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The purpose of this systematic review was to critically analyse the recent literature and present the state of the art in customised reconstruction of orbital fractures. Three electronic databases and manual search approaches were used to identify relevant articles. Only controlled clinical studies were included. Primary outcome was defined as the status of recovery (complete/partial functional, and aesthetic disturbances). The benefit of intrasurgical navigation should be described. The secondary outcome was defined as the time of surgery, post-surgical events, and hospitalisation. Of the 552 records identified, eight met the inclusion criteria. Post-surgical results regarding recovery were superior in the customised group, and were comparable to the control group in five studies. The time of surgery was shorter in the customised groups, and liquid infusion and time of hospitalisation were reduced. Four studies documented more accurate reconstruction with the use of navigation. All the studies presented at least one bias, and considerable heterogeneity was evaluated. This review found that the use of customised meshes in combination with surgical navigation resulted in more accurate reconstruction. A significant reduction in surgical time was revealed., (Copyright © 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Saccadic eye movement plays an important role in the rapid movement of the eyes to visual targets; however, it has not been fully investigated in patients with an orbital floor fracture. Thus, this study investigated saccadic eye movement before and after surgery in patients with an orbital floor fracture. The saccadic peak velocity (PV) was recorded using an eye-tracking device before and after surgery in nine eyes of nine patients with an orbital floor fracture. The type of fracture was a depressed fragment fracture in all cases, and there was no trap-door fracture. Ocular motility and diplopia were evaluated by the Hess area ratio (HAR%) and the scoring of binocular single vision (BSV). The preoperative HAR% and those at 1 month post-surgery and the final post-surgery observation were 62 ± 6%, 83 ± 11%, and 91 ± 8%, respectively. The preoperative, 1 month post-surgery, and final observation post-surgery BSV scores were 34 ± 18, 46 ± 8, and 50 ± 8 points, respectively. The postoperative HAR% and BSV were significantly improved at the final post-surgery observation ( p < .05 each). The saccadic PVs of adduction, abduction, and downgaze before and after surgery were not significantly different in both the non-injured eyes and the injured eyes. However, the upgaze saccadic PVs at 1 month and the final post-surgery observation in the injured eyes were significantly increased ( p < .05 each). The saccadic PV may be useful to evaluate detailed and precise extraocular muscle function before and after surgery for orbital floor fractures.

The two surgical approaches to access orbital fractures are transconjunctival and transcutaneous. The aim of this study was to assess the outcomes of orbital repairs with a focus on lid-related complications and their management. A retrospective analysis was carried out over a five-year period (January 2015 to January 2020) to assess all consecutive orbital repairs in our unit. Data were collected for variables including demographics, fracture pattern, surgical approach, and details of postoperative complications. A total of 111 patients were included in the study, 94 were male (85%), the majority being between 16 and 45 years of age. A total of 46 (41%) had isolated orbital floor fractures, 31 (28%) zygomaticomaxillary complex, and 18 (16%) Le Fort pattern fractures. Eighty per cent (n = 91) received a transconjunctival approach as first choice. In the transconjunctival group, six (6.6%) had entropion and increased scleral show, four (4.4%) had ectropion, and none had canthal malposition. In the transcutaneous group (n = 20) there was a higher rate of ectropion (25%, n = 5), a lower rate of entropion (n = 1, 5%) and higher rate of increased scleral show (n = 2, 10%). Factors associated with a higher rate of complications included complex fractures, use of conjunctival sutures, and increased length of time to surgery. Seventy-two per cent of patients who suffered entropion required further surgical treatment. The most common complication of the transconjunctival approach was entropion, and clinicians should have a low threshold for early surgical management. We feel that this should be part of the consenting process, especially in high-risk cases., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the demographic details, clinical presentation, and surgical outcomes in patients presenting with strabismus following orbital wall fractures., Methods: A retrospective review was conducted over a 6-year period on 347 consecutive patients with strabismus who presented after orbital wall fractures. The patients were evaluated for their demographic data, clinical presentation, and profiles, management, complications, and outcomes of strabismus., Results: Strabismus following orbital wall fractures was noted in 347 patients: 87.03% were men (n = 302) and 12.97% were women (n = 45). Fracture of the orbital floor in isolation or in combination with other walls was more frequently noted in 72.3% of patients (n = 251). The resultant strabismus included paralytic, restrictive, or both etiologies. Exotropia was noted most frequently in 25.65% of patients (n = 89), followed by exotropia with hypotropia in 20.75% of patients (n = 72). Ten percent of patients with strabismus (n = 34), who were observed for at least 6 months after injury, underwent surgical correction for strabismus. Preoperative diplopia was observed in 79.41% of patients (n = 27) and persisted after strabismus surgery in 15% of patients (n = 6). A successful outcome regarding the postoperative angle of deviation of 10 prism diopters or less horizontal and/or 5 prism diopters or less of vertical deviation with elimination of diplopia was observed in 41.17% of patients., Conclusions: Strabismus following orbital wall fractures is complex and requires a tailored strategy. The current study found the orbital floor to be more frequently involved in orbital wall fractures. However, the resultant strabismus was a combination of paralytic and restrictive etiologies. [ J Pediatr Ophthalmol Strabismus . 2022;59(3):172-179.] .

