The Outcomes of Orbital Blowout Fracture Repairment by Transconjunctival Endoscopic Technique

The Outcomes of Orbital Blowout Fracture Repairment by Transconjunctival Endoscopic Technique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Outcomes of Orbital Blowout Fracture Repairment by Transconjunctival Endoscopic Technique Yunyan Ye, Feng Hu, Qiao Kong, Zhiguo Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3704126/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: The purpose of this case series is to present the benefits and results of using a transconjunctival endoscopic technique to repair orbital blowout fractures. Patients and methods: In this retrospective interventional case series, 133 patients with ocular blowout fractures were enrolled. Between January 2021 and December 2022, these patients underwent transconjunctival orbital blowout fracture repair using an endoscopic technique and a Medpor-Titanium sheet implant. Results: This study included 133 individuals (135 eyes) with orbital blowout fractures, 129 of whom were adults and 4 of whom were pediatric patients. 63 eyes had medial wall fractures, 23 eyes had inferior wall fractures, and 49 eyes had both types of wall fractures. Preoperative eyeball enophthalmos was 2.33 mm on average. In 132 eyes, postoperative exophthalmia improved by ≥2 mm, while it improved by < 2 mm in 6 eyes. After surgery, 73 individuals' diplopia disappeared one month after surgery. 42 patients' facial paresthesia recovered one to three months following surgery. After a 6-month follow-up, 131 out of 133 cases had been cured, and 2 had improved. There was a 100% effective rate and a 95.56% cure rate. Conclusion: This article details the results and experience of using a transconjunctival endoscopic technique to repair orbital blowout fractures. The procedure is efficient in restoring orbital structure and improving visual function, and it has a low rate of postoperative complications. Health sciences/Diseases/Trauma Health sciences/Diseases/Eye diseases Endoscopic Orbital Blowout Fracture Medpor-Titanium. Figures Figure 1 Figure 2 Figure 3 Figure 4 Summary What was known before Orbital blowout fractures are common facial injuries that destroy orbital components while also impairing appearance and vision function. In most cases, correcting surgery is necessary. Traditional surgery, modified incision surgery, and nasal endoscopic surgery all have benefits and drawbacks. Traditional surgery is inadequate due to poor visualization of the fracture area and facial scars. It results in difficult operation with limited repair effect. The adjusted conjunctival incision as well failed to achieve the desired repair result. Endoscopic orbital blowout fracture repair has been widely used in the repair of orbital medial wall fracture and has a better surgical field and repair effect, but the operation time is long, the nasal trauma is major, and the implant's direct exposure in the nasal cavity increases the risk of infection. Medpor-Titanium sheet (porous polyethylene Composite Titanium mesh) combines the qualities of the two materials. It has good stability and safety in orbital blowout fracture repair. In children, the most common clinical signs of orbital trapdoor fracture are vertical ocular motility disorders, which might be accompanied by nausea and vomiting. Because of the uniqueness of children's orbital structures, clinical symptoms are obvious, surgery is difficult, and the selection of surgical methods and repair materials are still debatable. The surgical management of orbital blowout fracture has generally demonstrated significant anatomical and visual improvements. What this study adds Our results propose that the transconjunctival endoscopic technique is an effective and safe way to repair orbital blowout fractures. All the cases showed anatomical and visual improvements. There was a 95.56% cure rate and a 100% effective rate. This method has also been utilized successfully in children with orbital trapdoor fractures, and Medpor-Titanium sheet has demonstrated high stability and safety following a two-year follow-up. Background In adults as well as in children, orbital fractures are quite common among the injuries of the facial part of the skull. Automobile crashes, blunt trauma, and workplace injuries are the main causes of it. Most orbit blowout fractures involve the inferior and medial walls, and they are commonly associated by dyskinesia, diplopia, ocular exophthalmia, and even visual impairment. In the case of orbital fracture in pediatric patients, limited eyeball movement is predominant, very often with the lack of or very discreet symptoms of soft tissue swelling. The orbit's limited operating space and intricate structure make repairs exceedingly challenging( 1 – 3 ). Restoring orbital stability and vision function is the aim of orbital blowout fracture repair( 4 ). A facial incision is made during traditional surgery, which is hard to perform and can have aesthetic consequences. The endoscope can perform delicate operations and offer great visualization. However, there are drawbacks to transnasal endoscope orbital fracture treatment, including significant trauma and a protracted recovery period that raise the risk of surgical complications and increase costs( 2 , 5 , 6 ). In this study, ocular blowout fractures were repaired by combining endoscopic techniques with conunctival incisions. Additionally, a summary of the key technical and anatomical issues is provided to help with clinical treatment strategy. Methods Patients and Study Design All 133 patients suffered from orbital blowout fracture were included in this retrospective study, who underwent orbital blowout fracture repairment by transconjunctival endoscopic technique at the Ophthalmology Department of Li Huili Hospital Affiliated with Ningbo University's between January 2021 and December 2022. Records were kept of the following: surgical parameters, ocular examinations, orbital computerized tomography (CT), injury causes, and demographic profiles. The best corrected visual acuity (VA), intraocular pressure (IOP), eyeball proptosis, fundus examination, slit lamp microscopy, and ocular motility were among the orbital examinations performed both before and after surgery. Using orbital CT, the orbital fracture and rectus muscles were assessed in each patient. All patients underwent surgery 7–15 days after injury. All surgeries were performed by an accomplished orbital surgeon (Dr. Qiao Kong), and each patient underwent follow-up care for at least 6 months following the surgery. This retrospective case series study was approved by the Ethical Committee of Li Huili Hospital affiliated with Ningbo University and adhered to the tenets of the Declaration of Helsinki. Indications for surgery Orbital CT was used to confirm the inferior orbital wall and/or medial wall fractures, and surgery was performed 7–21 days following the injury. It also needs to fulfill one of the following requirements: 1) Diplopia is still present. 2) Eyeball enophthalmos ≥ 2 mm. 3) The CT scan revealed a considerable herniation of soft tissue and/or entrapment of extraocular muscles, and the passive pull test was positive. 4) Children with trapdoor fractures experienced severe nausea and vomiting. Diagnosis and evaluation based on orbital CT imaging The multi-slice spiral computerized tomography (MSCT) scan is used to identify orbital blowout fractures. The patient lay supine with both heads and eyes fixed on the scanning table. Every patient underwent a CT scan with a layer thickness of 1 mm, scanning the horizontal, coronal, and sagittal planes simultaneously while in the main eye position. Multiplanar reconstruction (MPR) was utilized to evaluate the orbital bone, entrapment of extraocular muscles, and other surrounding soft tissues after the pictures were preserved and uploaded to Multimodality Workplace (MWP). Furthermore, medial wall fracture (Fig. 1 A, B), inferior wall fracture (Fig. 2 A, B), and medial and inferior wall fracture (Fig. 3 A, B, C) were the three groups of patients based on CT imaging. One week following surgery, the orbital CT was reviewed to evaluate the position of the Medpor-Titanium sheet and the restoration of orbital structure and soft tissue. Surgical procedure All patients under general anesthesia. Transconjunctival incisions were used to repair the inferior wall fracture (Fig. 5 A, blue dotted line). The tissues were separated from the periorbita to the infraorbital rim with the aid of an endoscope. The subperiosteal space was used to separate the tissues after the periorbita was cut along the infraorbital rim (Fig. 5 B). Then, using a brain spatula and periosteal detacher, the