Ocular and periocular injuries associated with an isolated orbital fracture depending on a blunt cranial trauma: Anatomical and surgical aspects

Are Orbital Fracture Location, Visual Disturbances, and Head Injury Associated With Severe Ocular and Periocular Injuries? A Retrospective Cohort Study

BACKGROUND

Cranio-maxillofacial fractures involving the orbits are common and may be associated with severe ocular and periocular injuries (OPOIs) requiring prompt management.

PURPOSE

The purpose of the study was to measure the association between orbital fracture (OF) location, visual disturbances (VDs), head injury (HI), and OPOI severity.

STUDY DESIGN, SETTING, AND SAMPLE

A retrospective cohort study was conducted at the University Hospital of Geneva (2008-2021). Inclusion criteria are as follows: subjects ≥18 years with OF due to blunt trauma, who underwent head computed tomography, comprehensive ophthalmological assessment, and had ≥1-year follow-up.

EXCLUSION CRITERIA

subjects <18 years, prior orbital/ophthalmic surgery, penetrating trauma, prior monocular or nonstereoscopic vision, lack of ophthalmological assessment, insufficient clinical data, or follow-up <1 year.

PREDICTOR VARIABLES

Predictors included OFs (categorized by anatomic location), VD (subjective/objective visual acuity decrease or diplopia), and HI, defined as (a) loss of consciousness, (b) Glasgow Coma Scale score, and/or (c) intracranial hemorrhage.

MAIN OUTCOME VARIABLE

The primary outcome was OPOI severity. Severe OPOI was defined as requiring immediate ophthalmic treatment (performed without delay or within 6 hours), while nonsevere OPOI did not require immediate intervention.

COVARIATES

Covariates included demographic and injury-related parameters.

ANALYSES

Descriptive, bivariate, and multivariate multinomial logistic regression analyses were performed to identify factors associated with OPOIs. Statistical significance was set at P ≤ .05.

RESULTS

The study included 824 patients (mean age: 47.2 ± 23.6 years), the majority of whom were male (n = 580; 70.4%). Adjusted analysis showed severe OPOIs were associated with medial orbital wall fractures (odds ratio [OR], 3.54; 95% CI, 1.78-7.07; P < .01); VD (OR, 3.57; 95% CI, 1.92-6.66; P < .01); HI (OR, 1.99; 95% CI, 1.06-3.74; P = .03) and older age (OR: 1.02; 95% CI: 1.01-1.03; P < .01).

CONCLUSION AND RELEVANCE

Within the limitations of the study, it appears that medial OFs, VD, HI, and older age are associated with severe OPOIs. These findings may help guide early risk assessment and management in patients with OFs.

Factors Associated with Ocular Injury in Orbital Fracture Patients: Who Requires Urgent Ophthalmic Evaluation?

Importance: Create validated criteria to identify orbital fracture patients at higher risk for significant ocular injuries. Objective: Determine history and physical examination findings in orbital fracture patients who are associated with ocular injury and warrant urgent assessment by an ophthalmologist. Design, Setting, and Participants: Retrospective chart review of 535 adult orbital fracture patients evaluated at a Level I emergency department between 2014 and 2017, without prior history of orbital fracture, ocular injury, or ocular/orbital surgery. Main Outcomes and Measure: Presence of ocular injury. Results: In total, 195 (36%) patients had an ocular injury. Those with and without ocular injury were compared in a multivariate logistic regression model including demographics, fracture characteristics, injury mechanism, and physical examination findings. Visual acuity change, radiographic retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye all had significant associations with ocular injury when other findings were controlled. Conclusion: This study shows a significant association between ocular injury and visual acuity change, retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye. These factors can help triage when to obtain an urgent ophthalmology consult.

