Staged Repair of Complex Pan-Orbital Trauma: A Novel Surgical Approach

This is the authors' abstract. We don't add key points for this paper.

Background: Traumatic injuries that result in complex pan-orbital fractures concurrent with other fractures of the skull base, calvarium, and midface present a unique challenge, and are difficult to repair in one setting. Neurosurgical repair of the dura along with orbital roof fracture repair may need to be followed by repair of the medial orbital wall and orbital floor.[ 1 ] Pushing orbital contents back into the orbit from below is especially difficult with swelling from a CSF leak, and the risk of damaging a newly repaired orbital roof and dura. Waiting the orbital roof and dural repair to heal is an option, but delayed repair of the other orbital walls is difficult once there is scarring and fibrosis of the orbital contents to sinus mucosa. In ballistic injuries with near-total destruction of the orbit, reconstruction is further complicated by the loss of natural anatomical landmarks. Objective: We present a novel staged operative repair of complex pan-orbital trauma due to a gunshot wound. This patient suffered multiple fractures of the orbit, including right orbital roof and medial orbital wall fractures, and orbital roof, floor, and medial orbital wall fractures. The patient also had bifrontal herniation, CSF leak, and suffered a left globe obliteration rendering that eye unsalvageable ([ Fig. 1 ]). Fig. 1 Methods: The initial surgery was performed by the ophthalmology, plastic surgery, and neurosurgery teams. First, a left eye evisceration with ocular implant placement was performed. Then, a bi-frontal craniotomy was performed and the dura was repaired. Through this approach, both orbital roofs were repaired with a Stryker Medpor Barrier 0.4 mm implant. An additional Barrier implant was then placed in the left orbital medially from above against any intact bone to cover the superior portion of the medial orbital wall fracture. The pericranial flap and the craniotomy were then closed ([ Fig. 2 ]). Fig. 2 Results: In a follow-up surgery 6 weeks later, the remainder of the left orbit was reconstructed through an inferior conjunctival approach. After reduction of tissue that had prolapsed into the orbital floor fracture, the tissue plane was dissected superiorly up the medial orbital wall fracture to locate the previously placed Barrier implant used to reconstruct the upper part of the medial orbital wall. The implant served as a guide to place a Stryker Medpor Titan Floor implant that curved up to meet the Barrier implant. The Titan Floor implant was then fixated to the inferior orbital rim with a screw ([ Fig. 3 ]). Fig. 3 Fig. 4 Conclusion: In patients with complex pan-orbital trauma, staging operative repair and using a previously placed medial orbital wall implant to guide the placement of an orbital floor implant may be a useful way to reconstruct the orbit and to improve surgical outcomes. Publication History Article published online: 05 February 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany