Three-dimensional virtual planning in orbital surgery enhances the accuracy of positioning prediction

Three-dimensional virtual planning in orbital surgery enhances the accuracy of positioning prediction | 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 Research Article Three-dimensional virtual planning in orbital surgery enhances the accuracy of positioning prediction Yulu Liu, Xiaohui Wang, Jing Wang, Cuixia Ma, Jie Chen, Yuxin Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7753120/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 Background The anatomical structure of the orbit is highly complex, with significant inter-individual variability, posing considerable challenges for surgical procedures. We utilized computer-assisted surgery (CAS) by importing CT scan data, constructing three-dimensional (3D) models, and optimizing surgical planning. Based on these models, we performed removal of intraorbital foreign bodies and orbital tumors. This study aims to evaluate the utility of virtual surgical planning (VSP) in preoperative assistance, with a particular focus on its effects on surgical predictability and accuracy. Methods Patients who underwent orbital surgery by a surgeon from July 2021 to April 2023 were included. Preoperative 3D modeling was performed using Mimics Medical 21.0 software to assist in the localization and surgical planning of intraorbital foreign bodies and orbital tumors. Results Of the 7 orbital surgeries that were performed with computer-aided technologies, 3 (43%) were performed to remove orbital foreign bodies and 4 (57%) were performed to remove orbital tumors. For all the operations, the application of preoperative CAS enhanced surgical efficiency and safety, leading to favorable outcomes. The use of CAS in preoperative planning for complex orbital surgeries significantly improved intraoperative precision and provided clinically relevant postoperative assessment. The accurate evaluation of tumor and foreign body location, as well as their relationship with surrounding soft tissues, made preoperative planning a crucial reference for intraoperative procedures. Conclusion CAS—particularly the preoperative phases of advanced diagnosis and VSP—offers substantial clinical benefits in managing orbital lesions, enhancing safety and accuracy without the need for costly intraoperative navigation. Computer-Assisted Surgery 3D Model Orbital Foreign Body Orbital Tumor Figures Figure 1 Figure 2 Figure 3 Background Orbital diseases encompass congenital defects, infections, inflammatory disorders, tumors (both benign and malignant), and traumatic injuries [ 1 ] . Based on their anatomical location, orbital lesions are generally categorized as either orbital wall lesions or orbital content lesions. Among them, an intraocular foreign body (IOFB) is a type of orbital content lesion that is complicated and severe ocular trauma, constituting 16.7% of all orbital injuries [ 2 ] . An IOFB is defined as a foreign body that is located in the orbital cavity, behind the orbital septum and the eyeball [ 3 ] ; moreover, due to its location, IOFBs frequently result in visual impairment and may cause damage to the globe, optic nerve, blood vessels, or extraocular muscles [ 4 ][ 5 ] . In addition, IOFBs can trigger chemical toxicity reactions, microbial infections, [ 6 ] and even invade extraorbital tissues, resulting in severe complications. Another clinically common orbital content lesion is the orbital tumor. These tumors may be benign or malignant and are typically associated with clinical manifestations such as proptosis, restricted ocular motility, diplopia, visual field defects, and optic nerve compression, potentially resulting in complete vision loss [ 7 ] . Orbital surgery is a highly complex procedure, with outcomes directly influencing patients' vision and quality of life. Postoperative complications frequently result from damage to peripheral soft tissues or nerves, largely due to the intricate anatomical structure of the orbit [ 8 ][ 9 ] . A major contributing factor is the inadequate localization accuracy during the preoperative and intraoperative stages, which significantly increases the risk and complexity of surgical interventions. In recent years, emerging intraoperative localization technologies, such as 3D navigation systems and endoscopy, have significantly improved surgical success rates and safety. Currently, surgeons commonly utilize innovative surgical and diagnostic tools, including surgical navigation and endoscopy, for the treatment of orbital fractures [ 10 ][ 11 ][ 12 ] . In addition, some preoperation plan analysis methods can also improve the accuracy of the surgery [ 13 ] . Although intraoperative localization is a commonly performed practice, preoperative diagnostic techniques are often underutilized. The following modalities are suitable for imaging the orbit and orbital contents: ultrasonography, magnetic resonance imaging(MRI), and two-dimensional (2D) or 3D radiologic imaging (e.g., radiographs or computed tomography [CT]) [ 14 ] . While ultrasound can detect orbital wall fractures, its sensitivity for orbital floor fractures remains limited [ 15 ] . Traditional imaging examinations such as CT and MRI can provide some diagnostic information, but for some complex cases, their diagnostic and localization precision are still limited. Several studies have shown that a complete preoperative evaluation can improve the surgical accuracy and success rate [ 16 ] . One of the most important challenges of orbital surgery is the lack of an accurate preoperative diagnosis. To solve this problem, there is a pressing need for further research to explore novel diagnostic approaches, enhance preoperative diagnostic precision, and facilitate more accurate surgical planning and intraoperative guidance. According to research, the CAS system with advanced 3D imaging diagnostic technology has been well applied in orthopedics [ 17 ] , but it has not been well popularized in ophthalmology. CAS is now an established adjunctive tool, widely used across various surgical specialties, particularly in head and neck surgery. It is a system in which hardware and software work cohesively to facilitate the merging of patients’ preoperative or intraoperative imaging data for three-dimensional localization of surgical instruments in real time [ 18 ] . CAS is widely available and intended to improve surgical accuracy to possibly shorten the operation time [ 19 ][ 20 ] . It is used for a variety of purposes, from trauma treatment to orthognathic surgery and pathological resection [ 21 ][ 22 ] . CAS can be divided into four steps [ 23 ] : 1. advanced diagnosis, 2. preoperative virtual planning (including the design of patient-specific implants), 3. intraoperative navigation, and 4. intraoperative and postoperative evaluation. However, the last two steps, intraoperative navigation and intraoperative and postoperative evaluations, require extremely expensive equipment, so the complete workflow of CAS is limited to well-equipped centers and is mainly used for complex surgeries. The first two steps are relatively easier to implement in hospitals of all levels. Advanced diagnosis: 3D imaging diagnostic technology is used in the first step. During the bone scanning phase, doctors use imaging techniques such as CT or MRI to scan the tissue and bones around the patient's orbit. These images are imported into computer programs to generate 3D models that clearly display the location of lesions or foreign objects. Preoperative virtual planning: In the virtual surgery planning stage, doctors can use 3D models to simulate virtual surgeries and determine the surgery plan based on the specific situation of the patient. Specifically, it allows the simulation of the surgical approach or is used to determine the size and position of the bone flap that needs to be removed based on 3D imaging, thereby laying the foundation for surgery. Existing literature on CAS predominantly emphasizes outcomes of the full CAS workflow [ 24 ][ 25 ][ 26 ] , including intraoperative navigation and postoperative evaluation. To the best of our knowledge, few studies have independently assessed the value of the preoperative phases—namely, advanced diagnosis and virtual planning. We hypothesize that preoperative virtual planning, even in the absence of intraoperative navigation, may still reduce the incidence of surgical complications, enhance accuracy and reliability, and facilitate postoperative recovery.This step may even be the most critical phase of the entire CAS workflow. As these initial steps are comparatively more accessible across a variety of clinical settings, this study specifically focuses on evaluating their clinical utility in orbital surgery. This study focuses on preoperative planning using CAS for the surgical removal of orbital masses and intraorbital foreign bodies. Preoperative CAS planning has the potential to enhance surgical precision and safety, while reducing operative duration and complication rates. Moreover, it assists clinicians in better understanding the lesion's characteristics and anatomical relationships, thereby facilitating the formulation of more informed and evidence-based surgical strategies. Materials and methods The anatomical structure of the orbit is highly complex, with significant inter-individual variability, posing considerable challenges for surgical procedures. This study aims to evaluate the utility of VSP in preoperative assistance, with a particular focus on its effects on surgical predictability and accuracy. This study was approved by the institutional review committee of the author's hospital. From July 2021 to April 2023, a total of 7 patients participated in this study. These patients underwent advanced diagnostic procedures and preoperative virtual planning, as well as orbital foreign body resection and orbital mass resection. All patients underwent preoperative CT to locate orbital foreign bodies or tumors, and the CT scans were collected by Siemens Sensation64 (Siemens Healthcare, Forchheim, Germany). The data were obtained from the Radiology Department at The Second Affiliated Hospital of Anhui Medical University. The scanning parameters were as follows: slice collimation 20x0.6 mm, 0.75 mm slice thickness, 0.4 mm slice increment, 512x512 matrix, 120 kV, 350 mAs, spacing 0.85, FOV 30 cm, hard tissue convolution core H70s and window W1600L400. Then, MIMICS software was used to carry out 3D modeling. MIMICS is a highly integrated and easy-to-use 3D image generation and editing processing software. It allows the input of various scanned data (CT, MRI) to establish 3D models for editing, and can output general computer-aided design (CAD), finite element analysis (FEA), and rapid prototyping (RP) formats. It can conduct large-scale data conversion processing on a personal computer. The MIMICS FEA module can quickly process the scanned input data and output the corresponding file format for FEA and computational fluid dynamics (CFD). Users can use the scanned data to establish 3D models and then mesh the surface for application in FEA analysis. The mesh redivision function in the FEA module optimizes the input data of FEA to the maximum extent. Based on the Heinz unit of the scan data, the volume mesh can be assigned materials. The preoperative plan was implemented by the senior operator using MIMICS 3D image generation and editing processing software, and the three-dimensional spatial relationship between the foreign body and tumor and the surrounding anatomical structure was dynamically displayed on full 360-degree visual enhanced CT, from the superficial skin, superficial blood vessels, superficial lymph nodes, muscles and tendons to the deep blood vessels and bones. Result From July 2021 to April 2023, CAS technology was applied in orbital surgeries for seven patients. Among them, 4 (57%) underwent orbital tumor resection, and 3 (43%) underwent orbital foreign body resection. It was primarily utilized during the preoperative planning stage to identify the location of intraorbital lesions and to guide the design of lateral orbital bone flap approaches. All procedures were successfully completed, and the application of CAS was associated with favorable outcomes. All lesions were successfully excised without significant intraoperative or postoperative complications. Representative cases are presented to illustrate the clinical application of CAS (Table 1 ). Table 1 Utility of CAS systems in preoperative planning for orbital surgery for the 7 reviewed cases. Indication Pre-operative planning Description Intraorbital foreign bodies n = 6 Orbital Tumors Orbitotomy Position of lateral orbital incision bone flap Pleomorphic adenom Left eye:0.15/0.2 11mm/13mm Dermoid cyst Right eye:0.4/0.4 21mm/15mm schwannoma Right eye:0.4/0.4 21mm/15mm schwannoma Right eye:0.6/0.8 21mm/15mm Removal of orbital foreign body Identification of dangerous areas Intraorbital foreign bodies Left eye:HM/HM / Left eye:0.8/1.0 / Left eye:0.8/1.0 / Removal of orbital foreign body A 40-year-old woman presented with an intraorbital foreign body due to trauma. The CT scan showed a high density shadow on the posterior wall of the right eyeball with gas accumulation, suggesting the presence of intraocular foreign bodies (Fig. 1 a,b).However, no foreign body was identified during the initial intraoperative exploration. Subsequently, 3D reconstruction using MIMICS software enabled precise identification of a foreign object located posterior to the right globe. The model provided accurate visualization of its size, depth, and anatomical relationship to adjacent structures, facilitating successful reoperation and foreign body removal (Fig. 1 c,d). A 38-year-old male was diagnosed with a metallic foreign body in the left orbit after trauma. The CT scan that was taken at the local hospital showed a foreign body in the left eye orbit (Fig. 2 d). However, 3D reconstruction using MIMICS revealed that the object had penetrated the orbital margin and extended into the nasal sinuses (Fig. 2 a,b,c). Intraoperatively, the foreign body was identified as a nail-shaped object with a plastic head and metallic body. The 3D model proved essential in delineating the object’s path and extent, guiding the surgical approach. Orbital tumor resection The patient is a 55-year-old male who was admitted due to right eye protrusion for over 10 years. After examination, the patient's right eye protrusion was 24 millimeters. A CT orbital plain scan shows a mass in the right posterior cone of the eyeball(Fig. 3 a). After using 3D imaging, the anatomical relationship between the tumor and the orbit was clearly displayed(Fig. 3 b,c,d). Based on virtual planning, a lateral orbital approach was selected. The surgery was completed in 49 minutes without complications, and the patient achieved satisfactory postoperative recovery. Discussion CAS has demonstrated significant clinical utility, even when limited to its first two components—advanced diagnosis and preoperative virtual planning. Advanced diagnosis gives surgeons the opportunity to perform a volume analysis, examine the unaffected side, analyze the size and extent of foreign bodies and tumors, compare several anatomical markers, and measure the angle to be a virtual guide during surgery [ 27 ] . VSP allows early feasibility assessments and precise localization of intraorbital lesions, facilitating surgical exploration. In the past few years, CAS has become a powerful auxiliary tool for neurosurgery and sinus surgery [ 28 ] and has shown significant effectiveness in orbital surgery. In this study, the first two steps of CAS were implemented in 7 patients who were undergoing orbital surgery. The technology offered diagnostic tools (e.g. volumetric analysis, mirroring) and comprehensive anatomical visualization for surgical preparation. Among them, advanced diagnosis relies on 3D imaging technology to clearly display the anatomical relationship between the tumor or foreign object and the eyeball, orbital wall, and surrounding tissues, nerves, and blood vessels. Preoperative virtual planning uses 3D imaging to predetermine the location of surgical incisions. For example, the surgical incision position of Qu'er's orbital foreign body or the lateral opening range of the orbital mass can be simulated in a 3D imaging model, which greatly facilitates the ophthalmologic preoperative evaluation of patients.Surgeons could conduct multiple virtual simulations to reconstruct the target anatomy accurately. In addition to clinical applications, VSP also holds substantial educational and research value. 3D models provide an intuitive and dynamic learning tool for medical education. In clinical teaching, instructors can rotate and layer models to explain anatomical relationships and surgical approaches. For instance, case models from this study were used to simulate key procedures such as incision selection and the extend of lesion resection, enabling trainees to gain experience through repeated virtual planning exercises. This supports its efficiency in skill acquisition. For residents, it enhances learning experiences, while experienced surgeons can use VSP to anticipate intraoperative challenges and prepare contingency plans. In complex cases, tools like mirroring can clarify anatomical asymmetries and assist in designing patient-specific implants [ 21 ][ 29 ] . Notably, VSP is highly feasible in resource-limited environments. It requires only conventional CT or MRI data and 3D modeling software. Several software platforms—including Mimics and open-source tools such as 3D Slicer or ITK-SNAP—offer accessible, user-friendly interfaces and are operable on standard computers without the need for high-end workstations. This lowers the technical barrier for implementation in lower-tier medical institutions and facilitates its broader dissemination. Additionally, VSP can aid clinical decision-making by helping determine which cases warrant referral to specialized tertiary care centers. The preoperative planning software is both cost-effective and accessible for clinics with limited infrastructure. If virtual planning enhances surgical predictability and reliability, the necessity of navigation-assisted surgery may be reduced in select cases. The absence of navigation systems eliminates the need for costly hardware, specialized scanning protocols with fiducial markers, and skull-mounted receiver calibration. CAS has also shown promise in other orbital procedures, including orbital decompression for thyroid-associated ophthalmopathy and reconstruction following orbital fractures. These applications highlight the versatility of CAS in complex orbital surgeries. This is consistent with previous studies, which have proven the role of CAS in orbital reconstruction and orbital decompression for patients with thyroid ophthalmopathy [ 30 ] . CAS is particularly useful in orbital surgery involving orbital bone because it will not move during surgery, so it has better positioning. The use of 3D reconstruction technology has enhanced the precision and scientific basis of modern surgical practice. It is particularly beneficial in clinical education, enabling junior clinicians and medical trainees to better visualize anatomical structures and surgical strategies. Patients also benefit from improved understanding of their conditions through intuitive 3D visualization. From a precision medicine perspective, incorporating an additional verification modality can further improve surgical accuracy. Preoperative 3D models serve as effective communication tools, allowing surgeons to clearly explain the planned procedure and potential intraoperative complications to patients and their families. This technology facilitates surgical planning and reduces the risk of misdiagnosis and missed diagnoses. Patients with orbital foreign bodies are particularly vulnerable to diagnostic errors when foreign objects are small and situated adjacent to the scleral wall, where conventional CT planes offer limited spatial resolution. In such cases, 3D imaging provides enhanced diagnostic accuracy, enabling timely and appropriate surgical intervention. Although the initial stages of CAS are relatively cost-effective and accessible, they still require specialized training to be implemented effectively. In this study, intraoperative navigation and postoperative evaluation—the latter two stages of CAS—were not employed, although prior research has demonstrated their clinical value.A significant limitation of CAS lies in its reliance on static virtual models, which do not account for soft tissue dynamics during surgery. Surgical manipulation can shift intraorbital tissues, altering the anatomy. Even a simple marginotomy may reduce accuracy due to soft tissue displacement after orbital rim removal [ 31 ] .Therefore, the benefits of intraoperative navigation and postoperative assessments warrant further evaluation. Three-dimensional modeling facilitates precise localization and characterization of orbital foreign bodies, enabling optimized surgical planning that minimizes damage to healthy tissues and enhances both safety and success rates. In the context of orbital tumors, preoperative 3D visualization provides detailed insights into the size, position, and anatomical relationships of the lesion, supporting more effective surgical strategy formulation and execution. However, this study has limitations. The sample size was small, and no control group was included for direct comparison. Additionally, soft tissue dynamics were not fully accounted for in the models, which may affect intraoperative accuracy. Future multicenter studies with larger cohorts and integration of artificial intelligence-assisted planning are warranted. CAS enhances surgeons’ understanding of orbital anatomy and anticipated intraoperative challenges, thereby improving surgical precision and safety. However, these technologies are not substitutes for clinical expertise. CAS still requires the oversight and judgment of skilled surgeons; thus, clinical decision-making ultimately remains in the hands of experienced professionals. In summary, as demonstrated in this study, CAS holds substantial practical value in the management of diverse orbital pathologies. With ongoing technological advancements, CAS is expected to further enhance surgical precision and improve patient outcomes. Conclusion In conclusion, CAS—particularly the preoperative components of advanced diagnosis and virtual surgical planning—offers substantial benefits in the management of orbital lesions. By enabling accurate visualization of intraorbital foreign bodies and tumors, CAS facilitates tailored surgical planning, minimizes operative risks, and contributes to more favorable clinical outcomes. In addition to its clinical utility, CAS serves as a valuable educational and decision-making tool, especially in resource-limited settings. However, clinical expertise remains indispensable and cannot be replaced by technology. With continued technological advancement and wider software accessibility, CAS is expected to further enhance surgical precision and patient care in orbital surgery. Abbreviations CAS computer-assisted surgery 3D three-dimensional VSP virtual surgical planning IOFB intraocular foreign body MRI magnetic resonance imaging 2D two-dimensional CT computed tomography CAD computer-aided design FEA finite element analysis RP rapid prototyping CFD computational fluid dynamics Declarations Conflicts of interest: The authors have no relevant financial or non-financial interests to disclose. Ethics approval and consent to participate: Approved by the Institutional Review Committee of the Second Affiliated Hospital of Anhui Medical University. Written informed consent was obtained from all participants. Consent for publication: Obtained from all patients included in this study. Funding: This work was supported by the Research Fund of Anhui Institute of Translational Medicine (2022zhyx-C73) and Anhui Provincial Higher Education Institutions Provincial Quality Engineering Project (2022xjzlts017). Author Contribution LYL conceived and designed the study, performed data collection and analysis, and drafted the manuscript. WXH contributed to study design and critically revised the manuscript. WJ provided clinical data and patient recruitment. MCX supervised the study process and provided revisions. CJ assisted in methodology and critical review. XYX supervised the overall study and approved the final manuscript. All authors read and approved the final version. Acknowledgements: Not applicable Data Availability Data are available from the corresponding author upon reasonable request. References Oles K, et al. IgG4-related inflammatory orbital pseudotumors - a retrospective case series. Folia Neuropathol. 2015;53(2):111–20. Gonullu ME. 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16:05:13","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76683,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7753120/v1/1b556e448949b9ccede7842f.html"},{"id":96454334,"identity":"5d89e1b6-784b-4356-9c07-85350f19c997","added_by":"auto","created_at":"2025-11-21 10:02:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":648103,"visible":true,"origin":"","legend":"\u003cp\u003eThree-dimensional reconstruction model of orbital foreign body\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7753120/v1/691ae50f9e124084c4a06aee.png"},{"id":96400422,"identity":"61e367b2-9a03-42b0-8857-570fde29b801","added_by":"auto","created_at":"2025-11-20 16:05:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":667170,"visible":true,"origin":"","legend":"\u003cp\u003eThree-dimensional reconstruction model of an orbital metallic foreign body\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7753120/v1/9a033d6038f8bc2427072cd8.png"},{"id":96453787,"identity":"8a851b50-9057-4bc2-b28b-310127f54d80","added_by":"auto","created_at":"2025-11-21 10:01:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":671837,"visible":true,"origin":"","legend":"\u003cp\u003eThree-dimensional reconstruction model of orbital tumor\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7753120/v1/50972652c252dd646c1db00c.png"},{"id":98204225,"identity":"145d7f5f-5b34-4357-a6fa-9ed84ae21228","added_by":"auto","created_at":"2025-12-15 08:25:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3430549,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7753120/v1/7e071a7f-8625-4c09-8573-4deaa95514e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThree-dimensional virtual planning in orbital surgery enhances the accuracy of positioning prediction\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eOrbital diseases encompass congenital defects, infections, inflammatory disorders, tumors (both benign and malignant), and traumatic injuries\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Based on their anatomical location, orbital lesions are generally categorized as either orbital wall lesions or orbital content lesions.\u003c/p\u003e\u003cp\u003eAmong them, an intraocular foreign body (IOFB) is a type of orbital content lesion that is complicated and severe ocular trauma, constituting 16.7% of all orbital injuries\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. An IOFB is defined as a foreign body that is located in the orbital cavity, behind the orbital septum and the eyeball\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e; moreover, due to its location, IOFBs frequently result in visual impairment and may cause damage to the globe, optic nerve, blood vessels, or extraocular muscles\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. In addition, IOFBs can trigger chemical toxicity reactions, microbial infections,\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and even invade extraorbital tissues, resulting in severe complications.\u003c/p\u003e\u003cp\u003eAnother clinically common orbital content lesion is the orbital tumor. These tumors may be benign or malignant and are typically associated with clinical manifestations such as proptosis, restricted ocular motility, diplopia, visual field defects, and optic nerve compression, potentially resulting in complete vision loss\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOrbital surgery is a highly complex procedure, with outcomes directly influencing patients' vision and quality of life. Postoperative complications frequently result from damage to peripheral soft tissues or nerves, largely due to the intricate anatomical structure of the orbit\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. A major contributing factor is the inadequate localization accuracy during the preoperative and intraoperative stages, which significantly increases the risk and complexity of surgical interventions.\u003c/p\u003e\u003cp\u003eIn recent years, emerging intraoperative localization technologies, such as 3D navigation systems and endoscopy, have significantly improved surgical success rates and safety. Currently, surgeons commonly utilize innovative surgical and diagnostic tools, including surgical navigation and endoscopy, for the treatment of orbital fractures\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. In addition, some preoperation plan analysis methods can also improve the accuracy of the surgery\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAlthough intraoperative localization is a commonly performed practice, preoperative diagnostic techniques are often underutilized. The following modalities are suitable for imaging the orbit and orbital contents: ultrasonography, magnetic resonance imaging(MRI), and two-dimensional (2D) or 3D radiologic imaging (e.g., radiographs or computed tomography [CT])\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. While ultrasound can detect orbital wall fractures, its sensitivity for orbital floor fractures remains limited\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Traditional imaging examinations such as CT and MRI can provide some diagnostic information, but for some complex cases, their diagnostic and localization precision are still limited. Several studies have shown that a complete preoperative evaluation can improve the surgical accuracy and success rate\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOne of the most important challenges of orbital surgery is the lack of an accurate preoperative diagnosis. To solve this problem, there is a pressing need for further research to explore novel diagnostic approaches, enhance preoperative diagnostic precision, and facilitate more accurate surgical planning and intraoperative guidance. According to research, the CAS system with advanced 3D imaging diagnostic technology has been well applied in orthopedics\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, but it has not been well popularized in ophthalmology.\u003c/p\u003e\u003cp\u003eCAS is now an established adjunctive tool, widely used across various surgical specialties, particularly in head and neck surgery. It is a system in which hardware and software work cohesively to facilitate the merging of patients\u0026rsquo; preoperative or intraoperative imaging data for three-dimensional localization of surgical instruments in real time\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCAS is widely available and intended to improve surgical accuracy to possibly shorten the operation time\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. It is used for a variety of purposes, from trauma treatment to orthognathic surgery and pathological resection\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. CAS can be divided into four steps\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e: 1. advanced diagnosis, 2. preoperative virtual planning (including the design of patient-specific implants), 3. intraoperative navigation, and 4. intraoperative and postoperative evaluation. However, the last two steps, intraoperative navigation and intraoperative and postoperative evaluations, require extremely expensive equipment, so the complete workflow of CAS is limited to well-equipped centers and is mainly used for complex surgeries. The first two steps are relatively easier to implement in hospitals of all levels.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAdvanced diagnosis: 3D imaging diagnostic technology is used in the first step. During the bone scanning phase, doctors use imaging techniques such as CT or MRI to scan the tissue and bones around the patient's orbit. These images are imported into computer programs to generate 3D models that clearly display the location of lesions or foreign objects.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePreoperative virtual planning: In the virtual surgery planning stage, doctors can use 3D models to simulate virtual surgeries and determine the surgery plan based on the specific situation of the patient. Specifically, it allows the simulation of the surgical approach or is used to determine the size and position of the bone flap that needs to be removed based on 3D imaging, thereby laying the foundation for surgery.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eExisting literature on CAS predominantly emphasizes outcomes of the full CAS workflow\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e][\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e, including intraoperative navigation and postoperative evaluation. To the best of our knowledge, few studies have independently assessed the value of the preoperative phases\u0026mdash;namely, advanced diagnosis and virtual planning. We hypothesize that preoperative virtual planning, even in the absence of intraoperative navigation, may still reduce the incidence of surgical complications, enhance accuracy and reliability, and facilitate postoperative recovery.This step may even be the most critical phase of the entire CAS workflow. As these initial steps are comparatively more accessible across a variety of clinical settings, this study specifically focuses on evaluating their clinical utility in orbital surgery.\u003c/p\u003e\u003cp\u003eThis study focuses on preoperative planning using CAS for the surgical removal of orbital masses and intraorbital foreign bodies. Preoperative CAS planning has the potential to enhance surgical precision and safety, while reducing operative duration and complication rates. Moreover, it assists clinicians in better understanding the lesion's characteristics and anatomical relationships, thereby facilitating the formulation of more informed and evidence-based surgical strategies.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThe anatomical structure of the orbit is highly complex, with significant inter-individual variability, posing considerable challenges for surgical procedures. This study aims to evaluate the utility of VSP in preoperative assistance, with a particular focus on its effects on surgical predictability and accuracy.\u003c/p\u003e\u003cp\u003eThis study was approved by the institutional review committee of the author's hospital. From July 2021 to April 2023, a total of 7 patients participated in this study. These patients underwent advanced diagnostic procedures and preoperative virtual planning, as well as orbital foreign body resection and orbital mass resection.\u003c/p\u003e\u003cp\u003eAll patients underwent preoperative CT to locate orbital foreign bodies or tumors, and the CT scans were collected by Siemens Sensation64 (Siemens Healthcare, Forchheim, Germany). The data were obtained from the Radiology Department at The Second Affiliated Hospital of Anhui Medical University. The scanning parameters were as follows: slice collimation 20x0.6 mm, 0.75 mm slice thickness, 0.4 mm slice increment, 512x512 matrix, 120 kV, 350 mAs, spacing 0.85, FOV 30 cm, hard tissue convolution core H70s and window W1600L400. Then, MIMICS software was used to carry out 3D modeling. MIMICS is a highly integrated and easy-to-use 3D image generation and editing processing software. It allows the input of various scanned data (CT, MRI) to establish 3D models for editing, and can output general computer-aided design (CAD), finite element analysis (FEA), and rapid prototyping (RP) formats. It can conduct large-scale data conversion processing on a personal computer. The MIMICS FEA module can quickly process the scanned input data and output the corresponding file format for FEA and computational fluid dynamics (CFD). Users can use the scanned data to establish 3D models and then mesh the surface for application in FEA analysis. The mesh redivision function in the FEA module optimizes the input data of FEA to the maximum extent. Based on the Heinz unit of the scan data, the volume mesh can be assigned materials.\u003c/p\u003e\u003cp\u003eThe preoperative plan was implemented by the senior operator using MIMICS 3D image generation and editing processing software, and the three-dimensional spatial relationship between the foreign body and tumor and the surrounding anatomical structure was dynamically displayed on full 360-degree visual enhanced CT, from the superficial skin, superficial blood vessels, superficial lymph nodes, muscles and tendons to the deep blood vessels and bones.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eFrom July 2021 to April 2023, CAS technology was applied in orbital surgeries for seven patients. Among them, 4 (57%) underwent orbital tumor resection, and 3 (43%) underwent orbital foreign body resection. It was primarily utilized during the preoperative planning stage to identify the location of intraorbital lesions and to guide the design of lateral orbital bone flap approaches. All procedures were successfully completed, and the application of CAS was associated with favorable outcomes. All lesions were successfully excised without significant intraoperative or postoperative complications. Representative cases are presented to illustrate the clinical application of CAS (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUtility of CAS systems in preoperative planning for orbital surgery for the 7 reviewed cases.