Lecture: Orbital Trauma: Rethinking Surgical Indications, Timelines, and How to Plan for Success

Good morning, everyone. My name is Dr. Bradford Lee. It’s nice to be here with all of you. Thank you for the tremendous interest from around the world. I’m coming to you from beautiful Hawaii. It’s probably very late at night in Asia and Africa and Europe. Thank you for tuning in or for watching this late air. I’m going to start my presentation here. Great. Today, we’re going to be talking a little about orbital trauma and thinking about what patients might need surgery, when is the proper time to have surgery, and how can we really optimize outcomes for success. A little about myself, I did my undergraduate studies at Harvard University followed by medical school at Stanford and ophthalmology residency at Bascom Palmar Eye Institute in Miami, Florida. And an oculoplastics fellowship at UC San Diego. For six years, I served as the Bascom Palmer faculty in oculoplastics, and two years ago I moved back home to Hawaii where I’m from. I started my own private practice and joined the University of Hawaii faculty in ophthalmology. Certainly, one of my highlights of my career thus far is being a volunteer faculty with Orbis. In 2019, I had the wonderful opportunity to work with some amazing ophthalmologists in Jamaica and throughout the Caribbean. We evaluated a lot of patients and had a lot of interesting cases in the operating room. It was a spectacular week trip. I hope all of you have had the opportunity at this point or if not, in the future have a chance to join one of orb bis’ drips. Today, we’ll start by talking about evaluating the patients with orbital trauma and fractures. Question the traditional thinking and teaching about fracture repair and think about who needs to have fracture repair and what is appropriate timing. Let’s first talk about the logistics of orbital trauma. When patients have orbital trauma, you may be called to see them in an ER set organize they may walk into the clinic days to weeks or months after their trauma. When you see them in the ER setting, it can be a little bit more chaotic and not exactly what we’re used to as ophthalmologists. Some patients have high energy, high impact blunt force trauma that can result in other life-threatening injuries. There can be other services involved, the ER doctors, the trauma service. In the U.S. most trauma centers have what they call face call. This is typically plastic surgery, ear, nose and throat, or oral maxillofacial surgery. A lot of times facial trauma involves the mandible and maxilla and as ophthalmologists we’re not trained to do maxilla and mandible fixation. They may get us involved as ophthalmologists or specialists. My first question for you is in your setting in the hospital you work at which specialty is responsible for most orbital fracture repairs? As you’re finalizing your choices, I will say that a lot of these other services, they’re generalists and may not be as comfortable and specialized with the expertise around the eye. So it looks like the majority is handled by oral maxillofacial surgery but ophthalmology is called in frequently to help manage the repairs. That is great. Let’s talk a little about the history when you first see a patient like this. So it’s very important first to consider the mechanism of injury. This determines the risk to the orbit, the face, and the brain. Again, if this is a softball injury or a baseball injury that hits the orbit or the eye, that’s a very different scenario than if someone was struck by a motor vehicle or had a big agricultural accident or was the victim of an assault. You really need to think about triaging the eye, the orbit, the brain, the cervical spine, and the patient’s life in some situations. We always have to ask about visual symptoms. Because as ophthalmologists we realize there can be intraocular injuries that may take presence dense over the orbital injuries. Visual change, retinal detachment symptoms. We always ask about diplopia. You really have to push the patient for this. I have had patients tell me, no, doc, I have no diplopia and I ask them to look up and they say oh, yes, I do have diplopia. You have to press them to look in different gaze conditions and document if they have preexisting double vision. That is one of the main indications for fracture repair and something we will track over time. I like to ask them, do you have a pulling sensation or a pain in specific gaze positions. If they do have an entrapped inferior rectus muscle, they say ouch, I feel that. It pulls or there is sudden pain when I look in a specific direction. We all have heard of the oculo cardiac reflex. This can almost stop your heart. I have seen patient where is their heart rate almost stopped due to traction on the rectus muscles and this can present symptomatically as lightheadedness, nausea, vomiting, and then I also say that it’s very important to ask about a past ocular history. This is something that we’re very used to for patients coming into the clinic. I find that sometimes when people are called into the hospital to see a patient, they assume that they’re a normal patient without my past ocular history. You really want to know if they had a history of strabismus or strabismus surgery or preexisting double vision. You don’t want to think the strabismus is all new and due to orbital trauma. Let’s talk about the exam. In addition to doing your regular standard complete eye exam, it’s very important in evaluating orbital trauma to focus in on the motility exam. I like to think about the motility in vertical, horizontal, and global muscle restriction. If you are concerned about an entrapped floor fracture in the infer row rectus muscle, you’re looking for a specific pattern of vertical restriction and pain in up and down gaze. The muscle is pinched and whether you look up or down, it’s going to hurt when they move their eye. If you have a very specific pattern of double vision and pain and restriction in horizontal gazes, that can suggest entrapped medial rectus muscle or medial wall fracture, which is less common but can certainly happen. And finally, you may have a pattern of global restriction. We have seen patients with severe retro bulbar hematomas and these patients have trouble moving their eye in any direction. That has to do with the compartment syndrome. Everything is tight and they can’t move their eye. If you have a generalized or global restrictive pattern, you might chalk that up to a retro bulbar hematoma or tissue edema but it’s less concerning for a type of entrapped. Finally, some people teach to do forced duction testing. You grab the rectus muscles are forceps and move the eye muscle up and down. This is not something I almost never do. I evaluate the patient clinically and with a CT scan and I can tell who has muscle entrapment and who does not. One of the classic findings of orbital fracture repair is G2 hypoesthesia. They have reduced sensation in the upper check, teeth, and sometimes alongside the nose. They say it feels like I went to the dentist. It’s numb. The infraorbital nerve