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O.336 MRI as primary imaging modality for pediatric orbital trauma
Oral Presentations O.336 MRI as primary imaging modality for pediatric orbital trauma C. Pautke, F. Hoelzle, B. Hohlweg-Majert, K.-D. Wolff, A. Kolk. Technical Universtiy of Munich, Department of Oral and Maxillofacial Surgery, Munich, Germany Up to now the gold standard in imaging of orbital fractures is the CT-scan. The weak points of this imaging modality, however, are the restricted soft tissue depiction as well as the radiation. Both attributes are of particular importance in children, because of the high rate of trapdoor fractures and the radiation to the lens. Although MRI is not associated with these drawbacks it was so far not established in the primary diagnosis of pediatric orbital fractures. Therefore, the aim of our study was to establish MRI with a special orbital coil for the primary diagnosis of pediatric orbital trauma. In our retrospective study 14 pediatric patients presented to our department with a blunt orbital trauma from 2003 until 2007. Out of these, 12 patients with orbital floor fractures required surgical reconstruction. Until 2004 imaging was performed by plain X-rays and CT-scan. Since introducing the MRI microscopy orbital coil in 2004, CT-scans have been replaced by MRI for the primary fracture diagnosis in 8 pediatric cases. We demonstrate our experience using MRI in combination with conventional x-rays for decision making concerning operative approach by two out of these pediatric cases suffering from blunt orbital trauma. The most common causes for pediatric orbital trauma in our collective were accidents. In all of the 8 cases using MRI as the primary imaging modality, depiction of the fracture dislocation and differentiation of the adjacent fatty and muscle tissue was excellent and thus indication for surgery was distinct. There was high interexamination and interrater agreement. MRI combined with a microscopy orbital coil is a valuable alternative to CT in the primary diagnosis of pediatric orbital fractures. Floor fractures and particularly muscle incarceration should be diagnosed by high resolution MRI combined with a microscopy coil instead of CT in order to avoid radiation to the lens and to obtain a better soft tissue depiction. O.337 Ocular motility after blow-out fractures in children P. Stanko, J. Mracna, D. Holly, A. Gerinec. Comenius University, St Elisabeth Hospital, Bratislava, Slovakia Objectives: Purpose of the study was refinement of indications to operation of orbital floor fractures and the report on influence of surgical/nonsurgical treatment on ocular motility and diplopia. Methods: A group of 26 children (24 boys, 2 girls, mean age 9.1 years, range 4−11 years) with blow-out fracture treated in the Department of Pediatric Ophthalmology and the Department of Maxillofacial Surgery Comenius University within years 1990– 2000 was analysed retrospectively. The decision for conservative treatment or surgery was done under clinical examination, x-ray and CT evaluations. Orbitotomy was indicated 2−3 weeks after trauma if deficiency of vertical mobility and diplopia persisted. Collagen membrane of own production was used for cover of the bone defects. Follow up ranged from 12 moths to 6 years. Results: Two main clinical types were found – with diplopia (19 patients, mostly involvement of oculomotoric muscles) and with enopthalmus (mostly orbital enlargement). Without surgery was possible to cure 10 patients (38.5%). The recovery of eye motility was achieved completely in 22 patients and incompletely in 4 of the cases. The long term results of operations were very effective with minimal complications. Conclusions: Authors suppose as the favorable prognostic factors: spontaneous motility improvement, no delayed operation, lateral orbital floor fracture, minimal extent of the fracture, minimal restriction of forward traction test and absence of infection.
