A clinical study of the effect of 3D reconstruction on exophthalmos after an operation on an old orbital wall fracture

Abstract

BACKGROUND:

Orbital blowout fracture is common in ocular trauma. Accurate measurement of orbital volume after fracture is key in improving intraocular correction.

OBJECTIVE:

This study aims to explore the impact of 3D reconstruction technology in restoring normal exophthalmos in patients with old orbital wall fractures.

METHODS:

A total of 31 patients were randomly divided into an experimental group ( $n=$ 15) and a control group ( $n=$ 16). For orbital wall repair and reconstruction, the conventional group used the conventional surgical scheme, and the 3D group used 3D printing technology.

RESULTS:

There was no statistical difference between the preoperative mean extraocular muscle volume of the healthy eye and the affected eye. However, the mean orbital volume (24.76 vs 27.11, $P=$ 0.005) and mean retrobulbar fat volume (17.53 vs 16.42, $P=$ 0.006) were significantly different between the healthy eye and the affected eye. After an average follow-up of 16 weeks, the differences in pre- and post-surgery exophthalmos in the two groups were 0.42 $\pm$ 0.08 mm and 1.63 $\pm$ 0.51 mm, respectively. The difference between the two groups was statistically significant ( $t=$ 4.42, $P=$ 0.003). The complications were not statistically different.

CONCLUSION:

Using 3D reconstruction technology preoperatively can significantly improve exophthalmos in patients with old orbital wall fractures.

Keywords

Orbital wall fracture old exophthalmos 3D reconstruction

1. Introduction

Orbital blowout fractures are common in ocular trauma. For some patients with an orbital fracture that lasts for more than three months and who have obvious eyeball depression and expansion of orbital volume caused by the fracture, the atrophy of orbital fat or other soft tissues leads to a reduction in the orbital contents; this is an important cause of enophthalmos. Therefore, it is difficult to completely repair the appearance of eyeball depression, even if the fracture is repaired by surgery [1]. Fan et al. [2] believed that the degree of enophthalmos in patients with an orbital blowout fracture is closely related to the change in orbital volume and that this can be precisely measured. For example, when the orbital volume increases by 1.0 cm ${}^{3}$ , the enophthalmos will be about 0.9 mm. This provides an objective basis for determining the treatment plan and the volume of intraorbital implants required. However, the degree of orbital fat atrophy varies between patients. Therefore, accurately measuring the change in orbital volume after a fracture is key to improving the surgical correction of enophthalmos. Computed tomography (CT) can accurately evaluate the changes in extraocular muscle and fat volume [3, 4, 5]. In this study, the extraocular muscle volume (MV), retrobulbar fat volume (FV), orbital volume (OV) and other related orbital measurement parameters were accurately calculated by CT and computer graphics processing software [6]. These parameters were associated with clinical features to evaluate the changes in orbital volume and intraocular fat in patients with orbital wall fracture, and the shape and size of the plastic patch were determined by graphic design. This method was called 3D reconstruction technology. This way, the surgeon can quantitatively design the operation plan before the surgery instead of relying on their own experience to ensure the symmetry of the patient’s eyes.

The study aimed to evaluate the effect of 3D reconstruction technology on exophthalmos after the operation on an old orbital wall fracture.

2. Materials and methods

2.1 General information

This was a retrospective case-control study. Patients with an old blowout fracture of the orbital wall treated at the department of Shanxi Bethune Hospital from January 2018 to June 2020 were included. They were divided into two groups by the random number table method. The experimental group ( $n=$ 15) included five cases of orbital floor wall fracture, three cases of orbital wall fracture and seven cases of orbital floor wall combined fracture. The control group ( $n=$ 16) included four cases of orbital floor wall fracture, four cases of medial wall fracture and eight cases of combined fracture of the medial wall of the orbital floor.

The inclusion criteria were: (1) trauma time $>$ 12 weeks; (2) degree of enophthalmos $\geqslant$ 2 mm, with or without extraocular muscle dysfunction; (3) fracture window area $>$ 2 cm ${}^{2}$ or bone wall displacement of 3 mm; (4) condition of the eyeball was stable; and (5) no eye injury, thyroid-associated ophthalmopathy, lacrimal gland inflammation, or other orbital diseases.

