Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
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Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study* Faaiz Alhamdani a, *, Justin Durham b, Mark Greenwood b, Ian Corbett b a b
Oral and Maxillofacial Department, College of Dentistry Al-Mustansiria University, Baghdad, Iraq Oral and Maxillofacial Surgery Department, School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 February 2015 Accepted 27 May 2015 Available online xxx
Objective: To investigate diplopia (binocular single vision [BSV] test) and ocular motility (uniocular field of fixation [UFOF] test) characteristics in blow-out fractures of the orbit and their value in fracture management. Material and methods: Patients with isolated blow-out fractures treated from 2000 to 2010 were included. BSV scores were stratified into three categories: low BSV category (0e60); moderate BSV category (61e80), and high BSV category (81e100). UFOF scores were also divided into three categories: low score (60e240), moderate score (241e270), and high score (271e365) categories. Results: A total of 183 patients (106 surgically and 77 conservatively managed) met the inclusion criteria. There was no significant improvement in BSV postoperatively in surgically managed patients with preoperatively high BSV, whereas there was significant improvement (p < 0.05) for the high BSV category in the conservative group. Preoperative BSV was found to be significantly related (p < 0.05) to postoperative BSV, subjective diplopia outcome, follow-up time, and number of follow-up visits. However, improvement of BSV score in the surgical group was not found to be significantly correlated with subjective outcome in relation to diplopia. Preoperative UFOF score has no influence on subjective outcome in relation to diplopia. Surgical timing, approach, and choice of implant material were not found to be statistically related to final diplopia outcome, follow-up time, or number of follow-up visits. Conclusions: BSV is better correlated with diplopia outcome, follow-up time, and number of follow-up visits than is UFOF. On the basis of this study, surgical intervention would not be recommended for blow-out fracture cases with BSV score >80% for correction of diplopia alone. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Orbital trauma Blow-out fracture Diplopia Management outcome
1. Introduction Management of isolated orbital blow-out fractures remains a topic of controversy (Alinasab et al., 2012). General consensus suggests that surgical intervention is indicated in cases of persistent diplopia, enophthalmos, or large defects, which may result in late enophthalmos (Turnbull et al., 2007). However, the criteria for diplopia, as an indication for surgery, as described in the literature is predominantly subjective, for example; ‘persistent troublesome diplopia’, ‘severe’, or ‘visually handicapping diplopia.’ (Cole et al., 2007; Biesman et al., 1996). Conversely, enophthalmos has more
* This study was a part of PhD project funded by Almustansiriya University and sponsored by Newcastle University and NHS. * Corresponding author. Tel.: þ964 7706047791. E-mail address: [email protected] (F. Alhamdani).
objective management criteria, with intervention suggested for enophthalmos of 2 mm or more and fracture defect greater than 2 cm2 or more than 50% (Putterman, 1991). In addition, it is generally accepted that when surgical intervention is indicated, early intervention, as far as the patient's condition permits, is advocated. Such general protocols have been adopted in numerous clinical studies investigating the evaluation and treatment of blowout fracture (Hawes and Dortzbach, 1983; Jaquiery et al., 2007). Despite the adoption of such criteria, surgical outcome, in terms of ocular motility and diplopia, in the last 2 decades has been less than ideal (Harris, 2006), with persistent postoperative diplopia frequently reported (Hosal and Beatty, 2002). Ocular motility disturbances in orbital injuries are usually assessed by Hess chart. The reliance of orbital trauma studies on Hess charts, only, makes diplopia subjectively represented and difficult to evaluate (Sveinsson, 1973). Attempts have been made to
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Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
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F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
quantify the Hess chart (Aylward et al., 1992; Furuta et al., 2006), although these have not been widely adopted. Furuta et al. (2006) used Hess area ratio (HAR) measurement to express the ocular motility in numerical values by comparing the Hess chart values between the affected and healthy sides. The authors reported that most of the patients with HAR% of >85% experienced no diplopia. It is hypothesised that the lack of such unifying quantitative clinical measures for the assessment of diplopia has hampered the progression in management of blow-out injury of the orbit (Hammer et al., 1995; Van Eeckhoutte et al., 1998). The terms “diplopia” and “ocular motility disturbance” have been used frequently in orbital fracture studies interchangeably (Egbert et al., 2000; Lee et al., 2005). Diplopia is the clinical manifestation of ocular motility disturbance. For the measurement of diplopia, a binocular single vision (BSV) test using a Goldmann Perimeter has been recommended for the routine evaluation of orbital trauma patients, providing a simple reliable method for quantifying diplopia (Kim and Woo, 1999; Banks, 2007). The uniocular field of fixation (UFOF) test provides an additional quantitative assessment of ocular motility, plotting the primary field of action of each of the six individual ocular muscles, again using a Goldmann perimeter (Haggerty et al., 2005). This test has been used in ocular motility assessment for Graves ophthalmology patients with different methods (Steel et al., 1995; Haggerty et al., 2005); however, its use in orbital trauma has not previously been reported. The aim of this retrospective study was to investigate the value of two objective measures, BSV and UFOF, in the management of blow-out fractures of the orbit. 