Orbital Wall Fractures and Ocular Injury: Impact on Management

Background: Orbital wall fractures are often associated with concomitant ocular injury. In some cases, detection and treatment of such injuries requires ophthalmology evaluation. Study Objective: To identify a change in ocular management as a result of ophthalmology evaluation in patients with orbital wall fractures. Materials and Methods: Retrospective cohort, patients >18 years of age with orbital wall fracture, and prompt evaluation by an ophthalmologist from 2012 to 2020 in a tertiary Level 1 trauma center. Results: Fifty percent of patients had a moderate and/or severe ocular injury. Ophthalmology evaluation led to an ocular management change in 27% of patients. Patients with eyelid laceration, extra-ocular motion (EOM) abnormality, and pupillary defect were more likely to have a change in management. There was no delay of surgical bony fracture management. Conclusion: In patients with midface trauma including orbital wall fractures those with eyelid laceration, EOM abnormality, and pupillary defect were likely to undergo ocular management change as a result of ophthalmology consultation.

Magnetic resonance imaging for three-dimensional printing of the bony orbit: is clinical use imminent?

The aim of this study was to examine the accuracy of three dimensionally (3D) printed models of the bony orbit derived from magnetic resonance imaging (MRI) for the purpose of preoperative plate bending in the setting of orbital blowout fracture. Retrospective computed tomography (CT) and MRI data from patients with suspected orbital fractures were used. Virtual models were manually generated and analysed for spatial accuracy of the fracture margins. 3D-printed models were produced and orbital fan plates bent by a single operator. The plates were then digitized and analysed for spatial discrepancy using reverse engineering software. Seven orbital blowout fractures were evident in six orbits. Analysis of the virtual models revealed high congruence between blowout fracture margins on CT and MRI (n=7, average deviation 0.85mm). Three zygomaticomaxillary complex fractures were seen, for which MRI did not demonstrate the same accuracy. For plates bent to the 3D-printed models of blowout fractures (n=6), no significant difference was found between those bent to CT versus those bent to MRI when compared for average surface and average border deviation (Wilcoxon signed rank test). Orbital blowout fractures can be defined on MRI with clinically acceptable accuracy. 3D printing of orbital biomodels from MRI for bending reconstructive plates is an acceptable and accurate technique.

Orbital Trauma

The orbit is contained within a complex bony architecture with overlying soft tissue that involves many important anatomical structures. Orbital trauma is a frequent cause of damage to these structures. The authors review the literature on reconstructive techniques focusing on fractures of the orbital rim, orbital roof, orbital floor, medial orbital wall, and naso-orbito-ethmoid complex. A thorough literature review was conducted using PubMed analyzing articles relevant to the subject matter. Various search terms were used to identify articles regarding orbital trauma presentation, diagnosis, management, as well as postoperative complications. Articles were examined by all authors and pertinent information was gleaned for the purpose of generating this review. Orbital trauma can result in a wide variety of complications in form and function. Not all orbital fractures require operative repair. However, bony disruption can cause enophthalmos, hypophthalmos, telecanthus, epiphora, cerebrospinal fluid leaks, orbital hematoma, and even blindness to name a few. Timing of operative repair as well as reconstructive method is dictated by the patient's individual presentation. Successful fracture management requires a detailed understanding of the anatomy and pathophysiology to ensure restoration of the patients' preoperative state. Orbital trauma encompasses a wide variety of mechanisms of injury and resulting fracture patterns. A variety of surgical approaches to the orbit exist as has been discussed allowing the surgeon access to all area of interest. Regardless of the fracture complexity, the principles of atraumatic technique, anatomic reduction, and stable fixation apply in all cases.

Ophthalmological injuries associated with fractures of the orbitozygomaticomaxillary complex

