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    Orbital fractures: surface coil MR imaging. Tonami H,Yamamoto I,Matsuda M,Tamamura H,Yokota H,Nakagawa T,Takarada A,Okimura T Radiology Twenty-six patients with orbital fractures diagnosed with plain radiography and computed tomography were examined with surface coil magnetic resonance (MR) imaging. Fifteen patients had blow-out fractures, and 11 had maxillofacial complex fractures. In all patients with blow-out fractures, the location of the fracture was precisely indicated by the presence of prolapsed orbital fat. Incarceration of the extraocular muscle or orbital fat was correctly diagnosed with MR imaging, which was less sensitive in depicting maxillofacial fractures but was useful in assessment of soft-tissue involvement. Postoperative follow-up MR studies provided valuable information about the cause of motility impairment. While T1-weighted images are useful for the detection of the fracture site, both T1- and T2-weighted images are usually necessary for evaluating soft-tissue lesions. The results of this study indicate that surface coil MR imaging is an important adjunct procedure in the diagnosis and treatment of orbital fractures. 10.1148/radiology.179.3.2027993
    Direct oblique sagittal CT of orbital wall fractures. Ball J B AJR. American journal of roentgenology Direct oblique sagittal CT was used to evaluate trauma to 77 orbits. Sixty-seven orbital wall fractures with intact orbital rims (36 floor, 22 medial wall, nine roof) were identified in 47 orbits. Since persistent diplopia and/or enophthalmos may warrant surgical repair of orbital floor fractures, optimal imaging should include an evaluation of extraocular muscle status, the nature and amount of displaced orbital contents, and an accurate definition of fracture margins. For orbital floor fractures, a combination of the direct oblique sagittal and direct coronal projections optimally displayed all fracture margins, the fracture's relationship to the inferior orbital rim and medial orbital wall, and the amount of displacement into the maxillary sinus. Inferior rectus muscle status with 36 floor fractures was best seen on the direct oblique sagittal projection in 30 fractures (83.3%) and was equally well seen on sagittal and coronal projections in two fractures (5.5%). Floor fractures were missed on 100% of axial, 5.5% of sagittal, and 0% of coronal projections. Since the direct oblique sagittal projection complements the direct coronal projection in evaluating orbital floor fractures, it should not be performed alone. A technical approach to the CT evaluation or orbital wall fractures is presented. 10.2214/ajr.148.3.601
    The role of CT and MRI in the investigation of orbital roof fractures. Williams G,Jackson A,Whitehouse R W,Kwartz J European journal of radiology
    Orbital blowout fractures. The prognostic significance of computed tomography. Gilbard S M,Mafee M F,Lagouros P A,Langer B G Ophthalmology Nineteen patients with orbital floor fractures were examined and underwent computed tomography of both orbits. By evaluating the amount of orbital expansion and soft tissue herniation, we were able to identify a group of patients at high risk for developing enophthalmos (3/7 in the group with the largest amount vs. 0/7 and 0/5 in the two other groups). By studying the appearance of the inferior rectus muscle, we were also able to identify a group of patients at high risk for developing persistent diplopia (5/5 with entrapped muscles, 0/2 with hooked muscles and 0/12 of patients with free inferior rectus positions).
    Dimensions and volumes of the orbit and orbital fat in posttraumatic enophthalmos. Ramieri G,Spada M C,Bianchi S D,Berrone S Dento maxillo facial radiology OBJECTIVES:To estimate from 2D and 3D-CT the anatomical defects that are most likely to be responsible for posttraumatic enophthalmos. MATERIALS AND METHODS:The morphology and dimensions of the orbit and of fat content were investigated in 25 patients 6-12 months after treatment for complex orbital fractures by image analysis and volumetric estimation from 2D and 3D-CT. RESULTS:The shape of orbit was very often changed from conical to more rounded due to enlargement of the posterior segment. The retrobulbar fat appeared fragmented and dislocated posteriorly. No changes were observed in the structural appearance or radiodensity of either the orbital fat or muscles. There was reduced sagittal eye projection, increased width of the orbital rim, downward dislocation of the posteromedial orbital floor, and increased volume in the posttraumatic orbits which was significantly different (P < 0.05). Enophthalmos was correlated with orbital volume and height of the retrobulbar portion of the orbit. The volume of fat did not correlate with enophthalmos. CONCLUSIONS:Posttraumatic enophthalmos appears to be more commonly related to failure in correcting the orbital volume and in reducing the outward dislocation of the posterior orbital floor and not to changes in the fat content. 10.1038/sj/dmfr/4600551
    Rounding of the inferior rectus muscle: a helpful radiologic findings in the management of orbital floor fractures. Levine L M,Sires B S,Gentry L R,Dortzbach R K Ophthalmic plastic and reconstructive surgery The authors describe a patient with an orbital floor fracture that did not demonstrate a distinct fracture on computed tomography (CT) imaging. The key radiologic finding was rounding of the inferior rectus muscle.
