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Traumatic orbital fracture with prolapse of the globe into the paranasal sinuses is very rare. The visual prognosis is poor, and the medical and surgical management is still a topic of debate. We herein describe an extremely rare case of globe dislocation into the left maxillary sinus with complete recovery of visual acuity. A 67-year-old man presented with an isolated left-sided orbital floor fracture with dislocation of the globe into the maxillary sinus. The visual acuity was no light perception in his left eye. He was immediately taken to the operating room for globe repositioning and orbital floor reconstruction. The spectacular visual recovery allowed a return to normal visual acuity. We summarize the clinical outcomes of traumatic globe dislocations between 1971 and 2023 and suggest treatment guidelines. Among the 31 cases reported in the literature, 26 (83.9%) were into the maxillary sinus (vs. ethmoid), of which only 3 (11.5%) had a complete recovery of visual acuity., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Postoperative diplopia is reported in up to 52% of orbital bone fracture (OBF) repair. Evidence on these risk factors is based on low-quality data, single-institution studies, and small sample sizes. Our study is the largest and first multicenter study to determine the predictors of postoperative diplopia following OBF repair., Methods: The authors conducted a retrospective review of patients who underwent OBF repair at 2 centers from 2015 to 2019. The authors' primary outcome was the incidence or persistence of postoperative diplopia at least 2 weeks after OBF repair. Descriptive statistics were calculated. Multivariable logistic regression was performed to determine significant predictors of postoperative diplopia., Results: Of 254 patients, the median age was 36.1 years (interquartile range, 27.8 to 50.7 years), and the median follow-up was 79.5 days (interquartile range, 40.3 to 157.3 days). The most common postoperative ocular symptom was diplopia (51 of 254 [20.1%]). Patients who had preoperative limited ocular motility or enophthalmos had greater odds of developing postoperative diplopia, compared with patients who did not have these preoperative symptoms (adjusted ORs, 2.33 [95% CI, 1.03 to 5.24] and 2.35 [95% CI, 1.06 to 5.24], respectively). Patients who had combined orbital floor and medial wall and moderate OBF (>2-cm 2 defect or >3-mm displacement) on preoperative computed tomographic scan had greater odds (adjusted ORs, 2.16 [95% CI, 1.04 to 4.46] and 3.77 [95% CI, 1.44 to 9.83], respectively) of developing postoperative diplopia, compared with patients without these preoperative computed tomographic findings., Conclusion: During primary assessment of the patient with OBF, preoperative ocular signs and symptoms, fracture severity, and location of OBF are key predictors of postoperative diplopia., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: This study aims to determine the incidence of pure orbital fractures with concomitant lacrimal drainage system injuries., Methods: A retrospective observational study involving 956 sides from 940 pure orbital blowout fracture patients was conducted in our institution. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded., Results: A total of 13 sides (1.4%) from 13 patients were included in the study. Canalicular laceration, bony nasolacrimal canal fracture, and lacrimal sac wall laceration were found in 9, 4, and 1 patients, respectively (one overlapping). Majority of the injuries resulted from either sports or falls. Inferomedial orbital strut fracture (23.1% vs. 7.6%; p  = .075) and orbital floor fracture occurring lateral to the infraorbital groove (30.8% vs. 9.9%; p  = .035) tended to be higher in patients with lacrimal drainage system injuries., Conclusion: There is a 1.4% incidence rate of pure orbital fractures with concomitant lacrimal drainage system injuries among the Japanese population included in this study. Inferomedial orbital strut fractures and orbital floor fracture lateral to the infraorbital groove were found to have higher association with lacrimal drainage system injuries.

Purpose: No definitive procedures have been proposed for orbital floor fractures extending to the slope of the posterior end, which is a challenging problem. This study demonstrates the effectiveness of an orbital reconstruction procedure based on anatomical landmarks that we developed, called the three landmarks procedure (TLP)., Methods: This study is a single-center retrospective cohort study conducted by the Department of Otorhinolaryngology, Japanese Red Cross Asahikawa Hospital. Data were collected from April 2000 to December 2023. The effect of TLP and the balloon procedure (BP) on ocular movement was compared. The prevalence of postoperative enophthalmos after TLP was examined., Results: The study included 17 patients who underwent TLP and 25 patients who underwent BP. Postoperative mean Hess area ratio (HAR%) was 98.3 (95% confidence interval (CI), 97.0-99.6) in the TLP group and 88.6 (95% CI 83.2-94.0) in the BP group. Among study patients with fractures extending to the posterior slope, 14 underwent TLP and 16 underwent BP. Postoperative mean HAR% was 98.5 (95% CI 97.3-99.7) in the TLP group and 89.2 (95% CI 82.4-95.8) in the BP group. Among all patients who underwent TLP, mean postoperative enophthalmos was 0.06 mm (95% CI - 0.32 to 0.44). It was 0.14 mm (95% CI - 0.31 to 0.59) among patients with fractures extending to the posterior slope., Conclusion: TLP resulted in better postoperative ocular movements than BP. Furthermore, TLP is an effective technique for treating fractures extending to the posterior slope, which are challenging to reconstruct., (© 2024. The Author(s).)

A 6-year-old boy presented with a lateral rectus muscle entrapment in a complex orbital fracture sustained during bicycle riding. He was diagnosed with a skull-base fracture with pneumocephalus and zygomatic and inferior orbital wall fractures at another hospital. The zygomatic fracture and pneumocephalus were treated conservatively. Although a detailed ocular motility examination could not be performed due to pain and inability to open the eyelid, the inferior wall fracture was surgically repaired. Postoperatively, persistent extraocular movement limitation prompted a referral to the authors' clinic. Orbital CT imaging demonstrated a fracture at the greater wing of the sphenoid with a hypoattenuated area in the adjacent middle cranial fossa. Orbital MRI taken thereafter revealed lateral rectus and orbital fat prolapse into the middle cranial fossa, indicating entrapment of these structures through the lateral wall fracture. The incarcerated lateral rectus was released using an endoscopic transorbital approach via an upper lid crease, resulting in the recovery of extraocular movement., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

BACKGROUND Acquired synkinesis is a well-known phenomenon following oculomotor nerve injury. The abnormal movement appears within the distribution of 1 nerve, or other cranial nerves may be involved. The common misdirection of aberrant regeneration of oculomotor nerve involves the lid, extraocular muscles, or pupil. This report presents a case of aberrant connection between abducens and oculomotor nerve, which is quite rare. CASE REPORT A 21-year-old man with history of left-sided frontal, lateral orbital wall, and zygomatic fracture from head trauma in a motor vehicle accident presented for evaluation. He was comatose for 6 weeks in the intensive care unit. Six months later, he presented to the ophthalmology clinic for an eye examination. He had no history of eye problems prior to this accident. His best corrected visual acuity in the right eye was 20/20 and the left eye had no light perception. The right eye exam was normal, with normal ocular motility. The left eye exam showed small esotropia in primary position with markedly decreased adduction, elevation, and minimal depression, but on attempted abduction, the left eye would adduct instead. There was no globe retraction when left eye abduction was attempted. The abnormal movement seen resulted from third nerve function during sixth nerve stimulation, due to unusual ocular motility with abnormal connection between the sixth and third cranial nerves. CONCLUSIONS The most likely pathophysiologic mechanism here is peripheral neuronal misdirection hypothesis after trauma. Careful and detailed examination of a patient presenting with unusual ocular motility after trauma is very important. The abnormal connection between the sixth and third cranial nerves is quite rare but can occur.

