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Study Design: Case series. Objective: To describe the assessment and surgical approach to dacryocystorhinostomy (DCR) for patients with nasolacrimal duct obstruction (NLDO) in the presence of orbital wall hardware. Methods: The pre-operative assessment, management and outcomes of two patients with secondary acquired NLDO following medial orbital wall fracture repair treated by nasal endoscopic DCR. Results: Anatomical and functional success was achieved in both cases at 6 weeks post operatively without disruption of the orbital plate. There was persistent success at 1 and 3 years' post-operatively. Conclusions: Endoscopic DCR is a good option for the treatment of NLDO in patients with previous medial orbital wall fracture repair where the location of the plate may complicate the external approach. [ABSTRACT FROM AUTHOR]

Study Design: N/A. Objective: This study investigated the different ways of orbital floor reconstruction with special focus on reconstruction materials, imaging modalities (intra-/ post-operative), 3D printing and navigation. Methods: The heads of all governmental-run or associated cranio-maxillofacial surgery units in Switzerland, Austria and Germany were asked in person or received an email link for an online survey with 12 questions. Results: The return rate was 57%. The most often selected number of reconstructions was between 10 and 50 per year. Resorbable polydioxanone (PDS) foils (41%) and titanium mesh (18 %) were most often used to reconstruct the orbital floor. 31% use 3D Navigation intraoperative. Post-operative imaging was most often performed with CBCT (34.5%) in patients without complications, whereas CT scans were most often performed (63.3%) in patients with persisting complications. In total, 27% stated that they never use preformed orbital plates, and the remaining units use them more or less regularly. 48% have access to a 3D printer and 75% of the respondents use patient specific implants. Conclusions: The majority of the participating units prefer to use resorbable material for the reconstruction of the orbital floor defects. 3D printing facilities are not available in the majority of units, but it can be expected that the number of units with 3D printing facilities will rise in the near future. [ABSTRACT FROM AUTHOR]

Background: Most tertiary-care teaching institutes in low and middle-income nations lack dedicated oral and maxillofacial surgery (OMFS) units in the emergency trauma centers. Consequently, most facial fractures need to be managed in the otolaryngology and head-neck surgery (ORL-HNS) setup. Objectives: To present a study on a series of patients with facial fractures attending the emergency and outpatient departments of ORL-HNS in a tertiary-care teaching institute in India that lacked the facility of OMFS in its emergency trauma center. Methodology: For the patients included in the study, a general protocol for managing polytrauma was followed. Patients with concomitant intracavitary and long bone injuries were excluded. Those with facial fractures that essentially required OMFS expertise were referred to dedicated maxillofacial centers. The most common presentation was pain/tenderness, followed by peri-orbital ecchymosis and trismus. Orbital symptoms were associated with orbital floor and zygomatico-maxillary complex fractures. Diagnosis and surgical planning were made following high-resolution computed tomography scan. Except for nasal bones, all the fractures were managed by open reduction and fixation. Results: The mean age of the 26 patients included in the series was 32.88 years (range 7–55 years) with a male preponderance of 2.7:1. The fractures involved orbital floor (n = 3), frontal bone (n = 2), mandible (n = 4), zygomatico-maxillary complex (n = 14), and nasal bone (n = 3). Road traffic accidents were the commonest etiology. Management of the respective facial bone fractures was done following the standard care of surgical practice. Conclusions: For their expertise in functionally and esthetically appropriate repair, a dedicated OMFS unit is desirable for managing facial fractures. The present series shares the experience of managing such fractures by the ORL-HNS team in the absence of an OMFS facility in the emergency trauma center, highlighting the importance of a multidisciplinary approach in the care delivery system. [ABSTRACT FROM AUTHOR]

Background: Recurrent or repeat orbital floor and/or medial wall fractures may have an increased risk of globe injury and vision loss. To see if the initial orbital floor repair technique and/or chosen material for reconstruction impact the result, we studied repeat offenders who engage in: (1) repeat assaults, (2) unprotected sports injuries, or (3) seizure disorders. Methods: From 715 patients who underwent traumatic orbital floor repair over an 18-year period, 58 "repeat offenders" suffered a subsequent orbital fracture and were studied. Type of repair and outcomes including globe injuries were documented. Results: Repeat offenders who had a second orbital fracture had initial repairs with: resorbable plates (63.8%), titanium mesh (12.1%), and split cranial bone grafts (14%). More significant globe injuries occurred when initial repair was with titanium plates (86%) and bone grafts (14%) compared to resorbable plates (0%). Of the total group with initial orbital fractures and repair, 15% were categorized as "at risk" to be repeat offenders based on their medical history and activity. Of the "repeat offenders" who had an additional orbital fracture, 95% (50/58) fell into the "at risk" category for "repeat offending." Conclusion: Resorbable plate orbital floor and/or medial wall fracture repair may offer less significant globe injury for repeat offenders at risk for subsequent orbital trauma. [ABSTRACT FROM AUTHOR]

PurposeMethodsResultsConclusions and RelevanceElectric scooters (e-scooters) have rapidly become a mainstream method of transportation in the U.S. but there is consequently limited data on their safety profile. This study evaluates ophthalmic injuries related to e-scooters compared to non-motorized scooters and off-road vehicles (ORV).This retrospective study uses the National Electronic Injury Surveillance System (2014 to 2023). Ocular injury profiles associated with conventional scooters, e-scooters, and off-road vehicles were included.E-scooter ocular injuries rose by 1950% between 2014 and 2023. E-scooter riders were 4.3 times more likely to sustain orbital fractures and 2.7 times more likely to be hospitalized than non-motorized scooter riders. ORV and e-scooter riders had comparable injury and hospitalization patterns. Alcohol use and lack of helmet use were significant contributors to injury severity.Injury patterns and hospitalization rates in e-scooter accidents resemble those of ORV incidents. Findings highlight the need for public health interventions to reduce the burden of e-scooter-related injuries. [ABSTRACT FROM AUTHOR]

Purpose: The objective is to investigate trends in cases of motor vehicle accident-associated (MVA-associated) ocular trauma in which the patient was the driver of the motor vehicle. Methods: The study utilizes data from the 2007–2014 National Trauma Databank (NTDB), a national trauma registry. Status as the driver of the motor vehicle was identified using E-Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Trauma diagnoses were identified using D-Codes from the ICD-9-CM. Statistics were performed using IBM SPSS Version 23. Results: We identified 49,660 cases of ocular trauma secondary to an MVA with a 25.3% increase in injuries over the 8-year time period. Men comprised 68.6% (34,057) of cases. Orbital floor fractures (OFFs) were the most commonly observed ocular injury, occurring in 17,647 (35.5%) cases. There were 2,787 cases of open globe injury (OGI) with the highest proportion of cases in the 65 + age group (6.5%). OGIs were seen in 3.0% of cases with OFFs vs. 7.1% in those without. Drivers under 18 were more likely to have optic pathway/cranial nerve injuries (4.4%) and ocular/adnexal contusions (41.2%) than adult drivers. The mortality rate was 4.3% and was highest in the 65 + age group (9.4%). Conclusion: Men and young adults comprised the majority of cases of MVA-associated ocular trauma. OFFs were seen in approximately one-third of cases of ocular trauma. OGIs were less commonly observed when a concurrent OFF was observed. Though the overall mortality was 4.3%, there was significant variation by age group. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate clinical presentations, computed tomography (CT) findings, and various prognostic factors affecting the surgical outcomes of trapdoor fractures. Methods: This retrospective multi-center study reviewed medical records and orbital CT scans of patients under 21 years old, diagnosed with isolated trapdoor fractures. The study was conducted across multiple medical centers, including emergency and clinical departments in Isfahan, Shiraz, and Tehran-Iran. The characteristics and outcomes following surgical intervention were assessed. Results: 45 patients with isolated trapdoor fractures were included in the study, with a mean age of 11.67 ± 4.69 years, predominantly male (84.4%). Vehicle accidents was the major cause of fractures (31.1%). 44 patients (97.8%) had orbital floor fracture, and one patient (2.2%) had medial wall involvement. Nausea/vomiting were reported in 41 patients (91.1%). Surgical intervention within 2 days, resulted in 85.0% of patients experiencing no postoperative diplopia. Delayed surgery beyond 2 days showed increased odds of diplopia, although not statistically significant. CT scan findings suggested a lower risk of diplopia in patients with soft tissue entrapment compared to muscle involvement (OR: 0.336, 95% CI: 0.077–1.462, p = 0.146). Shorter time to surgery (within 2 days) was significantly associated with normal postoperative eye movements (p = 0.002). Nausea/vomiting were more prevalent in patients with muscle entrapment (p < 0.05). Conclusion: Surgical intervention within 48 h is crucial for improving ocular motility following trapdoor fractures. Extraocular symptoms, including nausea/vomiting, should raise suspicion for trapdoor fractures in cases of orbital trauma associated with ocular movement impairment. Clinical trial number: Not applicable. [ABSTRACT FROM AUTHOR]

