-
Oral and Maxillofacial Surgery Dec 2023This retrospective study aims to define the optimal timing of the surgical treatment of orbital floor trapdoor fractures (OFTFs) in adults according to clinical and...
PURPOSE
This retrospective study aims to define the optimal timing of the surgical treatment of orbital floor trapdoor fractures (OFTFs) in adults according to clinical and radiological findings.
METHODS
From January 2006 to December 2020, 382 patients with isolated orbital floor fracture were admitted to the Division of Maxillofacial Surgery of Turin, Italy. The criteria for inclusion were age ≥ 16 years, preoperative computed tomography showing a linear (1a) or medial hinge fracture (1b), diplopia, and 6 months of follow-up data. Aetiology and mechanism of injury, presence of post-traumatic enophthalmos and oculocardiac reflex, time between trauma occurrence and surgery [stratified as < 24 h (urgent treatment), 24-96 h (early treatment), and > 96 h (late treatment)], days of hospitalisation, and clinical outcomes were examinated.
RESULTS
Twenty-four patients (18 males; mean age, 23.2 years) presented with OFTFs. The most common cause was sport injury (50%). Type 1a fracture was observed in eight patients (mean age, 19.5 years), type 1b fracture in 16 patients (mean age, 23.6 years). Urgent, early, and late treatments were performed in eight patients each. The mean time between trauma occurrence and surgery was 3,8 days (range: 0-17 days). Resolution of diplopia was observed 1 week after surgery in 10 patients, 1 month in 12. Diplopia persisted in 2 patient, both treated > 96 h after trauma.
CONCLUSION
Although the number of patients was too small to define a standard protocol, the authors recommend early treatment of adult OFTFs to promote complete resolution of diplopia.
Topics: Adult; Humans; Male; Young Adult; Diplopia; Orbit; Orbital Fractures; Retrospective Studies; Treatment Outcome; Female
PubMed: 35841436
DOI: 10.1007/s10006-022-01099-2 -
Plastic and Reconstructive Surgery.... May 2022Diplopia is a common symptom after blowout fractures, with an incidence of 43.6%-83%. Although there is some consensus toward surgical correction, diplopia is not always...
UNLABELLED
Diplopia is a common symptom after blowout fractures, with an incidence of 43.6%-83%. Although there is some consensus toward surgical correction, diplopia is not always resolved by surgery. Thus, there is a clinical dilemma for surgeons with regard to performing surgery at a specific time. This review aimed to create an algorithm to support accurate and effective decision-making.
METHODS
We reviewed articles published on PubMed during 2013-2020 regarding orbital fractures. Articles discussing surgical treatment for blowout fractures and diplopia were included. Five reviews, six prospective cohort studies, and 33 retrospective studies were identified. After reviewing and summarizing these articles, a step-by-step algorithm was created.
RESULTS
Most authors advise immediate surgery when a patient presents with either a positive oculocardiac reflex or a "trapdoor" fracture. Early surgical correction is recommended in children to prevent profound muscle damage. In other scenarios, most authors recommend performing surgery within 2 weeks. The algorithm begins with the aspect of motility, including muscle entrapment assessed by computed tomography or limited movement of the extraocular muscle. When there is no abnormality in motility, the algorithm continues to the aspect of position. Generally, an orbital floor defect of more than 50% or 2 cm or an enophthalmos of more than 2 mm is indicated for surgery. However, diplopia may also gradually resolve after improvement of periorbital edema or swelling.
CONCLUSION
We proposed a step-by-step approach to help surgeons make effective decisions concerning surgical correction for patients suffering from blowout fractures with diplopia at different time points.
PubMed: 35558136
DOI: 10.1097/GOX.0000000000004308 -
Journal of the American Veterinary... Apr 2022To evaluate neurological tests and expected results in inland bearded dragons (Pogona vitticeps) and generate recommendations for bearded dragon-specific neurological...
