Blindness associated with midfacial fractures

Epidemiology of Blindness From Facial Trauma: A Multi-Centre Nigerian Study

Study Design

This is a multi-centre retrospective study.

Objective

To determine the prevalence of blindness and pattern of facial trauma associated with blindness among Nigerians.

Methods

A multi-centre retrospective study of all patients with facial trauma resulting in blindness, that were co-managed by maxillofacial surgeons and ophthalmologists in 4 Nigerian public tertiary hospitals between January 2010 and December 2019 was undertaken. Data was analysed by IBM SPSS Statistics (version 21.0 for windows, IBM© Inc, Chicago, IL).

Results

Of 2070 patients who presented with major facial injuries during the study period, 61 eyes of 56 (2.7%) patients were blind. Blindness was bilateral and unilateral in 5 (8.9%) and 51 (92.1%) patients, respectively. The mean age (SD) at presentation was 36.2 (16.6) years, and 47 (83.9%) of these patients were males. Road traffic accident (n = 27; 48%) was the commonest mechanism of facial trauma, the cheek (n = 18; 40.9%) was the commonest site of associated soft tissue injury and zygomatic complex fracture (n = 19; 24.1%) was the commonest related fracture. Globe rupture (n = 34; 55.7%) was the leading cause of blindness. Enucleation (n = 7; 13.2%) and evisceration (n = 22; 41.5%) were performed on 29 eyes of which 12 (41.4%) patients had ocular prosthesis post-operatively.

Conclusions

Blindness was recorded in 2.7% of Nigerians with facial trauma. The commonest mechanism of trauma and cause of blindness in at least one eye were road traffic accident and globe rupture, respectively. Eye removal surgery was necessary in about half of the blind eyes.

Children in Boxing and Martial Arts Should Be Better Guarded From Facial Injuries

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

Childhood participation in boxing and martial arts has increased over the past decade, and these activities are well-known causes of traumatic injury. We hypothesized that the face is frequently injured in the setting of pediatric boxing and martial arts trauma in the United States and that there are identifiable injury patterns.

METHODS

We performed a cross-sectional study of consecutive pediatric patients in the National Electronic Injury Surveillance System (NEISS) from January 1, 2010 to December 31, 2019. Patients were included in our study if they were younger than 18 years of age and evaluated in the emergency department (ED) after boxing or martial arts trauma. Primary outcome was facial injury. Other variables of interest include age, sex, ED disposition, type and location of injury. Descriptive and univariate statistics of the primary outcome were computed with these variables.

RESULTS

There were 4,978 total pediatric patients injured due to boxing and martial arts trauma reported by NEISS-participating EDs during the study period, and 264 patients experienced injury to the face (264/4978; 5.3%). Over 20% (n = 60) of reported facial injuries were fractures; the most fractured structure was the nose (42/60; 70), orbit (11/60; 18.3%), and mandible (6/60; 10%). Almost 20% (11/60%) of pediatric facial fractures due to boxing and martial arts trauma involved fighting a family member or friend, and a punch was the most common mode of fracture (42/58; 72.4%).

CONCLUSIONS

Facial injuries comprise about 5% of injuries after boxing and martial arts trauma and 22% of these facial injuries are fractures. If children choose to participate, parents, coaches, trainers, officials, and community leaders should make the greatest effort possible to minimize risk, including the mandatory use of head and face protective gear and elimination of training fighting, or "sparring."

A Prospective Study on the Incidence and Outcome of Cranial Nerve Injuries in Patients with Traumatic Brain Injuries

Background Posttraumatic cranial nerve injuries are not uncommon and can occur by shearing forces, rapid acceleration/deceleration, or injury to the skull base. The incidence of cranial nerve injury in craniocerebral trauma varies between 5 and 23 percent in various literature.

Methodology A prospective study was conducted on the incidence and outcome of cranial nerve injuries (CNI) in 256 consecutive cases of traumatic brain injuries (TBI). Patients over the age of 5 years with a follow-up of 6 months in the period from September 2017 to November 2018 in our institution were sampled.