confined tissue was brought back into orbit while bone fragments were extracted. Under the endoscopic view, the fracture area was visible (Fig. 5 C). The Medpor-Titanium sheet was adaptively formed and implanted in the defect area, and the implant was made in accordance with the fracture area and shape (Fig. 5 D). To enable the repair material to be smoothly put into the deep, it can be wrapped in plastic film. This will both push away the herniated fat and prevent the material from pulling out the fat. When placing the repair material, take care not to damage the lacrimal canaliculi. The caruncular pathway (Fig. 5 A, black dotted line) was used to repair the orbital medial wall fracture, and the tissue was separated to the posterior lacrimal crest under endoscopic view. The tissue was then removed from the orbit along the subperiosteum gap after the periosteum was cut behind the posterior lacrimal crest (Fig. 5 E). Cauterize the anterior ethmoid artery and remove the broken bone fragments (Fig. 5 F). The orbital wall's fracture edges were completely visible (Fig. 5 G). placed a sheet of Medpor-Titanium inside the injured area (Fig. 5 H). It should be isolated from the normal area in order to reveal the full extent of the fracture. First, the lowest portion of the fracture was isolated, and subsequently the higher portion. The middle fracture margin was detached subsequent to the separation of the normal ocular periosteum. Cotton pads should be used to separate the fracture margin and to return the herniated tissue since the periosteal detacher is tiny and sharp, making it easy to puncture the periosteal. The medial and inferior wall fractures were repaired using a combination of caruncular and conjunctival incisions (Fig. 5 A). Firstly, the inferior orbital wall fracture was initially fully exposed under endoscopic view, and the periosteal detacher and brain spatula were used to release the trapped tissue back into the orbit (Fig. 5 I). The integrity of the ethmoid-maxillary bone buttress (EMBB, Fig. 2 J) requires particular care. After that, the entrapped tissue was recovered, and the medial wall fracture area became visible (Fig. 5 K). To fix the medial and inferior wall flaws, two pieces of Medpor-Titanium sheets were implanted (Fig. 5 L). In order to support the orbital tissues, efforts should be taken to reconstruct the corner structure and unite the inferior and medial walls. Additionally, it's critical to recognize the pre-ethmoid/postethmoid/artery, and optic nerve canal anatomical structures because harm to them can result in serious consequences. After-operation supervision For one to three days, the surgical eye used a pressure dressing to halt bleeding and minimize edema. Broad-spectrum antibiotics for one day and intravenous dexamethasone 10 mg Qd for three days are recommended to avoid infection. After surgery, they underwent reviews one day, one week, three months, and six months later. During each review, postoperative VA, IOP, diplopia, eyeball proptosis, and eye movements were noted. After surgery, orbital CT was reviewed one week later. Statistical analysis Statistical analysis was performed using Prism 9 software. Measurement data with normal distribution are represented by mean while measurement data without normal distribution are represented by median and percentile. For comparison of measurement data, paired t-test was used for data distribution consistent with normal distribution, and the signed rank sum test was used for data distribution inconsistent with normal distribution. p < 0.05 was considered statistically significant. Results Clinical Course 135 eyes with orbital blowout fractures were included in this study. The male-to-female ratio was 2.33 and the mean age was 46.89 years (range 8–77 years). There were 39.85% of cases with diplopia and a mean ocular enophthalmos of 2.33 mm. Table 1 provides a summary of the clinical and demographic information. The figure (Fig. 4 ) displays the injury's etiology and comorbidities. The primary causes include industrial accidents, car accidents, and punching injuries (Fig. 4 A). The most frequent complications are several facial fractures and lacerations to the eyelid (Fig. 4 B). Every operation went well; the average operation duration was 1.68 hours, and the blood loss was 5.35 milliliters, a considerable decrease from the conventional operation approach. Table 1 Demographic profiles and Clinical data Patients, n 135 Eyes, n 133 Average age, years (range) 46.89 (8–77) Pediatric patient, n 4 Right eye: Left eye 57:76 Bilateral case, n 2 Female: male, n 40:93 Enophthalmos, n 112 eyeball enophthalmos (mm) 2.33 = 2mm, n 88 > 2mm, n 24 Preoperative diplopia, n (%) 53 (34.19) Preoperative facial paresthesia, n (%) 17 (23.61) Orbital blowout fracture Medial orbital walls, n 63 Inferior orbital walls, n 23 Inferior and medial orbital walls, n 49 Secondary surgery, n (eye, %) 6 (4.44%) Retrobulbar hemorrhage, n 4 Adjust Medpor sheet position, n 2 A total of 135 eyes, comprising 86 eyes with unilateral and 49 eyes with bilateral orbital wall fractures, underwent orbital blowout fracture repair via transconjunctival endoscopic methods. Two patients underwent an additional surgery to adjust the position of the Medpor-Titanium sheet. Four patients underwent an additional operation because of retrobulbar hemorrhage (RBH) (Table 1 ). RBH is a rare postoperative complication feared by ophthalmologists, because it can lead to blindness if not appropriately managed( 7 ). The incidence rates of 0.055 to 3.2% have been reported, depending on type of surgery( 8 , 9 ). Results of orbital CT examination after surgery According to the postoperative orbital CT scan, the orbital structure was restored and the medial and inferior wall fractures (Figs. 1 C, D), 2 C, D, and 3 D, E, and F) were all repaired. Because the Medpor-Titanium sheet had a good supportive role in all types, the enophthalmos was totally modified, and the orbit and soft tissue were returned to their natural physiological shape. The enophthalmos improved ≥ 2 mm in 131 patients, and < 2 mm in 6 patients who had severe eyeball rupture injuries, resulting in eyeball atrophy. There was a 100% effective rate and a 95.56% cure rate. Four pediatric patients with an average age of 11.5 years (range 8–15 years), were present. One inferior orbital fracture case and 3 medial orbital fractures secondary to blunt trauma. After surgery, there was no diplopia, eye movement was normal, the extraocular muscle pull test was negative, and each ocular exophthalmos was consistent. Following up for 2 years, neither the Medpor-Titanium sheets shifting, nor any other negative responses occurred. Diplopia and eye movement The diplopia before and after the surgery is depicted in Fig. 4 (C). For unilateral and bilateral wall fractures, the incidence of diplopia was 30.23% and 55.10%, respectively. Twenty individuals experienced new diplopia following surgery; this is a 20% new incidence rate. Diplopia is typically linked to serious problems with eye movement. Horizontal diplopia and restricted external eye movement are the symptoms of a medial wall fracture and medial rectus muscle entrapment. A combination of inferior wall fracture and entrapment of the inferior rectus muscle results in limited up- or down-turning as well as vertical diplopia. After surgery, the herniated tissue was replaced, however, the rectus muscle's function did not return right away because of postoperative tissue edema. As a result, diplopia persisted for a while until disappearing after 1 month. Facial paresthesia Facial paresthesia before and after the surgery is depicted in Fig. 4 (D). Seventeen patients of the 72 patients with inferior orbital wall fractures experienced facial paresthesia, with a 45.45% incidence. After surgery, 25 patients experienced facial paresthesia, with a 45.45% incidence. Facial paresthesia is a common complication of inferior orbital wall fracture, which caused by infraorbital nerve injury. The infraorbital nerve was compressed by tissue edema, resulting in postoperative face paresthesia. According to our findings, all the facial paresthesia recovered 1 to 3 months after surgery. Other complications Common postoperative complications included conjunctival hyperemia, subconjunctival bleeding, eyelid edema, and eyelid congestion; all of these recovered in shortly after surgery. At the 6-month follow-up, the orbital fractures were repaired effectively, and there were no severe complications like infection, implant displacement, or cerebrospinal fluid leakage. Discussion Because of the rise in industrial injuries and traffic accidents, orbital blowout fractures are becoming a prevalent trauma. Surgery is usually