Introduction: The aim of the study was to evaluate the associated patterns of orbital wall fractures, diagnostic parameters of Traumatic optic neuropathy and its progress with Mega dose steroid therapy., Materials and Methods: 25 patients with unilateral orbital wall fractures of traumatic aetiology were evaluated with ophthalmologic and radiographic parameters. All patients were prescribed Mega Dose Intravenous steroids irrespective of the timing of presentation. Ophthalmic assessment was repeated for same parameters every alternate day upto 2 weeks., Results: Lateral orbital wall was found to be most commonly involved. Visual acuity, Pupillary Reactivity, Visual Field and Visual Evoked Potential showed statistically significant improvement post steroid therapy in early as well as late presenters., Discussion: Highest incidence of Traumatic optic neuropathy was noted in multiple linear orbital wall fractures with highest incidence with lateral orbital wall involvement. Literature regarding Choice and timing of initiation of steroids based on timing of presentation is inadequate to justify skipping steroids to observe or undertake surgical intervention. In the present study marked improvement was noted post steroid therapy regardless of timing of presentation. The authors conclude that Visual evoked potential should be objectively tested and Mega dose steroid therapy should be initiated for all patients with Traumatic optic neuropathy for maximum benefit to the patient., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Purpose: To investigate the effects of orthoptic training for residual diplopia after blowout fracture (BOF) surgery., Methods: We retrospectively reviewed the medical records of 14 (average age, 22.9 ± 13.1 years) patients with residual diplopia, who had undergone orthoptic training after BOF surgery at the Department of Ophthalmology, Kindai University Hospital, between August 2013 and September 2019. The orthoptic training included exercises for eye movement, convergence, and fusional area expansion. We assessed the training effects by scoring patients' Hess screen (Hess) test results and fields of binocular single vision (BSV). The scores obtained before/after surgery and after training were compared. We also investigated the factors that influenced patients' BSV scores after training. p < 0.05 was considered statistically significant., Results: The respective pre- and postoperative and after-training average scores were 7.0 ± 5.3, 5.4 ± 4.3, and 2.5 ± 3.2 points for Hess and 50.0 ± 41.3, 48.2 ± 35.9, and 89.4 ± 14.0 points for BSV. Neither Hess nor BSV score showed a significant difference before and after surgery (p > 0.05, the Steel-Dwass test). Compared to the postoperative (i.e., before training) scores, both Hess and BSV scores significantly improved after training (p < 0.05 for Hess, p < 0.01 for BSV; the Steel-Dwass test)., Conclusion: Orthoptic training appeared effective in resolving residual diplopia after BOF surgery by improving patients' ocular motility and expanding the BSV field., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The aim of this study was to present a case series emphasizing low medial maxillary (pyriform) buttress displacement in naso-orbito-ethmoid (NOE) fractures as an operative indication, in the absence of the typical NOE surgical indications (medial canthus displacement, midface bony comminution, nasal bone collapse, and orbital indications), to prevent nasal airway obstruction., Methods: Five cases of minor NOE fractures are reviewed, where only the low medial maxillary buttress was displaced. The typical surgical indications for NOE repair were absent., Results: In each case, the pyriform buttress was medially and posteriorly displaced, creating nasal airway obstruction in each patient. The medial canthal tendons were all nondisplaced, there was no diplopia, and the other 2 cardinal buttresses (infraorbital rim and nasofrontal junction) were minimally displaced or greensticked. In the acute setting, patients were treated with open reduction and internal fixation. With delayed presentation, septorhinoplasty or osteotomy and fixation were used. Among the patients who had adequate follow-up, nasal airway obstruction was resolved., Conclusions: This series suggests that, in NOE fractures with isolated displacement at the medial maxillary buttress, nasal airway obstruction should be considered an operative indication (independent of the classical indications) in order to prevent or resolve nasal airway obstruction., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare the incidence of lower eyelid malposition following repair of isolated orbital floor fractures with that of complex orbitofacial fractures (defined as multi-wall fractures or prior orbital fracture repairs requiring revision) by oculofacial plastic surgeons via a transconjunctival or swinging eyelid approach., Methods: Retrospective review of 175 patients who underwent surgical repair of orbital fractures at our institution. The primary outcomes were the occurrence of lower eyelid malposition (ectropion, entropion, and eyelid retraction) and the need for subsequent surgical correction., Results: Of 95 patients with isolated orbital floor fractures, 4 developed eyelid malposition (4.2%), 1 of which required surgical repair (1.1%). Of 80 patients with complex orbitofacial fractures (48 multi-wall fractures, 32 secondary revisions), 10 had pre-operative eyelid malposition and were excluded from further analysis. Fourteen of the remaining 70 patients developed postoperative eyelid malposition (20%), 3 of which required surgical repair (4.3%). The difference in the occurrence of eyelid malposition between groups was statistically significant ( p = .001), but the difference in rates of those requiring subsequent repair was not ( p = .182). There was no statistically significant difference in the occurrence of eyelid malposition when considering other surgical factors including lateral canthotomy, conjunctival closure, implant material, or anterior rim screws., Conclusions: The incidence of lower eyelid malposition following orbital fracture repair via a fornix-based approach was significantly higher for the repair of complex orbitofacial fractures than for isolated floor fractures. However, very few patients in either group required surgical repair for eyelid malposition. Surgical factors including implant material did not affect outcomes.

