• Written By: Shimon Rumelt, MD

    This retrospective study found that the endoscopic transcaruncular approach (ETA) is effective for large medial orbital wall fractures near the orbital apex. It facilitated clear delineation of all the fracture edges, enabled repositioning of all the prolapsed orbital contents, and ensured the placement of implants over the posterior edge so that full fracture correction could be achieved in all cases.

    Although these are excellent results, the authors did not define symmetry. They also did not address the benefits of this approach over the conventional transcaruncular approach. Endoscopic repair of orbital fractures especially near the apex is different from endoscopic dacryocystorhinostomy and brow lifting. It is more changeable because the normal anatomy is disrupted. Bleeding may occur and soft tissue swelling interferes with passing the instruments.  

    The authors reviewed the charts of 93 consecutive patients with large isolated medial orbital wall fractures near the orbital apex who underwent fracture repair with an ETA. The vertical and horizontal fracture defects measured during surgery ranged from 16 to 30 mm and from 25 to 34 mm, respectively.

    Six months after surgery, complete reconstruction of the bony defects was demonstrated by orbital CT scans in all eyes, and symmetry of both eyes was achieved in all but one patient.

    Of 30 patients with significant preoperative enophthalmos of more than 2 mm, 29 were corrected, with a mean improvement of 3.37 mm. Diplopia within the 30° visual field of the gaze was resolved in 40 of 43 patients. Three patients had residual diplopia on medial gaze because of presumed paralysis of the medial rectus muscle. Intraorbital hemorrhage occurred in one patient on the day after surgery and resolved with conservative treatment.