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Purpose of the Study: Posttraumatic enophthalmos cause complex cosmetic problems to fix. In order to get better results, we wanted to calculate the volume of parietal bone graft needed to be put in place, know where to place it in orbit and study soft tissues' participation., Patients and Method: In a retrospective study, we have calculated on scanner the volume of bone and soft tissue as well as the volume and the location of the graft. We have compared, between two groups ("good result" and "insufficient result"), graft volumes, taking into account differences in bone's volume between the healthy and the traumatized orbit. A comparison of the locations of the graft was also made. We were trying to find out if these factors were involved in the quality of the result., Results: Twenty-nine surgeries on 24 patients were analyzed. The average bone's volume of an orbit with enophthalmos was 24.76 cm(3) for 17.12 cm(3) of soft tissue. Retro-lens distance was the most reliable measurement method of enophthalmos (P=0.001). There was a trend to a more substantial over-correction in the group "good result". A significant increase (P=0.0008) of soft tissue volumes in the traumatized orbit was found., Conclusion: This last result is surprising. Many authors believe that there is a scar retraction of soft tissues. But Kronish et al. showed an increase of the fat density and connective tissue. This, together with the assumption of a weathering of the ligament suspension of the globe, may affect our aesthetic results. MRI, ultrasound and anatomopathological studies would allow a better understanding of the fat, muscle and ligament pathophysiologies of an orbit with enophthalmos., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: We evaluated the indication of orthoptic evaluation for the management of orbital floor fractures in a prospective series., Material and Method: Forty-seven patients presenting with an orbital floor fracture were included in our prospective study. Consultations in orthoptics and maxillo-facial surgery were regularly carried out. Diplopia and motility were systematically assessed as well as a coordimetric examination according to Hess-Lees's technique., Results: Nineteen percent of coordimetric motility disorders were observed among asymptomatic patients, after trauma. No diplopia or clinical motility disorder were observed 1 and 2 months after trauma, and coordimetric examinations came back to normal 2 and 3 months after trauma respectively for non-operated (26) and operated (21) patients., Conclusions: An orthoptic evaluation is necessary for the management of orbital floor fractures to diagnose the type of diplopia, motility disorders, and to indicate a coordimetric examination if diplopia is present. We suggest this orthoptic evaluation for patients presenting with diplopia between 5 and 10 days following trauma, 1 month after trauma for non-surgical treatment and 2 months after trauma for surgical treatment., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Purpose: Orbital wall fracture may occur during endoscopic sinus surgery, resulting in oculomotor disorders. We report the management of four cases presenting with this surgical complication., Methods: A non-comparative observational retrospective study was carried out on four patients presenting with diplopia after endoscopic ethmoidal sinus surgery. All patients underwent full ophthalmologic and orthoptic examination as well as orbital imaging., Results: All four patients presented with diplopia secondary to a medial rectus lesion confirmed by orbital imaging. A large horizontal deviation as well as limitation of adduction was present in all cases. Surgical management consisted of conventional recession-resection procedures in three cases and muscle transposition in one patient. A useful field of binocular single vision was restored in two of the four patients., Conclusion: Orbital injury may occur during endoscopic sinus surgery and cause diplopia, usually secondary to medial rectus involvement due to the proximity of this muscle to the lamina papyracea of the ethmoid bone. Surgical management is based on orbital imaging, duration of the lesion, evaluation of anterior segment vasculature, results of forced duction testing and intraoperative findings. In most cases, treatment is aimed at the symptoms rather than the cause, and the functional prognosis remains guarded., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Acute traumatic orbital encephalocele is a rare entity, with less than 25 cases reported. We hereby describe the first bilateral orbital encephalocele through a blow-in orbital fracture after a blunt cranial traumatism. Early treatment of the orbital traumatic encephalocele is necessary in order to avoid the increase of the intra orbital pressure that might damage the optic nerve. Repairing the orbital roof has to be performed in a rigid manner in order to avoid the transmission of the intracranial pressure variation to the orbit. In the present case, the reconstruction of orbital roof was performed using a subfrontal approach supported by a titanium mesh fixed with screws and a mixture of bone powder mixed and fibrin glue.