    [Diagnosis of magnetic resonance imaging (MRI) for blowout fracture--three advantages of MRI]. Nishida Y,Aoki Y,Hayashi O,Kimura M,Murata T,Ishida Y,Iwami T,Kani K Nippon Ganka Gakkai zasshi INTRODUCTION:Magnetic resonance imaging (MRI) gives a much more detailed picture of the soft tissue than computerized tomography (CT). In blowout fracture cases, it is very easy to observe the incarcerated orbital tissue. SUBJECTS:We performed MRI in 19 blowout fracture cases. RESULTS:After evaluating the images, we found three advantages of MRI. The first is that even small herniation of the orbital contents can easily be detected because the orbital fatty tissue contrasts well around the other tissues in MRI. The second is that the incarcerated tissues can be clearly differentiated because a clear contrast between the orbital fatty tissue and the extraocular muscle can be seen in MRI. The third is that the running images of the incarcerated muscle belly can be observed because any necessary directional slies can be taken in MRI. CONCLUSION:These advantages are very important in the diagnosis of blowout fractures. MRI should be employed in blowout fracture cases in addition to CT.
    Orbital soft-tissue trauma. Chazen J Levi,Lantos Joshua,Gupta Ajay,Lelli Gary J,Phillips C Douglas Neuroimaging clinics of North America In the clinical assessment of orbital trauma, visual acuity and extraocular muscle motility are critical for rapid evaluation of injury severity. However, assessment of these parameters may be limited by edema and concomitant injuries. Imaging may further delineate the trauma pattern and extent of injury. This review focuses on orbital soft-tissue injuries that can exist with or without orbital fracture. Imaging techniques and soft-tissue injuries, including those involving the anterior chamber, iris and ciliary body, lens, globe, posterior segment, and optic nerve, are reviewed, in addition to intraocular foreign bodies and cavernous-carotid fistulas. 10.1016/j.nic.2014.03.005
    High resolution magnetic resonance imaging with an orbital coil as an alternative to computed tomography scan as the primary imaging modality of pediatric orbital fractures. Kolk Andreas,Stimmer Herbert,Klopfer Matthias,Wolff Klaus-Dietrich,Hohlweg-Majert Bettina,Ploder Oliver,Pautke Christoph Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons PURPOSE:The computed tomography (CT) scan is currently the gold standard in the imaging of orbital fractures. The weak points of this imaging modality, however, include restricted soft tissue depiction as well as the radiation. Both attributes are of particular importance in children because of the high rate of trapdoor fractures and the radiation to the lens. Although magnetic resonance imaging (MRI) is not associated with these drawbacks, it has not been established in the primary diagnosis of pediatric orbital fractures. The aim of our study was to establish the use of MRI with a special orbital coil for the primary diagnosis of pediatric orbital trauma. PATIENTS AND METHODS:In our retrospective study, 14 pediatric patients presented to our department with a blunt orbital trauma from 2003 to 2007. Twelve of 14 patients with orbital floor fractures required surgical reconstruction. Until 2004, imaging was carried out by plain x-rays and CT scan for a decision regarding the necessity of surgery. Since introducing the MRI microscopy orbital coil in 2004, CT scans have been replaced by MRI for the primary fracture diagnosis in 8 pediatric cases. Kappa statistics have been applied to assess inter- and intraobserver reliability for CT scans and MRI. This study shows our experiences using MRI in combination with conventional x-rays to determine the operative approach in 2 of the 8 pediatric cases suffering from blunt orbital trauma. RESULTS:The most common causes for pediatric orbital trauma in our collective were accidents. In 8 cases using MRI as the primary imaging modality, depiction of the fracture dislocation and differentiation of the adjacent fatty and muscle tissue was excellent and indication for surgery was distinct. MRI reached a high intra- and inter-rater agreement level (kappa=0.80). CONCLUSION:MRI combined with a microscopy orbital coil is a valuable alternative to the CT scan in the primary diagnosis of pediatric orbital fractures. Floor fractures, and particularly muscle incarceration, should be diagnosed by high resolution MRI combined with a microscopy coil instead of CT to avoid radiation to the lens and to obtain a better soft tissue depiction. 10.1016/j.joms.2008.04.003
