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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.)

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.)

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.)

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.)

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.)

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.)

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.)

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.)

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.)

Background: The use of an acellular dermal matrix is rarely reported in orbital wall fracture reconstruction. This study aimed to share the author's experience with the cross-linked acellular dermal matrix as an allograft material for enophthalmos correction., Methods: In this retrospective study, the author evaluated the medical records and 3-dimensional facial computed tomography scans of patients with enophthalmos caused by neglected orbital fractures between May 2021 and June 2022. Facial computed tomography scans confirmed the clinical diagnosis of enophthalmos. A single surgeon performed all surgical operations. In all patients, the author accessed the orbital floor via subciliary incision while approaching the medial wall with a retrocaruncular incision. After fully exposing the lesion, the author used a 1.0-mm-thick cross-linked acellular dermal matrix (ADM) (MegaDerm; L&C Bio, South Korea). After trimming the cross-linked ADM to a proper size, the author implanted the ADM into the lesion., Results: During May 2021 and June 2022, 3 cases of enophthalmos were successfully corrected with cross-linked ADM at the author's hospital. All patients were improved clinically and radiologically., Conclusion: This is the first study to show the effectiveness of cross-linked ADM for the correction of enophthalmos., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Enophthalmos is one of the most distressing complications of blowout orbital fractures. Although several studies have been conducted on the topic of indications of early surgical correction, none have been performed using a set of measurable parameters., Methods: The study quantitatively examined orbital fracture areas (OFA) and volumes (OFV) retrospectively of 242 patients with isolated medial orbital wall fractures that were treated conservatively during a 12-year period (from 2009 to 2021). Three plastic surgeons measured enophthalmos >6 months after trauma. The correlations between parameters and enophthalmos in the study cohort were analyzed. In addition, patients treated operatively, and nonoperatively were compared with assess the suitability of the predictive model., Results: Significant correlations were observed between several parameters and late enophthalmos. Total 2.59 cm 2 of OFA (ie, OFA >2.59 cm 2 ) or 1.45 cm 3 of OFV (ie, OFV >1.45 cm 3 ) corresponds to 2 mm of enophthalmos. Multiple regression analysis revealed the following coefficients: -0.208 is a constant ( P <0.001), with 0.695 and 0.372 for OFA and OFV, respectively ( P <0.001 for both OFA and OFV)., Conclusions: The study shows that enophthalmos can be more accurately predicted when OFA and OFV are simultaneously considered in patients with isolated medial wall fractures. Finally, an algorithm and a "blowout fracture coordinate plane" was proposed to aid treatment decision-making in isolated medial wall fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Orbital roof fractures are relatively rare facial bone fractures that usually occur in conjunction with other facial bone fractures or intracranial hematoma during high-velocity facial trauma. This study reports a patient with a significant blow-out orbital roof fracture combined with a nondisplaced frontal bone fracture and epidural hematoma at the superior aspect of unilateral frontoparietal convexity. Despite the severe superiorly-displaced fracture segment, the follow-up computed tomography scans taken 4 days after the injury showed a spontaneous reduction of blow-out orbital roof fracture. At the 1-week follow-up, the coronal image of craniofacial magnetic resonance imaging was taken, showing spontaneous realignment of orbital roof fracture and physiological evolution of cerebral contusion. In conclusion, conservative treatment can acquire the best outcome regarding cosmesis and function unless the patient requires an emergent operation for other medical conditions. This is key for successfully returning the patient's form and function., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Introduction: Orbital trapdoor fractures in children and adolescents can cause persistent problems with vision and appearance. Early surgery is recommended, although, because of the rarity of these fractures, there is a lack of evidence regarding the optimal timing of surgery.The objective of this study was to examine the effect of the time from trauma to surgery on the recovery time and severity of diplopia in children and adolescents with orbital trapdoor fractures., Materials and Methods: A retrospective cohort study was performed of all orbital fractures in children and adolescents aged 0 to 20 years, treated at a tertiary referral center in 2005-2017. Data relating to demographics, cause of injury, surgery, time of follow-up, and final outcomes were extracted. The cases of trapdoor fracture were specifically examined with regard to the time from trauma to surgery and diplopia at last follow-up, which was the primary outcome., Results: One hundred thirty-five patients, aged 2.4 to 20 years (mean 17.0), were treated for orbital fractures during the period; 37 (27%) had an isolated orbital floor fracture and 12 (9%) had a trapdoor fracture. All patients with trapdoor fractures underwent surgery; the mean time to surgery was 11.9 days in 2007-2011 and 1.1 days in 2012-2017. Although statistical significance cannot be proven in this small and retrospective study, a shorter time from trauma to surgery seems to lead to fewer problems with diplopia and 2 patient cases that highlight this are presented., Conclusions: Delayed surgical intervention in pediatric orbital trapdoor fractures increases the risk of delayed recovery and persistent diplopia. Other factors, such as the degree of muscle incarceration and necrosis and the surgeon's experience and skill, may, however, also influence the outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Traditionally, in zygomaticomaxillary complex and orbital fractures, miniplates and titanium orbital mesh are used and adapted intraoperatively, which may cause fatigue of the metal and increase the surgical time. Recently, computer-assisted surgery and 3-dimensional printing enable the surgeon to employ 3-dimensional segmentation and mirroring tools, which mimic the pretraumatized anatomy on which the miniplates and titanium orbital mesh are preoperatively molded to precisely duplicate the orbital volume, enophthalmos, and zygomatic bone position., Aim: To evaluate the results of computer technology using 3-dimensional printing model to prebend miniplates and titanium orbital mesh in the restoration of orbital volume, enophthalmos, and zygomatic bone position in the initial management of patients with zygomaticomaxillary complex and/or orbital fractures., Patients and Methods: This prospective clinical study included 10 Iraqi male patients who met the eligibility criteria and subjected to open reduction and internal fixation utilizing virtual surgical planning and a 3-dimensional model to prebend miniplates and titanium orbital mesh as a treatment modality for facial fractures. The data were analyzed according to the orbital volume, enophthalmos, zygomatic bone position, age, gender, etiology of the fracture, and complications. The patients were radiographically followed up with a computed tomography scan at 4 months postoperatively. The statistical analysis was performed using percentages, the mean±SD, Shapiro-Wilk test, Paired t test, One Way Anova, and Independent t test., Results: The age of the patients ranged from 18 to 66 years, with an average of 28.6 years and a SD of±14.5 years. Regarding gender, all patients were males. By utilizing virtual surgical planning and 3-dimentional model to prebend miniplates and titanium orbital mesh and concerning the fracture types, which include the zygomaticomaxillary complex, orbital, and combined fractures, there was no significant difference between the measurement of intact side and 4 months postoperatively in orbital volume, enophthalmos, and zygomatic bone position ( P >0.05)., Conclusion: This study demonstrated that computer-aided techniques, virtual planning, and the use of prebend miniplates and titanium orbital mesh enable anatomically precise reduction and fixation of the orbital, zygomaticomaxillary complex, and combined fractures regarding orbital volume, enophthalmos, and zygomatic bone position., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: Saddle nose deformity following naso-orbital ethmoidal (NOE) fractures remain a challenging problem for the reconstructive surgeon. Early reduction and internal fixation allow for fracture stabilization but is unable to address the problem of the depressed nasal dorsum, especially after soft tissue shrinkage. The aim of this study is to evaluate the outcome of primary rhinoplasty in patients with NOE fractures., Materials and Methods: From 2016 to 2019, 9 patients presented to our department with NOE fractures complicated by saddle nose deformity underwent primary nasal reconstruction at the time of their fracture fixation. Life size (1:1) frontal and lateral postoperative photographs were taken. Three objective measurements were made, including the nasofrontal angle, tip projection, and radix projection. These measurements were compared between normal persons (group 1), preoperative patients (group 2), and postoperative patients (group 3). Nose aesthetic assessment was carried out via a panel assessment using a Visual Analog Scale of 5. Patient satisfaction was further assessed subjectively by the patient themselves using the Visual Analog Scale., Results: When comparing group 3 to 2, a significant reduction in the nasofrontal angles was found with an accompanying increase in the radix and tip projection ( P <0.05). No statistical significance between normal persons and postprimary rhinoplasty patients was noted between groups 1 and 3. Average patient satisfaction scored 3.86±1.07 compared with 3.63±0.84 by laypersons and 4±0.77 by specialists' panel., Conclusion: Primary nasal reconstruction may be an alternative method for achieving optimum results following NOE fractures preventing the development of secondary saddle nose deformity with a shortened nose which may potentially be more difficult to correct., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Abstract: This study summarizes the process of digital-assisted multidisciplinary treatment (MDT) of naso-orbital-ethmoid (NOE) fractures and evaluates the treatment outcomes. From October 2018 to December 2020, 39 patients with NOE fractures were treated in our department, 21 of whom were diagnosed and treated by a multidisciplinary team. After preoperative multidisciplinary discussions and personalized virtual surgical planning, they received MDT with the assistance of a surgical navigation system. The other 18 patients received traditional single-disciplinary treatment, that is, no preoperative multidisciplinary discussions. Oral and maxil-lofacial surgeons performed surgical design and digitally-assisted surgery alone. After the operation, treatment outcomes were evaluated in terms of aesthetic appearance and function. The duration of preoperative preparation and postoperative aesthetic outcomes were not significantly different in patients who received single-disciplinary treatment and MDT ( P > 0.05). However, postoperative functional outcomes were significantly better in patients who received MDT ( P < 0.05). Furthermore, no significant complications were found. Digital-assisted MDT has a high application value in repair and appearance reconstruction, especially restoring functionality after NOE fracture; thus, it should be promoted in clinical practice., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the orbital anatomy and completely understand the important components relevant to surgical correction of enophthalmos, including oculo-orbito relations. 2. Understand the pathophysiology and predictive factors for posttraumatic enophthalmos and identify the challenges associated with correction of enophthalmos in the late setting. 3. Develop a surgical plan for late enophthalmos repair and understand the value and utility of osteotomies, intraoperative navigation, and patient-specific implants. 4. Discuss the expected outcomes, possible complications, and adjunctive surgery as related to late enophthalmos repair., Summary: This article addresses the current management of late posttraumatic enophthalmos. In this article, the authors describe surgically relevant orbital anatomy and oculo-orbital relations, the pathophysiology of enophthalmos, clinical and radiologic findings, decision-making in management, and surgical treatment. The authors attempt to cover some of the main challenges and recent advances in the management of late posttraumatic enophthalmos, including intraoperative navigation and patient-specific implants., Competing Interests: Disclosure:The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information contained in this article. No sources of funding were used for the creation of this article., (Copyright © 2022 by the American Society of Plastic Surgeons.)