Objective: To assess the management of orbital floor fractures and their aftereffects in children., Patients and Methods: We retrospectively studied five children with isolated orbital floor fractures who were operated (with a perioperative steroid and antibiotic treatment) between 1998 and 2007 in our pediatric hospital. At the first visit, they all had a complete clinical examination, a Hess-Lancaster test, and a computed tomography (CT) scan. At the last visit, they all had a clinical examination and four children underwent a Hess-Lancaster test., Results: After a median follow-up of 26 months (range, 4-100 months), no child had diplopia, all Hess-Lancaster tests were normal, and two children suffered from infraorbital hypoesthesia., Conclusion: Surgical repair associated with steroids and antibiotics in orbital floor fracture with our surgical indications has led to good functional results with minimal complications.

We report the case of a 36-year-old man who underwent neurosurgery for a T9 spine fracture consecutive to a fall. The patient had complete postoperative blindness which did not totally recover during the hospital stay. Decreased visual acuity and postoperative vision loss are not uncommon in spine surgery. Such postoperative complications in spine surgery are severe. To avoid them, it is mandatory to identify the contributing factors and set up a preventive strategy.

Introduction: Compressive-orbital haematoma is a rare, but dreaded, complication in facial traumatology., Observation: The authors report a case of postoperative blindness after a delayed procedure for an orbit-floor fracture, complicated by Methylbacterium mesophilicum septicemia. Three surgical procedures were performed, simple drainage, down fracture of the orbit floor, and osteotomy of the zygoma, without any improvement., Discussion: The role of M. mesophilicum in a major coagulation deficiency is discussed. Decompressive-orbital procedures are reviewed and discussed for this special case.

Introduction: Ophthalmologic examination may rule out an ocular wound in the event of orbital traumatism. Some lesions are obvious but others may not be detected. We report a case of superior oblique muscle trochlea trauma. This infrequent pathology is illustrated with a scanned imagery and magnetic resonance imaging (MRI)., Observation: The initial penetrating trauma was caused by a hook in the medial canthus. The wound was sutured in the emergency unit. Three days later, oblique diplopia developed. Three weeks later, abnormal ocular movements appeared when contracting the frontal muscle. The patient then decided to consult. One month after the traumatism, the orthoptic assessment confirmed the presence of an acquired Brown syndrome suggesting a lesion of the superior oblique muscle. Orbital MRI could not find the trochlea and revealed a thickening by retraction of the posterior portion of the muscle and a hypotrophic aspect of the anterior portion. A fracture of the right orbital edge was revealed by the scanner. Surgical exploration was performed., Discussion: The trochlea is located very anteriorly and likely to be affected in the event of an internal palpebral wound. A direct traumatism of the pulley and/or the superior oblique muscle leads to an acquired Brown syndrome. This observation stresses the importance of surgical wound exploration for the supero-medial palpebral area as well as using MRI which allows proving the diagnosis.

Introduction: Evulsion of the optic nerve is a rare but serious injury. It occurs generally after an ocular contusion and may cause blindness., Case: We report the case of a 53-year-old woman who presented with a blunt ocular trauma after having been punched by her husband. Initial examination of the left eye was impossible due to a major palpebral oedema. A CT scan of the orbit revealed a thickened optic nerve. No improvement was noted., Discussion: Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as its globe entry level. The diagnosis can be confirmed by examination of the ocular fundus or by medical imaging such as CT scan of the orbital cavity as in our case report. The prognosis is usually poor.

Purpose: Orbital emphysema is a common complication of orbital wall fractures (50% of blow-out fractures). It is generally a benign and self-limited condition. However, it may compromise retinal and optic nerve vascularization and therefore requires rapid management., Patient and Method: We report a case of traumatic orbital emphysema resulting in ischemic optic neuritis. The orbital emphysema was drained using a 25-gauge needle mounted on a syringe filled with normal saline, with the plunger removed, and guided by air bubble eruption., Results: Vision was promptly recovered following drainage of the orbital emphysema., Conclusion: The development of orbital emphysema after an orbital fracture is a consequence of a forceful expiratory effort raising intranasal pressure. It must be drained, as described, in cases of vascular compression.