Introduction: Post-traumatic avulsion of the globe is a rare and uncommon pathology with serious morpho-physiological, cosmetic and aesthetic implications. The association with complex fractures of the skull increases the morbidity and complexity of the case., Case Report: We present a rare case of FSNOE complex fracture associated with avulsion of the left globe, with complete sectioning of the optic nerve and loss of vision., Disscusion: The prompt diagnosis and the immediate establishment of a correct multidisciplinary treatment, led to the favorable evolution of the case. Three-dimensional reconstruction of the skull architecture and resizing of the orbital contour, as well as successful prosthesis of the eyeball concured for a satisfactory anatomic and cosmetic result., Conclusion: The therapeutic decision to reposition the globe in the case of complete avulsion should be made depending on the severity of associated lesions, the patient's general state, age, and the risk of potential postoperative complications., Key Words: Word, Post-traumatic, Avulsion of the globe, Frontal sinus, Naso-orbito-ethmoid, NOE, Fracture.

Competing Interests: Competing interests: None declared.

Background: Several materials for medial orbital wall reconstruction have been mentioned in the literature. Our main purpose was to investigate postoperative enophthalmos and diplopia after medial orbital wall reconstruction with polydextro- and polylevolactic (poly- L / DL ) acid (P[ L / DL ]LA) mesh plates and porous polyethylene plates., Methods: Using a retrospective study design, we enrolled a cohort of isolated medial blowout fracture patients treated during a 58-month interval. The predictor variable was medial orbital wall reconstruction materials (P( L / DL )LA mesh plate and porous polyethylene plate. The main outcome variables included the occurrence of postoperative enophthalmos and diplopia at 1 week, 1, 3, 6, and 12 months post-surgery. Appropriate descriptive, uni- and bivariate statistics were computed, and P < 0.05 was considered significant., Results: Three hundred-two isolated medial blowout fracture patients were included (24.5% females, 67% treated with P( L / DL )LA mesh plate). Exophthalmos measured highest in both groups 1 week after surgery and decreased steadily for 6 months postoperatively. Statistically significant differences were observed between both groups at 1 week, 1 month, and 3 months after surgery, with a higher incidence of exophthalmos observed in the P( L / DL )LA mesh plate group (P < 0.001). No significant differences were observed at 6 and 12 months after surgery., Conclusion: The occurrence of enophthalmos after medial blowout fracture reconstruction with P( L / DL )LA mesh plate is comparable with the use of porous polyethylene plate. Both P( L / DL )LA mesh and porous polyethylene plates are, therefore, reliable implants for medial orbital wall reconstruction., Competing Interests: Declaration of Competing Interest No potential conflict of interest relevant to this article was reported., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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.)

The purpose of this article is to highlight the importance of appropriate management of acute orbital trauma, in order to prevent permanent impaired vision and double vision. Orbital blowout fractures with entrapment, so-called trapdoor fractures, occur more often in children than in adults, and require immediate surgical intervention. A blowout fracture with impingement, so-called open door fracture, does not require immediate intervention. However, if the motility does not improve within 1-2 weeks surgery may be required. The symptomatology in children with orbital fractures may differ significantly from that in adults, and vasovagal symptoms such as bradycardia and nausea are common.  Orbital compartment syndrome is characterized by an acute increase in orbital pressure, and may result in irreversible blindness if not promptly treated with lateral canthotomy and cantholysis.

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 and Objectives: In patients with orbital floor blowout fracture (OFBF), accurate diagnosis of ocular motility disorder is important for decisions about conservative or surgical therapy. However, the accuracy of the traditional test for detecting binocular diplopia/ocular motility disorder using a moving pencil or finger (hereinafter, "finger test") has been generally accepted as correct and has not been subject to scrutiny so far. Hence, its accuracy relative to full orthoptic examination is unknown. Materials and Methods: In this paper, the results of the "finger test" were compared with those derived from a complex examination by orthoptic tests (considered "true" value in patients with OFBF). Results: "Finger test" detected ocular motility disorder in 23% of patients while the full orthoptic examination proved much more efficient, detecting ocular motility disorder in 65% of patients. Lancaster screen test and test with color filters were the most important tests in the battery of the orthoptic tests, capable of identifying 97.7% and 95.3% of patients with ocular motility disorder, respectively. Still, none of the tests were able to correctly detect all patients with ocular motility disorder in itself. Conclusions: As the presence of ocular motility disorder/binocular diplopia is an important indication criterion for the surgical solution of the orbital floor blowout fracture, we conclude that a complex orthoptic evaluation should be always performed in these patients.

