Search

The authors describe a 20-year-old man who sustained multiple facial fractures in a high-speed motor vehicle crash, including a bone fragment from a skull base fracture that penetrated the orbital soft tissues superomedially. Serial CT scans documented spontaneous resorption over a 6-month period. While it is known that autologous bone grafts used in craniofacial reconstruction exhibit variable amounts of bone resorption, the complete resorption of an intraorbital fracture fragment has not been documented in the literature. His clinical care and the report of his case were undertaken in a fashion in accordance with the principles of the Health Insurance Portability and Accountability Act regulations.

Purpose: To determine whether patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) repaired within 7 days of injury have statistically greater postoperative vertical binocular fusion than similar patients who undergo later surgery., Methods: Prospective and retrospective surgical case series. Inclusion criteria were orbital floor (with or without medial wall) blowout fracture repair, preoperative coronal orbital CT scans, and patient age of at least 12 years at time of postoperative binocular visual field., Results: Twenty-five patients met inclusion criteria. Ten patients (group 1) had surgery within 7 days of injury, and 15 patients (group 2) had surgery more than 7 days after injury. The total cohort had a median postoperative vertical binocular fusion of 90°. Group 1 had postoperative vertical binocular fusion averaging 100°. Nine of 10 patients (90%) were above and 1 of 10 (10%) were below the median for the entire cohort. Group 2 had postoperative vertical binocular fusion averaging 70°. Three of 15 patients (20%) were above and 12 of 15 patients (80%) were below the median for the entire cohort. The difference between the average postoperative vertical binocular fusion of the 2 groups was statistically significant by two-tailed unpaired t test with p value 0.0022., Conclusions: Patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) have statistically greater average postoperative vertical binocular fusion if repaired within 7 days of injury than similar patients who undergo later surgery.

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.

Purpose: To evaluate the experience with sterilized x-ray film in the repair of orbital blow-out fractures (BOFs)., Methods: A retrospective review of case notes from 56 patients with orbital BOF repaired using sterilized x-ray film onlay implants at 2 institutions between November 2004 and December 2010. Patient demographics, timing of surgery, surgical approach, postoperative complications, and length of follow up were recorded., Results: Fifty-six patients (44 men, 12 women) received sterilized x-ray film implants during the 6-year study period. Mean age at the time of repair was 29 years (range 4-85 years). For 68% of patients, surgical repair was performed within 2 weeks of injury. Average length of postoperative follow up was 5.5 months (range 1-36 months), 48% had follow up >3 months. Following surgical repair, diplopia in primary or down gaze reduced from 98% to 4% and enophthalmos ≥2 mm reduced from 21% to 5% cases. One patient required a second operation for repositioning of an incompletely reduced fracture. A second patient presented 9 months postoperatively with recurrent episodes of proptosis, and the implant and its surrounding pseudocapsule were subsequently removed. There were no cases of visual loss, implant infection, or migration., Conclusions: This series has demonstrated that in selected orbital fractures sterilized x-ray film can provide a safe, effective, and low-cost onlay implant.

Purpose: To introduce a new surgical technique for repairing large medial wall fractures stably with insufficient bony structures., Methods: This is a case series of 29 patients who underwent surgery for repairing large medial wall fractures using the new supporting implant technique in Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. Medical records and radiologic images of the patients were reviewed retrospectively. The outcomes evaluated were the incidence and the degree of diplopia and enophthalmos, and orbital volume restoration after surgery. The institutional review board approved this study, and the study adhered to the tenets of the Declaration of Helsinki., Results: Orbital reconstruction using the supporting implant technique was performed without any complications. The incidence of diplopia was 51.7% including 6.9% of significant diplopia before and 27.6% with no significant diplopia 3 months after surgery (p = 0.022). The average enophthalmos was successfully corrected from 0.93 mm preoperatively to 0.36 mm at 3 months postoperatively (p = 0.001). Orbital volume was corrected from 25.71 to 23.59 cm2 after surgery, which was not significantly different from the contralateral unaffected orbit (p = 0.157)., Conclusions: The supporting implant technique is a simple and effective surgical method that provides sufficient support and prevents implant migration in large medial orbital wall fractures.

