This video illustrates the use of porous polyethylene implant stabilized with cyanoacrylate glue to repair an orbital floor fracture by the transconjunctival technique in a 10-year-old child who had sustained a facial trauma. She had an incarcerated inferior rectus muscle in the fracture, causing diplopia in upgaze. This technique has many advantages including simplicity of the technique, excellent structural support, shorter operative time and cost-effectiveness.

Presentation: Dr. Raksha Rao, Centre for Sight, Hyderabad, India
Surgeon: Dr. Santosh G. Honavar, Centre for Sight, Hyderabad, India

Transcript

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Fractures of the periorbital region are the third most common facial fractures, with the orbital floor being the most frequent fracture pattern. Fractures of the orbit occur either in isolation or in association with more complex fracture patterns involving the zygoma, maxilla, or the nasoethmoidal complex. Periorbital wall blowout fractures result from the backward displacement of the globe, caused by a blunt, non-penetrating object, which raises the intraorbital pressure sufficiently to fracture the orbital wall. Most commonly, it involves a posterior medial orbital floor, followed by the lamina papyracea of the ethmoid. Orbital floor fractures, especially blowout fractures, can lead to complications, including diplopia, paresthesia of the infraorbital nerve, and enophthalmos. Operative intervention of orbital floor fractures is generally reserved for orbital fracture patterns that produce diplopia or clinically detectable aesthetic deformities. Generally accepted guidelines in the decision making for an operative intervention include a fracture involving more than 50% of the orbital floor, muscle incarcerated in the fracture, systematic diplopia, and enophthalmos greater than 2 millimeters. Repair of an orbital floor fracture involves bridging of the floor defect using one of the various biomaterials. More commonly, titanium meshes, porous polyethylene sheets, or autologous bone grafts. Titanium meshes and bone grafts are radiopaque. However, titanium meshes add to the cost of the surgery, while bone graft requires additional graft donor site. In contrast, porous polyethylene is not really opaque, but it allows easy contouring and tissue ingrowth, thus preventing implant migration, and is also cost effective. Porous polyethylene lends a good support for the majority of fractures. Cyanoacrylate is a tissue adhesive that rapidly polymerizes in the presence of water, forming a strong bond between the two surfaces. An orbital floor fracture can be approached by two ways: Either the transcutaneous or the transconjunctival approach. We commonly utilize the transconjunctival approach, combined with the lateral canthotomy and an inferior cantholysis, for a better exposure. In this video, we illustrate the use of porous polyethylene implant stabilized with cyanoacrylate glue to repair an orbital floor fracture by the transconjunctival technique in a 10-year-old child who has sustained a facial trauma. She had an incarcerated inferior rectus muscle in the fracture, causing diplopia in upgaze. The surgery is generally done under general anesthesia. After the patient has been prepped and draped, a forced duction test is performed and any restricted movement of the globe recorded. A lateral canthal incision of about 5 to 8 millimeters in length is marked along a skin crease. Using a radio frequency probe, a lateral canthal skin incision is made along the previously marked crease. The incision is deepened to expose the periosteum of the lateral orbital margin, and a lateral canthotomy performed, followed by an inferior cantholysis. A 4-0 silk traction suture is passed through the upper lid to keep the lid away from the surgical field. Three traction sutures are then passed through the lower lid to maintain traction and stability during the surgery. The lower lid is then everted, and a conjunctival incision made just below the inferior border of the tarsus, extending from just below the inferior punctum to meet the lateral canthotomy incision. A plane of dissection is created anterior to the orbital septum, and dissection carried out in the suborbicularis plane to reach the inferior orbital margin. A periosteal incision is made 2 millimeters below the rim. Periosteum is dissected off the underlying bone, and the dissection continued onto the orbital floor, with gentle retraction of the orbital contents using the retractors. The site of the fracture is identified and the margins carefully exposed, using the periosteal elevator, taking care to release the pressure on the retractors and to check the patient’s pupil at regular intervals. The prolapsed orbital contents are lifted out of the fracture site by gentle pull on the tissues. The posterior margin of the fracture should be adequately exposed. This helps to support the implant, preventing it from prolapsing into the maxillary antrum. A porous polyethylene implant has the advantage that it can be easily cut and shaped to the precise dimensions required. It is placed over the fracture site, ensuring that all margins are covered, and that no tissue is allowed to herniate from the orbit again. For this, it is important that the implant be of an adequate size and shape. Porous polyethylene develops a fibrosing growth in a period of time, thus preventing implant migration. As an additional measure, cyanoacrylate adhesive is used to glue the implant onto the fracture edges. A forced duction test is repeated, which now demonstrates unrestricted movement of the globe. The lateral aspect of the tarsus is attached to the periosteum of the lateral orbital margin, using a single 6-0 vicryl suture to deform the lateral canthus. The edges of the periosteum are identified over the inferior orbital margin and closed with interrupted 6-0 vicryl sutures. The conjunctiva is reapproximated to the inferior border of the tarsus. The skin incision is closed with two interrupted 6-0 vicryl sutures. Orbital floor fractures can result in severe aesthetic and functional complications if inappropriately managed. Repair of an orbital floor fracture by the transconjunctival technique and the use of porous polyethylene implant, stabilized with cyanoacrylate glue, has many advantages, including simplicity of the technique, excellent structural support, shorter operative time, and cost effectiveness. Our patient did very well, and regained her extraocular movements to fully normal, relieving her of diplopia at two months follow-up.

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March 8, 2018

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