    Can a Specific Computed Tomography-Based Assessment Predict the Ophthalmological Outcome in Pure Orbital Floor Blowout Fractures? Bruneau Stéphane,De Haller Raoul,Courvoisier Delphine S,Scolozzi Paolo The Journal of craniofacial surgery The aim of this study was to determine the predictive value of a specific computed tomography (CT)-based assessment for the final functional ophthalmological outcome in pure orbital floor blowout fractures. Data of 34 consecutive patients with pure blowout fractures who had undergone a period of at least 6 months of medical and ophthalmological follow-up were analyzed. The following 3 CT scan-based parameters were included: area ratio of the fractured orbital floor (RF), maximum height of periorbital tissue herniation (MH), and a 4-grade muscular subscore (MSS) describing the inferior rectus muscle displacement relative to the orbital floor level. The orthoptic complications (diplopia, enophthalmos, and ocular motility restriction) were evaluated by an experienced strabologist. The CT parameters' predictive value was analyzed using receiver operating characteristic curves and area under the curve (AUC), logistic regression, and Spearman correlation.The RF had a significant predictive value for enophthalmos appearance (AUC = 0.75, P = 0.02), and MH for diplopia (AUC = 0.80, P = 0.03). Among patients with complications, the relevance of MSS and MH as well as the severity of vertical deviation were also clinically strongly associated (rho = -0.52 and -0.56).Our study revealed the significantly predictive value of RF for occurrence of enophthalmos and of MH for diplopia persistence. Although statistically unable to predict the occurrence of ocular motility restriction, MH and MSS were clinically strongly correlated with the severity of ocular deviation limitations. 10.1097/SCS.0000000000003077
    Medial wall fracture: an update. Thiagarajah Christopher,Kersten Robert C Craniomaxillofacial trauma & reconstruction This article is a review of the literature and update for management of medial orbital wall fractures. A retrospective review of the literature was performed via PubMed to review the diagnosis and management of medial wall orbital fractures. Medial wall orbital fractures though commonly accompanying orbital floor fractures can also occur alone. There are two primary theories explaining the pathophysiology of medial wall fractures: the hydraulic theory and buckling theory. Most fractures do not require treatment. "White-eyed" trapdoor fractures necessitate immediate surgery to reduce the risk of muscle fibrosis. Trapdoor fractures are more common in the pediatric population. The vast majority of nondisplaced fractures without entrapment do not require surgery. Evaluating patients with medial wall fractures requires evaluation of muscle motility and relative enophthalmos. Patients with entrapped muscles require immediate treatment to prevent permanent injury to the muscle. 10.1055/s-0029-1224775
    Medial orbital wall fracture with associated medial rectus entrapment and retrobulbar hematoma. Turko Arthur,Talbot Simon,Pomahac Bohdan Plastic and reconstructive surgery 10.1097/PRS.0b013e31819a3516
    Pediatric orbital floor trapdoor fractures: outcomes and CT-based morphologic assessment of the inferior rectus muscle. Neinstein Ryan M,Phillips John H,Forrest Christopher R Journal of plastic, reconstructive & aesthetic surgery : JPRAS INTRODUCTION:Trauma to the pediatric orbit may produce a unique fracture in which entrapment of the periorbital tissue and/or inferior rectus muscle may occur due to a "trap-door" effect of the compliant orbital floor. This study was designed to assess the outcome following the surgical management of orbital trapdoor fractures in children and to examine alterations in the morphology of the inferior rectus (IR) muscle. METHODOLOGY:Outcome assessment on patients undergoing surgery at the Hospital For Sick Children, Toronto with symptomatic orbital floor trapdoor fractures over a 10-year period