A C T A 0 P H T H A L M 0 L O G IC A
68 (1990) 118-124
Orbital blowout fractures the influence of age on surgical outcome R. J. Leitch, J. P. Burke and I. M. Strachan Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield,England
Abstract. We report the frequency of troublesome diplopia in 17 patients (11 patients 6 2 1 years) who underwent surgical repair of traumatic orbital blowout fractures. Thirteen patients had primary surgery performed within 21 days of injury, 2 patients at 4 and 6 weeks and 2 cases at 6 and 24 months. The latter continues to complain of diplopia. Contrary to previous studies, we found that young patients were no more likely to suffer from symptomatic post-operative residual diplopia than their adult counterparts. Key Words: diplopia - visual loss - medial wall blowout fracture - traumatic enophthalmos - surgery for orbital blowout fractures.
The term orbital blowout fracture was coined by Smith & Regan in 1957 for orbital fractures that spared the orbital rim. Symptomatic extraocular muscle dysfunction is a frequently recognised complication whose natural history and management remains controversial. It was the purpose of this study to evaluate the functional and cosmetic results of 17 patients managed surgically. We specifically looked at our results in relation to the patients' ages at the times of injury and surgery as it had been suggested that younger patients may be at greater risk of developing residual symptomatic diplopia (Wadell et al. 1982; McCarry et al. 1984; Mein & Harcourt 1986).
primary surgical repair of the orbital defect. Preoperative assessment included visual acuity determination, slit-lamp biomicroscopy, direct and binocular indirect ophthalmoscopy, se 'a1 ocular motility analyses including Hess chart ng and binocular visual field testing and forced duction testing. Preoperative radiological studies included orbital X-rays with tomography and/or orbital computed tomographic scanning. Patients were followed for a minimum of 5 days. At variable intervals thereafter, cases with markedly symptomatic diplopia that were not spontaneously improving and considered to be mechanical in nature underwent surgery. The surgical procedure consisted of subperiosteal exploration of the orbital defect, the release of incarcerated tissues and the insertion of a silastic plate, in the majority of cases. An unsatisfactory result was defined as a patient with persistent troublesome diplopia at the end of follow-up. A successful result occurred if a patient achieved an adequate field of binocularity in the primary position extending in all directions with emphasis on downgaze and in whom residual diplopia, if any, was not troublesome. Two case reports are detailed. One patient suffered total but reversible visual loss following surgery (case 9) while the other describes the most symptomatic patient (case 11) in the series.
P
Patients and Methods Seventeen patients attending the eye department of the Royal Hallamshire Hospital over a 7-year period with orbital blowout fractures underwent 118
Results Seventeen patients were evaluated (Table 1).There were 12 males and 5 females. Their ages ranged
Patient No. 1 2 3 4 5 6
7 8 9 10 11
12 13 14 15 16 17 '@
Age at surgery (years)
7 10 12 13 15 16 21 23 25 26 32 8 12 15 21 31 32
Interval to surgery
Site of orbital fracture
6 months 12 days 15 days 21 days 14 days 16 days 18 days 16 days 8 days 10 days 2 years 7 days 6 weeks 5 days 1 months 13 days 11 days
Floor Floor Floor Medial wall Floor Medial wall Floor Floor Floor and medial Floor Floor Floor Floor and medial Floor Floor and medial Medial wall Floor
Persistent diplopia
Field of BSV*
No No No No No No No No No No Yes No No
3 1 1 1 2 2 1
i)TO
No No No
2 1 1
2 1 1 1 1 1 1
BSV binocular single vision; 1=central field with 30 or more degrees in all directions; 2 =central field with 30 or more degrees in downgaze but less than 30 degress all around; 3=central field but less than 30 degrees in downgaze.
from 7.0 to 32 years at the time of surgery, and 11 of these were 21 years or younger. Post-operative follow-up ranged from 1 to 7.25 years (mean= 2.5 years) in cases 1 to 11 and from 2 to 9 months
(mean= 5 months) in cases 12 to 17. The shorter mean follow-up in the latter patients reflected their more rapid recovery. Eleven patients had isolated fractures of the orbital floor, 3 had medial
Fig. 1. Case 9. Preoperative Hess chart showing gross limitation of adduction of right eye.