Purpose: This study reports a series of 14 consecutive patients of nasolacrimal duct obstruction secondary to naso-orbito-ethmoid fractures (NOE), their presentations, surgical interventions, and outcomes., Methods: Fourteen consecutive patients presenting with secondary acquired nasolacrimal duct obstructions following naso-orbito-ethmoid fractures were included in a retrospective, noncomparative case series. Medical records were reviewed for demographic data, mode of trauma, types of NOE fractures, type of fracture repair, symptoms at presentation, duration of symptoms, areas of lacrimal obstructions, surgical interventions, lengths of follow up, and outcomes. Success was defined as both anatomical patency of the lacrimal passages and resolution of symptoms., Results: The mean age at presentation was 26.4 years (range: 4-46). The most common mode of trauma was a road traffic accident (71.4%), and the most common type of fracture was NOE type II (64.2%). The majority of the fractures (71.4%) were repaired by open reduction and internal fixation. All patients presented with epiphora, and 50% of them also presented with a swelling below the medial canthus. The mean duration of symptoms were 19.5 months (range: 1-48). All patients underwent an external DCR with mitomycin C and silicone intubation. All stents were removed at 12 weeks following surgery. The mean follow up after stent removal was 6 months (range 3-24 months) with a minimum follow up of 3 months. At the last follow up, the success rate was 92.8%. There was one failure, which was due to cicatricial closure of the ostium., Conclusion: External dacryocystorhinostomy with Mitomycin-C and intubation is effective in treatment of acquired nasolacrimal duct obstructions following NOE fractures. A delayed dacryocystorhinostomy did not appear to influence the outcomes.

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 51-year-old woman underwent endoscopic nasal polypectomy and ethmoidectomy with accidental entry into the right orbit causing enophthalmos and transection of the medial rectus muscle (MR). The repair of a fracture and of a damaged MR is technically challenging, particularly when large portions of bone and muscle are missing. We report a rare case of repair of the bony defect with an implant and reattachment of the MR with a silicone retina band, through a combined transcaruncular and transconjunctival approach. Postoperatively, the patient had residual enophthalmos and strabismus; further surgical options are discussed.

Spontaneous orbital fracture is a rare entity. A 32-year-old man presented with thyroid eye disease and was found to have an orbital floor fracture on routine preoperative imaging without any antecedent relevant symptom or sign. To the best of the authors' knowledge, this is the first report of an asymptomatic orbital fracture in a patient with thyroid eye disease.

Trapdoor fractures occur almost exclusively in the pediatric population. The authors describe an adult with an entrapped inferior rectus muscle sheath in a trapdoor fracture. A 37-year-old man presented with persistent diplopia 3 weeks after blunt right orbital trauma. The only abnormal findings on clinical examination were limited vertical ductions. No bony defect or displacement was evident on CT. However, several small pockets of air were visible adjacent to the inferior rectus muscle. On surgical exploration, a linear nondisplaced orbital floor fracture was confirmed, and the entrapped inferior rectus muscle was released. One month postoperatively, extraocular motility had improved with no diplopia in primary or reading positions. This case demonstrates that trapdoor fractures can occur in adults and should be considered when suggestive findings are encountered. Clinicians should be aware of this because timely diagnosis and treatment might achieve more favorable outcomes.

Purpose: Seprafilm is a hybrid product of carboxymethylcellulose and sodium hyaluronate that can act as an absorbable barrier to decrease the formation and severity of postoperative adhesions in abdominal, thoracic, and pelvic surgeries. The authors report their experience with use of Seprafilm in "trap door" orbital wall fracture repair., Methods: Retrospective case series of 4 consecutive patients with trap door orbital wall fractures secondary to blunt trauma with entrapped orbital soft tissue who underwent surgical repair with placement of Seprafilm implant in 2008. Orbitotomy was performed via standard transconjunctival and/or transcaruncular approaches with release of entrapped tissues, and placement of Seprafilm implant over the fracture site without fixation. Patients were followed for at least 6 months. Ophthalmic and orbital examinations, including ocular motility and Hertel exophthalmometry measurements, were recorded., Results: All 6 orbital wall fractures (4 floor, 2 medial wall) were successfully corrected with resolution of restrictive motility in the follow-up period (average 10 months; range 6 months to 1.5 years). Mean patient age was 13.5 years (range, 9-20 years). Two of the 4 patients had 2 separate fractures. There were no complications and no need for reoperation., Conclusions: Seprafilm may have a role in reconstruction of the "trap door" type of orbital wall fractures. The ease of use, lack of fixation, and absorbable properties without inflammation are encouraging for further study.