This study aimed to identify and quantify the variations in PSI designs intended for an identical patient. Records from 10 patients with an orbital fracture involving two walls, for which a primary orbital reconstruction was indicated, were retrospectively included. Clinical engineers from two centers independently generated proposal designs for all patients. Following web meeting(s) with the surgeon from the same institute, the PSI designs were finalized by the engineer. A cross-over of the engineer with the surgeon of the other center created two new design teams. In total, 20 proposal and 40 final PSI designs were produced. A three-dimensional comparison between different PSI designs for the same patient was performed by computing a difference score. Initially, the design proposals of the two engineers showed a median difference score of 37%, which was significantly reduced to a median difference score of 26% for the final designs with different engineers. The median difference score of 22% between surgeons demonstrated that both parties introduced notable user variations to the final designs. Evidence supporting the advantages of an experienced design team was found, with significantly fewer modifications, fewer meetings, and less time required to complete the design (up to 40% time reduction). The findings of the study underline the dependency of PSI design on the surgeon and engineer, and support the need for a more evidence-based protocol for PSI design. [ABSTRACT FROM AUTHOR]

Purpose: The orbital floor is frequently involved in head trauma. Current evidence on the use of reconstruction materials for orbital floor repair is inconclusive. Accordingly, this study aimed to compare the impact of polydioxanone (PDS) foil thickness on reconstruction of the orbital geometry after isolated orbital floor fractures. Methods: Standardized isolated orbital floor fractures were symmetrically created in 11 cadaver heads that provided 22 orbits. PDS foils with thicknesses of 0.25–0.5 mm were inserted. Computed tomography (CT) scans of the native, fractured, and reconstructed orbits were obtained, and orbital volume, orbital height, and foil bending were measured. Results: Orbital volume and height significantly (p < 0.01) increased after the creation of isolated orbital floor fractures and significantly (p = 0.001) decreased with overcorrection of the orbital geometry after orbital floor reconstruction with PDS 0.25 mm or PDS 0.5 mm. The orbital geometry reconstruction rate did not differ significantly with respect to foil thickness. However, compared to PDS 0.5 mm, the use of PDS 0.25 mm resulted in quantitatively higher reconstructive accuracy and a restored orbital volume that did not significantly differ from the initial volume. Conclusion: Orbital floors subjected to isolated fractures were successfully reconstructed using PDS regardless of foil thickness, with overcorrection of the orbital geometry. Due to its lower flexural stiffness, PDS 0.25 mm appeared to provide more accurate orbital geometry reconstruction than PDS 0.5 mm, although no significant difference in reconstructive accuracy between PDS 0.25 mm and PDS 0.5 mm was observed in this cadaveric study. [ABSTRACT FROM AUTHOR]

Purpose To analyze the correlation between orbital computed tomography (CT) scan measurements including the fracture area (FA), the fracture location, the soft-tissue herniation volume (HV), the fractured orbital volume ratio (OVR) to the normal orbit, and the clinical enophthalmos in acute isolated orbital floor fractures. Methods We enrolled 100 patients with acute isolated unilateral orbital floor fractures from May 2017 to January 2021. Based on the CT scan findings, we measured the FA, HV, OVR, and fracture site. We assessed enophthalmos using both clinical (CE) and radiographic (RE) measurements. Additionally, we investigated the correlation between CE and the measured parameters, along with the relationship between the pattern of diplopia and the fracture site. Results We identified enophthalmos in 81% and diplopia in 78% of the patients with an acute blowout orbital floor fracture. CE was moderately correlated with the FA (R2 = 0.4341, P < 0.001). CE was weakly correlated with the HV (R2 = 0.2861, P = 0.04). Anterior fractures caused diplopia in both vertical gazes, but posterior fractures were mostly associated with diplopia in the up gaze. OVR was strongly associated with RE (R2 = 0.663, P < 0.0001) and moderately associated with CE (R2 = 0.4378, P < 0.0001). The univariate regression analysis also showed that OVR could significantly predict CE and RE. Conclusions OVR surpasses other CT scan measurements such as FA and HV in the prediction of clinical enophthalmos. Thus, OVR could be utilized to estimate clinical enophthalmos at the time of presentation, especially when the acute clinical setting prohibits the proper clinical evaluation.

Abstract Objectives To date, no study provides a comprehensive analysis of traumatic orbital floor fractures across the United States. We aimed to characterize patient demographics, injury‐related variables, and operative management in this population. Method The National Trauma Data Bank was queried for open or closed orbital floor fractures from 2008 to 2016. Clinical data were extracted. Results Overall, 148,592 orbital floor fractures were identified, with 142,577 (95.9%) closed‐ and 6158 (4.1%) open‐type fractures. A total of 106,243 (71.5%) patients were male and the median patient age was 41 years. The majority of patients (79.2%) had abbreviated injury scale scores of ≤2, indicating minor/moderate injury. Fracture mechanism of injury (MOI) differed by gender, with the most frequent being unarmed fights in men (34.3%) and falls in women (14.0%). There were 29,600 patients (19.9%) with isolated orbital floor (I‐OF) fractures. The MOI most strongly associated with operative intervention of with I‐OF fractures were penetrating injuries caused by a firearm (odds ratio [OR]: 2.91; 95% confidence interval [CI]: 1.62–5.20) and cuttings/piercings (OR: 2.17; 95% CI: 1.29–3.65). Conclusion This large epidemiological study reveals that orbital floor fractures tend to present with minor or moderate injuries and are more likely to require operative intervention in setting of firearm or cut/pierce injuries.

Objective: To analyze the types and causes of complications following orbital fracture reconstruction and enhance clinicians' capacity to manage or prevent such complications. Methods: We conducted a retrospective case series analysis, retrospectively collecting and analyzing clinical data of patients with orbital fractures who received surgical treatment at the Affiliated Eye Hospital of Nanchang University from May 2012 to May 2022. Descriptive statistics were employed to document common postoperative complications, and we recorded complications persisting after a minimum 6-month follow-up period. Results: Among the 227 patients who underwent orbital fracture surgery, they were followed up for 6 to 36 months, and complications occurred in 15 cases, resulting in an incidence rate of 6.61%. These complications included implant material infections and rejections (4 cases), persistent diplopia (3 cases), intraorbital hematomas (2 cases), epiphora (2 cases), lower eyelid eversion or retraction (2 cases), and skin scars (2 cases). The primary cause of postoperative infection was chronic inflammation in the paranasal sinuses or closed cavities within the fracture area. Postoperative complications in orbital fractures were associated with various factors, including the timing of surgery, surgical approach, repair materials, surgical skills, and auxiliary techniques. Conclusion: Standardizing surgical techniques and implementing precise auxiliary technologies may reduce the incidence of complications and enhance the operation's success rate. Precis: This study systematically analyzed the complications and underlying causes of orbital fracture surgery. By mitigating these factors, it aims to decrease or manage surgical complications, thereby enhancing patients' treatment outcomes. [ABSTRACT FROM AUTHOR]

A 37-year-old scuba diver developed sudden severe headache, mid-facial pressure/pain and diplopia while diving. Upon examination, he had signs and symptoms consistent with silent sinus syndrome (SSS), including bilateral enophthalmos, hypoglobus, and diplopia/strabismus in conjunction with CT findings of occluded maxillary sinus ostia, atrophic/collapsed maxillary sinuses, and bilateral orbital floor fractures with fat herniation. As there was no history of trauma or chronic sinusitis, this rare case of bilateral SSS was deemed the cause of the spontaneous fractures (i.e. barotrauma secondary to a lack of equalization to ambient surrounding pressure). Transconjunctival repair of the fractures was successful and maxillary sinus antrostomies re-established aeration of the sinuses. We present this case and its management, as well as review the literature concerning sinus barotrauma as a result of diving and SSS. There have been no reports of orbital fractures primarily caused by scuba diving, nor secondarily from diving with the rare entity, SSS. [ABSTRACT FROM AUTHOR]

