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S. P. Kresovsky, H. B. Lee, W. R. Nunery; Orbital Adherence Syndrome After Repair of Orbital Floor Fracture With Titanium Mesh Implant. Invest. Ophthalmol. Vis. Sci. 2008;49(13):2303.
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Titanium mesh is a common material used in the reconstruction of orbital floor fractures. it has been observed that the occurrence of subsequent inflammation may cause adherence between the mesh and orbital tissue. While this intense inflammatory reaction and scarring can be desirable with some fractures (i.e. mandible), this may compromise normal orbital structure and function.
A case series was investigated of 5 consecutive patients, referred to a tertiary center between 6/06 and 6/07, presenting with lower eyelid retraction after orbital floor fracture repair with titanium mesh implant. All 5 patients had primary reconstruction performed at an outside facility. The orbital floor repairs were performed using titanium mesh in a wrap-around fashion over the inferior orbital rim.
The patients in the series presented due to development of symptomatic lower eyelid retraction after surgical repair of an orbital floor fracture with titanium mesh. 3/5 (60%) patients had reconstruction to remove the titanium mesh implant. In the 3 (100%) who underwent correction of lower eyelid retraction, a full thickness skin graft was utilized to improve the function and appearance of the lower eyelid. Intraoperatively, all 3 corrected patients demonstrated a significant cicatrix of the middle lamella (septum and lower eyelid retractors) to the implant over the inferior orbital rim. 2/5 elected not to undergo surgery, however clinical presentation was similar to the other cases, and it is assumed that the underlying pathology was similar. All 3 surgical patients improved dramatically after cicatricial lower eyelid retraction repair with full thickness skin grafts.
Titanium has been shown to produce an intense inflammatory reaction which can lead to fibrosis to adjacent structures. It has been shown that a cascade of cytokines and cellular response leads to coating of the implant with protein and inflammatory debris. This fibrosis is important in the repair of many fracture sites, however in the dynamic orbit, this can be an undesired consequence. When used along the inferior orbital rim, this fibrosis can lead to cicatrization and lower eyelid retraction. Due to these observations, it is suggested to utilize materials with less inflammatory potential for repair of orbital floor fractures.
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