Orbital subdural hematoma should be considered in victims of head and face trauma with signs of exophthalmia. Early diagnosis and treatment, consisting of decompression, is mandatory to avoid long-term functional complications.

Purpose: The authors retrospectively analyzed four cases of posttraumatic superior orbital fissure syndrome and reviewed the literature., Method: Four patients (three male and one female) were followed for this complication in the department from october 1995 to december 1996., Results: The mean age was 31 years, the median follow-up was 8 month. Computed tomography showed involvement of the superior orbital fissure but no in three patients, in the fourth. The treatment consisted of osteosynthesis of craniofacial fracture in three patients and corticosteroid therapy in the last one. All patients presented partial recuperation of external ophthalmoplegia and ptosis. Twelve months after the traumatism, one patient underwent surgery for persistant ptosis and diplopia., Conclusion: The superior orbital fissure syndrome is an exceptional complication of orbital traumas. Partial recuperation of the neuro-ophthalmologic function usually occurs within a period of several months.

Orbital fracture can be complicated by medial rectus muscle entrapment which usually involves the anterior part of the muscle (pseudo Duane syndrome). We describe an unusual case of isolated medial orbital wall fracture with medial rectus entrapment. Our patient had entrapment of the posterior part of the muscle with exotropia and limitation of adduction. This rare complication must be recognized so the appropriate management could be instituted early to avoid potential functional sequelae.

Purpose: Fractures of the orbit floor have very disabling oculomotor after effects. The objective of this study was to report that close collaboration between the maxillo-facial specialist and ophthalmologist is necessary to avoid oculomotor after effects., Methods and Patients: Our study included 10 cases of the fracture of the orbit floor. These cases were recorded between 1992 and 1996., Results: This pathology affected young subjects aged between 20 and 40 years in 70 % of the cases. 80 % of the subjects were males. 90 % of the patients presented a vertical diplopia as a result of a transitory oculomotor deficit. 20 % of the subjects presented a permanent oculomotor deficit at the stage of after effects. All these deficits were of a mechanical origin and, contrary to other authors, we found no deficit with nervous sensory origin., Conclusion: Therapeutic success is based on early diagnosis and treatment that requires close collaboration between the maxillo-facial and ophthalmology teams.

The article is an overview of the available literature on post-traumatic enophthalmos (PTE). The PTE has a clinical definition and its diagnosis is based on a clinical examination. Fully assessment of the deformity requires complete ophthalmological examination and a measurement of the globe backward displacement by the mean of Hertel's ophthalmometer. Focusing on the pathophysiology, we insist on the role of periorbit and extraocular muscle retraction; nevertheless, according to most of the author's, opinion, the main pattern of the PTE seems to be the increased orbital post-traumatic volume, as it can be demonstrated by computed tomography (CT scan). In fact, thorough evaluation of the deformity needs at less a CT scan examination, providing horizontal and coronal slices. Sometimes, even a three-dimensional reconstruction can be obtained, helping the surgeon assessing the orbital deformity pre-operatively. We present five patients victims of a high-energy facial injury (motor vehicular accidents is responsible for an overwhelming majority of cases) leading to severe orbital lesions, and presenting a PTE as the main sequelae. We use homologous bone grafts to repair orbital fractures, especially calvarial bone. Osteotomy of the zygomatic bone (total or partial) can be proposed, combined with grafting of the orbit, to improve the correction of PTE. Most of all, patients with acute orbital trauma must be operated on as quick as possible: the sooner the surgery, the lower the probability for the PTE to occur.

Introduction: Orbital blow-out fractures can result in chronic oculomotor restriction. This is the consequence of orbital fasciae or muscle trapped within the fracture. A delayed treatment usually results in incomplete repair. However, when the extrapped tissues are freed by reconstruction of the orbital floor, oculomotor sequelae can be prevented or at least limited., Patients and Treatment: Twelve adults and 2 children were treated for blow-out fracture in the past two years at the Eye Department of Geneva University Hospital. All of these patients had a non regressive oculomotor restriction, an enophthalmus and/or an infraorbital hypoesthesia with evidence of a blow-out fracture on the CT-scan. They were operated on between the second and the sixth week following trauma. Extrapped fasciae were freed under microscope and the orbital floor was reconstructed with a thin plate of biomaterial (PDS)., Results: Tissues could be entirely removed and kept separated from the underlying structures by the biomaterial used for reconstruction. Ocular motility returned to normal in 13 cases within 1 to 3 months, without further intervention. Only one patient had to wear a low grade prism with vertical action., Discussion: In case of blow-out fractures, the long term prognosis of the ocular motility depends on immediate management following the trauma. Orbital floor reconstruction is indicated when consecutive oculomotor restriction is likely avoiding in the majority of the cases any residual oculomotor restriction. On the contrary when delayed, treatment is often difficult generally with limited mobility., Conclusion: From an ophthalmological point of view, microsurgical extraction of incarcerated orbital fasciae and reconstruction of the orbital floor is indicated for early treatment of oculomotor restriction.

Over a period extending from January 1993 to December 1995, we treated 242 patients with 268 orbital floor fractures in our department. Surgical indications were broad and relied on clinical criteria (enophthalmos, diplopia, hypoesthesia) and/or CT analysis (bony collapse, extrusion of orbital contents, suspicion of muscular entrapment, dislocation of the infraorbital rim). Two years after surgery, 91% of the patients showed good results (absence of diplopia or severe enophthalmos). The analysis of these results points out that the degree of sequelar enophthamos was not only related to the degree of initial bony collapse but above all to the quality of the bony reconstruction. Sequelar diplopia was linked with the presence of a preoperative diplopia and its severity was a direct function of operative delay. Hypoesthesia in the infraorbital nerve territory was the most common sequela; some were postoperative complications. The type of material used for the restoration of the orbital floor was not involved in the development of these sequela. Our good results suggest that an interventionist attitude is warranted in these kind of fractures, the more so as the X-ray examinations often underestimate injuries.

We report a case of bilateral switch nerve palsy following minor head trauma. We discuss available literature, frequency and pathophysiology of bilateral abducens nerve palsy after minor head trauma. We also present current knowledge of prognosis and treatment of oculomotor palsies after trauma.

We report three cases of isolated medial orbital wall blow out fracture with medial rectus entrapment. Few cases have been reported in the literature, predominantly in black people as in this paper. Predominance of this rare fracture in black population could be explained by an anatomic hypothesis based on racial origin. The diagnosis is often suggested by the medial rectus entrapment. Depending on the position of the incarceration in front of or behind the equator of the eyeball, the eye presents pseudo-Duane syndrome or exotropia with decreased adduction. The diagnosis is established by orbital computed tomography visualizing the lamina papyracea of the ethmoid bone fracture and the medial rectus incarceration. This exceptional fracture must be detected to avoid complications: enophthalmos and motility disturbances.

Post-traumatic ptosis may be classified as follows: ptosis occurring during lid avulsion, ptosis associated with fractures of the orbital roof and with foreign bodies, post-contusional ptosis, cicatricial ptosis, neurogenic ptosis and post-surgical ptosis. The patient must be thoroughly examined, including examination of the eye-ball, extra-ocular muscles, eyelid and evaluation of upper eyelid levator function and orbital and facial examination. The various surgical methods proposed include levator muscle surgery, aponeurotic surgery, Müller's muscle surgery and frontalis suspension surgery. Surgical indications and choice of surgical method essentially depend on the anatomo-clinical forms. The general rule is to operate under local anesthesia to obtain better control of the muscular function. Some cases are simple to treat such as post-contusional ptosis with good levator function which allows functional surgery with excellent static and dynamic results. Other relatively simple cases with non functional levators may only be treated on a static basis. Last but not least are more difficult cases in which levator function is difficult to evaluate pre-operatively because of severe fibrosis. The aim in such cases is to explore the eyelid by an anterior approach under local anesthesia and to propose either muscular surgery or a frontalis suspension according to the anatomical and functional status of the levator muscle.