The reconstruction of orbital fracture sequelae is a major challenge due to concerns regarding surgical approach and implant stability. Few anatomical sites of such minute size have presented with as much variation in treatment as the orbital floor fractures and related sequelae. Our patient developed sequelae of an orbital fracture over the last 3 years, presenting with dystopia, ophthalmoplegia, and diplopia in the supra- and lateroversion and aesthetic impairment. The variety of implant materials for reconstruction after orbital fractures is extensive, and the decision as to which material to use continues to be debated. The continuing development of computer-aided diagnosis and management and the construction of stereolithographic models offer comparable reproduction of anatomical detail. This technology is described in relation to the planning of trauma surgery and sequelae and the planning of ablative surgery for malignant neoplasms of the head and neck. The use of specific 3D printed titanium implants for bone defects was first reported in cranial reconstruction in 2012, and several studies have reported their use in orbital fractures. The advantages of this implant were increased stiffness, preventing shape loss during placement, a precise fit, and decreased surgical time. However, in the existing literature, the one-piece implant done in this way was a precise fit; therefore, it is possible that navigation between intraoperative anatomical landmarks is lost. However, in cases where reconstruction is difficult, such as extensive orbital wall fractures and large orbital sequelae, the 3D printed implant has been helpful in decreasing surgical time and can be accessed by a limited surgical approach with a precise fit. Our clinical case involved a 37-year-old male patient who experienced severe physical aggression in 2020, amid the COVID-19 pandemic. At the time, due to the overwhelming healthcare demands and resource constraints imposed by the pandemic, immediate surgical intervention for the correction of the fracture was not feasible. As a result of this delay, the patient developed sequelae of the orbital fracture over the last 3 years.

The anatomically complex craniofacial skeleton demands special consideration when caring for cases of polytrauma or medically compromised patients with craniofacial fractures. This paper utilises a systematic review and multidisciplinary opinions to create an algorithm for the hospital-based care of patients with craniofacial fractures (base of skull, orbit, paranasal sinus, and mandible) who require non-invasive ventilation (NIV). Each fracture location has a unique predisposition to a different type of emphysema and associated morbidity. The risk of developing emphysema, combined with its potential severity, is stratified against the harm of not providing NIV for the holistic care of the patient. The aim of this paper is to synthesise evidence from a systematic review of existing literature with multidisciplinary opinions to develop a concise algorithm that outlines the optimal treatment of patients with craniofacial fractures who require NIV. [ABSTRACT FROM AUTHOR]

Fractures of the orbit are frequently noted in craniomaxillofacial trauma. The complexity of the anatomy and the proximity to various vital structures often complicates the surgical management of these fractures. The authors have thus attempted to review the literature on anatomy of the bony orbit and its soft tissue envelope in a simplified manner with due emphasis on surgical anatomy and exploration of the orbit with a surgical perspective. The contents of this narrative literature review may be useful for young maxillofacial surgeons and will aid in the process of management of orbital fractures. [ABSTRACT FROM AUTHOR]

Purpose: To determine risk factors for substantial closed-globe injuries in orbital fractures (SCGI) and to develop the best multivariate model for the prediction of SCGI. Methods: A retrospective study was performed on patients diagnosed with orbital fractures at Farabi Hospital between 2016 and 2022. Patients with a comprehensive ophthalmologic examination and orbital CT scan were included. Predictive signs or imaging findings for SCGI were identified by logistic regression (LR) analysis. Support vector machine (SVM), random forest regression (RFR), and extreme gradient boosting (XGBoost) were also trained using a fivefold cross-validation method. Results: A total of 415 eyes from 403 patients were included. Factors associated with an increased risk of SCGI were reduced uncorrected visual acuity (UCVA), increased difference between UCVA of the traumatic eye from the contralateral eye, older age, male sex, grade of periorbital soft tissue trauma, trauma in the occupational setting, conjunctival hemorrhage, extraocular movement restriction, number of fractured walls, presence of medial wall fracture, size of fracture, intraorbital emphysema and retrobulbar hemorrhage. The area under the curve of the receiver operating characteristic for LR, SVM, RFR, and XGBoost for the prediction of SCGI was 57.2%, 68.8%, 63.7%, and 73.1%, respectively. Conclusions: Clinical and radiographic findings could be utilized to efficiently predict SCGI. XGBoost outperforms the logistic regression model in the prediction of SCGI and could be incorporated into clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: This pilot study aims to evaluate the feasibility and effectiveness of computer-assisted surgery protocol with 3D-preformed orbital titanium mesh (3D-POTM), using presurgical virtual planning and intraoperative navigation in primary inferomedial orbital fracture reconstruction. Methods: Between March 2021 and March 2023, perioperative data of patients undergoing surgery for unilateral inferomedial orbital fracture treated with 3D-POTM were analyzed. Presurgical virtual planning with a Standard Triangle Language file of preformed mesh was conducted using the mirrored unaffected contralateral side as a reference, and intraoperative navigation was used. The reconstruction accuracy was determined by: correspondence between postoperative reconstruction mesh position with presurgical virtual planning and difference among the reconstructed and the unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were assessed. Results: Twenty-six patients were included. Isolated orbital floor fracture was reported in 14 (53.8%) patients, meanwhile medial wall and floor one in 12 (46.1%) cases. The mean difference between final plate position and ideal digital plan was 0.692 mm (95% CI: 0.601–0.783). The mean volume difference between reconstructed and unaffected orbit was 1.02 mL (95% CI: 0.451–1.589). Preoperative diplopia was settled out in all cases and enophthalmos in 19 (76.2%) of 21 patients. Conclusion: The proposed protocol is an adaptable and reliable workflow for the early treatment of inferomedial orbital fractures. It enables precise preoperative planning and intraoperative procedures, mitigating pitfalls and complications, and delivering excellent reconstruction, all while maintaining reasonable costs and commitment times. [ABSTRACT FROM AUTHOR]

This study aimed to compare the accuracy of inferomedial orbital fracture restoration using customized orbital implant versus 3D preformed titanium mesh. Patients were divided into two groups. Group 1 underwent surgery with customized orbital implants and intraoperative navigation, while group 2 was treated using 3D preformed titanium meshes with preoperative virtual surgical planning (VSP) and intraoperative navigation. Reconstruction accuracy was assessed by: (1) comparing the postoperative reconstruction mesh position with the preoperative VSP; and (2) measuring the difference between the reconstructed and unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were also evaluated. Fifty-two patients were enrolled (25 in group 1 vs 27 in group 2). The mean difference between final plate position and ideal digital plan was 0.62 mm (SD = 0.235) in group 1 and 0.69 mm (SD = 0.246) in group 2, with no statistical difference between the groups (p = 0.282). The mean volume differences between the reconstructed and unaffected orbits were 0.95 ml and 1.02 ml in group 1 and group 2, respectively, with no significant difference between the groups (p = 0.860). Overall clinical improvements, as well as complications, were similar. 3D preformed titanium meshes can reconstruct inferomedial fractures with the same accuracy as customized implants. Therefore, in clinical practice, it is recommended to use 3D preformed meshes for this type of fracture due to their excellent results and the potential for reducing time and costs. [ABSTRACT FROM AUTHOR]

We report a rare case of orbital roof “blow-in” fracture in a 27-year old with concomitant communited fractures of frontal and ethmoid bones. A 27-year-old male presented with a history of assault by unknown persons and sustained injury to the left eye. Computed Tomography (CT) head revealed a blow-in fracture of the orbital roof on the left side with bony fragment displacement noted in the intraconal compartment. Surgical intervention was indicated and performed in order to prevent any visual complications arising due to the displaced bony fragment. The case report is followed by a brief overview of orbital fractures.

