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Surgery for orbital trauma is challenging. A good understanding of the orbit, its normal form, function, and the varying patterns of its disruption due to trauma is essential for its proper management. The aim of this chapter is to provide a comprehensive clinical overview of all facets of orbital trauma for the young surgeon. The chapter has been...
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... and Converse in 1960 recognized the phenomenon of blowout fractures (Fig. 57.10a). These fractures may involve entrapment or herniation of periorbital tissues resulting in restricted eye movements and/or enophthalmos due to reduction in the volume of intra-orbital contents [3,11]. Blow-in" type of orbital fractures was described by Dingman and Natvig [3,12] in 1964 wherein the intra-orbital space is reduced by an ...
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... involve entrapment or herniation of periorbital tissues resulting in restricted eye movements and/or enophthalmos due to reduction in the volume of intra-orbital contents [3,11]. Blow-in" type of orbital fractures was described by Dingman and Natvig [3,12] in 1964 wherein the intra-orbital space is reduced by an internally displaced bony fragment (Fig. 57.10b). Such types of fractures are usually accompanied with proptosis on the affected side [13]. ...
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... of the first mechanisms of orbital wall fractures was suggested by Pfeiffer [14] in 1943, called globe-to-wall theory or hydraulic theory ( Fig. 57.11a), wherein posterior displacement of the globe after sustaining a direct hit was propounded to transmit force along the walls resulting in fracture of the thinner walls. There are two more widely accepted mechanisms of orbital wall fractures, namely, ...
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... American Association of Ophthalmology [23] advocates an 8-point ophthalmological examination which includes the following (Box 57.3): 1. Visual acuity: Visual acuity test for each eye is recorded using a Snellen chart ( Fig. 57.12a) and includes ability to read letters, count fingers, perceive hand movements, and light perception. If visual acuity is extremely poor and recording of a chart test fails, the patient is subjected to a finger counting test or at times even assessed for primary light perception alone. 2. Pupillary examination: Pupillary examination is ...
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... (c) symmetry, (d) and direct/indirect reflex to light. Glaucoma, previous history of surgery, and/or injury to ocular system may also account for anisocoria or irregular pupils. Peaked or irregular pupils may also be indicative of perforation of the globe. The swinging flashlight test is performed for relative afferent pupillary defect (RAPD) (Fig. 57.12b). 3. Extraocular motility and alignment: The patient is first screened for all the six cardinal gazes ( Fig. 57.12c). First checked binocularly for versions of both sides and then checked monocular for ductions. A thorough heterotropia check is also performed. Diplopia and restrictions in gazes are noted. Clinically, a forced duction ...
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... system may also account for anisocoria or irregular pupils. Peaked or irregular pupils may also be indicative of perforation of the globe. The swinging flashlight test is performed for relative afferent pupillary defect (RAPD) (Fig. 57.12b). 3. Extraocular motility and alignment: The patient is first screened for all the six cardinal gazes ( Fig. 57.12c). First checked binocularly for versions of both sides and then checked monocular for ductions. A thorough heterotropia check is also performed. Diplopia and restrictions in gazes are noted. Clinically, a forced duction test under topical anesthesia is done to elicit mechanical impediment to movement of the globe. This may also be ...
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... Lacerations involving the eyelids ( Fig. 57.14c) • Injuries to the canthal apparatus (medial and ...
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... muscle and unrestricted action of dilator pupillae. (v) Impairment of direct pupillary reflex due to blocked ipsilateral efferent arc, whereas consensual reflex is preserved due to intact ipsilateral efferent and contralateral efferent arcs. Management may be conservative or exploratory surgery of the orbit including surgical decompression [33]. (Fig. 57.18) (Box ...
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... radiographs have a minimal role in the diagnosis and planning of orbital fractures. CT scans ( 57.19 (a, b) Axial CT scan of patient with direct traumatic optic neuropathy demonstrating a skull base fracture and bony spicule at the entry of the optic nerve into the canal Box 57. of fractures of the floor and the roof, while the axial scans provide better information regarding the fractures of the medial and lateral walls. Axial sections are also important to study the optic canal integrity. ...
