The document discusses orbital trauma and injuries. It begins by introducing the orbital region and some key anatomical features, such as the bones that form the orbit and average orbital volume. It then discusses different types of orbital injuries, including those caused by low or high impact forces. Principles of examination and assessment are provided, including inspection of the eye and surrounding tissues, defining the extent of injuries, and evaluating pupillary response and eye movements. Surgical anatomy of the various orbital walls, soft tissues, and nerves is outlined. Assessment methods like imaging, orthoptic tests, and diplopia evaluations are also summarized.
4. Introduction :
Anatomical region of clinical and surgical interest
“Cross roads” , signposts - complex
injuries needs additional expertise
Often underestimated and undertreated
Interesting & difficult areas in facial trauma
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5. Orbit :
Bony vault houses eyeball
Quadrangular based pyramid
Average volume - 30cc,globe - 7cc (1/4)
Growth completed by 83% by 5yrs
Seven bones form orbit
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6. Orbital injuries :
Alone or associated with others
Low impact force - floor,NOE
High impact force - roof,supraorbital rim
Complicated by their proximity
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13. Surgical anatomy : Lateral wall
By zygoma & greater wing sphenoid
Inclined 45* - orbital apex,90*- each other
FZ suture - line of relative weakness
Orbital tubercle - 1cm below FZ suture
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14. Medial wall :
By very thin plate of ethmoid
Anterior & posterior ethmoidal foramen
Weakened by nasolacrimal apparatus
Splaying apart
1. Walls
- Traumatic hypertelorism
2. Ligament - Traumatic telecanthus
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15. Roof :
Reinforced by greater wing of sphenoid
Mainly of frontal bone - anterior cranial fossa
Rim thick becomes thin posterior from edge
Elderly - roof resorbed in selected areas
Dura confluent with peri orbita - careful dissection
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16. Floor :
Orbital portion of maxilla & zygoma
Posteriorly by small piece of palatine bone
Triangular -“Guitar plectrum”
Inferior orbital groove - 2.5cm from rim
Inferior orbital canal - 5mm below rim
Thin 0.5mm, weakest portion medial to groove
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17. Cont :
Not horizontal slopes upwards & medially 45*
ascends posteriorly at 30*
Weakened by presence of groove
Blow-out fracture occur medial to it
Sagging of contents into maxillary sinus
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18. Orbital rims :
Supero lateral & inferior - thicker
Part posterior to it and medial - thinner
Floor & medial - common site #
Inward displacement - increased intraocular pressure herniation
Paranasal & ethmoidal sinuses - air bags
Globe perforation - uncommon
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19. Inferior orbital rim :
Unable to withstand force
Depression - origin of inferior oblique
# often leads to diplopia
Greatest diameter lies within and not at
periphery
Direction of instrument changed - periosteal
elevation
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20. Soft tissues : Eyelids
Skin is thin - very lax areolar tissue
Careless dissection -“Button-holing”
Rich arterial & venous supply
Trauma - circum orbital ecchymosis,”black eye”
Delayed onset - # roof or anterior cranial fossa
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21. Nerve injury :
Anastomosis between sensory & motor
Opening principally by levator
Innervation - occulomotor - ptosis
Closing principally by orbicularis oris
Innervater by facial - lower eyelid drooping
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22. Orbicularis oculi :
3 parts
Orbital ,palpebral , lacrimal
Lateral eyebrow incision - parallel to palpebral
In line of hair follicles,long axis of eyebrow
Crows feet wrinkles - skin right angle to fibres
FZ suture 1cm above outer canthus
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23. Levator palpebrae superioris :
From under surface of lesser wing
Divides into 2 lamella
Upper attached to tarsal plate & skin of eyelid
Lower attached to upper margin of tarsal plate
Mullers muscle - nonstriated,sympathetic
Trauma - Ptosis,pseudo-enopthalmos,miosis
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24. Orbital septum :
Skeletal framework of eyelids