Results A total of 256 patients were included in our study. The incidence of CNI in TBI patients was 14.8% (38 patients). Facial nerve was the most common cranial nerve to be involved, followed by olfactory nerve and vestibulocochlear nerve. Cranial nerve injury was more common in patients with severe head injury (p < 0.005), younger age group, associated base of skull fractures (p < 0.001), and facial fractures (p < 0.005). Twenty-eight patients (73.7%) had a delayed presentation of CNI (p < 0.001). Of the 73.6% patients who recovered, 16 (42%) patients had partial recovery, while 12 (31%) patients had complete recovery. Younger age group (p < 0.05) and delayed onset of deficit (p < 0.001) were associated with significant better outcome.

Conclusions CNI are a major cause of morbidity in TBI patients. All patients admitted with TBI should be examined meticulously for CNI on follow-up.

A Clinical Study of the Evaluation and Assessment of the Etiology and Patterns of Ocular Injuries in Midfacial Trauma in a Tertiary Care Hospital

Aims

The aim is to study the pattern of ocular injuries in midfacial trauma and to evaluate the overall incidence of ophthalmic injury of any severity following maxillofacial trauma.

Methods and Materials

The maxillofacial surgeon conducted routine facial examination of patients with midfacial fractures, which also included a detailed ophthalmologic examination of patients, at the time of initial presentation. These patients were then further evaluated by an ophthalmologist for thorough examination of the eye.

Results

The total number of recorded midface maxillofacial trauma cases was 181. Out of 181 patients, 161 had ocular injuries. Among 181 cases, 161 (88.95%) cases were due to road traffic accidents, which was the prime etiologic factor. Out of total 181 patients, 172 (95.03%) were males and 9 (4.97%) were females. The maximum number of cases were of zygomaticomaxillary complex fractures (44.75%) followed by nasal bone fractures (21.5%). Periorbital ecchymosis accounted for the maximum number of cases, amounting to 61.88%. Loss of vision or blindness was seen in eight (4.42%) patients.

Conclusions

The study stresses further on the importance of long-term and continuous data collection and record management of trauma patients, which may help health care providers with necessary information to develop treatment protocols and device measures for the prevention of complications.

Screening Criteria for Detecting Severe Ocular Injuries in the Setting of Orbital Fractures

PURPOSE

Define incidence of severe ocular trauma in orbital fracture patients and determine if ocular signs and symptoms are useful predictors of severe ocular injuries.

METHODS

Retrospective chart review was performed on all patients with orbital fractures between April 1, 2013, and December 31, 2014. Patients were included if they had radiographic evidence of acute fracture of at least one orbital wall and were evaluated by the Ophthalmology service. Demographics, concurrent injury data, and symptoms and signs of ocular trauma were collected. Concurrent ocular injuries were grouped by severity. Predictive signs or symptoms for severe ocular trauma were identified by stepwise logistic regression analysis. The threshold point for predictive signs and symptoms was detected by a receiver operating characteristic (ROC).

RESULTS

Five-hundred-twelve patients were included. The most common mechanisms of injury were assault (39%), fall (25%), and motor vehicle accident (21%). The incidence of any concurrent ocular trauma was 75% (383/512), with 14% (70/512) being severe. Four signs and symptoms were predictors of severity: blurred vision (P < 0.0001), pain with eye movements (P < 0.0001), visual acuity worse than 20/40 in the ipsilateral eye (P < 0.001), and restricted motility (P < 0.001). The presence of 2 or more of these signs or symptoms was predictive of severe ocular trauma with high sensitivity (91%) and specificity (86%).

CONCLUSIONS

In cooperative patients with acute orbital wall fractures, the presence of 2 or more signs or symptoms is predictive of severe ocular trauma and necessitates the need for urgent ophthalmic consultation.Severe ocular injury associated with orbital wall fracture is more likely in patients with 2 or more ophthalmic signs or symptoms.

Is specialized ophthalmologic evaluation necessary after orbital fractures? A prospective 64-case study

INTRODUCTION AND OBJECTIVE

The objective of this study was to determine whether there is a need for ophthalmologists to perform a specialized assessment after the occurrence of orbital fractures.

MATERIALS AND METHODS

Sixty-three patients (64 orbits) diagnosed with orbital fractures were evaluated preoperatively (up to 24 h after the trauma) and in 90-day postoperative period.