Purpose: To evaluate a technique of implanting a single 0.4-mm-thick nylon foil (Supramid) continuously across combined medial wall and floor fractures within weeks of orbital trauma., Methods: This retrospective, interventional case series includes patients with combined medial wall and floor fractures with or without external orbital and facial fractures, without prior surgery, and who were in the early posttrauma phase. One hundred two orbits in 98 consecutive patients were treated with a "wraparound" technique. The surgical technique is provided in detail. Comatose patients, those with cranial nerve palsies, severe globe injury, anophthalmia, or previous repair of the same fractures were excluded. Patients underwent surgery from 5 to 21 days after trauma. Postoperatively (average, 6.2 months), patients were evaluated for enophthalmos, extraocular motility, and diplopia., Results: In 101 of 102 orbits, normal globe position, and full extraocular motility without diplopia was accomplished. One orbit had persistent enophthalmos, requiring a second procedure. This same patient had ipsilateral restriction in extreme upgaze, but no diplopia symptoms. This orbit had complete loss of inferomedial strut support. Overall, strut loss was not a risk factor for subsequent enophthalmos. No other patient had globe malposition, restrictive myopathy, or diplopia. Implant migration, hemorrhage, fistula, or infection was not observed. The transconjunctival and canthal wounds were hidden and tolerated by all patients with no eyelid cicatrization, webbing, or malposition., Conclusions: The "wraparound" technique for 0.4-mm nylon foil implantation continuously across orbital floor and medial wall fractures was associated with almost no enophthalmos and diplopia in this series.

Purpose: The SupraFOIL smooth nylon foil implant is a polyamide sheet available in varying thicknesses that has been used in orbital reconstruction following trauma. The authors report their experience with smooth nylon foil implants in the repair of orbital fractures., Methods: A retrospective chart review of patients having undergone repair of orbital fractures between January 1, 1995 and December 31, 2003 was conducted. The Wilcoxon test was used to compare cases with complications and those with no complications., Results: Of 282 orbits that underwent fracture repair with alloplastic material, 87 were excluded because non-nylon foil implants were used alone or in combination with nylon foil to repair the orbital fracture. An additional 14 fractures were excluded because of insufficient clinical data or lack of follow-up, for a total of 181 orbits that underwent orbital fracture repair with only nylon foil. A transconjunctival approach was used in 98% cases, and all 181 implants were fixated with at least 1 titanium screw. Average follow-up was 362.8 days. The overall complication rate was 1.7%. One patient had an acute postoperative orbital hemorrhage (0.6% acute complication rate). Two patients had late orbital infections, 683 days and 984 days following repair (1.1% late complication rate)., Conclusions: The authors found the smooth nylon foil implant to be safe and effective in orbital fracture repair. The lower rate of complications the authors observed compared with previously reported series may be related to implant fixation. A titanium screw secured just posterior to the orbital rim may decrease long-term complications by providing more stability than implants left without fixation.

A tree surgeon suffered a traumatic floor fracture complicated by multiple organic foreign bodies. CT confirmed a left floor fracture and medial wall fracture and decreased attenuation in the inferior orbit and maxillary sinus. Exploration of the orbital floor led to the removal of multiple wooden fragments up to 2.5 cm in length. Additional surgeries led to the removal of additional wooden fragments. Detection of organic intraorbital foreign bodies requires a high degree of clinical suspicion and close consultation with a radiologist.

Purpose: To estimate posttraumatic enophthalmos using computer-based volume measurement of the orbital fracture to provide information on surgical guidelines., Methods: The fracture volume of orbital wall fractures in 35 patients who did not undergo surgery was measured using a Rapidia work station system. Hertel ophthalmometry, diplopia, and ocular motility were investigated. The fracture volume measurements relative to the intact contralateral orbit were correlated with enophthalmos, diplopia, and ocular motility. Patients were examined at the initial visit, then at 1 week, 1 month, and 3 months., Results: There was a correlation between the fracture volume and enophthalmos. Late enophthalmos increased in size in proportion to the volume of the fractured site. The predicted orbital fracture volume with an enophthalmos measurement of 2 mm or more was 2.30 ml., Conclusions: Computer-based measurements of orbital fracture volume can be used to predict overall enophthalmos and provide useful information to surgeons.

