## 4 Discussion  
Orbital wall fractures are very common because of the weakness of the bony structures composing the orbit [3]. In particular, the medial orbital wall is the weakest wall: the lamina papyracea is described as having the thinnest structure (0.2-0.4 mm) and, for this reason, it represents the most fractured orbital wall [1]. The biomechanics of this kind of fracture consists of two theories: the buckling theory, where the force is absorbed and transmitted from the orbital rim to the surrounding anatomical structures, until a point of weakness is encountered, such as the medial orbital wall; and the hydraulic theory, which describes how the force is transferred from the globe to the orbit until the medial orbital wall becomes fractured [11]. In our population, 50% of cases were victims of high kinetic energy events, such as a traffic accident, in line with the trend described in the literature. Causes of trauma such as fighting and sportive accidents were reported in the younger population of the study, while traumas originated from accidental falls involved older patients. We observed that the most significant clinical signs and symptoms, such as diplopia and enophthalmos, derived from traffic accidents, supporting the force transmission theories. The surgical treatment of isolated medial orbital wall fractures is still a much debated topic in the literature because of different surgical access availability [12]. The most used approaches are the cutaneous approaches, such as the subciliary, the transcaruncular, the \"Lynch\" approach, with or without endoscopic assistance, and the pure endoscopic approach with transethmoidal endonasal access [3; 6]. The gradual development and diffusion of endoscopic surgery has reduced the invasiveness of classic surgical procedures and improved aesthetic outcomes, especially in maxillofacial traumatology [5; 7]. Endoscopic assistance in cutaneous approaches improves the operating field view and allows for checking the correct positioning of the selected repairing material. [13]. The advantages of the pure endoscopic approach are represented by the absence of external skin scars, a close and direct visualization of the fracture site, and  
Figure 7: Discrepancy values of nine medial orbital wall points between immediately post treatment affected orbit image and affected orbit at 6 months post treatment for Group A compared with Group B.  
the possibility of not implanting alloplastic material [14; 15]. The most significative limit to this procedure is represented by the long learning curve. In our casuistry, the anteroposterior ethmodectomy was performed after 3 years of experience. For this reason, it was possible to consider two different populations, with and without direct posterior visualization of the medial wall. To reach the fracture, particularly if it is sited behind the lamina basalis of the middle turbinate, it is necessary to pass through some important structures, as normally performed during FESS/ESS surgery. The lamina papyracea is normally encountered on the way to the sphenoid sinus. For this reason, in this approach, the medial orbital wall can be considered a key point, being normally identified during sinus surgery. The anatomical buttressing of the lamina papyracea is unique: despite its thinness, many ethmoidal cell septa perpendicularly support the wall [4]. Another important supporting structure is represented by the middle turbinate (MT), a crucial landmark in the identification of the skull base, ethmoid cells, and lamina papyracea in functional endoscopic sinus surgery (FESS) [7; 16]. The MT is composed of an intranasal part, called the \"lamina recurved\", and an intraethmoidal lamina, the lamina basalis. This second structure describes the entry zone for the posterior ethmoid: to pass gently through this structure plays a key role in maintaining structure long-term stability [9]. The most recent literature was examined to evaluate the different surgical techniques adopted.