terms of preoperative and postoperative clinical parameters and radiological findings. The analysed parameters were type of fracture, diplopia, gaze restriction, enophthalmos, materials used for repair, surgical approach and timing of the surgical intervention. Burst type fractures were more often found than punched-out fractures. The most frequently used surgical approach was a preseptal transconjunctival approach. An overall decrease of gaze restriction (93%), diplopia (89%) and enophthalmos (86%) was observed. According to the fracture size, we used Ethisorb patches in smaller fractures and resorbable or titanium meshes or autologous bone in larger fractures in most cases. Patients who underwent surgery more than 7 days after the trauma showed better results with regard to an improvement of diplopia and motility disturbances than patients who were treated immediately. In indicated cases, the surgical repair of OFF leads to very good results if the anatomical and functional properties of the orbit and its contents are respected. The applied strategy and means presented in our study proved of value and can therefore be recommended.
Evolving Trends in the Management of Orbital Floor Fractures
Journal of Craniofacial Surgery, 2014
Background: The management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. Methods: A survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002Y2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. Results: The survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon's operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%).
The Management of Orbitozygomatic Fractures
Plastic and Reconstructive Surgery, 2003
Transconjunctival and Subciliary Approach in the Treatment of Orbital Fractures: A Study on Oculoplastic Complication
Journal of Clinical Medicine, 2021
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
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