Purpose: To evaluate our initial experience with a porous polyethylene implant with embedded titanium in orbital reconstruction., Methods: A retrospective review of the charts was performed for patients receiving at least 1 orbital porous polyethylene implant with embedded titanium from October 2004 through April 2006. Patient demographics, implant type and size, method of fixation, postoperative complications, and length of follow-up were recorded., Results: One-hundred six patients received at least one embedded titanium implant (80 men, 26 women). Age ranged from 3 years to 85 years (mean, 31 years). Indications included orbital fracture repair (102 patients), correction of enophthalmos (3 patients), and reconstruction after tumor resection (1 patient). The average floor implant used was 22.3 mm wide by 27.9 mm long. The average medial wall implant was 13.6 mm tall by 22 mm long. Implants were fixated with 1 or 2 microscrews in 75 patients (70.8%) and placed without fixation in 31 patients (29.2%). Four postoperative complications were noted: a retrobulbar hemorrhage on postoperative day 3 that resolved without sequelae, a vertical overcorrection requiring removal of the implant, a transient oculomotor disturbance, and a screw placed in proximity to the infraorbital nerve canal resulting in hypesthesia and chronic pain that required removal of the screw. In the 3 complications potentially related to the implant, the embedded titanium allowed postoperative implant visualization and guided subsequent management. No implant extrusions or postoperative infections were noted., Conclusions: Porous polyethylene implants with embedded titanium provide a new alternative to alloplastic implant materials for orbital reconstruction with a profile that combines several advantages of porous polyethylene and titanium implants.

A 21-year-old man presented with sudden-onset orbital hemorrhage, vision loss, and epistaxis 4 days after experiencing blunt trauma. Computed tomography revealed a subperiosteal hematoma in the medial orbit, extending to the orbital apex, and fractures of the medial and inferior orbital walls. After the hematoma was evacuated through a medial orbitotomy, orbital and visual symptoms improved. Although rare, vision-threatening subperiosteal hemorrhages may develop days after blunt orbital trauma and may require surgical evacuation.

Purpose: To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma., Methods: Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period., Results: Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance., Conclusions: The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

Fractures of the orbit most commonly involve the orbital floor, and enophthalmos is a common sign of orbital fractures. Complete globe dislocation in the maxillary sinus, however, has rarely been reported. Herein we report on an 18-year-old man referred to us 1 week following a car accident. At presentation, the globe was not seen within the right orbit. CT revealed a large orbital floor fracture with globe dislocation in the right maxillary sinus. The patient underwent repair of the fracture using a Medpor implant together with repositioning of the globe. Preoperative vision was no light perception, which remained unchanged during follow-up.

A 46-year-old man with a history of right orbital fractures and blindness underwent simultaneous fracture repair and enucleation with orbital implantation. During surgery, an orbital catheter was placed for administering local anesthesia to control postoperative pain. After administration of local anesthesia through the catheter on postoperative day 1, the patient had development of a complete ptosis, total ophthalmoplegia, mydriasis, vision loss from 20/20 to NLP, and hypesthesia of the V1 and V2 trigeminal nerve distribution. Intraocular pressures and dilated funduscopic examination were normal. There was no evidence of central nervous system effects or respiratory depression. After 4 hours of observation, the vision, sensation, motility, ptosis, and pupil response all returned to normal. Although rare, contralateral cavernous sinus/orbital apex syndrome may occur with indwelling orbital catheter administration of local anesthetic in an orbit with fractures.

Purpose: To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005., Methods: Retrospective chart review and literature review., Results: Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal., Conclusions: Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye.

A 37-year-old man presented to the emergency department with a visor impacted in the left orbit after a motorbike accident. His initial injury appeared to be limited to the orbit. Because the bleeding appeared disproportionate to the orbital injury, an intracranial injury was suspected. Subsequently, on hemicraniotomy, the tip of the visor was found at the bifurcation of the internal carotid artery. The avulsed upper eyelid was found under the frontal lobe. The patient underwent the clipping of internal carotid artery and middle and anterior cerebral artery with replantation of the upper eyelid. Neurologic damage was limited to loss of vision, right foot drop, and bowel and bladder incontinence. This case of penetrating orbital trauma demonstrates that the absence of focal neurologic deficit and radiologic signs suggestive of intracranial injury may not rule out life-threatening intracranial injury.