119
Fig. 2. Diffuseright orbital and ethmoidal sinus shadowing. Silastic plate in medial orbital wall. (Day 1 post-operatively).
wall fractures and 3 had combined orbital floor and medial wall fractures. The aetiology of these injuries were: assault (9 cases), accidents (4 cases) and sport (4 cases). The timing of orbital repair
ranged from 5 to 21 days in 13 cases and 4 to 6 weeks in 2 cases. The 2 remaining patients (cases 1 and 11) were operated on at 6 and 24 months, respectively. Further surgery was required in 2 pa-
Fig.?. Case 9. Post-operative Hess chart showing improved ocular motility.
120
. result had poor vision from commotio retinae. On
Fig.4. Case 9. Post-operative field of binocular single vision (hatched lines correspond to diplopia).
tients, case 9 required silastic plate removal, while case 1 required an ipsilateral inferior rectus resection. Selected cases Case 9. A 25-year-old male was punched in the right eye while playing rugby. Ten years previously he had injured the left eye playing rugby, and as a
admission, his visual acuity measured O.D. 616, and O.S. counting fingers. He was complaining of diplopia. He had periorbital swelling with crepitus and 360 degrees of subconjunctival haemorrhage. Ocular .movementsof the right eye were grossly restricted with no adduction and limited abduction. There was no field of binocular single vision. A diagnosis of medial wall blowout fracture was confirmed by tomography. Eight days later surgical repair was undertaken with release of the trapped tissues and insertion of a silastic plate. At first dressing, the following day, acuity measured no light perception and there was a right afferent pupillary defect. An orbital computed tomographic scan showed some bony fragments close to the insertion of the articifkal orbital wall posteriorly, possibly reducing the dimensions of the bony optic canal. In addition there was diffuse orbital shadowing which was presumed haemorrhagic in nature. The orbit was re-explored and the silastic plate removed. Six weeks later the vision had returned to 619 and improved to 616 by 4 months. At discharge (2.5 years later) the vison was 616 and there was mild optic disc pallor. The ocular motility had improved substantially and there was a good field of binocular single vision. Case 11. A 32-year-old man presented 18 months following a road traffic accident with right hypo-
HESSSCREEN CHART FIELDOF LEFTEYEII~mngw~lh righieye)
i.mP
-
DIAGNOSIS
Green belore t e l l Eye
Green brlorr Righi Eye
Fig 5. Case 11. Post-operativeHess chart showing gross limitation of elevation of right eye. 121
Fig. 6. Case 11. Post-operative Hess chart showing persisting limitation of elevation.
tropia and enophthalmos. At presentation his visual acuity measured O.D. 6/18, O.S. 6/9. There was 5 mm of right enophthalmos with retraction on adduction and on attempted downgaze. Ocular movements were grossly restricted in all positions of elevation with downdrift on abduction. The right eye suffered from longstanding amblyopia and diplopia while appreciated, was not the major
complaint. Tomography confirmed a blowout fracture of the posterior orbital floor. Surgical repair revealed a large fracture involving the posterior orbital floor and medial wall. The incarcerated tissues were freed and a double thickness stainless steel mesh was fashioned and covered with a 3 nun silastic plate. Symptomatic motility problems persisted 2 years post-operatively and were related to restricted upgaze and limited abduction and adduction. The field of binocular single vision remains poor even though a small field centrally and in depression has been achieved. The cosmesis is excellent with no residual enophthalmos.
Discussion
Fig. 7. Case 11. Post-operative field of binocular single vision (hatched lines correspond to diplopia).
122
In this study 17 patients had orbital blowout fractures surgically repaired. Sixteen (94%)were satisfied in that any residual diplopia was not troublesome. At the time of injury 11 patients were aged 21 years and younger while 3 were over 26 years. The management, indications for and timing of surgery for orbital blowout fractures is controversial (Hornblass 1984; Dulley & Fells 1975; Putterman et al. 1974; Helveston 1977; Roper-Hall 1989; Wilkins & Havens 1982; Holt & Holt 1988). Dulley & Fells argue that a decision regarding surgical intervention can be made within 14 days of the injury. They found that the results of surgery were
good for a period of up to 2 months after injury, but may be poor thereafter. More than 213 of the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were operating within 2 weeks of the injury when their individual criteria, whatever those criteria for surgery were, was present (Wilkins & Havens 1982).Thirteen of the 17 cases in our series (76%)had surgery within 3 weeks of injury for diplopia that failed to resolve ‘significantly’ and in whom tissue incarceration was believed to exist. All of these patients are now free of troublesome diplopia. The single patient with troublesome diplopia (aged 32 years) presented 18 months after his injury with significant enophthalmos, diplopia and tissue incarceration. Some studies suggest (Waddell et al. 1982; McCarry et al. 1984) that young patients (
68 (1990) 118-124
Orbital blowout fractures the influence of age on surgical outcome R. J. Leitch, J. P. Burke and I. M. Strachan Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield,England
Abstract. We report the frequency of troublesome diplopia in 17 patients (11 patients 6 2 1 years) who underwent surgical repair of traumatic orbital blowout fractures. Thirteen patients had primary surgery performed within 21 days of injury, 2 patients at 4 and 6 weeks and 2 cases at 6 and 24 months. The latter continues to complain of diplopia. Contrary to previous studies, we found that young patients were no more likely to suffer from symptomatic post-operative residual diplopia than their adult counterparts. Key Words: diplopia - visual loss - medial wall blowout fracture - traumatic enophthalmos - surgery for orbital blowout fractures.