Orbital floor fractures subsequently lead to consequences such as diplopia and enophthalmos. The graft materials used in orbital floor fractures varied from autografts to alloplastic grafts, which possess certain limitations. In the present study, a novel porcine bone matrix decellularized by supercritical CO2 (scCO2), ABCcolla® Collagen Bone Graft, was used for the reconstruction of the orbital framework. The study was approved by the institutional review board (IRB) of Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH). Ten cases underwent orbital floor reconstruction in KMUH in 2019. The orbital defects were fixed by the implantation of the ABCcolla® Collagen Bone Graft. Nine out of ten cases used 1 piece of customized ABCcolla® Collagen Bone Graft in each defect. The other case used 2 pieces of customized ABCcolla® Collagen Bone Graft in one defect area due to the curved outline of the defect. In the outpatient clinic, all 10 cases showed improvement of enophthalmos on CT (computerized tomography) at week 8 follow-up. No replacement of implants was needed during follow-ups. To conclude, ABCcolla® Collagen Bone Graft proved to be safe and effective in the reconstruction of the orbital floor with high accessibility, high stability, good biocompatibility, low infection rate and low complication rate., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Luxation of the globe is a rare, vision-threatening event that can presently spontaneously or following trauma. A 35-year-old man presented with bilaterally luxated globe, postroad traffic accident. On imaging, bilateral LeFort fracture type 1, 2 and 3 with palatal split along with nasal bone and orbital floor fracture. Both condyles and left parasymphysis of mandible were fractured. There was no evidence of intracranial injury. There was pneumothorax on the right side for which intercostal drainage (ICD) tube was placed. On exploring, bilateral optic nerve avulsion was present. Both the globes were repositioned and a temporary tarsorrhaphy was placed for cosmetic rehabilitation. On follow-up visits after 6 months, both eyes were in their sockets with minimal exodeviation. It is important to reposition the globes, even with extensive periorbital fracture at the earliest. The longer the globe and orbital structures are prolapsed, the poorer are the structural and cosmetic prognosis owing to ocular ischaemia., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

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.)

Purpose: The use of antibiotic prophylaxis for the prevention of infection in nonoperative orbital fractures is controversial, with limited high-quality evidence and inconsistent recommendations in the current scientific literature. Our primary study objective was to identify the prophylactic antibiotic prescribing pattern at our institution for nonoperative orbital fractures and to determine the effect of antibiotic prophylaxis., Methods: We retrospectively reviewed 16 years of data from a single institution on patients with acute traumatic fractures of the orbital floor or medial orbital wall. Prophylactic administration of antibiotics and complication rates were evaluated, and complication rates and patient characteristics analyzed., Results: Of 154 patients with nonoperative orbital fractures, 17 patients (group 1) received IV or oral antibiotics and 137 patients (group 2) did not. No patient in either group had documented infectious orbital complications following their orbital injury. Patients receiving antibiotics were more likely to have a concurrent periorbital laceration (58.8% ± 11.9% vs. 28.5% ± 3.9%; P = 0.01)., Conclusion: We present the largest cohort yet reported of patients managed without antibiotic prophylaxis for nonoperative orbital fractures, with no infectious complications identified. Currently there is no evidence of utility to prophylactic antibiotics in the setting of nonoperative traumatic orbital fractures. Rather than prescribing antibiotics, we recommend clinicians educate patients on return precautions and offer close follow up for the rare, but potentially severe infectious complications of orbital trauma., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

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.)

Background: Retrobulbar hemorrhage (RBH) is a rare complication after orbital surgery but associated with ocular complications including blindness. The aim of this study was to identify clinical characteristics of patients with RBH requiring emergent orbital decompression after blowout fracture repair., Method: A retrospective review of 426 blowout fracture patients at a tertiary oculoplastic clinic provided data regarding demographics, physical examination findings, and computed tomography (CT) images. Extraocular motility had been recorded in patient charts on a scale from 0 to - 4. Patients requiring emergent orbital decompression due to RBH after surgery (RBH group) were compared with those who did not (Control group), using the Mann-Whitney U-test. Incidences of RBH according to primary or secondary surgery were also investigated, using Fisher's exact test., Result: Five (1.2%) of the 426 patients who underwent blowout fracture repair developed RBH requiring emergent intervention. All RBH patients fully recovered after the decompression procedure or conservative treatment. Number of days to surgery was significantly longer in the RBH group (97.0 ± 80.1) than in the Control group (29.0 ± 253.0) (p = 0.05). Preoperative enophthalmos was also significantly greater in the RBH group (RBH vs. Control group, 3.6 ± 1.7 mm versus 1.2 ± 1.3 mm (p = 0.003)). The incidence of RBH was significantly higher in patients that underwent secondary surgery (odds ratio = 92.9 [95% confidence interval, 11.16-773.23], p = 0.001)., Conclusions: Surgeons should pay more attention to hemostasis and postoperative care in patients with a large preoperative enophthalmic eye, when time from injury to surgery is long and in revision cases. When RBH occurs, time to intervention and surgical decompression is critical for visual recovery and preventing blindness., Trial Registration: The institutional review board of the Yeungnam University Medical Center approved this study ( YUMC 2018-11-010 ), which was conducted in accord with the Declaration of Helsinki.