Background: We aimed to retrospectively measure the incidence of missed orbital blowout fracture diagnosis in primary examinations of patients with surgically treated fractures, to identify the causes of the diagnostic oversight, and to describe the clinical manifestations of the fractures., Material and Methods: A retrospective cohort of all patients with unilateral orbital blowout fractures who underwent subsequent surgical fracture reduction at the Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, from January 2011 to July 2021, was gathered. Demographics, fracture type, associated injuries, clinical manifestations, reconstruction indication, diagnostic delay, and causes of fractures were analysed. For statistical analysis, Fisher's exact test, unpaired t-test, and the Wilcoxon Rank Sum were used. Significance was set at P˂0.05., Results: Fracture diagnosis was missed in 26 (13%) of 207 patients: in 40% of patients aged under 18 years and in 10% of patients aged 18 years or over (P=0.005). Suboptimal eye examination was found in 62% of patients with missed fracture and in 13% of those with timely diagnosis (P<0.001). Adjusted odds ratios for missed diagnosis in patients aged under 18 years versus patients aged 18 years and over was 9.3 (95% CI 2.4-35) and in patients with suboptimal versus sufficient eye examination 13.6 (95% CI 5.1-37). More common clinical manifestations in patients aged under 18 years were diplopia or restricted eye movements (P=0.005), pain in eye movements (P=0.010), nausea and/or vomiting (P<0.001), and bradycardia (P=0.014); periorbital haematoma was rarer (P<0.001). Suboptimal eye examination was involved in 62% and misinterpretation of computed tomography images in 50% of missed fractures, together explaining 85% of cases., Conclusions: Orbital blowout fractures are often missed in primary examination, especially in children and adolescents, who also present with subtler clinical manifestations. While the diagnosis can be difficult, appropriate clinical and radiological examination will reveal most cases.

Importance: Create validated criteria to identify orbital fracture patients at higher risk for significant ocular injuries. Objective: Determine history and physical examination findings in orbital fracture patients who are associated with ocular injury and warrant urgent assessment by an ophthalmologist. Design, Setting, and Participants: Retrospective chart review of 535 adult orbital fracture patients evaluated at a Level I emergency department between 2014 and 2017, without prior history of orbital fracture, ocular injury, or ocular/orbital surgery. Main Outcomes and Measure: Presence of ocular injury. Results: In total, 195 (36%) patients had an ocular injury. Those with and without ocular injury were compared in a multivariate logistic regression model including demographics, fracture characteristics, injury mechanism, and physical examination findings. Visual acuity change, radiographic retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye all had significant associations with ocular injury when other findings were controlled. Conclusion: This study shows a significant association between ocular injury and visual acuity change, retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye. These factors can help triage when to obtain an urgent ophthalmology consult.

Background: Orbital floor fractures result in critical changes in the shape and inferior rectus muscle (IRM) position. Radiological imaging of IRM changes can be used for surgical decision making or prediction of ocular symptoms. Studies with a systematic consideration of the orbital floor defect ratio in this context are missing in the literature. Accordingly, this study on human cadavers aimed to systematically investigate the impact of the orbital floor defect ratio on changes in the IRM and the prediction of posttraumatic enophthalmos., Methods: Seventy-two orbital floor defects were placed in cadaver specimens using piezosurgical removal. The orbital defect area (ODA), orbital floor area (OFA), position and IRM shape, and enophthalmos were measured using computed tomography (CT) scans., Results: The ODA/OFA ratio correlated significantly (p < 0.001) with the shape (Spearman's rho: 0.558) and position (Spearman's rho: 0.511) of the IRM, and with enophthalmos (Spearman's rho: 0.673). Increases in the ODA/OFA ratio significantly rounded the shape of the IRM (ß: 0.667; p < 0.001) and made a lower position of the IRM more likely (OR: 1.093; p = 0.003). In addition, increases in the ODA/OFA ratio were significantly associated with the development of relevant enophthalmos (OR: 1.159; p = 0.008), adjusted for the defect localization and shape of the IRM. According to receiver operating characteristics analysis (AUC: 0.876; p < 0.001), a threshold of ODA/OFA ratio ≥ 32.691 for prediction of the risk of development of enophthalmos yielded a sensitivity of 0.809 and a specificity of 0.842., Conclusion: The ODA/OFA ratio is a relevant parameter in the radiological evaluation of orbital floor fractures, as it increases the risk of relevant enophthalmos, regardless of fracture localization and shape of the IRM. Therefore, changes in the shape and position of the IRM should be considered in surgical treatment planning. A better understanding of the correlates of isolated orbital floor fractures may help to develop diagnostic scores and standardize therapeutic algorithms in the future., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Facial fractures and their historical link to potential blindness have been well-documented, often attributed to optic canal injuries or retinal vascular occlusion. This dire consequence can result from both direct and indirect ocular trauma, including retrobulbar hemorrhage. Traumatic orbital compression can manifest in various forms, such as hematomas, fractured bone fragments, and emphysema, all posing a significant threat to vision, necessitating immediate intervention. In this study, 9 clinical cases of traumatic orbital compression are presented, each characterized by distinct etiologies. The study delves into traumatic orbital compressive syndromes, underscoring the critical imperative of early recognition and treatment to prevent vision loss. Orbital compression, whether from edema, hematoma, or emphysema, collectively culminates in elevated intraorbital pressure and the potential for optic nerve ischemia. Through the presentation of these 9 clinical cases, the article emphasizes the pressing need for timely intervention in addressing orbital compressive syndromes to avert vision loss. Various surgical techniques are elucidated, highlighting the pivotal role of expeditious medical intervention. This article offers invaluable insights into the diagnosis, management, and outcomes of traumatic orbital compressive syndromes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Purpose: To present the demographics and clinical characteristics of pure (rim-sparing) orbital roof fractures., Methods: This retrospective observational study used 10 years of data from a single institution. Patient age, sex, laterality, field of binocular single vision, associated injuries, and radiologic features were analyzed. Orbital roof fractures were categorized into four groups: comminuted/open, hinged, trapdoor, and linear. These were further subdivided into blow-in (-down) and blow-out (-up) fractures. Injury etiology was classified into fall, traffic accidents, sports injuries, assault, work-related, and others., Results: Data documented a low incidence rate of 2.5% (27 patients) in 1074 patients. Most patients were male (81%). The most common cause of injury was fall (48%), followed by traffic accidents (22%). Comminuted/open fractures constituted the bulk of fracture types (54%), followed by hinged, and linear fractures. Blow-in and blow-out fractures had an incidence rate of 50% each. Concomitant fractures of the medial and inferior orbital walls were predominant. Low surgical intervention was noted owing to acceptable field of binocular single vision outcomes, and the field of binocular single vision included the primary position of gaze in 88% of patients., Conclusion: Pure orbital roof fractures occurred in 2.5% of patients with pure orbital fractures. Patients were predominantly male with trauma caused by high energy forces, which regularly caused comminution of the roof and fractures of the medial and inferior orbital walls. Most patients were managed conservatively., Competing Interests: Conflict of Interest Statement The authors have no conflicts of interest to disclose., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