Our aim was to evaluate ophthalmological injuries associated with fractures of the orbitozygomaticomaxillary complex that required operative treatment, and we collected data retrospectively over a period of five years (2012-2016 inclusive). Of the 190 patients, 162 were male with a median age of 31 (IQR 25 -39) years. Assault was the most common mechanism of injury (125/190, 66%). Minor ophthalmic injuries (those unlikely to cause permanent visual disturbance) and major ophthalmic injuries (those with the potential to cause permanent visual disturbance) were recorded. The common minor ophthalmic injuries were: diplopia, enophthalmos, proptosis, subconjunctival haemorrhage, and restriction of the extraocular muscles. Commotio retinae, traumatic mydriasis, retro-orbital haemorrhage, and hyphaema were the common major ophthalmic injuries. All 13 different major ophthalmic injuries were recorded in the group who had had orbital fractures reconstructed, which suggested that more intraocular damage can be caused by this type of fracture than by others. Visual acuity was reduced in 26/190 patients with only four having persistent postoperative changes at six weeks. The odds ratio for those patients who had a major ophthalmological injury and were unable to drive was 0.07 (95% CI 0.02 to 0.21, p=0.001), which was highly significant. Ophthalmological assessment is strongly recommended for patients with fractures of the orbitozygomaticomaxillary complex.

Surgical Treatment of Posttraumatic Ophthalmoplegia Through the Reconstruction of the Lateral Orbital Wall

Orbital fractures are injuries frequently related to traumas of the midface. These fractures can be associated with ocular lesions, ranging from small abrasions on the cornea to serious complications such as hyphema and ocular globe rupture. Diplopia and ophthalmoplegia are common findings in orbital fractures. They can be caused by mechanical factors as bone fragments or muscle imprisonment. The aim of this study was to report a case of a 40-year patient, male showing diplopia and ophthalmoplegia due to the orbital fracture. The patient was treated by general anesthesia. It was performed a supra orbital approach and the fragments were removed. A titanium mesh to restore the orbital anatomy was installed. After 40 days of follow-up, the patient has no aesthetic or functional complaints. In orbital traumas, the ophthalmological evaluation should be performed carefully aiming to avoid ocular sequelaes. In surgical patients, the surgery should be done as early as the clinical conditions permit, to restore the ocular function.

Isolated orbital roof blow-in fracture

We report a rare case of a right orbital roof blow-in fracture in a 40-year-old male with concomitant basal skull fracture and intracranial hemorrhage after a fall backward. Trauma, neurosurgery, ophthalmology, and maxillofacial surgery consultations were obtained. Conservative, non-surgical management was recommended for all injuries, and outpatient follow up for orbital fracture with no surgery offered.

Peribulbar anesthesia causing bilateral orbital hemorrhage

We report a case of bilateral orbital hemorrhage as a complication of peribulbar anesthesia in a 78 year old man. Initially, unilateral orbital hemorrhage occurred but quickly spread to the contralateral side. Neuroophthalmological assessment revealed a proptosed tense globe with normal retinovascular findings. Visual acuity was adversely affected and this was conservatively managed with no lasting ophthalmic sequela. This patient’s case was reported as it illustrates an unusual complication of bilateral spread of orbital hemorrhage secondary to peribulbar anesthesia. It highlights how early ophthalmic assessment can ensure a good visual outcome in the setting of appropriate ophthalmic monitoring. The mechanisms of orbital hemorrhage spread and appropriate management options are discussed.

Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury

OBJECTIVES/HYPOTHESIS

Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient's history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision.

STUDY DESIGN

A retrospective clinical chart review was performed at a tertiary academic medical center.

METHODS

Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test.

RESULTS

In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P = 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P = 0.0029 and 0.0001, respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P = 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury.

CONCLUSION

Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Subjects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment.

LEVEL OF EVIDENCE

IV.

Diplopia and driving: a problematic issue

The aim of this article was to review the literature regarding diplopia and driving license and to review the West European legislations about this topic, in order to obtain appropriate indications for hospitals specialists and patients. A systematic review of articles published about diplopia and driving was performed. In addition a review of West European national legislations about driving license regulations for medical illnesses was performed, in addition to the European Union Directive on driving licenses. In the literature, the presence of diplopia has not been considered a reliable predictor of the safety of driving behavior, or it has not appeared to be a contraindication for driving according to some authors who were unable to demonstrate significant differences on driving simulator performance between subjects with chronic stable diplopia and control subjects. Nevertheless, in all western European legislations, acute diplopia constitutes an important limitation for driving, thus making the knowledge of current regulations fundamental for specialists involved in managing patients with diplopia. Ophthalmologists and maxillofacial/head and neck surgeons, may advise patients before hospital discharge about current legislations in their respective countries.