Background: Orbital fractures are common injuries in adults and children. Although the mechanism of blowout fracture is generally similar regardless of age, due to differences in anatomy, clinical symptoms of these fractures vary in the 2 groups of patients. Numerous articles describe the methods of orbital reconstruction leading to enophthalmos correction; however, the current literature lacks articles presenting the comparison of enophthalmos treatment results in adults and children with orbital blowout fracture., Objectives: The aim of this study was to compare the results of the treatment of enophthalmos in orbital blowout fracture in children/adolescents and adults with regard to the location of the fracture, the time from the injury to surgical treatment, the type of surgical procedure, and the donor location of an autogenous bone graft., Material and Methods: The treatment results of 2 groups were compared: 530 adults (patients over 18 years of age; 18-77 years; average age: 34 years); and 200 children/adolescents (4-18 years; average age: 12.1 years). Data was obtained retrospectively through a review of the medical history of patients treated for a fracture of the orbital floor and/or medial wall in our department in the years 1975-2015., Results: In patients with post-traumatic enophthalmos, the correct positioning of the eyeball was achieved in 313 adults (59.1%) and 139 children (69.5%), improvement in 159 adults (30%) and 49 children (24.5%), and no improvement in 58 adults (10.9%) and 12 children (6%). Recovery after surgical treatment was achieved in 311 adults (60.9%) and 94 children (52.8%), improvement in 120 adults (23.5%) and 59 children (33.1%), and no improvement in 80 adults (15.7%) and 25 children (14%)., Conclusions: The relationship between post-traumatic enophthalmos and the location of the fracture was more significantly marked in the adult group. In cases that required bone graft reconstruction, better results were achieved in adults. Cite as.

Purpose: This study evaluated outcomes of surgical treatment for enophthalmos after pediatric orbital blowout fracture. Associations of fracture type, fracture site, time from injury to treatment, and type of surgical procedure with treatment outcomes were assessed., Methods: The medical records of 200 children and adolescents (38 girls and 162 boys) with orbital fractures treated in the authors' department from 1975 to 2015 were reviewed retrospectively. The main causes of injury were accidental blows to the orbit and sports injuries. This study included only patients with fracture of the floor and/or medial wall of the orbit, which is referred to in the English literature as pure, or internal, blowout fracture. Patients with fracture of the orbital rim, lateral wall, or roof were excluded. Surgical treatment was performed for 178 patients; the other 22 children were treated conservatively., Results: In the surgically treated group, treatment outcomes did not differ in relation to the severity of post-traumatic enophthalmos. The setting of the eyeball improved in 83% of patients., Conclusion: The severity of post-traumatic enophthalmos was not associated with surgical outcome in children.

Importance: Orbital fractures are common in ocular trauma, and there is a need to develop predictive tools to estimate risk of concurrent ocular injury., Objective: To identify clinical and radiographic features that are associated with increased risk of substantial ocular injury in the setting of orbital fracture., Design, Setting, and Participants: Retrospective consecutive case series of patients who sustained orbital fractures between 2012 and 2018. Examinations were done at 1 of 2 level 1 trauma centers in the emergency or inpatient setting. A total of 430 consecutive patients (500 eyes) between 2012 and 2017 met inclusion criteria for the training sample. After building a predictive model, 88 additional consecutive patients (97 eyes) between 2017 and 2018 who met inclusion criteria were collected as a test sample., Main Outcomes and Measures: The primary outcome measure was substantial ocular injury distinct from orbital fracture., Results: The mean age of our patient population was 53.5 years (range, 16-100 years). The overall rate of substantial ocular injury was 20.4%, and the rate of injury requiring immediate ophthalmic attention was 14.4%. Five variables were found to be associated with increased risk of substantial ocular injury: blunt trauma with a foreign object (odds ratio [OR], 19.4; 95% CI, 6.3-64.1; P < .001), inability to count fingers (OR, 10.1; 95% CI, 2.8-41.1; P = .002), roof fracture (OR, 9.1; 95% CI, 2.8-30.0; P = .002), diplopia on primary gaze (OR, 6.7; 95% CI, 1.7-25.1; P = .003), and conjunctival hemorrhage or chemosis (OR, 4.2; 95% CI, 2.2-8.5; P < .001). The results were translated into a bedside tool that was tested in an independent group of eyes (n = 97) and found to be associated with substantial ocular injury with a 95% sensitivity (95% CI, 77.2-99.9), 40% specificity (95% CI, 28.9-52.0), 31.8% positive predictive value (95% CI, 27.5-36.5), and 96.8% negative predictive value (95% CI, 81.3-99.5)., Conclusions and Relevance: A minority of patients with an orbital fracture had a substantial ocular injury. Certain radiographic and clinical findings were associated with substantial ocular injury. Testing of the algorithm in prospective longitudinal settings appears warranted.

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.)

Traumatic optic neuropathy is sinister sequelae of craniofacial trauma leading to vision loss. The decision between early medical or surgical intervention is usually individualised. Visual evoked potentials may guide the treatment plan. We describe a young male presenting 5 days after a road traffic accident with no perception of light vision in the right eye. He was managed medically with high dose of intravenous steroids. At the 3-month follow-up, he reported a reversal of vision loss with return of visual acuity to 3/60, which improved to 6/36 at 5 months and remained stable at 8 months., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Although orbital blowout fractures are common, there is no consensus with respect to treatment decision making and long-term outcome. The purpose of this study was to evaluate the association between inferior rectus muscle (IRM) displacement and fracture size and the surgical repair decisions and clinical outcomes in patients with blowout fractures (BOFs)., Patients and Methods: We designed a prospective cohort study and enrolled all patients who presented to the University Hospital of Geneva for evaluation of a BOF. The primary predictor variables were the IRM grade, measuring the severity of downward displacement of the IRM relative to the level of the fracture's edge (mild [grade I], moderate [grade II], or severe [grade III]), and fracture size. The primary outcome was surgical repair. The secondary outcomes were post-trauma diplopia (at baseline and at 10 days) and persistent annoying diplopia and/or enophthalmos considered independently or as a composite outcome. Other study variables included demographic and injury-related parameters. Descriptive, bivariate, and multiple logistic regression statistics were computed, and the significance level was set at P ≤ .05., Results: The sample was composed of 108 patients with a mean age of 46.8 ± 23 years; 73.1% were men. The IRM grade was associated with surgical repair (P < .001), post-trauma diplopia (P < .001), and the composite outcome (P = .003). Fracture size was associated with enophthalmos (P = .03) and the composite outcome (P = .009). In the adjusted model, only IRM grades II and III were associated with the decision for surgical repair (P < .001)., Conclusions: The results of this study suggest that the IRM grade, unlike fracture size, may be a valid measurement in surgical decision making, as well as in determining BOF severity, as evidenced by the correlation between the IRM grade and surgical repair, as well as clinical outcome., (Copyright © 2020 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

The aim of the study was to determine the influence of posttraumatic enophthalmos in orbital blow-out fracture on the treatment results. The relationship between time from injury to treatment, type of surgical reconstruction, bone graft site, type of diplopia and treatment results were evaluated. The relationship between the location of the fracture and the degree of enophthalmos was also analyzed. The study included 730 patients, 128 women and 602 men, aged 4 to 77 years, average 28 years, treated because of orbital blow-out fracture in our Department between 1975 and 2015. The study included only patients with an isolated orbital floor or medial wall fracture, so-called "pure blow-out" or "internal blow- out". Fractures of the lower rim, roof or lateral wall of the orbit, as well as the coexistence of other fractures of the facial part of the skull, were excluding citeria from the study. Complete recovery in surgically treated patients was achieved in 405 (58.8%) patients, improvement in 179 (26%) and no improvement in 105 (15.2%) patients. The degree of post-traumatic enophthalmos affects the result of the treatment. The location of the orbital fracture affects the enophthalmos, in our group of patients the largest incidence occurred in the fracture located in the orbital floor combined with medial wall. Patients who underwent surgical treatment up to 14 days after the injury achieved better results than those postponed.

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.

Background: Quantifying diplopia to determine management and track outcomes for orbital fracture patients is vital for standardization between visits, physicians, and coordination among the multiple specialties that manage these patients. However, standardization is challenging, as diplopia is often reported subjectively. This study sought to describe the utility of the digital Hess screen in patients with orbital fractures compared with a control group. Materials and Methods: A prospective pilot study was designed in which adult patients who presented with orbital fractures between November 2017 and January 2019 without prior history of orbital pathology were recruited. Subjects underwent digital Hess screen testing, in which they wore anaglyph glasses and aligned targets on a computer screen to quantify static eye alignment. The degree of any eye misalignment was analyzed and compared with controls. Results: Ninety-one patients and 35 controls were enrolled. All participants were able to complete the digital Hess screen. Average cumulative deviation score of orbital fracture patients within 1 month of injury was 0.65°, compared with 0.28° in controls. This was a statistically significant difference ( p  < 0.01, 95% confidence interval -0.18 to 0.18). Conclusion: The Hess screen has been used to quantify phoria as a correlate of eye alignment and diplopia, but older versions were cumbersome and difficult to analyze. This study is the first to report on using the digital Hess screen to quantify phoria in orbital fracture patients and provides a more concise and standardized means to track clinical and surgical outcomes of eye alignment.