Membraneous sheet attached to lacrimal crest
& orbital rims
Thickened to form upper & lower tarsal plates
Inferomedial aspect - incomplete - air escape to
preseptal space - periorbital swelling
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25. Palpebral ligaments :
By fibrous extensions of tarsal plates
Lateral canthus - Y shaped
Superficial bundle - frontal process of zygoma
Deep bundle
- whitnalls tubercle
Medial canthus - Y shaped
Anterior fibres - frontal process of maxilla
Posterior fibres - lacrimal fossa
Maintain level & shape of orbiral fissure
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26. Cont :
Small muscle from inferior orbital rim to
posterior limb against lacrimal sac
Enables lower eyelid movement - empty sac
Transconjunctival incision - avoid damage
Trauma - FZ suture - antimongoloid slant
Medial aspect - traumatic telecanthus
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28. Tenons capsule :
Applied like bursa to eyeball
Thickened both sides - check ligaments
“Suspensory ligament of lockhood” - inferior bulbi
Determinant of globe position - vertical
Other determinants - intact walls, fat ,muscles
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29. Periorbital fat :
Cushion against which eye rotates
Balance of fat with others - AP position of globe
Many fibrous septa
Blow out # - mechanical entrapement
Interference with free rotation
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30. Extraocular muscles :
4 recti - “annulus of zinn” at back of orbit
Superior oblique - lesser wing of sphenoid
Inferior oblique - inferior orbital floor
Medial & lateral recti - only horizontal movements
Superior & inferior recti - complex combinations
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41. MRI :
Soft tissue injury & entrapment
Radiolucent foreign body - wood
Unresolving orbital emphysema
Potential for displacement of metallic objects
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42. Colour doppler :
Provides 2D image
Assessment of blood flow
For post traumatic high flow cavernous fistula
Angiography - confirmatory
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43. Cover test :
Diplopia & hypoglobus
Occluding one eye followed by other
Disappearance of peripheral image
Affected eye & muscle involved
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44. Hess or Lees chart :
A dissociation test
Reproducible pictorial record of ocular movements
of eye in all gaze
Distinguish between entrapment & neurological
impairment
Non injured eye will over react
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45. Cont :
Screen divided into squares
Inner field - 9 dots ( cardinal positions of gaze )
Outer field - 16 dots
Chart plotted - showing limitation & overaction
Patient 0.5m from screen , red & green glasses
Examiner - red torch, patient - green torch
Glasses reversed, also with normal eye
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46. Interpretation :
Position of central dot - deviation
Smaller field - affected eye
Constriction - limitation, enlargement - overaction
Larger field - unaffected eye
Narrow field - restricted in opposite direction mechanical restriction
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49. Diplopia :
When non corresponding points stimulated in
two eyes by same object
Minor degree - compensation - overaction of
synergistic muscle in unaffected eye
Monocular - dislocated lens,macula lesion,retinal
detachment
Binocular - following trauma
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50. Binocular diplopia :
False image projected in same direction which
ineffective muscle normally moves eye
Horizontal diplopia - false image on right of true direction of lateral rectus
Vertical diplopia - false image above true direction of superior rectus
Identification - Cover test
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51. Diplopia following trauma :
Not due to paresis of prime mover
Inability of antagonist to “pay out rope’
Fibrosis between sheath & periosteum
Inferior rectus entrapement - superior rectus
mechanically ineffective
Axis of rotation shifted posteriorly
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52. Cont :
Elevation associated with posterior movement
of pole
Deepening of supra tarsal crease
“RETRACTION SIGN”
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53. Binocular fixation test :
Demonstrate over which conjugate movement
possible
Displays areas of binocular vision & diplopia