necessary for orbital blowout fractures( 10 ). Removing the trapped orbital contents, restoring the normal orbital morphology and visual function, and preventing complications are the main goals of surgical treatment for orbital fractures. For surgeons, minimizing complications and increasing surgical accuracy provide a challenge( 11 , 12 ). The conventional surgical procedure for orbital medial wall fractures involves making a skin incision, which has two drawbacks: the scar on the face and the difficulty of dealing with the inner canthal ligament and lacrimal sac. The modified technique selected the subciliary incisions to prevent damage to the lacrimal sac and the inner canthus ligaments. The disadvantage of this approach is that the orbit's anterior and superior walls are not well exposed( 6 , 13 ). The rapid development of endoscopic technology in recent years has made it possible to treat orbital blowout fractures through the maxillary sinus or ethmoid sinus using a nasal endoscope, resulting in more precise surgical exposure and medial wall repair. This method's drawback is that it must open ethmoidal sinus or ethmoid sinus, which increases the surgical procedure and raises costs. In addition, the transplant is directly exposed to the nasal cavity result in the risk of infection is increased( 14 ). Considering the benefits and drawbacks of the aforementioned approaches, we advise using the endoscopic technique outlined in this study to repair orbital wall fractures via caruncular incision. Identifying the Honer's muscle is essential for transconjunctival endoscopic medial ocular blowout repair. The interlaminar space of the Honer's muscle can be directly accessed by severing the link between the lacrimal sac and the medial palpebral ligament. The lacrimal sac and medial palpebral ligament won't be harmed because this space can be naturally reached by the orbit medial wall. Following surgery, there will be a brief period of vertical diplopia if the trochlear nerve is injured. In addition, tissue separation must be done carefully and delicately to avoid any injuring the orbital periosteum. Handling the fat in the tiny operating space becomes troublesome once the orbital periosteum ruptures and the fat herniates, greatly increasing the difficulty of the surgery. Another significant anatomical site is the anterior ethmoidal artery. The link between the frontal bone and the ethmoid bone is going to be the frontal bone, and it will run between the anterior and posterior ethmoid arteries. The base of the skull will be reached by separating from the anterior ethmoidal artery. When the fracture area is large, special caution should be taken to locate this area on CT in order to prevent intraoperative invasion of the skull base( 15 ). Because the inferior orbital wall is far away from the optic nerve, surgery is relatively secure. A transconjunctival incision was made, which involves cutting the conjunctiva from the inferior fornix, reaching the orbital septum, and finally arriving at the lower orbital rim. There was no face scar since all surgical procedures were taken out outside the periorbita itself. It is crucial to notice that the infraorbital nerve has an artery that runs from the infraorbital sulcus to the infraorbital canal. This artery should be electrocoagulated to separate rather than bluntly severed, as it will bleed severely if it ruptures. Additionally, the inferior orbital fissure must be clearly detected using an endoscope. If the suborbital fissure tissue is separated as the herniated tissue, this could result in loss of vision and a reduced view field. Furthermore, the jawbone is strong and substantial so that the posterior edge of the Medpor-Titanium sheet for the inferior orbital wall repair should be positioned on it( 15 , 16 ). In the case of fractures of the medial and inferior walls, the fracture range is broader, the procedure is more complex, and we should avoid injuring the lower oblique muscle. The ethmoid-maxillary bone buttress (EMBB) should also be considered. Fractures involving the EMBB have some imaging features on CT: the "plate bridge" of the ethmomaxillary plate, which spans between the orbit and the nasal cavity and separates the ethmoidal sinus from the maxillary sinus, collapses, and the orbital cavity is significantly enlarged, the orbital content is herniated into the sinus cavity, and the enophthalmos is more obvious( 13 , 15 ). Rebuilding the corner structure connecting the medial and inferior walls can support the orbital contents, provide functional restoration, and keep the EMBB stable. Fractures involving EMBB require a repair material with greater flexibility and hardness( 17 ). Titanium mesh has high hardness, while high-density porous polyethylene has good histocompatibility and vascularization properties, Medpor-Titanium sheet (porous polyethylene Composite Titanium mesh) mixes the two materials to bring these properties together. Our clinical experience showed that Medpor-Titanium sheet can achieve good results in orbital fracture repairment( 17 ). Infraorbital nerve injury is most common in inferior orbital wall fractures (85%). The clinical symptoms are mostly paresthesia in the ipsilateral lower eyelid, nasal alar skin, upper lip skin, and mucous membrane. The following were the reasons: ( 1 ) Traumatic edema of peri-nerve tissue causes increased pressure in the infraorbital canal and severe nerve compression; ( 2 ) Orbital fractures including the infraorbital canal, infraorbital sulcus, and infraorbital foramen, which can directly compress and impair the nerve( 4 , 18 ). In our study, the incidence was 23.61%; 17 patients with facial paresthesia had a zygomaticomaxillary complex (ZMC) fracture and had maxillofacial repair surgery. After-surgery facial paresthesia is caused by swollen tissue pushing on the infraorbital nerve and normally disappears on its own within 1–3 months. Conclusion Endoscopic technique has revolutionized orbital fracture repair. Direct view operation, good lighting, and high-definition photographs can clearly disclose the fracture extent, particularly the posterior boundary. Minimally invasive surgery avoids facial scarring and reduces orbital tissue damage, resulting in improved surgical outcomes and fewer complications. Endoscopic transconjunctival orbital blowout fracture treatment shifts the focus from functional to anatomic repair, making the procedure more precise and simpler. Declarations Acknowledgments Not applicable. Conflict of Interest The authors declare that they have no conflict of interest. Funding Not applicable. Author Contribution Statement Conceptualization and writing original draft: [Yunyan Ye]; Data collection and prepare figures: [Feng Hu]; Project administration: [Qiao Kong]; Writing review & editing [Zhiguo li]. The authors read and approved the final manuscript. Availability of data and materials The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. References Jordan DR, Mawn L, Klapper SR. Blowout fractures of the orbit. Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery. 2021:1237-61. Ozturker C, Sari Y, Ozbilen KT, Ceylan NA, Tuncer S. Surgical repair of orbital blow-out fractures: outcomes and complications. Beyoglu Eye J. 2022;7(03):199-206. Koryczan P, Zapała J, Gontarz M, Wyszyńska-Pawelec G. Comparison of the results of the treatment of enophthalmos in orbital blowout fracture in children/adolescents and adults. Dental and Medical Problems. 2021;58(2):179-86. Rajantie H, Kaukola L, Snäll J, Roine R, Sintonen H, Thorén H. Health-related quality of life in patients surgically treated for orbital blow-out fracture: a prospective study. Oral and Maxillofacial Surgery. 2021;25:373-82. Yamanaka Y, Watanabe A, Rajak SN, Nakayama T, Sotozono C. Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures. Graefe's Archive for Clinical and Experimental Ophthalmology. 2022;260(1):319-25. Homer N, Huggins A, Durairaj VD. Contemporary management of orbital blowout fractures. Current opinion in otolaryngology & head and neck surgery. 2019;27(4):310-6. Park JH, Kim I, Son JH. Incidence and management of retrobulbar hemorrhage after blowout fracture repair. BMC ophthalmology. 2021;21:1-8. Gosau M, Schöneich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures—complications, outcome, and review of literature. Clinical oral investigations. 2011;15:305-13. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Ophthalmic Plastic & Reconstructive Surgery. 2004;20(6):426-32. Lozada KN, Cleveland PW, Smith JE, editors. Orbital trauma. Seminars in plastic surgery; 2019: Thieme Medical Publishers. Kono S, Vaidya A, Takahashi Y. Mechanisms of Development of Orbital Fractures: A Review. Ophthalmic Plastic & Reconstructive Surgery. 