The exclusion criteria were: (1) patients with other facial fractures; (2) a previous history of orbital wall fracture; and (3) pregnant or lactating women.

The study was approved by the Ethics Committee of Shanxi Bethune Hospital. All patients were aware of the purpose of the operation and signed the informed consent form before the operation.

2.2 Method

The experimental group ( $n=$ 15) included five orbital floor wall fractures, three medial wall fractures and seven combined floor and medial wall fractures. CT imaging software was used preoperatively to calculate the orbital fat atrophy volume and bilateral orbital volume difference. The size and shape of the patch were then designed. The orbital cavity was reduced while repairing the fracture defect, and the orbital volume difference was remedied. The conventional group ( $n=$ 16) included four orbital floor wall fractures, four medial wall fractures and eight combined floor and medial wall fractures. The range and size of the fracture defect were determined preoperatively using a thin-slice CT scan, and the defect area of the fracture was repaired with a patch.

The volume of orbital fat atrophy and bilateral orbital volume difference was calculated by CT imaging software before the operation in the experimental group. Then the size and shape of the patch were designed. While repairing the fracture defect, the orbital cavity was reduced, and the orbital volume difference was corrected. In the control group, the range and size of the fracture defect were determined by thin-layer CT scanning before the operation, and the fracture defect area was repaired with a patch.

2.2.1 Measurement method of orbital-related volume

The CT scan data (window width 350 Hu, window level 50 Hu, slice thickness 0.625 mm) were imported into the computer. Then, 266 thin slice CT images of the orbit were collected by using radiant software. Four kinds of images were generated: horizontal, coronal, sagittal and three-dimensional images of the bone window.

2.2.2 Binocular symmetry points of interest

The binocular symmetry points of interest were as follows: (1) the midpoint of retrobulbar, that is, the intersection of optic nerve and sclera; (2) scleral implantation of the superior rectus, inferior rectus, medial rectus and lateral rectus; (3) supraorbital, infraorbital, medial and lateral marginal points; (4) orbital apex, i.e. lateral edge of optic foramen; and (5) each point at the outer edge of soft tissue in the fractured window of the affected eye [7].

2.2.3 Orbital measurement of healthy and affected eyes

The orbits of the healthy and affected eyes were measured. The region of interest (ROI) was drawn by hand, and the volume of the interest (VOI) was measured. According to the marked points of interest, the ROI was determined after connecting the lines, and the contour of the ROI was the outer edge of the volume [7]. The VOI was calculated according to the Hu value range and the ROI [8]. The MV, FV, OV and other related orbital measurement parameters were accurately calculated by CT using the computer graphics processing software Radiant [9, 10]. Because it is difficult to measure retrobulbar FV, it was defined as all soft tissues, including the orbital fat, connective tissue, nerve tissue and vascular components but excluding the extraocular muscles. Measurements were performed three times, and the results were recorded as the average values of these. When measuring volume, errors were reduced by using the guidelines proposed by Bijlsma et al. [11]. The differences between the FV and the OV of the healthy and the injured eyes were calculated. The sum of the difference in the FV and OV was defined as the visual volume difference of the eyes (Fig. 1A–C).

Figure 1.

Marking images after preoperative CT digital imaging: A: manually marking the range of OVI in horizontal film; B: manually marking the range of internal rectus muscle, optic nerve and external rectus muscle in OVI; C: manually marking the range of extraocular muscle in coronal film. Similarly, the range of eye health can be marked, and FV, OV and MV can be calculated by CT processing software after the marking. The mesh size and volume can be determined by calculating its difference.

