Randall L. Beatty

Diplopia and enophthalmos after surgical repair of blowout fracture

PURPOSE : To evaluate the incidence of residual diplopia and enophthalmos and the possible risk factors leading to their occurrence in patients who had orbital blowout fracture repair. METHODS : Forty-two patients with pure orbital blowout fracture who had at least 6 months postoperative follow-up were included in the study group. Nineteen (45.2%) patients had orbital floor, two (4.8%) patients had medial orbital wall and 21 (50%) patients had a combination of orbital floor and medial orbital wall fractures. The frac-ture was reconstructed with porous polyethylene (Medpore R ) in 22, supramide in 12 and gelatin (Gelfilm R ) in 8 orbits. Mean postoperative follow-up was 11 months. RESULTS : Preoperatively, 35 patients (83%) had diplopia and 13 patients (30.9%) had enophthalmos greater than 2 mm. Of 35 patients who had preoperative diplopia, only 7 (17%) patients experienced diplopia postoperatively. Diplopia improved 1 to 4 weeks (mean, 3 weeks) following surgery in 28 patients. Timing of surgery and age of the patient were significant for the development of postoperative diplopia (p < 0.05). Sex, location of the blowout fracture and the alloplast material were not found to be significant for the development of postoperative diplopia (p > 0.05). Enophthalmos persisted in three (7%) patients postoperatively. CONCLUSION : Old patients were more likely to have residual postoperative diplopia. Surgical repair of blowout fractures within two weeks of trauma decreases the incidence of residual diplopia.

Mechanisms of Visual Loss in Severe Proptosis

Vision loss in orbital hypertension secondary to sudden space-occupying lesions is usually attributed to one of three causes: central retinal artery occlusion, direct compressive optic neuropathy, or compression of optic nerve vasculature. Accepted modes of decompressive therapy include lateral canthotomy and cantholysis; drainage of localized orbital air, hematoma, or abscess; and bony wall decompression. Five cases are presented in which orbital hypertension caused severe proptosis with traction on the optic nerve and tenting of the posterior globe. Another mechanism contributing to visual loss is proposed in these cases: ischemie optic neuropathy due to stretching of nutrient vessels. In these cases, rapid posterior decompression should theoretically be favored to reduce orbital pressure and relieve traction on the optic nerve vasculature.

The use of maxillary sinus endoscopy in the diagnosis of orbital floor fractures

PURPOSE The goal of the current study was to evaluate the ability to diagnose the presence of an inferior orbital wall fracture through the use of a transantral endoscopy technique at bedside. PATIENTS AND METHODS Seven trauma patients with initial axial computed tomography (CT) scan findings consistent with an orbital floor fracture were studied. Before endoscopy, the patients underwent a coronal CT scan with 3-mm cuts for later comparison with the endoscopic findings. The surgeon performing the endoscopy procedure was blinded to the results of the coronal CT scan. Visual acuity, intraocular pressure, and measurement for enophthalmos were performed before endoscopy. The endoscopic procedure was performed at the bedside using local anesthesia. A trocar was used in the canine fossa to gain access to the maxillary sinus. A 30 degrees and then a 70 degrees endoscope were introduced through the trocar to evaluate the integrity of the orbital floor (ie, maxillary sinus roof). The degree of mucosal injury of the orbital floor and the presence of blood or orbital contents in the sinus were recorded. The ophthalmologic examination was repeated after completion of endoscopy. RESULTS The endoscopic procedure was able to be completed in all patients. There was no change in the ophthalmologic examination in any patient as a result of endoscopy. In six of the seven patients studied, the endoscopic findings correlated with the need for surgical intervention to repair the orbital floor predicted on the basis of coronal CT scan. This was determined by the degree of injury to the orbital floor and the presence of hematoma, exposed bone, or fat. In the remaining case, endoscopy was not diagnostic for the presence of a fracture because only ecchymosis of the orbital floor was noted. CONCLUSIONS The ability to perform endoscopy under local anesthesia at the bedside is useful in those trauma patients whose concomitant injuries may prohibit other diagnostic modalities.

Intraoral palatal mucosal graft harvest

The anatomy of the hard palate is reviewed with respect to the clinical considerations of harvesting intraoral hard palate grafts for various reconstructive eyelid procedures. Recommendations for harvesting grafts based on these anatomic principles are given.

Nuclear retinoic acid receptors in the lacrimal gland

The lacrimal gland secretes and metabolizes retinoids and responds to retinoic acid in culture. Like other retinoid responsive organs it is expected to express the nuclear retinoid receptors. The goal of this study was to identify the retinoic acid receptors (RAR) in the lacrimal glands of rats, rabbits, and humans. Total RNA was prepared from whole lacrimal glands and rat lacrimal gland acinar cells grown in culture. RNA was subjected to Northern blot analysis and probed for the RAR alpha, RAR beta, and RAR gamma mRNAs. Nuclear extracts of rat and rabbit lacrimal glands were incubated with 3H-all-trans retinoic acid and analyzed by gel filtration chromatography. Western blots of the nuclear extracts were probed using monoclonal antibodies to RAR alpha and RAR beta. Rat lacrimal gland expresses RAR alpha mRNA with two transcripts (3.8 and 3.0 kb), a single RAR beta mRNA transcript (3.3 kb), and a single RAR gamma mRNA transcript (3.3 kb). Cultured rat lacrimal acinar cells also expressed the mRNA for all three RAR subtypes. Rabbit lacrimal glands express mRNAs for RAR alpha (3.7 and 2.9 kb) and RAR beta (3.2 kb) but RAR gamma mRNA is not detectable. Human lacrimal glands also express mRNA for RAR alpha (3.5 and 2.3 kb), RAR beta (3.4 kb) and RAR gamma (3.0 kb). Lacrimal gland nuclear extracts contain proteins in the 50 kDa range that specifically bind retinoic acid with Kd = 1.25 nM in rat lacrimal gland and 0.3 nM in rabbit. The monoclonal antibodies identified RAR alpha and RAR beta in both rat and rabbit lacrimal glands. The results of this study support a role for retinoids in maintaining the structure and function of the lacrimal gland. The presence of RARs suggests potential interactions of these receptors with other members of their superfamily, including androgen and thyroid receptors, which also may be involved in lacrimal function.

Guidelines in the Management of Traumatic Scars and Surgical Incisions

General guidelines for the postoperative management of traumatic facial scars and surgical incisions after primary closure and suggestions for postoperative care and scar revisions are discussed.

Complex facial fractures in the periorbital region.

Recognition of periorbital facial fractures with appropriate clinical and diagnostic evaluation is essential for surgical decision making. Treatment planning should be directed at correcting any demonstrable functional problem or cosmetic deformity. The radiographic presence of a fracture line should not be the sole criterion for surgery. When surgical intervention is indicated, early repair will usually provide a more favorable result.