Orbital floor fractures can be explored through the eyelid with a subciliary or a smile-crease incision. A two-plane incision is made to expose the orbital rim. Orbital contents are removed from the sinus, and an allopla...Orbital floor fractures can be explored through the eyelid with a subciliary or a smile-crease incision. A two-plane incision is made to expose the orbital rim. Orbital contents are removed from the sinus, and an alloplastic implant is used to cover the fracture. The periosteum is closed over the implant. Fine suture material is used to close the skin. These approaches give good exposure of the orbital floor and excellent postoperative cosmesis.
Thirty-eight patients with computed tomography (CT)-proven orbital fractures and diplopia were studied prospectively to determine the efficacy of steroids in the medical management of orbital fractures. The protocol is b...Thirty-eight patients with computed tomography (CT)-proven orbital fractures and diplopia were studied prospectively to determine the efficacy of steroids in the medical management of orbital fractures. The protocol is based on double-blind assignments to steroid (ST) and non-steroid (NT) treatment groups. Outcome analysis was based on sorting fractures into three CT classes: I-without soft tissue prolapse (n = 15); II-with soft tissue prolapse (n = 14); and III-CT evidence of inferior rectus entrapment (n = 9). Results included resolution of diplopia without surgery in both ST and NT groups in CT classes I and II. Median time course of resolution was compressed to less than 5 days in the ST treatment group, however, versus 13 days in the nontreatment group. All fractures in class III had residual diplopia with five of nine patients having surgical results that were enhanced in the ST treatment group. In addition, enophthalmos was unmasked in the ST treatment group within 1 week of treatment versus 5 months without treatment. A protocol for medical management and surgical decision-making in blowout fracture is presented.
Computed tomography (CT) can be used to aid surgical decision making when the clinical picture is unclear. Patients with blowout fractures and a large amount of orbital expansion and soft tissue herniation have a high ri...Computed tomography (CT) can be used to aid surgical decision making when the clinical picture is unclear. Patients with blowout fractures and a large amount of orbital expansion and soft tissue herniation have a high risk for developing enophthalmos. Patients with entrapped inferior rectus muscles on CT may continue to have significant diplopia unless they are treated surgically.
Autogenous bone grafts play a major role in facial and orbital reconstruction following trauma. We discuss harvesting rib, iliac, and calvarial bone grafts for such cases, and point out the controversies in the use of al...Autogenous bone grafts play a major role in facial and orbital reconstruction following trauma. We discuss harvesting rib, iliac, and calvarial bone grafts for such cases, and point out the controversies in the use of alloplastic versus autogenous grafting materials.
High-velocity trauma to the orbit is characterized by complete disruption of the orbital rim and comminution of the walls of the orbital cavity. The incidence of associated injury to the intraorbital contents, and to con...High-velocity trauma to the orbit is characterized by complete disruption of the orbital rim and comminution of the walls of the orbital cavity. The incidence of associated injury to the intraorbital contents, and to contiguous facial skeletal structures, is significant. Failure to recognize and repair the skeletal injuries results in progressive contracture of the overlying soft tissues, collapse of the bony framework of the orbit, and atrophy of incarcerated intraorbital contents. Immediate orbital reconstruction aims to restore and maintain the normal anatomy of the craniofacial skeleton. The introduction of computed tomography (CT) and craniofacial surgical techniques facilitates comprehensive evaluation of orbital fractures. Further adaptation of the principles and techniques of rigid internal skeletal fixation and primary bone grafting permits a stable, three-dimensional, anatomic reconstruction of virtually any traumatic orbital deformity.
A successfully rehabilitated anophthalmic socket must hold and support a prosthetic device that mimics the contralateral globe. The goal is symmetry. Static symmetry of the palpebral apertures, canthal angles, and superi...A successfully rehabilitated anophthalmic socket must hold and support a prosthetic device that mimics the contralateral globe. The goal is symmetry. Static symmetry of the palpebral apertures, canthal angles, and superior sulci are basic objectives. Full versions of the socket implant and prosthesis and full upper lid excursion are definitely desirable but difficult to attain. Adequate lid levels and contours and sufficiently deep conjunctival fornices are necessary to keep the prosthesis in place. Buccal mucous membrane and composite dermis-fat grafts as well as vascular pedical flaps can be used to expand contracted sockets. Canthal tendon shortening and fixation can be effectively used to reestablish lid and canthal contours and to support the prosthesis.
