Combined Subciliary/Transantral Approach for Reconstruction of Orbital Floor Fracture

Orbital floor fracture, especially with constriction of orbital soft tissue, should be reconstructed surgically. Although various approaches to treat the orbital floor have been reported, procedures have not been unified among hospitals or surgeons. Since 2009, we have adopted a procedure combining a transorbital approach via subciliary incision with a transantral approach through upper gingival incision. The combined approach compensates for the shortcomings of each approach, leading to successful reconstruction. It is applicable safely for trapdoor fracture of the orbital floor in children, which more frequently constricts orbital soft tissue and which leaves permanent diplopia. This report retrospectively assessed clinical preoperative findings and postoperative outcomes of patients who received reconstruction of orbital floor fracture with the combined approach in our department from August 2009 through March 2021. Data of 21 patients with orbital floor fracture were analyzed, only one (4.8%) of whom had postoperative diplopia. Specifically, we describe children with trapdoor fracture treated with the combined approach, resulting in complete recovery. The combined approach stands as an excellent procedure for reconstruction of orbital floor fracture in adults and even in children.

Influence of the Neural Crest Derived Stem Cells to Optic Nerve Regeneration After Its Experimental Injury

Purpose: Orbital trauma is a challenging problem due to such severe sequel as diplopia, decrease of vision or eye motility disorder. However, the conditions of orbital soft tissue content still become underestimated. The aim of this study was to investigate structural changes in the rat optic nerve after experimental injury followed by treatment with stem cells. Materials and Ьethods: An experimental model of injury to the orbital soft tissue content in the rat was developed. Forty Wistar rats maintained under daylight were divided into two equal experimental groups. Unlike the rats of Group I, in rats of Group II, the site of injury to the orbital soft tissue mass received postnatal multipotent stem cells, epidermal neural crest stem cells (NCSCs) derived from the bulge of hair follicles. Results: Comparing the number of glial cells per certain area of the slice (NC) between group І and site without injury (control) after 3 week of observation, it was higher in group I more than 258.8% (p < 0.0001) and on 272.4% in group II (p < 0.0001). After 6 weeks NC in group I was higher than at previous terms: more then 128.9% (р < 0.0001). At the same, NC in group II was higher comparing with previous terms only on 17.1% (р = 0.0212). Between the animals of group I at terms of 12 and 24 weeks NC high and wasn’t significantly differ between this terms of observation (ANOVA p = 0.4379). In contrast, NC in group II stopped rising between 6 and 12 weeks demonstrating statistical equality (p = 0.4563). Conclusions: It can be assumed that the application of mesenchymal stem cells, derivates of the neural crest, after the experimental orbital trauma, stimulates a recovery of the optic nerve. Further studies should be performed to more deeply discover the neural crest derived stem cell populations, ivoleved into recovery of damaged optic nerves.

Teprotumumab for the treatment of chronic thyroid eye disease

Background Teprotumumab, a novel IGF-1R antibody was recently shown to significantly reduce the signs of active Thyroid eye disease (TED). The current study reviews its efficacy in chronic TED. Methods In this retrospective review, consecutive patients with chronic stable TED (>2 years), who had received ≥3 infusions of teprotumumab were included. All patients had measurements of proptosis, and calculation of the CAS and diplopia scores before and after therapy. Five-point strabismus scores were also calculated. Patients who had imaging within 4 months prior to therapy and 6 weeks post therapy underwent orbital 3D volumetric analysis. Results Thirty-one patients met the inclusion criteria. The mean (SD) duration of TED was 81 months (56) and the mean (SD) number of infusions received by each patient was 7 (2). Mean (SD) reduction in proptosis for each study orbit was 3.5 mm (0.4) and 3 mm (0.3) for the fellow orbit. The CAS response was 90% for the study orbit and 87% for the fellow orbit. Of the 15 patients who had diplopia at baseline, 67% had a clinically significant response, while 47% had complete resolution following treatment. Following teprotumumab, mean (SD) reduction of muscle tissue was 2011 mm3 (1847) in the study orbit and 1620 mm3 (1759) in the fellow orbit. The mean (SD) reduction of fat volume was 2101 mm3 (1681) in the study orbit and 1370 mm3 (1181) in the fellow orbit. Conclusion Teprotumumab significantly reduces proptosis, inflammation, diplopia, strabismus and orbital soft tissue volume in patients with chronic TED.