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-operative planning\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntraorbital foreign bodies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003en = 6\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eOrbital Tumors Orbitotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePosition of lateral orbital incision bone flap\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePleomorphic adenom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft eye:0.15/0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11mm/13mm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDermoid cyst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight eye:0.4/0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21mm/15mm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eschwannoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight eye:0.4/0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21mm/15mm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eschwannoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRight eye:0.6/0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21mm/15mm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eRemoval of orbital foreign body\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIdentification of dangerous areas\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIntraorbital foreign bodies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft eye:HM/HM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft eye:0.8/1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLeft eye:0.8/1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch3\u003eRemoval of orbital foreign body\u003c/h3\u003e\u003cp\u003eA 40-year-old woman presented with an intraorbital foreign body due to trauma. The CT scan showed a high density shadow on the posterior wall of the right eyeball with gas accumulation, suggesting the presence of intraocular foreign bodies (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea,b).However, no foreign body was identified during the initial intraoperative exploration. Subsequently, 3D reconstruction using MIMICS software enabled precise identification of a foreign object located posterior to the right globe. The model provided accurate visualization of its size, depth, and anatomical relationship to adjacent structures, facilitating successful reoperation and foreign body removal (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec,d).\u003c/p\u003e\u003cp\u003eA 38-year-old male was diagnosed with a metallic foreign body in the left orbit after trauma. The CT scan that was taken at the local hospital showed a foreign body in the left eye orbit (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). However, 3D reconstruction using MIMICS revealed that the object had penetrated the orbital margin and extended into the nasal sinuses (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea,b,c). Intraoperatively, the foreign body was identified as a nail-shaped object with a plastic head and metallic body. The 3D model proved essential in delineating the object’s path and extent, guiding the surgical approach.\u003c/p\u003e\u003ch3\u003eOrbital tumor resection\u003c/h3\u003e\u003cp\u003eThe patient is a 55-year-old male who was admitted due to right eye protrusion for over 10 years. After examination, the patient's right eye protrusion was 24 millimeters. A CT orbital plain scan shows a mass in the right posterior cone of the eyeball(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). After using 3D imaging, the anatomical relationship between the tumor and the orbit was clearly displayed(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb,c,d). Based on virtual planning, a lateral orbital approach was selected. The surgery was completed in 49 minutes without complications, and the patient achieved satisfactory postoperative recovery.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCAS has demonstrated significant clinical utility, even when limited to its first two components\u0026mdash;advanced diagnosis and preoperative virtual planning. Advanced diagnosis gives surgeons the opportunity to perform a volume analysis, examine the unaffected side, analyze the size and extent of foreign bodies and tumors, compare several anatomical markers, and measure the angle to be a virtual guide during surgery\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. VSP allows early feasibility assessments and precise localization of intraorbital lesions, facilitating surgical exploration.\u003c/p\u003e\u003cp\u003eIn the past few years, CAS has become a powerful auxiliary tool for neurosurgery and sinus surgery\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e and has shown significant effectiveness in orbital surgery. In this study, the first two steps of CAS were implemented in 7 patients who were undergoing orbital surgery. The technology offered diagnostic tools (e.g. volumetric analysis, mirroring) and comprehensive anatomical visualization for surgical preparation. Among them, advanced diagnosis relies on 3D imaging technology to clearly display the anatomical relationship between the tumor or foreign object and the eyeball, orbital wall, and surrounding tissues, nerves, and blood vessels. Preoperative virtual planning uses 3D imaging to predetermine the location of surgical incisions. For example, the surgical incision position of Qu'er's orbital foreign body or the lateral opening range of the orbital mass can be simulated in a 3D imaging model, which greatly facilitates the ophthalmologic preoperative evaluation of patients.Surgeons could conduct multiple virtual simulations to reconstruct the target anatomy accurately.\u003c/p\u003e\u003cp\u003eIn addition to clinical applications, VSP also holds substantial educational and research value. 3D models provide an intuitive and dynamic learning tool for medical education. In clinical teaching, instructors can rotate and layer models to explain anatomical relationships and surgical approaches. For instance, case models from this study were used to simulate key procedures such as incision selection and the extend of lesion resection, enabling trainees to gain experience through repeated virtual planning exercises. This supports its efficiency in skill acquisition. For residents, it enhances learning experiences, while experienced surgeons can use VSP to anticipate intraoperative challenges and prepare contingency plans. In complex cases, tools like mirroring can clarify anatomical asymmetries and assist in designing patient-specific implants\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eNotably, VSP is highly feasible in resource-limited environments. It requires only conventional CT or MRI data and 3D modeling software. Several software platforms\u0026mdash;including Mimics and open-source tools such as 3D Slicer or ITK-SNAP\u0026mdash;offer accessible, user-friendly interfaces and are operable on standard computers without the need for high-end workstations. This lowers the technical barrier for implementation in lower-tier medical institutions and facilitates its broader dissemination.\u003c/p\u003e\u003cp\u003eAdditionally, VSP can aid clinical decision-making by helping determine which cases warrant referral to specialized tertiary care centers. The preoperative planning software is both cost-effective and accessible for clinics with limited infrastructure. If virtual planning enhances surgical predictability and reliability, the necessity of navigation-assisted surgery may be reduced in select cases. The absence of navigation systems eliminates the need for costly hardware, specialized scanning protocols with fiducial markers, and skull-mounted receiver calibration.\u003c/p\u003e\u003cp\u003eCAS has also shown promise in other orbital procedures, including orbital decompression for thyroid-associated ophthalmopathy and reconstruction following orbital fractures. These applications highlight the versatility of CAS in complex orbital surgeries. This is consistent with previous studies, which have proven the role of CAS in orbital reconstruction and orbital decompression for patients with thyroid ophthalmopathy\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. CAS is particularly useful in orbital surgery involving orbital bone because it will not move during surgery, so it has better positioning.\u003c/p\u003e\u003cp\u003eThe use of 3D reconstruction technology has enhanced the precision and scientific basis of modern surgical practice. It is particularly beneficial in clinical education, enabling junior clinicians and medical trainees to better visualize anatomical structures and surgical strategies. Patients also benefit from improved understanding of their conditions through intuitive 3D visualization. From a precision medicine perspective, incorporating an additional verification modality can further improve surgical accuracy. Preoperative 3D models serve as effective communication tools, allowing surgeons to clearly explain the planned procedure and potential intraoperative complications to patients and their families.\u003c/p\u003e\u003cp\u003eThis technology facilitates surgical planning and reduces the risk of misdiagnosis and missed diagnoses. Patients with orbital foreign bodies are particularly vulnerable to diagnostic errors when foreign objects are small and situated adjacent to the scleral wall, where conventional CT planes offer limited spatial resolution. In such cases, 3D imaging provides enhanced diagnostic accuracy, enabling timely and appropriate surgical intervention.\u003c/p\u003e\u003cp\u003eAlthough the initial stages of CAS are relatively cost-effective and accessible, they still require specialized training to be implemented effectively. In this study, intraoperative navigation and postoperative evaluation\u0026mdash;the latter two stages of CAS\u0026mdash;were not employed, although prior research has demonstrated their clinical value.A significant limitation of CAS lies in its reliance on static virtual models, which do not account for soft tissue dynamics during surgery. Surgical manipulation can shift intraorbital tissues, altering the anatomy. Even a simple marginotomy may reduce accuracy due to soft tissue displacement after orbital rim removal\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e.Therefore, the benefits of intraoperative navigation and postoperative assessments warrant further evaluation.\u003c/p\u003e\u003cp\u003eThree-dimensional modeling facilitates precise localization and characterization of orbital foreign bodies, enabling optimized surgical planning that minimizes damage to healthy tissues and enhances both safety and success rates. In the context of orbital tumors, preoperative 3D visualization provides detailed insights into the size, position, and anatomical relationships of the lesion, supporting more effective surgical strategy formulation and execution.\u003c/p\u003e\u003cp\u003eHowever, this study has limitations. The sample size was small, and no control group was included for direct comparison. Additionally, soft tissue dynamics were not fully accounted for in the models, which may affect intraoperative accuracy. Future multicenter studies with larger cohorts and integration of artificial intelligence-assisted planning are warranted.\u003c/p\u003e\u003cp\u003eCAS enhances surgeons\u0026rsquo; understanding of orbital anatomy and anticipated intraoperative challenges, thereby improving surgical precision and safety. However, these technologies are not substitutes for clinical expertise. CAS still requires the oversight and judgment of skilled surgeons; thus, clinical decision-making ultimately remains in the hands of experienced professionals.\u003c/p\u003e\u003cp\u003eIn summary, as demonstrated in this study, CAS holds substantial practical value in the management of diverse orbital pathologies. With ongoing technological advancements, CAS is expected to further enhance surgical precision and improve patient outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, CAS\u0026mdash;particularly the preoperative components of advanced diagnosis and virtual surgical planning\u0026mdash;offers substantial benefits in the management of orbital lesions. By enabling accurate visualization of intraorbital foreign bodies and tumors, CAS facilitates tailored surgical planning, minimizes operative risks, and contributes to more favorable clinical outcomes. In addition to its clinical utility, CAS serves as a valuable educational and decision-making tool, especially in resource-limited settings. However, clinical expertise remains indispensable and cannot be replaced by technology. With continued technological advancement and wider software accessibility, CAS is expected to further enhance surgical precision and patient care in orbital surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputer-assisted surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e3D\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ethree-dimensional\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVSP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003evirtual surgical planning\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIOFB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eintraocular foreign body\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e2D\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003etwo-dimensional\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCAD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputer-aided design\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFEA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003efinite element analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003erapid prototyping\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCFD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputational fluid dynamics\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cp\u003eApproved by the Institutional Review Committee of the Second Affiliated Hospital of Anhui Medical University. Written informed consent was obtained from all participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eObtained from all patients included in this study.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis work was supported by the Research Fund of Anhui Institute of Translational Medicine (2022zhyx-C73) and Anhui Provincial Higher Education Institutions Provincial Quality Engineering Project (2022xjzlts017).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLYL conceived and designed the study, performed data collection and analysis, and drafted the manuscript. WXH contributed to study design and critically revised the manuscript. WJ provided clinical data and patient recruitment. MCX supervised the study process and provided revisions. CJ assisted in methodology and critical review. XYX supervised the overall study and approved the final manuscript. All authors read and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOles K, et al. IgG4-related inflammatory orbital pseudotumors - a retrospective case series. Folia Neuropathol. 2015;53(2):111\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGonullu ME. The Surgical Strategy for the Intraorbital Foreign Bodies. J Craniofac Surg. 2016;7(27):1785\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSzabo B. Intraorbital Penetrating and Retained Foreign Bodies - A Neurosurgical Case Series. Turk Neurosurg. 2019;4(29):538\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrewal AM, et al. Long-term ophthalmic anatomical and functional outcomes after surgical removal of intraorbital foreign bodies. Eur J Ophthalmol. 2021;31(1):263\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim YH, Kim H, Yoon ES. Unrecognized intraorbital wooden foreign body. Arch Craniofac Surg. 2018;19(4):300\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCho W, et al. Orbital and Orbitocranial Trauma From Pencil Fragments: Role of Timely Diagnosis and Management. Am J Ophthalmol. 2017;180:46\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePfortner R, et al. Orbital tumors: operative and therapeutic strategies. Facial Plast Surg. 2014;30(5):570\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrucoli M, et al. Analysis of complications after surgical repair of orbital fractures. J Craniofac Surg. 2011;22(4):1387\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu SR, et al. Postoperative Improvement of Diplopia and Extraocular Muscle Movement in Patients With Reconstructive Surgeries for Orbital Floor Fractures. J Craniofac Surg. 2016;27(8):2043\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarkiewicz MR. Does intraoperative navigation restore orbital dimensions in traumatic and post-ablative defects༟. J Craniomaxillofac Surg. 2012;2(40):142\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCai EZ. Computer-assisted navigational surgery improves outcomes in orbital reconstructive surgery. J Craniofac Surg. 2012;5(23):1567\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDubois L, J.J.S.R.. Predictability in orbital reconstruction: A human cadaver study. Part I: Endoscopic-assisted orbital reconstruction. J Craniomaxillofac Surg. 2015;10(43):2034\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePagnoni M, et al. Late treatment of orbital fractures: a new analysis for surgical planning. Acta Otorhinolaryngol Ital. 2014;34(6):439\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChazen JL, et al. Orbital Soft-Tissue Trauma. Neuroimaging Clin N Am. 2014;24(3):425\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePruksapong C, Wongprakob N, Panphichet M. Accuracy of linear-probe ultrasonography in diagnosis of infraorbital rim fractures. Crit Ultrasound J. 2023;15(1):9\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKeating TC, Jacobs JJ. Augmented Reality in Orthopedic Practice and Education. Orthop Clin North Am. 2021;52(1):15\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHussain A. Perceptions and use of computer-assisted surgery (CAS) in the orbit. Orbit. 2019;3(38):180\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSie\u0026szlig;egger M, et al. Image guided surgical navigation for removal of foreign bodies in the head and neck. J Cranio-Maxillofacial Surg. 2001;29(6):321\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDubois L, et al. Predictability in orbital reconstruction. A human cadaver study, part III: Implant-oriented navigation for optimized reconstruction. J Cranio-Maxillofacial Surg. 2015;43(10):2050\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRana M, et al. 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J Ophthalmol, 2021. 2021: p. 6691203.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGander T, et al. Patient specific implants (PSI) in reconstruction of orbital floor and wall fractures. J Cranio-Maxillofacial Surg. 2015;43(1):126\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrevost A, et al. Outcomes of orbital decompression using surgical navigation in thyroid-associated ophthalmopathy. Int J Oral Maxillofac Surg. 2020;49(10):1279\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTel A, et al. Virtual planning and navigation for targeted excision of intraorbital space-occupying lesions: proposal of a computer-guided protocol. Int J Oral Maxillofac Surg. 2022;51(2):269\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e\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":"Computer-Assisted Surgery, 3D Model, Orbital Foreign Body, Orbital Tumor","lastPublishedDoi":"10.21203/rs.3.rs-7753120/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7753120/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe anatomical structure of the orbit is highly complex, with significant inter-individual variability, posing considerable challenges for surgical procedures. We utilized computer-assisted surgery (CAS) by importing CT scan data, constructing three-dimensional (3D) models, and optimizing surgical planning. Based on these models, we performed removal of intraorbital foreign bodies and orbital tumors. This study aims to evaluate the utility of virtual surgical planning (VSP) in preoperative assistance, with a particular focus on its effects on surgical predictability and accuracy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePatients who underwent orbital surgery by a surgeon from July 2021 to April 2023 were included. Preoperative 3D modeling was performed using Mimics Medical 21.0 software to assist in the localization and surgical planning of intraorbital foreign bodies and orbital tumors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf the 7 orbital surgeries that were performed with computer-aided technologies, 3 (43%) were performed to remove orbital foreign bodies and 4 (57%) were performed to remove orbital tumors. For all the operations, the application of preoperative CAS enhanced surgical efficiency and safety, leading to favorable outcomes. The use of CAS in preoperative planning for complex orbital surgeries significantly improved intraoperative precision and provided clinically relevant postoperative assessment. The accurate evaluation of tumor and foreign body location, as well as their relationship with surrounding soft tissues, made preoperative planning a crucial reference for intraoperative procedures.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCAS\u0026mdash;particularly the preoperative phases of advanced diagnosis and VSP\u0026mdash;offers substantial clinical benefits in managing orbital lesions, enhancing safety and accuracy without the need for costly intraoperative navigation.\u003c/p\u003e","manuscriptTitle":"Three-dimensional virtual planning in orbital surgery enhances the accuracy of positioning prediction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 16:05:08","doi":"10.21203/rs.3.rs-7753120/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":"db0d181f-79ec-4b2a-b51f-c030aec95046","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T08:24:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 16:05:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7753120","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7753120","identity":"rs-7753120","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}