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Pediatric orbital trauma with fracture involving the junction of roof and medial wall leading to superior oblique entrapment is rare. Here the authors report a case of orbital fracture at the junction of roof and medial wall with entrapment of the superior oblique muscle presenting clinically as canine tooth syndrome which was surgically released. Postoperatively, the ocular motility improved, and the patient was relieved of diplopia. They recommend early surgical exploration in such cases, which lead to successful resolution of diplopia.

Purpose: To describe a series of orbital fractures and associated ophthalmic and craniofacial injuries in the pediatric population., Methods: A retrospective case series of 312 pediatric patients over a 9-year period (2002-2011) with orbit fractures diagnosed by CT., Results: Five hundred ninety-one fractures in 312 patients were evaluated. There were 192 boys (62%) and 120 girls (38%) with an average age of 7.3 years (range 4 months to 16 years). Orbit fractures associated with other craniofacial fractures were more common (62%) than isolated orbit fractures (internal fractures and fractures involving the orbital rim but without extension beyond the orbit) (38%). Roof and medial wall fractures were most common (30% and 28%, respectively), followed by orbital floor (24%) and lateral wall (18%) fractures. Orbital roof fractures are the most common fracture in patients <8 years old, whereas orbital floor fractures are the most common fracture in patients older than 8 years. Eighty-seven patients (28%) underwent surgical repair. There is an increasing incidence of surgery in older patients (p = 0.02). Associated neurologic injuries were more common (23%) than associated ophthalmic injuries (20%)., Conclusions: Pediatric orbit fracture patterns are dictated by the age of the patient with respect to their craniofacial morphology and mechanism of injury. Orbital roof fractures are more likely to occur in younger patients and not require surgery, whereas orbital floor fractures are more common in older patients and are more likely to require surgery.

The authors report a rare case of medial orbital wall erosion with an orbital inflammatory mass and resultant lacrimal obstruction secondary to rhinotillexomania. A 67-year-old male with known history of compulsive nose picking (rhinotillexomania) sought treatment for complaints of watering in his OD. Examination revealed a blocked right inferior canaliculus. Nasal endoscopy showed a large nasal septal defect with multiple areas of crusting and bleeding. Hematologic investigations were normal. CT scan confirmed a large nasal septal and right medial orbital wall defect with an adjacent soft tissue mass in the medial orbit. Investigations ruled out systemic pathology. Histologic examination of medial orbital mass, sinus, and nasal mucosa revealed a reactive inflammatory infiltrate with surface Gram-positive cocci. The authors hypothesized that the patient had enlarged an existing nasal septal defect due to repetitive nose picking resulting in recurrent infection and inflammation of sinuses, leading to erosion of his medial orbital wall.

Purpose: To compare the postoperative outcomes of large orbital fractures repaired with porous polyethylene (PP) channel implants (PPCIs) and PP titan barrier implants (PPTBs)., Methods: Medical records of 42 patients who underwent surgical reconstruction for a large orbital fracture with either PPCI or PPTB were reviewed retrospectively. The degree of diplopia, determined with a binocular single vision test, and enophthalmos, measured by a Hertel exophthalmometer, was compared between 2 implant groups. Orbital volumes were calculated using CT scans and the measuring tool., Results: Of the 42 patients examined, 16 received PPCI and 26 received PPTB. No significant difference in the degree of diplopia was observed between the 2 implant groups before surgery, and 1 and 3 months after surgery (p = 0.256, 0.408, and 0.432, respectively). Preoperative average enophthalmos measuring 1.28 mm and 1.04 mm was successfully corrected to 0.19 mm and 0.25 mm 3 months after reconstruction with PPCI and PPTB, respectively. The fractured orbit volumes and nonfractured contralateral orbit volumes were 24.96 ± 2.32 cm3 and 23.18 ± 1.733 cm in the PPCI group, and 26.80 ± 2.10 cm3 and 24.13 ± 2.28 cm3 in the PPTB group, respectively. After surgery, the fractured orbit volumes significantly decreased to 23.39 ± 2.82 cm3 in the PPCI group and to 23.53 ± 1.74 cm3 in the PPTB group; these values were not significantly different from that of the nonfractured orbit (p = 0.681 for PPCI and 0.204 for PPTB)., Conclusions: Porous polyethylene channel implant and PPTB are both effective implant materials for the repair of large orbital fractures; however, PPTB has the additional benefit of not requiring screw fixation.

A 55-year-old white man presented with orbital cellulitis and suspicion of an intraorbital foreign body after ocular trauma. He underwent orbital exploration, but no intraorbital foreign bodies were identified. Intraoperative orbital and conjunctival cultures grew Yersinia enterocolitica O:8. The patient's signs and symptoms resolved with intravenous antibiotic treatment after this exploratory orbitotomy. This is the first case, to our knowledge, of human orbital cellulitis caused by Y. enterocolitica O:8. The single visible interpalpebral conjunctival ulceration was suspected to be an entry wound by the patient's primary physician, the emergency room physician, and the orbital surgeon prior to surgical investigation, at which time all the other ulcerations were identified. Therefore, the physical manifestations of this rare but important infection are presented because they may mislead clinicians in suspecting an intraorbital foreign body.

