Treatment of orbital fractures – a critical analysis of ophthalmic outcomes and scenarios for re-intervention
DOI:
https://doi.org/10.2340/jphs.v58.6580Keywords:
orbital fractures, orbital implant, outcome, complications, orbital volume, orbit, enophthalmosAbstract
Background: Malplaced implants in orbital reconstruction may lead to serious complications and necessitate re-intervention. The aim of this study was to describe outcomes, complications and scenarios of re-intervention in a historical case series of orbital fractures treated with free-hand orbital wall reconstruction. The main hypothesis was that early re-interventions are mainly because of malplaced implants in the posterior orbit.
Methods: Retrospective review of 90 patients with facial fractures involving the orbit, reconstructed with radiopaque orbital wall implants, from 2011 to 2016. Data were obtained from medical records and computed tomography images. Recorded parameters were fracture type, ocular injury, ocular motility, diplopia, eye position, complications and re-interventions. Secondary reconstructions because of enophthalmos were volumetrically evaluated.
Results: Early complications requiring re-intervention within 1 month were seen in 12 (13%) patients, where all except two were because of malplaced implants. The implant incongruence was without exception found in the posterior orbit. Late complications consisted of four (4%) cases of ectropion and five (5%) cases of entropion that needed corrective surgery. The majority of the patients with eye-lid complications had undergone repeated surgeries. Secondary orbital surgeries were performed in nine (10%) patients. Five of these patients had secondary reconstruction for enophthalmos and associated diplopia. None of these patients became completely free from either enophthalmos or diplopia after the secondary surgery.
Conclusion: Re-intervention after orbital reconstruction is mainly related to malplaced implants in the posterior orbit. Incomplete results in patients requiring secondary surgery for enophthalmos infer the importance of accurate restoration of the orbit at primary surgery.
Abstract presented at: Swedish surgery Week 2021 and SCAPLAS 2022.
Downloads
References
Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol. 2003;14(5):236–240. https://doi.org/10.1097/00055735-200310000-00002 DOI: https://doi.org/10.1097/00055735-200310000-00002
Biesman BS, Hornblass A, Lisman R, et al. Diplopia after surgical repair of orbital floor fractures. Ophthal Plast Reconstr Surg. 1996;12(1):9–16; discussion 17. https://doi.org/10.1097/00002341-199603000-00002 DOI: https://doi.org/10.1097/00002341-199603000-00002
Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109(7):1207–1210; discussion 1210–1211; quiz 1212–1213. https://doi.org/10.1016/s0161-6420(02)01057-6 DOI: https://doi.org/10.1016/S0161-6420(02)01057-6
Senese O, Boutremans E, Gossiaux C, et al. Retrospective analysis of 79 patients with orbital floor fracture: outcomes and patient-reported satisfaction. Arch Craniofacial Surg. 2018;19(2):108–113. https://doi.org/10.7181/acfs.2018.01837 DOI: https://doi.org/10.7181/acfs.2018.01837
Ridgway EB, Chen C, Colakoglu S, et al. The incidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival incisions. Plast Reconstr Surg. 2009;124(5):1578–1586. https://doi.org/10.1097/PRS.0b013e3181babb3d DOI: https://doi.org/10.1097/PRS.0b013e3181babb3d
Hoşal BM, Beatty RL. Diplopia and enophthalmos after surgical repair of blowout fracture. Orbit Amst Neth. 2002;21(1):27–33. https://doi.org/10.1076/orbi.21.1.27.2598 DOI: https://doi.org/10.1076/orbi.21.1.27.2598
Schlittler F, Schmidli A, Wagner F, et al. What is the incidence of implant malpositioning and revision surgery after orbital repair? J Oral Maxillofac Surg. 2018;76(1):146–153. https://doi.org/10.1016/j.joms.2017.08.024 DOI: https://doi.org/10.1016/j.joms.2017.08.024
Bly RA, Chang SH, Cudejkova M, et al. Computer-guided orbital reconstruction to improve outcomes. JAMA Facial Plast Surg. 2013;15(2):113–120. https://doi.org/10.1001/jamafacial.2013.316 DOI: https://doi.org/10.1001/jamafacial.2013.316
Nysjö J. Interactive 3D image analysis for cranio-maxillofacial surgery planning and orthopedic applications. 2016. Acta Universitatis Upsaliensis, Uppsala.