White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are attributed to the tendency of younger bone to break and reapproximate owing to greater elasticity. This phenomenon, commonly referred to as the greenstick fracture, increases the risk of entrapment of surrounding soft tissue structures in orbital floor fractures. Further concern arises in the presence of an oculocardiac reflex, which requires urgent intervention to prevent serious bradycardia. Prolonged entrapment can go unnoticed and result in irreversible ischemic damage to entrapped tissues. This case discusses the presentation 16-year-old female who sustained a left sided, white-eyed blowout fracture from a face-first ground level fall. On admission, she displayed restrictive strabismus and mild periorbital edema around the left eye. Vertical gaze was restricted when looking inferiorly on the affected side. With sustained upward gaze, her heart rate decreased from 99 to 81 beats per minute. High-resolution non-contrast computed tomography scans of the head showed entrapment of the inferior rectus muscle and periorbital fat. Liberation of entrapped tissues with reduction of bony segments was performed urgently, utilizing a MEDPOR® Titan 3D orbital floor plate and secured with two screws. The patient had an uneventful postoperative period and showed considerable improvements in periorbital edema, duction, and ophthalmalgia on the affected side. In addition, the oculocardiac reflex could no longer be elicited on prolonged upward gaze. Mild and improving paresthesia was noted in the maxillary distribution of the left trigeminal nerve. Sensory deficits like this are the result of fracture communication with the infraorbital canal, which may cause irritation of the infraorbital nerve responsible for sensation by the maxillary division. By postoperative week 7, she had complete resolution of periorbital edema, indiscernible duction abnormalities, and complete healing of surgical incision sites, and an oculocardiac reflex could not be elicited., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Purpose: To evaluate the clinical effectiveness and safety of bioresorbable implants for treating paediatric zygomaticomaxillary complex (ZMC) fractures with concomitant orbital floor defects., Methods: A retrospective review of paediatric patients who underwent ZMC repair with concomitant orbital floor fractures with bioresorbable implants in Shanghai Ninth People's Hospital from July 2015 to June 2019 was performed. The primary outcome measures included ocular motility, diplopia, enophthalmos, facial deformities, and restricted mouth opening, as well as complication rates. Pre- and post-operative computed tomography scans were obtained for clinical diagnosis and surgical effectiveness., Results: Twenty two children were included in this study. Facial deformities were corrected in all 22 cases by surgical reconstruction postoperatively, and the average relative distance of Portals point-Zygomaxillare and Anteriornasalspine-Zygomaxillare were 1.3 ± 0.6mm ( P = 0.22) and 1.2 ± 0.5mm ( P = 0.19). The eye movement restored to normal in 13 patients. The mean amount of relative enophthalmos was 1.0 ± 0.4 mm ( P = 0.12). 12 cases had complete resolution of diplopia postoperatively at the extremes of the gaze, and 1 case presented persistent diplopia on the down gaze as before, but from level III to level I. Facial numbness was resolved completely in 6 cases, and 2 cases presented with persistent numbness but relieved significantly. The average Hounsfield units of RapidSorb plates and OrbFloor PI were 154 ± 5 and 99 ± 4 respectively on computed tomography image obtained 1 week postoperatively, which showed no obvious difference compared with 0.5 year postoperatively ( P > 0.1). Hounsfield units of implants gradually declined around 1 year postoperatively. Hounsfield units of RapidSorb plates (20 ± 1) were consistent with periorbital tissue during postoperative 2-year follow-up, and Hounsfield units of OrbFloor PI (19 ± 1) were consistent with periorbital tissue during postoperative 1.5-year follow-up. No patients had severe sequelae or implant related complications postoperatively. None of bone nonunion, malunion, infection or rejection occurred during the follow-up periods., Conclusions: Open reduction and internal fixation for the treatment of ZMC fracture have achieved significant improvement in functional and cosmetic outcomes postoperatively. Bioresorbable materials have been proved to be effective and safe in the treatment of children's ZMC and orbital wall fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Summary: Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. However, identifying those at risk for delayed enophthalmos and requiring subsequent repair has remained a challenge. This study aimed to validate the Orbital Index, a prediction tool using computed tomography to stratify risk for delayed enophthalmos and establish a threshold for repair. The Orbital Index stratifies fractures by size, location, and inferior rectus rounding (a surrogate for fascioligamentous sling disruption) on a scale 0 to 6. A 22-year (1998 to 2020) multi-institution analysis of unilateral isolated orbital floor fractures was performed. Index scores were assigned to each scan, unoperated patients invited for blinded Hertel exophthalmometry assessment, and enophthalmos measurements correlated with Index scores. Interobserver scoring reproducibility was assessed with weighted Cohen kappa. Preintervention and postintervention Likert scale surveys were administered to determine whether this tool improved understanding and communication. The Orbital Index demonstrated high fidelity and interobserver reproducibility and identified a score of four or greater as a surgical threshold. Of 1769 computed tomography scans, 395 met criteria and were included for analysis. Eighty of 395 were managed operatively (operative rate, 20.3 percent). Of 315 patients managed nonoperatively, 41 (13.0 percent) agreed to follow-up evaluation and 28 (68.3 percent) were found to have enophthalmos. Unoperated patients with an Orbital Index score of 4 or higher were more likely to have enophthalmos than those with a score of 3 or less ( p = 0.001). The mean weighted Cohen kappa was 0.73, corroborating reproducibility. Communication ( p = 0.0003) and ability to correctly identify surgical need ( p = 0.01) were improved with use of this tool. The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Abstract: Combined orbital medial wall and floor fractures and large isolated orbital floor fractures commonly require surgical treatment due to the high probability of diplopia and enophthal-mos. Primary reconstruction of these orbital fractures requires a high-level surgeon with a great amount of technical surgical skill. The use of novel technology can greatly improve the accuracy of reconstruction and achieve satisfactory clinical outcomes. Hence, the authors aimed to present our findings and overall experience with respect to extensive floor and medial wall orbital fracture reconstruction according to the Computerized Operation Neuronavigated Surgery Orbital Recent Trauma (CONSORT) protocol, a workflow designed for the primary reconstruction of orbital fractures with customized mesh and intraoperative navigation. A total of 25 consecutively presenting patients presenting with unilateral extensive orbital floor fractures and orbital floor and medial wall fractures were treated following the CONSORT workflow from January 2017 to March 2020. Fractures were surgically treated with a customized implant and intraoperative navigation. Patients underwent surgery within 14 days of the trauma injury. Preopera-tive and postoperative functional and aesthetic outcomes are described herein. All fractures were successfully reconstructed. Postoperatively, all 19 patients with preoperative diplopia reported the resolution of diplopia. Enophthalmos resolved in 18/20 cases. No patients had major complications during