mohammad azhar sheikh

1. In the name of Allah, The MostIn the name of Allah, The Most
CompassionateCompassionate,,
The Most MercifulThe Most Merciful

2. Applied anatomy of the orbit.Applied anatomy of the orbit.
The recipe for safe dissectionThe recipe for safe dissection
Muhammad Azhar SheikhMuhammad Azhar Sheikh
Prof: Oral & Maxillofacial SurgeonProf: Oral & Maxillofacial Surgeon
Islamic Int’l Dental College & Allied HospitalsIslamic Int’l Dental College & Allied Hospitals

3. Orbital fracturesOrbital fractures
Orbital fractures are common
Proper repair is key to restoring normal
facial appearance and function
Concerns due to critical structures – eyeConcerns due to critical structures – eye
ball and contents of SOF, IOF and Opticball and contents of SOF, IOF and Optic
NerveNerve

4. Bony OrbitBony Orbit

6. Orbital Fracture & EyeOrbital Fracture & Eye
Documentation of the condition of the eye
before and after surgery is critical.
Young patients with small floor fractures,
particularly when experiencing severe pain
or nausea, must be suspected of having
an entrapped inferior rectus muscle.

7. Mean Values of important structuresMean Values of important structures
RontalRontal et al.et al.
Infra-orbital foramen to midpoint of IOFInfra-orbital foramen to midpoint of IOF - 24mm- 24mm
Ant lacrimal crest to ant ethmoidal foramenAnt lacrimal crest to ant ethmoidal foramen - 24mm- 24mm
Ant lacrimal crest to Medial aspect of optic canalAnt lacrimal crest to Medial aspect of optic canal - 42mm- 42mm
FZ suture to superior Orbital fissureFZ suture to superior Orbital fissure - 35mm- 35mm
Supraorbital notch to SOFSupraorbital notch to SOF - 40mm- 40mm
Supraorbital notch to superior aspt of orbital canalSupraorbital notch to superior aspt of orbital canal - 45mm- 45mm

8. DissectionDissection
No bone removal behind Post ethmoidalNo bone removal behind Post ethmoidal
foramen – this is 30 mm from anteriorforamen – this is 30 mm from anterior
lacrimal crest.lacrimal crest.
Perisoteum elevation – line extending fromPerisoteum elevation – line extending from
FZS to FES medially upto 30mm fromFZS to FES medially upto 30mm from
supraorbital rim without risking anysupraorbital rim without risking any
structure passing through superior orbitalstructure passing through superior orbital
fissurefissure

9. SummarySummary (Randal et al.)(Randal et al.)
Superiorly & Medially – 30mm from superiorSuperiorly & Medially – 30mm from superior
orbital rim and anterior lacrimal crestorbital rim and anterior lacrimal crest
Inferiorly & laterally – 25mm from outer rimInferiorly & laterally – 25mm from outer rim
Care – medial canthal ligament, lacrimalCare – medial canthal ligament, lacrimal
apparatus, pulley of superior oblique muscle,apparatus, pulley of superior oblique muscle,
supraorbital NV bundles, Structures attachedsupraorbital NV bundles, Structures attached
to whitnall’s tubercle and origin of IO muscle.to whitnall’s tubercle and origin of IO muscle.

10. Age & Gender VariationAge & Gender Variation
The orbital floor angle was greater in males than
in females, and in children than in adults. That is
steeper in males and children
The location of the lowest point of the orbital
floor moves postero-inferiorly with increasing
age.
NAGASAO et al. Journal of Cranio-Maxillofacial Surgery (2007) 35, 112–119

11. Deep OrbitDeep Orbit
Evans and Webb. BJOMS 2007Evans and Webb. BJOMS 2007

12. Reliable landmarks are available
that are based on the relations of
anatomical structures within the
orbit rather than absolute
distances.
Evans and Webb. BJOMS 2007Evans and Webb. BJOMS 2007

13. The anatomical landmarks of the deep
orbit are both hard and soft tissue
structures:
– the infraorbital nerve;
– the inferior orbital fissure;
– the greater wing of the sphenoid; and
– the orbital plate of the palatine bone.

14. Surgical LandmarksSurgical Landmarks
Evans and Webb. BJOMS 2007Evans and Webb. BJOMS 2007
IO nerve run parallelIO nerve run parallel
to medial wallto medial wall
It does not go to OpticIt does not go to Optic
nerve - safenerve - safe
Follow the nerve untilFollow the nerve until
inferior orbital fissure.inferior orbital fissure.

15. Orbital plate of palatine boneOrbital plate of palatine bone
The orbital plate of the
palatine bone provides a
constant and reliable
landmark in the medial
orbital floor.
Reconstruction of the floor
of the orbit does not need to
extend beyond this.

16. PearlsPearls
Muscle entrapment does not occur in large
fractures, but muscle herniation does.
Floor implants should be placed far enough
posterior to the orbital rim that they are not
palpable.
Approximately 1 cm of floor fracture will allow
the eye to move posteriorly about 1 mm

17. SummarySummary
So-called safe distances, and the subperiosteal
plane of dissection within the orbit, do have a
role, but are best considered as adjuncts to
orbital dissection rather than absolutes.
Used in conjunction with the anatomical
landmarks of the deep orbit, safe and
reproducible dissection within the orbit is
possible in every case of non-ballistic injuries to
the orbit, no matter the extent of orbital
disruption.

20. Retrobulbar HemorrhageRetrobulbar Hemorrhage
Signs and SymptonsSigns and Symptons
PainPain
Decreasing visual acuityDecreasing visual acuity
Diplopia ( if vision preserved)Diplopia ( if vision preserved)
Proptosis (often acute onset)Proptosis (often acute onset)

21. Retrobulbar HemorrhageRetrobulbar Hemorrhage
Treatment - MedicalTreatment - Medical
IV mannitol (200ml of a 20% sol)IV mannitol (200ml of a 20% sol)
IV acetazolamide (Diamox) 500mgIV acetazolamide (Diamox) 500mg
IV papaverine 40mgIV papaverine 40mg
IV hydrocortisone 100mgIV hydrocortisone 100mg
If no improvement within 20 minutes,If no improvement within 20 minutes,
surgical decompression is necessarysurgical decompression is necessary