Orbital pathology and surgery I
S85
O.338 Open vs transconjunctival access to large orbital fractures A. Kolk, B. Ketterl, A. Neff, F. H¨olzle, H. Deppe, K.-D. Wolff, C. Pautke. University of Technology of Munich, Munich, Germany Objective: To analyse different surgical approaches and to identify the optimal surgical access for managing of decisive orbital fracture locations longterm complications and outcome were analysed. Methods: This study was conducted in a combined pro- and retrospective fashion. First medical records of 185 patients with different orbital fractures being treated between 2005 and 2007 were reviewed regarding fracture type, location and surgical approach. Patients and ophthalmologists were interviewed about any possible persisting findings. Reexamination succeded in case of longterm intricacies. Each 50 patients with orbital floor and medial wall fractures were treated either open or transconjunctival aproaches and permanently checked. Results: In 40 of 185 cases motility disturbances persisted over 4 months. Even though fracture size and location were most influencing (p < 0.05) large posterior floor fractures showed a persisting motility deficits rate of 36%, isolated medial fractures of 38% and combined fractures of 30% using a tranconjunctival approach. Less symptoms (p < 0.05) persisted in open access cases. By the latter large posterior orbital floor fractures demonstrated a complication rate of 18%, while large combined fractures came along with 28%. As an exception the transcaruncular approach was the most suitable one for access to the apex region. Conclusion: Our findings showed that large fractures of the orbital floor or its posterior portion as well as combined fractures should be treated via an open approach as they have better longterm outcomes, while the transconjunctival access is sufficient for small trapdoor fractures or that of the anterior part of the orbit. O.339 Orbital decompression for endocrine orbitopathy A. Baumann, D. Holzinger, C. Schopper, G. Dorner. Dept of OMFS, Medical University of Vienna (MUW), Vienna, Austria Objectives: Endocrine orbitopathy is a common feature of autoimmune thyroid disease. This may result in functional and also in cosmetic impairment. Orbital decompression is one of the therapy modalitites for endocrine orbitopathy. There are used different approaches for orbital decompression. We present a minimal invasive technique for three wall orbital decompression. Methods: Orbital decompression was proceeded in 32 orbits (17 patients). The average age was 44 years. Indication for surgery was progression of functional interferences (compression of nerv/muscles or proptosis) under cortisone therapy. In 24 orbits a lateral orbital ring osteotomy was additionally done. The approach was a lateral eye brow incision, a transconjunctival and an intraoral incision. According to the clinical situation the periorbita was incised medial and caudal. All patients were checked pre- and postoperative for visus, Hertel, diplopia, motility disturbances. Also cosmetic satisfaction was evaluated. Results: The incisons were sufficient for the orbital decompression procedures. The change in the Hertel measurement was 7 mm in average. There was no visus aggravation postoperative. Strabismus correction was done postoperative in 3 patients out of preoperative diplopia. All patients were satisfied with the cosmetic result. Conclusion: Orbital wall decompression can be done by this minimal approach. It results in a sufficient correction of the proptosis and a good cosmetic outcome.
Orbital pathology and surgery I
S85
O.338 Open vs transconjunctival access to large orbital fractures A. Kolk, B. Ketterl, A. Neff, F. H¨olzle, H. Deppe, K.-D. Wolff, C. Pautke. University of Technology of Munich, Munich, Germany Objective: To analyse different surgical approaches and to identify the optimal surgical access for managing of decisive orbital fracture locations longterm complications and outcome were analysed. Methods: This study was conducted in a combined pro- and retrospective fashion. First medical records of 185 patients with different orbital fractures being treated between 2005 and 2007 were reviewed regarding fracture type, location and surgical approach. Patients and ophthalmologists were interviewed about any possible persisting findings. Reexamination succeded in case of longterm intricacies. Each 50 patients with orbital floor and medial wall fractures were treated either open or transconjunctival aproaches and permanently checked. Results: In 40 of 185 cases motility disturbances persisted over 4 months. Even though fracture size and location were most influencing (p < 0.05) large posterior floor fractures showed a persisting motility deficits rate of 36%, isolated medial fractures of 38% and combined fractures of 30% using a tranconjunctival approach. Less symptoms (p < 0.05) persisted in open access cases. By the latter large posterior orbital floor fractures demonstrated a complication rate of 18%, while large combined fractures came along with 28%. As an exception the transcaruncular approach was the most suitable one for access to the apex region. Conclusion: Our findings showed that large fractures of the orbital floor or its posterior portion as well as combined fractures should be treated via an open approach as they have better longterm outcomes, while the transconjunctival access is sufficient for small trapdoor fractures or that of the anterior part of the orbit. O.339 Orbital decompression for endocrine orbitopathy A. Baumann, D. Holzinger, C. Schopper, G. Dorner. Dept of OMFS, Medical University of Vienna (MUW), Vienna, Austria Objectives: Endocrine orbitopathy is a common feature of autoimmune thyroid disease. This may result in functional and also in cosmetic impairment. Orbital decompression is one of the therapy modalitites for endocrine orbitopathy. There are used different approaches for orbital decompression. We present a minimal invasive technique for three wall orbital decompression. Methods: Orbital decompression was proceeded in 32 orbits (17 patients). The average age was 44 years. Indication for surgery was progression of functional interferences (compression of nerv/muscles or proptosis) under cortisone therapy. In 24 orbits a lateral orbital ring osteotomy was additionally done. The approach was a lateral eye brow incision, a transconjunctival and an intraoral incision. According to the clinical situation the periorbita was incised medial and caudal. All patients were checked pre- and postoperative for visus, Hertel, diplopia, motility disturbances. Also cosmetic satisfaction was evaluated. Results: The incisons were sufficient for the orbital decompression procedures. The change in the Hertel measurement was 7 mm in average. There was no visus aggravation postoperative. Strabismus correction was done postoperative in 3 patients out of preoperative diplopia. All patients were satisfied with the cosmetic result. Conclusion: Orbital wall decompression can be done by this minimal approach. It results in a sufficient correction of the proptosis and a good cosmetic outcome.