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... demonstrating a skull base fracture and bony spicule at the entry of the optic nerve into the canal Box 57. of fractures of the floor and the roof, while the axial scans provide better information regarding the fractures of the medial and lateral walls. Axial sections are also important to study the optic canal integrity. Indications for an MRI (Fig. 57.21a, b) scan are limited to determining soft tissue injuries and entrapment of muscles and to assessing damage to the optic nerve. It is also used to identify intra-orbital herniation of brain in the case of blowin fractures. ...
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... mentioned above. Reconstruction of the roof of the orbit is not a procedure routinely indicated. However in cases where there is an absolute necessity for reconstruction like prevention of brain herniation or restoration of intra orbital volume which has been significantly altered, the choice may vary between the use of titanium meshes (Fig. 57.31) or porous polyethylene implants fixed with micro-screws to split calvarial grafts. Figure 57.32a−f demonstrates the management of a malunited fronto-basilar fracture along with a blow-in fracture of the orbital roof compressing the eyeball producing restriction of ...
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... Acute injury to the orbit showing evidence of immediate clinical enophthalmos and/or hypophthalmos [55] ( Fig. 57.15), necessitating a primary surgical intervention. Post-surgical outcome may get compromised with delay due to progressive atrophy of intra-orbital fat. 2. Severe restriction of ocular motility with CT or MRI evidenced muscle entrapment or incarceration of periorbital soft tissue. 3. "White eye blowout" fracture in a child or young adult ...
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... aspect of the orbit (Hammer's key area) to achieve anterior projection of the globe. It is imperative to understand that reconstruction of the floor posterior to the equator of the globe influences anterior projection of the globe, while reconstruction of the equatorial region of the floor influences only the supero-inferior position of the globe (Fig. 57.41). Figure 57.42a−d shows a case of delayed correction of enophthalmos in a patient with an orbital floor ...
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Citations
... In comminuted blow-in fractures, first described by Dingman and Natvig in 1964, the intra-orbital space may be reduced by internally displaced bony fragments [41]. Such types of fractures have subsequently the potential to increase IOP and are usually accompanied with proptosis on the affected side [30]. According to the AO craniomaxillofacial (CMF) Classification system, another way to describe orbital fractures is based on clinical aspects: The term "displacement," if we refer to the orbit, defines a defect which increase orbital volume or downsizes it, particularly if the lateral wall is involved [19]. ...
Post-traumatic orbital meningoencephaloceles related to orbital roof fractures are a challenging clinical entity because of their rarity and difficult differential diagnosis. We report a case of post-traumatic intra-orbital meningoencephalocele in a 69-year-old man, secondary to a likely trapdoor mechanism, treated with a modified one-piece orbitozygomatic craniotomy. We also performed an extensive literature review of traumatic Intra-Orbital Encephalocele related to Orbital Roof Fracture focused on adult patients on electronic databases including Scopus, MEDLINE/PubMed, and Google Scholar. Patient well recovered after surgery with immediate exophthalmos resolution and discharged without visual or neurological deficits. The literature review included 22 papers with a total of 28 patients: 22 males (78.6%) and 6 females (21.4%), with a median age of 34.7 years. Twenty-six patients (92.9%) reported ocular injuries, with associated intracranial complications in 16 cases (61.5%). Twenty-seven patients (96.4%) were surgically treated, 18 of those underwent unilateral or bilateral frontal approach. Most orbital roof fractures can be managed nanoperatively if asymptomatic. Indeed, when the intra-orbital volume decreases, for example due to an encephalocele, the intra-orbital pressure could increase and determine an orbital compartment syndrome. In our case, we performed a one-piece modified orbitozygomatic approach, which has several advantages in comparison to the frequent unilateral or bilateral frontal craniotomy like the better exposure of the brain and orbit and a minimum brain retraction.
... Unsightly morphological changes may occur in various circumstances being either post-traumatic (consequences of hitting, bodily injury, acts committed intentionally or through fault) or they can be acquired post-surgically [6][7][8]. Visible scars, especially those located on the face, have aesthetic and psychological consequences, such as increased anxiety and low self-esteem. The stigma due to the presence of scars is perceived depending on their appearance and location, so the affected people adapt by hiding them, they become less sociable, lower self-confidence, negatively affecting their personal and professional relationships as well as their leisure activities [9]. ...