RESULTS

Eight injuries required either specialized clinical or surgical ophthalmologic intervention. Of these patients, four required emergency eye surgery: two patients with corneal lacerations had lesions larger than 2 mm. Two patients had extensive ocular lesions after multiple traumas with uveal exposure and without light perception. Another four patients (iridodialysis associated with lens subluxation, anterior uveitis, direct lesion on the optic nerve, and chorioretinitis sclopetaria) received conservative management.

CONCLUSION

This study concluded that a specialized ophthalmologic examination as soon as possible is important, particularly in cases in which the signs and symptoms of severity are associated. The non-ophthalmologist surgeon must have the basic medical knowledge required to provide basic primary ophthalmologic care and to discern the severity of the injury.

Rehabilitation of an ocular defect with intraorbital implant and custom-made prosthesis using digital photography and gridded spectacle

Accidental trauma involving the eye may necessitate surgical removal of the eye ball. Immediate management should consider future prosthetic rehabilitation. Insertion of eye ball implant after enucleation or evisceration preserves socket anatomy, maintains sulcus and fornix which ensures proper retention of ocular prosthesis in future. Placement of intraorbital ball implant also reduces the weight as well as enhances motility of the prosthesis, thus imparting life-like appearance. Custom-made acrylic prosthesis has been shown to deliver superior functional and esthetic result. Exact positioning of the iris disc on a custom-made scleral blank is critical from esthetic point of view. This clinical report describes prosthetic rehabilitation of an anophthalmic socket where intraorbital ball implant was inserted during evisceration. Custom-made acrylic ocular prosthesis with a prefabricated iris button was used. Here, digital photography and a specially fabricated spectacle gridded with mm scale were used for positioning iris button on the ocular prosthesis. These two methods of centration of iris button may be used to reduce chairside time and increase patient cooperation with a positive clinical outcome.

Blindness after facial trauma: epidemiology, incidence and risk factors: a 27-year cohort study of 5708 patients

OBJECTIVES

This was a 27-year study of a cohort of 5708 patients who had sustained maxillofacial fractures. Our purpose was to present the etiology, mechanism of trauma, site, and concomitant injuries that led to visual loss. We hypothesize that fractures caused by high-energy impact of the midface may be associated with blindness. A discussion of the treatment approaches is also included.

STUDY DESIGN

The study included 5708 patients who had sustained a maxillofacial fracture during the years 1985-2012. Patients' records were reviewed for gender, age, fracture site, etiology of trauma, concomitant injuries, method of treatment, length of hospital stay, and cause of blindness. The relationship of the above variables to blindness was investigated.

RESULTS

The incidence of loss of vision was 0.34%. A very strong association between firearm injuries and blindness was observed (P < .001). These patients spent much longer time in hospital (P < .01) and suffered serious concomitant injuries involving the brain.

CONCLUSIONS

Retrobullbar hemorrhage should be treated with lateral canthotomy, whereas in traumatic optic neuropathy, observation seems to be the safest thing to do. In patients with penetrating injuries of the globe, the immediate involvement of an ophthalmic surgeon is of paramount importance.

Traumatic eye ball luxation: A stepwise approach to globe salvage

Craniofacial trauma is often associated with orbital and ocular injuries. We report a case of a 21-year-old male with motor vehicular accident, orbital roof blow-in fracture, cerebrospinal fluid (CSF) leak, and left sided globe luxation with corneal abrasion and complete conjunctival denuding. The patient was managed by a multispeciality team and the eyeball was protected by amniotic membrane graft (AMG) biological dressing with novel use of inverted sterile metallic bowl as mechanical protection till the patient stabilized. During surgery, eyeball was reposited and ocular surface was reconstructed using amniotic membrane and symblepharon ring. Surgical correction and plating of the facial fractures and dural repair with autologus tensor fascia lata was done. Post surgery ocular surface was intact, ocular motility was well preserved and the globe was prephthisical. Traumatic eyeball luxation is a rare, but dramatic presentation which may occur in a blow in fracture when the intra orbital volume reduces and expels the eye ball out of the socket. This may be associated with extra ocular muscle rupture or optic nerve avulsion. The visual prognosis is nil in majority cases. However, the management is targeted towards globe preservation in view of psychological benefit and ease of cosmetic or prosthetic rehabilitation. Knowing the mechanism of luxation helps to plan the management. A stepwise approach for globe salvage is recommended. Team efforts to take care of various morbidities with special steps to safeguard the eye help to optimize outcomes.

