Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair

Kim, Jane S.; Lee, Bradford W.; Scawn, Richard; Korn, Bobby S.; Kikkawa, Don O.

doi:10.1097/iop.0000000000000591

Cited by 39 publications

(30 citation statements)

References 21 publications

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“…The potential late cosmetic deformities include superior sulcus deformity, hypoglobus, and enophthalmus. 6,7 Surgeons predict the potential risk for functional and/or late cosmetic symptoms based on clinical and CT scan findings, knowing that not all BOFs require surgical treatment. 8 The cut-off points between surgical and nonsurgical treatment have been recommended at > 1.5 mL volume of herniation, 9 an orbital floor fracture > 1.0 cm, 2,10 or > 50% fractured orbital floor.…”

mentioning

confidence: 99%

New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study

Alinasab

Borstedt

Rudström

et al. 2018

Craniomaxillofacial Trauma & Reconstruction

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Despite extensive debate and publications in the management of blowout fracture (BOF), there are still considerable differences in the surgeons’ management of BOF due to a lack of reliable evidence-based studies. This article aimed to evaluate which BOF patients require surgical treatment due to functional and/or cosmetic deformities; evaluate which computed tomography (CT) scan findings predict these problems; and provide an algorithm in the management of BOF. Seventy-nine patients with BOF were treated conservatively and followed up prospectively regarding functional and cosmetic deformities for at least 1 year. The patients’ CT scans were analyzed and several measurements were performed. Patients’ symptoms and the clinical findings were correlated to the CT scan measurements. We found visible deformity in 37% of the patients, but only 10% chose to proceed to surgery due to cosmetic deformities. In patients with inferior BOF and a herniation < 1.0 mL, a visible deformity was found when the ratio between fracture and the fractured orbital wall areas was ≥42%, or the total area of the fracture was ≥ 2.3 cm2. In patients with inferior BOF and a herniation ≥ 1.0 mL, a visible deformity was found when the distance from the inferior orbital rim to the posterior edge of the fracture was ≥ 3.0 cm. In patients with inferomedial fracture, a visible deformity was found when the herniation was ≥ 0.9 mL. Diplopia improved significantly and remained in only 3% of the patients in nonoperated group. Hypoesthesia of the infraorbital nerve improved significantly, but 23% of the nonoperated and 50% of the operated patients still experienced loss of sensation at final control. In this prospective study, we found that not only herniated orbital volume but also other CT scan findings in BOF were crucial to predict late visible deformities. Based on these findings, we propose an algorithm for the prediction of late visible deformity with 83% accuracy. There are indications that diplopia without ocular motility disorder is due to edema and we recommend observation as long as the diplopia improves gradually.

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mentioning

confidence: 99%

New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study

Alinasab

Borstedt

Rudström

et al. 2018

Craniomaxillofacial Trauma & Reconstruction

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“…Previous reports showed that 27.5% of the patients had residual enophthalmos and 20%–37% of patients had postoperative diplopia after surgery [14–16]. The decision for secondary repair was based on clinical presentation correlated with radiographic findings, such as a malpositioned or absent orbital implant [6]. Secondary orbital reconstruction for unsatisfactory primary orbital repair can improve functional deficits and aesthetic results [6].…”

Section: Discussionmentioning

confidence: 99%

“…Inadequate primary orbital repair causing functional defects and cosmetic deficits is a great challenge for those surgeons who decide to perform secondary reconstruction surgery. Scarring accompanying the primary incision and fibrosis in response to implanted orbital materials increase the risks of complications associated with secondary surgery [6]. Nevertheless, if secondary surgery is performed, it can substantially improve patients' quality of life.…”