Merry ZC Ruan,1,2 Elana Meer,1,2 Gurbani Kaur,2 Nikan K Namiri,2 Davin C Ashraf,3 Bryan J Winn,1,4 Robert Kersten,1,4 M Reza Vagefi,1,4 Seanna Grob1,4 1Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA; 2Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; 3Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, Oregon Health & Sciences University, Portland, OR, USA; 4Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USACorrespondence: Seanna Grob, Department of Ophthalmology, Academic Director, Oculofacial Plastic and Orbital Surgery, University of California, San Francisco, San Francisco, CA, USA, Tel +1 858-349-1813, Fax +1 415-476-0336, Email seanna.grob@ucsf.eduIntroduction: To evaluate eye and orbital injuries in non-powered scooter, electric-scooter (e-scooter), and hoverboard riders in the United States (US) between 2014 and 2019.Methods: The National Electronic Injury Surveillance System (NEISS) was queried for head and neck injuries by body part codes related to non-powered scooters and powered scooters/hoverboards from 2014 to 2019. The NEISS complex sampling design was used to obtain US population projections of injuries and hospital admissions. Keywords were queried in case narratives to analyze trends in location, type, and mechanism of eye and orbit injuries.Results: Since their introduction, a 586% (p=0.01) increase in e-scooter injuries and 866% (p< 0.001) increase in hoverboard injuries were observed with an increase in hospital admissions seen in young adults (18– 34) in urban areas (e-scooter: 5980% and hoverboard: 479%). Descriptive narratives of the trauma noted eye injuries in 242 unweighted NEISS cases with only 30 cases appropriately documented under body part code 77: eyeball. Eye injuries increased 96.9% during the study period (p=0.23). Specifically, the most common ophthalmic injuries reported included eyebrow (40.9%) and eyelid (11.3%) lacerations, periorbital contusions (18.7%), orbit fractures (6.6%), and corneal abrasions (5.1%).Conclusion: There was a significant increase in both head and neck injury cases and hospital admissions related to e-scooters. Eye and orbit injuries similarly increased but were underreported by body part code compared to injury narratives. Orbital fractures were reported more frequently in injuries from e-scooters than non-powered scooters.Plain language summary: From 2014 to 2019, there were significant increases in both head and neck injuries and hospital admissions related to e-scooters, with eye and orbital injuries similarly increased but underreported by body part code compared to the injury narratives.Keywords: scooter, e-scooter, electric scooter, hoverboard, eye trauma, orbital fracture, orbit

The finite element method(FEM)is a widely employed mathematical technique in mechanical research that divides an object into discrete and interacting finite elements. Medically, finite element analysis(FEA)enables the simulation of biomechanical experiments that are challenging to conduct. Orbital surgery poses significant challenges to ophthalmologists due to its inherent difficulty and steep learning curve. FEM enables the simulation and analysis of the mechanical properties of orbital tissue, offering a novel approach for diagnosing and treating orbital-related diseases. With technological advancements, FEM has significantly matured in the diagnosis and treatment of orbital diseases, becoming a popular area of research in orbital biomechanics. This paper reviewed the latest advancements in orbital FEM, encompassing the development of orbital FEA models, simulation of orbital structure, and its application in orbital-related diseases. Additionally, the limitations of FEM and future research directions are also discussed. As a digital tool for auxiliary diagnosis and treatment, orbital FEA will progressively unlock its potential for diagnosing and treating orbital diseases alongside technological advancements.

Background: During blow-out fracture surgery, restoration of the orbital volume and rigid implant fixation are essential. The migration of an implant is a concern of most surgeons. The purpose of this study was to introduce a simple idea of molding and fixing an orbital implant. Methods: In the tongue-in-groove method, an incision of about 2 mm was made on the edge of the implant and it was bent to form a slot. A hole was made in the center of the implant for fitting a bone hook, and the implant was firmly fit into the remaining intact bone. Before and after surgery, computed tomography (CT) was used to evaluate changes in the orbital volume and the location of the implant. Statistically significant restoration of the orbital volume was confirmed on postoperative CT. Results: Compared with the unaffected orbital volume, the affected orbital volume was increased from 87.06 ± 7.92% before surgery to 96.14 ± 6.11% after surgery (p < 0.001). There was one case of implant migration during follow-up. However, the degree of movement was not severe, and there were no events during the follow-up period. Conclusions: The tongue-in-groove technique offers advantages, such as easy fixation of the implant, with minimal trauma to the surrounding tissues. In addition, the method offers advantages, such as being easy to learn, requiring little time for trimming the implant, and being relatively low cost. Therefore, it can be one of the options for implant fixation. [ABSTRACT FROM AUTHOR]

Subciliary incision is a common approach for facial fracture surgery; however, it has a higher incidence of lower lid ectropion, which can be particularly challenging for beginning surgeons to manage. This study reports the usage of lateral tarsoplasty combined with a full-thickness skin graft (FTSG) to correct severe ectropion following the subciliary approach for infra-orbital rim fractures. We retrospectively reviewed all facial fracture cases involving infra-orbital rim fractures through a subciliary approach treated in our department between March 2021 and May 2023. Electronic medical records and clinical digital photographs of patients who met the inclusion criteria were reviewed. After reviewing 196 cases that used the subciliary approach, we found 6 patients (3.06%; 4 males and 2 females; mean age, 68.5 ± 4.89 years) with postoperative severe ectropion managed using lateral tarsoplasty and FTSG. The mean ectropion development and correction times after facial fracture surgery were 0.78 ± 0.24 and 0.91 ± 0.37 months, respectively. At the 12-month follow-up, all patients showed favorable outcomes, and the position of their lower eyelids was well maintained without ectropion recurrence. Based on these successful outcomes, lateral tarsoplasty combined with FTSG is proposed to be an effective and straightforward method for managing lower eyelid ectropion caused by facial fracture surgery. [ABSTRACT FROM AUTHOR]

Background: Orbital floor fractures involve damage to the orbital floor but not the infraorbital margin. Despite intensive research, they remain a controversial topic. The aim of this study was to investigate the relationship between parameters gathered by means of computed tomography (CT), the clinical presentation, and treatment outcomes, in patients suffering from orbital floor fractures. Methods: Forty patients with orbital floor fractures were included in this study. Information regarding diplopia, impaired ocular mobility, asymmetric eyeball placement, and infraorbital paresis was gathered from the medical records. Nine CT-based parameters were assessed. Two parameters were calculated, based on them. The follow-up data of 30 patients were analyzed. The results were statistically evaluated. The significance level was p < 0.05. Results: Statistical evaluation revealed multiple correlations between CT-based findings, symptoms, and treatment results. Among others, the hernia into the maxillary sinus was significantly larger in patients without improvement in infraorbital paresis (p = 0.0031) and without improvement in assymetric eyeball placement (p = 0.0037). There was no correlation between the entrapment of the rectus inferior muscle and impaired ocular mobility (p = 0.664431; p = 0.420289) and between the direct fracture of the infraorbital canal and infraorbital paresis (p = 0.371102). Conclusions: The widely assumed thesis that impaired ocular mobility in orbital fractures is caused by entrapment of the rectus inferior muscle is disproved by CT-based data. CT-based findings, symptoms, and treatment results in patients with orbital floor fractures were significantly correlated. A large hernia may be a negative prognostic factor. [ABSTRACT FROM AUTHOR]

Prompt diagnosis and management of orbital entrapment fractures in the pediatric patient have been advocated. This retrospective study analyzed a cohort of orbital entrapment fractures in pediatric patients with regard to diagnostic pitfalls, treatment and outcomes in a Level I trauma center in Germany. Based on medical records and radiological imaging, patients under the age of 18 years who presented with orbital fractures during 2009–2021 were analyzed. Overall, 125 patients presented with orbital fractures, of whom 29 patients (23.2%) had orbital entrapment fractures. The majority of patients presented with monocle hematoma (n = 23), diplopia (n = 20), and/or restricted extraocular eye movement (n = 14). While all patients with orbital entrapment fractures underwent three-dimensional imaging, 10 radiological reports (34.5%) did not include findings on orbital entrapment fractures. All patients underwent surgical exploration in less than 24 h. In 12 patients, clinical symptoms such as diplopia and restricted ocular elevation were documented upon postoperative evaluation before discharge. Considering the significant proportion of orbital entrapment fractures that are not noted on radiological imaging, prompt clinical examination should be initiated in pediatric patients at risk for orbital fractures. Urgent surgical intervention should be recommended in entrapment fractures. [ABSTRACT FROM AUTHOR]

Purpose: Foreign body reaction to non-absorbable alloplastic orbital implants utilized for bony reconstruction are infrequently documented in the literature. We present the workup and surgical management of a giant cystic mass encapsulating a patient's alloplastic orbital implant, which was ultimately deemed to be a result of foreign body reaction. Observations: A 41-year-old male patient with distant history of a right orbital floor fracture had undergone repair with the placement of a nylon foil implant. The patient presented twenty years later with progressive ipsilateral globe proptosis and was found to have a giant inferior orbital cyst. Surgical exploration and removal of the implant and capsule were performed. Histopathology confirmed a delayed foreign body reaction around the patient's alloplastic implant. Conclusions: Alloplastic implants may result foreign body reaction and cyst encapsulation as a delayed complication.