Purpose: Enophthalmos greater than 2 mm should be considered clinically relevant and can be responsible for esthetic and functional morbidity. The difficulty has always been the best method to use to accurately determine when the orbital wall displacement will lead to clinically relevant enophthalmos. None of the currently used techniques is able to accurately predict for post-traumatic enophthalmos (PE). The aim of the present study was to systematically review the use of orbital volumetric tools in the prediction of PE after orbital fracture., Materials and Methods: The terms searched in each database were "(orbital volumetry) and enophthalmos," "volumetry and enophthalmos," "volume and enophthalmos," and "volumetric and enophthalmos." The relationship between PE and the orbital volume (OV) was assessed., Results: The initial search yielded 346 results. Of the 346 studies, 14 were included and analyzed. Every study reported a different numerical relationship between the OV and PE, with a mean enophthalmos of 0.80 mm after a 1-cm 3 increase in the OV., Conclusions: The present review found that most studies concluded that a direct relationship exists between the OV and PE and defined the degree of PE in relation to the OV expansion. Enophthalmos assessment using radiologic evaluation provides increased accuracy and reproducibility compared with clinical measurement using an exophthalmometer. It has been notoriously difficult to determine when orbital wall displacement will lead to clinically relevant enophthalmos. Measurement of the OV could have a role in the decision for surgical or conservative treatment., (Copyright © 2020 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly identified strain of coronavirus in the human body and was reported in Wuhan at the end of 2019. So far, the epidemic is continuing and very serious, with the number of infections and deaths increasing. Despite active investigations around the world to better understand the dynamics of transmission and the scope of clinical disease, COVID-19 continues to spread rapidly from person to person. The common signs and symptoms of SARS-CoV-2 infection include fever, fatigue, dry cough, and dyspnea; in severe cases, patients may have acute respiratory distress syndrome, septic shock, metabolic acidosis difficult to treat and coagulation disorder. However, some patients who test positive for SARS-CoV-2 in their respiratory tract may not have such clinical signs and symptoms. This report presents a case study analysis of a patient admitted in the Fourth Taiyuan People's Hospital, who had suffered traumatic injuries from a car accident and survived COVID-19, with pleural effusion as the initial symptom. We report a case of 2019-NCOV with pleural effusion as the first symptom. Describe in detail the differential diagnosis, diagnosis, clinical management, and cure of this case. In order to combat the novel CoronaviruscoVID-19 in the process to provide lessons and help.

Zygomaticomaxillary complex (ZMC) and orbital blow out fractures are commonly encountered midfacial fractures that may result in aesthetic and functional impairment. This retrospective study reports on the surgical treatment and associated postoperative complications in our patient collective. We evaluated 100 patients who underwent open reduction and internal fixation of midfacial fractures between 2010 and 2015. Preoperative clinical features, surgical technique and postoperative complications were analyzed. Surgery was performed with a mean latency of 7 days after trauma. We used titanium mesh and polydioxanone sheets to reconstruct the orbital floor. Most ZMC fractures were stabilized with two point fixation with titanium plates. Preoperative symptoms were present in 70 patients (70%). Infraorbital hypesthesia occurred in 49 patients, diplopia in 41 patients and ocular motility impairment in 24 patients. Postoperative symptoms persisted during a mean follow-up time of 4.5 months in 47 patients (47%) showing infraorbital hypesthesia in 24%, diplopia in 17%, ectropion in 7% and ocular motility impairment in 4%. Complications requiring revision were retrobulbar hematoma 3% ( n  = 3), ectropion 3% ( n  = 3), diplopia 1% ( n  = 1), exophthalmos 1% ( n  = 1), implant dislocation 1% ( n  = 1), implant discomfort 2% ( n  = 2), persisting fracture dislocation 1% ( n  = 1). All patients recovered without significant impairment. Surgery is required in the majority of the patients with midfacial fractures. Among others ectropion is challenging due to its aesthetic and functional impact on patients. To prevent ectropion, additional canthopexy or the transconjunctival surgical approach are reasonable options in selected cases. Level of Evidence: Level V, descriptive study. AbbreviationsCTcomputed tomographyOForbital floorPDSpolydioxanoneORIFopen reduction and internal fixationZMCzygomaticomaxillary complex.

Purpose : We investigated the feasibility of isolated medial orbital wall fracture reconstruction using an unsintered hydroxyapatite particles/poly L-lactide (u-HA/PLLA) sheet implant with the assistance of intraoperative navigation via the transcaruncular approach. Patients and methods : Ten consecutive patients (5 males and 5 females; mean age, 57.5 years) were included based on the clinical and imaging criteria. All patients underwent surgical treatment of the isolated medial orbital wall fracture using transcaruncular incision and the u-HA/PLLA implant under navigation. The follow-up time was greater than 6 months. Preoperative and postoperative clinical data regarding the presence of diplopia, eye motility restriction, and enophthalmos were assessed. The orbital volumes of the injured and uninjured orbit were also evaluated using computed tomography images. Results : All patients had improved ophthalmologic functional and esthetic outcomes and were successfully treated without any long-term complications arising during follow-up. There was a significant difference between the preoperative and postoperative injured orbits due to herniation of the orbital contents. Moreover, the orbital volume of the postoperative injured side following surgery was the same as that of the unaffected side, indicating that anatomically good reconstruction had been obtained. Conclusions : Surgical treatment using the transcaruncular approach and u-HA/PLLA materials with intraoperative navigation is a safe, promising, and effective technique for isolated medial orbital wall fracture reconstruction.

