Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Management of Orbital Trauma and Fractures 379
method. It is can be used for repair of isolated floor or medial wall fractures not associated with orbital rim fractures. It has also been tested for repair of delayed cases with promising results. It offers a hidden incision, improved fracture visualization, and avoidance of postoperative eyelid malposition, however, specific knowledge of endoscopic anatomy is required.
Via an endoscopic endonasal approach, a wide middle meatal antrostomy in case of floor fractures or intransal ethmoidectomy in case of medial wall fracture is created. Adhesions between the protruded periorbita and the paranasal sinus mucosa are dissected and the bone fragments are removed. The orbital floor is supported by a saline filled balloon, which is connected with an infant feeding catheter and passed through the middle meatal antrostoma. After confirming the reduction of the orbital floor by postoperative CT, the catheter is ligated and cut in short to keep it in the nasal cavity. A silastic or Medpore implant sheet soaked in antibiotic solution can also be used for the floor or medial wall fracture repair. Temporary supporting of the orbital wall with a detachable temporary balloon, or a silastic sheet and Merocel packing was removed 4 weeks after surgery in the outpatient clinic (Figure 18).
Figure 18: Endoscopic view of floor fracture
(A) Before surgery, (B) After repair
380 Oculoplasty and Reconstructive Surgery
Management of Old Standing Orbital Trauma
The patient is evaluated in a manner similar to acute cases with more stress on the globe position, ocular motility, forced duction testing as well as diplopia fields. If globe reposition is indicated, it should be done before muscle or eyelid surgeries. Bonyorbitmayberestoredbyosteotomiesandopenreduction or volume augmentation.by placing an implant in the subperiosteal space. Soft tissues incarcerated in the sinus shouldbecarefullyremovedhowever,fibrosisrenderthisstep difficult with more possibility of tissue injury. Adjustable suturetechniqueisbetterusedformusclesurgeryinsuchcases. Sometimes,glasseswithpluslensescanbeprescribedforblind eyes to reduce the apparent enophthalmos.
Orbital Contour Deformity
This may arise from old trauma that was not or poorly repaired. If the defect is small, no further management will be needed. In case of large defects, subperiosteal custom-made implants are used. The extent of the deformity is defined by radiological studies and the ocularist takes mold of the affected region incorporating the defect. A positive impression is fashioned from the mold using the desired alloplastic material. This can be designed using special computer programs. Methyl methacrylate and proplast implants are usually effective.
Surgical technique: Under general anesthesia, one or two small incisionsareplacedadjacenttobutnotoverlyingthedeformity in conformity with Langer’s lines. The incision is carried down till the deformity using sharp and blunt dissection. If the periostium isintact,a periostealpocketis createdto receivethe implant. Alloplastic materials soaked in antibiotic solution are mildly modified using scissors. The surrounding bone may be
Management of Orbital Trauma and Fractures 381
modified using a drill with fine burr head. The alloplastic material is placed within the periosteal socket and secured in place using 2-0 supramid sutures.
The wound is closed in two or three layers with interrupted sutures.
Late Hypophthalmos or Enophthalmos
Implantation of various materials in the subperiosteal space along the orbital floor can augment this area thus raising the globe and moving it anteriorly. Materials used for orbital floor fractures are used to correct globe malpositions yet they are thicker especially posterior. Beads and pellets forms of these materials can be used and they require smaller incisions. The floor exposure is very similar to the approaches described for orbital floor fracture repair. The periostium is incised elevated from the floor using periosteal elevator and malleable retractors. The implant is placed in the created space with the same precautions taken for floor fracture implants, i.e. pupil and forced duction test. Some authors inserted porous polyethylene (Medpor) particles diced about 1 × 1 cm diameter through a lateral canthal incision to orbital floor with successful results. The advantages of this technique are limited incision, decreased postoperative edema, volumetric adjustability, and applicability under local anesthesia.
Soft tissue fillers have been tried to correct enophthalmos, They include autologous fat, cross linked collagen (Zyplast) and self inflating hydrogel pellets. The latter should not be used in cases with visual potential as they may induce high pressures. Calcium hydroxyapatite gel (Radiesse) as well as hyaluronic acid can be injected to augment the volume in eyes with mild enophthalmos and intact vision. Hyaluronic acid was described to be injected intraconal.
382 Oculoplasty and Reconstructive Surgery
The surgeon should always compare to the sound side for globe position, restoration of the supratarsal sulcus as well as alignment with the sound side. Correction of the condition may result in aggravating existing ptosis that requires surgical intervention.
Late Persistent Handicapping Diplopia
Muscle surgery is advocated after the motility and diplopia measurements are stabilized. Orbital floor surgery can improve it when it is performed up to 5 weeks post-trauma yet the extraocular muscle motility rarely improves after that. The surgery is individualized according to the degree of ocular imbalance. Adjustable sutures are preferred.
Most of patients suffer from diplopia on downgaze interfering with reading. If the eye can move up normally with normal forced duction test on upgaze. A reverse Knapp procedure is performed in which the medial and lateral recti are placed at or several millimeters behind the original inferior rectus insertion.