Objectives: Many orbital fracture patients are transferred to tertiary care centers for immediate ophthalmology consultation, though few require urgent ophthalmic evaluation or intervention. This overutilizes limited resources and overburdens patients and the health care system with travel and emergency department (ED) expenses. A simple, easy-to-use, clinical decision-making tool is needed to aid local EDs and triage services in effectively identifying orbital fracture patients who need urgent ophthalmic evaluation. Design: Single center, retrospective cohort study. Subjects: Orbital fracture patients aged ≥ 18 years who presented to the study institution’s emergency department and received an ophthalmology consultation. Methods: Ocular injuries that required close monitoring or an intervention within the first few hours after presentation were termed urgent. Two Hawkeye Orbital Fracture Prioritization and Evaluation (HOPE) algorithms were developed to identify orbital fracture patients needing urgent evaluation; including 1 algorithm incorporating computerized tomography (CT) scans interpreted by ophthalmology (HOPE+CT). Algorithms were compared with 3 previously published protocols: the University of Texas Health Science Center at Houston (UTH), the South Texas Orbital Fracture Protocol (STOP), and Massachusetts Eye and Ear (MEE) algorithms. Main Outcome Measures: Correct triage of patients with orbital fractures who have urgent ocular or orbital conditions. Results: In the study institution’s ED, 134 adult patients (145 orbits) were seen with orbital fractures in 2019. Eighteen (13.4%) had ocular or orbital conditions categorized as urgent. The HOPE tool resulted in 100% sensitivity and 78.4% specificity. The HOPE+CT tool resulted in 100.0% sensitivity and 94.0% specificity. The UTH algorithm was 91.7% sensitive and 76.5% specific. South Texas Orbital Fracture Protocol and MEE were both 100% sensitive but only 35.1% and 32.8% specific, respectively. Conclusions: The HOPE and HOPE+CT algorithms were superior or equal to the UTH, STOP, and MEE algorithms in terms of specificity while detecting all urgent cases. Implementation of a triage protocol that uses the HOPE or HOPE+CT algorithms could improve resource utilization and reduce health care costs through identification of orbital fracture patients needing urgent evaluation. An online tool that deploys the HOPE+CT algorithm in a user-friendly interface has been developed and is undergoing prospective validation before public dissemination. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

This study aimed to evaluate the clinical, radiological and functional outcome of early (within 24 h) surgical intervention of displaced orbital roof fractures. This is a prospective observational study for patients with displaced orbital roof fractures. Six patients underwent early surgical management within hours of admission. The primary outcome variables were functional and aesthetic (evaluated through clinical and radiological assessments). The rate of immediate and delayed complications over a 6-months minimum follow-up period was recorded. All patients were males. The median age at the time of presentation was 23.5 years ranging from 4 to 40 years. The etiology was a high impact traffic accident in all patients. In three patients, the orbital roof fractures were unilateral, and in the other three patients, the fractures were bilateral. All patients were treated via transcranial approach at the same time as the neurosurgery. The median follow-up period was 10 months ranging from 6 to 15 months. During the follow-up period, there were no signs of meningitis, cerebrospinal fluid leakage, facial asymmetry, enophthalmos, exophthalmos, restriction of ocular motility, or blindness. Traumatic optic neuropathy was present in two patients (one unilateral and the other bilateral), of whom, one patient achieved full visual acuity recovery, while the other patient showed a mild decrease in visual acuity which improved within 6 months (OD;20/30, OS;20/25). One patient had mild ptosis and recovered spontaneously within 3 months after surgery. Postoperative CT scans showed a good anatomical reconstruction of orbital roof fracture in all cases. Early definite management of displaced orbital roof fractures secures reliable functional and cosmetic results and reduces the incidences of intracranial and ocular complications. [ABSTRACT FROM AUTHOR]

Introduction: Orbital wall fractures that may develop in maxillofacial traumas (MFTs) may cause ophthalmic complications (OCs). The aim of this study is to determine the frequency of orbital fractures (OFs) accompanying MFTs and findings suspicious for orbital traumatic involvement. Materials and Methods: Computed tomography (CT) images of 887 patients who presented to the emergency department within a 1-year period with a history of MFT were retrospectively scanned. During the examination, patients with orbital wall fractures, craniofacial bone fractures, and posttraumatic soft tissue changes were recorded. Results: OF was observed in 47 (5.3%) of the patients admitted for MFT. In cases with OFs, accompanying nasal (25.5%), ethmoid (2.1%), frontal (19.1%), maxillary (38%), and zygomatic bone fracture (10.6%), sphenoid (4.3%), and soft tissue damage (55.3%) were observed. It was observed that the pathologies mentioned at these levels were significantly higher than in patients without orbital involvement (p < 0.05). In our study, mild (48.9%) and moderate-severe (2.12–4.25%) OCs accompanying OFs were observed after MFT. Conclusions: The frequency of MFT varies depending on various factors, and such studies are needed to take preventive measures. Knowing the risk and frequency of orbital damage accompanying MFTs may help reduce complications by allowing rapid and accurate diagnosis. [ABSTRACT FROM AUTHOR]

Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits. This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval. 278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3–27.2) and 5.22 (95%CI: 1.9–13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161). OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma. [ABSTRACT FROM AUTHOR]

Abstract Background Three-dimensional printing is an underutilized technology in ophthalmology training; its use must be explored in complex educational scenarios. This study described a novel approach to trainee education of orbital fracture repair utilizing three-dimensional (3D) printed models as a teaching tool. Methods Ophthalmology residents and oculoplastic fellows from multiple training institutions underwent an educational session on orbital fractures, learning through four different models. Participants analyzed orbital fractures through computerized tomography (CT) imaging alone and then utilizing CT imaging with the aid of a 3D printed model. Participants completed a questionnaire assessing their understanding of the fracture pattern and surgical approach. After the training, participants were surveyed on the impact of the educational session. Components of the training were rated by participants on a 5-point Likert scale. Results A statistically significant difference (p

Purpose: This pilot study aims to evaluate the feasibility and effectiveness of computer-assisted surgery protocol with 3D-preformed orbital titanium mesh (3D-POTM), using presurgical virtual planning and intraoperative navigation in primary inferomedial orbital fracture reconstruction. Methods: Between March 2021 and March 2023, perioperative data of patients undergoing surgery for unilateral inferomedial orbital fracture treated with 3D-POTM were analyzed. Presurgical virtual planning with a Standard Triangle Language file of preformed mesh was conducted using the mirrored unaffected contralateral side as a reference, and intraoperative navigation was used. The reconstruction accuracy was determined by: correspondence between postoperative reconstruction mesh position with presurgical virtual planning and difference among the reconstructed and the unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were assessed. Results: Twenty-six patients were included. Isolated orbital floor fracture was reported in 14 (53.8%) patients, meanwhile medial wall and floor one in 12 (46.1%) cases. The mean difference between final plate position and ideal digital plan was 0.692 mm (95% CI: 0.601–0.783). The mean volume difference between reconstructed and unaffected orbit was 1.02 mL (95% CI: 0.451–1.589). Preoperative diplopia was settled out in all cases and enophthalmos in 19 (76.2%) of 21 patients. Conclusion: The proposed protocol is an adaptable and reliable workflow for the early treatment of inferomedial orbital fractures. It enables precise preoperative planning and intraoperative procedures, mitigating pitfalls and complications, and delivering excellent reconstruction, all while maintaining reasonable costs and commitment times.

