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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.)

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.

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.

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.

In 23 patients with traumatogenic enophthalmos and diplopia autologous (rib cartilage, iliac crest bone), heterologous (lyophilized dura), and alloplastic (Silastic, P.D.S., HA-blocks) material was implanted into the orbit in a late secondary intervention. The results were encouraging as for the improvement of the diplopia as well as the enophthalmos. If rib cartilage should not or cannot be used a hydroxyapatite ceramic block is the best alloplastic implant material due to its stability, inertia, and availability.

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.

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.

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.

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.

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.