travels within the floor of the eye socket. Certain fractures, you get a numbness. Many times that will improve somewhat over the first three months or so. We’ve talked about the oculo-cardiac reflex but take a peek at the monitor and make sure they don’t have bradycardia or hypotension. It’s important to document the exam with photos and a good motility video. I always ask staff and medical students and residents and fellows to take videos, have the patients look up, to the sides, down, even from what we call the worm’s eye view. You tilt the chin up and look up at the ceiling. This helps you capture the degree of exophthalmos or enophthalmos and I can engage patients to take their own photos at home to monitor progress. And sometimes they’re remote and they share videos and photos with me, I can say based on the photos they share, the motility improved. They don’t have severe exophthalmos and it’s a very helpful exam. Finally, if patients are critically ill, they may be intubated and unable to talk and give you a good exam or follow commands. In this case it’s possible to use the doll’s eye reflex to get the patients to see if there is muscle restriction as well. There can be other types of complicating factors in the orbital fracture patient. Intraocular injuries are extremely important whether this is a ruptured globe, a hyphema, a retinal detachment. These are all very important things that are relative contraindications or sometimes hard contraindications to going in for orbital fracture repair. With a ruptured globe, this is something that you focus on the ruptured globe because you don’t want to try to fix a fracture and putting a lot of traction on the globe, raising the intraocular pressure and potentially expulsing the vitreous, the aqueous, the uvea. Orbital emphysema is something we warn patients about. Typically, we talk to patients about not blowing their nose and not pinching their nose when they sneeze. What happens when you do that, you can blow air from the sinuses into the orbit and it can cause compartment syndrome. Sometimes the air is trapped and can’t get out of the orbit. I tell patient ifs you need to clear your nose, you can suck air in as much as you want. You can sniff in like that, but don’t pinch and blow. And finally, sometimes orbital fracture patients come in having had multiple prior surgeries. This is extremely challenging because oftentimes the prior surgeons have already caused scar tissue and disrupted the blood supply and it makes everything more challenging and prone to scarring and poor outcomes. This poor patient over here came to me with about 12 to 15 prior surgeries. And she had, as you can see along the floor, she not only has a fracture but a bone graft where they took bone tissue from the skull and used it as an orbital floor implant and it was not a very anatomical repair. It does not look like a mirror image to the other side. That caused hyperglobus and the surgeon said let’s take another bone graft and put it on the roof to push the eye back down. Severe scarring of the muscles. Severe restrictive strabismus and lid malposition and it made the final repair very challenging and not as good an outcome as if she had come to us primarily. Our next audience response question, what situations would make orbital fractures contraindicated? Okay. So most of you wrote orbital emphysema. Which, actually, the correct answer is hyphema. If you have a hyphema, there is concern that manipulating the eye and the global, the orbital tissues will disturb the hyphema, the red blood cells can clog the trabecular meshwork and you can cause severe rise in the intraocular pressure. Orbital emphysema is something that can be addressed. Sometimes you have to place a needle in to allow the air to egress out of the orbit. Sometimes if in is a large fracture, the air can come out on its own. That is something this can be associated with an orbital fracture repair but if needed you need to address that. So it’s not a contraindication for orbital fracture repair. So we all get scared about the term entrapment. Often when you read the radiology report, they throw around the term entrapment but they throw it around loosely. I would like to clarify there are different types of entrapment. There is entrapment of the muscle, the muscle sheaths or the intramuscular septa. There can be entrapment of fat. What we really care about is tight impingement of the muscle. If it’s between a bone fragment, it becomes ischemic and will die and becomes fibrotic and never will function again. They will be a strabismus-type of pattern. In you have a tightly — rectus muscle, that is a good indication for repair. They can have an oculo-cardiac reflex. In evaluating clinical entrapment, it’s a very specific pattern of pulling or pain in vertical or horizontal gazes. You look for the oculo-cardiac reflex. You look on the skin for that muscle. Here on this scan, you see the nice pancake looking infer row rectus muscle on the normal side resting on the floor. And oh my gosh, where did the inferior rectus go, you can visualize it poking into the macular sinus through the fracture. If you see an absent inferior rectus, that suggests that there are cuts on the CT scan. So the muscle may be dipping through on one of those in between cuts but normally you can see it poking through the fracture. I also think it’s important to look at the inferior rectus muscle conformation. This is ovalization of the inferior rectus. Instead of the pancake on the normal side, it’s a vertically oriented oval. This patient is not only more likely to have double vision acutely but they’re more likely to have persistent double vision. It changed the configuration of the muscle based on how the orbital tissue prolapsed into the maxillary sinus. Forced duction testing may be possible but normally not necessary. Again, this is just another patient of mine who presented with what looked like an entrapped inferior rectus muscle. It’s a green stick fracture in a young patient. You see two different types of tissue entrapped here. There is tissue that looks exactly like extra ocular muscle tissue and that looks suspicious for muscle entrapment. You see a doll lop of fat coming down. This is iso intense with the orbital fat. You have to look at it and look at the radio intensity of the entrapped tissue and see if it looks muscle-like coming through the fracture site. Here the clinical correlation is when the patient looked up, he was very restricted and had pain in up gaze and the left eye cannot go up as well as the right eye. Our next audience response question, which is not associated with entrapment of the inferior rectus muscle. Okay. Let’s go through the answers here. The first one, pulling and pain and pulling is very much associated with entrapment of the inferior rectus muscle. Enophthalmos with hypo-globus is not associated. When you have this, it’s a large more significantly displaced fracture and harder to get the tight pinching of the inferior rectus muscle. Slowing of the heart rate, bradycardia, can be associated with entrapment. A minimally displaced