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., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Trauma-induced orbital blowout fracture (OBF) with eyeball displacement into the maxillary sinus is rare., Case Presentation: We present the case of a 14-year-old with a closed head injury, OBF, and displacement of the eyeball into the maxillary sinus following a car accident. A prompt transconjunctival access surgery was performed for eyeball repositioning and orbital reconstruction in a single session, mitigating anaesthesia-related risks associated with multiple surgeries. At the 12-month follow-up, his visual acuity was 20/200. Despite limited eye movement and optic nerve atrophy, overall satisfaction with the ocular appearance was achieved., Conclusions: This report offers novel insights into the mechanisms of OBF occurrence and the development of postoperative complications., (© 2024. The Author(s).)

Abstract: A 31-year-old male with a history of right zygomaticomaxillary complex (ZMC) fracture presented with aesthetic concerns, continuous tearing, and double vision. The patient had undergone multiple surgeries post accident, resulting in an asymmetrical cheek bulge, persistent diplopia, and epiphora. Investigations revealed abnormal placement of an orbital mesh and damage to the lacrimal sac. A surgical plan was devised to remove the plates, reposition the muscles, secure the floor, correct the epiphora, and provide the desired aesthetics. The surgery involved removal of the mesh and a long plate, refracturing of the zygoma, approximation and securing of the fractured zygoma with plates, and creation of an osteum on the lateral wall of the nose. Post-operatively, the patient's healing was uneventful and he was satisfied with the outcome. This case underscores the importance of a proper surgical technique and patient-centered care in managing complex facial fractures., (Copyright © 2024 Copyright: © 2024 Indian Journal of Dental Research.)

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., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

To clinically and radiographically evaluate patient-specific titanium meshes via a trans-antral approach for correction of enophthalmos and orbital volume in patients with recent unilateral orbital floor fracture. Seven patients with unilateral orbital floor fractures received patient-specific titanium meshes that were designed based on a mirror-image of the contralateral intact orbit. The patient-specific implants (PSIs) were inserted via a trans-antral approach without endoscopic assistance. The patients were evaluated clinically for signs of diplopia and restricted gaze as well as radiographically for enophthalmos and orbital volume correction. Diplopia was totally resolved in two of the three patients who reported diplopia in the upward gaze. Whereas enophthalmos significantly improved in all but two patients, with a mean value of 0.2229 mm postoperatively compared to 0.9914 mm preoperatively. CT scans showed excellent adaptation of the PSIs to the orbital floor with a mean reduction of the orbital volume from 29.59 cc to 27.21 cc, a mean of 0.6% smaller than the intact orbit. It can be concluded that the proposed PSI can offer good reconstruction of the orbital floor through an isolated intraoral transantral approach with minimal complications. It could of special benefit in extensive orbital floor fractures., Competing Interests: Declaration of competing interest No conflict of interest declared., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

To compare the reconstruction of orbital fractures using patient-specific implants (PSI) and conventional pre-formed titanium mesh; to develop a method of three-dimensional (3D) superimposition and analysis of the reconstructed orbits; and to present the pitfalls in 3D planning of orbital PSI and how to avoid them. This was a retrospective study of patients with orbital fractures who were treated in our institution between the years 2022 and 2023 using PSI or conservative prefabricated titanium mesh. Three different methods for virtual reconstruction of orbital fractures were used and are detailed with advantages, disadvantages and indications. Data acquired included age, gender, method of reconstruction, functional outcomes and aesthetic outcomes. 3D analysis for accuracy of reconstruction was performed. A total of 23 patients were included; 12 were treated using PSI and 11 using prefabricated titanium meshes. There were 8 male and 4 female patients in the PSI group comparted to 5 and 6 in the prefabricated group. All three virtual methods for reconstruction were used successfully, each with the proper indications. When comparing PSI reconstruction to conventional mesh, a significant difference in accuracy was observed; PSI cases showed an inaccuracy of 0.58 mm compared to 1.54 mm with the conventional method. Complications are presented, and tips for avoiding them are detailed. Three different methods for virtual reconstruction were used successfully; automated computerized reconstruction is used for small defects, repositioning is the superior method for non-comminuted cases while mirroring is the method of choice in comminuted fractures. 3D analysis can be performed using a novel method detailed in this report. PSI reconstruction showed superior results, indicating it should be the method of choice when possible. Pitfalls are presented and approaches to prevent them are discussed. Orbital reconstruction is a very important entity in maxillofacial surgery with crucial functional and esthetical implications, and one should use virtual planning and PSI implants, as they significantly improve outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Orbital fat herniation is often accompanied by orbital floor fractures. Furthermore, herniation through the inferior orbital fissure (IOF) is rare, and its pathophysiology remains largely unknown. Here, the authors report a case of a patient with IOF herniation and diplopia caused by orbital trauma. The patient was a 58-year-old male who had undergone reduction of a left zygomatic fracture 15 years previously; however, reduction of the lateral orbital wall displacement was not performed at that time. The patient presented with refractory diplopia following a sports-related orbital injury. Although no new facial fractures occurred, an asymmetric IOF herniation was observed in the left orbital fissure, which caused persistent diplopia. Surgical repair of the orbital fat herniation was performed 46 days after injury. Two months after the surgery, the herniation of the orbital fat and diplopia completely disappeared. Surgery for an IOF herniation should be considered when ocular symptoms persist after orbital trauma., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 by Mutaz B. Habal, MD.)