Purpose: To describe the spectrum of ophthalmic injuries in children involved in all-terrain vehicle (ATV) crashes., Methods: We retrospectively reviewed the medical records of a level 1 children's trauma center to identify cases with ICD-9 codes pertaining to crashes involving ATVs and cross-referenced for ophthalmic trauma. From these cases, we documented the nature of the crash, patient's age, ophthalmic injuries received, and length of hospitalization., Results: Twenty children, 5 to 16 years of age (mean, 11.1 years), involved in ATV crashes were admitted between June 1997 and April 2002. One was riding with an adult and 3 with other children; 16 were operating the vehicles alone at the time of their crashes. None was wearing a helmet, and all had head trauma. Nine patients had ophthalmic injuries, including lacerations of the eyelid (n = 5), orbital fractures (n = 9), and traumatic optic neuropathies (n = 2). The latter two had final visual acuities of count fingers and no light perception. The average length of hospitalization was 6.6 days., Conclusions: Ophthalmic trauma is a frequent complication of ATV crashes involving children. Injuries may range from minor lacerations to complex orbital fractures; visual loss may be severe. We believe that the age of the vehicles' operators and their failure to wear protective helmets contribute to the severity of injuries.

Purpose: The purpose of this study was to investigate the two accepted mechanisms of the orbital blowout fracture (the hydraulic and the buckling theories) from a clinical, experimental, and theoretical standpoint., Methods: Clinical cases in which blowout fractures resulted from both a pure hydraulic mechanism and a pure buckling mechanism are presented. Twenty-one intact orbital floors were obtained from human cadavers. A metal rod was dropped, experimentally, onto each specimen until a fracture was produced, and the energy required in each instance was calculated. A biomathematical model of the human bony orbit, depicted as a thin-walled truncated conical shell, was devised. Two previously published (by the National Aeronautics and Space Administration) theoretical structural engineering formulas for the fracture of thin-walled truncated conical shells were used to predict the energy required to fracture the bone of the orbital floor via the hydraulic and buckling mechanisms., Results: Experimentally, the mean energy required to fracture the bone of the human cadaver orbital floor directly was 78 millijoules (mJ) (range, 29-127 mJ). Using the engineering formula for the hydraulic theory, the predicted theoretical energy is 71 mJ (range, 38-120 mJ); for the buckling theory, the predicted theoretical energy is 68 mJ (range, 40-106 mJ)., Conclusion: Through this study, we have experimentally determined the amount of energy required to fracture the bone of the human orbital floor directly and have provided support for each mechanism of the orbital blowout fracture from a clinical and theoretical basis.

Purpose: To determine the efficacy of using a scaffold of hydroxyapatite blocks within the maxillary sinus to treat patients with large orbital floor fractures and secondary vertical globe dystopia., Methods: Case series of five patients. Hydroxyapatite blocks were stacked within the maxillary antrum to support the reconstructed orbital floor., Results: All patients had good results, though mild residual enophthalmos persisted in three patients. The orbital floor implants and globe positions remained stable during follow-up intervals ranging from 46 to 65 months. No adverse postoperative complications, such as sinusitis, developed., Conclusions: Hydroxyapatite block scaffolding is a useful alternative to metallic floor implants and autologous bone grafts in the reconstruction of large traumatic orbital floor defects associated with vertical globe dystopia.

Purpose: To evaluate the effectiveness of a modified porous polyethylene implant in orbital fracture repair. A porous polyethylene channel implant (PPCI) has internal channels that accept mini- or microplates from conventional plating systems, facilitating fixation to bone in the reconstruction of large, complex orbital fractures., Methods: The authors used 29 PPCIs to repair 25 orbits. Seventeen cases involved repair of an acute (less than two weeks after injury) fracture of one or more orbital walls. Eight cases represented delayed reconstruction of orbital walls for late enophthalmos or for residual defects after previous operations., Results: A PPCI provides a stable platform for orbital soft tissue. Excellent results were obtained in all patients with acute orbital fractures, whereas good or excellent corrections of enophthalmos and hypoglobus were achieved in all patients who underwent late repair. There were no instances of orbital infection, implant exposure or migration, worsening diplopia, visual loss, or loss of structural support during 31 months of follow-up., Conclusions: A PPCI allows controlled placement of a porous polyethylene sheet with secure fixation to stable bone. The implant design allows it to be cantilevered from the orbital rim to serve as a stable platform when fractures are too large to support the implant in the posterior orbit. PPCIs are ideally suited for reconstruction of defects resulting from displacement of orbital walls and for repair of posterior floor fractures, medial wall fractures, and combined floor and medial wall defects.

The authors describe a patient with an orbital floor fracture that did not demonstrate a distinct fracture on computed tomography (CT) imaging. The key radiologic finding was rounding of the inferior rectus muscle.

Synthetic orbital floor implants carry the risk of infection, rejection, anterior migration with prolapse, and posterior migration with optic nerve compression. Banked irradiated homologous fascia lata has been used as an orbital floor implant in the repair of 18 patients with surgically indicated orbital floor fractures. All patients had improvement in diplopia. There was no infection, anterior migration, or posterior migration of the implant. There was no reported transmission of communicable diseases. Early results suggest that banked irradiated fascia can be used effectively and safely as an orbital floor implant in selected cases.

Seven patients with significant frontal trauma involving the supraorbital region associated with orbital roof "blow-in" fractures were admitted to the Maryland Institute for Emergency Medical Services Systems (MIEMSS) at the University of Maryland Medical System over a 16-month period. High-resolution computed tomography (HRCT) with three-dimensional reconstructions demonstrated a downward displacement of the orbital roof in the absence of any orbital rim discontinuity. Associated findings included contussive and hemorrhagic injury to the ipsilateral frontal and parietal lobes, proptosis, ptosis, chemosis, orbital hematoma, and optic nerve contusion. The only long-term ocular pathology in this group of patients was mild to severe optic atrophy. It is recommended that all patients with frontal bone trauma have thin-cut computed tomographic evaluation of the orbit.

A blow-in fracture is a less common consequence of orbital trauma. Fragments of orbital bone may increase the orbital pressure, causing direct or indirect damage to the globe. This paper describes a blow-in fracture where a bone fragment perforated the globe causing globe disorganization and necessitating enucleation.