Background: Little attention has been paid to combined orbital floor and medial wall fractures with the involvement of the inferomedial orbital strut. Managing this particular fracture can prove challenging. However, various innovative techniques have been introduced to assist with the process. Our study focuses on sharing our approach to orbital wall reconstruction using navigation guidance and titanium-reinforced porous polyethylene plates, specifically cases involving the inferomedial orbital strut. We believe that implementing a navigation system can effectively lead surgeons to the fracture site with utmost safety. Also, we hypothesized that this navigation system is beneficial to use singe fan titanium-reinforced porous polyethylene plates with orbital wall fractures involving IOS while minimizing possible complications. Methods: We retrospectively reviewed 131 patients with medial orbital wall and orbital floor fractures with or without combined other facial bone fractures who underwent orbital wall reconstruction by a single surgeon from May 2021 to May 2023. Amongst, we identified fourteen orbital wall fractures involving the inferomedial orbital strut. We used a subciliary incision as the only approach method for performing titanium-reinforced porous polyethylene plates for navigation-guided orbital wall reconstruction. Patients were followed up for at least three months. Results: All cases were effectively resolved using titanium-reinforced porous polyethylene plates. There were no complications during the patient's complete recovery, confirmed clinically and radiologically. Based on the serial CT results, it was discovered that implanted titanium-reinforced porous polyethylene plates successfully covered the defect. Conclusion: Based on our retrospective analysis, it has been determined that among the 131 recorded cases of orbital fractures, 14 of them (or 10.7%) involved the inferomedial orbital strut. Navigation-guided reduction using titanium-reinforced porous polyethylene (TR-PPE) plates can lead to predictable, reliable, and excellent outcomes for treating orbital fractures involving the inferomedial orbital strut without complications. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the visual outcome in patients with traumatic optic neuropathy (TON) with respect to different treatment modalities, to study the correlation of initial visual loss with the final visual outcome, and to find out the predictor of final visual outcome in patients with indirect TON. Methods: A retrospective analysis of 36 eyes with TON was done. Data on clinical profile, including demographics, mode of trauma, best corrected visual acuity (BCVA), pupillary reflex examination, and anterior and posterior segment examination, was collected. Presence and location of orbital and cranial fractures were identified from computed tomography scan. Visual outcomes following steroid therapy, optic nerve (ON) decompression, and in untreated patients were analyzed. Pre- and post-treatment BCVA were divided into three groups based on logarithm of the minimum angle of resolution (logMAR) as follows: group A: 3, group B: 2.9-1.3, and group C<1.3. BCVA values at follow-up visits were taken as the primary outcome measure. Association between various risk factors and final visual outcome in patients with indirect TON was also analyzed. Results: Out of 34 patients whose 36 eyes were studied, three (8.8%) patients were females and 31 (91.2%) patients were males. Most common mode of trauma was road traffic accident (RTA; 91.2%), which was followed by fall (8.8%) and assault (2.9%). Pre- and post-treatment BCVA values of 36 eyes were compared, and improvement in BCVA after treatment was found to be statistically significant. Also, 28.6% of patients with presenting BCVA of no light perception showed improvement compared to 94.1% and 100% in groups B and C, respectively. Orbital wall fractures were seen in 80.5% (n = 29) of the patients, with lateral wall fracture being the most common (58.3%) followed by medial wall (33.3%), roof (27.7%), floor (27.7%), and optic strut (5%). Conclusion: Baseline BCVA had significant association with final vision improvement. Lateral wall fracture was the most common fracture associated with indirect TON. Patients treated with high-dose corticosteroids, irrespective of the time of presentation, had a better visual outcome. [ABSTRACT FROM AUTHOR]

Introduction: Blowing the nose and sneezing are ubiquitous physiologic processes. While exceedingly rare, traumatic injuries have been described. We detail a case of spontaneous intracranial hemorrhage and orbital fractures sustained as a result of these two phenomena in an otherwise healthy adult without known risk factors for bleeding or intracranial hemorrhage. Case Report: A 79-year-old female presented to the emergency department after blowing her nose with an episode of sneezing following mild epistaxis. She denied any history of trauma, anticoagulation use, bleeding disorders, or pain associated with her symptoms. On examination, she had notable right periorbital swelling. Computed tomography revealed multiple areas of intracranial hemorrhage along with right-sided orbital and zygomatic fractures. After consulting trauma surgery and neurosurgery, we elected to pursue conservative management with repeat imaging. The patient had an uneventful course and was discharged with outpatient follow-up two days later. Conclusion: To our knowledge, this is the first case described of this constellation of injuries after a relatively benign process. Despite not having increased risk factors for intracranial hemorrhage (anticoagulation use, history of trauma, history of coagulopathy), this patient had severe injuries that presented with few external symptoms. This case serves as a reminder that while physiologic processes are almost always benign, serious traumatic injuries can result. Clinicians should have a low threshold for advanced imaging when there is a high clinical suspicion of facial fractures or more ominous processes. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the visual outcome in patients with traumatic optic neuropathy (TON) with respect to different treatment modalities, to study the correlation of initial visual loss with the final visual outcome, and to find out the predictor of final visual outcome in patients with indirect TON. Methods: A retrospective analysis of 36 eyes with TON was done. Data on clinical profile, including demographics, mode of trauma, best corrected visual acuity (BCVA), pupillary reflex examination, and anterior and posterior segment examination, was collected. Presence and location of orbital and cranial fractures were identified from computed tomography scan. Visual outcomes following steroid therapy, optic nerve (ON) decompression, and in untreated patients were analyzed. Pre- and post-treatment BCVA were divided into three groups based on logarithm of the minimum angle of resolution (logMAR) as follows: group A: 3, group B: 2.9–1.3, and group C

Jungyul Park,1,2 Sunghyun Jo,1 Hee-Young Choi1,2 1Department of Ophthalmology, School of Medicine, Pusan National University Hospital, Busan, South Korea; 2Biomedical Research Institute, Pusan National University, Busan, South KoreaCorrespondence: Hee-Young Choi, Department of Ophthalmology, School of Medicine, Biomedical Research Institute, Pusan National University, 179 Gudeok-Ro, Seo-Gu, Busan, 49241, Republic of Korea, Tel +82-51-240-7324, Fax +82-51-242-7341, Email hychoi@pusan.ac.krBackground: Detachment of the inferior oblique muscle may be necessary under certain circumstances to repair a large inferomedial orbital fracture involving the orbital strut. This study aimed to evaluate the outcomes of patients who underwent surgeries with and without inferior oblique muscle reattachment after its detachment to repair the orbital wall fractures.Methods: Forty patients who underwent repair of combined floor and medial orbital wall fracture involving the orbital strut at a single tertiary institution between January 2014 and December 2020 were reviewed. Groups 1 and 2 comprised 20 patients each, who underwent surgery with inferior oblique muscle detachment without and with reattachment, respectively, and were followed up for at least 6 months postoperatively. Enophthalmos, Goldmann diplopia test, alignment test, ocular motility test, and orbital inferomedial angle ratio were the outcome measures.Results: Statistically significant improvement was observed in ocular motility, diplopia, and enophthalmos postoperatively at the 1- and 6-month follow-up (p < 0.01). The mean postoperative inferomedial angle ratio (102.28 ± 10.62%) was improved significantly compared with the preoperative inferomedial angle ratio (115.61 ± 4.38%) (p = 0.004) in all patients. After surgery, inferior oblique muscle underaction was observed in seven and six patients in groups 1 and 2, respectively, which was associated with preoperative extraocular movement limitation and strabismus. Two patients showed diplopia in both groups at the last follow-up; they had inferior oblique muscle underaction but no enophthalmos.Conclusion: Orbital fracture repair with or without inferior oblique muscle reattachment was clinically effective and safe; however, patients with preoperative strabismus and extraocular motility limitation should be informed of the increased risk of postoperative complications.Keywords: orbital fracture, inferior oblique muscle, diplopia, strabismus, post-operative complications