Pediatric patients often present with orbital fractures after facial trauma, most commonly fractures of the orbital floor. Evaluation of orbital fractures for entrapment of the extraocular muscles is crucial, as urgent surgical exploration and possible repair are needed in these cases. We report a 2-year-old male who presented after a fall with multiple left orbital wall fractures, including a roof fracture. On examination, the patient's OS appeared fixed in an upward gaze. Positive forced ductions revealed clinical concern for entrapment of the superior rectus. The patient was taken to the operating room for exploration, and the entrapped superior rectus muscle was freed from the fracture. The patient subsequently recovered fully with complete extraocular movements. This represents the first reported case of superior rectus entrapment in an orbital roof fracture., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Postoperative diplopia is the most common complication following orbital fracture repair (OFR). Existing evidence on its risk factors is based on single-institution studies and small sample sizes. Our study is the first multi-center study to develop and validate a risk calculator for the prediction of postoperative diplopia following OFR. We reviewed trauma patients who underwent OFR at two high-volume trauma centers (2015-2019). Excluded were patients < 18 years old and those with postoperative follow-up < 2 weeks. Our primary outcome was incidence/persistence of postoperative diplopia at ≥ 2 weeks. A risk model for the prediction of postoperative diplopia was derived using a development dataset (70% of population) and validated using a validation dataset (remaining 30%). The C-statistic and Hosmer-Lemeshow tests were used to assess the risk model accuracy. A total of n = 254 adults were analyzed. The factors that predicted postoperative diplopia were: age at injury, preoperative enophthalmos, fracture size/displacement, surgical timing, globe/soft tissue repair, and medial wall involvement. Our predictive model had excellent discrimination (C-statistic = 80.4%), calibration (P = 0.2), and validation (C-statistic = 80%). Our model rules out postoperative diplopia with a 100% sensitivity and negative predictive value (NPV) for a probability < 8.9%. Our predictive model rules out postoperative diplopia with an 87.9% sensitivity and a 95.8% NPV for a probability < 13.4%. We designed the first validated risk calculator that can be used as a powerful screening tool to rule out postoperative diplopia following OFR in adults., (© 2024. The Author(s).)

Background: Growing skull fracture (GSF) of the orbital roof is a rare complication of head injury in infancy and early childhood. Analysis of the Medline database between 1983 and 2023 identified 17 articles describing 63 children after surgical treatment of GSF of the orbital roof., Material and Methods: We present a 2-year-old child with moderate traumatic brain injury (TBI) complicated by GSF of the orbital roof. Neuroimaging and literature data are described., Results: Severe ophthalmological symptoms in acute period of TBI subsequently partially regressed with persistent swelling of the upper eyelid and hypophthalmos. CT and MRI revealed a linear fracture of the frontal bone extending to superior orbital wall and intraorbital collection of cerebrospinal fluid (pseudomeningocele) mixed with blood. MR signs of GSF of the orbital roof with pseudomeningocele shrinkage were found in 5 weeks after injury. After 6 months, CT and MRI revealed signs of more severe GSF. Surgical treatment implied craniotomy, excision of scars, arachnoid membrane and abnormal brain matter, resection of deformed fracture edges, dura mater sealing and orbital roof reconstruction with bone autograft. Ophthalmological symptoms regressed after 6 months. The follow-up period was 6 years. There were no signs of fracture recurrence., Conclusion: In this case, acute intraorbital pseudomeningocele led to GSF of the orbital roof in 5 weeks after injury. Incomplete regression of ophthalmological symptoms, their aggravation or delayed appearance in children with orbital roof fracture requires a thorough examination including high-resolution CT and MRI, and orbital roof GSF should be considered in the differential diagnosis.

Purpose: To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment., Methods: We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision., Results: We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed., Conclusion: Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Lower eyelid malposition can be a complication following orbital floor fracture surgeries. We present our incidence of lower eyelid malposition from a large case series of orbital floor fracture repairs using the 'swinging eyelid' approach and 'hang back' technique., Methods: A retrospective review of all orbital fracture surgeries at our institution from November 2011 to March 2021 was performed. Primary outcomes included the incidence of lower eyelid malposition by category, the average time to presentation after primary surgery, and reoperation rates among cases with lower eyelid complications., Results: A total of 438 cases that involved repair of the fractured orbital floor were identified. Six patients (1.37 %) developed lower eyelid malposition following primary orbital floor repair. Two patients (0.46 %) developed reverse ptosis of the lower eyelid. Two patients (0.46 %) returned with lower lid cicatricial ectropion. One patient (0.23 %) had postoperative lower eyelid retraction. One patient (0.23 %) had postoperative lower eyelid cicatricial entropion. No cases of lower lid flattening, lower eyelid fat flattening, or eyelid notch was noted. All patients with lower eyelid malposition underwent additional surgeries except one patient with reverse ptosis (83.3 %). The average time to the presentation of postoperative complications from the surgery date was 292.8 days (range = 49 days to 3.5 years)., Conclusion: Lower eyelid malposition after orbital floor repair is a known complication that can be decreased by employing the 'swinging eyelid' with a preseptal approach and closure by the 'hang back' technique., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Summary: Long-term enophthalmos is a common orbital fracture sequela. Various autografts and alloplastic materials have been studied in posttraumatic enophthalmos repair. However, expanded polytetrafluoroethylene (ePTFE) implantation in late enophthalmos repair has rarely been reported. The authors report novel use of ePTFE for late posttraumatic enophthalmos repair. This retrospective study included patients with posttraumatic long-term enophthalmos who underwent hand-carved ePTFE intraorbital implantation for enophthalmos correction. Computed tomography data were collected preoperatively and at follow-up. The volume of ePTFE, the degree of proptosis (DP), and enophthalmos were measured. Postoperative and preoperative DP and enophthalmos were compared using the paired t test. The correlation between ePTFE volume and DP increment was established using linear regression. Complications were identified by chart review. From 2014 to 2021, 32 patients were included, with a mean follow-up of 19.59 months. The mean volume of implanted ePTFE was 2.39 ± 0.89 mL. After surgery, the DP of the affected globe improved significantly, from 12.75 ± 2.12 mm to 15.06 ± 2.50 mm ( P < 0.0001). A significant linear correlation was found between ePTFE volume and DP increment ( P < 0.0001). Enophthalmos was substantially ameliorated from 3.35 ± 1.89 mm to 1.09 ± 2.07 mm ( P < 0.0001). Twenty-five patients (78.23%) had postoperative enophthalmos of less than 2 mm. Infection and implant dislocation were not observed. The authors concluded that ePTFE intraorbital implantation exhibited long-term efficacy and safety for late posttraumatic enophthalmos repair and represents an effective and predictable alternative., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: Intraorbital encephalocele (OMEC) is a rare entity in adults, usually secondary to an orbital pathology or prior trauma, in particular orbital roof fractures. Treatment of the OMEC is warranted to alleviate the pulsating exophthalmos and prevent potential visual decline. OMEC and orbital roof fractures have been predominantly treated via a craniotomy with a reconstruction of the orbital roof using various implants. With the advances in the endoscopic techniques, neuroendoscopy found its application in the treatment of orbital pathologies. We report a minimally invasive alternative: endoscopic transorbital repair of OMEC., Material and Methods: The repair technique is described with illustrations and clinical images. Narrated operative video demonstrating the procedure is provided., Results: Illustrative case: 50-year-old female presented with progressive right eye proptosis over 6 months. Computed tomography (CT) demonstrated bony erosion in the lateral orbital roof, and magnetic resonance imaging (MRI) showed a small hyperintense T2-weighted and T1-weighted contrast enhancing lesion in the orbit, in the area of the bony erosion. Intraoperatively, the lesion was found to be an orbital encephalocele. The orbital defect was successfully repaired by employing the 'sandwich' technique, in which a dural substitute reinforced with tissue glue were deployed without repair of the osseous orbital roof. The patient tolerated the procedure well with ultimate resolution of proptosis. The cosmetic outcome was excellent., Conclusion: The transorbital neuroendoscopic approach (TONES) presents a feasible, minimally invasive alternative treatment option for circumscribed intraorbital encephaloceles with minimal side effects, well tolerated by patients.