and a CT-based morphometric analysis of the inferior rectus muscle were performed. RESULTS:18 patients (5F, 13M) mean age 12.6 years (range 8.3-16.6 years) underwent surgical exploration (average time to surgery 9.7 ± 3.5 days (range 1-45 days). Follow-up was 15.4 months (range 6-36 months). All patients noted improvement in extra-ocular muscle (EOM) range of motion post-operatively: 7 patients had normal EOM with no diplopia; 9 patients had minimal diplopia on extreme secondary (upwards) gaze and 2 patients had residual significant diplopia with upward gaze. CT morphologic assessment (8 patients) demonstrated: a) zone of bony injury was posterior to the equator of the globe; b) minimal to no extra-conal fat exists to protect the IR muscle; c) a trend toward increased length in the injured IR muscle. CONCLUSIONS:With surgical intervention, improvement of diplopia (complete or near-complete resolution) occurred in 16/18 (89%) of patients presenting with symptomatic trapdoor orbital floor fractures. CT-based assessment demonstrated the vulnerability of the inferior rectus muscle with close proximity to the orbital floor and lack of periorbital fat for protection. Alteration of the length of the IR muscle may impact the force-length relationship and play a role in the outcomes. Early surgical intervention for symptomatic trapdoor fractures is recommended. 10.1016/j.bjps.2012.02.004
    Isolated medial orbital wall fractures with medial rectus muscle incarceration. Brannan Paul A,Kersten Robert C,Kulwin Dwight R Ophthalmic plastic and reconstructive surgery PURPOSE:To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005. METHODS:Retrospective chart review and literature review. RESULTS:Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal. CONCLUSIONS:Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye. 10.1097/01.iop.0000217565.69261.4f
    Evaluation of a computed-tomography-based assessment scheme in treatment decision-making for isolated orbital floor fractures. Frohwitter Gesche,Wimmer Stephan,Goetz Carolin,Weitz Jochen,Ulbig Michael,Kortuem Karsten U,Dangelmaier Julia,Ritschl Lucas,Doll Christian,Ristow Oliver,Kesting Marco R,Koerdt Steffen Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery INTRODUCTION:Treatment decisions for fractures of the orbital floor are based on clinical appearance, ophthalmological examination, and computed tomography (CT) scans. In extensive fractures, decisions are easily made between conservative and surgical treatment. However, objective parameters are rare in inconclusive cases. MATERIALS AND METHODS:Our retrospective study included 106 patients with unilateral isolated orbital floor fractures. Correlations between preoperative ophthalmological examinations and specific CT parameters were performed. RESULTS:The defect size of the fracture appeared to be significantly associated with the presence of diplopia. CT-morphological parameters and preoperative ophthalmological results showed statistical significance for diplopia and incarceration of inferior rectus muscle (IRM), diplopia and displacement of IRM, decreased mobility and incarceration of IRM, and decreased mobility and displacement of IRM. DISCUSSION:Our clinical assessment scheme for CT scans of orbital floor fractures is aimed at facilitating treatment decision making using four CT-based variables. As critical size defects of the orbital floor of ≥2 cm are likely to cause clinically significant posterior displacement of the globe, resulting in enophthalmos, the proposed parameters offer a readily accessible and easy to evaluate scheme that helps to identify patients in need of surgical intervention. 10.1016/j.jcms.2018.06.016
    Swelling of the inferior rectus muscle and enophthalmos in orbital floor fracture. Kang Seok Joo,Lee Kyung Ah,Sun Hook The Journal of craniofacial surgery 10.1097/SCS.0b013e31827c7fdb
    Delayed-onset inferior rectus muscle hematoma after orbital floor fracture. Costin Bryan R,McNutt Steven A,Sakolsatayadorn Natta,Perry Julian D JAMA ophthalmology 10.1001/jamaophthalmol.2013.2399