A 19-year-old man sustained a blowout fracture to the left orbital floor. Subcutaneous emphysema developed after a protracted sneezing episode. Some signs of respiratory distress ensued, and the patient was emergently intubated. He underwent surgical repair of the fracture and then had further extension of the subcutaneous emphysema. The left nasal cavity was packed and the emphysema slowly resolved. Clinically significant subcutaneous emphysema is an uncommon complication of orbital blowout fracture. Informing the patient to avoid excessive nose-blowing and to avoid occluding the nose while sneezing may prevent this complication.

We describe a case of an orbital floor fracture resulting in obstruction of the maxillary sinus ostium by herniated orbital contents. Our patient had delayed enophthalmos in a manner similar to silent sinus syndrome or imploding antrum syndrome. Obstruction of the maxillary sinus ostium by orbital contents carries the potential for delayed-onset enophthalmos and therefore suggests an additional indication for orbital floor fracture repair.

We describe the clinical features, treatment, and histologic changes of a case of severe localized orbital inflammation associated with the use of porcine dermal collagen xenograft (Permacol) as an orbital floor implant in a 14-year-old boy. After uneventful blowout fracture repair with normal forced duction testing after insertion of a Permacol implant, progressive elevation and depression deficit developed in the postoperative period. There was no improvement after removal of the Permacol implant. Exploratory surgery revealed gross fibrosis of the inferior rectus muscle accounting for the abnormal ocular motility. Biopsy of the inferior rectus muscle showed chronic granulomatous inflammation suggestive of foreign body reaction. Although porcine dermal collagen xenograft has been suggested as an implant for orbital floor repair because of its reported high strength, ease of handling, and high biocompatibility, we believe that further studies are necessary before it can be recommended for this use.

Purpose: This report aims to increase awareness of an unusual mechanism of orbital injury sustained by bicycle riders., Methods: In this retrospective small case series, we describe two cases of orbital injury caused by upper eyelid penetration. A 5-year-old boy (patient 1) and a 6-year-old boy (patient 2) presented to our service within a 2-week period. Both had been injured by similarly styled, handlebar-mounted bicycle hand brake levers. Patient 1 had an orbital roof fracture and penetrating brain injury and underwent repair of a left upper eyelid laceration, craniotomy for pseudoencephalocele, and ptosis repair. Patient 2 had orbital hemorrhage and underwent repair of left upper eyelid laceration., Results: In both cases, a handlebar-mounted bicycle hand brake lever perforated the left eyelid when the rider fell onto it. Neither patient was wearing protective headwear or eyewear. Two months after surgery, patient 1 had 20/25 visual acuity OU and excellent cosmetic appearance. Patient 2 had baseline amblyopic vision 2 days after surgery but moved from town and was lost to follow-up., Conclusions: Orbit injuries from bicycle brake levers are rare, and helmets or protective eyewear probably would not have prevented these injuries. However, a change in the design and/or mounting location of handlebar-mounted brake levers might help prevent further injuries of this type.

Purpose: To evaluate the use of computer-assisted volumetric measurement for the prediction of late enophthalmos and for volume estimation of implant material in the correction of late enophthalmos secondary to orbital blowout fractures (BOF)., Methods: This is a prospective observational study of 16 patients. Computer-assisted orbital volume measurements were made with the use of axial CT scans. Hertel exophthalmometry was used for the measurement of enophthalmos. The Lancaster test was used for measurement of diplopia. Autogenous bone or hydroxyapatite composite material was used for the repair of orbital defects and the correction of orbital volume expansion in 16 patients with enophthalmos caused by BOF. The volume of implant material was calculated from the orbital volume increment. Patients were followed for an average of 8 months after surgery., Results: There is a high correlation between the increment of orbital volume and the degree of enophthalmos; 1 cm3 orbital volume increment causes 0.89 mm of enophthalmos. Before surgery, 10 of the 16 patients had moderate enophthalmos (3 to 4 mm) and 6 patients had severe enophthalmos (> or = 5 mm). Six months after surgical intervention, 13 patients (81%) achieved satisfactory results; 3 patients had no enophthalmos and 10 had mild enophthalmos (1 to 2 mm). Three patients had moderate to severe enophthalmos., Conclusions: The measurement of orbital volume in patients with BOF can be used to predict the degree of late enophthalmos. Use of the orbital volume increment to determine the amount of implant material can improve the therapeutic outcome in the correction of late enophthalmos caused by BOF.