Ocular Injuries in Patients of Zygomatico-Complex (ZMC) Fractures

PURPOSE

Mid face injuries commonly destroy the integrity of the orbital skeleton, and are frequently complicated by injury to the eye, ranging between 2.7 and 90.6 % as reported in literature. The eye injuries range from simple subconjunctival haemorrhage to globe rupture. The paper aims to study the types of ocular injuries in patients with ZMC fractures.

PATIENTS AND METHODS

A study of 67 patients, who had sustained facial trauma sufficient to lead to a facial bone fracture, was undertaken in the department of Oral and Maxillofacial Surgery, Govt Dental College, Srinagar from 2008 to 2014 and the patients received a comprehensive examination by an ophthalmologist within 1 week of injury. All the patients sustaining confirmed ZMC fracture were examined by an ophthalmologist for any associated ocular injury. A thorough ophthalmologic examination included assessment of visual acuity, pupillary reactivity, anterior and posterior segment examination and extraocular motility. The variables reviewed included patient's gender, mechanism of injury, visual acuity, pupillary reactivity, extra ocular motility, presence or absence of diplopia, ocular and orbital findings, and intraorbital hypoesthesia.

RESULTS

The most common etiology of trauma was RTA (64.1 %), followed by falls (14.9 %) in our study. In our study 83.5 % of the patients were males. Minor ocular injuries such as subconjunctival haemorrhage and corneal injury accounted for most of the cases. Subconjunctival haemorrhage was the most common injury, present in 86.5 % of the cases. Hyphema was present 13.4 %, vitreous haemorrhage 2.98 %, retinal haemorrhage 1.49 %, corneal abrasion 4.47 %, mydriasis 1.49 %, choroidal rupture 5.97 %, retinal detachment 2.98 %, decreased visual activity 13.4 %, retinal tear and angle recession was present 7.46 % times.

CONCLUSION

ZMC fractures are associated with higher incidence of ocular injuries. The incidence of traumatic optic neuropathy and other ocular injuries warrants a prompt ophthalmologic examination of all patients with ZMC fractures as quickly as possible to prevent morbidity.

Blunt forehead trauma and optic canal involvement: finite element analysis of anterior skull base and orbit on causes of vision impairment

BACKGROUND

Clinical studies report on vision impairment after blunt frontal head trauma. A possible cause is damage to the optic nerve bundle within the optic canal due to microfractures of the anterior skull base leading to indirect traumatic optic neuropathy.

METHODS

A finite element study simulating impact forces on the paramedian forehead in different grades was initiated. The set-up consisted of a high-resolution skull model with about 740 000 elements, a blunt impactor and was solved in a transient time-dependent simulation. Individual bone material parameters were calculated for each volume element to increase realism.

RESULTS

Results showed stress propagation from the frontal impact towards the optic foramen and the chiasm even at low-force fist-like impacts. Higher impacts produced stress patterns corresponding to typical fracture patterns of the anterior skull base including the optic canal. Transient simulation discerned two stress peaks equalling oscillation.

CONCLUSIONS

It can be concluded that even comparatively low stresses and oscillation in the optic foramen may cause micro damage undiscerned by CT or MRI explaining consecutive vision loss. Higher impacts lead to typical comminuted fractures, which may affect the integrity of the optic canal. Finite element simulation can be effectively used in studying head trauma and its clinical consequences.