2.2.4 Operation method

All 31 patients underwent a routine ophthalmic examination before the operation. The details of the fracture were determined by high-resolution CT scanning. The scanning layer thickness and layer spacing were 1 mm. The control group (16 cases) received conventional orbital wall repair as follows: successively complete the surgical approach, cut the conjunctiva, separate the tissue and periosteum, expose the fracture area, deal with the herniated tissue, implant a suitable artificial bone plate in combination with CT images and clinical experience, fix, determine the flexibility of passive eye movement and suture. The experimental group (15 cases) used 3D printing orbital wall repair as follows: (1) Based on the data provided by high-resolution CT, the 3D virtual model was established, and the orbital model was made by a 3D printer (Aurora Erwo 3D printer: model z-603s). The repair material was Medpor, with a ratio of 1:1 (Fig. 2A and B); (2) According to the shape of the affected side orbit after reconstruction of the healthy side orbit, the 3D model was printed after simulating the placement of the bone slice; and (3) The artificial bone plate was made according to the above model, and the surgical approach was determined. The other surgical procedures were the same as those in the control group. Finally, the position of the mesh was adjusted so that the four walls of the fractured window were completely suitable for the mesh and the local soft tissue is completely integrated into the orbit. After confirming that there was no implant in the sinus cavity, the position of the patch was fixed with medical glue (Beijing KangTuo Medical Instruments Co., Ltd., China). The periosteum, orbital septum, conjunctiva and skin were sutured layer by layer with 6–0 absorbable sutures. Antibiotic eye ointment was applied, and the eyes were covered with a compression bandage.

Figure 2.

Marking the fracture window and mesh after preoperative digital 3D imaging: A: Manually marking the size and scope of the fracture window during 3D imaging. B: Calculate the shape and volume of patch processed by software. An 1:1 3D orbital model was printed, and the designed mesh was put into the fracture window. The “fine sand filling method” was used to compare with the healthy eye to achieve the consistent volume of orbital content on both sides.

2.2.5 Measurement of exophthalmos

The degree of exophthalmos was measured both preoperatively and at three months postoperatively. The measurement methods were as follows. In CT digital images, the image of the centre of the lens and the intraorbital segment of the optic nerve at the same level were selected as the measurement level. The orbital distance, i.e., the line connecting the anterior edges of the lateral bone wall, was measured in both eyes. The vertical distance from the corneal vertex to the connecting line was also measured. The measurements were performed three times by the same doctor, and the average values were obtained.

2.3 Postoperative follow-up

Postoperatively, visual acuity, eye movement and the anterior and posterior segments were routinely examined. The position of the patch was observed by a re-examination of the orbital CT. The degree of exophthalmos was re-examined and recorded three months postoperatively (Fig. 3). The preoperative results are shown in Fig. 3a and b. The postoperative results are shown in Fig. 3c and d.

Figure 3.

A 34 years old female patient, who had a blowout fracture of the right orbital wall caused by an accident for more than 4 months. A: The preoperative photograph, viewed from the front and the back, it could be seen that the bulbar depression of the right eye was formed, and the inferior concave of the upper eyelid was formed, with obvious bilateral asymmetry. B: The horizontal tissue window film of preoperative CT digital imaging. The bilateral ocular protrusion was measured: 1.21 cm in the right eye, 1.59 cm in the left eye, and 9.95 cm in the orbital distance. C: Positive view $+$ elevation view 3 months after the operation. It can be seen that the right eye depression has been relieved and the binocular protrusion is basically symmetrical. D: The horizontal tissue window film of postoperative CT digital imaging. The protrusion of both eyes was measured: 1.66 cm in the right eye, 1.61 cm in the left eye, and the orbital distance was 10.06 cm.

2.4 Statistical analysis

Data were statistically analysed using SPSS19.0 software. Measurement data were expressed as mean $\pm$ standard deviation ( $\bar{x}$ $\pm$ SD). A paired sample $t$ -test was used to compare the preoperative and postoperative parameters. A value of $P<$ 0.05 was considered statistically significant.

3. Results

3.1 Baseline characteristics

A total of 31 patients with an old blowout fracture of the orbital wall, who were treated at the Department of Ophthalmology, Shanxi Bethune Hospital from January 2018 to June 2020, were included in this study, including 14 males and 17 females. The age range of the subjects was 22–52 years old, with an average age of 32.25 $\pm$ 4.36. There were seven cases of medial wall fracture, nine cases of orbital floor wall fracture and 15 cases of combined floor and medial wall fractures. The time from trauma to surgery was 13–28 weeks, and the mean duration was 17.32 $\pm$ 1.24 weeks. There were 17 males and 14 females – 15 cases had right eye trauma and 16 cases had left eye trauma. The causes of injuries included motor vehicle accidents (13 patients), assault (8 patients), falls (6 patients), sports-related incidents (2 patients) and falling objects (2 patients). Presenting complaints included diplopia (8 patients), enophthalmos (26 patients) and discomfort with eye movement (4 patients).