2. Material and Methods Patients attending the Orthoptic Department, Royal Victoria Infirmary, Newcastle upon Tyne, following orbital trauma in the period 2000e2010 inclusive were identified from a patient database. Patients' records were obtained and hand searched for the following information: demographic information; date of injury, presentation, and subsequent attendances; clinical findings; orthoptic examination; orbital surgery; ophthalmology examination; and BSV and UFOF scores. Included in the study were patients who had a computed tomography (CT) e confirmed blow-out fracture involving orbital floor and/or medial wall, who were managed surgically or conservatively, in the period 2000e2010 inclusive, with recorded preoperative and postoperative BSV scores available. Excluded were patients who sustained orbital fractures involving orbital margins identified either pre- or perioperatively. Orthoptic examinations included weighted BSV (Sullivan et al., 1992) and UFOF tests for both affected and unaffected sides. UFOF scores were taken as the sum score for the 6 extraocular muscles (Haggerty et al., 2005). Departmental policy for patients undergoing surgery was to have at least two BSV measurements performed by an orthoptist, one taken shortly after presentation and the other postoperatively. For conservatively managed patients, one orthoptic examination was requested. At the time of the first orthoptic visit, patients were also examined by an ophthalmologist. For statistical analysis BSV scores were stratified into three categories: low BSV category (0e60); moderate BSV category (61e80), and high BSV category (81e100). UFOF scores were similarly stratified into low score (60e240), moderate score (241e270), and high score (271e365) categories. At the final orthoptic review, a subjective assessment of diplopia was made by the orthoptist, categorising patients as “asymptomatic,” “not concerned by diplopia,” “symptomatic,” and “requiring further measures.” Further measures included provision of prism glasses and strabismus surgery.
Collected data were analysed using SPSS version 17 software. Statistical analyses were performed using the Wilcoxon signed ranks test to determine the statistical difference between data that was not normally distributed. The Pearson correlation was used to test statistical correlation between interval data, and the c2 was used to determine the statistical relation for nominal data. Correlation analysis between ordinal data was performed using the Spearman test. 3. Results Of 391 patients identified from the orthoptic database, 259 patients were recorded as having isolated blow-out fractures. Surgery was performed in 152 patients, leaving 107 patients who were conservatively managed. A total of 183 patients (106 surgically and 77 conservatively managed) were included in the study. However, only 87 patients (70 from the surgical group and 17 from the conservative group) had complete follow-up data (Fig. 1). This might be related to a failure to record data correctly in the patient records. Failure to record information accurately also affected the quality of the available follow-up data for surgical patients, with 56 of 70 patients having complete data to discharge. The patients ranged from 9 to 80 years of age, with a median age of 35 years. Of the patients, 19 were female and 68 were male. As shown in Fig. 2, diplopia was the most common presenting complaint, with a low incidence of enophthalmos at presentation in this group. Reported ophthalmic injuries included corneal abrasion, conjunctival chemosis, hyphema, traumatic mydriasis, peripheral retinal haemorrhage, and commotio retinae. Table 1 shows the timeline of patient management. More than 50% of the surgical cases were treated within the first 2 weeks of the injury (Fig. 3), and 12.5% were treated more than 1 month after the injury. Most of these were late presenters. The surgical approach for the vast majority of the cases was the first skin crease incision. The conjunctival approach was the least-used approach (7% of the cases) in this sample (Fig. 4). A Silastic sheet was the most common implant material, followed by titanium mesh. Bone graft was used in less than 9% of the cases. Only two cases were managed without placement of implant material (Fig. 5). Surgical timing and
Fig. 1. Flow chart with included patients' groups
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
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Fig. 2. Findings on presentation.
Table 1 Patient management timelines. Variable
Minimum
Maximum
Mean
Median
Patient age, y Time (days) from injury to presentation (surgical group) Time (days) from injury to orthoptic Time (days) from injury to surgery Time (in days) from surgery to postoperative orthoptic Follow-up time (mo) Number of follow-up visits
9 1 1 1 14 0.5 1
80 37 60 134 130 15 7
36.33 7.36 12.55 18.84 43.93 5 2.25
35 4 8 14 36 3 1
Fig. 3. Timing of surgical intervention.