An accurate interactive segmentation and volume calculation of orbital soft tissue for orbital reconstruction after enucleation

Background Accurate measurement and reconstruction of orbital soft tissue is important to diagnosis and treatment of orbital diseases. This study applied an interactive graph cut method to orbital soft tissue precise segmentation and calculation in computerized tomography (CT) images, and to estimate its application in orbital reconstruction. Methods The interactive graph cut method was introduced to segment extraocular muscle and intraorbital fat in CT images. Intra- and inter-observer variability of tissue volume measured by graph cut segmentation was validated. Accuracy and reliability of the method was accessed by comparing with manual delineation and commercial medical image software. Intraorbital structure of 10 patients after enucleation surgery was reconstructed based on graph cut segmentation and soft tissue volume were compared within two different surgical techniques. Results Both muscle and fat tissue segmentation results of graph cut method showed good consistency with ground truth in phantom data. There were no significant differences in muscle calculations between observers or segmental methods (p > 0.05). Graph cut results of fat tissue had coincidental variable trend with ground truth which could identify 0.1cm3 variation. The mean performance time of graph cut segmentation was significantly shorter than manual delineation and commercial software (p < 0.001). Jaccard similarity and Dice coefficient of graph cut method were 0.767 ± 0.045 and 0.836 ± 0.032 for human normal extraocular muscle segmentation. The measurements of fat tissue were significantly better in graph cut than those in commercial software (p < 0.05). Orbital soft tissue volume was decreased in post-enucleation orbit than that in normal orbit (p < 0.05). Conclusion The graph cut method was validated to have good accuracy, reliability and efficiency in orbit soft tissue segmentation. It could discern minor volume changes of soft tissue. The interactive segmenting technique would be a valuable tool for dynamic analysis and prediction of therapeutic effect and orbital reconstruction.

Periorbital Reconstruction by “Periorbital Patch” Technique Using a Pericardium-Based Collagen Membrane and Titanium Mesh

Objective: Titanium mesh is a commonly used material for the reconstruction of orbital floor fractures. However, in some instances, a subsequent inflammatory reaction can occur that causes the adhesion of orbital tissue to the titanium mesh. The adhesion of the orbital soft tissue to the mesh causes diplopia, lid rigidity and extraocular movements restriction. This study was performed to determine if the placement of a collagen membrane over a titanium mesh can prevent the adhesion of orbital soft tissue for an improved clinical outcome. Clinical considerations: A case study was performed investigating 106 patients undergoing a periorbital restoration. Seventy-two patients received a titanium mesh without a barrier membrane, 12 patients received a barrier membrane composed of autologous auricular cartilage to provide a barrier function and 22 patients received a pericardium collagen membrane and titanium mesh. Conclusions: Titanium has been shown to generate an intense inflammatory reaction in host tissues, which can cause fibrosis to adjacent structures. Fibrosis is an essential factor in the repair of fracture sites, however this can lead to adverse effects in the orbital socket. Fibrosis can cause cicatrization and lower eyelid retraction when induced along the lower orbital rim. An improved outcome can be achieved by using a barrier between the titanium mesh and the soft tissue, such as autogenous auricular cartilage, however, only patients treated with a resorbable collagen membrane to act as a soft tissue barricade during site regeneration, prevented the fibrosis reaction and related problems from occurring.

Measurement of the Orbital Soft Tissue Volume in Chinese Adults Based on Three-Dimensional CT Reconstruction

Quantitative measurement of the orbital soft tissue volume plays a very important role in the study of orbital diseases. The purpose of this study is to establish a computed tomography- (CT-) based three-dimensional (3D) reconstruction model and measure the orbital soft tissue volume in Chinese adults. We collected data from 103 Chinese adults (52 males and 51 females) who underwent orbital CT. The CT images of these adults were used to reconstruct a 3D model of the orbital bony cavity, orbital fat, extraocular muscle, and intraorbital optic nerve using Mimics software, and their respective volumes were measured. The mean (±SD) orbital bony cavity volume (OV), orbital fat volume (FV), extraocular muscle volume (MV), and intraorbital optic nerve volume (iONV) of the males were 22.2 ± 2.2 cm3, 8.9 ± 1.8 cm3, 1.9 ± 0.34 cm3, and 0.41 ± 0.08 cm3, respectively. The mean OV, FV, MV, and iONV of the females were 20.2 ± 1.5 cm3, 8.1 ± 1.7 cm3, 1.6 ± 0.3 cm3, and 0.36 ± 0.074 cm3, respectively, which were all significantly lower than those in males (all p<0.05). FV (r = 0.370; p<0.001) and MV (r = 0.283; p=0.007) were significantly correlated with body mass index (BMI), while iONV was not correlated with BMI (r = −0.070; p=0.480). This study shows that FV, MV, and iONV were higher in males than in females. With increasing BMI, FV and MV both increased, but iONV did not exhibit this trend.