    Correlation between changes of medial rectus muscle section and enophthalmos in patients with medial orbital wall fracture. Kim Yong Kyu,Park Chang Sik,Kim Hyoung Kyu,Lew Dae Hyun,Tark Kwan Chul Journal of plastic, reconstructive & aesthetic surgery : JPRAS BACKGROUND:Enophthalmos is the most distressing and common complication of the blow-out fracture. In spite of well-established indications for early operative repair of orbital fracture, 7-10% of patients treated non-operatively develop enophthalmos. There have been reports on the correlation between changes of orbital bone and enophthalmos; however, there is no report on muscle changes in computed tomography (CT) in medial blow-out fracture. The present authors have documented the correlation between change of medial rectus muscle and enophthalmos using CT scan in medial blow-out fracture patients. METHODS:In this study (from January 2001 to December 2006) of 340 patients diagnosed with medial blow-out fracture, 24 patients were treated non-operatively. Nine patients (Group 1) have over 2-mm enophthalmos and 15 patients (Group 2) have enophthalmos less than 2mm. The height-to-width (H-W) ratios of medial rectus muscle were measured in coronal views, and the size of defects were measured in coronal and axial views in CT. Hertel's exophthalmometry was measured on both eyes for all patients. RESULTS:The H-W ratios measured in the affected orbits were statistically significant between the two groups (p<0.0001). However, the size of defect is not related with enophthalmos in two groups statistically (P=0.421). CONCLUSION:These results mean that the H-W ratio of medial rectus muscle in coronal views of CT is a useful parameter to predict enophthalmos, and whether H-W ratios of medial rectus muscle over 0.7 need surgical correction. 10.1016/j.bjps.2008.06.042
    Mechanisms of extraocular muscle injury in orbital fractures. Iliff N,Manson P N,Katz J,Rever L,Yaremchuk M Plastic and reconstructive surgery The gross and microscopic events that occur after orbital blowout fractures were evaluated to assess the mechanisms of diplopia and muscle injury. Intramuscular and intraorbital pressures were evaluated in experimental animals, in cadavers, and at the time of orbital fracture explorations for repair of orbital fractures in humans. Histologic and circulatory changes, muscle pressure recordings, and operative observations were evaluated. Creation of a compartment syndrome was evaluated to include a histologic evaluation of the orbital fibrous sheath network for the extraocular muscles and the intramuscular vasculature. These experiments and observations do not support the role of a compartment syndrome in ocular motility disturbances because (1) intramuscular pressures were subcritical in both humans and animals; (2) no limiting fascial compartment could be demonstrated; and (3) microangiograms and histologic evaluations did not confirm areas of compartmental ischemic necrosis. Muscle contusion, scarring within and around the orbital fibrous sheath network, nerve contusion, and incarceration within fractures remain the probable causes of diplopia, with the most likely explanations being muscle contusion and fibrosis or incarceration involving the muscular fascial network. 10.1097/00006534-199903000-00004
    Prognostic CT findings of diplopia after surgical repair of pure orbital blowout fracture. Jung Hyena,Byun Jae Young,Kim Hyung-Jin,Min Ji Hye,Park Gyeong Min,Kim Ha Youn,Kim Yi Kyung,Cha Jihoon,Kim Sung Tae Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery PURPOSE:Diplopia is a common sequela of blowout fracture even after proper surgical management. We investigated the prognostic factors of diplopia after surgery of pure blowout fracture. MATERIALS AND METHODS:We retrospectively reviewed CT images of 181 patients with pure orbital blowout fracture who underwent at least six months of postoperative follow-up. We evaluated the following CT factors: (1) fracture site (orbital floor, medial wall of the orbit, or both), (2) fracture type (closed flap, open flap), (3) fracture size, (4) volume of herniated orbital soft tissue, (5) ratio of volume of herniated orbital soft tissue to fracture size, (6) number of points of contact between extraocular muscle (EOM) and bony edge, (7) presence of EOM thickening, (8) EOM swelling ratio, (9) presence of displacement of EOM, (10) presence of deformity of EOM, (11) presence of tenting of EOM, and (12) presence of entrapment of EOM. The associations between diplopia at six