Fig. 4. Surgical approaches for surgically treated patients.
implant material choice were not significantly related (p > 0.05) to postoperative BSV (BSV2) score. An example of plotted BSV maps is shown in Fig. 6. The median BSV1 for the presurgical group was 59.5%, whereas the median BSV1 for the conservative group was 86% (Table 2). Of the included cases, 55 fall in the low BSV category and 88 fall in the high BSV category, leaving 40 cases in the moderate BSV category. There was a highly statistically significant relationship (p < 0.001) between preoperative BSV (BSV1) and postoperative BSV (BSV2) for the surgical group. Also, there was a highly significant relationship (p < 0.001) between UFOF1 and both BSV1 and BSV2. There was significant difference between preoperative and postoperative BSV scores in both low and middle BSV categories (p < 0.001 and p < 0.05 respectively) in the surgical group. The high BSV category, however, showed no significant (p > 0.05) change (Fig. 7). In contrast, there was a significant difference (p < 0.05) in
Fig. 5. Implant materials for defect repair.
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
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F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
Fig. 6. Example of BSV maps for conservatively and surgically managed patients.
Table 2 Descriptive statistics for orthoptic data.
UFOF normal side BSV1 surgical group UFOF1 surgical group BSV1 conservative group UFOF1 conservative group
Minimum
Maximum
Mean
Median
202 0 61 0 191
342 97 334 100 319
282.98 48.84 234.14 72.65 260.5
281.5 59.5 237 86 262
BSV, binocular single vision; UFOF, uniocular field of fixation.
the BSV score for the high BSV category (n ¼ 11) in the conservative management group (paired t-test). The time between the first and second orthoptic examination ranged between 10 days and 2 weeks. More than half of the surgical patients reported symptomatic diplopia as a subjective orthoptic outcome (Fig. 8). These patients showed variable degrees of improvement, although residual diplopia was present in at least one field of gaze. There was a negative relationship between BSV1 score and the final diplopia outcome categories (p < 0.05) (Fig. 9). BSV1 also was found to be statistically related to the follow-up time and number of the followup visits (p < 0.01). The level of improvement in BSV score was found to be directly related to the follow-up time (p < 0.05). However, BSV
Fig. 7. Change in the means of BSV categories for surgical group.
improvement was not significantly related to the subjective outcome in relation to diplopia (p > 0.05). A significant relationship also was found between UFOF1 and the number of follow-up visits (p < 0.05). However, there was no significant relationship (p > 0.05) between UFOF1 and the final diplopia outcome and the follow-up time for the surgical group. The surgical timing and the choice of implant material were not significantly related to the BSV score improvement, subjective
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
Fig. 8. Final outcome categories in relation to diplopia.
Fig. 9. Mean BSV1 and BSV2 for each diplopia outcome category.
diplopia outcome, follow-up time, or number of follow-up visits (p > 0.05). 4. Discussion The main focus of this study was to investigate the possible factors might influence ocular motility and diplopia in blow-out fractures of the orbit. In relation to enophthalmos, there has been, over the last decade, general agreement about the relation of orbital size changes and resultant enophthalmos. In addition, diplopia, which is the most important complication of orbital blowout fracture (Percy, 1971), appears to be the main factor in management dilemmas. BSV measurement, using a Goldman Perimeter, has been suggested as the gold standard for diplopia assessment (Holmes et al., 2005). It has been recommended for routine evaluation of orbital trauma patients by several authors, providing a simple reliable method for quantifying diplopia (Stocker et al., 2005). Despite such reports, BSV has not been reported routinely in the literature. The UFOF test provides a quantifiable alternative to Hess charts. This current study demonstrates that UFOF scores correlate with both preoperative and postoperative BSV and the number of follow-up visits. UFOF has not previously been reported in orbital trauma studies. The need for surgical intervention is frequently decided subjectively, based on persistent diplopia, with a fracture confirmed on computed tomography. Baseline orthoptic examination has been used to support the clinical decision rather than as an indicator of the need for surgery. Our data suggest that BSV score thresholds may be of value in determining the need for treatment. Surgical
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patients in the low BSV category (80%) demonstrated no overall improvement in terms of postoperative BSV score. Conservatively managed patients within the same BSV score category, however, showed significant improvement within 2 weeks. This may suggest that a period of watchful waiting is indicated in orbital fracture patients with a high BSV, before undertaking surgery. Although there is general consensus that delaying surgery is not advisable, there is a disagreement about what constitutes delay, with “early management” ranging between 1 week and 2 months of injury (Kuttenberger et al., 2008). In the current study, the vast majority of the patients were treated within 30 days from the injury and more than half within 14 days, which is a widely adopted time frame (Kiel and Chen, 2001; Gosse et al., 2009). Some authors have found that ocular motility disturbances could be successfully corrected even 3 months after trauma (Hinohira et al., 2008). This would support the delay in intervention for fractures with high BSV to determine spontaneous improvement. Timing of surgery in this study was not found to have an influence on BSV2, the reported final diplopia outcome, or the number of the follow-up visits. Jin et al. also found that surgical timing was not statistically related to postoperative diplopia. They considered surgical timing to be crucial in cases with trapdoor fractures with extraocular muscle entrapment (Jin et al., 2007). However, this disagrees with a report by Hosal and Beatty, who found significant relation between timing of surgery and postoperative diplopia (Hosal and Beatty, 2002). The reason for this disagreement may be attributed to the difference in the subjective criteria for diplopia. This further demonstrates the need for unifying quantitative measurement criteria for diplopia. Putterman believes that orbital surgery after 5 weeks is unlikely to improve the ocular motility disturbances for such cases in which extraocular muscle surgery is appropriate (Putterman, 1991). Interestingly, our data showed that there was no significant influence of BSV improvement after surgery over the subjective diplopia outcome, despite the functional scoring criteria adopted in this study. The absence of a significant relation between BSV improvement and subjective diplopia outcome might be explained by the fact that patients with low BSV1 could still end up with a moderate BSV2, despite significant improvement in BSV score. However, patients with high BSV1 with little improvement will still have high BSV2. In this case series, the orthoptic follow-up time exceeded 1 year for some patients (up to 7 postoperative visits), dictated by the level of diplopia and resolution. The mean and median follow-ups were 5 and 3 months, respectively, with about 50% of surgical patients having only 1 visit. Studies published to date have reported variable postoperative follow-up periods, with little agreement about follow-up protocols (Poeschl et al., 2011). Orgel suggested review on a monthly basis; however, the end point was not stated (Orgel, 1971). Management controversy in blow-out fractures of the orbit has been attributed to the absence of clear criteria for surgical versus conservative management (Mustaffa et al., 2008), a reflection of personal preference (Courtney et al., 2000) and multi-disciplinary intervention (Yano et al., 2009). It should be noted, however, that surgery does not address direct extraocular muscle injury (Iliff et al., 1999); indeed, muscle injury may occur during surgical manipulation (Kugelberg, 1998). Iliff et al. stated that close proximity of the inferior rectus muscle to the orbital floor in posterior orbit makes it more susceptible to contusion after fracture. In the anterior half of the orbit, the extraocular muscles are protected by a cushion of extramuscular fat (Iliff et al., 1999). Stocker et al. found
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
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that patients with posterior blow-out fractures generally have lower BSV scores compared to patients with anterior fractures (Stocker et al., 2006). It seems that direct muscle injury as a result of this type of trauma has not received enough attention in terms of surgical treatment. The primary aim of surgical repair for blow-out fracture is to minimise orbital soft tissue damage and to restore a full field of functional binocular single vision (Carroll and Ng, 2010). This is usually achieved through releasing of the herniated or entrapped orbital tissue in the fracture defect. However, tissue involvement in orbital blow-out fracture, which surgery aims to rectify, is not the only influential factor on ocular motility. Damage to the fibroefattyemuscular complex should be considered in this type of injury (Koornneef, 1982). Therefore, the outcome of surgery might be unpredictable, as the extent of orbital tissue damage and its contribution to ocular motility deficit may not be readily determined at the time of injury. The controversy regarding surgical intervention versus conservative management may not reflect only the inability to predict, on clinical basis, who would recover from the ocular motility disturbances (Gosse et al., 2009), but may be related, as our data showed, to the limited role of surgery in terms of timing, approach, and the type of implant material in improving the ocular motility outcome. Evidently surgery does not provide the ideal solution for all ocular motility problems in this type of trauma. About 80% of our patients presented with variable degrees of diplopia postoperatively. Furthermore, patients with low preoperative diplopia scores that showed better improvement in comparison with higher BSV scores, which might justify surgical intervention, were at risk for unfavourable outcomes. Koornneef believed that repair of a pure blowout fracture by placement of an implant may not address the real cause of the diplopia, which is disruption of the ligament system and septa (Koornneef, 1982). This could be the reason why diplopia is unlikely to be completely corrected by surgery (Stassen and Kerawala, 2007), which concurs with our findings. One drawback of this study was the lack of follow-up data relating to conservatively managed patients, the majority having only a single orthoptic visit. Measurement of diplopia score improvement (BSV) for this group would have provided us with quantitative measurements to compare the surgical versus conservative approaches. Because of lack of adequate follow-up data from the conservatively managed patient group, it would be difficult to suggest definitive guidelines for the management of blowout fractures of the orbit. 5. Conclusions BSV has better correlation with diplopia outcome, follow-up time and number of follow-up visits than UFOF. On the basis of this study, surgical intervention would not be recommended for blow-out fracture patients with BSV scores >80% for correction of diplopia alone.
Conflict of interests There are no financial competing interests in relation to this manuscript. Acknowledgement This study was part of PhD project funded by Al-Mustansiria University and sponsored by NHS and Newcastle University.
The authors would like to thank Mrs. Kate Taylor for her great assistance in using the collection of patients' data from the orthoptic database in RVI Hospital e Newcastle.
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Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study* Faaiz Alhamdani a, *, Justin Durham b, Mark Greenwood b, Ian Corbett b a b
Oral and Maxillofacial Department, College of Dentistry Al-Mustansiria University, Baghdad, Iraq Oral and Maxillofacial Surgery Department, School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 February 2015 Accepted 27 May 2015 Available online xxx
Objective: To investigate diplopia (binocular single vision [BSV] test) and ocular motility (uniocular field of fixation [UFOF] test) characteristics in blow-out fractures of the orbit and their value in fracture management. Material and methods: Patients with isolated blow-out fractures treated from 2000 to 2010 were included. BSV scores were stratified into three categories: low BSV category (0e60); moderate BSV category (61e80), and high BSV category (81e100). UFOF scores were also divided into three categories: low score (60e240), moderate score (241e270), and high score (271e365) categories. Results: A total of 183 patients (106 surgically and 77 conservatively managed) met the inclusion criteria. There was no significant improvement in BSV postoperatively in surgically managed patients with preoperatively high BSV, whereas there was significant improvement (p < 0.05) for the high BSV category in the conservative group. Preoperative BSV was found to be significantly related (p < 0.05) to postoperative BSV, subjective diplopia outcome, follow-up time, and number of follow-up visits. However, improvement of BSV score in the surgical group was not found to be significantly correlated with subjective outcome in relation to diplopia. Preoperative UFOF score has no influence on subjective outcome in relation to diplopia. Surgical timing, approach, and choice of implant material were not found to be statistically related to final diplopia outcome, follow-up time, or number of follow-up visits. Conclusions: BSV is better correlated with diplopia outcome, follow-up time, and number of follow-up visits than is UFOF. On the basis of this study, surgical intervention would not be recommended for blow-out fracture cases with BSV score >80% for correction of diplopia alone. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Orbital trauma Blow-out fracture Diplopia Management outcome
1. Introduction Management of isolated orbital blow-out fractures remains a topic of controversy (Alinasab et al., 2012). General consensus suggests that surgical intervention is indicated in cases of persistent diplopia, enophthalmos, or large defects, which may result in late enophthalmos (Turnbull et al., 2007). However, the criteria for diplopia, as an indication for surgery, as described in the literature is predominantly subjective, for example; ‘persistent troublesome diplopia’, ‘severe’, or ‘visually handicapping diplopia.’ (Cole et al., 2007; Biesman et al., 1996). Conversely, enophthalmos has more
* This study was a part of PhD project funded by Almustansiriya University and sponsored by Newcastle University and NHS. * Corresponding author. Tel.: þ964 7706047791. E-mail address: [email protected] (F. Alhamdani).
objective management criteria, with intervention suggested for enophthalmos of 2 mm or more and fracture defect greater than 2 cm2 or more than 50% (Putterman, 1991). In addition, it is generally accepted that when surgical intervention is indicated, early intervention, as far as the patient's condition permits, is advocated. Such general protocols have been adopted in numerous clinical studies investigating the evaluation and treatment of blowout fracture (Hawes and Dortzbach, 1983; Jaquiery et al., 2007). Despite the adoption of such criteria, surgical outcome, in terms of ocular motility and diplopia, in the last 2 decades has been less than ideal (Harris, 2006), with persistent postoperative diplopia frequently reported (Hosal and Beatty, 2002). Ocular motility disturbances in orbital injuries are usually assessed by Hess chart. The reliance of orbital trauma studies on Hess charts, only, makes diplopia subjectively represented and difficult to evaluate (Sveinsson, 1973). Attempts have been made to
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Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
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F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
quantify the Hess chart (Aylward et al., 1992; Furuta et al., 2006), although these have not been widely adopted. Furuta et al. (2006) used Hess area ratio (HAR) measurement to express the ocular motility in numerical values by comparing the Hess chart values between the affected and healthy sides. The authors reported that most of the patients with HAR% of >85% experienced no diplopia. It is hypothesised that the lack of such unifying quantitative clinical measures for the assessment of diplopia has hampered the progression in management of blow-out injury of the orbit (Hammer et al., 1995; Van Eeckhoutte et al., 1998). The terms “diplopia” and “ocular motility disturbance” have been used frequently in orbital fracture studies interchangeably (Egbert et al., 2000; Lee et al., 2005). Diplopia is the clinical manifestation of ocular motility disturbance. For the measurement of diplopia, a binocular single vision (BSV) test using a Goldmann Perimeter has been recommended for the routine evaluation of orbital trauma patients, providing a simple reliable method for quantifying diplopia (Kim and Woo, 1999; Banks, 2007). The uniocular field of fixation (UFOF) test provides an additional quantitative assessment of ocular motility, plotting the primary field of action of each of the six individual ocular muscles, again using a Goldmann perimeter (Haggerty et al., 2005). This test has been used in ocular motility assessment for Graves ophthalmology patients with different methods (Steel et al., 1995; Haggerty et al., 2005); however, its use in orbital trauma has not previously been reported. The aim of this retrospective study was to investigate the value of two objective measures, BSV and UFOF, in the management of blow-out fractures of the orbit. 2. Material and Methods Patients attending the Orthoptic Department, Royal Victoria Infirmary, Newcastle upon Tyne, following orbital trauma in the period 2000e2010 inclusive were identified from a patient database. Patients' records were obtained and hand searched for the following information: demographic information; date of injury, presentation, and subsequent attendances; clinical findings; orthoptic examination; orbital surgery; ophthalmology examination; and BSV and UFOF scores. Included in the study were patients who had a computed tomography (CT) e confirmed blow-out fracture involving orbital floor and/or medial wall, who were managed surgically or conservatively, in the period 2000e2010 inclusive, with recorded preoperative and postoperative BSV scores available. Excluded were patients who sustained orbital fractures involving orbital margins identified either pre- or perioperatively. Orthoptic examinations included weighted BSV (Sullivan et al., 1992) and UFOF tests for both affected and unaffected sides. UFOF scores were taken as the sum score for the 6 extraocular muscles (Haggerty et al., 2005). Departmental policy for patients undergoing surgery was to have at least two BSV measurements performed by an orthoptist, one taken shortly after presentation and the other postoperatively. For conservatively managed patients, one orthoptic examination was requested. At the time of the first orthoptic visit, patients were also examined by an ophthalmologist. For statistical analysis BSV scores were stratified into three categories: low BSV category (0e60); moderate BSV category (61e80), and high BSV category (81e100). UFOF scores were similarly stratified into low score (60e240), moderate score (241e270), and high score (271e365) categories. At the final orthoptic review, a subjective assessment of diplopia was made by the orthoptist, categorising patients as “asymptomatic,” “not concerned by diplopia,” “symptomatic,” and “requiring further measures.” Further measures included provision of prism glasses and strabismus surgery.
Collected data were analysed using SPSS version 17 software. Statistical analyses were performed using the Wilcoxon signed ranks test to determine the statistical difference between data that was not normally distributed. The Pearson correlation was used to test statistical correlation between interval data, and the c2 was used to determine the statistical relation for nominal data. Correlation analysis between ordinal data was performed using the Spearman test. 3. Results Of 391 patients identified from the orthoptic database, 259 patients were recorded as having isolated blow-out fractures. Surgery was performed in 152 patients, leaving 107 patients who were conservatively managed. A total of 183 patients (106 surgically and 77 conservatively managed) were included in the study. However, only 87 patients (70 from the surgical group and 17 from the conservative group) had complete follow-up data (Fig. 1). This might be related to a failure to record data correctly in the patient records. Failure to record information accurately also affected the quality of the available follow-up data for surgical patients, with 56 of 70 patients having complete data to discharge. The patients ranged from 9 to 80 years of age, with a median age of 35 years. Of the patients, 19 were female and 68 were male. As shown in Fig. 2, diplopia was the most common presenting complaint, with a low incidence of enophthalmos at presentation in this group. Reported ophthalmic injuries included corneal abrasion, conjunctival chemosis, hyphema, traumatic mydriasis, peripheral retinal haemorrhage, and commotio retinae. Table 1 shows the timeline of patient management. More than 50% of the surgical cases were treated within the first 2 weeks of the injury (Fig. 3), and 12.5% were treated more than 1 month after the injury. Most of these were late presenters. The surgical approach for the vast majority of the cases was the first skin crease incision. The conjunctival approach was the least-used approach (7% of the cases) in this sample (Fig. 4). A Silastic sheet was the most common implant material, followed by titanium mesh. Bone graft was used in less than 9% of the cases. Only two cases were managed without placement of implant material (Fig. 5). Surgical timing and
Fig. 1. Flow chart with included patients' groups
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
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Fig. 2. Findings on presentation.
Table 1 Patient management timelines. Variable
Minimum
Maximum
Mean
Median
Patient age, y Time (days) from injury to presentation (surgical group) Time (days) from injury to orthoptic Time (days) from injury to surgery Time (in days) from surgery to postoperative orthoptic Follow-up time (mo) Number of follow-up visits
9 1 1 1 14 0.5 1
80 37 60 134 130 15 7
36.33 7.36 12.55 18.84 43.93 5 2.25
35 4 8 14 36 3 1
Fig. 3. Timing of surgical intervention.
Fig. 4. Surgical approaches for surgically treated patients.
implant material choice were not significantly related (p > 0.05) to postoperative BSV (BSV2) score. An example of plotted BSV maps is shown in Fig. 6. The median BSV1 for the presurgical group was 59.5%, whereas the median BSV1 for the conservative group was 86% (Table 2). Of the included cases, 55 fall in the low BSV category and 88 fall in the high BSV category, leaving 40 cases in the moderate BSV category. There was a highly statistically significant relationship (p < 0.001) between preoperative BSV (BSV1) and postoperative BSV (BSV2) for the surgical group. Also, there was a highly significant relationship (p < 0.001) between UFOF1 and both BSV1 and BSV2. There was significant difference between preoperative and postoperative BSV scores in both low and middle BSV categories (p < 0.001 and p < 0.05 respectively) in the surgical group. The high BSV category, however, showed no significant (p > 0.05) change (Fig. 7). In contrast, there was a significant difference (p < 0.05) in
Fig. 5. Implant materials for defect repair.
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
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Fig. 6. Example of BSV maps for conservatively and surgically managed patients.
Table 2 Descriptive statistics for orthoptic data.
UFOF normal side BSV1 surgical group UFOF1 surgical group BSV1 conservative group UFOF1 conservative group
Minimum
Maximum
Mean
Median
202 0 61 0 191
342 97 334 100 319
282.98 48.84 234.14 72.65 260.5
281.5 59.5 237 86 262
BSV, binocular single vision; UFOF, uniocular field of fixation.
the BSV score for the high BSV category (n ¼ 11) in the conservative management group (paired t-test). The time between the first and second orthoptic examination ranged between 10 days and 2 weeks. More than half of the surgical patients reported symptomatic diplopia as a subjective orthoptic outcome (Fig. 8). These patients showed variable degrees of improvement, although residual diplopia was present in at least one field of gaze. There was a negative relationship between BSV1 score and the final diplopia outcome categories (p < 0.05) (Fig. 9). BSV1 also was found to be statistically related to the follow-up time and number of the followup visits (p < 0.01). The level of improvement in BSV score was found to be directly related to the follow-up time (p < 0.05). However, BSV
Fig. 7. Change in the means of BSV categories for surgical group.
improvement was not significantly related to the subjective outcome in relation to diplopia (p > 0.05). A significant relationship also was found between UFOF1 and the number of follow-up visits (p < 0.05). However, there was no significant relationship (p > 0.05) between UFOF1 and the final diplopia outcome and the follow-up time for the surgical group. The surgical timing and the choice of implant material were not significantly related to the BSV score improvement, subjective
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
F. Alhamdani et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e7
Fig. 8. Final outcome categories in relation to diplopia.
Fig. 9. Mean BSV1 and BSV2 for each diplopia outcome category.
diplopia outcome, follow-up time, or number of follow-up visits (p > 0.05). 4. Discussion The main focus of this study was to investigate the possible factors might influence ocular motility and diplopia in blow-out fractures of the orbit. In relation to enophthalmos, there has been, over the last decade, general agreement about the relation of orbital size changes and resultant enophthalmos. In addition, diplopia, which is the most important complication of orbital blowout fracture (Percy, 1971), appears to be the main factor in management dilemmas. BSV measurement, using a Goldman Perimeter, has been suggested as the gold standard for diplopia assessment (Holmes et al., 2005). It has been recommended for routine evaluation of orbital trauma patients by several authors, providing a simple reliable method for quantifying diplopia (Stocker et al., 2005). Despite such reports, BSV has not been reported routinely in the literature. The UFOF test provides a quantifiable alternative to Hess charts. This current study demonstrates that UFOF scores correlate with both preoperative and postoperative BSV and the number of follow-up visits. UFOF has not previously been reported in orbital trauma studies. The need for surgical intervention is frequently decided subjectively, based on persistent diplopia, with a fracture confirmed on computed tomography. Baseline orthoptic examination has been used to support the clinical decision rather than as an indicator of the need for surgery. Our data suggest that BSV score thresholds may be of value in determining the need for treatment. Surgical
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patients in the low BSV category (80%) demonstrated no overall improvement in terms of postoperative BSV score. Conservatively managed patients within the same BSV score category, however, showed significant improvement within 2 weeks. This may suggest that a period of watchful waiting is indicated in orbital fracture patients with a high BSV, before undertaking surgery. Although there is general consensus that delaying surgery is not advisable, there is a disagreement about what constitutes delay, with “early management” ranging between 1 week and 2 months of injury (Kuttenberger et al., 2008). In the current study, the vast majority of the patients were treated within 30 days from the injury and more than half within 14 days, which is a widely adopted time frame (Kiel and Chen, 2001; Gosse et al., 2009). Some authors have found that ocular motility disturbances could be successfully corrected even 3 months after trauma (Hinohira et al., 2008). This would support the delay in intervention for fractures with high BSV to determine spontaneous improvement. Timing of surgery in this study was not found to have an influence on BSV2, the reported final diplopia outcome, or the number of the follow-up visits. Jin et al. also found that surgical timing was not statistically related to postoperative diplopia. They considered surgical timing to be crucial in