OBJECTIVE
To evaluate neurological tests and expected results in inland bearded dragons (Pogona vitticeps) and generate recommendations for bearded dragon-specific neurological examination.
ANIMALS
26 healthy adult inland bearded dragons.
PROCEDURES
A complete neurological examination utilizing tests described in both mammals and reptiles was performed on each lizard, and test feasibility and outcome were recorded.
RESULTS
Tests with poor feasibility included oculocardiac reflex (successfully completed in 62% [16/26] of animals) and voluntary ambulation and swallowing by use of a food item (0% [0/26] of animals). Tests with outcomes considered abnormal in mammals but attributable to normal bearded dragon behavior included head position (head tilt present in 12% [3/26]) and head movement (head bob present in 4% [1/26]). Many tests had absent or inconsistent outcomes, including menace response (present in 19% [5/26]), proprioceptive positioning (present in 4% [1/26] in the thoracic limbs and 0% [0/26] in the pelvic limbs), vent reflex (present in 27% [7/26]), and myotatic reflexes (biceps present in 8% [2/26]; patellar, gastrocnemius, and triceps present in 0% [0/26]). Extensor postural thrust was absent in all successfully tested animals, but a novel reflex termed the caudal thoracic extensor reflex was noted instead in all observed animals (100% [21/21]).
CLINICAL RELEVANCE
Tests with poor feasibility or inconsistent outcomes should have low priority or be excluded from neurological examinations of inland bearded dragons. Normal behaviors should be considered for head position and movement. A bearded dragon-specific neurological examination protocol derived from these findings is described and recommended in order to decrease stress and improve neurolocalization.
Topics: Animals; Lizards; Mammals; Neurologic Examination
PubMed: 35417409
DOI: 10.2460/javma.20.12.0706 -
Journal of Maxillofacial and Oral... Mar 2022Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of... (Review)
Review
BACKGROUND
Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24 h to greater than 2 weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex.
METHODS
A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies.
RESULTS
A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24 h to more than 1 month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2 weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48 h.
DISCUSSION
Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2 weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.
PubMed: 35400913
DOI: 10.1007/s12663-021-01543-y -
Anesthesia, Essays and Researches 2021Strabismus surgery may be associated with several undesirable complications as increased incidence of the oculocardiac reflex (OCR), hemodynamic changes, emergency...
BACKGROUND
Strabismus surgery may be associated with several undesirable complications as increased incidence of the oculocardiac reflex (OCR), hemodynamic changes, emergency agitation (EA), postoperative pain, nausea, and vomiting. Previous studies suggested that deeper anesthesia monitored by bispectral index (BIS) protects against OCR. This study aims to evaluate the effect of the type of anesthesia on the quality of anesthesia in pediatric patients.
PATIENTS AND METHODS
One hundred American Society of Anesthesiologists physical status classes I and II pediatric patients, aged between 3 and 6 years old of both genders, who were subjected to strabismus surgery under general anesthesia were enrolled in this study. Patients were randomized into two equal groups (each = 50); in the first group, anesthesia was induced and maintained with sevoflurane (Group S), and in the second group, anesthesia was induced and maintained with propofol (Group P). Hemodynamics and BIS were monitored, and OCR and the need for atropine were recorded. Furthermore, EA using the Cravero scale was recorded.
RESULTS
The propofol group showed a higher incidence of OCR while the sevoflurane group had a higher incidence of postoperative agitation, pain, nausea, and vomiting, without statistically significant differences regarding hemodynamics.
CONCLUSION
Although sevoflurane anesthesia may be superior to propofol in ameliorating OCR, it has been associated with an increased incidence of postoperative complications.
PubMed: 35320953
DOI: 10.4103/aer.AER_93_20 -
Oral and Maxillofacial Surgery Jun 2023Paediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite...
PURPOSE
Paediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis.
METHODS
This retrospective study was conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to a major trauma unit in London between 2010 and 2020.