Optic nerve trauma induces loss of vision and absence of direct pupillary light reflex. Persistence of consensual pupillary light reflex excludes anatomical section. Trans ethmoidal-sphenoidal decompression relieves the optic nerve and allows an improvement of visual function. Ten patients among 15 surgical decompressions recovered visual function. There is a good correlation between improvement and the release of an anatomical nerve compression. Recognition of direct or indirect computed tomographic signs of optic nerve compression are essential in the surgical indications. The prognosis post-surgical improvement is dependent on the sensitivity of computed tomography scan.

The authors describe their experience with a homogeneous series of 88 fractures of the floor of the orbit. After a clinicopathological and therapeutic summary, the authors describe the sequellae encountered in their series. Sensory disorders are the most frequent sequellae, being noted in 30% of all cases. The maxillofacial surgeon and the ophthalmologist must cooperate to accurately evaluate the physical injury. The various items of damage are analyzed and evaluated.

The superior orbital syndrome has been reported as a very rare complication of orbital fracture. In emergency clinical examination and computed tomography of the cranio-orbital region have provided diagnosis of the compression of the superior orbital fissure content by oedema and/or hematoma. These examinations have determined the type of cranio-orbital fractures and the absence of extra-dural haemorrhage, optical nerve damage or compression, which required emergency treatment. After surgical treatment of the cranio-orbital fracture by temporal and transconjunctival approach, the orbital fissure syndrome has required supervision. The recovery of ophthalmoplegia has taken several months. Minor after effects have been observed for the patient reported.

The authors report their experience based on a homogeneous series of 70 fractures of the orbital floor. Different anatomo-clinical forms were defined in particular fractures of the orbital floor, accompanying an "internal pivoting" of the cheek bone, which by their incarceration mechanism resemble the trap-door fractures. The blow-out fracture associated with the lower orbital margin also raises therapeutic problems. After a clinical and CT study, the authors recommend treatment via the lower orbital approach using silastic implants. The different sequelae are described clinically and are appraised medically and legally.

Traumatic ptosis is most often secondary to a fasciomuscular lesion of the levator system. Less frequently, it results from the paralysis of the levator muscle due to an injury to the third pair of cranial nerves. This ptosis is observed in comminuted orbital fractures or fractures of the base of the skull involving the orbital apex, and it is then associated with oculomotor paralysis. In favorable cases seen early, repairing surgery of the levator system produces excellent results. When associated with ophthalmoplegia or corneal anesthesia, neurogenic ptosis requires a watch and wait policy.

Isolated fractures of the medial orbital wall are always blowout fractures. They are usually diagnosed when horizontal diplopia occurs (lateral movements of the globe and Lancaster test). If the medial rectus muscle is encapsulated (forced ductions and CT-scan), the area of restriction has to be explored surgically.

The authors report a rare case of displacement and immobilisation of the eyeball by bone fragments. Emergency corrective surgery led to total recovery after two months.

Based on 8 cases, the authors study the mechanisms involved in post-traumatic enophthalmos and demonstrate that they result from an increase in orbital volume. There are no grounds to suggest that the disappearance of orbital fat is involved.

The authors describe the clinical and anatomical appearance of orbital fractures operated on in their centre, based on an analysis of a homogeneous series of 105 cases. They define their indications, operative technique and results.

Oculomotor disturbance resulting from orbital floor fractures have different etiologic factors, sometimes damage of one of the ocular motor nerves, caused by direct injury to the orbit; this damage occurs also to one or more of the extrinsic ocular muscles, especially the obliques; frequently, the diplopia is caused by prolapsed orbital tissues with or without muscle entrapment or by a muscle fibrosis; when the diplopia appears after orbital floor reconstruction there is often a palsy of the inferior rectus muscle in front of silicone implant or bone graft on the orbital floor. In oculomotor disturbance after orbital floor fracture, the first stage will be to recognize the mechanism of the diplopia by a clinical examination, motility in the nine positions, Hess Charts, binocular vision and field, forced duction, radiography and sometimes coronal computed tomography which also allow visualization of soft tissues densities, including all extraocular muscles. If there is an indication of orbital surgery, it will be done always in first; oculomotor surgery will be done if necessary at the second stage, if there is a permanent diplopia without evolution during six months. The purpose of the treatment is to obtain orthophoria in primary position and in down gaze. A series of cases of fracture of the orbital floor with resulting diplopia are described. The method, the time, and the indications of orbital or oculomotor surgery are discussed according the variety of cases.