Eric J Kim,1 Arjun Ganga,1 Chaerim Kang,2 William Elnemer,3 James Y Lee,4 Yasmyne C Ronquillo,5 Phillip C Hoopes,5 Majid Moshirfar5– 7 1Division of Ophthalmology, Warren Alpert Medical School at Brown University, Providence, RI, USA; 2Program in Liberal Medical Education, Brown University, Providence, RI, USA; 3Johns Hopkins School of Medicine, Baltimore, MD, USA; 4Brown University, Providence, RI, USA; 5Hoopes Vision Research Center, Draper, UT, USA; 6John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 7Utah Lions Eye Bank, Murray, UT, USACorrespondence: Eric J Kim, Division of Ophthalmology, Warren Alpert Medical School at Brown University, Providence, RI, USA, Tel +1 978-289-0659, Email eric_kim2@brown.eduPurpose: Motorcycle-related injuries involving the eye and orbit are not well characterized, with a paucity of prospective studies focusing specifically on motorcycle-associated eye injuries nor literature reviews having been conducted on the subject. To better understand the injury types and descriptive characteristics of patients experiencing motorcycle-associated eye injuries, we sought to conduct a narrative review.Methods: The research team utilized the following databases: PubMed, EMBASE, and Web of Science to query for English articles from peer-reviewed journals that provided some patient data regarding eye injury due to motorcycle or moped accidents or usage.Results: A total of 65 studies were included in our qualitative synthesis. Of these studies, 40 (61.5%) were case reports, 20 retrospective case series (30.8%), and five (7.69%) were observational prospective studies. Among the 25 retrospective and prospective studies, 12 (48.0%) of these studies primarily focused on motorcycle-associated injuries. These 65 studies described a wide variety of motorcycle-associated eye injuries, including but not limited to orbital fractures and associated sequelae, foreign bodies, vitreoretinal trauma, neuro-ophthalmic trauma, corneal injuries, open globe injuries, lacerations, and globe avulsions.Conclusion: The current state of the literature indicates that knowledge regarding the ocular manifestations of motorcycle accidents is limited to mostly case reports and few retrospective cohort studies focused specifically on motorcycle-associated eye injuries. However, it is evident that the types of motorcycle-associated eye injuries are legion and predominantly seen in adult males, potentially leading to severe injuries and loss of vision and blindness.Keywords: motorcycle, ocular injury, eye, trauma, orbital fracture, ruptured globe, corneal injury, vitreoretinal damage, vehicular accidents

Background: Three-dimensional printing is an underutilized technology in ophthalmology training; its use must be explored in complex educational scenarios. This study described a novel approach to trainee education of orbital fracture repair utilizing three-dimensional (3D) printed models as a teaching tool. Methods: Ophthalmology residents and oculoplastic fellows from multiple training institutions underwent an educational session on orbital fractures, learning through four different models. Participants analyzed orbital fractures through computerized tomography (CT) imaging alone and then utilizing CT imaging with the aid of a 3D printed model. Participants completed a questionnaire assessing their understanding of the fracture pattern and surgical approach. After the training, participants were surveyed on the impact of the educational session. Components of the training were rated by participants on a 5-point Likert scale. Results: A statistically significant difference (p <.05) was found in participant confidence conceptualizing the anatomic boundaries of the fracture and planning the orbital fracture approach for repair of three out of four models on pre-test post-test analysis. On exit questionnaire, 84.3% of participants thought the models were a useful tool for surgical planning, 94.8% of participants thought the models were a useful tool for conceptualizing the anatomic boundaries of the fracture, 94.8% of participants thought the models were a useful tool for orbital fracture training, and 89.5% of participants thought the exercise was helpful. Conclusion: This study supports the value of 3D printed models of orbital fractures as an effective tool for ophthalmology trainee education to improve understanding and visualization of complex anatomical space and pathology. Given the limited opportunities trainees may have for hands-on orbital fracture practice, 3D printed models provide an accessible way to enhance training. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the incidence of severe ocular injury requiring emergent ophthalmic evaluation in visually asymptomatic patients presenting with orbital fractures. Methods: We performed a retrospective chart review of all adult and pediatric orbital fractures between 2012-2022 at a level 1 trauma center. Ocular injuries were categorized into severe, moderate, and mild. We evaluated symptoms, mechanism of injury, visual acuity (VA), and severity of injuries using the Cochran-Armitage and linear-by-linear tests. Results: Of the 2495 cases, 1534 had ophthalmology evaluation. The mean ± standard deviation age was 40.4 ± 20.4 years. Most patients were male (73.1%) and Caucasian (75.9%). The mean time to evaluation was 0.6 ± 2.5 days. 486 (31.7%) were visually symptomatic, 760 (49.5%) were asymptomatic, and 288 (18.8%) were unknown. Of the symptomatic, 135 (27.8%) had severe injuries, 108 (22.2%) had moderate injuries, 216 (44.4%) had mild injuries, and 27 (5.6%) had no injuries. Of the asymptomatic, 67 (8.8%) had severe injuries, 183 (24.1%) had moderate injuries, 468 (61.6%) had mild injuries, and 42 (5.5%) had no injuries. Symptoms correlated with injury severity (p-value <.001). The most common mechanism of injury were falls (24.0%), assaults (22.2%), and motor vehicle accidents (14.8%). Conclusions: Visually asymptomatic orbital fractures were less likely to have severe ocular injuries; however, many patients were unable to express symptoms. Emergent ophthalmology evaluation should be considered in all patients presenting with orbital fractures, especially patients with visual symptoms or are unable to report symptoms. [ABSTRACT FROM AUTHOR]

Purpose: The present study aims to investigate how well CT images correlate to surgical findings in orbital floor fractures and to the presence of diplopia. Methods: In this cross-sectional study, 27 consecutive patients already selected for surgery due to an orbital floor fracture underwent a routine CT scan (axial, coronal, sagittal). An ophthalmologist established any presence of diplopia. Extent of fracture/injury seen on CT was compared to that discovered during surgery. Results: In the surgeons´ opinions CT-images were in concordance with surgical findings in 71% of the cases. Agreement for pure blow out fractures was high (92%). Tetrapod fractures as a cause of an orbital floor fracture was only identified as such by surgeons in three of 11 cases, all subjected to orbital exploration, not only a closed reduction. Diplopia showed a significant correlation to rounding of the inferior rectus muscle at coronal CT. "Rounding" significantly correlated with the presence of a floor defect, to herniation of soft tissues and to the volume of displaced tissue. Conclusions: The results imply that the joint professional interaction between neuroradiology and surgery is important and would benefit from the use of an easy and well-defined classification system of orbital floor fractures. In Sweden a national record to collect data on all zygomaticomaxillary complex fractures assessed is to be started aiming at making general statements possible by time. [ABSTRACT FROM AUTHOR]

Purpose: We present our experience of titanium-milled two-piece patient-specific implants (PSIs) for primary reconstructions of extensive orbital floor and medial wall fractures (EOFMFs) and evaluate their postoperative functional and aesthetic outcomes in relation to commercially available implants. Methods: We included all patients with primary reconstructions (< 22 days from injury) of EOFMFs treated in our department between January 2011 and October 2020. Extensive orbital floor and medial wall fracture was defined as involvement of orbital floor, medial wall and maxilloethmoidal junction; a fracture defect 5 mm or more; defect size more than a third of both inferior and medial walls; and Jaquiéry classification III or more. Patient characteristics, details of fracture defects and surgeries, postoperative outcomes and implant positions were retrospectively evaluated and compared between study groups. Results: Nineteen patients were included: 5 with two-piece PSIs and 14 with commercial implants. Implant position was good in 4/5 patients with two-piece PSIs and 2/14 with commercial implants. Revision surgery, globe malposition (GMP) > 2 mm, significant diplopia and poor implant position were more frequent in patients with commercial implants than two-piece PSIs. None of the patients with a good overall implant position had any significant postoperative symptoms. Conclusion: Extensive orbital fracture reconstructions are somewhat rare, and surgical treatment is associated with a high rate of complications and postoperative symptoms. Titanium-milled two-piece PSIs are well suited for primary reconstructions of EOFMFs, as they lead to more precise reconstructions and fewer postoperative symptoms than commercially available implants. [ABSTRACT FROM AUTHOR]

This study aimed to perform a systematic review and meta-analysis to compare pre-shaped implants on a patient-specific 3D-printed (3DP) model to manual free-hand shaping (MFS) for orbital wall reconstruction. The PRISMA protocol was followed in this study, and the review was registered in the PROSPERO database (CRD42021261594). A search was conducted in MEDLINE (PubMed), Embase, Cochrane Library, Clinicaltrials.gov, Google Scholar, and the grey literature. Ten articles were included, and six outcomes were analyzed. In total, 281 patients were in the 3DP group and 283 were in the MFS group. The studies had an overall high risk of bias. 3DP models resulted in a better accuracy of fit, anatomical angle reproduction, and defect area coverage. The correction of orbital volume was also superior with statistical significance. There was a higher percentage of the correction of enophthalmos and diplopia in the 3DP group. Intraoperative bleeding and hospital stay were reduced in the 3DP group. The meta-analysis of operative time showed a reduction in the average operative time by 23.58 min (95% CI: −43.98 to −3.19), which was statistically significant (t(6) = −2.8299, p = 0.0300). The 3DP models appear advantageous for an accurate orbital wall reconstruction, with fewer complications than those for conventional free-hand-shaped implants. [ABSTRACT FROM AUTHOR]