fracture in a young patient is also more classically associated with entrapped rectus muscle. And finally the vertical double vision without horizontal double vision with that associated pinching and pulling, that also is fairly classic for an entrapped inferior rectus muscle. The correct answer is enophthalmos with hypo-globus. That is more significantly displaced fracture. Let’s move onto evaluating the CT scan. This is really critical to properly evaluate the patient. Just as much as the clinical exam. So if you’re going to the ER, the ER doctor has conveniently ordered all of these scans for you and decided which are the appropriate scans. But if you’re the first person to see the patient, you need to decide what type of CT scan. I normally order, if I’m just concerned about the orbit, you can order a CT orbit and non-contrast typically. We’re not looking for inflammation. We’re focusing in on the bone. CT orbits, non-contrast with fine, 2 to 3 mm cuts. If I’m concerned about a pan facial trauma, laport fracture or a tripod fracture that involves the maxilla and sometimes the zygomatic arch, you order a CT face. If you’re worried about traumatic brain injury, you need to order a CT brain and other things. You should know about the difference between orbits versus face. When looking at the bone and trying to see how large a fracture is and how displaced it is, bone window is for bone which is very intuitive here. This is an example of the bone window. There is very crisp, fine definition of the bone. Here you see that depressed fracture of the orbital floor here. When looking at the soft tissue and trying to highlight the difference between the extra ocular muscles and the orbital fat or blood, we switch to soft tissue window. Which gives nice resolution between the muscles and the fat. You see that the bones are a little bit more glare-y and a little bit thicker. But it shows us the nice change in the conformation of the inferior rectus muscle here. If we’re looking for ovalization or tenting of the muscle. And finally, I like to think about orbital volume expansion and tissue herniation. I think in my mind about the normal side and having a perfect reflection across midline and where the anatomical orbital floor should lie. I think about how much tissue of the orbit dropped down outside of the normal anatomical confines. And here, you see that inferior rectus muscle change in conformation and the tissue prolapse. There are also different views on a CT scan, there are coronals and axial and sagittal views. The coronal views that we saw before are best for looking at the floor, the medial wall, the tissue prolapse through the floor. The axials are less important. Axials are not good for looking at orbital floors. They show you the medial walls and lateral walls. Then the sagittals if you’re the surgeon is good for looking for the posterior ledge. When we place an orbital floor implant we have to balance it on a platform or stabilize it so it doesn’t drop into the maxillary sinus below. You can draw an imaginary line and think how much of a ledge do you have to balance the implant. If you don’t have a posterior ledge, that makes the repair more challenging and we use different techniques to cantilever the implant along the medial wall or fixate it along the rim. You can draw the imaginary line of the normal anatomical floor and think of how much tissue prolapse it and that determines how many op thalamus and hypo-globus they have later. Now we’re going to question the traditional management teachings or I’ll say misconceptions. A lot of the other services are under the impression that most fractures need to be repaired. I have seen this so commonly in trauma centers across the country and the U.S. They are seen by oral maxillofacial surgery and almost everybody gets a fracture repair within the first few days. This can be a function of the trainees wanting to get more surgical experience fixing fractures but we have to think about what is best for the patient and think about whether it necessitates repair. I will say that most fractures often times do not need repair. There is also a misconception that repairs must be done within the first two weeks or so to have a good outcome and it’s very challenging to fix the fractures when it’s further out. If you do the fracture repair early on, there is less scarring and the fat is not stuck down and it’s easier to place an implant. But with a well-trained surgeon, it’s possible to have an excellent outcome if you fix a fracture months to years after the trauma. So we have to think in our minds and realize that you can definitely have a good outcome if you have a late or delayed fracture repair: Finally, we all know about the indications from a muscle entrapment, double vision, enophthalmos, hypo-globus, superior sulcus aspect. But one of the classic teachings is fractures involving half of the orbital floor require repair. And this is not always true. And I’ll tell you why. I like to think about this instead in terms of how much orbital volume expansion has there been? If you consider the — if you’re thinking from a volume standpoint, volume is made up of the size of the fracture as well as the amount of displacement of the fracture. So if you do a thought experiment here, you can have a very large orbital fracture but if it’s minimally displaced, that results in a minimal volume expansion. As we have greater displacement of that fragment, the volume and the amount of tissue prolapse dramatically increases. So orbital, 50 percent of the orbital floor is typically referring to a linear measurement on the coronal view and the size of the bone fragment. But we have to think a large minimally displaced fracture translates to minimal volume expansion but a large and highly displaced fracture translates to a larger volume expansion, larger tissue herniation. I will also say, if we’re thinking about the overall orbital volume expansion, if you start expanding multiple walls like the floor and medial wall together, that dramatically increases the over all orbital volume expansion and these patients are more likely to have enophthalmos and hypo-globus. Our next audience response question is diplopia from orbital fractures usually resolves over which timeframe. If you were going to give you patient enough time as necessary to really know if the double vision is going to resolve on its own, how long should you give the patient? Wonderful, so we have the right answer here is the first 3 to 6 months. As we will talk about, diplopia very often times improves on its own in almost all cases if you give it enough time. 3 to 6 months is what I use in my practice. 