Management of tripod fractures (zygomaticomaxillary complex) 1 point and 2 point fixations: A 5-year review

The zygomaticomaxillary complex (ZMC) plays a key role in the structure, function, and esthetic appearance of the facial skeleton. They can account for approximately 40% of mid-face fractures. They are the second most common facial bone fracture after nasal bone injuries. The fracture complex results from a direct blow to the malar eminence and results in three distinct fracture components that disrupt the anchoring of the zygoma. In addition, the fracture components may result in impingement of the temporalis muscle, trismus (difficulty with mastication) and may compromise the infraorbital foramen/nerve resulting in hypesthesia within its sensory distribution. A 4-year retrospective review of all patients treated with ZMC fractures at oral and maxillofacial surgery department, sree balaji dental college and hospital was performed. Computed tomography scans were reviewed. Demographics, treatment protocols, outcomes, complications, reoperations, and length of follow-up were identified. A total of 245 patients was identified by the Current Procedural Terminology codes for ZMC fractures. Closed or open reduction methods were performed with the goal of treatment being preservation of normal facial structure, sensory function, globe position, and mastication functionality. Unacceptably poor surgical outcomes are uncommon. Significant facial asymmetry requiring surgical revision occurs in 3-4% of patients. Postoperative infection rates are extremely low, and these infections nearly always resolve with oral antibiotics. In general, the long-term prognosis after repair of ZMC fractures is very good.

Reconstructive dilemma after blindness

Blindness associated with mid-facial fractures is rare. Here we present a case of panfacial fracture associated with loss of vision of right eye. The reconstruction of left orbital region posed a challenge, as post surgical vision loss can be a remote complication. Through this case report we highlight our dilemma and describe the different philosophies adopted by other specialties in management.

Vehicle occupant restraint systems impact on eye injuries: a review

Vehicle occupant trauma to the eyes and associated facial structures has evolved rapidly in conjunction with safety-oriented vehicle design, including restraint systems. Trends vary worldwide with culture, personal factors, vehicle safety equipment, and the traffic environment-including physical, legislative, and enforcement. Wearing safety belts is essential to occupant protection. Airbags were designed as a supplement to protect the head from hard surfaces in frontal crashes, not as a primary countermeasure. Even where vehicle fleets are new with high airbag prevalence, but safety culture and knowledge of restraints is less than robust, injury attributable to not wearing seatbelts is frequent, especially in countries where high-powered vehicles are prevalent. Upper bodies of rapidly forward-moving unrestrained occupants collide with rearward-accelerating airbags. Airbag deployment produces injuries such as corneal abrasions, alkali burns, and the effects of globe compression.

Evaluation of the relationship between the pattern of midfacial fractures and amaurosis in patients with facial trauma

PURPOSE

To evaluate the relation between patterns and numbers of midfacial bone fracture patterns and amaurosis in traumatized patients.

MATERIALS AND METHODS

This is a cross-sectional study of traumatized patients with midfacial fractures who presented to Shahid Rajaee and Chamran hospitals (Shiraz, Iran) from 2010 through 2011. The predictor variable was midfacial fractures and the outcome variable was amaurosis. P < .05 was considered statistically significant.

RESULTS

The study was composed of 112 subjects. Prevalence of amaurosis was 6.25% (7 of 112). Le Fort III fracture was the only fracture pattern that had a significant association with amaurosis (P = .004). Nasoorbitoethmoid fracture was the second most correlative pattern, although this relation was not statistically significant.

CONCLUSIONS

This study showed a meaningful relation between Le Fort III fractures and amaurosis in patients with facial trauma. There was also a high prevalence of nasoorbitoethmoid fracture in blinded patients.

Complications in pediatric facial fractures

Despite recent advances in the diagnosis, treatment, and prevention of pediatric facial fractures, little has been published on the complications of these fractures. The existing literature is highly variable regarding both the definition and the reporting of adverse events. Although the incidence of pediatric facial fractures is relative low, they are strongly associated with other serious injuries. Both the fractures and their treatment may have long-term consequence on growth and development of the immature face. This article is a selective review of the literature on facial fracture complications with special emphasis on the complications unique to pediatric patients. We also present our classification system to evaluate adverse outcomes associated with pediatric facial fractures. Prospective, long-term studies are needed to fully understand and appreciate the complexity of treating children with facial fractures and determining the true incidence, subsequent growth, and nature of their complications.

Role of the maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fractures

Aim:

This study was designed to evaluate the incidence of severe ocular injuries associated to maxillofacial fractures and report their management in the Emergency Department.

