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Purpose: To present the application of computer-assisted surgery (CAS) in pre-operative planning, intra-operative navigation, and post-operative assessment as an adjunct tool in orbital surgery., Methods: An IRB-approved, retrospective review was performed to identify patients who had undergone orbital surgery by a single surgeon from July 2013 to December 2019 with attention to pre-operative virtual surgical planning, intra-operative navigation, and post-operative assessment. The reasons and methods of CAS use were classified., Results: The use of computer-assisted technologies was identified in 91 cases out of 464 orbital surgeries (19.6%). This included 23 (25.3%) orbital decompression surgeries, 39 (42.9%) fracture repairs, and 25 (27.5%) orbital tumors. In all cases, pre-, intra-, and post-operative CAS allowed for increased operative efficiency and safety with good outcomes., Conclusions: Use of CAS in orbital surgery can allow for complex radiographic analysis and in select cases is a great tool to add to the orbital surgeon's armamentarium.

Late-onset orbital hemorrhage is a rare complication of alloplastic implant use in orbital wall reconstruction following trauma. The authors report 3 patients with chocolate cysts presenting 3 to 9 years after orbital fracture repair with porous polyethylene implants. All patients were managed by implant removal and evacuation of cyst contents. Complete excision of the cyst was performed in 1 patient, while partial excision of the capsule was performed in 2 patients. Improvement of symptoms associated with the mass effects of the cyst was noted after surgical intervention. The authors also report the first case of orbital volume expansion from a chocolate cyst associated with a nonbarriered porous polyethylene implant. Delayed hemorrhage with capsule formation, although extremely rare, is a possible complication following orbital fracture repair with porous polyethylene implants., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2020 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma., Methods: A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity., Results: Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026)., Conclusions: The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.

Purpose: Reconstruction of orbital wall fractures is demanding and has improved dramatically with the implementation of new technologies. True-to-original accuracy of reconstruction has been deemed essential for good clinical outcome, and reasons for unfavorable clinical outcome have been researched extensively. However, no detailed analysis on the influence of plate position and surface contour on clinical outcome has yet been published., Materials and Methods: Data from a previous study were used for an ad-hoc analysis to identify predictors for unfavorable outcome, defined as diplopia or differences in globe height and/or globe projection of >2 mm. Presumed predictors were implant surface contour, aberrant implant dimension or position, accuracy of reconstructed orbital volume, and anatomical fracture topography according to the current AO classification., Results: Neither in univariable nor in multivariable regression models were unfavorable clinical outcomes associated with any of the presumed radiological predictors, and no association of the type of implant, i.e., standard preformed, CAD-based individualized and non-CAD-based individualized with its surface contour could be shown., Conclusion: These data suggest that the influence of accurate mechanical reconstruction on clinical outcomes may be less predictable than previously believed, while the role of soft-tissue-related factors may have been underestimated., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To evaluate the usage of preoperative digital anatomic implant evaluation in internal orbital fractures., Methods: An IRB-approved review of cases of orbital fracture repair was conducted and cases where digital implant modeling was performed were selected for comprehensive review. The surgical time of these cases was also compared with surgeon and implant matched controls., Results: A total of 25 patients and 26 orbits underwent preoperative virtual fitting and were reviewed. There were no complications or revision surgeries needed. Postoperative assessment demonstrated accuracy to the preoperative target with an average maximum deviation of 1.9 mm., Conclusions: Preoperative digital fracture assessment, implant manufacturer and size selection, and virtual cutting guide creation provides additional tools for orbital surgeons to achieve anatomic restoration without significant differences in operating time.

Background: Restoration of orbital volume after internal orbital fractures can prevent enophthalmos. A variety of allografts are commonly used including titanium mesh with and without porous polyethylene coating. Some controversy exists over the use of uncoated titanium mesh in the orbit. Newer products contoured to the three dimensional orbital anatomy aim to improve reestablishment of the complex orbital shape though studies of outcomes with their use are limited., Methods: A retrospective chart review was performed to evaluate surgical outcomes in all patients who underwent orbital fracture repair with DePuy/Synthes titanium MatrixMIDFACE prefabricated implants (PFTi) as compared with porous polyethylene/titanium hybrid implants (PPETi) including Stryker Medpor Titan, MTB, and BTB implants. Incidence of reoperation, diplopia, and movement restriction between PFTi and PPETi groups and the risk ratio of the above outcomes between implant types were compared., Results: A total of 464 orbital implants were reviewed. Patients were divided by implant type with 195 patients receiving a PFTi implant and 269 patients receiving PPETi implant. (PFTi) and 269 had placement of a porous polyethylene/titanium hybrid implant. Despite statistically significant increased probability of utilization in more complex and delayed fractures, the PFTi implant showed no significant difference in complication profile or reoperation rate compared to the more commonly used PPETi., Conclusions: PFTi implants, designed to replicate the native orbital shape, have similar surgical outcomes and no difference in complication profile compared to standard porous polyethylene/titanium implants hybrid plates., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: A variety of implants are available for orbital reconstruction. Titanium orbital mesh plates are available either as standard preformed implants or able to be individualized for the patient. The aim of this study was to analyze whether individualized orbital implants allow a more precise reconstruction of the orbit than standard preformed implants., Materials and Methods: A total of 195 patients treated between 2010 and 2014 were followed up to 12 weeks after surgery. Of the patients, 100 had received standardized preformed and 95 individualized implants. The precision of orbital reconstruction with the different implants was determined by comparing the variances in the volume difference between the reconstructed and the contralateral orbit on the postoperative computed tomographic scans. Clinical volume-related parameters including globe position, vision, motility, and diplopia and surgical details including approach, timing and technique of implant modification, use of navigation, duration of surgery, as well as adverse events were documented., Results: Orbital reconstruction was significantly more precise when individualized implants were used. The same was seen with intraoperative navigation. An overlap in the use of individualized implants and navigation makes it difficult to attribute the improved precision to a single factor., Conclusion: This study demonstrated that individualization and navigation provide clinical benefit., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Pediatric orbital fractures represent a challenging and sometimes controversial clinical problem. Patients may present with clear indications for surgery, but most require balancing benefits against intraoperative and late complications. The authors assessed these fractures at a state-designated ophthalmology referral center to develop criteria for surgery., Methods: Institutional review board approval was obtained to retrospectively analyze pediatric trauma registry patients with orbital fracture diagnoses at the Wilmer Eye Institute over 10 years. Patients were excluded if they did not undergo a full ophthalmologic examination, never followed up after their injury, or had significant facial fractures outside of the orbit., Results: One hundred fifty patients met selection criteria; 116 patients (77 percent) completed all follow-up (average, 309 days). Two patients had 20/40 vision or worse at the end of follow-up. One hundred ten patients (71 percent) underwent surgery; 96 underwent acute repair (<3 weeks) and 11 underwent delayed repair (median, 49 days). Three patients required reoperation, two for plate infection and one for hyperglobus, with an overall complication rate of 4.7 percent., Conclusions: The authors analyzed the largest series of operative pediatric orbital fractures to propose criteria for surgical intervention. There are four potential indications: (1) rectus muscle entrapment; (2) early enophthalmos; (3) central-gaze diplopia or extraocular movement restriction after the resolution of swelling; and (4) loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision. In our series, application of these principles offered excellent long-term aesthetic and ophthalmic outcomes with an acceptably low complication profile., Clinical Question/level of Evidence: Therapeutic, III.

The advent of computer-assisted technology has revolutionized planning for complex craniofacial operations, including orbital reconstruction. Orbital reconstruction is ideally suited for virtual planning, as it allows the surgeon to assess the bony anatomy and critical neurovascular structures within the orbit, and plan osteotomies, fracture reductions, and orbital implant placement with efficiency and predictability. In this article, we review the use of virtual surgical planning for orbital decompression, posttraumatic midface reconstruction, reconstruction of a two-wall orbital defect, and reconstruction of a large orbital floor defect with a custom implant. The surgeon managing orbital pathology and posttraumatic orbital deformities can benefit immensely from utilizing virtual planning for various types of orbital pathology.