Preoperative parameters in both eyes were as follows: extraocular MV of 3.62 $\pm$ 0.51 cm ${}^{3}$ and 3.84 $\pm$ 0.63 cm ${}^{3}$ , orbital OV of 24.76 $\pm$ 2.39 cm ${}^{3}$ and 27.11 $\pm$ 2.57 cm ${}^{3}$ , retrobulbar FV of 17.53 $\pm$ 1.82 cm ${}^{3}$ and 16.42 $\pm$ 1.43 cm ${}^{3}$ in the healthy and affected eye, respectively. As shown in Table 1, there was no significant difference in extraocular MV between the healthy and affected eye ( $t=$ 0.67, $P=$ 0.504). There were significant differences in retrobulbar FV and orbital OV between the healthy and affected eyes ( $P<$ 0.05).

Table 1
The volume difference of each measurement parameter before surgery

Eye parting	MV	FV	OV
Affected eye	3.84 $\pm$ 0.63	16.42 $\pm$ 1.43	27.11 $\pm$ 2.57
Healthy eye	3.62 $\pm$ 0.51	17.53 $\pm$ 1.82	24.76 $\pm$ 2.39
Volume difference	0.22 $\pm$ 0.09	$-$ 1.11 $\pm$ 0.38	2.35 $\pm$ 0.54
$t$	0.67	2.97	3.82
$P$	0.504	0.006	0.005

Note: $t$ value and $P$ value is affected eye compared with healthy eye; MV: muscle volume; FV: fat volume; OV: orbital volume.

3.2 Comparison of exophthalmos between the two groups

The differences in these measurements were noted preoperatively and one month and three months postoperatively. A summary of these measurements is shown in Table 2.

Table 2
The difference of degrees with exophthalmos of two groups of patients after surgery

Groups	Time	$-$ 1 degree	0 degree	1 degree	2 degrees	3 degrees
Experimental group	Before surgery	0	0	0	9	6
	1 month after surgery	4	11	0	0	0
	3 months after surgery	0	13	2	0	0
Control group	Before surgery	0	0	0	9	7
	1 month after surgery	2	9	5	0	0
	3 months after surgery	0	9	5	1	0

Note: The difference of exophthalmos: $-$ 1 degree $<$ 0 mm: 0 mm $<$ 0 degree $\leqslant$ 1 mm, 1 mm $<$ 1 degree $\leqslant$ 2 mm, 2 mm $<$ 2 degree $\leqslant$ 4 mm, 3 degree $>$ 4 mm.

Table 3

The difference of exophthalmos of two groups of patients before and after surgery (mm)

Groups	N	Before surgery	3 months after surgery	$t$	$P$
Experimental group	15	4.12 $\pm$ 0.37	0.42 $\pm$ 0.08	10.23	0.001
Control group	16	4.35 $\pm$ 0.29	1.63 $\pm$ 0.51	8.97	0.001
$t$		0.43	4.32
$P$		0.720	0.003

The difference between the two eyes was measured preoperatively. The average difference was 4.12 $\pm$ 0.37 mm in the 3D group and 4.35 $\pm$ 0.29 mm in the conventional group. The three-month postoperative measurements showed a difference of 0.42 $\pm$ 0.08 mm in the 3D group and 1.63 $\pm$ 0.51 mm in the conventional group. The difference between the two groups was statistically significant ( $t=$ 4.42, $P=$ 0.003). As shown in Table 3, the intra-group comparison was also carried out. The difference between the experimental group and the control group before and after the operation was also statistically significant ( $t=$ 10.23, $P=$ 0.001; $t=$ 8.97, $P=$ 0.001).

3.3 Postoperative complication

No intraoperative complications occurred in all patients. At a follow-up of 16 $\pm$ 4 weeks, there were no significant differences in serious complications between the two groups. No strabismus, ptosis, intraorbital implant exposure or infection occurred in all patients.