2023;39(6):542-7. Khojastepour L, Moannaei M, Eftekharian H, Khaghaninejad M, Mahjoori-Ghasrodashti M, Tavanafar S. Prevalence and severity of orbital blowout fractures. British Journal of Oral and Maxillofacial Surgery. 2020;58(9):e93-e7. Borstedt KJ, Alinasab B. The measurement of orbital blowout fractures cannot be made with geometric estimations. Otorhinolaryngol Neck Surg. 2019;4:1-6. Shim WS, Jung HJ. Management of Orbital Blowout Fractures: ENT Surgeon's Perspective. Journal of Rhinology. 2019;26(2):65-74. Felding UNA. Blowout fractures-clinic, imaging and applied anatomy of the orbit. Dan Med J. 2018;65(3):B5459. Ghosh SK, Narayan RK. Fractures involving bony orbit: A comprehensive review of relevant clinical anatomy. Translational Research in Anatomy. 2021;24:100125. Xu Q-H, Yu J-H, Wang Y-H, Wang A-A, Liao H-F. Analysis of the effect of repair materials for orbital blowout fracture on complications. International Journal of Ophthalmology. 2019;12(11):1746. Rath EM. Surgical treatment of maxillary nerve injuries: the infraorbital nerve. Atlas of the Oral and Maxillofacial Surgery Clinics. 2001;9(2):31-41. Additional Declarations There is no conflict of interest Supplementary Files Figure5.jpg Supplementary Information Figure 5. Surgical procedure A. Incisions for surgical procedures. The blue dotted line represents a transconjunctival incision, while the black dotted line represents a caruncular incision. B-D: Surgical procedure of the inferior orbital fracturerepair. E-H: Surgical procedure of the medial orbital fracturerepair. I-L: Surgical procedure of the medial and inferior orbital fracture repair. B. Sutures are used to label the conjunctiva, and a stripper is used to remove the periosteum and entrapped tissue under endoscopic guidance. C. Endoscopic view of a broad orbital rim and a fractured inferior floor. D. Endoscopic view of inferior orbital floor repair (Medpor-Titaniumimplant). E. Remove the bone fragments and repair the herniated tissues under endoscopic supervision. F. Remove the bone fragments and repair the herniated tissues under endoscopic supervision. G. Endoscopic view of the orbital rim and fractured medial floor. H. A brain pressure plate is used to separate the orbital tissue, and a Medpor-Titanium implant is inserted. I. Endoscopic view of the orbital rim and a fracture in the inferior floor.. J. Endoscopic view of the medial and inferior wall corner, revealing a fracture with a substantial amount of entrapped tissue. K. Endoscopic view of orbital rim and medial floor fracture. L. Under the endoscopic view, the Medpor-Titanium implant are placed over the fracture edges. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3704126","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":274447228,"identity":"2a95ecd6-bd21-4b52-84ba-64d60d12e183","order_by":0,"name":"Yunyan Ye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBACPgnmBhib8QEjmJ2AXwubBCNcC7MByVpgbEJapBvbJD62Hc4zOH72WHXhjsMM/Ow5Bgw/d+DRInOwTXJm2+FigzN5abdnnjnMINnzxoCx9ww+hyW2SfO2HU7ccCDH7DaQwWBwI8eAmbGNgJa/IC3n35gVg7TYE6WFEaTlRo4ZM9gWCcJami17zqUnzrzxxlia90w6j8SZZwUHe/Fo4ZdIPnjjR5l1Yt/5HMPPvDus5fjbkzc++IlHCxCwSDCyMTAoHIDweEDEAbwagJH+geEPA4N8AwFlo2AUjIJRMHIBACtpVDBxbiY/AAAAAElFTkSuQmCC","orcid":"","institution":"Li Huili Hospital affiliated with Ningbo University","correspondingAuthor":true,"prefix":"","firstName":"Yunyan","middleName":"","lastName":"Ye","suffix":""},{"id":274447229,"identity":"7347a096-a306-46cd-8373-3ad825ff9d41","order_by":1,"name":"Feng Hu","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Hu","suffix":""},{"id":274447230,"identity":"d5b45ea3-db57-47c4-811c-1a01bc7ca81c","order_by":2,"name":"Qiao Kong","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Qiao","middleName":"","lastName":"Kong","suffix":""},{"id":274447231,"identity":"322bf750-0530-40d5-bfd1-6f9606223499","order_by":3,"name":"Zhiguo Li","email":"","orcid":"https://orcid.org/0009-0005-2325-1405","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Zhiguo","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2023-12-04 06:05:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3704126/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3704126/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51766347,"identity":"f1f6b718-38f4-4f29-baf7-7c9201d83aa0","added_by":"auto","created_at":"2024-02-28 18:52:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":331221,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOrbital CT image of a medial orbital wall blowout fracture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Preoperative orbital coronal CT scans revealed a right medial orbital fracture caused by brutal trauma.\u003c/p\u003e\n\u003cp\u003eB. Preoperative orbital horizontal CT scans revealed the right medial orbital fracture.\u003c/p\u003e\n\u003cp\u003eC. A coronal CT scans of medial orbital fracture repairment 1 week after surgery.\u003c/p\u003e\n\u003cp\u003eA horizontal CT scans of medial orbital fracture repairment 1 week after surgery.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3704126/v1/3b1063b3af531080fd22c194.jpg"},{"id":51767247,"identity":"00736b06-ea2b-42fd-bbfa-a64c2f138a11","added_by":"auto","created_at":"2024-02-28 19:00:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":308095,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOrbital CT image of an inferior orbital wall blowout fracture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Preoperative orbital coronal CT scans revealed a right inferior orbital fracture secondary to blunt trauma.\u003c/p\u003e\n\u003cp\u003eB. Preoperative orbital sagittal CT scans revealed the inferior medial orbital fracture.\u003c/p\u003e\n\u003cp\u003eC. A coronal CT scans of inferior orbital fracture repairment 1 week after surgery.\u003c/p\u003e\n\u003cp\u003eD. A sagittal CT scans of inferior orbital fracture repairment 1 week after surgery.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3704126/v1/3d0a1460d8748e5ef4fe2d1c.jpg"},{"id":51766346,"identity":"e40f56b1-e499-4c53-92ac-0419eb3585d9","added_by":"auto","created_at":"2024-02-28 18:52:01","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":408484,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOrbital CT image of a medial and inferior orbital wall blowout fracture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Preoperative orbital coronal CT scans revealed a large left medial and inferior orbital fracture secondary to blunt trauma.\u003c/p\u003e\n\u003cp\u003eB. Preoperative orbital horizontal CT scans revealed the medial orbital fracture.\u003c/p\u003e\n\u003cp\u003eC. Preoperative orbital sagittal CT scans revealed the inferior medial orbital fracture.\u003c/p\u003e\n\u003cp\u003eD. A coronal CT scans of the medial and inferior orbital fracture repairment 1 week after surgery.\u003c/p\u003e\n\u003cp\u003eE. A horizontal CT scans of medial orbital fracture repairment 1 week after surgery.\u003c/p\u003e\n\u003cp\u003eF. A sagittal CT scans of inferior orbital fracture repairment 1 week after surgery.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3704126/v1/bb990d3fba0108d237449ac8.jpg"},{"id":51766349,"identity":"a378dd69-74f0-4005-aa97-d2f32dd5b6f5","added_by":"auto","created_at":"2024-02-28 18:52:01","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":666870,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe causes and comorbidities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. The causes of injury.\u003c/p\u003e\n\u003cp\u003eB. Comorbidities of orbital blowout fracture.\u003c/p\u003e\n\u003cp\u003eC. The occurrence of diplopia before and after surgery.\u003c/p\u003e\n\u003cp\u003eD. The occurrence of facial numbness before and after surgery\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3704126/v1/fdbccf38791b5b82335f33f3.jpg"},{"id":56527158,"identity":"3cb34c07-b7b6-4010-941b-be2279dba7bb","added_by":"auto","created_at":"2024-05-15 10:50:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2193052,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3704126/v1/6709a54c-cc23-45e1-ab5e-9df861e554f6.pdf"},{"id":51766350,"identity":"278b5a47-3bf4-4fc8-ad71-8fd50a835bc2","added_by":"auto","created_at":"2024-02-28 18:52:02","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1794879,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 5. Surgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Incisions for surgical procedures. The blue dotted line represents a transconjunctival incision, while the black dotted line represents a caruncular incision.\u003c/p\u003e\n\u003cp\u003eB-D: Surgical procedure of the inferior orbital fracturerepair.\u003c/p\u003e\n\u003cp\u003eE-H: Surgical procedure of the medial orbital fracturerepair.