cases with trapdoor fractures with extraocular muscle entrapment (Jin et al., 2007). However, this disagrees with a report by Hosal and Beatty, who found significant relation between timing of surgery and postoperative diplopia (Hosal and Beatty, 2002). The reason for this disagreement may be attributed to the difference in the subjective criteria for diplopia. This further demonstrates the need for unifying quantitative measurement criteria for diplopia. Putterman believes that orbital surgery after 5 weeks is unlikely to improve the ocular motility disturbances for such cases in which extraocular muscle surgery is appropriate (Putterman, 1991). Interestingly, our data showed that there was no significant influence of BSV improvement after surgery over the subjective diplopia outcome, despite the functional scoring criteria adopted in this study. The absence of a significant relation between BSV improvement and subjective diplopia outcome might be explained by the fact that patients with low BSV1 could still end up with a moderate BSV2, despite significant improvement in BSV score. However, patients with high BSV1 with little improvement will still have high BSV2. In this case series, the orthoptic follow-up time exceeded 1 year for some patients (up to 7 postoperative visits), dictated by the level of diplopia and resolution. The mean and median follow-ups were 5 and 3 months, respectively, with about 50% of surgical patients having only 1 visit. Studies published to date have reported variable postoperative follow-up periods, with little agreement about follow-up protocols (Poeschl et al., 2011). Orgel suggested review on a monthly basis; however, the end point was not stated (Orgel, 1971). Management controversy in blow-out fractures of the orbit has been attributed to the absence of clear criteria for surgical versus conservative management (Mustaffa et al., 2008), a reflection of personal preference (Courtney et al., 2000) and multi-disciplinary intervention (Yano et al., 2009). It should be noted, however, that surgery does not address direct extraocular muscle injury (Iliff et al., 1999); indeed, muscle injury may occur during surgical manipulation (Kugelberg, 1998). Iliff et al. stated that close proximity of the inferior rectus muscle to the orbital floor in posterior orbit makes it more susceptible to contusion after fracture. In the anterior half of the orbit, the extraocular muscles are protected by a cushion of extramuscular fat (Iliff et al., 1999). Stocker et al. found
Please cite this article in press as: Alhamdani F, et al., Diplopia and ocular motility in orbital blow-out fractures: 10-year retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.05.022
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that patients with posterior blow-out fractures generally have lower BSV scores compared to patients with anterior fractures (Stocker et al., 2006). It seems that direct muscle injury as a result of this type of trauma has not received enough attention in terms of surgical treatment. The primary aim of surgical repair for blow-out fracture is to minimise orbital soft tissue damage and to restore a full field of functional binocular single vision (Carroll and Ng, 2010). This is usually achieved through releasing of the herniated or entrapped orbital tissue in the fracture defect. However, tissue involvement in orbital blow-out fracture, which surgery aims to rectify, is not the only influential factor on ocular motility. Damage to the fibroefattyemuscular complex should be considered in this type of injury (Koornneef, 1982). Therefore, the outcome of surgery might be unpredictable, as the extent of orbital tissue damage and its contribution to ocular motility deficit may not be readily determined at the time of injury. The controversy regarding surgical intervention versus conservative management may not reflect only the inability to predict, on clinical basis, who would recover from the ocular motility disturbances (Gosse et al., 2009), but may be related, as our data showed, to the limited role of surgery in terms of timing, approach, and the type of implant material in improving the ocular motility outcome. Evidently surgery does not provide the ideal solution for all ocular motility problems in this type of trauma. About 80% of our patients presented with variable degrees of diplopia postoperatively. Furthermore, patients with low preoperative diplopia scores that showed better improvement in comparison with higher BSV scores, which might justify surgical intervention, were at risk for unfavourable outcomes. Koornneef believed that repair of a pure blowout fracture by placement of an implant may not address the real cause of the diplopia, which is disruption of the ligament system and septa (Koornneef, 1982). This could be the reason why diplopia is unlikely to be completely corrected by surgery (Stassen and Kerawala, 2007), which concurs with our findings. One drawback of this study was the lack of follow-up data relating to conservatively managed patients, the majority having only a single orthoptic visit. Measurement of diplopia score improvement (BSV) for this group would have provided us with quantitative measurements to compare the surgical versus conservative approaches. Because of lack of adequate follow-up data from the conservatively managed patient group, it would be difficult to suggest definitive guidelines for the management of blowout fractures of the orbit. 5. Conclusions BSV has better correlation with diplopia outcome, follow-up time and number of follow-up visits than UFOF. On the basis of this study, surgical intervention would not be recommended for blow-out fracture patients with BSV scores >80% for correction of diplopia alone.
Conflict of interests There are no financial competing interests in relation to this manuscript. Acknowledgement This study was part of PhD project funded by Al-Mustansiria University and sponsored by NHS and Newcastle University.
The authors would like to thank Mrs. Kate Taylor for her great assistance in using the collection of patients' data from the orthoptic database in RVI Hospital e Newcastle.
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