Craniomaxillofacial trauma is a challenging entity to manage effectively and often necessitates serial evaluation and treatment. A multidisciplinary team is best served to evaluate and treat these complex injury patterns with the use of necessary adjuncts, such as neuronavigation, intraoperative imaging, custom implant use, and virtual surgical planning. Complications of facial trauma can present at a spectrum of time points and manifest in a variety of manners and as such patients should be observed closely and longitudinally. Although not all complications and secondary deformities can be avoided, this article highlights some common pitfalls and our unique management strategies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background:  Periorbital fractures are a condition encountered after high-energy trauma in the face region. In the follow-ups after surgical repair, some changes may occur in the lower eyelid. Scleral show, ectropion, entropion, and canthal malposition are the most common complications. In this study, the effect of subciliary soft tissue approaches on lower eyelid position in patients with infraorbital rim fracture was investigated., Methods:  Patients admitted with orbital lower rim fracture between January 2017 and January 2021 were included in the study. A total of 90 patients, 15 patients in each group, were followed up for 6 months. Before the operation, the patients were randomly assigned to the groups by an impartial observer and the surgeons who would perform the operation were informed about the method. The patients were divided into six groups according to the type of soft tissue approach for fracture repair., Results:  There were 6 groups in total and each group included 15 patients. The mean age was 41.4 in group 1, 50.6 in group 2, 38.2 in group 3, 36.4 in group 4, 38 in group 5, and 39.9 in group 6. There was no statistically significant difference between the groups in terms of age ( p  = 0.090), gender distribution ( p  = 0.835), and smoking ( p  = 0.685). Ectropion was observed in 14 of 73 male patients and 5 of 17 female patients. Ectropion was observed in 9 of 38 smokers and 10 of 52 nonsmokers. When all groups were evaluated together, the scleral show measurement was 0.072 on the operated side and 0.034 on the healthy side. This measurement was statistically significant ( p  = 0.000)., Conclusion:  Subciliary skin-only or step incision approaches can be used safely in the exposure of infraorbital rim fractures, but both approaches must be supported by canthopexy., Competing Interests: None declared., (Thieme. All rights reserved.)

Blowout fractures of the orbit are relatively common injuries of the viscerocranium. However, there is still no general consensus on the optimal timing and method of treatment. This article gives a comprehensive review of the pathology of the fracture, process of diagnosis, management and follow-up, including results of a retrospective study done in the Department of Maxillofacial and Oral Surgery, Dubrava University Hospital, Zagreb, in which we collected and analyzed medical records of 91 patients treated for blowout fractures in our institution over a period of three years. Our study showed that the patients admitted to our department more than 48 hours from the injury were more than 4 times likely to develop a complication that would require additional treatment. In other words, of our 91 patients, those admitted to our department in the first 48 hours from the injury had a more than 4 times lower rate of complications, likely due to early recognition of the injury with early intravenous antibiotic and corticosteroid administration, multidisciplinary treatment, and early recognition of candidates for emergency and early surgical treatment. The results of our study show the importance of treating blowout fractures in a tertiary care facility with expertise on the subject., (Sestre Milosrdnice University Hospital.)

Background: The use of an acellular dermal matrix (ADM) has not been reported in medial orbital wall fracture reconstruction previously. This study aimed to share our early experience with the cross-linked ADM as an allograft material for medial orbital wall reconstruction., Methods: In this study, the author evaluated the medical records and serial facial computed tomography scans of 27 patients with pure medial orbital wall fractures reconstructed by a single surgeon between May 2021 and March 2023. The author routinely approached the medial orbital wall with a retrocaruncular incision. Five out of 27 patients were reconstructed with trimmed, multiple folded, 1.0-mm-thick cross-linked ADM (MegaDerm; L&C Bio, South Korea)., Results: All cases reconstructed with cross-linked ADM improved clinically and radiologically without complications. The serial computed tomography findings revealed that implanted cross-linked ADM successfully covered the defect while providing a significant volumizing effect., Conclusions: This is the first study to show the efficacy of cross-linked ADM for orbital medial wall fracture reconstruction. Our strategy of orbitalization of ethmoidal sinus with stacked cross-linked ADM would be an excellent surgical option., Competing Interests: The author reports no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