\u003c/p\u003e\n\u003cp\u003eI-L: Surgical procedure of the medial and inferior orbital fracture repair.\u003c/p\u003e\n\u003cp\u003eB. Sutures are used to label the conjunctiva, and a stripper is used to remove the periosteum and entrapped tissue under endoscopic guidance.\u003c/p\u003e\n\u003cp\u003eC. Endoscopic view of a broad orbital rim and a fractured inferior floor.\u003c/p\u003e\n\u003cp\u003eD. Endoscopic view of inferior orbital floor repair (Medpor-Titaniumimplant).\u003c/p\u003e\n\u003cp\u003eE. Remove the bone fragments and repair the herniated tissues under endoscopic supervision.\u003c/p\u003e\n\u003cp\u003eF. Remove the bone fragments and repair the herniated tissues under endoscopic supervision.\u003c/p\u003e\n\u003cp\u003eG. Endoscopic view of the orbital rim and fractured medial floor.\u003c/p\u003e\n\u003cp\u003eH. A brain pressure plate is used to separate the orbital tissue, and a Medpor-Titanium implant is inserted.\u003c/p\u003e\n\u003cp\u003eI. Endoscopic view of the orbital rim and a fracture in the inferior floor..\u003c/p\u003e\n\u003cp\u003eJ. Endoscopic view of the medial and inferior wall corner, revealing a fracture with a substantial amount of entrapped tissue.\u003c/p\u003e\n\u003cp\u003eK. Endoscopic view of orbital rim and medial floor fracture.\u003c/p\u003e\n\u003cp\u003eL. Under the endoscopic view, the Medpor-Titanium implant are placed over the fracture edges.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3704126/v1/e02bebf1c6bea26430f25a80.jpg"}],"financialInterests":"There is no conflict of interest","formattedTitle":"The Outcomes of Orbital Blowout Fracture Repairment by Transconjunctival Endoscopic Technique","fulltext":[{"header":"Summary ","content":"\u003cp\u003e\u003cstrong\u003eWhat was known before\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul start=\"12\"\u003e\n \u003cli\u003eOrbital blowout fractures are common facial injuries that destroy orbital components while also impairing appearance and vision function. In most cases, correcting surgery is necessary.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTraditional surgery, modified\u0026nbsp;incision surgery, and nasal endoscopic surgery all have benefits and drawbacks.\u003c/li\u003e\n \u003cli\u003eTraditional surgery is inadequate due to poor visualization of the fracture area and facial scars. It results in difficult operation with limited repair effect. \u0026nbsp;The adjusted conjunctival incision as well failed to achieve the desired repair result.\u003c/li\u003e\n \u003cli\u003eEndoscopic orbital blowout fracture repair has been widely used in the repair of orbital medial\u0026nbsp;wall fracture and\u0026nbsp;has a better surgical field and repair effect, but the operation time is long, the nasal trauma is major, and the implant\u0026apos;s\u0026nbsp;direct exposure in the nasal cavity increases the risk of infection.\u003c/li\u003e\n \u003cli\u003eMedpor-Titanium sheet (porous polyethylene Composite Titanium mesh) combines the qualities of the two materials. It has good stability and safety in orbital blowout fracture repair.\u003c/li\u003e\n \u003cli\u003eIn children, the most common clinical signs of orbital trapdoor fracture are vertical ocular motility disorders, which might be accompanied by nausea and vomiting. Because of the uniqueness of children\u0026apos;s orbital structures, clinical symptoms are obvious, surgery is difficult, and the selection of surgical methods and repair materials are still debatable.\u003c/li\u003e\n \u003cli\u003eThe surgical management of orbital blowout fracture has generally demonstrated significant anatomical and visual improvements.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul start=\"12\"\u003e\n \u003cli\u003eOur results propose that the transconjunctival endoscopic technique is an effective and safe way to repair orbital blowout fractures.\u003c/li\u003e\n \u003cli\u003eAll the cases showed anatomical and visual improvements. There was a 95.56% cure rate and a 100% effective rate.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThis method has also been utilized successfully in children with orbital trapdoor fractures, and Medpor-Titanium sheet has demonstrated high stability and safety following a two-year follow-up.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eIn adults as well as in children, orbital fractures are quite common among the injuries of the facial part of the skull. Automobile crashes, blunt trauma, and workplace injuries are the main causes of it. Most orbit blowout fractures involve the inferior and medial walls, and they are commonly associated by dyskinesia, diplopia, ocular exophthalmia, and even visual impairment. In the case of orbital fracture in pediatric patients, limited eyeball movement is predominant, very often with the lack of or very discreet symptoms of soft tissue swelling. The orbit's limited operating space and intricate structure make repairs exceedingly challenging(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRestoring orbital stability and vision function is the aim of orbital blowout fracture repair(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A facial incision is made during traditional surgery, which is hard to perform and can have aesthetic consequences. The endoscope can perform delicate operations and offer great visualization. However, there are drawbacks to transnasal endoscope orbital fracture treatment, including significant trauma and a protracted recovery period that raise the risk of surgical complications and increase costs(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, ocular blowout fractures were repaired by combining endoscopic techniques with conunctival incisions. Additionally, a summary of the key technical and anatomical issues is provided to help with clinical treatment strategy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and Study Design\u003c/h2\u003e \u003cp\u003eAll 133 patients suffered from orbital blowout fracture were included in this retrospective study, who underwent orbital blowout fracture repairment by transconjunctival endoscopic technique at the Ophthalmology Department of Li Huili Hospital Affiliated with Ningbo University's between January 2021 and December 2022. Records were kept of the following: surgical parameters, ocular examinations, orbital computerized tomography (CT), injury causes, and demographic profiles. The best corrected visual acuity (VA), intraocular pressure (IOP), eyeball proptosis, fundus examination, slit lamp microscopy, and ocular motility were among the orbital examinations performed both before and after surgery. Using orbital CT, the orbital fracture and rectus muscles were assessed in each patient. All patients underwent surgery 7\u0026ndash;15 days after injury. All surgeries were performed by an accomplished orbital surgeon (Dr. Qiao Kong), and each patient underwent follow-up care for at least 6 months following the surgery. This retrospective case series study was approved by the Ethical Committee of Li Huili Hospital affiliated with Ningbo University and adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIndications for surgery\u003c/h2\u003e \u003cp\u003eOrbital CT was used to confirm the inferior orbital wall and/or medial wall fractures, and surgery was performed 7\u0026ndash;21 days following the injury. It also needs to fulfill one of the following requirements:\u003c/p\u003e \u003cp\u003e1) Diplopia is still present.\u003c/p\u003e \u003cp\u003e2) Eyeball enophthalmos\u0026thinsp;\u0026ge;\u0026thinsp;2 mm.\u003c/p\u003e \u003cp\u003e3) The CT scan revealed a considerable herniation of soft tissue and/or entrapment of extraocular muscles, and the passive pull test was positive.\u003c/p\u003e \u003cp\u003e4) Children with trapdoor fractures experienced severe nausea and vomiting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis and evaluation based on orbital CT imaging\u003c/h2\u003e \u003cp\u003eThe multi-slice spiral computerized tomography (MSCT) scan is used to identify orbital blowout fractures. The patient lay supine with both heads and eyes fixed on the scanning table. Every patient underwent a CT scan with a layer thickness of 1 mm, scanning the horizontal, coronal, and sagittal planes simultaneously while in the main eye position. Multiplanar reconstruction (MPR) was utilized to evaluate the orbital bone, entrapment of extraocular muscles, and other surrounding soft tissues after the pictures were preserved and uploaded to Multimodality Workplace (MWP). Furthermore, medial wall fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, B), inferior wall fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B), and medial and inferior wall fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, B, C) were the three groups of patients based on CT imaging. One week following surgery, the orbital CT was reviewed to evaluate the position of the Medpor-Titanium sheet and the restoration of orbital structure and soft tissue.