follow-up. Thus, the authors conclude that the CONSORT protocol introduced by the authors is an adaptable and reliable workflow for the early treatment of orbital fractures and can clearly optimize functional and aesthetic outcomes, reduce costs and intensive time commitments, and make customized and navigated surgery more available for institutions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Purpose: To determine factors influencing postoperative enophthalmos after reconstruction of orbital wall fracture., Method: Data of consecutive patients who were diagnosed with unilateral medial or inferior orbital wall fracture from March 2013 to February 2020 were retrospectively reviewed. Forty-three patients were included in this study (24 with medial orbital wall fracture and 19 with inferior orbital wall fracture). Their medical records including Hertel exophthalmometry, preoperative computed tomography (CT) scan, and postoperative CT scan were reviewed. The degree of enophthalmos developed was calculated by measuring exophthalmos before surgery and at 6 months after surgery. Patients were classified into 2 groups depending on whether reduction was good after surgery or not. Data (eg, age, gender, onset, fracture size, and so on) were then compared between these 2 groups., Results: A total of 43 patients were included in the study. Their mean age was 40.1 years. There were 34 (79.1%) males. The mean onset from trauma to surgery was 8.1 days. Insufficient soft tissue reduction was found in 9 patients through postoperative CT scan. Preoperative mean enophthalmos was - 1.70 mm. Postoperative mean enophthalmos was -0.45 mm after 6 months. The mean fracture size was 213.74 mm2. There was no statistically significant difference in enophthalmos at 6 months after surgery regardless whether the reduction was good or not. Enophthalmos at 6 months after surgery was associated with preoperative fracture size and onset., Conclusions: Postoperative enophthalmos development might be associated with preoperative fracture size and onset. Delayed operation in case of large orbital wall fracture might lead to undesired result. Thus, surgeons should keep that in mind., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Introduction: Neurological sequelae of infraorbital nerve (ION) lesion 6 months after orbital floor or zygomaticomaxillary complex (ZMC) fractures, associated with initial ION injury, were compared according to the treatment performed and the type of fracture. The topographic and symptomatic sequelae at 6 months were described., Materials and Methods: Patients with orbital floor or ZMC fracture associated with initial ION injury, between November 2018 and April 2020 and clinically reassessed 6 months after trauma were included. Detailed neurological symptomatology was assessed by a questionnaire., Results: A total of 81 patients were included. Forty-two patients (51.8%) showed persistent neurological signs, i.e., isolated hypoesthesia in 28 patients (66.7%), isolated pain in 10 patients (23.8%) and both in 5 patients (9.5%). The most affected area was the cheek (42.8%). Thirty-eight patients (46.9%) presented associated signs, which were intermittent in 78.9% of cases. A pronounced improvement happened for 65.1% of patients and 76.7% were not or only slightly hindered in their daily activities. There were significantly more neurologic symptoms at 6 months in the surgical group than in the observational group and more in the ZMC fracture group than in the orbital floor fracture group., Discussion: Neurological symptomatology was more frequent in patients treated surgically. Our results suggest the interest of a surgical decompression when orbital or ZMC fracture is associated with nerve damage but more data are needed. Neurological injury requires a careful initial clinical evaluation and regular follow-up to help patients coping, painful symptoms may benefit from specialized care., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: Traumatic optic neuropathy (TON) is a rare disease but leaves critical sequelae to patient. Purpose of this study is to evaluate the incidence of TON in each orbital wall fracture., Materials and Methods: Retrospective review of 2629 patients with orbital wall fracture was performed in from January 2010 to March 2019, based on diagnostic code, Korean Standard Classification of Diseases, 7th Revision. The orbital wall fractures were divided into 4 subtypes: superior, medial, inferior, and lateral wall. Incidence of TON is analyzed according to subtypes, single and multiple wall fracture., Results: Among 2629 patients with orbital wall fractures, 27 patients were diagnosed with TON with an incidence of 1.02%. In single wall fracture, only lateral wall showed significantly high TON incidence, which only zygomatic fracture was included in single lateral wall fracture. In multiple wall fracture, it was statistically significant in the superior wall., Conclusions: Fracture on lateral and superior orbital wall showed a tendency to increase the incidence of TON. Based on the above results, radiologic evaluation and physical examination is necessary for patient who has lateral and superior orbital wall fracture., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Abstract: Blowout fractures of the floor of the orbit can serve as a "trap door" for extraocular muscles. Presentation of inferior orbital muscle entrapment classically involves an upward gaze restriction. Diplopia and exophthalmos can also be present. Rarely, orbital fractures can result in an oculocardiac reflex, which is a triad of bradycardia, syncope, and nausea. The purpose of this study was to describe a patient who had orbital floor fracture with symptoms highly suggestive for oculocardiac reflex after a traumatic injury. Although entrapment of extraocular muscles does require early intervention to prevent ischemia and tissue necrosis, the presence of oculocardiac reflex warrants emergent evaluation and management by an ophthalmologist due to the risk of developing arrhythmias. Frequently, there may be none or very subtle clinical findings present, and abnormal motility may be the only apparent clinical sign, which can be difficult to assess in very young and uncooperative children; therefore, a high index of suspicion must be maintained for early identification and management as well as a reduction of complications., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to report 3 cases of orbital complications in patients with secondary sinusitis due to medial orbital wall fracture. We believe that sinusitis can be secondary to the fracture of the medial orbital wall when the sinus drainage orifice is blocked due to some fracture pieces or other blocking factors. We precisely show the direct evidence of the blocking factors through radiology., Design: Retrospective, noncomparative, interventional case series., Participants: All patients had intraorbital complications and a history of traumatic orbital medial fracture as well as imaging findings of sinusitis., Methods: A medical record review of clinical history, imaging studies, and surgical and treatment outcomes were performed., Main Outcome Measures: Postoperative visual acuity, appearance, eye movement, surgical and imaging findings., Results: Three patients (2 males and 1 female; average age 38.33 years [range, 11-65]) received endoscopic surgery for orbital complications related to sinusitis. All patients had evidence of paranasal sinusitis after the orbital injury. Two patients were treated with antibiotics before the operation, but there was no significant improvement. All patients underwent transnasal endoscopic sinotomy. Two patients received orbital abscess incision and drainage surgery and 1 patient underwent a cyst excision operation. The visual acuity of the 3 patients was improved after the operation, and the clinical examination was significantly improved., Conclusions: The anatomy of the orbit is closely related to the nasal cavity. The fracture of the medial