Plotted on perimeter,white target used for fixation
Patient follows target from centre to periphery
Appreciated diplopia recorded
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54. Interpretation:
Field displaced away from direction of maximum
limitation
Greater limitation - smaller field
Narrow field - mechanical limitation
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55. Soft tissue injuries - Eyelid :
Most common is bruise
Deep bruising - demarcation line, eye of panda
Direct ocular injury - posterior limit seen
Massive swelling of eyelid - sign of retrobulbar
Laceration on medial side - lacrimal apparatus
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56. Steps in eyelid closure :
First
- suture to cut ends of tarsal plate
Second - close posterior lamella of lid
Third
- suture grey line to opposite side
Fourth - suture 0rbicularis oculi within wound
Fifth
- suture skin
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58. Torsorrhaphy :
To protect cornea
For ectropion & paralytic drooping of lower eyelid
Incise 6-8mm inter marginal tissues
Incise base of bare area to open wounds
Closure
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63. Berlins edema :
Traumatic retinal edema
Whitening of eye
Blurring of vision
Opthalmoscopy - milk-white against red fundus
Edema at macula - eclipse blindness
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64. Classification :
Associated zygomatic complex #
1. # stable after elevation
2. # unstable after elevation
Isolated # of orbital rims
Isolated # of orbital floor
Complex comminuted #
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65. # - clinical features :
Circumorbital ecchymosis , subconjunctiva haemorrhage
Proptosis - blood posterior to septum ,tenderness
Surgical emphysema - crackling sensation,nasal
communication - attempt to blow nose
Pneumogram in x-ray, through antral wall or roof
Paraesthesia over infra orbital distribution - #
Diplopia,telecanthus,ocular cant,epiphora,CSF leak
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68. Orbital rim & wall # :
Inferior orbital rim - most common
Supra orbital margin - highest resistance to impact
Isolated # - kinetic energy absorbed over small area
Early ages - lack of frontal sinus - anterior cranial fossa #
Medial - NOE complex #
Lateral - zygomatic complex #
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69. Treatment :
Supra orbital margin - no treatment
Closed reduction - digital manipulation , bone hooks
Open reduction FZ suture - lateral eyebrow
Base of frontal process of zygoma - Subciliary,lateral part
Trans osseous wires, bone plates,K wire,external pins
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71. Orbital floor # :
Most common - thinnest - 0.27mm
Hydraulic force - sudden application of pressure
2 types - Direct , Indirect
Inclination of walls - medial & downward direction of force
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72. Indirect :
Classical blow-out # by Converse & Smith - 1957
Object of greater diameter than rim - blow out #
# of bony floor anterior to inferior orbital fissure
Blunt trauma to globe - increased intra orbital pressure
Herniation of orbital fat , inferior rectus & oblique - antrum
Rim intact , also called as “impure #”
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73. Direct :
# of orbital floor through extension of force
Trauma to rim
# of rim - also called as “pure #”
Herniation may or may not be present
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74. Blow-out – C/F :
Diplopia
Enophthalmos , supratarsal fold deepening
Narrowing of palpebral fissure
Paresthesia, alteration of occular level
Restricted movement of eye - full vertical
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76. Traction test :
Forced duction test
Performed bilaterally in conscious patient
Tendon of inferior rectus grasped - LA
Rotate eye upwards
Restriction - muscle entrapment, fibrous adhesions
No restriction - does not exclude floor defect
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77. Others :
Electromyography - Bjork - Diagnosis of combined lesion
inferior rectus incarceration & superior rectus weakness
Orbitography - radio opaque contrast medium - Milauskas Communication between orbit & antrum
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78. Blow-in # :
Dingmann & Natvig - 1964
Elevation of fragments of floor or roof , intact rim
Upward herniation of floor
Compression of air within antrum
Linear shock wave with negative pressure from rebound
of orbital contents
Rarely demands surgical correction
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79. Surgical intervention :
Defect <1cm,>5mm, positive clinical & x-ray ,duction test
Defect >1cm
Emert et al - diplopia with positive duction - delay 2wks
Putterman et al - all blow out # waited for 4-6 months
Most clinicians - waiting period 2 wks
Diplopia & enopthalmos - surgical intervention
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“Sooner the better”
80. Access – Blow-out :
Antral approach
Trans conjunctival
Infra orbital
1. Subciliary
2.Subpalpebral
Pre existing scar
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81. Antral approach :
Cald well luc, inspect floor - fibroptic source
Trap- door #, fragments attached to periosteum - support
Antral pack - material of choice
Exert controlled force upon specific area of antral roof
3-6m of gauze soaked in whitehead varnish, aural forceps
Build up in layers ,avoid force in postero superior corner
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82. Cont :
Inspect ocular level - avoid overpacking
Pack - free of infection - iodoform
Pack removal - 3wks
Antral balloon - 30ml Foley catheter - Jackson et al (1965)
Through intranasal antrostomy - No 16 -18 catheter
Disadvantage - no selective pressure
Removal - after 14www.indiandentalacademy.com
days
83. Trans conjunctival :
Bourguet - 1928 - cosmetic procedure
Traction suture - eyelids, fixation suture - fornix
Incision between conjunctiva & tarsal plate
Incise palpebral portion of oculi superficial to septum
Small incision 3mm below tarsal plate
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84. Cont :
Conjunctiva & septum freed from orbicularis oculi
Dissection upto rim
Incise periosteum 5mm below,rim - periorbital fat herniation
Sub periosteal dissection - retraction with copper strip
Dissection upto inferior orbital fissure
Excellent access - floor . Inferior orbital rim
Invisible scar , restricted access
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88. Inferior marginotomy:
WOLFE - 1982
Access to herniated fat at posterior limit of floor
Rim intact , elective osteotomy - 1.5cm each side of foramen
From rim to level of infraorbital nerve
Vertical cuts joined horizontally,convergent cuts along floor
Segment mobilised - excellent access to affected area
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Wired back in position
89. Reconstruction :
To seal off antral cavity
Physiologically acceptable smooth surface - adhesions
Restore dimension & contour of orbit
Indirect support for globe
“Key area” - posterior part of medial wall
1.Main support for anterior projection of globe
2.Paper thin structure - damaged in orbital injuries
3.Technically difficult to repair
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90. Key points :
Medial canthal ligament left undisturbed
2 steps - Orbital frame ,Internal orbit
Orbital frame - reduce zygoma ,arch,lateral orbital wall - key
Internal orbit - key area - platform for further grafts
Globe protrude 2mm - compensate for volume loss - swelling
End of reconstruction - forced duction test
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98. Homograft :
Defect less than 1cm
Lyodura since 1970
Absorbed & replaced with fibrous tissue - indistinguishable
Inert , non allergic , sterile
Subperiosteal location
Pre sterilized packs - rehydrated with saline
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99. Allelograft :
Encapsulated by fibrous tissue - not replaced
Function - seal off communication until encapsulation
Polyglactin & tricalcium phosphate,polydiaxone - resorption
Teflon (tetrafluoro ethylene ), silicone
Dacron reinfoced silastic - better retention
Extent - 3mm behind rim to tnferior orbital fissure
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Passive , no pressure
102. Reconstruction of orbital floor fracture with polyglactin
910/polydioxanon 2005 May;63(5):646-50.retrospective study.
patch (ethisorb): a
J Oral Maxillofac Surg.
Buchel P, Rahal A, Seto I, Iizuka T.
Department of Cranio-Maxillofacial, Skull Base, Facial Plastic and Reconstructive Surgery,
Inselspital University of Berne, Switzerland.
PURPOSE: We sought to evaluate the effectiveness and the complications related to
the use of Ethisorb (resorbable alloplastic material) in the reconstruction of orbital floor
fractures. PATIENTS AND METHODS: We retrospectively reviewed the charts of all
patients who underwent orbital floor fracture reconstruction with Ethisorb since 2001.