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eAll patients under general anesthesia. Transconjunctival incisions were used to repair the inferior wall fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA, blue dotted line). The tissues were separated from the periorbita to the infraorbital rim with the aid of an endoscope. The subperiosteal space was used to separate the tissues after the periorbita was cut along the infraorbital rim (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eB). Then, using a brain spatula and periosteal detacher, the confined tissue was brought back into orbit while bone fragments were extracted. Under the endoscopic view, the fracture area was visible (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eC). The Medpor-Titanium sheet was adaptively formed and implanted in the defect area, and the implant was made in accordance with the fracture area and shape (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eD). To enable the repair material to be smoothly put into the deep, it can be wrapped in plastic film. This will both push away the herniated fat and prevent the material from pulling out the fat. When placing the repair material, take care not to damage the lacrimal canaliculi.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe caruncular pathway (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA, black dotted line) was used to repair the orbital medial wall fracture, and the tissue was separated to the posterior lacrimal crest under endoscopic view. The tissue was then removed from the orbit along the subperiosteum gap after the periosteum was cut behind the posterior lacrimal crest (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eE). Cauterize the anterior ethmoid artery and remove the broken bone fragments (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eF). The orbital wall's fracture edges were completely visible (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eG). placed a sheet of Medpor-Titanium inside the injured area (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eH). It should be isolated from the normal area in order to reveal the full extent of the fracture. First, the lowest portion of the fracture was isolated, and subsequently the higher portion. The middle fracture margin was detached subsequent to the separation of the normal ocular periosteum. Cotton pads should be used to separate the fracture margin and to return the herniated tissue since the periosteal detacher is tiny and sharp, making it easy to puncture the periosteal.\u003c/p\u003e \u003cp\u003eThe medial and inferior wall fractures were repaired using a combination of caruncular and conjunctival incisions (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA). Firstly, the inferior orbital wall fracture was initially fully exposed under endoscopic view, and the periosteal detacher and brain spatula were used to release the trapped tissue back into the orbit (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eI). The integrity of the ethmoid-maxillary bone buttress (EMBB, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eJ) requires particular care. After that, the entrapped tissue was recovered, and the medial wall fracture area became visible (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eK). To fix the medial and inferior wall flaws, two pieces of Medpor-Titanium sheets were implanted (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eL). In order to support the orbital tissues, efforts should be taken to reconstruct the corner structure and unite the inferior and medial walls. Additionally, it's critical to recognize the pre-ethmoid/postethmoid/artery, and optic nerve canal anatomical structures because harm to them can result in serious consequences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAfter-operation supervision\u003c/h2\u003e \u003cp\u003eFor one to three days, the surgical eye used a pressure dressing to halt bleeding and minimize edema. Broad-spectrum antibiotics for one day and intravenous dexamethasone 10 mg Qd for three days are recommended to avoid infection. After surgery, they underwent reviews one day, one week, three months, and six months later. During each review, postoperative VA, IOP, diplopia, eyeball proptosis, and eye movements were noted. After surgery, orbital CT was reviewed one week later.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using Prism 9 software. Measurement data with normal distribution are represented by mean while measurement data without normal distribution are represented by median and percentile. For comparison of measurement data, paired t-test was used for data distribution consistent with normal distribution, and the signed rank sum test was used for data distribution inconsistent with normal distribution. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical Course\u003c/h2\u003e\n \u003cp\u003e135 eyes with orbital blowout fractures were included in this study. The male-to-female ratio was 2.33 and the mean age was 46.89 years (range 8\u0026ndash;77 years). There were 39.85% of cases with diplopia and a mean ocular enophthalmos of 2.33 mm. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e provides a summary of the clinical and demographic information. The figure (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) displays the injury\u0026apos;s etiology and comorbidities. The primary causes include industrial accidents, car accidents, and punching injuries (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eA). The most frequent complications are several facial fractures and lacerations to the eyelid (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eB). Every operation went well; the average operation duration was 1.68 hours, and the blood loss was 5.35 milliliters, a considerable decrease from the conventional operation approach.\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic profiles and Clinical data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePatients, n\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEyes, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAverage age, years (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.89 (8\u0026ndash;77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatric patient, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight eye: Left eye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57:76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilateral case, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale: male, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40:93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnophthalmos, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eeyeball enophthalmos (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e= 2mm, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;2mm, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative diplopia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (34.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative facial paresthesia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (23.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrbital blowout fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedial orbital walls, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInferior orbital walls, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInferior and medial orbital walls, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary surgery, n (eye, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4.44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetrobulbar hemorrhage, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdjust Medpor sheet position, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eA total of 135 eyes, comprising 86 eyes with unilateral and 49 eyes with bilateral orbital wall fractures, underwent orbital blowout fracture repair via transconjunctival endoscopic methods. Two patients underwent an additional surgery to adjust the position of the Medpor-Titanium sheet. Four patients underwent an additional operation because of retrobulbar hemorrhage (RBH) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). RBH is a rare postoperative complication feared by ophthalmologists, because it can lead to blindness if not appropriately managed(\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). The incidence rates of 0.055 to 3.2% have been reported, depending on type of surgery(\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eResults of orbital CT examination after surgery\u003c/h2\u003e\n \u003cp\u003eAccording to the postoperative orbital CT scan, the orbital structure was restored and the medial and inferior wall fractures (Figs.