orbital wall often causes abnormal anatomy of the sinus outflow tract. For the 3 of our patients, the blocking factors of sinus orifices were fracture fragment, orbital bone deformation, and the formation of giant nasal intraorbital mucocele. Sinusitis possibly occurs when drainage is not smooth. Infections develop due to the secretions retaining and accumulation of microorganisms. Inflammation from the sinus can be spread into the orbit in various ways. Our 3 patients indicate that a fracture of the inner orbital wall may cause sinusitis. When the patient is injured again or sneezing or in other conditions when the pressure in the nasal cavity increases, inflammation of the sinuses enters the orbit, causing serious intraorbital complications. It is necessary to carefully follow-up on the medical history, combined with imaging examination, to prevent the misdiagnosis of intraorbital hemorrhage or hematoma from affecting the treatment.In recent years, more and more cases of intraorbital complications caused by sinusitis have been reported.1,2 Severe intraorbital inflammation can pose a threat to vision and even life. With the great tool of the endoscope, nasal-orbital problems can be well solved. For our 3 patients, we opened the paranasal sinus and removed the occlusion of the sinus orifice through transnasal endoscopy. All patients achieved good surgical and clinical results., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Abstract: The oculocardiac reflex has been well described in the literature and was first defined in 1908 by Aschner. The phenomenon involves the afferent limb of the ophthalmic division of the trigeminal nerve as well as the efferent pathway involving the vagal nerve leading to negative chronotropic effects. It results in a decrease in heart rate and oftentimes a decrease in blood pressure associated with compression of the eye or traction of the extraocular muscles. This reflex has clinical significance in both the operating room during ophthalmic procedures and in the emergency department in patients having sustained craniofacial trauma. The typical dysrhythmia described in literature is sinus bradycardia. Our patient, however, had a ventricular escape rhythm with a complete left bundle branch block pattern., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation., Methods: The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures., Results: One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02)., Conclusions: The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool., Clinical Question/level of Evidence: Risk, III., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Introduction: Radiographic assessment of facial fractures with computed tomography (CT) scanning has become standard of care. As imaging resolution has improved, findings such as herniation of extraocular muscles (EOM) have become a means of diagnosing conditions like orbital entrapment. However, the sensitivity and specificity of these findings has not been well-studied. We sought to evaluate the value of radiographic findings such as fat herniation, EOM contour irregularity, and EOM herniation in predicting orbital entrapment after orbital fracture. Secondary endpoints include diplopia, abnormal EOM motility, and the need for surgical fixation., Methods: A single institution, retrospective review at a regional level 1 trauma center was conducted. Patients with orbital fractures were identified by International Classification of Disease (ICD) codes and CT reports were queried for the terms "herniation," "herniated," "entrapped," and "entrapment." Four hundred records were analyzed., Results: Sixty-seven percent of radiology reports mentioned "entrapped" or "entrapment," while the incidence of clinical entrapment was 2.8%. The odds of entrapment, diplopia, and abnormal EOM motility were higher in those with EOM herniation; however, EOM herniation had a positive predictive value of 7.9% for clinical entrapment. Fat herniation alone and EOM contour irregularity had positive predictive values of 4.2% and 4.8%, respectively., Conclusions: While the odds of entrapment appear higher in patients with EOM herniation, this imaging finding is not predictive of clinical entrapment. Fat herniation and EOM contour irregularity did not have higher odds of entrapment, nor were they predictive. Diagnosis of orbital entrapment should be based primarily on physical exam, with CT as an adjunct only. The assumption that radiographic findings indicate orbital emergencies may result in unnecessary interfacility transfers, subspecialist consultations, and emergency operative procedures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Background: Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients., Methods: This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures., Results: Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients., Conclusions: High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored., Clinical Question/level of Evidence: Risk, II., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Introduction: Persistent diplopia following orbital fracture is a well-recognized problem. While observation is the standard-of-care, symptoms may be protracted. Orthoptic vision therapy is a form of ocular physical therapy that achieves functional rehabilitation through targeted exercises. This study presents a protocol for post-traumatic orthoptics and describes preliminary results., Materials and Methods: Protocols for home-therapy/office-assessment were developed using commercial software and exercises targeting motility and fusion. Office-assessment also included validated questionnaire chronicling symptomatology. Healthy-volunteers (n = 10) trailed the protocol three times (n = 30) and normative data was compiled. Comparative measurements were made in chronic (>1year; n = 8) and acute (<2 weeks; n = 4) fracture cohorts. Time-of-therapy was recorded, monetary cost-analysis performed, and side-effects assessed., Results: Severe/moderate motility limitation was found in 3 of 4 acute fracture patients but not in chronic or healthy cohorts. The acute cohort had worse fusion when comparing convergence (mean break/recovery of 8.0/6.5 prism diopters (pd) versus 31.87/21.23pd; P = 0.001/0.015) and divergence (3.00/1.50pd versus 18.37/12.83pd; P = 0.000/0.001) to the healthy cohort. Those with chronic fracture had lower convergence (15.71/5.00pd; P = 0.01/0.001) and divergence (12.29/4.71pd; P = 0.04/0.002) when compared with healthy subjects, but better function than acute patients. Acute fracture patients reported greater symptomatology than chronic (mean score 18.8 versus 4.6; P = 0.003) or healthy (5.0; P = 0.02) groups, but there was no difference between chronic and healthy groups (P = 0.87). Assessment took <10 minutes. Per patient software cost was <$70. Mild eyestrain related to therapy was self-resolving in all cases., Conclusions: Orthoptic therapy may improve fusion and motility following orbital fracture. This protocol serves as basis for prospective work., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Abstract: Pure orbital wall fractures represent until 25% of the facial fractures and its reconstruction it's considering a challenge for the maxillofacial surgeons. There are many biomaterials used to repair these fractures according to the literature however, the most common are the titanium mesh and autogenous bone graft.The aim of this work is to report a rare case of blow-in roof orbital fracture associated to an intracranial hematoma in the cranium base., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Background: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis., Methods: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses., Results: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases., Conclusions: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population., Clinical Question/level of Evidence: Risk, III., (Copyright © 2020 by the American Society of Plastic Surgeons.)

The orbital complications of endoscopic sinus surgery, including diplopia and ocular motility restriction, are mainly caused by direct injury to the orbital structures. These complications are rare, but can have catastrophic consequences. Symptoms occur immediately after surgery in most cases. The authors encountered an unusual case of delayed ocular motility restriction after endoscopic sinus surgery in a patient with old medial wall fracture, without direct orbital injury during the procedure. A 77-year-old man with an old medial wall fracture of the right orbit underwent endoscopic sinus surgery for chronic pansinusitis. He complained mild diplopia on right lateral gaze after 2 weeks, which gradually worsened. After 2 months, he exhibited severe lateral gaze movement impairment in the right eye and finally underwent surgical exploration. His symptoms improved after adhesiolysis of the overgrown ethmoid sinus mucosa and periorbital tissue. The authors reported this unusual case and discussed the possible mechanism underlying ocular motility restriction.

Introduction: A closed globe trauma is often associated with orbital wall fractures. In addition to diplopia, further eye disturbances can be observed. The aim of this preliminary prospective study was to investigate the optical coherence tomography (OCT) findings in patients that presented with orbital fractures in association with diplopia but without decreased visual acuity or further ocular symptoms., Methods: Only patients who were admitted and surgically treated for orbital wall fractures and that presented diplopia were included in this study. Patients with post traumatic ocular symptoms were excluded. All the patients that were diagnosed with an orbital fracture underwent an ophthalmological assessment, including best-corrected visual acuity (BCVA), examination of fundus oculi, Hess Scheme, OCT, and OCT angiography., Results: Five patients met the inclusion criteria and were enrolled. Hess Scheme examinations confirmed the presence of diplopia in all the included patients. The examination of fundus oculi did not reveal any pathology in 4 patients, whereas in a patient a commotio retinae (Berlin's Edema) was diagnosed in the infero-papillary field. Following OCT assessment, a pachycoroid was observed in 4 patients., Conclusions: A thorough ophthalmological assessment in patients that have suffered from orbital fractures is fundamental. In particular, OCT examinations seem to provide more insight into the detection and monitoring of choroidal changes after ocular trauma without visible macular changes.

