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A CT-Based Orbital Volume Measurement for Evaluation of Orbital Wall Reconstructive Effect

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A CT-Based Orbital Volume Measurement for Evaluation of Orbital Wall Reconstructive Effect Eye (2017) 31, 713–719 © 2017 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0950-222X/17 www.nature.com/eye 1 2 3 ‘Orbital volume JM Wi , KH Sung and M Chi CLINICAL STUDY restoration rate after orbital fracture’; a CT-based orbital volume measurement for evaluation of orbital wall reconstructive effect Abstract Purpose To evaluate the effect of orbital underwent operation within 14 days of reconstruction and factors related to the effect trauma had a better reconstruction rate at of orbital reconstruction by assessing of orbital final follow up than patients who underwent volume using orbital computed tomography operation over 14 days after trauma (CT) in cases of orbital wall fracture. (P = 0.039). Methods In this retrospective study, 68 Conclusion Computer-based measurements patients with isolated blowout fractures were of orbital fracture volume can be used to evaluated. The volumes of orbits and evaluate the reconstructive effect of orbital herniated orbital tissues were determined by implants and provide useful quantitative CT scans using a three-dimensional information. Significant reduction of orbital 1Department of reconstruction technique (the Eclipse volume is observed immediately after orbital Ophthalmology, Konyang Treatment Planning System). Orbital CT was wall reconstruction surgery and the University, Kim’s Eye performed preoperatively, immediately after reconstruction effect is maintained for more Hospital, Seoul, Korea surgery, and at final follow ups (minimum of than minimum 6 months. Patients that 6 months). We evaluated the reconstructive undergo surgery within 14 days of trauma has 2Department of Radiation effect of surgery making a new formula, better reconstruction rates at final follow up, Oncology, Gachon ‘ ’ University Gil Medical orbital volume reconstruction rate from which supports the need for early surgery. Center, Incheon, Korea orbital volume differences between fractured Eye (2017) 31, 713–719; doi:10.1038/eye.2016.311; and contralateral orbits before surgery, published online 13 January 2017 3Department of immediately after surgery, and at final Ophthalmology, Gachon follow up. University Gil Medical Introduction Results Mean volume of fractured orbits Center, Incheon, Korea before surgery was 23.01 ± 2.60 cm3 and that The orbital floor and medial wall are susceptible Correspondence: ± 3 of contralateral orbits was 21.31 2.50 cm to trauma and are common fracture sites. When M Chi, Department of (P = 0.005). Mean volume of the fractured an orbital fracture causes complications, such as, Ophthalmology, Gachon orbits immediately after surgery was enophthalmos, impaired ocular motility or University Gil Medical 21.29 ± 2.42 cm3, and that of the contralateral diplopia, orbital wall reconstruction is needed.1 Center, #21 Namdong- orbits was 21.33 ± 2.52 cm3 (P = 0.921). Mean The effect of orbital wall reconstruction is daero, 774beon-gil, fi Namdong-gu, Incheon volume of fractured orbits at nal follow up frequently estimated based on enophthalmos 21565, Korea 3 was 21.50 ± 2.44 cm , and that of contralateral improvement. Various causes of enophthalmos Tel: +82 32 460 3364; orbits was 21.32 ± 2.50 cm3 (P = 0.668). The associated with orbital wall fracture have been Fax: +82 32 460 3358. mean orbital volume reconstruction rate was suggested, such as increased orbital volume due E-mail: [email protected] 100.47% immediately after surgery and to displacement of bony orbit and orbital tissue, 99.17% at final follow up. No significant necrosis and fibrosis of orbital soft tissue, and Received: 9 June 2016 Accepted in revised form: difference in orbital volume reconstruction dislocation of an intra-orbital supporting 27 November 2016; 2 rate was observed with respect to fracture site tendon. Among these, increased orbital volume Published online: or orbital implant type. Patients that is considered the main cause and thus a number 13 January 2017 Orbital volume assessment in orbital reconstruction JM Wi et al 714 of recent studies have measured orbital volumes and used were repositioned by a periosteal elevator, a suction tip, them to assess the efficacy of orbital wall and a malleable retractor. Orbital wall defects were – reconstruction.2 7 However, these studies were limited by reconstructed using orbital implants (cut to fit the small subject numbers (under 30 patients) and/or short anatomies of fracture sites and soaked in saline mixed follow-up periods (under 6 months). Furthermore, with antibiotics) by insertion under periosteum at fracture various aspects, such as, type of orbital implant, orbital sites. After this procedure, a forced duction test was wall fracture