Purpose: To determine a relationship between preoperative soft tissue disruption and postoperative ocular motility in orbital blowout fractures., Methods: This retrospective cohort study reviewed 30 patients who met all criteria: retrievable coronal computed tomography (CT) scans; internal fractures of the orbital floor, with or without medial wall extension; preoperative diplopia; repair by a single surgeon; complete release of entrapped tissues; and postoperative binocular visual fields (BVFs). Motility outcomes were quantified by one group of the authors, who measured the vertical fusion within BVFs. Other authors analyzed CT scans, designating each fracture as either A or B, based on lesser or greater soft tissue distortion relative to the configuration of bone fragments. The interval between trauma and surgery was also determined., Results: Among the 15 patients with a postoperative motility outcome poorer than the median (86 degrees or less), four (27%) had A fractures; 11 (73%) had B fractures. Among the 15 patients with an outcome better than the median (88 degrees or more), 10 (67%) had A fractures; five (33%) had B fractures. Differences were more defined away from the median. Among five patients with B fractures and better than the median result, three (60%) had surgical repair during the first week after injury. Among the 11 patients with B fractures and less than the median result, one (9%) had repair during the first week., Conclusions: Postoperative motility is influenced by soft tissue-bone fragment relationships. Whether the outcome can be altered by earlier surgery in selected cases will be determined by prospective studies.

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.

Management of blowout fractures involving the orbital floor has been controversial over the past several decades. One school of thought recommends conservative treatment for 4 to 6 months while another recommends a 'wait and watch' period of 2 weeks before intervention. The authors have encountered a group of patients with such fractures, commonly children (less than 16 years of age), who have sustained a blow to the periocular area, yet have marked motility restrictions in up and down gaze, minimal soft tissue signs of trauma, lack of enophthalmos, and very minimal evidence of floor disruption on radiologic exam. A 2-week waiting period has been found to be of little benefit in these persons and possibly harmful to their motility. We advocate surgery within the first few days after injury as it may help to avoid permanent motility restriction. The authors have termed this entity 'the white-eyed blowout fracture.'

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.

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.

The purpose to this study was to determine whether early surgical repair is indicated for a severely entrapped inferior rectus muscle following orbital blowout fracture. We report two patients with small blowout fractures, severe entrapment of the inferior rectus muscle, and an absence of the inferior rectus muscle in multiple contiguous coronal computed tomography cuts. At surgery, we released the severely entrapped inferior rectus muscles with resolution of diplopia. We concluded that patients with the "missing muscle syndrome" require urgent surgical intervention and that clinician review of radiologic studies is always prudent.

Sixteen patients with combined paresis and restriction of extraocular muscle(s) orbital fracture repair were studied before and after in order to determine the clinical features and management of such patients. All 16 patients showed limited ductions of the involved eye in the field of action of the entrapped, paretic muscle and of the antagonist muscle after orbital fracture. Single extraocular muscles (13 patients) and two extraocular muscles (three patients) were demonstrated adjacent to the fracture site on orbital computed tomography (CT). In three patients prior to orbital surgery, a deviation in primary position was present. After fracture repair with release of the entrapped muscle in all patients, evidence of paresis of the muscle was demonstrated by underaction in its field of action and overaction in the field of its antagonist. There was a resultant manifest tropia or phoria in the primary position. In seven patients, the paresis gradually improved with no tropia and little diplopia in the functional fields of gaze. Three patients had minimal deviations and required no further treatment. Six patients with significant deviations required prisms (three patients) or strabismus surgery (three patients). The latter three patients had two muscles involved. Results of this study demonstrate that the ophthalmologist must appropriately diagnose patients with paresis and restriction of an extraocular muscle and counsel them that "new" diplopia may occur after orbital fracture repair and that this diplopia may require additional therapy.