Lower eyelid malpositions following transconjunctival repair of the floor and the zygomaticomaxillary complex fractures are rarely observed. The case series includes three patients (mean age, 22 years; 3 males) who developed lower eyelid entropion following orbital fracture repair (two complexes, one isolated type) using titanium mesh (n = 2) or iliac bone grafting (n = 1) through the transconjunctival approach. Entropion repair was attempted with scar release and Jones procedure in one, and posterior lamellar lengthening with mucous membrane graft in two patients. At a median follow-up of 25 months (range, 3-24), two patients had symptomatic relief without any lash globe touch, and one patient had persistent entropion after multiple interventions including failed mucous membrane graft (n = 1), full-thickness blepharotomy with everting sutures (n = 1), and scleral spacer grafting for posterior lamellar lengthening (n = 1). The literature is inconclusive about the association between eyelid malpositioning and any specific implant material, type of fracture, or incision closure technique. [ABSTRACT FROM AUTHOR]

Objectives: To assess the relationship between orbital wall fractures connecting to paranasal sinuses (OWF-PNS) and SARS-CoV-2 ocular surface contamination (SARS-CoV-2-OSC) in asymptomatic COVID-19 patients. Methods: This was a prospective case–control study enrolling two asymptomatic COVID-19 patient cohorts with vs. without OWF-PNS in the case–control ratio of 1:4. All subjects were treated in a German level 1 trauma center during a one-year interval. The main predictor variable was the presence of OWF-PNS (case/control); cases with preoperative conjunctival positivity of SARS-CoV-2 were excluded to rule out the possibility of viral dissemination via the lacrimal gland and/or the nasolacrimal system. The main outcome variable was laboratory-confirmed SARS-CoV-2-OSC (yes/no). Descriptive and bivariate statistics were computed with a statistically significant P ≤ 0.05. Results: The samples comprised 11 cases and 44 controls (overall: 27.3% females; mean age, 52.7 ± 20.3 years [range, 19–85]). There was a significant association between OWF-PNS and SARS-CoV-2-OSC (P = 0.0001; odds ratio = 20.8; 95% confidence interval = 4.11–105.2; R-squared = 0.38; accuracy = 85.5%), regardless of orbital fracture location (orbital floor vs. medial wall versus both; P = 1.0). Conclusions: Asymptomatic COVID-19 patients with OWF-PNS are associated with a considerable and almost 21-fold increase in the risk of SARS-CoV-2-OSC, in comparison with those without facial fracture. This could suggest that OWF-PNS is the viral source, requiring particular attention during manipulation of ocular/orbital tissue to prevent viral transmission. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective study aimed to analyze the relationship between the volume of the fractured and the normal orbit in patients with unilateral orbital fractures with and without indirect traumatic optic neuropathy (TON). Subjects: Data of 25 patients with unilateral orbital fractures who underwent computer tomography between January 2016 and December 2020 were investigated. Emergency imaging was performed within 2 hours of arrival at the emergency room. The subjects were categorized into two groups: unilateral orbital fractures with and without TON. Methods and measures: The assessment of TON was performed during a comprehensive ophthalmologic examination by an ophthalmologist. The stereographic orbit was reconstructed, and the volume was calculated. Other variables examined included age, sex, and cause of orbital trauma. The variables were compared using paired t-tests. Statistical significance was set at p < 0.05. Results: The orbital volume of the non-fractured orbit was 27.50 ± 2.26 and 27.48 ± 2.64 cm3 in the groups with and without TON, respectively. The average volume of the fractured orbit in the TON group was 27.78 ± 2.56 cm3, and there was no significant volumetric difference between the fractured and non-fractured sides in this group. However, the average volume of the fractured orbit without TON was 28.76 ± 3.18 cm3, larger than that of the non-fractured orbit (p = 0.016). Conclusions: Non-expansion of the fractured orbit was a risk factor for indirect TON in patients with unilateral orbital fractures. Volumetric analysis from primary imaging would expedite the diagnosis and treatment of TON, resulting in optimal outcomes. [ABSTRACT FROM AUTHOR]

Subciliary incision is a common approach for facial fracture surgery; however, it has a higher incidence of lower lid ectropion, which can be particularly challenging for beginning surgeons to manage. This study reports the usage of lateral tarsoplasty combined with a full-thickness skin graft (FTSG) to correct severe ectropion following the subciliary approach for infra-orbital rim fractures. We retrospectively reviewed all facial fracture cases involving infra-orbital rim fractures through a subciliary approach treated in our department between March 2021 and May 2023. Electronic medical records and clinical digital photographs of patients who met the inclusion criteria were reviewed. After reviewing 196 cases that used the subciliary approach, we found 6 patients (3.06%; 4 males and 2 females; mean age, 68.5 ± 4.89 years) with postoperative severe ectropion managed using lateral tarsoplasty and FTSG. The mean ectropion development and correction times after facial fracture surgery were 0.78 ± 0.24 and 0.91 ± 0.37 months, respectively. At the 12-month follow-up, all patients showed favorable outcomes, and the position of their lower eyelids was well maintained without ectropion recurrence. Based on these successful outcomes, lateral tarsoplasty combined with FTSG is proposed to be an effective and straightforward method for managing lower eyelid ectropion caused by facial fracture surgery.

Background: Orbital floor fractures involve damage to the orbital floor but not the infraorbital margin. Despite intensive research, they remain a controversial topic. The aim of this study was to investigate the relationship between parameters gathered by means of computed tomography (CT), the clinical presentation, and treatment outcomes, in patients suffering from orbital floor fractures. Methods: Forty patients with orbital floor fractures were included in this study. Information regarding diplopia, impaired ocular mobility, asymmetric eyeball placement, and infraorbital paresis was gathered from the medical records. Nine CT-based parameters were assessed. Two parameters were calculated, based on them. The follow-up data of 30 patients were analyzed. The results were statistically evaluated. The significance level was p < 0.05. Results: Statistical evaluation revealed multiple correlations between CT-based findings, symptoms, and treatment results. Among others, the hernia into the maxillary sinus was significantly larger in patients without improvement in infraorbital paresis (p = 0.0031) and without improvement in assymetric eyeball placement (p = 0.0037). There was no correlation between the entrapment of the rectus inferior muscle and impaired ocular mobility (p = 0.664431; p = 0.420289) and between the direct fracture of the infraorbital canal and infraorbital paresis (p = 0.371102). Conclusions: The widely assumed thesis that impaired ocular mobility in orbital fractures is caused by entrapment of the rectus inferior muscle is disproved by CT-based data. CT-based findings, symptoms, and treatment results in patients with orbital floor fractures were significantly correlated. A large hernia may be a negative prognostic factor.

Introduction: Blunt trauma to the orbital rim is a frequent cause of both orbital fractures and damage to the surrounding facial bones and soft tissues. The inception of endoscopy and minimal invasive intervention has revolutionized the surgical treatment of blow out fracture of orbital walls. Thus, the present study was conducted to compare the outcome of conventional open reduction approach with endoscopic approach for orbital floor repair. Materials and method: The study included 10 patients with clinical and radiographic evidence of orbital floor fracture, divided randomly into two groups: Group I-operated using endoscopic approach; and Group II- operated using conventional external approach. All the patients were evaluated clinically preoperatively, immediate post-operative and after 1 month for Diplopia, Extrinsic ocular motility, Enophthalmos and Hypoglobus. Results: The study consisted of 40% females and 60% males, with mean age of Endoscopic and Conventional group being 27.20 ± 6.14 years and 27.60 ± 7.23 years respectively. In relation to diplopia, an insignificant difference was observed statistically. The mean change in enophthalmos and hypoglobus in endoscopic and conventional group showed a significant difference statistically (p