RESULTS
Thirteen patients with isolated orbital fractures presented to our unit in this period. The average age was 13 years. Surprisingly the predominant aetiology was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. One medial wall fracture case was missed in the emergency department. Eight patients required surgical intervention due to diplopia caused by muscular entrapment of extraocular muscles; the final patient had a large defect resulting in enophthalmos requiring a large titanium plate. A transconjuctival approach was preferred for surgical access and resorbable sheet was used in the remaining cases. Five patients had nausea, vomiting or bradycardia associated with the oculocardiac reflex. Surgical intervention occurred within 24-48 h of injury in 6 cases. Resolution of diplopia occurred in 7 patients within 6 months.
CONCLUSION
Paediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.
Topics: Humans; Child; Adolescent; Orbital Fractures; Trauma Centers; Retrospective Studies; Diplopia; United Kingdom
PubMed: 35312892
DOI: 10.1007/s10006-022-01056-z -
Pharmaceuticals (Basel, Switzerland) Feb 2022Vitreoretinal surgeries require the administration of general anesthesia (GA) in selected groups of patients. The administration of intraoperative rescue narcotic...
Vitreoretinal surgeries require the administration of general anesthesia (GA) in selected groups of patients. The administration of intraoperative rescue narcotic analgesia (IRNA) during GA poses the risk of postoperative nausea and vomiting (PONV). The surgical pleth index (SPI), a crucial component of the adequacy of anesthesia (AoA) guidance of GA, optimizes the intraoperative titration of IRNA. The current analysis evaluated the risk factors for the occurrence of PONV and the oculo-cardiac reflex (OCR) in patients undergoing pars plana vitrectomy (PPV) under AoA guidance. In total, 175 patients undergoing PPV were randomly allocated to receive either GA with SPI-guided IRNA administration using fentanyl alone or in addition to different preoperative analgesia techniques. Any incidence of PONV or OCR was recorded. Obesity, overweight, smoking status, motion sickness, postoperative intolerable pain perception, female gender, fluid challenge and arterial hypertension did not correlate with an increased incidence of PONV or OCR under AoA guidance. Diabetes mellitus, regardless of insulin dependence, was found to correlate with the increased incidence of PONV. The AoA regimen including SPI guidance of IRNA presumably created similar conditions for individual subjects, so no risk factors of the occurrence of PONV or OCR were found, except for diabetes mellitus. We recommend using AoA guidance for GA administration to reduce OCR and PONV rates.
PubMed: 35215349
DOI: 10.3390/ph15020237 -
Indian Journal of Ophthalmology Dec 2021:To evaluate the outcomes of large-angle exotropia by single-stage adjustable strabismus surgery (SSASS) under monitored conscious anesthesia.
PURPOSE
:To evaluate the outcomes of large-angle exotropia by single-stage adjustable strabismus surgery (SSASS) under monitored conscious anesthesia.
METHODS
A prospective study was done in 33 patients above 14 years with ≥40 prism diopters (PD) of exotropia. All patients underwent SSASS under monitored conscious anesthesia (topical anesthesia plus intravenous sedation). For deviations of ≤55 PD, two horizontal rectus muscles, and for >55 PD, three rectus muscles were operated and a decision on adjustment/operating on an additional rectus muscle was taken after assessing the alignment. Monitored conscious anesthesia allowed us to check our results after surgery and plan further surgery/adjustment to achieve the desired alignment.
RESULTS
Mean preoperative deviation for distance was 52 ± 11.1 PD. The target alignment was achieved with the initial surgical plan in 10/21 patients with <55 PD exotropia and 4/12 patients with >55 PD exotropia, and one patient in each group needed adjustment. The remaining patients needed additional rectus muscle surgery. One patient with >55 PD exotropia needed both adjustment and additional rectus surgery. The success rate for distance correction was 85% at 6 months and 1 year. The overall success rate was 71% at 6 months. Percentage of patients with binocular single vision improved from 31% preoperatively to 78% by 6 months. Incidence of oculocardiac reflex was 6.1%.