A retrospective study and review of the literature was performed on the use of demineralized bone implants for the correction of orbital and craniofacial defects. Demineralized bone implants heal by endochondral osteogenesis, inducing a transformation of local cells, as well as by osteoconduction, similar to autogenous grafts. They induce the chemotaxis and transformation of mesenchymal cells into chondroblasts, followed by ossification. They also act as a scaffold, with bone resorption taking place simultaneous with bone formation. This study reviewed 21 patients and 31 orbits, in which demineralized bone was used for orbitocranial reconstruction for congenital deformities (nine patients), after surgery for orbital fractures (seven patients: four floor, three roof), and orbital tumors (five patients). The surgical technique is described, and the results are discussed. The follow-up period averaged 15 months (6 months to 33 months). The overall resorption rate of the demineralized bone implants was estimated based on follow-up radiologic studies (facial films, computed tomography scans, and magnetic resonance imaging scans), as well as clinical examinations. All patients had a satisfactory to excellent result. The demineralized bone and Grafton (Osteotech, Shrewsbury, NJ, U.S.A.) was obtained from the Musculoskeletal Transplant Foundation of Holmdel, New Jersey, and it was all processed and reconstituted in a standard manner with Alloprep System. Surgical complications were cerebrospinal fluid leaks (one patient) with infection, transient chemosis, enophthalmos, and hypophthalmos. There were no complications related to demineralized bone alone. Properly prepared demineralized bone is a safe material for orbital reconstruction that eliminates the need for a second operative site to harvest a bone graft.

The objective of this study was to determine the effectiveness of hinged silicone covered metallic implant for the repair of large fractures of the internal orbital skeleton. Twelve patients underwent reconstruction of the orbital floor (and medial wall) with a hinged silicone covered metallic implant that was fixated at or just inside the inferior orbital rim with screws. The surgical technique permits intraoperative graded overcorrection because the implant is secured at the orbital rim and bent at its "hinge" to elevate the entire implant to the desired height. Nine of 12 patients had late repairs (> or = 4 weeks after injury); 3 patients had early repairs < or = 3 weeks of injury. All 12 patients had acceptable results with regards to enophthalmos and hypo-ophthalmos. One patient underwent secondary soft tissue upper eyelid augmentation for a residual superior sulcus deformity. The hinged silicone covered metallic implant is a useful technique for reconstruction of large orbital floor and medial wall defects. Long-term complications of this implant are unknown.

Traumatic blow-out fractures of the orbital floor are a common injury that can lead to significant morbidity. Accepted indications for surgical repair include displaced fractures consisting of a defect > 50% of the orbital floor, extraocular muscle entrapment, and clinically significant enophthalmos. Although infraorbital nerve hypesthesia has been reported as an indication for repair of fractures of the zygomatic complex and is often encountered as an associated finding in fractures of both the orbital floor and inferior orbital rim, it has not been generally regarded as a primary indication for blow-out fracture repair. We report two patients in whom severe, progressive infraorbital nerve hypesthesia served as the primary indication for surgical repair. Both patients experienced improvement in infraorbital nerve function following surgical repair, accompanied by persistent pain and paresthesias in the distribution of the infraorbital nerve. We suggest that progressive infraorbital nerve hypesthesia should be considered a primary indication for blow-out fracture repair in selected patients in whom hypesthesia is both severe and progressive.

The grease gun injury is an uncommon injury to the orbit. However, high-pressure injection of grease, oil, or paint is frequently reported in injuries of the hand and usually affects the fingers or palm, which require complicated surgical and medical care. Two cases of grease gun injury to the orbit are reported: one, a catastrophic injury, and the other resulting in satisfactory recovery after surgical debridement and adjuvant medical treatment. Presentation, investigation, and therapy are discussed.

An unusual case of cervical emphysema and pneumomediastinum following a blowout fracture of the medial orbital wall is presented. Severe pulmonary distress did not occur, and the trapped air rapidly absorbed. The source of the emphysema and its progression is discussed considering the anatomic relations of the facial and cervical subcutaneous space and the mediastinum. To our knowledge, this complication is rare and has been documented only once before in an isolated blowout fracture of the orbit.

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.

Posttraumatic tension orbitus developed in a young man causing subconjunctival emphysema and proptosis. Intraocular pressures were monitored as a means of indirectly measuring intraorbital pressure. The patient was serially examined for evidence of compressive optic neuropathy. Because of the possibility of orbital pressure increasing several hours from the time of injury, we recommend monitoring of these patients through intraocular pressure measurement and evaluation of the optic nerve for evidence of compression. Our findings, however, do support previous documentation that the intraocular pressure rise following orbital trauma with orbital emphysema is usually not of sufficient severity or duration to result in visual compromise.

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.