Patients and Methods:

Among the 1779 patients admitted for maxillofacial fractures, those with partial or total loss of vision at the time of emergency consultation were included in the study. Data collected from the patients’ medical records included age, gender, mechanism of injury, location and type of facial fractures, type of ocular injuries and cause of blindness, methods of treatment, and days of hospitalization.

Results:

Forty patients (2.2%), 32 men and 8 women, ranging from 17 to 85 years of age, presented with severely reduced vision or blindness associated to fractures of the facial middle third with involvement of one or more orbital walls, mainly caused by motor vehicle and work accidents. In 18 patients, severe ocular injuries were determined by direct lesion of the globe, in 14 by direct or indirect traumatic optic neuropathy and in 8 by a retrobulbar hematoma. Direct lesion of the eyeball was treated by prompt repair or enucleation of the globe, though no or little recovery of vision was obtained. Ophthalmologic and/or maxillofacial treatment of the anterior compartment lesions of the eye allowed a partial or total recovery of the vision. A partial or total recovery of the vision was observed in almost all the patients with indirect traumatic optic neuropathy after administration of steroids according to NASCIS II protocol. Likewise, an evident improvement of the vision was obtained by immediate drainage of retrobulbar hematoma.

Conclusions:

Early diagnosis of the nature of the ophthalmic injury and treatment are important, and involvement of the ophthalmologist is mandatory.

Facial fractures - association with ocular injuries: A 13-year review of one practice in a tertiary care centre

BACKGROUND

The incidence of ocular injury associated with facial fractures has been reported to be between 0.8% and 30%.

OBJECTIVE

Because of this wide range of incidences, a system to stratify the risk of ocular injury by type of facial fracture was sought.

METHODS

The present study reviewed 266 patients with facial fractures to determine the risk factors for ocular injury. The anatomy of each facial fracture was classified using an orbit-centred approach according to the number of orbital walls fractured. Patients were then grouped using this classification system. Charts documenting follow-up for each patient over a minimum of one year were examined and initial emergency room presentations of patients with subsequent visual impairment were recorded.

RESULTS

The incidence of severe visual impairment and blindness was 4.5% overall. Although all facial fractures (including isolated fractures of the mandible) had a notable incidence of ocular injury, an increased number of orbital wall fractures were correlated with an increased incidence of permanent visual disability. One of 147 (0.68%) patients without an orbital wall fracture sustained permanent severe ocular injury or blindness, while 13.5% (five of 37) of three-wall orbital fracture patients and 25% (four of 16) of four-wall orbital fracture patients sustained the same injury.

CONCLUSIONS

The risk of ocular injury in complex facial fractures can be stratified by the degree of orbital wall involvement. However, because all patients with persistent visual impairment had ocular findings on initial examination, it is proposed that oculovisual testing is a more sensitive indicator of lasting ocular injuries than the type of facial fracture.

Blindness caused by retrobulbar hemorrhage (orbital compartment syndrome)

A szerző osztályán 2007 augusztusától 2010 márciusáig 199 arcközéptörést szenvedett beteg közül öt betegnél alakult ki a sérülést követően retrobulbaris haematoma (2,5%). Ezen betegek közül négy vesztette el véglegesen és teljesen szeme világát az érintett oldalon. Egy betegnél az időben történt beavatkozás a szemet megmentette. A szerző a különböző osztályokról gyakorlatilag vak állapotban érkezett betegek retrospektív analízisét ismerteti. Az orbitatörés miatt létrejövő, szemgolyó mögötti vérzés – retrobulbaris haematoma – és oedema a kevéssé tágulni képes orbitában gyors nyomásfokozódást okoz – orbitakompartment-szindróma –, és emiatt alakul ki a nervus opticus ischaemiája, nekrózisa és a következményes vakság. A retrobulbaris haematoma tüneteinek (proptosis, chemosis, ecchymosis, ophthalmoplegia, mydriasis), illetve panaszainak észlelésekor (fájdalom, diplopia, látásélesség-csökkenés, majd vakság) azonnal elkezdett gyógyszeres (intravénás szteroid, mannitol, acetazolamid kombináció) és sebészi kezelés (lateralis canthotomia, cantholysis és orbitadekompresszió) esélyt adhat a beteg szemének, látásának megmentéséhez, ellenkező esetben már akár 20 percen túl is irreverzíbilis, végleges vakság alakul ki. A retrobulbaris haematoma leírása és kezelése nem szerepel a magyar egyetemi tankönyvek tananyagában, ezért, sajnos, a betegekkel először találkozó kollégák – amint azt a bemutatott esetek történetei is jelzik – bizonytalanok a diagnózist, a sürgősséget és a tennivalókat illetően. A szerző hiánypótlásként foglalja össze a tünetegyüttest és a kezelés lehetőségeit. A kórkép ismerete mellett elképzelhető, hogy az előfordulás gyakoribb, mint gondolnánk. A korrekt betegellátás céljából lehetséges, hogy az egyetemi, illetve posztgraduális képzésben is szükség lenne a betegség ismertetésére. Orv. Hetil., 2010, 38, 1537–1544.