3-D analysis of dislocation in zygoma fractures

OBJECTIVE

When fractured, zygomas rotate and dislocate. The present study quantitatively elucidates the pattern of the rotation.

METHODS

50 patients with tri-pod-type zygoma fractures were involved in this study. After defining a 3-dimensional coordinate system--consisting of the M-L axis (the axis directed from the medial to lateral side of the skull), I-S axis (directed from the inferior to superior side), and P-A axis (directed from the posterior to anterior side), the degree with which the fractured zygomas rotated around each of these axes was measured using 3-dimensional graphic software. Thereafter, the tendency of the rotation was compared between the three rotational axes.

RESULTS

Rotation around the I-S axis was the most frequent with a 96% incidence, followed by a substantial margin by rotation around the M-L axis with a 26% incidence; rotation around the P-A axis was rare, with an incidence of 10%. Furthermore, the degree of P-A axis rotation was minor compared to I-S and M-L axis rotations.

CONCLUSION

The main factor of zygoma dislocation in zygoma fracture is rotation around the I-S axis. This finding is helpful for effective performance to reposition fractured zygomas.

Endoscopic transmaxillary transMüller's muscle approach for decompression of superior orbital fissure: a cadaveric study with illustrative case

BACKGROUND

In an effort to avoid the damage and inconvenience associated with transcranial approaches, we developed an endoscopic transmaxillary transMüller's muscle approach for decompression of the superior orbital fissure (SOF).

METHODS

The endoscopic transmaxillary transMüller's muscle route was performed in ten cadaveric heads. We measured important anatomic landmarks, and angles radiographically. This approach was initially attempted in one patient with traumatic superior orbital fissure syndrome (tSOFS).

RESULTS

A maxillary antrostomy was carried out with a buccal sulcus incision. The sinus ostium and the course of infraorbital nerve were used as endoscopic anatomic landmarks. Then the inferior orbital fissure was drilled out, followed by separating the Müller's muscle. The periorbita were peeled off from the lateral wall, followed by the endoscope going along the periorbital space, until the lateral aspect of the SOF could be visualized. Decompression was successfully performed in all specimens. The initial clinical application justified this approach. The patient had an uneventful postoperative course and satisfactory recovery.

CONCLUSION

This approach offers sufficient endoscopic visualization and reliable decompression of SOF. It avoids the need for brain retraction, temporalis muscle manipulation, or any external incision, and appears to be able to deliver satisfying aesthetic results as well as favourable functional recovery.

Post-operative orbital haematomas over a 12-year period. A description of three cases among 280 orbital procedures

PURPOSE

To evaluate the incidence of orbital haematoma requiring surgical treatment following procedures including fracture repairs and orbital osteotomies over a 12-year period and to discuss their management.

METHODS

The records of all the patients who underwent a procedure involving the orbits from 1998 to 2011 were reviewed for evidence of post-operative haematomas. Medical data including clinical presentation, time between diagnosis and treatment, management and subsequent outcome were collected.

RESULTS

280 patients were included, 257 procedures for orbital or zygomato orbital fractures and 23 osteotomies for dysthyroid orbitopathy or malunited orbital fractures. Three cases (1.07%) of post-operative haematomas were observed as follows: 2/257 orbital fractures (0.77%) and 1/23 osteotomies (4.34%). All cases occurred in the early post-operative period of less than 6 h. No spontaneous loss of vision or pain was described by patients. All could be operated on as soon as the diagnosis was established; no CT-scans were required. Orbital drainage was successfully performed in all cases.

CONCLUSION

Post-operative orbital haematomas are uncommon complications. Diagnosis is based on a clinical examination, including pain, proptosis and alteration in visual acuity. Surgical treatment should be undertaken immediately following diagnosis.