CONCLUSION
SSASS under monitored conscious anesthesia is a viable option for large-angle strabismus correction with good patient comfort and safety.
Topics: Anesthesia, Local; Exotropia; Follow-Up Studies; Humans; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Prospective Studies; Retrospective Studies; Strabismus; Suture Techniques; Treatment Outcome; Vision, Binocular
PubMed: 34827002
DOI: 10.4103/ijo.IJO_85_21 -
Brazilian Journal of Anesthesiology... 2021The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this... (Observational Study)
Observational Study
BACKGROUND AND OBJECTIVES
The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this complication. This study aimed to investigate whether an association exists between the occurrence of OCR and the type of extraocular muscle manipulated during strabismus in a pediatric population.
METHODS
A total of 53 pediatric patients who were operated for strabismus under sevoflurane anesthesia were enrolled in this prospective study. The association between surgical techniques and the occurrence of OCR was investigated.
RESULTS
This study included 30 (56.6%) males and 23 (43.4%) females, with a mean age of 8.4 years. Overall, 83 eyes with 93 extraocular muscles were operated. Surgery was performed most frequently on the medial (44.6%) and lateral (36.1%) recti. OCR occurred in 33 (62.3%) patients. OCR was found to be significantly higher in the first operated muscle compared with the second muscle, regardless of muscle type, as identified in the statistical analysis based on the sequence of the operated muscles.
CONCLUSIONS
The manipulation of the first extraocular muscle has a higher risk of OCR in the pediatric population undergoing two-muscle surgery for strabismus.
Topics: Child; Female; Humans; Male; Oculomotor Muscles; Prospective Studies; Reflex, Oculocardiac; Sevoflurane; Strabismus
PubMed: 34715994
DOI: 10.1016/j.bjane.2020.12.015 -
Journal of Clinical Medicine Sep 2021The intraprocedural immobilization of selected subsets of patients undergoing pars plana vitrectomy (PPV) requires the performance of general anesthesia (GA), which...
The intraprocedural immobilization of selected subsets of patients undergoing pars plana vitrectomy (PPV) requires the performance of general anesthesia (GA), which entails the intraoperative use of hypnotics and titration of opioids. The Adequacy of Anesthesia (AoA) concept of GA guidance optimizes the intraoperative dosage of hypnotics and opioids. Pre-emptive analgesia (PA) is added to GA to minimize intraoperative opioid (IO) usage. The current additional analysis evaluated the advantages of PA using either COX-3 inhibitors or regional techniques when added to AoA-guided GA on the rate of presence of postoperative nausea and vomiting (PONV), oculo-emetic (OER), and oculo-cardiac reflex (OCR) in patients undergoing PPV. A total of 176 patients undergoing PPV were randomly allocated into 5 groups: (1) Group GA, including patients who received general anesthesia alone; (2) Group T, including patients who received preventive topical analgesia by triple instillation of 2% proparacaine 15 min before induction of GA; (3) Group PBB, including patients who received PBB; (4) Group M, including patients who received PA using a single dose of 1 g of metamizole; (5) Group P, including patients who received PA using a single dose of 1 g of acetaminophen. The incidence rates of PONV, OCR, and OER were studied as a secondary outcome. Despite the group allocation, intraoperative AoA-guided GA resulted in an overall incidence of PONV in 9%, OCR in 12%, and OER in none of the patients. No statistically significant differences were found between groups regarding the incidence of OCR. PA using COX-3 inhibitors, as compared to that of the T group, resulted in less overall PONV ( < 0.05). Conclusions: PA using regional techniques in patients undergoing PPV proved to have no advantage when AoA-guided GA was utilised. We recommend using intraoperative AoA-guided GA to reduce the presence of OCR, and the addition of PA using COX-3 inhibitors to reduce the rate of PONV.
PubMed: 34575281
DOI: 10.3390/jcm10184172