Purpose: The purpose of this study is to determine whether bradycardia associated with the oculocardiac reflex is a significant source of morbidity in the post injury period following orbital floor fractures in children., Materials/methods: A retrospective review of all pediatric patients who presented to our emergency department with an orbital floor fracture from May 1, 2016 to June 1, 2018 were included. Basic demographic data was collected as well as mechanism of injury, presence of bradycardia, and time to operating room. Morbidity was based on the need for medications to treat bradycardia., Results: Thirty-five pediatric patients with orbital floor fractures were reviewed. 6 (17.1%) patients had post injury bradycardia, with one patient requiring medication to stabilize their heart rate. There was no statistically significant difference in sex, race/ethnicity, or age in patients with or without bradycardia (p > 0.05) however there was a significant relationship between bradycardia and need for operative repair (X 2  = 7.88, df = 1, p = 0.005). The most common mechanism of injury was motor vehicle collision (45.7%). The average time to the operating room was 145 h (6.04 days)., Conclusions: While activation of the oculocardiac reflex is a legitimate concern in the post injury period, there is unlikely to be significant morbidity due to bradycardia, and the greater concern should be for the ischemic muscle injury incurred from the fracture., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To present and examine the results of surgical correction of simultaneous ocular elevation and depression deficit in patients who underwent reconstruction surgery for orbital floor fracture., Methods: A retrospective analysis of medical records of patients who had undergone surgical correction for diplopia associated with orbital fracture which persisted after orbital reconstruction surgery. All patients underwent orthoptic evaluation before surgery and postoperatively with various times of follow-up., Results: Eight cases of blow-out fracture of the orbital floor were identified. Surgical plan varied from case to case. It included thorough revision of inferior rectus/oblique complex with or without recession of the former or flap tear repair and additional procedures. Postoperatively 4 patients (50%) were diplopia free, 3 (37.5%) presented diplopia in extreme upgaze and 1 (12.5%) in mid-upgaze and adduction. None of the patients reported diplopia in the primary position neither downgaze., Conclusion: Diplopia persisting after reconstructive surgery of a fractured orbital floor may be corrected surgically. Our results suggest that at least two surgical procedures are necessary to achieve satisfying outcomes. Contralateral inferior rectus recession combined with superior oblique recession and superior rectus posterior fixation appears to be effective procedures for use.

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.

Introduction: Tension pneumo-orbit is a rare but eye-threatening sequelae of orbital trauma. Minimal trauma to the lamina papyracea can result in a valve effect leading to rapid-onset proptosis and optic nerve compression in the absence of a haematoma., Case Report: We describe a case of medial orbital wall fracture in a 35-year-old lady following a minor fall at home. She presented with severe proptosis of the left eye. Imaging showed marked pneumo-orbit, which was managed definitively by endoscopic orbital decompression., Discussion: Tension pneumo-orbit requires prompt recognition and surgical decompression. An endonasal approach may be used to decompress the orbit via the medial wall., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Purpose: To establish a linear measuring method in computed tomographic (CT) images to predict the displacement of the globe late after orbital blowout fracture., Methods: Subjects were retrospectively included. Inclusion criteria were as follows: (1) adult subjects (≥18 years old at the time of trauma); (2) unilateral orbital medial-wall and/or floor fractures; (3) CT examination at least 30 days after trauma. Exclusion criteria were as follows: (1) facial or orbital fracture extending to other parts of the orbit than medial-wall and/or floor; (2) history of orbital or ocular abnormality other than the orbital trauma; (3) severe ocular trauma accompanied by the orbital trauma; (4) orbital fracture treated surgically before the CT examination. A co-ordinate system was built based on the orbital CT scans. Displacements of orbital walls, displacement of the globe and relative location of the fracture site were measured. Correlations between the variables were investigated., Results: Ninety-nine per cent of fracture sites of the medial wall and 100% of fracture sites of the floor were posterior to the centre of the unaffected globe. The affected globe moved significantly medially (p < 0.001) and backwards (p < 0.001) in pure medial-wall fracture; backwards (p < 0.001) and downwards (p = 0.017) in pure floor fracture; and medially (p < 0.001), backwards (p < 0.001) and downwards (p < 0.001) in medial-wall and floor fractures. Displacement of the globe was correlated with displacements of the orbital walls, and the regression formulae were therefore fitted. Application of the formulae revealed that the same extent of orbital wall displacement caused more displacement of the globe in female patients than in male patients., Conclusions: A linear measuring method in a three-dimensional co-ordinate system was established to identify the displacements of orbital walls and the displacement of the globe in orbital blowout fractures. The regression formulae generated in this study might be used in clinical practice to predict late displacement of the globe by measuring the displacements of orbital walls., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)