The aim of this study is to investigate the feasibility of perpendicular plate of ethmoid as material for the reconstruction of medial orbital wall. The main outcome measurement was preoperative and postoperative orbital volume. The authors performed a study including 17 patients who have isolated medial orbital wall fracture (blow-out fracture). All the patients were fixed the defect using autologous perpendicular plate of ethmoid under endonasal approach. The authors compared the preoperative and postoperative orbital volume difference (unaffected orbit, affected orbit) of all the patients, and observed the improvement of diplopia or ocular motility disorders after operation. All 17 medial orbital wall reconstruction surgeries were successful with no severe postoperative ophthalmic complications. Statistically significant differences were found between the preoperative and postoperative orbital tissue volumes for the affected orbit. There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction. And postoperative computed tomography showed the implant is in place and there is no medial rectus incarceration. Autologous perpendicular plate of ethmoid proved to be safe and effective in the reconstruction of medial orbital wall under endonasal approach with cost-effectivence, low complication rate, high biocompatibility, and minimally invasion., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Preoperative computer-assisted planning and intraoperative navigation are becoming popular for orbital fracture treatment. However, not all institutions currently have access to these computer-aided applications. The authors present a simple and intuitive operative algorithm to guide orbital fracture reconstructions. The operative algorithm was based on linear measurements of orbital defects on high-resolution Computer tomography (CT) scans using specific axial, coronal, and sagittal plane images. The fractures were then divided into 3 types based on site and defect-size area. For each type, the authors suggested a surgical approach and material reconstruction. Between February 2022 and January 2023, 57 patients were treated according to the described CT-based protocol. The quality of reconstruction was classified as ideal, satisfactory, acceptable, and poor based on postoperative CT. Diplopia, enophthalmos, and postoperative complications were assessed. Fifty-seven patients were included. Forty-four (77.2%) patients were included in the type 1 group, 4 (7.01%) in the type 2 group, and 9 (15.79%) in the type 3 group. The reconstruction was considered ideal in 54 (94.7%) cases, satisfactory in 2 (3.5%), and acceptable in 1 (1.8%). No revision surgery was required. In all cases, preoperative diplopia was settled out, and only 1 patient reported postoperative enophthalmos. No complications occurred, with good clinical results and orbital symmetry. The linear CT measurement-based protocol is a simple and reliable workflow to guide the surgeon's choice of reconstruction material and surgical approach for primary orbital reconstruction. It allows good management of orbital trauma and could help standardize treatment decisions with an imaging technique available in all institutions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Although orbital fractures are common, prediction of outcomes in orbital surgery can be quite challenging., Purpose: We aim to identify predictors of intraoperative difficulty, operating time, and postoperative examination abnormalities in subjects undergoing post-traumatic orbital reconstructions., Study Design, Setting, and Sample: This is a retrospective cohort study of all consecutive orbital operations performed at a private, Level 1 trauma center in Portland, Oregon, USA over an 82-month period. All subjects that underwent exploration of the internal orbit for traumatic indications during the study period were included in the cohort., Predictor Variables: Four plating styles, surgical approach (transorbital vs transantral), days from injury to first surgery, fracture size (approximated as a rectangle using linear measurements from computed tomography scans), anteroposterior fracture position, and medial wall involvement were examined., Outcome Variables: The primary outcome variable was intraoperative difficulty (defined as requiring revision after intraoperative imaging or return to the operating room). Secondary outcome variables included operating time and postoperative examination abnormalities., Covariates: Age and sex were included., Analyses: χ 2 and Regression analyses were performed using a significance level of P < .05., Results: One hundred and sixty four orbital operations were performed (90 isolated injuries and 74 combined orbital/midface injuries) on 155 subjects (73% male, mean age 39.8 years, standard deviation 16.7). In subjects with isolated orbital fractures, medial wall involvement was associated with intraoperative difficulty (P = .01). When using a transantral approach, intraoperative difficulty was more likely in more anterior fractures (P = .02). Plating style was associated with operating time (P = .03), with median times from 81 to 105 minutes (range 21 to 248 minutes). Postoperative examination abnormalities were more likely in the transorbital approach group (P = .01). Neither days to first surgery nor intraoperative difficulty were associated with postoperative examination abnormalities. Postoperative eyelid changes were seen in 13.6% of transorbital approaches and 0% of transantral approaches. Correction of gaze restriction and enophthalmos were more likely than correction of diplopia (P < .01)., Conclusions and Relevance: Medial wall involvement is associated with intraoperative difficulty in orbital surgery. Anteriorly positioned fractures are better treated transorbitally, while posterior fractures may be amenable to transantral repair, thus avoiding risk of lower eyelid changes., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

A few mucoceles developing secondary to facial bone fractures have been reported. Mucocele formation is thought to be attributable to displacement of the respiratory mucosa with obstruction of the sinus opening, especially if untreated. Accurate diagnosis and management are required; a growing mucocele will gradually destroy adjacent bony structures and cause irreversible complications. The authors describe a patient who presented with diplopia and mild discomfort when gazing upward. She had undergone reconstruction of medial and inferior orbital fractures 20 years previously. The patient was diagnosed with a mucocele developing after orbital fracture repair. The patient underwent mucocele removal and orbital reconstruction using a polyetheretherketone patient-specific implant. In a patient with orbital symptoms but without acute trauma, a mucocele should be among the differential diagnoses if history-taking reveals past orbital trauma and surgery. A polyetheretherketone patient-specific implant was effective for orbital reconstruction after mucocele removal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Introduction: Orbital floor (OF) fractures accompany all zygomaticomaxillary complex (ZMC) fractures, but guidelines for repair of OF fractures in this setting are unclear. Objectives: To compare ophthalmologic outcomes of ZMC repair with and without concurrent OF repair. Methods: We retrospectively reviewed patients undergoing ZMC fracture repair with and without OF repair between 2016 and 2018. Patients were reviewed for demographics, preinjury characteristics, and ophthalmologic outcomes. Results: Of 61 total patients, 32 underwent concomitant OF repair while the remaining 29 underwent ZMC repair alone. The OF repair group had increased OF fracture size, displacement in the coronal plane, and malar eminence displacement ( p  < 0.05). Eight patients in the OF repair group had postoperative diplopia compared with no patients in the group without OF repair ( p  < 0.05). Conclusion: Retrospective analysis of ZMC fracture repair without and with OF repair did not reveal a significant difference in short-term ophthalmologic outcomes while controlling for fracture size.

Objective: The optimal approach and timing of complex orbital fracture repair is an unresolved issue that is complicated by unique clinical presentations and patient-specific considerations. Early surgical repair in less than 14 days is associated with fewer complications; however, there are no guidelines addressing the optimal timing for surgical repair. This study assesses the time of surgical repair and surgical outcomes of complex orbital fractures., Methods: Retrospective chart review from 2010 to 2022. Adult patients with orbital fractures are treated with surgical repair., Results: In all, 94 patients presented with orbital fractures and were treated with 108 surgeries. Postoperative complications: vision disturbance 33/108 (30.6%), gaze restriction 12/108 (11.1%), lid malposition 10/108 (9.3%), globe complication 13/108 (12.0%), and hardware issues 14/108 (13.0%). Postoperative complications were not significantly associated with the surgical approach used for fracture repair or the time of surgical repair., Conclusion: Postoperative complications following surgical repair of orbital fractures are not associated with surgical approach or time of repair following the initial injury., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: This study aimed to analyze saccades in patients with orbital-wall fractures with little or no ocular motor impairment., Methods: We included 7 eyes of 7 patients with unoperated orbital-wall fractures (3 cases of orbital-floor fractures and 4 cases of medial orbital-wall fractures) with mild or no diplopia who presented to our hospital between August 2019 and March 2021. Eye movements were assessed at the first visit and after 1 month using the Hess area ratio according to the Hess screen test, binocular single vision (BSV) scores (total 59 points) obtained using Goldman perimetry, and maximum velocity and amplitude of saccades within 15 degrees obtained using an eye tracker system., Results: Hess area ratio and BSV scores at the first visit and after 1 month were 88.6±8.2% and 97.4±3.6% and 49.6±8.5 points and 53.5±6.6 points, respectively, with no significant change (Hess area ratio, P =0.06; BSV, P =0.44). Next, the authors compared the velocity and amplitude of the saccades between the first visit and 1 month later and found no significant changes in any of the 4 directions (adduction, abduction, upgaze, and downgaze). Similarly, no significant differences were observed between the velocity and amplitude of the saccades between the injured and noninjured eyes, both at the first visit and after 1 month., Conclusions: In patients with orbital-wall fractures with little or no eye movement impairment, eye tracker-based saccade analysis showed that the saccade velocity and amplitude did not change during the natural course of healing of the fracture., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: 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., Methods: 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., Results: 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)., Conclusions: 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.

Displacement of the globe of the eye into the maxillary sinus is very rare in cases of facial trauma. Herein, we report a case of complete dislocation of the left globe into the maxillary sinus following a road traffic collision. The patient had prompt surgery to replace the globe after CT imaging confirmed the diagnosis. Subsequently, ongoing follow-up has focused on cosmesis in the affected, non-seeing eye. A multidisciplinary approach has been key throughout the patient's journey., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution., Methods: A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes., Results: Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures., Conclusions: These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Orbital floor fracture defect size and inferior rectus (IR) rounding index are currently accepted indications for surgery to prevent late enophthalmos. The authors analyzed the positive predictive value (PPV) of these indications., Methods: Twenty-eight patients with orbital floor fractures presenting without enophthalmos underwent Hertel exophthalmometry at presentation and at weeks 1, 2, 3, 6, 13, 26, and 52 or more after injury. Orbital defect size and IR rounding index were measured from computed tomographic scans, and PPVs of defects of 1.5 to 2 cm 2 or larger and IR rounding index of 1 or higher for enophthalmos (≥2 mm) were calculated., Results: Nineteen patients had isolated orbital floor fractures (group A), three had noncontinuous orbital floor and medial wall fractures (group B), and six had continuous orbital floor with medial wall fractures (group C). Mean follow-up time was 440 days. Of all patients, 20 had a defect size of 1.5 cm 2 or larger, 12 had a defect of 2.0 cm 2 or larger, and 13 had an IR rounding index of 1 or higher. Of the 28 patients, only one from group A and two from group C developed enophthalmos of 2 mm only. The PPVs of orbital floor defect size of 1.5 cm 2 or larger and 2 cm 2 or larger (groups A and B only) for late enophthalmos were 6.7% and 0%, respectively. The PPV of IR rounding index of 1 or higher for late enophthalmos (all groups) was 0%., Conclusions: For patients with orbital floor fractures presenting without enophthalmos, defects of 1.5 cm 2 or larger and 2 cm 2 or larger, and IR rounding index of 1 or higher, are weakly predictive of late enophthalmos. Furthermore, patients who do not develop enophthalmos within 3 weeks of injury are unlikely to develop significant (>2 mm) late enophthalmos., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: For patients without dysfunctions, the main purpose of secondary correction for craniofacial fractures is restoring facial symmetry. Computer-assisted surgery techniques including virtual surgical planning and intraoperative navigation provide the help to restore the bony symmetry as much as possible. The authors retrospectively quantitatively analyzed patients who received computer-assisted secondary correction for craniofacial fractures on facial symmetry pre and postoperation., Methods: This observational study reviewed the medical records of 17 patients requiring secondary correction for craniofacial fractures. Pre and postoperative computed tomography data were used to quantitatively analyze the changes in facial symmetry and enophthalmos., Result: All patients enrolled in this study showed mid-facial asymmetry but without dysfunctions except for enophthalmos, and 5 patients had bone defects in the frontal-temporal area. The corrective surgical techniques were different for each patient according to their specific condition. Virtual surgical planning with or without intraoperative navigation was performed for all patients. Compared with the preoperative condition, their facial symmetry was significantly improved. The maximum discrepancy value between the affected side and the mirrored unaffected side decreased from 8.10 ± 2.69 to 3.74 ± 2.02 mm postoperatively, and the mean discrepancy value decreased from 3.58 ± 1.29 to 1.57 ± 0.68 mm. In addition, the Enophthalmos Index decreased from 2.65 to 0.35 mm., Conclusion: This observational study objectively demonstrated that computer-assisted secondary correction for craniofacial fractures can significantly improve facial symmetry. And the authors recommend that virtual surgical planning and intraoperative navigation should be a must step in craniofacial fracture correction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Objective: Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture., Design: Retrospective chart review., Participants: Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018., Methods: Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI., Results: Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ 2 analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%)., Conclusions: Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma., (Copyright © 2022 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Aim: We describe the clinical settings and the factors predicting outcomes in open globe injuries with concurrent orbital fractures., Methods: Retrospective, consecutive, non-comparative study. All eyes from January 2014 to January 2021 with concurrent open globe injuries with orbital fractures that underwent management were included. The clinical data of each patient who underwent a comprehensive ophthalmic examination was entered into a browser-based electronic medical records system (eyeSmart EMR) by uniformly trained ophthalmic personnel and supervised by an ophthalmologist using a standardized template. Favorable functional outcome was defined as the final best corrected visual acuity of >20/200 as per the World Health Organization (WHO) definitions of severe visual impairment and blindness. A favorable anatomic outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. Multivariate logistic regression analysis was done to assess the effect of various demographic and clinical factors and the type of orbital fracture on the final anatomic and functional outcome., Results: Ninety-one eyes of 91 patients were included in the study. Females accounted for 74/91 (81.3%) of the eyes. Modes of trauma was rupture in 67%, perforating in 5.5% and penetrating in 27.5% of the cases. Orbital rim involvement was seen in 79.1%. The most common isolated fracture seen was a medial wall (19.78%), which was followed by the orbital floor (15.38%). Favorable functional outcome was seen in 10 eyes (11%), while a favorable anatomic outcome was achieved in 45 (49.5%). Odds of a favorable functional outcome were 6.12 (95% CI 1.22 to 30.71), p = .02 for an open globe injury with orbital fracture in the absence of a concurrent retinal detachment. Odds of a favorable anatomic outcome were 55.55 (95% CI 2.43 to 1250), p = .01 when the injury did not involve zone 3, 9.94 (95% CI 2.05 to 48), p = .004 when concurrent retinal detachment was absent, 16.3 (95% CI 1.42 to 187.19), p = .02 when the orbital rim was intact and 7.83 (95% CI 1.09 to 56.19), p = .04 when only one orbital wall was involved., Conclusions: Open globe injuries with concurrent orbital fractures result in a very poor functional outcome. Concurrent retinal detachment is a negative predictive factor. Associated fractures involving the orbital rim increase the risk of eyeball loss.

We present clinical and imaging predictors of ocular injuries that required medical management versus surgical intervention in cases of orbital fractures. From 2014 to 2020, a retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed scan (CT) analysis at a level I trauma center was performed. Inclusion criteria were patients with confirmed orbital fracture on CT and ophthalmology consultation. Patient demographics, associated injuries, comorbidities, management, and outcomes were collected. Two hundred and one patients and 224 eyes (11.4% bilateral orbital fractures) were included. Overall, 21.9% of orbital fractures presented with a significant concomitant ocular injury. Associated facial fractures were present in 68.8% of eyes. Management included surgical treatment in 33.5% of eyes and ophthalmology-directed medical treatment in 17.4%. On multivariate analysis, clinical predictors of surgical intervention were retinal hemorrhage (OR=4.7 (1.0-21.0), P =0.0437), motor vehicle accident injury (OR=2.7 (1.4-5.1), P =0.0030) and diplopia (OR=2.8 (1.5-5.3), P =0.0011). Imaging predictors of surgical intervention were herniation of orbital contents (OR=2.1 (1.1-4.0), P =0.0281) and multiple wall fractures (OR=1.9 (1.01-3.6), P =0.0450). Predictors of medical management were corneal abrasion (OR=7.7 (1.9-31.4), P =0.0041), periorbital laceration (OR=5.7 (2.1-15.6), P =0.0006), and traumatic iritis (OR=4.7 (1.1-20.3), P =0.0444). We demonstrated a 22% incidence of concomitant ocular trauma in orbital fracture patients at our level I trauma center. Predictors of the surgical intervention included multiple wall fractures, herniation of orbital contents, retinal hemorrhage, diplopia, and motor vehicle accident injury. These findings emphasize the importance of a multidisciplinary team in managing ocular and facial trauma., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: Orbital volume increase has been previously linked with post-traumatic enophthalmos. However, this varies and some studies show no correlation. This systematic review and meta-analysis aimed to synthesize the correlation between orbital volume and enophthalmos and to determine if surgical intervention, enophthalmos measurement method, fracture location, or timing affect this correlation., Methods: Automation tools were used to assist in this review of 6 databases. Searches were performed across all dates. Included studies quantitatively reported orbital volume and enophthalmos following traumatic orbital wall fractures in at least 5 adult subjects. Correlational data were extracted or calculated. Random-effects meta-analysis was used with subgroup analyses for each of the secondary aims., Results: Twenty-five articles describing 648 patients were included. The pooled correlation between orbital volume and enophthalmos was r =0.71 ( R2 =0.50, P <0.001). Operative status, enophthalmos measurement method, and fracture location did not affect pooled correlation. The delay between trauma or surgery and enophthalmos measurement was not shown to modulate correlation for unoperated patients ( R2 =0.05, P =0.22) but showed a negative relationship for postoperative patients ( z =-0.0281, SE=0.0128, R2 =0.63, P =0.03), but this was heavily influenced by a single article. All results had high residual heterogeneity. Studies were rated as moderate, low, or very low quality with few stating explicit hypotheses or limitations., Conclusions: Bony orbital volume expansion accounts for around 50% of post-traumatic enophthalmos. The other half is probably explained by soft tissue or geometric bony, rather than volumetric, changes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: This study aims to investigate trends and risk factors associated with work-related ocular injuries occurring in adults aged 19-64 using the National Trauma Databank (NTDB)., Methods: In this retrospective, cross-sectional study, the NTDB was used to collect all patients with an ICD-9 code of work-related ocular trauma from 2007 to 2014. Demographic data and risk factors collected included age, gender, race, setting, machinery, and mechanism. Descriptive statistics, univariate, and logistic regression multivariate analyses were conducted., Results: Between 2007 and 2014, 234,983 cases of work-related trauma were identified, of which 11,097 (5.7%) cases involved ocular trauma. The mean age of patients was 40.7 years (SD = 12.2), and the majority of patients (93.7%) were male. Most injuries occurred in an industrial facility, and the most common injuries were orbital floor fractures (OFFs), ocular contusions, open wounds to the adnexa, and open globe injuries (OGIs). OFFs most commonly involved a concurrent fracture of another facial or skull bone. Male gender (RR = 1.22; CI 1.09-1.38), accidental falls (RR = 1.50; CI 1.41-1.60), trauma from falling objects (RR = 1.34; CI 1.21-1.48), involvement in an unarmed fight (RR = 1.63; CI 1.39-1.91), assault by a blunt object (RR = 1.59; CI 1.31-1.91), and injury caused by animals (RR = 1.63; CI 1.30-2.02) were risk factors for OFFs. Patients with OFFs were less likely to have a concurrent OGI (RR = 0.27; CI 0.23-0.32). On the other hand, injuries occurring in industrial facilities (RR = 1.29; CI 1.11-1.51) and injuries with a loose foreign body striking the eye or adnexa (RR = 1.54; CI 1.28-1.84) were risk factors for OGI. The most common causes of work-related ocular trauma were accidental falls, motor vehicle accidents, and accidentally being struck in the eye. The mean length of hospital stay was 6.56 days (SD = 10.82); 36.7% of patients required ICU admission, and the overall in-hospital mortality rate was 2.8%., Conclusion: The majority of work-related ocular trauma occurred in men, most commonly in industrial locations. Accidental falls were the most common identified cause of trauma. OFF was the most common ocular injury; 80% of OFF cases involved additional facial and skull fractures. Patients with OFFs were less likely to have a concurrent OGI compared with patients without OFFs., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)