(1) Background: Scars are the consequence of physiological inherent healing processes of post-traumatic and surgical lesions with a psychological impact. Post-traumatic scarring may induce emotional and behavioral changes through social stigma. In this study we analyze the internalization of scars and their impact on hopelessness, depression, or the perception of social support in subjects with post-traumatic scars compared to people with surgical scars. (2) Methods: to research this suggested model, we analyzed data collected from 110 participants 61 women and 49 men, aged between 18 and 64 years; 55 participants had post-traumatically and 55 surgically acquired scars. They all were examined to assess the characteristics of scars, were asked to complete four psycho-social scales, and the results were compared. (3) Results: our results indicate that people with post-traumatic scars are oriented toward the internalization of scars, depending on their shape and size. We argue that hopelessness, appreciation of scars, age, and how scars are produced are important predictors of internalization. (4) Conclusions: the patient’s attitude toward the appearance of a scar is an indicator of how he/she will react in the future and it could predict the vulnerability to hopelessness. Finally, we nuance the impact of objective bodily harm on the psychological and moral suffering.
Zygomaticomaxillary complex and isolated orbital walls fractures are one of the most common fractures of the midface, often presenting orbital symptoms and complications. Our study was born with the aim of understanding the trend in the incidence of orbital presurgical symptoms, specifically diplopia, enophthalmos and exophthalmos, in the Campania Region in southern Italy. We conducted a retrospective, monocentric observational study at the Maxillofacial Surgery Unit of the Federico II University Hospital of Naples, enrolling 402 patients who reported a fracture of the zygomaticomaxillary complex and orbital floor region from 15 June 2021 to 15 June 2022. Patients were evaluated by age, gender, etiology, type of fracture, preoperative orbital side effects and symptoms. Pre-surgical side effects were studied, and 16% of patients (n = 66) developed diplopia. Diplopia was most common in patients previously operated on for orbital wall fractures (100%), and least common in patients who reported trauma after interpersonal violence (15%) and road traffic accidents (11%). Exophthalmos appeared only in 1% (six cases); whereas it did not appear in 99% (396 cases). Enophthalmos was present in 4% (sixteen cases), most commonly in interpersonal violence cases (two cases). The frequency of orbital complications in patients with zygomaticomaxillary complex and isolated orbital walls fractures suggests how diplopia remains the most common pre-surgical orbital side effect.
Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. However, identifying those at risk for delayed enophthalmos and requiring subsequent repair has remained a challenge. This study aimed to validate the Orbital Index, a prediction tool using computed tomography to stratify risk for delayed enophthalmos and establish a threshold for repair. The Orbital Index stratifies fractures by size, location, and inferior rectus rounding (a surrogate for fascioligamentous sling disruption) on a scale 0 to 6. A 22-year (1998 to 2020) multi-institution analysis of unilateral isolated orbital floor fractures was performed. Index scores were assigned to each scan, unoperated patients invited for blinded Hertel exophthalmometry assessment, and enophthalmos measurements correlated with Index scores. Interobserver scoring reproducibility was assessed with weighted Cohen kappa. Preintervention and postintervention Likert scale surveys were administered to determine whether this tool improved understanding and communication. The Orbital Index demonstrated high fidelity and interobserver reproducibility and identified a score of four or greater as a surgical threshold. Of 1769 computed tomography scans, 395 met criteria and were included for analysis. Eighty of 395 were managed operatively (operative rate, 20.3 percent). Of 315 patients managed nonoperatively, 41 (13.0 percent) agreed to follow-up evaluation and 28 (68.3 percent) were found to have enophthalmos. Unoperated patients with an Orbital Index score of 4 or higher were more likely to have enophthalmos than those with a score of 3 or less ( p = 0.001). The mean weighted Cohen kappa was 0.73, corroborating reproducibility. Communication ( p = 0.0003) and ability to correctly identify surgical need ( p = 0.01) were improved with use of this tool. The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.