We only included patients with a minimum follow-up of 3 months. The following data
were recorded for every patient: age, gender, cause of trauma, time from trauma to
surgery, signs and symptoms, concomitant ocular injuries, radiographic analysis,
pertinent intraoperative findings (including the type of approach), follow-up time, and
postoperative complications. RESULTS: Eighty-seven patients were included in the
study. Twenty-one patients (24.1%) experienced postoperative complications. Of
these, only 3 patients (3.4%) had permanent complications directly related to the
Ethisorb membrane (diplopia, enophthalmos). Two of these patients required revision
surgery and are discussed in the article. CONCLUSIONS: The results of our study
demonstrate the effectiveness of Ethisorb in the repair of small-to-moderate
orbital floor fracture defects (up to a maximum size of 2 x 2 cm).
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103. DOI : 10.2240/azojomo0106
Bioceramic Orbital Plate Implant
Jocelyn P. Reyes, Josefina R. Celorico, Lina C. dela Cuesta, James M. Filio, Leonilo G
Daan, Severino T. Bernardo and Jessica Marie Abano
Porous biphasic calcium phosphate bioceramic orbital plate implant consisting of about 77% βTCP and 23% HAp was developed as a low cost alternative to commercially available orbital
plate implant. The pore size of the material, which is 198 microns, contributed to the early
fibrovascular ingrowth into the pores of the plate implant. 12 orbits of 6 adult domestic cats
underwent orbital plate implantation. Results of biocompatibility tests show the excellent
potential of the developed bioceramic orbital plate implant for orbital floor fracture
reconstruction. It is biocompatible, allows vascularization, resistant to resorption, and has
proven to have physiological bone induction as well as bone conduction properties.
Conclusion
Bioceramics orbital plate implant was successfully developed using calcium phosphate dihydrate
and calcium carbonate as the starting materials. The processing conditions for the fabrication of
this material include the calcination of the starting materials at 800°C, the addition of clay as
binder and sintering at 1280°C for 3 hours. These contribute to the formation of a biphasic
calcium phosphate ceramic consisting of 77% beta-tricalcium phosphate and 23%
hydroxyapatite. The pore size of the material, which is 198 microns, promotes early
fibrovascular ingrowth into the pores of the plate implant. Moreover, post –operative
examinations showed that the developed orbital plate implants were biocompatible and did not
exhibit any kind of adverse effects to the surrounding tissues. Results of biocompatibility
tests on adult cats demonstrated the promising potential of the developed orbital plate
implant as an attractive and affordable option for orbital floor fracture reconstruction.
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104. Complications :
Retrobulbar haemorrhage
Superior orbital fissure syndrome
Orbital apex syndrome
Carotico - cavernous fistula
Enophthalmos
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105. Decompression :
Measurement - Hertel exophthalmometer
Normal - 16-21mm beyond rim , > 21mm - diagnostic
Remove any of walls
Through caldwell-luc - ethmoidectomy
Remove lamina papyracea,ethmoidal arteries intact
Remove roof of antrum , later incise periosteum , support
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106. Retrobulbar haemorrhage :
Less than 1% - mid face trauma
Injury within intraconal space - short ciliary artery
Compression of other arteries
Changes in perfusion pressure gradient
Venous congestion & edema around optic
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107. Cont :
Central retinal vessels - obstruction
Infarction - end result
Irreversible retinal cell damage - 15 – 20 min
Pressure gradient
Normal
- 2kPa(15mmHg)
Retrobulbar haemorrhage - 13.3kPa(100mmHg)
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108. Mechanisms – Hertley et al :
Two mechanisms
Direct pressure
- Increased volume of contents
Forward pressure - upon iris - obstruction outflow
aqueous humor
Through canal of schlemm
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109. Clinical features :
Pain, Decreasing visual acuity
Diplopia , opthalmoplegia & severe ptosis
Marked subconjunctival edema & haemorrhage