4. Discussion

3D model reconstruction based on medical images has an important application value in the medical field [12, 13, 14]. In the early stages of an orbital blowout fracture, some studies revealed that designing the position and size of the implant material using a 3D print model could accurately repair the window of the orbital wall fracture [15]. However, due to swelling and bleeding in the soft tissue, it is impossible to evaluate the degree of atrophy of orbital fat and other soft tissues. In severe blunt eye injuries, even if there was no fracture of the orbital wall, enophthalmos would occur. As a result, the authors of this current study realised that the change in orbital volume caused by the atrophy of periorbital soft tissue after trauma cannot be ignored. To lessen the degree of enophthalmos, both the enlargement of the orbital cavity and the atrophy of the soft tissue after a fracture must be considered. In this study, the subjects were patients with old orbital wall fractures. As a result, bone window size and soft tissue atrophy had become stable. CT and other digital imaging software were used to measure the OV, orbital FV and fracture size. From this, the MV, OV and FV could be calculated accurately. Using this calculation and the digital images obtained, the shape and volume of the implant material were designed and calculated to reduce the orbital volume difference between the orbits caused by soft tissue atrophy [16, 17]. Therefore, the methodology of this study is designed in three steps. The first step is calculation. As described in Section 1.2, the CT value range can be set in CT images of patients; for example, the volume of orbital fat can be measured by calculating the volume of $-$ 40 Hz to $-$ 60 Hz (adipose tissue) in orbit. But the organisation such as muscle, optic nerve, sclera CT value is relatively close, setting the CT value measuring method error is bigger, so, hand-painted manual annotation predicts the amount of the boundary of the organisation (of course, the work is great, it is necessary to indicate level, crown each CT images for the organisation of the border) of the final computer integration from stereoscopic 3D graphics. The computer can calculate the volume of the figure.

The second step is designing. As the shape of the fractured window varies from person to person, computer graphics assistance software is needed to design the shape of the mesh, hand-draw the shape and size of the fractured window, draw pseudo-colour matting, print the graph according to the actual size and then make an aluminium sheet as the mesh model, which is a plane model. The mesh was then shaped again in the 3D printed orbital model to change the three-dimensional shape. Admittedly, this step can be completed by computer, but considering the factors such as the large error of the CT value measurement method and the heavy workload of hand-drawn measurement, the author selected the fine sand method for measurement and finally designed the shape and size of the pre-implanted mesh. The third step is surgery. This will not be discussed here.

Fat necrosis and fat volume loss certainly affect the surgery outcome. As was identified in this study, even though 3D reconstruction technology was used, the exophthalmos after surgery was 0.42 $\pm$ 0.08 m, which is still not ideal. However, it is difficult to measure the true effect on fat necrosis and fat volume loss, and no study provides exact data about the effect. Some surgeons have tried to eliminate the effect by increasing the thickness of the implant or inserting a wedge, but the effects of these methods need to be further studied.

Many surgeons also try to improve the results by increasing the thickness of the implant or inserting a wedge. It is difficult to determine the size and location of implants using the empirical wedge-shaped implants to reduce the volume difference. Prefabricated titanium mesh can repair an orbital wall fracture accurately, which can significantly improve enophthalmos and diplopia, and is widely used in a diverse range of orbital blowout fractures. In this study, the use of certain repair materials was not a prerequisite, but the focus was on the individualised preform design of repair materials. For orbital wall fractures, with the aid of digital measurement software of CT, the shaped repair materials were selected preoperatively using the graphic design of the software. This ensured the accurate positioning of the implant material without squeezing or incarcerating the muscle. The accurate design of the patch shape can ensure that the 3D shape of the orbital wall can be restored more accurately after the operation, making the degree of exophthalmos of the eyes consistent.

In old orbital wall fractures, due to softening or fibrosis of the local fracture fragments, the fracture wound, and the surrounding soft tissue fibre scarring, intraoperative separation is difficult because the edge of the bone window is blurred, and it is easy to cause secondary damage to soft tissue during the operation [18]. Under these conditions, it is common for errors to be made when calculating the size of the patch. Therefore, it is important to perform the patch preoperatively. A previous study revealed that, when using an orbital CT in the process of orbital volume reconstruction, the smaller the slice thickness of the CT scanning, the higher the accuracy [19]. It is important to note that the likelihood of surgical trauma in an old orbital wall fracture is higher than in an early orbital wall fracture, although there is more fault tolerance between the orbits. In this study, the degree of exophthalmos in two patients in the 3D group was decreased by 1.4 mm when compared with the contralateral exophthalmos three months postoperatively. No displacement of the implanted patch was found in the postoperative CT scan. It is believed that the reason for this was that the intraorbital fat atrophy and soft tissue fibrosis were aggravated by trauma caused during the operation, resulting in enophthalmos. A current study has counteracted the shortcomings of surgery by using autologous fat injection. Qiu [20] reported that nine patients with posttraumatic retrobulbar and orbital depression were treated with autologous fat granule transplantation, and a good result was achieved.

