Blindness without direct injury to the globe: a complication of facial fractures

Bilateral complete avulsion of ocular globes in a Le Fort III maxillofacial fracture: a case report and review of the literature

PURPOSE

The purpose of this paper is to demonstrate a case of bilateral complete avulsion of the globes following maxillofacial trauma.

METHODS

A 23-year-old man with bilateral complete globe avulsion following a maxillofacial trauma. Both globes were luxated out of the orbit and suspended on the skin of the upper lid below the brows. No direct or indirect light reflexes or any eye movements could be noted. Computerized tomography showed complete lacerations of both optic nerves at a level just anterior to the optic canal. There were also multiple fractures corresponding to Le Fort III fracture with Le Fort II components. The brain parenchyma was normal with an exception of brain edema. As the globes were unsuitable for repositioning, both were enucleated. The maxillofacial fractures were immobilized with plates and screws. Although the patient gained consciousness with normal vital signs in the early postoperative period, he died on the ninth day due to Pseudomonas aeruginosa infection, despite invasive antibiotic treatment.

DISCUSSION

The optic nerve and the globes are very resistant to mild and moderate trauma. The avulsion of the nerve at the canalicular or more posterior level may demonstrate central nervous system complications resulting in life-threatening conditions. The most critical issue in complete globe avulsions with a transected optic nerve is to rescue the vision. In total transected optic nerves the final eyes could only have had cosmetic benefits. In spite of promising experimental research on optic nerve regeneration, there are unknowns, such as the methods to eliminate the risk of anterior segment ischemia and phthisis bulbi.

CONCLUSIONS

Globe avulsions with a complete optic nerve cut remain a challenging problem. More research is required to better understand the pathophysiology of optic nerve repair.

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.

Orbital emphysema and the medial orbital wall: a review of the literature with particular reference to that associated with indirect trauma and possible blindness

Orbital emphysema is not an uncommon finding following fractures of the facial skeleton. Both its significance as a threat to sight and its diagnostic value may well be underestimated. Fractures of the paranasal sinuses may occur as a result of indirect trauma. This article reviews the literature on the subject with particular reference to blindness as a possible sequel. Two cases of orbital wall fracture that occurred as a result of indirect trauma and which produced orbital emphysema are discussed.

Orbital blow-out fractures: long-term visual outcome of associated ocular injuries

Severe ocular injuries are uncommon in patients with pure orbital blow-out fractures. Over a 3-year period, 45 patients with radiologically proved blow-out fractures were reviewed by an ophthalmologist. Decrease in visual acuity was the main clinical finding accompanying significant eye injury. Although most eye injuries were transient, early ophthalmic assessment is recommended to exclude potentially serious complications such as traumatic optic neuropathy. Troublesome diplopia may delay rapid rehabilitation.

The characteristics of midfacial fractures and the association with ocular injury: a prospective study

Ocular injuries commonly occur in patients with facial fractures. This prospective study was set up to determine the incidence of ocular injuries, as assessed by an ophthalmologist, in patients who had sustained midfacial fractures. Over a 2-year period, a study of 363 patients who had sustained midfacial trauma sufficient to lead to a facial bone fracture (438 fractures) was undertaken and patients received a comprehensive examination by an ophthalmologist and an orthoptist within 1 week of injury. The characteristics of the eye injuries sustained were related to the aetiology of the fracture, the type of fracture, and the sex and age of each patient. Ninety percent of patients sustained ocular injuries of various severities. Sixty three percent of patients sustained only minor or transient ocular injuries, 16% suffered moderately severe ocular injury and 12% experienced severe eye injuries. Road traffic accident was associated with the highest incidence of severe ocular disorder (9/45 = 20%) whilst assaults had the second highest incidence at 11% (20/181). One third of all patients with comminuted malar fracture suffered a severe ocular disorder (9/27) whilst blow-out fracture came second at 16.7% (6/36). Fifty six patients (15.4%) had a decrease in their visual acuity and 9 patients (2.5%) had significant traumatic optic neuropathy. Decrease in visual acuity was the main clinical finding accompanying the majority of significant eye injuries. When ocular injuries were related to aetiology, it was apparent that road traffic accidents and assaults associated with alcohol abuse showed the highest incidence of major ocular dysfunction. It is suggested that all patients sustaining midfacial fracture associated with a significant decrease in visual acuity either pre- or postoperatively should have an early ophthalmological review.

Optic nerve blindness following a malar fracture

Optic nerve blindness following a malar fracture is an uncommon and usually permanent complication. When the loss of vision is immediate and total, the prognosis is poor. The case of a patient who suffered immediate and complete loss of vision after a malar fracture is presented. Computed tomography revealed compression of the optic nerve by bony fragments. No improvement was observed after megadose steroids and surgical treatment. The incidence, pathogenesis, diagnostic approach and therapeutic possibilities are discussed and the importance of establishing precisely the moment of the loss of vision is stressed.