2 years is — it’s not going to change after 6 months. So my colleagues formerly at UCSF and Mayo Clinic published a nice review editorial in 2018 in ophthalmology making a case for why we should consider delayed fracture repair. They came up with a few different arguments having reviewed the literature. As we’ve talked about, urgent repair is only indicated for true trapped fractures with tight impingement where we’re worried about muscle necrosis. Almost 100% of double vision resolves over six months. So you really need to be patient and advise a patient, don’t worry about double vision if there is no impingement and entrapment of the muscle. Almost all will improve in vision if given time. Late enophthalmos is rare even with large floor fractures. After looking at the CT scan, a lot of times there is a hemorrhage, the tissues are all swollen and as that swelling and the hematoma resolve, there is less outward pressure pushing the bone fragment outward. As that resolves, sometimes the tissues go back into the orbit. The bone fragment is less displaced and the bone remodels. If you were to take a repeat CT scan, you might discover that fracture doesn’t look as bad as it looked initially. Even, so beyond that, even in patients who do have enophthalmos or hypo-globus, it’s nice to let the patient make their own decision about how badly affecting their appearance and how much it bothers them. For the right patient, they may say I know my eye is deeper set there but I wouldn’t want to have surgery for that and I don’t want to have surgery. And they’re quite happy with that. I like to give the patient’s enough time for all of that edema, the hematoma to resolve which is typically by three months. If they look in the mirror and say, you know, I see some difference but it doesn’t bother me, that indication for disfigurement has disappeared and you let the patient make their own decision. Fracture repair can still fix diplopia and enophthalmos. This is important to recognize. It may be more scared down and require a little more skill as a surgeon but you can definitely have great outcomes if you fix it months to years later. The exception to this would be if you have a tripod fracture with or what we call a ZMC fracture that involves the orbital rim, the floor, the zygomatic, fronto-zygomatic suture, sometimes the zygomatic arch and the maxilla. These fractures if you wait a long time, everything scars into place and it’s difficult to mobilize the large fragment and fix it in the anatomical position. You have to go in with a saw and cut all of the sites to mobilize the fracture and plate all of them. It’s easier to fix these fractures often times in combination with ENT or OMFS. That is the one exception where we try to go in earlier to mobilize the fragment and avoid making cuts with a saw to reosteotomize them. Not all of you are going to do orbital fracture repairs and are sometimes more involved in the management of orbital trauma, but for those who are doing the surgery, there are certain considerations here. I would say that you should not attempt this procedure if you’ve never done it before and you’ve only watched You Tube videos. Orbital fracture repair and doing it well is a slightly challenging procedure even for trained orbital surgeons. You want to have someone who has experience and good training. There can be complications and you can cause more harm to the patient if you’re not doing things properly. In terms of incision planning, I think the proper way to do this and the one that has much better outcomes is through a trans-conjunctival incision. It’s a perfect incision if you’re fixing an orbital wall fracture, a medial wall fracture, a trans-caruncular and you can do a combined incision. And this way all of the incisions and scars are hidden on the inside. There is no visible skin or sub ciliary incisions or scars and the patients are less likely to develop eyelid retraction, ectropion or unsightly scars. Navigating the inferior oblique can be a challenge. There are two different methods. Some people dis-insert the inferior oblique on the periosteum and others like to hook the inferior oblique with sutures and reattach it at the end of the surgery. Here you see, this is a figure where we hooked the muscle, we tag it can sutures and divide it. Do the entire fracture repair and at the end replace it and reattach it to the stump. What this allows you to do is have a beautiful panoramic view showing the entire floor and medial wall. It’s a little more precise than just inserting it and allowing it to fall back into position. In a small percentage of the time, it doesn’t fall back and you risk having some torsional diplopia. Finally, one of the big challenges is all of the orbital fat tends to billow over the retractors and spill around the implant. This can be very challenging when you’re trying to hold everything up into the orbit and carefully place the implant on the posterior ledge. Some techniques are hand-over-hand malleables and triangle shaped retractors the size of the orbital floor. And one of my favorite techniques is to have a template or oftentimes just a piece of plastic that you’re using as a template and that holds all the fat in and you can just retract the template and that is effective for holding and retracting the orbital fat. Let’s talk about implants. I always recommend placing an implant. A super mid nylon foil implant. It’s a fancy term for a thin flexible piece of plastic. This is one of my favorite types of implants. It’s easy to insert into the orbit. It’s low cost. Very flexible and there’s no metal hardware which, you know, a patient might not like feeling after the surgery. Another favorite implant is porous polyethylene coated titanium mesh. It’s nice and malleable and flexible and contour-able. There are strips where you can fixate screws if necessary. But the titanium mesh is cored. These can be on the expensive side. The companies that make the implants may have a program they can donate these types of implants. Some like to use dissolvable implants and this can be nice in pediatric orbital fractures because you don’t have to worry about the orbital bones growing and potentially having issues with the implants down the road. Finally I would say, decades ago, we had to use autogenous grafts. We saw an example of a Calvarial bone graft that is harvested from the skull and auricular cartilage from the ear. In some settings it’s easier to harvest tissue than have an implant that needs to be purchased. But I will say these have donor site morbidity. And with the Calvarial bone, we can’t mold it to be anatomical and perfect contour for the floor and medial wall. I would highly advise against using bare titanium mesh. This causes a lot of scarring and problems. The implant, in addition to the material, we have to fashion it into the proper size and with the appropriate anatomical contour. With this type of implant, we have to cut it into the right size to fit the orbital floor and mold it into a triangular or sometimes a guitar pick shape. The implant should be larger than the defect because you don’t want the implant to be too small so it is shifting horizontally or anterior posteriorly. Then it can expose the fracture and have reentrapment of tissue. A nice technique is sometimes to contour it in a way that it has a wing for the medial wall as well as doing the floor. And it’s very easy to slip these types of implants in along the floor and medial wall. One tip is that I always like to place an implant to avoid reentrapment. I have seen cases