When is a retrobulbar haemorrhage not a retrobulbar haemorrhage?

Retrobulbar haemorrhage (RBH) is a well described condition which is said to be a common cause of acute proptosis following trauma, but the evidence for this is not strong. The authors reviewed 186 publications on the subject, finding 82 cases of RBH related to trauma. This analysis suggests that in over half of the cases described, RBH was never proven conclusively. In the authors' experience RBH is not a common cause of acute proptosis following trauma and other causes need to be considered if patients are to be managed appropriately.

Blindness following facial fracture: treatment modalities and outcomes

Blindness is an uncommon, yet documented complication of facial trauma. Numerous case studies, series, and retrospective analyses have been published, with a reported incidence around 3%. Hippocrates first noted the association between maxillofacial trauma and blindness; millennia later, this was expounded upon by Berlin, who discovered such trauma may directly lead to fracturing of the optic canal. As diagnostic modalities such as computed tomographic scanning evolved, particularly over the past few decades, more specific, in-depth reports analyzing maxillofacial trauma and subsequent sequelae have emerged. It is the goal of this article to examine the current literature for those publications that have addressed the issue of blindness following facial trauma (including operative interventions) and create a concise review for maxillofacial surgeons.

Ocular injuries in patients with major trauma

AIM

To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures.

METHODS

A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma.

RESULTS

Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs).

CONCLUSION

The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.

[Blindness following reduction of a malar fracture]

Blindness is the most serious injury to the eye following a midfacial fracture. The onset of blindness complicating the midfacial fracture may be immediate (with the trauma), delayed (hours to days), or postoperative. The incidence of postoperative blindness lies between 0.3 and 8.3%. There are multiple mechanisms responsible for blindness but the most common reason with about 66% is probably increased intraorbital pressure attributable to intraorbital hemorrhage. The management of surgical decompression of the orbit for acute blindness is essential when treatment of a midfacial fracture is intended. Acute orbital compartment syndrome can effectively be relieved by lateral canthotomy and cantholysis and administration of high doses of corticosteroids. Further possibilities of surgical decompression of the orbit are discussed in this case report with postoperative irreversible blindness after reduction of a malar fracture and rapidly performed surgical decompression.

Blindness and visual impairment from severe midface trauma in Nigerians

Reports have shown that severe midface trauma causes blindness and visual impairment but information from sub-Saharan Africa is sparse. A retrospective analysis was carried out of patients who sustained trauma to the midface and subsequently lost vision in one or both eyes. There were 25 males and 7 females whose ages ranged from 5 to 65 years (mean +/- SD, 33 +/- 13.3 years). All patients presented between 1 h and 7 days of sustaining injury (mean +/- SD, 1.9 +/- 1.9 days). Road traffic accidents (37.5%) and gunshot injuries (34.4%) were the commonest causes. Of the 32 patients identified with loss of vision, half sustained fractures of the zygomatic complex while a total of 54 soft-tissue and bony injuries were recorded. The majority of patients (68.8%) had a ruptured globe, followed by vitreoretinal haemorrhage and traumatic optic neuropathy in 18.7% and 12.5%, respectively. Visual acuity ranged from 6/60 to 'no light perception'. Surgical exploration, enucleation, evisceration or exenteration was the treatment method used for those with ruptured globes. About 10.8% of patients with severe midface trauma also sustained loss of vision in one eye. Loss of vision associated with severe midface trauma is most likely to occur with road traffic accidents and gunshot injuries. High impact from such incidents often causes extensive damage to the eyeball resulting in immediate and irreversible blindness.