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC, D), 2 C, D, and 3 D, E, and F) were all repaired. Because the Medpor-Titanium sheet had a good supportive role in all types, the enophthalmos was totally modified, and the orbit and soft tissue were returned to their natural physiological shape. The enophthalmos improved\u0026thinsp;\u0026ge;\u0026thinsp;2 mm in 131 patients, and \u0026lt;\u0026thinsp;2 mm in 6 patients who had severe eyeball rupture injuries, resulting in eyeball atrophy. There was a 100% effective rate and a 95.56% cure rate.\u003c/p\u003e\n \u003cp\u003eFour pediatric patients with an average age of 11.5 years (range 8\u0026ndash;15 years), were present. One inferior orbital fracture case and 3 medial orbital fractures secondary to blunt trauma. After surgery, there was no diplopia, eye movement was normal, the extraocular muscle pull test was negative, and each ocular exophthalmos was consistent. Following up for 2 years, neither the Medpor-Titanium sheets shifting, nor any other negative responses occurred.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eDiplopia and eye movement\u003c/h2\u003e\n \u003cp\u003eThe diplopia before and after the surgery is depicted in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e (C). For unilateral and bilateral wall fractures, the incidence of diplopia was 30.23% and 55.10%, respectively. Twenty individuals experienced new diplopia following surgery; this is a 20% new incidence rate. Diplopia is typically linked to serious problems with eye movement. Horizontal diplopia and restricted external eye movement are the symptoms of a medial wall fracture and medial rectus muscle entrapment. A combination of inferior wall fracture and entrapment of the inferior rectus muscle results in limited up- or down-turning as well as vertical diplopia. After surgery, the herniated tissue was replaced, however, the rectus muscle\u0026apos;s function did not return right away because of postoperative tissue edema. As a result, diplopia persisted for a while until disappearing after 1 month.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eFacial paresthesia\u003c/h2\u003e\n \u003cp\u003eFacial paresthesia before and after the surgery is depicted in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e (D). Seventeen patients of the 72 patients with inferior orbital wall fractures experienced facial paresthesia, with a 45.45% incidence. After surgery, 25 patients experienced facial paresthesia, with a 45.45% incidence. Facial paresthesia is a common complication of inferior orbital wall fracture, which caused by infraorbital nerve injury. The infraorbital nerve was compressed by tissue edema, resulting in postoperative face paresthesia. According to our findings, all the facial paresthesia recovered 1 to 3 months after surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eOther complications\u003c/h2\u003e\n \u003cp\u003eCommon postoperative complications included conjunctival hyperemia, subconjunctival bleeding, eyelid edema, and eyelid congestion; all of these recovered in shortly after surgery. At the 6-month follow-up, the orbital fractures were repaired effectively, and there were no severe complications like infection, implant displacement, or cerebrospinal fluid leakage.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBecause of the rise in industrial injuries and traffic accidents, orbital blowout fractures are becoming a prevalent trauma. Surgery is usually necessary for orbital blowout fractures(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Removing the trapped orbital contents, restoring the normal orbital morphology and visual function, and preventing complications are the main goals of surgical treatment for orbital fractures. For surgeons, minimizing complications and increasing surgical accuracy provide a challenge(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe conventional surgical procedure for orbital medial wall fractures involves making a skin incision, which has two drawbacks: the scar on the face and the difficulty of dealing with the inner canthal ligament and lacrimal sac. The modified technique selected the subciliary incisions to prevent damage to the lacrimal sac and the inner canthus ligaments. The disadvantage of this approach is that the orbit's anterior and superior walls are not well exposed(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The rapid development of endoscopic technology in recent years has made it possible to treat orbital blowout fractures through the maxillary sinus or ethmoid sinus using a nasal endoscope, resulting in more precise surgical exposure and medial wall repair. This method's drawback is that it must open ethmoidal sinus or ethmoid sinus, which increases the surgical procedure and raises costs. In addition, the transplant is directly exposed to the nasal cavity result in the risk of infection is increased(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Considering the benefits and drawbacks of the aforementioned approaches, we advise using the endoscopic technique outlined in this study to repair orbital wall fractures via caruncular incision.\u003c/p\u003e \u003cp\u003eIdentifying the Honer's muscle is essential for transconjunctival endoscopic medial ocular blowout repair. The interlaminar space of the Honer's muscle can be directly accessed by severing the link between the lacrimal sac and the medial palpebral ligament. The lacrimal sac and medial palpebral ligament won't be harmed because this space can be naturally reached by the orbit medial wall. Following surgery, there will be a brief period of vertical diplopia if the trochlear nerve is injured. In addition, tissue separation must be done carefully and delicately to avoid any injuring the orbital periosteum. Handling the fat in the tiny operating space becomes troublesome once the orbital periosteum ruptures and the fat herniates, greatly increasing the difficulty of the surgery. Another significant anatomical site is the anterior ethmoidal artery. The link between the frontal bone and the ethmoid bone is going to be the frontal bone, and it will run between the anterior and posterior ethmoid arteries. The base of the skull will be reached by separating from the anterior ethmoidal artery. When the fracture area is large, special caution should be taken to locate this area on CT in order to prevent intraoperative invasion of the skull base(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBecause the inferior orbital wall is far away from the optic nerve, surgery is relatively secure. A transconjunctival incision was made, which involves cutting the conjunctiva from the inferior fornix, reaching the orbital septum, and finally arriving at the lower orbital rim. There was no face scar since all surgical procedures were taken out outside the periorbita itself. It is crucial to notice that the infraorbital nerve has an artery that runs from the infraorbital sulcus to the infraorbital canal. This artery should be electrocoagulated to separate rather than bluntly severed, as it will bleed severely if it ruptures. Additionally, the inferior orbital fissure must be clearly detected using an endoscope. If the suborbital fissure tissue is separated as the herniated tissue, this could result in loss of vision and a reduced view field. Furthermore, the jawbone is strong and substantial so that the posterior edge of the Medpor-Titanium sheet for the inferior orbital wall repair should be positioned on it(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the case of fractures of the medial and inferior walls, the fracture range is broader, the procedure is more complex, and we should avoid injuring the lower oblique muscle. The ethmoid-maxillary bone buttress (EMBB) should also be considered. Fractures involving the EMBB have some imaging features on CT: the \"plate bridge\" of the ethmomaxillary plate, which spans between the orbit and the nasal cavity and separates the ethmoidal sinus from the maxillary sinus, collapses, and the orbital cavity is significantly enlarged, the orbital content is herniated into the sinus cavity, and the enophthalmos is more obvious(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Rebuilding the corner structure connecting the medial and inferior walls can support the orbital contents, provide functional restoration, and keep the EMBB stable. Fractures involving EMBB require a repair material with greater flexibility and hardness(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Titanium mesh has high hardness, while high-density porous polyethylene has good histocompatibility and vascularization properties, Medpor-Titanium sheet (porous polyethylene Composite Titanium mesh) mixes the two materials to bring these properties together. Our clinical experience showed that Medpor-Titanium sheet can achieve good results in orbital fracture repairment(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInfraorbital nerve injury is most common in inferior orbital wall fractures (85%). The clinical symptoms are mostly paresthesia in the ipsilateral lower eyelid, nasal alar skin, upper lip skin, and mucous membrane. The following were the reasons: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Traumatic edema of peri-nerve tissue causes increased pressure in the infraorbital canal and severe nerve compression; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Orbital fractures including the infraorbital canal, infraorbital sulcus, and infraorbital foramen, which can directly compress and impair the nerve(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In our study, the incidence was 23.61%; 17 patients with facial paresthesia had a zygomaticomaxillary complex (ZMC) fracture and had maxillofacial repair surgery. After-surgery facial paresthesia is caused by swollen tissue pushing on the infraorbital nerve and normally disappears on its own within 1\u0026ndash;3 months.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEndoscopic technique has revolutionized orbital fracture repair. Direct view operation, good lighting, and high-definition photographs can clearly disclose the fracture extent, particularly the posterior boundary. Minimally invasive surgery avoids facial scarring and reduces orbital tissue damage, resulting in improved surgical outcomes and fewer complications. Endoscopic transconjunctival orbital blowout fracture treatment shifts the focus from functional to anatomic repair, making the procedure more precise and simpler.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Contribution Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization and writing original draft: [Yunyan Ye]; Data collection and prepare figures: [Feng Hu]; Project administration: [Qiao Kong]; Writing review \u0026amp; editing [Zhiguo li]. The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJordan DR, Mawn L, Klapper SR. Blowout fractures of the orbit. Smith and Nesi\u0026rsquo;s Ophthalmic Plastic and Reconstructive Surgery. 2021:1237-61.\u003c/li\u003e\n\u003cli\u003eOzturker C, Sari Y, Ozbilen KT, Ceylan NA, Tuncer S. Surgical repair of orbital blow-out fractures: outcomes and complications. Beyoglu Eye J. 2022;7(03):199-206.\u003c/li\u003e\n\u003cli\u003eKoryczan P, Zapała J, Gontarz M, Wyszyńska-Pawelec G. Comparison of the results of the treatment of enophthalmos in orbital blowout fracture in children/adolescents and adults. Dental and Medical Problems. 2021;58(2):179-86.\u003c/li\u003e\n\u003cli\u003eRajantie H, Kaukola L, Sn\u0026auml;ll J, Roine R, Sintonen H, Thor\u0026eacute;n H. Health-related quality of life in patients surgically treated for orbital blow-out fracture: a prospective study. Oral and Maxillofacial Surgery. 2021;25:373-82.\u003c/li\u003e\n\u003cli\u003eYamanaka Y, Watanabe A, Rajak SN, Nakayama T, Sotozono C. Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures. Graefe\u0026apos;s Archive for Clinical and Experimental Ophthalmology. 2022;260(1):319-25.\u003c/li\u003e\n\u003cli\u003eHomer N, Huggins A, Durairaj VD. Contemporary management of orbital blowout fractures. Current opinion in otolaryngology \u0026amp; head and neck surgery. 2019;27(4):310-6.\u003c/li\u003e\n\u003cli\u003ePark JH, Kim I, Son JH. Incidence and management of retrobulbar hemorrhage after blowout fracture repair. BMC ophthalmology. 2021;21:1-8.\u003c/li\u003e\n\u003cli\u003eGosau M, Sch\u0026ouml;neich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures\u0026mdash;complications, outcome, and review of literature. Clinical oral investigations. 2011;15:305-13.\u003c/li\u003e\n\u003cli\u003eHass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Ophthalmic Plastic \u0026amp; Reconstructive Surgery. 2004;20(6):426-32.\u003c/li\u003e\n\u003cli\u003eLozada KN, Cleveland PW, Smith JE, editors. Orbital trauma. Seminars in plastic surgery; 2019: Thieme Medical Publishers.\u003c/li\u003e\n\u003cli\u003eKono S, Vaidya A, Takahashi Y. Mechanisms of Development of Orbital Fractures: A Review. Ophthalmic Plastic \u0026amp; Reconstructive Surgery. 2023;39(6):542-7.\u003c/li\u003e\n\u003cli\u003eKhojastepour L, Moannaei M, Eftekharian H, Khaghaninejad M, Mahjoori-Ghasrodashti M, Tavanafar S. Prevalence and severity of orbital blowout fractures. British Journal of Oral and Maxillofacial Surgery. 2020;58(9):e93-e7.\u003c/li\u003e\n\u003cli\u003eBorstedt KJ, Alinasab B. The measurement of orbital blowout fractures cannot be made with geometric estimations. Otorhinolaryngol Neck Surg. 2019;4:1-6.\u003c/li\u003e\n\u003cli\u003eShim WS, Jung HJ. Management of Orbital Blowout Fractures: ENT Surgeon\u0026apos;s Perspective. Journal of Rhinology. 2019;26(2):65-74.\u003c/li\u003e\n\u003cli\u003eFelding UNA. Blowout fractures-clinic, imaging and applied anatomy of the orbit. Dan Med J. 2018;65(3):B5459.\u003c/li\u003e\n\u003cli\u003eGhosh SK, Narayan RK. Fractures involving bony orbit: A comprehensive review of relevant clinical anatomy. Translational Research in Anatomy. 2021;24:100125.\u003c/li\u003e\n\u003cli\u003eXu Q-H, Yu J-H, Wang Y-H, Wang A-A, Liao H-F. Analysis of the effect of repair materials for orbital blowout fracture on complications. International Journal of Ophthalmology. 2019;12(11):1746.\u003c/li\u003e\n\u003cli\u003eRath EM. Surgical treatment of maxillary nerve injuries: the infraorbital nerve. Atlas of the Oral and Maxillofacial Surgery Clinics. 2001;9(2):31-41.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endoscopic, Orbital Blowout Fracture, Medpor-Titanium.","lastPublishedDoi":"10.21203/rs.3.rs-3704126/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3704126/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThe purpose of this case series is to present the benefits and results of using a transconjunctival endoscopic technique to repair orbital blowout fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and methods:\u003c/strong\u003e In this retrospective interventional case series, 133 patients with ocular blowout fractures were enrolled. Between January 2021 and December 2022, these patients underwent transconjunctival orbital blowout fracture repair using an endoscopic technique and a Medpor-Titanium sheet implant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThis study included 133 individuals (135 eyes) with orbital blowout fractures, 129 of whom were adults and 4 of whom were pediatric patients. 63 eyes had medial wall fractures, 23 eyes had inferior wall fractures, and 49 eyes had both types of wall fractures. Preoperative eyeball enophthalmos was 2.33 mm on average. In 132 eyes, postoperative exophthalmia improved by ≥2 mm, while it improved by \u0026lt; 2 mm in 6 eyes. After surgery, 73 individuals' diplopia disappeared one month after surgery. 42 patients' facial paresthesia recovered one to three months following surgery. After a 6-month follow-up, 131 out of 133 cases had been cured, and 2 had improved. There was a 100% effective rate and a 95.56% cure rate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This article details the results and experience of using a transconjunctival endoscopic technique to repair orbital blowout fractures. The procedure is efficient in restoring orbital structure and improving visual function, and it has a low rate of postoperative complications.\u003c/p\u003e","manuscriptTitle":"The Outcomes of Orbital Blowout Fracture Repairment by Transconjunctival Endoscopic Technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-28 18:51:57","doi":"10.21203/rs.3.rs-3704126/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cafa7e9e-d709-44cb-a227-287a9180cbe9","owner":[],"postedDate":"February 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28930145,"name":"Health sciences/Diseases/Trauma"},{"id":28930146,"name":"Health sciences/Diseases/Eye diseases"}],"tags":[],"updatedAt":"2024-06-14T06:34:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-28 18:51:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3704126","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3704126","identity":"rs-3704126","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}