where an implant wasn’t placed and the tissue reentrapped. I like to always put something to prevent reentrapment. These are some of the newest types of implants that have come out in the U.S. These are pre-contoured implants that are fashioned to the anatomically average adult orbit. So these are really nice, you don’t have to worry about cutting out an implant yourself and molding it. Sometimes you need to trim off the wings a little bit to fit it in properly. But these can be a nice option and my colleagues and I, we published our experience and had nice outcomes using the prefab bring waited and pre-contoured implants. Finally, we’ll talk about implant fixation. Ideally, we do it in a way that avoids palpable titanium screws and hardware. The eyelid is thin and if you screw in a titanium screw and fold the rings over the orbital rim, it’s sometimes visible or palpable to the patient. So normally when we do fixation, we’re trying to avoid anterior migration of the implant. You don’t want it to jut forward and have the patient feel the rim of the implant. The most elegant technique is just by carefully closing the periosteum typically with a Vicryl suture and this avoids all of the hardware. I cut off the metal rings here and carefully close the periosteum and that prevents migration. You can place a screw behind the orbital ring behind the Zygoma here. This is thick bone you can screw into here. If it’s done at the right angle, we avoid palpable hardware around the rim. If there is no posterior ledge and you have no other options, you can use these ring tabs and put in a titanium screw. But it’s palpable and it’s a permanent reminder that the patient has hardware and had a trauma. We talked about the posterior ledge, when doing the fracture repair it’s critical to find the posterior ledge to seat the implant properly so the implant doesn’t fall into the orbit. My colleagues and I published a paper and a series of secondary reconstruction in those patients with prior orbital fracture repair that was not done properly. Here is a patient presenting with hypo-globus and enophthalmos and a sulcus deformity. You see the floor implant is too far down. On the sagittal, it’s not resting on the posterior ledge. It’s falling way down into the maxillary sinus. They didn’t dissect back enough and find the bone and place the implant on the bone. This is after repair and you can see even though it’s a delayed revisional procedure, there is nice improvement in the hypo-globus and enophthalmos and sulcus deformity. This was an interesting patient. On the sagittals she did not have much posterior ledge and clinically you see she has restriction in up gaze. On the coronals, you see the implant is too high up. Not at the anatomical floor. What happened is they — the implant way upwards so when she looked upward, it impinged on the optic nerve and having transient gaze evoked visual problems. We had to remove this and replace it and she had improvement in the hypo-globus and enophthalmos. There was scarring from the prior surgery so there is lid retraction and up gaze. The lid is better and the enophthalmos and hypo-globus is better. The final audience response question, what is not a potential complication of orbital fracture repair. In other words, all of the following are potential complications of fracture repair except. Perfect. This was easy. So you all got that. This is just to highlight the fact there are things that can go wrong with orbital fracture repair. It’s not a beginner orbital surgery. If you don’t have the expertise and you don’t have colleagues who might have the expertise, you can call Orbis and have them send in some docs to help you. But definitely don’t try to do anything that is dangerous or will cause more harm to the patient. Finally, this is an interesting technological innovation that my surgery colleagues in Miami have started to do. They had a series of malpositioned implants they kept taking back to the OR. They now use intraoperative CT scans so you can roll this into the OR and get a scan of the implant after it’s placed and double check yourself right then and there to make sure the implants is in proper position. This is from an article that showed first try, not on the posterior ledge, second try, not on the posterior ledge. Third try, it’s on the posterior ledge. If you’re not sure about the implant position, you can check the implant intraoperatively and make sure you got it right before closing up. In conclusion, a detailed clinical history and exam and review of the CT scans is very, very important in determining who needs urgent repair or who can have a late and delayed fracture repair. If there is no true muscle entrapment, I like to wait 3 to 6 months to allow the patient to have the double vision resolved and see the aesthetic outcome and let them make the decision to have it repaired. Orbital volume expansion is who might have enophthalmos and hypo-globus. Not only the size of the fracture but the displacement and the tissue herniation. And finally, please emphasize to patients that late repair can be very successful to correct enophthalmos and diplopia. Even if think don’t have access to a surgeon in the next month to a year or so, they can always wait for the right person to come and have their fracture fixed. Whether that be through Orbis or visiting oculoplastic surgeons or going somewhere else to a higher acuity hospital. So thank you very much. It’s been a pleasure to spend the morning with you over here. Please feel free to reach out to me over email or check me out on Instagram. I will say if you do feel that you need more training and would like to raise your level of care in orbital trauma and fracture repair, please let Orbis know. There was an overwhelming response to today’s lecture. We had almost 1400 people register for this event and we would be happy to make a trip out to visit with you, work with you. The American society of ophthalmic and place tick and reconstructive surgery has a foundation and big interest in global ophthalmology. If you’re interested in partnering with AAOSPers. Reach out to them as well. We will move into the question and answer section. Okay. So our first question is what is the op mall timing for a fracture repair? I think we coffered this. We talked about entrapped muscles need to go right away, ideally within 24 hours but without the concern of muscle necrosis and ischemia, we often times want to wait 3 to 6 months. See if they really need and meet the indications for repair and they can always have a delayed fracture repair. The next question, does enophthalmos progress over time? It does. Like we talked about, as tissue edema resolves and as the orbital hematomas resolve, things will go inwards. I always tell patients that enophthalmos, you’ll see your final enophthalmos and hypo-globus results 3 months after the trauma. If at that time you’re not bothered by the enophthalmos or hypo-globus, it shouldn’t get worse at that point. The next question, if I have a trap door fracture with a hyphema, should I wait or should I repair it? Definitely like we talked