Differential Volumetric Orbital Restoration ( DVOR ) for Correction of Traumatic Ocular Malposition

Background: Severe orbital factures may lead to ocular malposition in the form of enophthalmos or dystopia not only due to loss of ocular support provided by the orbital floor or incarceration of the extra-ocular muscles but also due interference with the delicate balance between the volume of the intra orbital contents and the total orbital volume. This occurs due to either increase of the total orbital volume induced by fracture or displacement of the conal fat through fascial ligament lacerations intraorbitally or extraorbitally. Restoration of the intra-orbital volume is mandatory to prevent and treat these cases, however the volume and location of this restored volume has to be accurately calculated to optimize the result. Inadequate management of orbital fractures leads to periocular fibrosis which plays a detrimental effect in operative restoration of the ocular position in the orbit. Patients and Methods: Twelve patients have been treated for ocular malposition after trauma, 10 patients were treated acutely within 4 weeks after trauma and 2 patients were treated after longstanding ocular malposition (6 months and 26 months after trauma). Three-dimensional CT scan and occasionally orbital volumetry (5 cases) were done, restoration of the orbital skeleton with mini-plates, and screws was achieved, and reconstruction of the orbital floor was done by titanium mesh in acute patients. Ocular position is determined and then the volume and exact location of the volume spacer was evaluated by introducing a Foley’s catheter and inflating its balloon until a proper ocular position restoration is achieved clinically which was followed by placement of a measurable dermo fat graft in the proper site. Results: There was immediate improvement postoperatively (normal ocular position) in all acute patients, one patient had postoperative diplopia without enophthalmos, which had resolved 2 weeks later, another patient had moderate enophthalmos 3 months later with diplopia in the upward gaze and the patient was followed up and his diplopia improved. while in chronic cases we had full improvement in one case (6 months after trauma) and 50% improvement in the other case (26 months after trauma) with stable results after one week and 3 months, the first patient had no diplopia preoperatively or postoperatively, the second patient had diplopia in upward gaze which improved partially after surgery. Conclusion: Differential Volumetric Orbital Restoration (DVOR) is a helpful tool to correct ocular malposition after severe orbital trauma as it refines the volume and the location of the orbital spacer to achieve accurate restoration of ocular position.