Section: Introductionmentioning

confidence: 99%

Bioresorbable Material in Secondary Orbital Reconstruction Surgery

Pan

Zhang

Tang

et al. 2019

Journal of Ophthalmology

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Purpose. To validate the potential of bioresorbable implantation in secondary revisional reconstruction after inadequate primary orbital fracture repair, with assessment of pre- and postoperative clinical characteristics and computed tomography image findings. Methods. A retrospective chart review was conducted on 16 consecutive patients treated for orbital fractures at Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, with inadequate prior surgeries between July 2010 and June 2017; patients who had suffered orbital blowout fractures had undergone primary surgeries elsewhere. Secondary repair of orbital fractures used bioresorbable material following unsatisfactory primary orbital repair. Patients’ demographics, degree of enophthalmos, ocular motility, diplopia test results, primary implants, and surgical complications were reviewed. Results. All 16 patients had primary orbital implants consisting of Medpor, titanium mesh, hydroxyapatite, or poly-L-lactide. Of the 16 cases, 14 had malpositioned implants posteriorly and two had implant infections. Findings following primary surgery included enophthalmos (12/16), diplopia (9/16), intraorbital abscess (2/16), and ocular movement pain (1/16). Mean preoperative enophthalmos was 3.8 ± 0.8 mm. Secondary reconstruction resulted in a mean reduction of enophthalmos by 3.1 ± 0.9 mm (P<0.01). Nine in ten patients experienced improvements in postoperative ocular motility and diplopia following secondary surgery. Intraorbital abscesses and eyeball movement-associated pain were cured. Conclusions. This study demonstrates that secondary orbital reconstruction of previously repaired orbital fractures using bioresorbable material can achieve excellent functional and aesthetic results with minimal complications. Bioresorbable material should be considered in secondary orbital reconstruction when clinically indicated.

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“…It is well known that entrapment of extraocular muscle is an absolute indication for immediate surgical intervention. 1 It is also known that BOF can result in considerable aesthetic deformities, 2,3 hypoesthesia of the infraorbital nerve, 4 and chronic diplopia. 5 Early assessment of the significance of the fracture through clinical examination and imaging and an informed decision between surgical and observational treatments are crucial for an optimal result.…”

mentioning

confidence: 99%

Prospective Randomized Controlled Pilot Study on Orbital Blowout Fracture

Alinasab

Borstedt

Rudström

et al. 2018

Craniomaxillofacial Trauma & Reconstruction

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To clarify the conflicting recommendations for care of blowout fracture (BOF), a prospective randomized study is required. Here, we present a prospective randomized pilot study on BOF. This article aimed to evaluate which computed tomography (CT) findings predict late functional and/or cosmetic symptoms in BOF patients with ≥ 1.0 mL herniation of orbital content into maxillary and/or ethmoidal sinuses. It also aimed to evaluate which patients with BOF would benefit from surgical treatment or observational follow-up. Twenty-six patients with BOF ≥ 1.0 mL herniation were randomized to observational ( = 10) or surgical treatments ( = 16) and were followed up for functional and cosmetic symptoms for at least 1 year. The results from CT scan measurements were correlated to the patients' symptoms and clinical findings which we report in this pilot study. Of the 10 patients randomized to observation, five had an inferomedial BOF with a herniation of ≥ 1.3 mL and all patients developed cosmetic deformities and required surgery. The remaining five patients in the observational group had inferior BOF and one of them had a distance of 3.3 cm from the inferior orbital rim to the posterior edge of the fracture and developed a cosmetic deformity but was unwilling to proceed to surgical treatment, and four patients had a median distance of 2.9 cm from the inferior orbital rim to the posterior edge of the fracture and did not develop cosmetic deformities. The median time from injury to surgery was 13 (3-17) days for the surgical group and 37 (17-170) days for the patients who underwent surgery in the observational group. The surgical results were similar for all the operated patients at the final control. Diplopia decreased and remained partly in one patient in the surgical group and in two patients in the observational group. Hypoesthesia of the infraorbital nerve decreased in nonsurgically treated patients, but surgery seemed to induce hypoesthesia. In this prospective randomized controlled pilot study on BOF, all patients in the observational group with inferomedial fractures developed visible deformity. Diplopia in BOF, without ocular motility limitation, is believed to be due to edema. Diplopia is not an indication for surgery as long as it reduces over time.

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Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair

Abstract: This study demonstrates that secondary orbital reconstruction can achieve excellent functional and cosmetic results with high patient satisfaction and minimal complications. Secondary reconstruction of previously repaired orbital fractures should be considered when clinically indicated.

Cited by 39 publications

References 21 publications

New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study

New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study

Bioresorbable Material in Secondary Orbital Reconstruction Surgery

Prospective Randomized Controlled Pilot Study on Orbital Blowout Fracture

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