about, the hyphema takes priority. We hate to throw someone into severe — having the RBCs clog the trabecular meshwork and have uncontrolled hypertension and glaucoma. You keep them on bedrest until the hyphema resolves. You can have great outcomes with late or delayed fracture repairs. The intraocular injuries take precedence. The next question, if enophthalmos is more than 2 mm and diplopia is gazing and primary gaze and deviation of more than 30 degrees, even then should we delay surgery? We talked about how the diplopia can resolve. In most cases it does resolve over the first six months. Seeing diplopia early on is not on indication for repair. Enophthalmos, if it’s severe and hypo-globus early on, if anything that is probably going to get worse over time. If that’s the case and you know it’s going to get worse and it’s already unacceptable for them, that can be an indication to do the surgery maybe a little bit sooner. Do you use 3D implants? Any experience about those results? I have used custom implants before: They are very, very expensive. These would be for very special circumstances. With 3D implants, I think what this question is about is, is it mapped and custom fit and 3D printed to the anatomical other side of the face that is uninjured. And in the U.S., these implants can cost up to 20, $30,000 for the hole process and 3D imaging and printing. There is also sometimes 3D implants refer to the 3D pre-contoured implants which I showed you previously. These are also expensive but in the U.S. they’re more of 2,500-dollar range. I used the pre-contoured 3D implants but those are not the 3D printed, and mapped through CT scans to the patient’s individualized contralateral side. Another question, up till how much time can we repair floor fractures after which time it will be of no value? I would say there is no limit. We once had a patient who had a fracture 20 to 30 years ago. Just had not been in the right place and time to have it fixed. We were able to fix it for him beautifully and he had a great outcome. There is no expiration date as long as you’re comfortable and trained to do those fractures. Can you please bring the slide with your email. My email address is [email protected]. Can orbital fracture repair cause any damage to the infraorbital nerve? Certainly if you don’t know what you’re doing you can damage the infraorbital nerve. More commonly when we do the orbital fracture repair, we talk to patients and say you may have numbness after the fracture repair because we have to pull and stretch on that nerve a little bit. Obviously, it would be very problematic if you cut through that nerve and that should never happen. But if you’re just dissecting orbital tissues off the infraorbital nerve, you can get temporary neurapraxia. They have transient numbness and it gets better over 3 months. Management of post-traumatic lacrimal canal obstruction. When and how. This is not the focus of our lecture here. I think the question is about canalicular lacerations and scarring and how do you fix this. Of course, we try to do this early to intubate the lacrimal canaliculus to avoid this. But if it happens later, sometimes if the obstruction and the scarring is very proximal, you can cut down on the canaliculus, find the patent distal canaliculus and place a stent and create a new punctum for the patient. That can be a nice option if the cut is fairly proximal. If it’s more distal, sometimes you can try using a lacrimal tree find (ph.) to core through the scar tissue. If there is a big displacement of the canaliculus, you can’t just core through and get into the near segment. It has to be relatively lined up and if there is scar tissue you can use a lacrimal tree find to core through it. If you have a traumatic global avulsion and medial fracture, how do you approach that? When you say globe avulsion, that is trauma or dis-insertion of the medial rectus muscle. Sometimes trauma to the optic nerve. In those types of situations, gosh, those are always challenging. Assuming that the globe is okay, if you think that you could reinsert the medial rectus muscle, you can try to do that. But it’s very, when you’re thinking about dis-insertion and trauma, full and through cut through the medial rectus muscle, you have to understand that the innervation of cranial nerve three branch to the medial rectus muscle innervates the muscle in the posterior 1/3, 2/3 junction. If you have disruption of the innervation, that muscle is never going to work and never move properly. This is a problem where in cases that ENT did an endoscopic sinus surgery, they fractured through the lamb muscles and — a portion of the medial rectus muscle. Those are challenges cases. If they disrupted and de-innervated the muscle, the muscle will never function properly even if you go in and repair the muscle. In those types of situations, you have to think about that. But I would more likely than not just delay the fracture repair, see how things go. See what the double vision is like and the first priority might be to try to get a better eye alignment first. Next question, can hypoesthesia remain after repair. It can. Normally, if you have numbness from damage to the infraorbital nerve that does not get better after the first 3 to 6 months or so, it’s probably not going to get better at that point. Normally with orbital fracture repair, if it’s done properly and you’re lifting or releasing the scar tissue off of the infraorbital nerve, you shouldn’t cause permanent nerve damage. The infraorbital nerve is a very, very thick nerve bundle. You would have to really cut into the nerve. If you’re just peeling off the tissue. Even if you got one or two axons while you were dissecting it off, it’s a very, very thick nerve bundle and you shouldn’t cause permanent worsening hypoesthesia. Have you used xeno graft bone grafts before. If so, how was the outcome. I have not used them. This is like a bone graft from another dead patient. I haven’t used cadaveric bone grafts from the same patient. One because of the morbidity and we talked about the malleability probability. It’s not as good as what we have for aloe plastic implants. You need a thin piece of plastic which is indicated for implantation in the human body. I have heard of cases in resource-poor settings where they improvised implants. In certain countries they take sterile saline bottles and cut out a thin piece of plastic and use that as the implant. I can’t say I endorse that officially because anything you put in a patient’s body should be cleared for true implantation in the human body. But yes, just having a thin plastic implant like the mid nylon foils are very inexpensive and hopefully are not cost prohibitive. Even in a resource-poor setting. Do you consider fillers for traumatic enophthalmos? Great question. If the only concern is enophthalmos and sulcus hollowing, you can use soft tissue fillers or autologous fat transfer to address the superior sulcus hollowing or address the hypo-globus or enophthalmos. Here the idea is we’re not recreating the anatomical orbital size but augmenting the soft tissue and orbital