Observation of the postoperative complications of old orbital wall fractures revealed that there were no significant differences in the complications experienced when compared with early fracture repairs. The reason for this is believed to be that the clinical symptoms in surgical patients often cannot be relieved immediately after surgery, but results are often delayed, sometimes for as long as several months [18]. In this study, all patients were followed up for three months. At the final follow-up, there were no complications – such as orbital implant-related infection, dislocation or exposure, or decreased vision – in either group. However, the recovery of extraocular muscle function and sensory function of the infraorbital nerve was poorer than in early fracture repair.

In summary, the main purpose of repairing old orbital wall fractures is to improve the appearance and to make the eyes symmetrical. In this study, 3D reconstruction using thin-layer CT scanning and digital imaging was used preoperatively to accurately measure the volume difference between the orbits. This was done to create an implant that was the right size and shape and to achieve the accurate positioning of the implant materials. However, it was also found in the study that the preoperative 3D printing model could well design the size of the mesh, but the method of determining the shape of the mesh combined with the ‘fine sand filling method’ was subject to the subjective influence of the surveyors, resulting in measurement errors. The shape of the designed mesh needs to be verified with CT digital simulation imaging again [21]. In the process of the operation, the determination of the mesh position still relies on the operator’s judgement based on experience. In this study, if digital navigation technology can be combined with intraoperative guidance, the mesh position will be more accurately determined [22, 23]. It was also found that it is difficult to accurately measure the orbital volume, even using 3D model reconstruction, for patients with multiple fractures from maxillofacial trauma who need combined operations that include the stomatology department due to the compound fracture of the orbital margin. To achieve a good effect, this treatment needs further study [24].

However, there were several limitations in this study that need discussion. First, the retrospective nature of the study prevented the drawing of stronger conclusions. The second limitation was the relatively small sample size. Patients with old orbital fractures that need an operation to restore exophthalmos are not common, so expanding the sample size is difficult at present. More multicentre prospective studies with large sample sizes are necessary to better understand the novel technique.

5. Conclusion

Conventional orbital wall fracture repair and 3D printing-assisted orbital wall repair can be used to treat patients with orbital wall fracture, and the clinical effect of the latter is ideal. It can significantly improve the exophthalmos of patients with old orbital wall fractures and has value for clinical promotion.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Shanxi Aier Eye Hospital. All participants signed an informed consent form for inclusion in the study.

Availability of data and materials

All data generated or analyzed during the study are included in this published article.

Funding

Not applicable.

Author contributions

WL Zhang and L Yang conceived the study; YJ Duan and XQ Cao participated in its design and coordination; and W Zhang helped draft the manuscript. All authors read and approved the final manuscript.

Footnotes

Acknowledgments

The authors would like to express their gratitude to everyone who helped them during the writing of this manuscript.

Conflict of interest

None of the authors have any personal, financial, commercial or academic conflicts of interest.

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A clinical study of the effect of 3D reconstruction on exophthalmos after an operation on an old orbital wall fracture

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 General information

2.2 Method

2.2.1 Measurement method of orbital-related volume

2.2.2 Binocular symmetry points of interest

2.2.3 Orbital measurement of healthy and affected eyes

2.3 Postoperative follow-up

3. Results

3.1 Baseline characteristics

Table 1 The volume difference of each measurement parameter before surgery

Table 2 The difference of degrees with exophthalmos of two groups of patients after surgery

4. Discussion

5. Conclusion

Ethics approval and consent to participate

Availability of data and materials

Funding

Author contributions

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
The volume difference of each measurement parameter before surgery

Table 2
The difference of degrees with exophthalmos of two groups of patients after surgery