location, time elapsed between trauma and performed to ensure the absence of restriction. During surgical intervention, and quantification of the effect of surgery pupil size was checked for optic nerve orbital wall reconstruction were not considered. In compression. To reduce orbital tissue swelling, addition, in the majority of studies orbital volume methylprednisolone (250 mg) was administered measurements were performed before and after surgery intravenously during surgery, after surgery, and the day only, and thus the maintenance effect of orbital wall after surgery, respectively. Thereafter, reconstruction was not estimated with the time course. methylprednisolone was given orally and tapered. To address these limitations, we measured orbital During the first month after surgery, patients were volumes by computed tomography (CT) using a three- observed weekly and then monthly. For all 68 patients, dimensional imaging software program (The Eclipse the observation period was more than six months. Treatment Planning System ver.13.0; Varian Medical Degrees of clinical improvement were assessed by Systems, Inc., Palo Alto, CA, USA) at three time points, grading clinical signs at 1, 3, and 6 months after surgery, that is, before surgery, immediately after surgery, and at as follows, diplopia within the central 20° visual field as final follow up (at least 6 months after surgery), using grade III, diplopia between 20° and 40° visual fields as measured fractured and contralateral orbit volumes. In grade II, diplopia only on the periphery beyond the 40° addition, we sought to evaluate the effect of orbital visual field as grade I, and ‘no diplopia’ was defined as reconstruction quantitatively and to identify factors the absence of diplopia. Extraocular movement limitation related to the effect of orbital reconstruction on orbital was assessed using the position of corneal reflection using volume. pen light illumination of the cornea with the eye looking in the direction of extraocular muscle action. Severe limitation with inability to move the eye was defined as a Materials and methods limitation of − 4; moderate limitation with corneal From April 2010 to March 2015, a total of 68 patients with reflection in contrary pupil margin as a limitation of − 3; a unilateral orbital blowout fracture treated surgically at moderate limitation with corneal reflection between the Department of Ophthalmology, Gachon University Gil contrary pupil margin and limbus as a limitation of − 2; Medical Center and followed for at least 6 months were mild limitation with corneal reflection in contrary limbus identified and included in this study. Gachon University as a limitation of − 1; and no limitation with a pen light IRB committee approved this study. This research reflection position beyond the limbus as a limitation of 0. adheres to the tenets of the Declaration of Helsinki. The CT examinations were performed on all study subjects exclusion criteria applied were; bilateral orbital wall before surgery, immediately after surgery, and at final fractures, orbital wall fractures combined with another follow up. Locations and ranges of orbital wall fractures facial bone fracture, thyroid associated ophthalmopathy, and strangulation of orbital soft tissues or extraocular and orbital tumor, all of which can cause orbital volume muscles were identified before surgery by CT. Locations measurement errors. Before surgery, the following tests of orbital implants and reductions of fractured orbits and were performed; visual acuity, a slit lamp examination, herniated orbital tissues were identified immediately after pupillary reflex test, fundus examination by indirect surgery, and orbital wall reconstruction maintenance was ophthalmoscopy, the Goldmann diplopia test by assessed at final follow up. A CT scanning system, ‘The perimetry, extraocular motility test, and Hertel Eclipse Treatment Planning System’ (ver.13.0, Varian exophthalmometry to measure enophthalmos; and Medical System, Inc.) was used to measure volumes of infraorbital nerve hypoesthesia was identified. In fractured and contralateral orbits before and after addition, the location and extent of orbital wall fractures surgery. In each case, bony orbital and herniated orbital and entrapment of extraocular muscle or soft tissue were tissue areas on sections were measured using a drawing identified by CT. cursor freehand. Drawn orbital contours were then Surgery was performed by one surgeon under general reconstructed as three-dimensional images and orbital anesthesia. Fractures were exposed through a volumes were calculated automatically. This program is transconjunctival incision for inferior orbital wall straightforward to use and provides low errors and high fractures, and through a transcaruncular incision for intra- and inter-operator reproducibilities. The anterior medial orbital wall fractures.
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