fat in the orbit to prop the orbit up to address the enophthalmos and is sulcus hollowing. I do that. You have to be careful. I like to inject along the floor of the orbit with blunt cannulas. You have to know what you’re doing and do liposuction and purify the fat and inject with cannulas. That can give a nice outcome. I have a whole talk about the use of fat transfer for addressing reconstructive indications whether it be ZMC fractures, orbital fractures, radiation, soft tissue atrophy. That can be a very powerful option. If you do hyaluronic acid fillers. You have to be careful about migration of the fillers. Sometimes you think you’re injecting into the orbit but it’s tracking back along the cannula or needle track and can cause significant tissue edema and swelling in the eyelid and may need to be dissolved. You just have to be careful with soft tissue fillers but it can augment the orbital volume. How to manage CSF rhinorrhea. That is where you have a fracture along the skull base. So sometimes you have a medial wall fracture but you have the fracture propagating through the cribriform. These are very difficult. I personally don’t manage these myself. I would do that in conjunction with ENT. But typically, they do some type of soft tissue graft, whether it be what we call a engeorgian (ph.) graft. A bovine collagen graft or use the patient’s autogenous tissue or some fat or dura or fascia to plug the hole and get the CSF leak to stop. With a CSF rhinorrhea, you have to think there can be nasal flora that can get inside and cause meningitis. That’s a concern with CSF rhinorrhea. This classically presents as a constant dripping, salty taste of dripping fluid in the nose and throat. How do you manage post-traumatic intraorbital hematoma if there is optic nerve dysfunction? Great question. Basically, this is a question of what do you do with the retro bulbar hematoma with optic nerve dysfunction? Well, this is classically, we have to try to alleviate the compartment syndrome as soon as possible. What happens is that there’s too much compression of the optic nerve due to the hematoma and it restricts the perfusion and blood supply to the optic nerve. These are classically emergencies. This is where you do the canthotomy and cantholysis. If you’re having trouble with the canthotomy and cantholysis. You can do the lid approach. You just take a scissors and make a big vertical cut through the midsection of the eyelid which is sometimes easier to do, maybe an ER physician is more comfortable doing this properly as well. And that widely splays open the lower eyelid and allows the globe to come forward and that can alleviate the compartment syndrome, lower the intraocular pressure and allow the optic nerve to perfuse. You have to do this urgently, within the first 1 to 2 hours. If you have loss of perfusion to the optic nerve, you can have permanent loss very quickly. Think of it like a stroke to the brain. It’s a stroke to the optic nerve. And strokes have to be addressed urgently if you want it to reperfuse properly. Can we do squint correction along with orbital fracture repair? Great question. If they needed to have muscle alignment surgery along with the fracture repair, I would say it’s better to stage this. Because if they have double vision, that’s partially due to the orbital fracture repair. It’s better to recreate the anatomical confines of the orbit and that might address the double vision and motility dysfunction. You may not have to mess at all with the extra ocular muscles themselves. If they do have residual double vision after the fracture repair and after the tissue edema has gone down, especially in primary or reading position, that may be an indication to move forward with a strabismus surgery repair or prism glass. Just like with the initial trauma, you got to wait at least 3 months after the fracture repair because it’s very common to have double vision after the fracture repair in the early postop period due to tissue edema and you have to wait for that to go down before you can appreciate the final result. How do you manage traumatic optic neuropathy? Honestly, I like to get my neuro ophthalmology colleagues involved. Unfortunately, there is not a lot of good evidence around this. If it’s due to a global — if it’s due to blunt force trauma, there is oftentimes no good treatment. Some people find steroids which can be plus/minus. I don’t think there is great evidence base for that. And steroids can certainly sometimes cause other side effects as well. Can you elaborate on OCR? I’m not sure what OCR — oculo-cardiac reflex. Oculo-cardiac reflex is where you, when you put traction or impinge the rectus muscles, whether through the muscle being pinched between a bone fragment and they’re looking up, that is putting traction on the muscles, they can cause the oculo-cardiac reflex. Which is a severe bradycardia reaction. You see the heart rate go down. They become lightheaded because they don’t get perfusion to the brain. They can get nausea and vomiting and feel awful as the heart is slowing down or almost stopping. In that setting with an entrapped muscle, I tell the patient to keep your eyes closed. Don’t move the eye. In those gaze positions where it’s causing impingement of the muscle and take them to the OR as soon as possible to free up the muscle and prevent reentrapment of the muscle. What material do you prefer, porous or titanium for orbital floor. I like the nylon foil. It’s a thin malleable piece of plastic or the porous polyethylene coated titanium mesh. These are a little more expensive but you have the benefit of the malleability of the titanium mesh as well as the benefit of the porous polyethylene that prevents scarring of the intra-rectus muscle to the metal. That’s the downside of a bare titanium mesh without the coating. You get a lot of scarring and fibrosis and it makes it very difficult to fix things later as I’ve been told if it needs to have a revision. How do you manage orbital compartment syndrome? We talked about this. Really, doing the canthotomy and cantholysis, the full thickness lid split approach to allow the orbital contents ton prolapse forward and prop toes the eye and relieve the compression on the optic nerve. Is oculo-cardiac reflex a sensitive indicator of a WEBOF in children? I would say yes. If you have oculo-cardiac reflex, especially if it’s gaze evoked, that means you’re having, you’re pulling on the muscle. And of course, we don’t look at that in isolation. If you have an oculo-cardiac reflex, be highly suspicious it’s more likely than not they have one. Look at the CT scan and the muscle dipping through the fracture site. Ask them, hey, little boy, are you having pain and pulling sensation when you look up and down. If the answer is yes, ouch, yes, it hurts. And when looking down, yes, ouch, it hurts. That is clinically an entrapped muscle. Use of 3D Cam in orbital fractures is a very good tool in the surgeries, the time in the OR is less and is wonderful. I think in 3D CAM. I think he means the 3D contoured implants. Wonderful, glad it’s working out for you. How would one