Spiral computed tomography is a gold standard in diagnostics of intraorbital pathological changes. Modern software provides great opportunities at viewing and analyzing DICOM files. Earlier, the authors introduced a method of computed exophthalmometry for precise measurement of globes' position even in the cases of lateral orbital rim fracture. However, eye proptosis is known to be depending on the eye length (ocular component), retrobulbar volume (orbital component), as well as anatomy of neurocranium and brain (cerebral component). Nevertheless, conventional Hertel exophthalmometry and other proposed methods do not specify the component, involved in the pathogenesis of enophthalmos or exophthalmos, that is why additional examinations are required. In this article, the authors propose a novel approach, which can complement and/or substitute instrumental methods used for differential diagnostics of enophthalmos or exophthalmos.

Purpose: We employed intraoperative tarsorrhaphy depending on the degree of edema to treat moderate conjunctival chemosis during orbital fracture repair surgery., Methods: This is a retrospective case review of 1367 patients (1384 eyes) who underwent orbital fracture repair surgery by a transconjunctival approach. All cases of moderate conjunctival chemosis during surgery were included and were divided into 2 groups. In one group, intraoperative tarsorrhaphy was performed immediately the chemosis reached a moderate degree and the conjunctiva was incarcerated by the lower eyelid margin; once severe chemosis developed, stitches were added to cover all of the prolapsed conjunctiva with a palpebral margin. In the second group, moderate chemosis was treated with bandage pressure without stitches even after appearance of severe chemosis. The time course of conjunctival edema was recorded., Results: The incidence of moderate conjunctival chemosis in orbital reconstruction surgery by the transconjunctival approach was 9.4%. The average time for resolution of moderate chemosis in the tarsorrhaphy group (3.5 ± 1.4 days) was obviously shorter than in the bandage group (6.2 ± 1.9 days). The incidence of severe chemosis in the intraoperative tarsorrhaphy group (14.1%) was significantly lower than in the bandage group (31.8%). Overall, the total duration of severe chemosis in the tarsorrhaphy group was obviously shorter than that of the bandage group., Conclusion: Intraoperative tarsorrhaphy was a highly effective method of treating moderate chemosis and preventing severe conjunctival chemosis during orbital fracture repair surgery.

Unilateral recurrent maxillary sinusitis is a common sinunasal pathology, mostly related to the ostiomeatal complex dysfunction. Although sinusitis can potentially spread to the adjacent structures, orbital cellulitis remains an exceptionally rare sequela.The authors report the unusual case of a patient who presented with recurrent maxillary sinusitis complicated by cyclic episodes of periorbital cellulitis related to ostiomeatal complex obstruction from herniated periorbital fat through an unnoticed medial orbital wall fracture. To the best of our knowledge, no other similar case has previously been reported. The possible explanation for such an unusual association is discussed.