If a patient has vision immediately following trauma, with subsequent deterioration of visual acuity and/or field, and the presence of a relative afferent pupillary defect, compression of the optic nerve or its vascular...If a patient has vision immediately following trauma, with subsequent deterioration of visual acuity and/or field, and the presence of a relative afferent pupillary defect, compression of the optic nerve or its vascular supply is very likely. We currently lack a proven optimal treatment, but in the otherwise healthy patient, we suggest an intravenous (IV) loading dose of methylprednisolone 30 mg/kg, and a second 15-mg/kg dose 2 hours after the initial dose, followed by 15 mg/kg every 6 hours. Optic nerve decompression is indicated in this situation when corticosteroids have only a temporary effect, a diminishing one, or none at all. It may also be indicated when there is evidence of a traumatic optic neuropathy with a fractured or narrowed optic foramen or with dislocated bone fragments that directly impinge on the nerve. Optic nerve sheath decompression is indicated in progressive traumatic optic neuropathy when an enlarged fluid-filled sheath has been demonstrated sonographically.
Injury to the optic nerve may occur after seemingly minor trauma. Evulsion of the nerve from the globe may be partial or complete as a result of several concussive or rotational forces. A depressed or visibly absent lami...Injury to the optic nerve may occur after seemingly minor trauma. Evulsion of the nerve from the globe may be partial or complete as a result of several concussive or rotational forces. A depressed or visibly absent lamina cribrosa indicates a disinsertion of the nerve fibers from the globe. Visual loss ranges from severe to complete. Transections of the optic nerve within the orbit generally occur after penetrating orbital injuries or surgical resection, resulting in complete blindness. Medical or surgical intervention has not been shown to improve the visual prognosis once such injuries occur. The etiology, clinical features, and histopathology are also discussed.
The etiology of traumatic optic neuropathy is uncertain, except when intraocular pressure is elevated and CRAO can be observed. Various mechanisms have been implicated, and the etiology probably varies with individual ca...The etiology of traumatic optic neuropathy is uncertain, except when intraocular pressure is elevated and CRAO can be observed. Various mechanisms have been implicated, and the etiology probably varies with individual cases. Prognosis is best when vision is initially intact and subsequently deteriorates, suggesting compression that may be reversible. Some authorities recommend high doses of systemic steroids as initial therapy. Anatomically, the orbit is a relatively closed compartment, and significant pressure may develop following intraorbital hemorrhage, edema, or emphysema. When clinical signs of severe orbital hemorrhage and pressure (proptosis) are associated with an optic neuropathy, the clinician is faced with a difficult decision. Mechanical decompression of the orbit is technically within our ability, and considerable positive experience has been derived from the treatment of compressive optic neuropathy in Grave's disease. Although the efficacy of decompression in trauma is uncertain, the literature provides anecdotal reports of restored vision. With full informed consent regarding these issues, orbital decompression seems appropriate for the rare case in which clinical signs of orbital pressure are impressive.
Trimalar fractures of the zygoma are not infrequent midfacial injuries and are a distinct clinical entity. Specific clinical findings include infraorbital anesthesia, trismus, diplopia, enophthalmos, palpable bony suture...Trimalar fractures of the zygoma are not infrequent midfacial injuries and are a distinct clinical entity. Specific clinical findings include infraorbital anesthesia, trismus, diplopia, enophthalmos, palpable bony suture line abnormalities, flattened malar eminences, and superior sulcus deformities. Six radiologic subgroups have been described. Optimal surgical management and treatment depend on the type of fracture. Three general surgical approaches are currently used: the Gillies technique, the supraorbital approach, and the maxillary sinus approach.
Many injuries and complications of orbital fractures are instantaneous and unpreventable, some develop over time, and some are a result of surgery. Most complications can either be managed or prevented and are anticipate...Many injuries and complications of orbital fractures are instantaneous and unpreventable, some develop over time, and some are a result of surgery. Most complications can either be managed or prevented and are anticipated based on the fracture location and size. A thorough search for probable complications is mandatory, especially ocular injuries and intracranial complications. Most patients are carefully followed for 7-14 days, and the significant residual sequelae are managed. Some complications, however, require urgent care.