Craniofacial trauma

The treatment of combined major dislocations of the face and skull requires a craniofacial team consisting of a plastic maxillofacial surgeon, a neurosurgeon, an anesthesiologist, and radiologists. The best results can only be achieved at the primary intervention both from a functional and an esthetic standpoint. Careful preoperative clinical and radiologic examinations are mandatory to reach these high goals. In primary repair, the cranial approach aims at constructing "a monobloc bone flap" to suture meningeal tears and to reinforce them with a pericranial graft, to close the cranial base completely using cancellous bone grafts, and to exclude the frontal sinuses. The facial skeleton is repaired by constructing a rigid external facial frame and thereafter progressing centrally finishing with the "internal" orbitonasal dislocations. The reconstruction aims at a self-stabilizing bone puzzle fixed with interosseous wires, making external fixation unnecessary. Secondary repair requires osteotomies at fracture sites to reposition malunited fractures and the use of autogenous bone grafts for stabilization.

Fractures of the sphenoid bone

Fractures of the sphenoid bone occur following injury to the orbit and base of the skull. Such fractures are important since they can cause loss of vision and damage to various neural and muscular tissues. Ocular injury is also commonly associated. This paper reviews the hospital records of 112 consecutive patients with fractures of the base of the skull for the cause, frequency of signs and symptoms, and treatment of the sphenoid bone injury. Various deformities and dysfunctions are correlated with imaging data and classified to describe specific clinical syndromes. Several cases of sphenoid bone fracture serve as examples of diagnostic and treatment techniques.

Blindness after trauma insufficient to cause bony injury: case report and review

Over the years, blindness following maxillofacial trauma has been reported by many workers. Although various mechanisms and suggested treatments have been proposed, blindness in the absence of any bony or direct penetrating injury is rare.

Incidence of eye injuries in facial fractures: an analysis of 727 cases

From 1973 to 1980, 727 patients with facial fractures received formal ophthalmologic consultation. The series included 174 mandible fractures, 29 nasal fractures, 436 midfacial fractures, and 88 frontal fractures. Of these, a total of 67% sustained some degree of ocular injuries. Seventy-nine percent of the eye injuries were categorized as temporary, 18% were serious, and 3% were blinding. Of the mandibular fractures, 29% had ocular injuries, 59% nasal fractures, 59% midfacial fractures, and 89% frontal fractures.

Ocular injuries sustained during blunt facial trauma

Ocular and adnexal injuries frequently occur during blunt facial trauma but the actual incidence and visual consequence of these injuries have not been heretofore established in any large series. Our review of 1,436 cases of maxillofacial trauma presenting from 1973-1980 outlines the types of fractures, associated specific ocular injuries, and their visual significance. Fifty-one percent (727) of these patients received complete ophthalmologic examination and 67% of these sustained ocular injuries. Seventy-nine percent of the eye injuries were categorized as temporary, 18% were serious, and 3% were blinding. The positive yield for eye injuries approached or exceeded 60% in nasal, midface, and frontal fractures. These data provide concrete evidence for placing high priority on ophthalmologic consultation in all cases of maxillofacial trauma.

Fronto-orbito nasal dislocations. Initial total reconstruction

The craniofacial trauma can produce compound fractures with bone displacement in the central part of the upper face, i.e. the bones constituting the forehead, orbit, and nose. such dislocations are called fronto-orbito-nasal dislocations. A total and definite surgical reconstruction in one stage offers advantages such as good aesthetic and functional results. An injured person can enter professional and social life without further delay. A major advantage is also the minimizing of the risk of meningeal fistula with infectious mortal risk. A prerequisite for this surgery is accurate clinical and radiological examination to permit a preoperative three-dimensional visualization of the lesions as a basis for careful planning of the operation. The surgical team should include neurosurgeons and plastic surgeons with experience in the maxillofacial area. The operative procedure should start with repair of the orbital frame, beginning at the upper and lateral side, followed by exploration of the four walls of the orbital chamber and of the lacrimal system. The reconstruction then proceeds with the eyelid ligaments and the nervous and vascular pedicles, especially the infra-orbital one, followed by reconstruction of the sinus maxillaris. Afterwards transnasal internal canthopexy wires are placed, the nose reconstructed and bone grafts are used to restore the orbital chamber behind the frame. The lacrimal system is repaired before the tightening of the canthopexies. In cases where neurosurgical intervention is necessary, such as suturing of dura sores or reconstruction of the anterior cranial fossa by bone grafting, this will precede the facial reconstruction. Without a strong frontal cornice it is impossible to restore the nose and orbit. Ocular injuries are treated by ophthalmic surgeons when the orbit is repaired. The last phase of the reconstruction is suturing of the muscular, mucosal and cutaneous lacerations.

Residual complications in patients with major middle third facial fractures

Residual complications associated with middle third facial fractures have been poorly documented in the literature. In the present study, 240 patients with fractures of the middle third of the facial skeleton, who were treated at the Royal Melbourne Hospital, Victoria, between 1969 and 1976, were reviewed to determine the residual complications of these fractures. Cranial complications were relatively uncommon, and 60 % of cases of cerebrospinal fluid rhinorrhoea ceased within 3 days of fracture reduction and fixation. Persistent infraorbital sensory defects occurred in 22 % of patients with Le Fort II or Le Fort III fractures. Orbital complications included diplopia, which remained in 8 % of cases, and was often corrected by secondary surgery. Residual complications involving the nose or maxillary sinus were uncommon (less than 5 %). Occlusal disharmony was present as a residual problem in 19.6 % of cases, although this could be managed by simple means in 89 % of these cases so that primary surgery and simple secondary dental procedures a satisfactory result in 98 % of all patients. The low incidence of dental complications is most likely a result of the rigid fixation employed in the fracture management, allowing accurate control of the bone fragments.