If the eye cannot move upwards normally with positive forced duction test, inferior rectus is recessed till the eye can be normally moved upwards during surgery. Then a modified reverse Knapp procedure is performed 3-6 months later; thus avoiding working on three muscles at the same time for fear of anterior segment ischemia.
Fadom operation can be done attaching the inferior rectus to the sclera in the sound eye. This decreases diplopia in down gaze yet it inhibits downwards movement and makes the patient tilt his/her head on reading.
Management of Orbital Trauma and Fractures 383
Telecanthus
A Y-shaped miniplates can be used to correct telecanthus when there is enough bony support. In case of bone destruction, transnasal wiring is the procedure of choice.
Surgical technique: A medial orbitotomy incision is made just medial to the medial canthus and anterior to the lacrimal drainage system. Soft tissue and scar are debulked, any displaced bone fragments are either reduced or removed. A Y-shaped miniplate is attached to the nasal bone or frontal bone with screws keeping the long limb directed posteriorly. The medial canthal tendon is engaged by a wire on a free needle then passed through the corresponding hole of the plate mirroring the place of the posterior lacrimal crest. One of the previously placed screws is loosened and the wire is wrapped around its head.
The wire is tightened while the assistant keeps medial traction on the canthal tendon aiming at over correction. Then the ends of the wire are cut, twisted and bent back into the miniplate.
The tissues are closed in anatomical layers and finally the skin is closed using 6-0 silk sutures.
SUMMARY
Orbital and globe injuries are common in maxillofacial traumas. Proper and systematic assessment is mandatory to detect any subtle lesion and should be done as soon as lifesaving measures are taken. Proper understanding of the anatomy, possible problems and their mechanisms is of utmost importance for proper management. Early reconstruction is desirable yet late repair is a challenge requiring many and staged procedures. The treatment is individualized according to the patient’s condition. Proper assessment and planning is the key for obtaining good results.
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Management of Orbital Trauma and Fractures 385
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PRESEPTAL CELLULITIS
Definition
It is an inflammatory process involving the tissue anterior to the orbital septum.4
The orbital septum is fibrous sheet that extends from periosteum of the orbit as arcus marginalis and lies deep to orbicularis muscle.
In upper lid the septum fuses with levator aponeurosis. In lower eye lid the septum fuses with orbital retractor.
The orbital septum limits the spread of infection from preseptal space to the orbit.
Causes
Preseptal cellulitis is more common in children than orbital cellulitis. The causes can be divided in to 3 groups:1, 3
1.Eyelid trauma: Suppurative cellulitis may be seen secondary to lid trauma. Commonest organisms associated are
Streptococcus aureus and Streptococcus pyogenes.
2.Association with upper respiratory tract infection: Organisms isolated are Hemophillus influenza and streptococci.
3.Infection: Periorbital edema develop from associated lid infection such as impetigo, herpes simplex, varicella or due to infected chalazion or dacryocystitis.
Preseptal Cellulitis and Orbital Cellulitis 387
Pathogenesis1,3,4
Preseptal cellulitis can occur by several mechanisms:
A.Infection due to local trauma like insect bite.
B.Secondary to spread from contagious structure like conjunctivitis, hordoleum, dacryocystitis and impetigo.
C.Infection secondary to hematogenous spread during bacterimia due to nasopharyngeal pathology.
Clinical Features
•Usual clinical presentation is unilateral periorbital edema, pain and fever.
•Bilateral involvement is rare.
•Previous history of trauma or upper respiratory infection is seen.
On examination (Figure 1):
•There is presence of erythema, tenderness on the lids,
•Absence of proptosis or decreased extraocular movement (seen in orbital cellulitis)
•Presence of purulent discharge
•Bluish purple discoloration of eyelid
Figure 1: Preseptal cellulitis (Courtesy: Online
Journal of Ophthalmology)
388 Oculoplasty and Reconstructive Surgery
Management
Detailed History and complete clinical examination is must before going to further investigation.
Diagnosis1,3
Children with local cause for periorbital edema rarely need any further investigation.
•Complete blood count is done to rule out infection.
•If there is underlying lid trauma then culture of wound discharge is done.
•Blood culture is done if bacterimia or sepsis is concern.
•Lumbar puncture and examination of the cerebrospinal fluid is done to rule out meningeal involvement in cases where H. Influenzae type b is suspected.
•Cultures are taken from nose, throat, conjunctiva and aspirates of the periorbital edema in cases upper respiratory tract infection. X-ray paranasal sinuses is also done.
•CT scan of the orbit is performed to rule out orbital and subperiosteal involvement and cavernous sinus thrombosis.
•MRI is the study of choice to rule out cavernous sinus thrombosis.
Treatment
Main aim of the treatment is to prevent further complication. Opinion from ENT surgeon and pediatrician is important before starting the treatment.
In trauma related cases gram-positive coverage with cephalexin, augmentin clindamycin is given.
In absence of trauma, broad spectrum cephalosporins like ceftriaxone are used or depending on the culture report appropriate drugs are given: