Usefulness of a Transconjunctival Approach in the Reconstruction of the Medial Blow-Out Wall Fracture

Abstract

Background: A transcaruncular approach is typically used for reconstructions of medial wall fractures. However, others reported that a transconjunctival approach was conducive for securing an adequate surgical field of view. In this study, we aimed to examine the extent of repair of medial wall fracture via a transconjunctival approach.

Methods: We retrospectively reviewed the medical records of 50 patients diagnosed as having medial wall fracture via preoperative computed tomography and who underwent surgery between March 2011 and February 2014. The fracture location was defined by dividing each of the anterior-posterior and superior-inferior distances into three compartments.

Results: A transcaruncular approach was used in 7 patients, while the transconjunctival approach was performed in the remaining 43 patients. The transconjunctival approach enabled a relatively broad range of repair that partially included the front and back of the medial wall, and was successful in 86% of the entire study population.

Conclusion: It is known that more than 50% of total cases of the medial wall fracture occur mainly in the middle-middle portion, a majority of which can be reconstructed via a transconjunctival approach. We used a transconjunctival approach in identifying the location of the fracture on image scans except for cases including the fracture of the superior portion in patients with medial wall fracture. If it is possible to identify the location of the fracture, a transconjunctival approach would be an useful method for the reconstruction in that it causes no damages to the lacrimal system and is useful in confirming the overall status of the floor.

Keywords: Ophthalmologic surgical procedure; Orbital fracture; Orbital implants; Reconstructive surgical procedure.

Fig. 1. Surgical approach for medial orbital fracture. A, transcruncular approach (vertical incision through lateral one third of the caruncle, about 1 cm); B, transconjunctival approach (horizontal incision at 3–4 mm inferior to lower eyelid margin, about 2.5 cm).

Fig. 2. A schematic illustration of the compartmentation of the medial wall. Distances extending from the anterior to posterior directions and form the superior to inferior ones were divided into three parts.

Fig. 3. The number and proportion of the patients with fractures depending on the compartment. Above is the munber of patients with proportion in brackets below. Middle-middle portion, anterior-middle portion and middle-inferior portionshowed predominant prevalence.

Fig. 4. Preoperative computed tomography scan. Axial views of preoperative computed tomography scans in the patients who were diagnosed with medial wall fracture.

Fig. 5. Postoperative computed tomography scan. Axial views of postoperative computed tomography scans. Porous polyethylene incorporating titanium was used for the reconstruction of the medial wall fracture.

Fig. 6. The extent of surgical approach via a transconjunctival approach. The extent of a transconjunctival approach was so great as to involve some parts of the superior and posterior side in the reconstruction of the medial wall fracture; this was seen in 86% of total patients.