The aim of this study was to investigate the clinical outcomes of orbital blowout fracture repair by using the three-dimensional (3D) printing-assisted fabrication of individual titanium mesh. Clinical and radiologic data were analyzed for 12 patients with orbital floor and/or medial wall fractures. Lower eyelid incision was used to expose the fractures. Preoperative computed tomographic data were input into an imaging software to rebuild a 3D orbit and mirror the unaffected side into the affected side to replace the demolished orbit. A resin model of the reshaped orbit was generated and used to develop an individual titanium mesh for repairing the fractured orbital. The surgical results were assessed by value of enophthalmos and a comparison of preoperative and postoperative orbital volume difference. All patients had a successful treatment outcome without any complications. Clinical significant enophthalmos were not observed after treatment, and diplopia were solved within 2 weeks postoperative. No extraocular muscle limitation was observed. Postoperative computed tomography scans demonstrated appropriate positioning of titanium mesh and there was no implant displacement. The postoperative orbital volume and enophthalmos difference between the 2 eyes decreased significantly than preoperative (P < 0.001). Three-dimensional printing-assisted fabrication of individual titanium mesh is appropriate for use in orbital blowout fracture.

Retrobulbar emphysema is a rare condition compared to the more common orbital emphysema. It is often associated with medial orbital wall fracture with rupture of the periosteum. In some severe patients, retrobulbar emphysema can increase the intraorbital pressure and lead to orbital compartment syndrome. Less extreme patients require only conservative treatment with careful observation. There is still no standard protocol for the management of orbital emphysema in general or specifically for retrobulbar emphysema. Visual acuity is the most widely used indicator to determine whether surgical intervention is needed. The patient presented here suffered from large retrobulbar intraconal emphysema and exophthalmos without visual loss after head trauma and nose blowing. He was observed closely without surgical intervention. After the emphysema had resolved, the patient's medial orbital wall defect was reconstructed using unsintered hydroxyapatite particles/poly L-lactide via the transcaruncular approach. The postoperative course has been uneventful with more than 1 year of follow-up to date.

Rationale: The precise cause of granulomatosis with polyangiitis (GPA) remains unclear. Herein we present a case of refractory GPA occurring after trauma., Patient Concerns: A 43-year-old man suffered fractures of the left orbital in an accident, and then received surgical repair. At a postoperative follow-up, he developed maxillary sinusitis. Seven months later, he was hospitalized with symptoms of cough, high-grade fever, and loss of weight., Diagnosis: He was diagnosed with GPA based on the symptoms of upper and lower respiratory tract involvement, granulomas in a lung biopsy specimen, and presence of PR3-ANCA., Interventions: Initially the patient responded well to the treatment of glucocorticoids and cyclophosphamide (CYC). Forty days later, he was hospitalized again with symptoms of fever, cephalgia, and recurrent ulcerated subcutaneous nodules, due to the vasculitic manifestations of GPA. This time he was treated with cyclophosphamide and glucocorticoids with no improvement, and then switched to rituximab., Outcomes: After 4 doses of rituximab, the symptom of cephalgia disappeared and subcutaneous ulcerations and conjunctival congestion diminished., Lessons: Trauma may act as an inflammatory stimulus to affect the course of disease in GPA. The combination of glucocorticoids and cyclophosphamide is the standard therapy for GPA. Nevertheless, patients who have no response to CYC, especially with predominantly vasculitic manifestations, could resort to rituximab.

Delayed repair of orbital trapdoor fractures can jeopardize the viability of entrapped contents and prolong recovery. Variation in presentations, both clinically and radiographically, complicate prompt diagnosis. The oculocardiac reflex may be the only indication of fracture with entrapped orbital contents, but, unfortunately, the reflex has variable onset patterns and can mimic common diagnoses. Therefore, the authors present the case of a 14-year-old male with a right orbital floor fracture, who presented with delayed symptoms secondary to an oculocardiac reflex. The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits. After admission to the hospital due to progressive symptoms, a CT scan showed concerns for a subacute orbital blowout fracture. The patient underwent orbital floor exploration with findings of scarred orbital fat herniating into a healing fracture site. Repositioning of the fat into the orbit resulted in immediate resolution of the patient's symptoms. Awareness of the presenting characteristics of the oculocardiac reflex can lead to prompt diagnosis and maximize clinical outcomes.

Trapdoor fractures are common in children because of elastic nature of the pediatric bone. Clinical signs and radiological evidence in these cases may be minimal.This study involves a 14-year-old girl who sustained blunt trauma to her left eye. Initial investigation, for pure orbital floor fracture included computerized tomography (CT scan) of the orbit, did not show any evidence of incarcerated rectus muscle. She had no limitation of extraocular movements nor enophthalmos. Following conservative treatment, she had a left persistent orbital pain and left monocular diplopia. This prompted a magnetic resonance imaging (MRI) of the orbit investigating soft tissue, which found fine partial muscle herniation through the self-sealed fracture needing surgical intervention.Although an orbital CT imaging is preferrd, in this acute setting, magnetic resonance imaging should be considered to delineate the soft tissue anatomy in relation to a trapdoor fracture, especially when there are not cardinal associated physical symptoms with a trap door fracture such as restricted eye movement and enophthalmos. Mono-ocular diplopia can be noted as an associated symptom to prompt early surgical repair.