Khonsari RH, Hennocq Q, Nysjö J, et al. Defining critical ages for orbital shape changes after frontofacial advancement in crouzon syndrome. Plast Reconstr Surg. 2019;144(5):841e–852e. https://doi.org/10.1097/PRS.0000000000006162 DOI: https://doi.org/10.1097/PRS.0000000000006162
Wilde F, Lorenz K, Ebner AK, et al. Intraoperative imaging with a 3D C-arm system after zygomatico-orbital complex fracture reduction. J Oral Maxillofac Surg. 2013;71(5):894–910. https://doi.org/10.1016/j.joms.2012.10.031 DOI: https://doi.org/10.1016/j.joms.2012.10.031
Nguyen E, Lockyer J, Erasmus J, et al. Improved outcomes of orbital reconstruction with intraoperative imaging and rapid prototyping. J Oral Maxillofac Surg. 2019;77(6):1211–1217. https://doi.org/10.1016/j.joms.2019.02.004 DOI: https://doi.org/10.1016/j.joms.2019.02.004
Menon A, Karikal A, Shetty V. Does C-arm guidance improve reduction of zygomatic arch fractures? – a randomized controlled trial. J Oral Maxillofac Surg. 2018;76(11):2376–2386. https://doi.org/10.1016/j.joms.2018.05.026 DOI: https://doi.org/10.1016/j.joms.2018.05.026
Nikunen M, Rajantie H, Marttila E, et al. Implant malposition and revision surgery in primary orbital fracture reconstructions. J Craniomaxillofac Surg. 2021;49(9):837–844. https://doi.org/10.1016/j.jcms.2021.04.008 DOI: https://doi.org/10.1016/j.jcms.2021.04.008
Evans BT, Webb AAC. Post-traumatic orbital reconstruction: anatomical landmarks and the concept of the deep orbit. Br J Oral Maxillofac Surg. 2007;45(3):183–189. https://doi.org/10.1016/j.bjoms.2006.08.003 DOI: https://doi.org/10.1016/j.bjoms.2006.08.003
Saiepour D, Messo E, Hedlund AJO, et al. Radiologic and long-term clinical outcome from treatment of isolated medial orbital wall blowout fractures. J Craniofac Surg. 2012;23(5):1252–1255. https://doi.org/10.1097/SCS.0b013e31825e4e8e DOI: https://doi.org/10.1097/SCS.0b013e31825e4e8e
Anand L, Sealey C. Orbital fractures treated in Auckland from 2010–2015: review of patient outcomes. N Z Med J. 2017;130(1458):21–26.
Gander T, Blumer M, Rostetter C, et al. Intraoperative 3-dimensional cone beam computed tomographic imaging during reconstruction of the zygoma and orbit. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018;126(2):192–197. https://doi.org/10.1016/j.oooo.2018.04.008 DOI: https://doi.org/10.1016/j.oooo.2018.04.008
Zimmerer RM, Ellis E, Aniceto GS, et al. A prospective multicenter study to compare the precision of posttraumatic internal orbital reconstruction with standard preformed and individualized orbital implants. J Craniomaxillofac Surg. 2016;44(9):1485–1497. https://doi.org/10.1016/j.jcms.2016.07.014 DOI: https://doi.org/10.1016/j.jcms.2016.07.014
Zavattero E, Ramieri G, Roccia F, et al. Comparison of the outcomes of complex orbital fracture repair with and without a surgical navigation system: a prospective cohort study with historical controls. Plast Reconstr Surg. 2017;139(4):957–965. https://doi.org/10.1097/PRS.0000000000003229 DOI: https://doi.org/10.1097/PRS.0000000000003229
Gart MS, Gosain AK. Evidence-based medicine: orbital floor fractures. Plast Reconstr Surg. 2014;134(6):1345–1355. https://doi.org/10.1097/PRS.0000000000000719 DOI: https://doi.org/10.1097/PRS.0000000000000719
Nowinski D, Messo E, Hedlund A. Treatment of orbital fractures: evaluation of surgical techniques and materials for reconstruction. J Craniofac Surg. 2010;21(4):1033–1037. https://doi.org/10.1097/SCS.0b013e3181e4345d DOI: https://doi.org/10.1097/SCS.0b013e3181e4345d
Zimmerer RM, Gellrich NC, von Bülow S, et al. Is there more to the clinical outcome in posttraumatic reconstruction of the inferior and medial orbital walls than accuracy of implant placement and implant surface contouring? A prospective multicenter study to identify predictors of clinical outcome. J Craniomaxillofac Surg. 2018;46(4):578–587. https://doi.org/10.1016/j.jcms.2018.01.007 DOI: https://doi.org/10.1016/j.jcms.2018.01.007
Chen CT, Huang F, Chen YR. Management of posttraumatic enophthalmos. Chang Gung Med J. 2006;29(3):251–261.
Pausch NC, Sirintawat N, Wagner R, et al. Lower eyelid complications associated with transconjunctival versus subciliary approaches to orbital floor fractures. Oral Maxillofac Surg. 2016;20(1):51–55. https://doi.org/10.1007/s10006-015-0526-1 DOI: https://doi.org/10.1007/s10006-015-0526-1
Chi MJ, Ku M, Shin KH, et al. An analysis of 733 surgically treated blowout fractures. Ophthalmologica. 2010;224(3):167–175. https://doi.org/10.1159/000238932 DOI: https://doi.org/10.1159/000238932
Greenwald HS, Keeney AH, Shannon GM. A review of 128 patients with orbital fractures. Am J Ophthalmol. 1974;78(4):655–664. https://doi.org/10.1016/s0002-9394(14)76304-4 DOI: https://doi.org/10.1016/S0002-9394(14)76304-4
Brucoli M, Arcuri F, Cavenaghi R, et al. Analysis of complications after surgical repair of orbital fractures. J Craniofac Surg. 2011;22(4):1387–1390. https://doi.org/10.1097/SCS.0b013e31821cc317 DOI: https://doi.org/10.1097/SCS.0b013e31821cc317
Cole P, Kaufman Y, Hollier L. Principles of facial trauma: orbital fracture management. J Craniofac Surg. 2009;20(1):101–104. https://doi.org/10.1097/SCS.0b013e318190e1b6 DOI: https://doi.org/10.1097/SCS.0b013e318190e1b6
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Anna A. E. Persson, Hanna M. Lif, Alberto Falk-Delgado, Daniel Nowinski
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from Volume 59 (2024) all published articles, unless otherwise specified, are published under CC-BY licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