help if someone is in a setting where there are no orbital implants and exenteration is the only approach, especially in children? I think we have to clarify here, when we talk about exenteration we’re talking about removing all of the orbital contents for different types of malignancy. Removing the globe, the rectus muscle, we think of that in the setting of rhabdo myosarcoma, invasive orbital malignancies. We’re typically not doing exenterations for orbital fractures and trauma. To the question about what do we do if we don’t have orbital implants, I guess your options are to, one, do, have a colleague or yourself harvest some type of autogenous tissue, auricular cartilage. Try to improvise a thin plastic sheet. Talk to Orbis about getting a donation. Talk to AASOP’s foundation about a donation. Talk to the big companies like striker about donating implants or do a delayed fracture repair. If the timing is not right, you don’t have the right surgeon, don’t have the right equipment and won’t have the best outcome. Let them know, we can have a great outcome for you. We just have to wait until we have the stars aligned. The right implant, the right surgeon and then we’ll fix your fracture. Why eyes remain white in orbital fractures in children? Is it because of the elasticity of the bones and green-stick fractures. Sometimes we have the term white eyed blow out fracture or green stick fracture. This typically happens in young children, teenagers and young adults in their 20s. The bones are malleable and flexible. Instead of an adult the bone fractures and depresses, children have very flexible bones that can fracture and snap back up. Because of this, sometimes there’s less orbital hematomas, less chemosis, maybe there are different types of fractures. They’re not having these giant blunt force injuries. Hopefully they’re more likely to be hit in the eye with a ball while playing. The mechanisms of injury are different and sometimes that’s also why there’s not a lot of retro bulbar hematomas. They’re not on blood thinners. There is a variety of reasons that kids are more likely to have a white eye blow out fracture. What do you expect from optometrists in facing an emergency ocular trauma situation? Optometrists are wonderful and the primary eye care providers in many settings. In the U.S. there are more optometrists than ophthalmologists. Your goal as the primary eye care doctor or provider is to advise the patient appropriately. You’re responsible for helping triage the patient. Figuring out who has muscle entrapment, who needs urgent surgery. Who needs to go to the ER and you call your colleagues for management. Or who can be triaged to say you don’t have muscle entrapment. This can be delayed. We will wait for the double vision to resolve. We can have the fracture repaired later. Counsel the patients about enophthalmos and seeing the final result after 3 months and seeing the double vision results after 6 months and then talk about how a fracture repair might work. In most cases acute management is medical management and counseling the patient properly and triaging. And an optometrist can certainly do that very well if they’re informed and educated. Do you recommend local anesthesia for ocular cardiac reflex control before surgery? I always recommend injecting local anesthesia before any type of surgery because even though the patient is under general anesthesia, we know that intraoperative pain results in preoperative pain through centralized pain mechanisms. And the epinephrine in the local anesthetic, we want less bleeding. If you have ocular cardiac reflex, you still need to go in and release the trapped tissue and place an implant and close them up. Why have excess bleeding. Use local anesthetic with epinephrine even for cases going to the OR for an entrapped muscle. How we can see your educational operation videos? This is challenging. I will say that filming orbital surgery is very difficult because you’re in a dark hole. You need to have a head light. It can be very difficult to watch this. I will make a plug for the atlas of oculofacial surgery of which I’m an author of various chapters. There is beautiful videoing of various types of orbital surgery as well as eyelid surgery. So if you’re hoping to augment your skills, that video atlas is a wonderful resource. It’s called the Corn and Tikowa (ph.) atlas of ocular surgery. There is a treasure-trove of videos that are recorded online for eyelid and orbital surgeries and I would point that out as a resource as well. You’re also welcome to talk to Orbis and talk to the AASOPer’s foundation about arranging a preceptorship. If you work with a surgeon in the U.S. or we arrange for oculoplastic surgeons to come and visit you and help you with your surgeries. That’s really invaluable to have preceptor and mentor teaching you live and coaching you live. Yes, CAM is computed assisted manufacture. This was a comment that computer assisted manufacturing can be helpful for DICOM data with CT studies. That is great. 3D printed implants, if you have the resources and it’s not cost prohibitive, that can be a great outcome. I will say the pre-contoured ones to the average human orbit, there is not a lot of variation between the average human orbit. That can sometimes be a much more cost effective option. How to manage oculo-cardiac reflex in orbital fractures. You take them for urgent repair. You have to pull the tissue out of the fracture site. Place an implant to prevent reentrapment and close up. You take them to the OR and free up the tissues that are entrapped between the minimally displaced fracture. Injection of atropin. No. Not atropine. Tell them to close their eyes and not move them until they go to the OR. How do you manage a patient with intravitreal hemorrhage alongside the blow out fracture with enophthalmos and lid lacerations? With intravitreal hemorrhage we want to minimize manipulation. Sometimes it’s difficult to get a good exam with the intravitreal exam and you might have a retinal detachment as well. Which is more reason we don’t want the vitreous moved around and the globe being manipulated. If there is no entrapment of the muscle, you can do, have a very good outcome with a delayed fracture repair. The answer is just do a delayed fracture repair and you can fix the enophthalmos later. If you can fix the eyelid lacerations in a minimally traumatic fashion that is not going to put pressure on the globe, you can fix the eyelid lacerations so they don’t have secondary intention and bad scarring. I think we answered almost all the questions. It’s 8:20. I think I’ve gotten instructions to wrap this up. Thank you all so much for spending time over here today. Feel free to review the lecture which will be posted on the Cybersight library. Feel free to contact me if I can help with anything. If you have an interest in raising your level of orbital surgery and orbital trauma and fracture repair, let Orbis know because there a lot of us here in the U.S. and all over the world who will be happy to make a trip out and help. Thank you very much. Have a good day and good evening.