Diagnosis and Treatment of Orbit Posttraumatic Subperiosteal Hemorrhage in a Child, Associated with a Subdural Intracranial Hemorrhage

We describe a rare case of traumatic subperiosteal orbital hematoma in a child, with intracranial hemorrhagic complication. Subperiosteal hematoma are the more infrequent occurrences among intraorbital hemorrhagic lesions and can be also associated with intracranial extradural hematoma in patients with orbital roof fracture. Here, we describe a case without roof fracture but with a never-before described intracranial subdural hematoma. The patient underwent computed tomography and magnetic resonance imaging, in an acute state, and later, a radiologic diagnosis of percutaneous drainage of the hematoma was mad. MRI was more sensitive and specific in the evaluation of the intracranial and intraorbital complication.

Surgical Timing in Orbital Fracture Treatment: Experience with 108 Consecutive Cases

Orbital fractures can lead to esthetic deformities and functional impairments, and adequate surgical timing is considered important in obtaining good results from surgery. By means of chart review, a retrospective analysis was carried out in 108 consecutive cases of pure orbital fractures to investigate the differences in surgical timing and the correlations with patient age and clinical and radiographic findings. In this analysis, surgical timing of pure orbital fractures was strongly related to the combination of parameters such as anatomical location of the fracture, eventual exposure of the fracture, cerebrospinal fluid (CSF) leakage or penetrating wounds, age of patients, eventual functional impairments or muscle entrapment, and serious conditions of compression or ischemia. As the data confirmed, an urgent approach was considered indispensable in severe orbital apex fractures and in orbital fractures with CSF leakage, penetrating objects, or exposure. Early surgery was necessary within 3 days in children with diplopia (type IIIb) and mainly within 7 days in adults with double vision (type IIIa). Delayed surgery, within 12 days in all cases, was performed orbital wall fractures with no impairments (type II) or in orbital rim fractures (type I). Data from this retrospective analysis confirm the need for an aggressive approach to all orbital fractures. In our experience, surgery was performed within 12 days and most orbital fractures were treated during the first week after trauma, which is earlier than previously reported.

Ocular and periocular injuries from orbital fractures

BACKGROUND

Orbital fractures are associated with ocular and periocular injuries. The role of the ophthalmologist in the evaluation and management of facial trauma, including orbital fractures, has not been clearly defined. The purpose of this study is to identify and characterize ocular and periocular injuries associated with orbital fractures to define the role of the ophthalmologist in the management of facial trauma.

STUDY DESIGN

Retrospective case review.

RESULTS

Three hundred sixty-five patients with orbital fractures who were evaluated by an ophthalmologist as part of their initial trauma evaluation were studied. The majority of the patients with orbital fractures (74%) did not have associated ocular or periocular injuries. Twenty-three of 104 (22%) ocular injuries in 23 of 95 (24%) patients required immediate intervention by an ophthalmologist.

CONCLUSIONS

Facial trauma and orbital fractures are associated with significant ocular and periocular injuries, the minority of which require immediate evaluation and treatment by an ophthalmologist. These results differ from those previously reported.

Traumatic optic neuropathy

Our concepts of optic nerve trauma and its treatment are evolving. Traditionally, optic nerve trauma was thought of as the syndrome of blunt force to the forehead causing visual loss, but iatrogenic injury is increasingly recognized as an important source of optic nerve trauma. Our understanding of this trauma as a type of brain injury is also evolving. For the past decade, it has been clinical dogma that high-dose methylprednisolone is beneficial in the treatment of optic nerve trauma. However, little clinical evidence has shown this to be the case, raising questions about whether methyprednisolone has any benefit in the treatment of optic nerve trauma. Increasingly, research in neuroprotection is thought to hold promise for the development of novel and effective treatments for optic nerve injury.