Dilated pupils - loss of light reflex with intact
consensual reflex
Ophthalmoscope - “Cherry red macular spots”
constricted retinal arterioles
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110. Medical treatment :
Intraocular pressure reduction - dehydration
Mannitol(200ml of 20%) - shrinks vitreous
Acetazolamide(500mg) - inhibits carbonic
anhydrase - reduced aqueous production
Hydrocortisone(100mg) - intraorbital edema , spasm
Mega dose steroids - dexamethasone 3-4mg/kg 6 hourly - 24hrs,1mg/kg - 48hrs,continued 5 days
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111. Surgical intervention :
Explore intraconal space
Post op - through intramuscular septum uniting inferior
& lateral rectus
Open antrum - suction
Lateral canthotomy - dividing intramuscular septum
Direct access to intraconal spacee - by Moriarty (1982)
Globe in extreme adduction - conjunctival flap raised divide lateral rectus insertion
Point where fasciawww.indiandentalacademy.com
bulbi around tendon is reflected
113. Decompression of optic
Unless clear evidence of compression
Perineural & interstitial edema - delayed blindness - benefit
from decompression
Electrophysiological testing - assessment of vision
Intra cranial approach - remove roof of canal
Niho et al - combined transantral & frontal sinus approach
Fukado - Transethmoidal approach
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114. Adjunct :
Spasmolytic agent - papaverine - cannula in
supraorbital artery
Paracentesis of anterior chamber
Incision parallel to iris anterior to canal of schlemm
Using catract knife
Iris return to normal position
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115. Superior orbital fissure syndrome:
Following impact from lateral aspect
Gross periorbital edema , proptosis
Subconjunctival haemorrhage
Complex opthalmoplegia & ptosis - 3,4,6 nerves
“Loss of direct light & consensual reflex”
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116. Cont :
Specific sign - altered sensation - forehead to
vertex - frontal branch of trigeminal
Dilated pupil - loss of corneal & accommodation
Wait for resolution - 3-6 months
Fixation of fracture with minimal manipulation
Operative intervention - deferred 10 - 14 days
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117. Orbital apex syndrome :
Extension of superior orbital fissure syndrome
Injury to optic nerve - hallmark
“Loss of consensual reflex in unaffected eye”
Ischemic optic neuropathy - common reason
Main area of impact - level of orbital roof
Lateral orbitotomy - procedure of choice
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118. Carotico-cavernous fistula :
Orbital trauma extending to basal fracture
Tears carotid artery within cavernous sinus
“Pulsating exophthalmos” , worse on bending
Relieved by occlusion of ipsilateral carotid
“Bruit de debale” - associated murmur
Opthalmoplegia,diplopia,dilated pupil,decreased acuity
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120. Enopthalmos :
Late consequence of orbital trauma
Soft tissue manifestation of bony defect
4 types
1.Simple enopthalmos
- related to abnormal bony position
2.With dystopia
- related to bone & soft tissue injury
3.Cicatrical enopthalmos - restriction in movement - scarring
4.Enopthalmos secondary to fat atrophy
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121. Treatment :
Correction of zygomatic position & orbital floor
Augmentation of retrobulbar bulge
Bone behind equator - push globe forward
Grafting - floor,medial,lateral,behind equator
Calvarial graft,iliac crest,rib,antral wall,auricular cartilage
“Calvarial” - less resorption (20%), difficult shaping
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Alloplastic - teflon, Homografts - lyodura & zenoderm
122. Hypoglobus :
Linked to ball in foam
Equator from lateral orbital plane to lacrimal crest
Bone 1cm at inferior orbital rim or under equator
Cantilevered from inferior orbital rim - deficient posteriorly
Correct position of zygoma
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123. Canalicular injuries :
Penetrating injuries - between punctum & lacrimal sac
Insert lacrimal probe - punctum into proximal severed part
Cut end paler , dye through intact upper canaliculi
Pigtail , through upper canaliculus
Reconstruction - fine nylon plastic tubing
6-0 silk suture in grey line, tube after 2 wks
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