Trapdoor fractures of the floor of the orbit were first described in 1965 by Soll and Poley. The authors discuss the pathology and pathogenic theories for these lesions and present 8 cases. The diagnosis is essentially clinical and is frequently supported by computed tomography when it is performed rapidly. The surgical procedure is designed to release the herniated tissues by lowering the orbital floor so as not to aggravate the constrictive lesions. These fractures constitute surgical emergencies and their prognosis depends on the nature of the tissues incarcerated.

An orbital injury can be responsible for compressing the optic nerve in the optic canal. This compression leads to a syndrome of physiological division with homo-lateral blindness and absence of pupillary reaction of light during stimulation of the injured eye, whereas the light reflex is present with contralateral stimulation. Computed tomography studies show the compression site directly: optic canal fracture, or indirectly: hematoma of posterior ethmoidal cells and sphenoidal sinus, fracture of the posterior part of the orbit. This type of injury can be improved by surgical decompression of the optic nerve via a trans-ethmoid-sphenoidal approach. The surgical technique will be first described. Then, the authors will report a series of 13 cases. In 6 cases, surgical decompression allowed recovery of visual acuity. The authors emphasize the uncomplicated post-operative course. Indeed, no complication was recorded and the hospitalization time was very short.

Adjustable sutures have been used as a curative procedure in 31 cases of diplopia, 16 cases of plegic causes, 4 cases of acute concomitant squint and 11 cases of mechanical strabismus: thyroid myopathy, orbital fracture, oculomotor imbalance after scleral indentation. In oculomotor paralysis if a few functional motor units remained at plegic muscle level, we were able to obtain new rotational balance by combining, with adjustable sutures, recession and resection of the couple agonist-antagonist. On the other hand, if no functional motor unit remained, it was then necessary to turn to the muscular translocation process modulated by adjustable surgery. In acute concomitant strabismus, adjustable retroposition of the medial rectus enabled us to fall back into an area controlled by fusional vergencies. Lastly, in mechanical strabismus by passive limitation, adjustable sutures usually enabled hyperaction of the contralateral synergists to be controlled and to bind a new rotational balance, compatible with a simple binocular field of vision. The advantage of this technique was to adapt, on adjustment, the motor response to the new innervational background which had disappeared under anaesthesia.

Among isolated fractures of the orbital floor, the authors are pointing out an unusual clinical type characterized by the irreducibility of the orbital contents ruptured in the maxillary sinus by using classical procedures. This primary failure is due to a bone fragment dropped in the sinus and being attracted by the herniated collar when trying to integrate the hernia in the orbit. To name this type of lesion, the word "valve fracture" is proposed because of the analogy of the one way function of a valve and its different mechanism from the classical trapdoor fracture. The different concepts of the pathogenesis of isolated fractures of the orbital floor and the physiopathology of the frequently associated ocular disturbances are briefly exposed. The authors report the case which confronted them to the valve fracture. Following a direct trauma to the right orbital area a 13-year-old child presented a limitation of the upwards movements of the right eye with diplopia and a positive forced duction test. The surgical exploration shows an orbital hernia in the sinus which is impossible to reposition either with a higher incision (under the orbital rim) or with a lever incision, upper vestibular incision (through maxillary sinus). Only the infraorbital marginotomy described by P. Tessier exposes completely the lesions and allows understanding of the mechanism of this primary irreducibility related to the valve movement of the fractured bone fragment. Above all, marginotomy allows an atraumatic set. If is performed combining gentle handles of pulling and forcing back on the ruptured pieces while keeping opened the valve.