months after surgical repair and various risk factors were analyzed using logistic regression models for univariable and multivariable analyses. RESULTS:EOM tenting and deformity and ratio of volume of herniated orbital soft tissue to fracture size were found to be statistically significant risk factors of diplopia at six months after repair on univariable analysis (all P < 0.05). Patients who showed EOM tenting or deformity on CT images had 5.22 and 10.85 times greater probability of diplopia after surgery, respectively (P-value, <0.001 and 0.026; 95% confidence interval of odds ratio, 2.071-13.174 and 1.323-88.915, respectively). On the other hand, ratio of volume of herniated orbital soft tissue to fracture size was not significant on multivariable analysis (P = 0.472). CONCLUSION:The prognosis of patients was predicted by CT evaluation. Patients who have tenting or deformity of EOM on CT scan are more likely to have postoperative diplopia. 10.1016/j.jcms.2016.06.030
    Correlation between ocular motility and evaluation of computed tomography in orbital blowout fracture. Furuta Minoru,Yago Keiko,Iida Tomohiro American journal of ophthalmology PURPOSE:To investigate outcomes of management of blowout fracture patients evaluating computed tomography (CT) findings and diplopia. DESIGN:Single-center retrospective interventional consecutive case series. METHODS:This study included 113 cases of pure blowout orbital fracture with diplopia. We investigated patients' satisfaction based on percentage of Hess area ratio (HAR%) on the Hess chart, evaluating fracture type and number of points of contact of extraocular muscles to the fracture edge (points of muscle contact) based on CT. RESULTS:Of the patients with HAR% > 85%, most experienced no diplopia. Sixty-two (55%) of 113 patients underwent surgical repair to improve diplopia, and 31 (50%) of 62 patients had surgery within three days after injury. A favorable outcome with HAR% > 85% was seen in 81 (72%) of 113 patients. Of 32 patients with two points of muscle contact at one extraocular muscle, 15 patients (47%) improved with a final HAR% > 85%. None of the four patients with medial wall fracture and two points of muscle contact had improved in their final HAR% > 85%. Thirty (97%) of 31 patients with either floor or medial wall fracture and no muscle involvement had a favorable outcome regardless of fracture type. Initial CT findings of the rectus muscle was strongly correlated with a mean initial HAR% (r = -0.94) and a mean final HAR% (r = -0.87). CONCLUSIONS:The clinical manifestations and prognosis of patients were approximately predicted through the analysis of CT on fracture type and number of points of contact of an extraocular muscle to the fracture edge. 10.1016/j.ajo.2006.06.054
    Association between preoperative inferior rectus muscle swelling and outcomes in orbital blowout fracture. Matsunaga Kazuhide,Asamura Shinichi,Morotomi Tadaaki,Wada Mitsuhiro,Wada Yoshitaka,Nakamura Norifumi,Isogai Noritaka Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery PURPOSE:In 18 patients with orbital blowout fracture who underwent reconstruction using a bone autograft, the association between preoperative inferior rectus muscle swelling and the outcome 1 year after the operation was evaluated. MATERIAL AND METHODS:The patients were classified according to outcomes into four groups: Group A without double vision showing normal ocular movements, Group B with double vision showing normal ocular movements, Group C with double vision showing improvement in ocular movements, and Group D with double vision showing no improvement in ocular movements. Inferior rectus muscle swelling was evaluated by calculating its swelling rate on the injured compared with the non-injured side on preoperative coronal CT images. RESULTS:Concerning outcomes, 12, 2, and 4 patients were classified as Groups A, B, and C, respectively, and no patient was classified as Group D. The inferior rectus muscle swelling rate was ≤1.2 in Group A, and 1.6-2.4 in Groups B and C. CONCLUSION:In patients in whom inferior rectus muscle swelling on the injured is ≥1.6 times that on the non-injured side on preoperative coronal CT images, double vision and slight impairment of eye movements may remain after surgery. 10.1016/j.jcms.2010.10.024