The term orbital blowout fracture was coined by Smith & Regan in 1957 for orbital fractures that spared the orbital rim. Symptomatic extraocular muscle dysfunction is a frequently recognised complication whose natural history and management remains controversial. It was the purpose of this study to evaluate the functional and cosmetic results of 17 patients managed surgically. We specifically looked at our results in relation to the patients' ages at the times of injury and surgery as it had been suggested that younger patients may be at greater risk of developing residual symptomatic diplopia (Wadell et al. 1982; McCarry et al. 1984; Mein & Harcourt 1986).
primary surgical repair of the orbital defect. Preoperative assessment included visual acuity determination, slit-lamp biomicroscopy, direct and binocular indirect ophthalmoscopy, se 'a1 ocular motility analyses including Hess chart ng and binocular visual field testing and forced duction testing. Preoperative radiological studies included orbital X-rays with tomography and/or orbital computed tomographic scanning. Patients were followed for a minimum of 5 days. At variable intervals thereafter, cases with markedly symptomatic diplopia that were not spontaneously improving and considered to be mechanical in nature underwent surgery. The surgical procedure consisted of subperiosteal exploration of the orbital defect, the release of incarcerated tissues and the insertion of a silastic plate, in the majority of cases. An unsatisfactory result was defined as a patient with persistent troublesome diplopia at the end of follow-up. A successful result occurred if a patient achieved an adequate field of binocularity in the primary position extending in all directions with emphasis on downgaze and in whom residual diplopia, if any, was not troublesome. Two case reports are detailed. One patient suffered total but reversible visual loss following surgery (case 9) while the other describes the most symptomatic patient (case 11) in the series.
P
Patients and Methods Seventeen patients attending the eye department of the Royal Hallamshire Hospital over a 7-year period with orbital blowout fractures underwent 118
Results Seventeen patients were evaluated (Table 1).There were 12 males and 5 females. Their ages ranged
Patient No. 1 2 3 4 5 6
7 8 9 10 11
12 13 14 15 16 17 '@
Age at surgery (years)
7 10 12 13 15 16 21 23 25 26 32 8 12 15 21 31 32
Interval to surgery
Site of orbital fracture
6 months 12 days 15 days 21 days 14 days 16 days 18 days 16 days 8 days 10 days 2 years 7 days 6 weeks 5 days 1 months 13 days 11 days
Floor Floor Floor Medial wall Floor Medial wall Floor Floor Floor and medial Floor Floor Floor Floor and medial Floor Floor and medial Medial wall Floor
Persistent diplopia
Field of BSV*
No No No No No No No No No No Yes No No
3 1 1 1 2 2 1
i)TO
No No No
2 1 1
2 1 1 1 1 1 1
BSV binocular single vision; 1=central field with 30 or more degrees in all directions; 2 =central field with 30 or more degrees in downgaze but less than 30 degress all around; 3=central field but less than 30 degrees in downgaze.
from 7.0 to 32 years at the time of surgery, and 11 of these were 21 years or younger. Post-operative follow-up ranged from 1 to 7.25 years (mean= 2.5 years) in cases 1 to 11 and from 2 to 9 months
(mean= 5 months) in cases 12 to 17. The shorter mean follow-up in the latter patients reflected their more rapid recovery. Eleven patients had isolated fractures of the orbital floor, 3 had medial
Fig. 1. Case 9. Preoperative Hess chart showing gross limitation of adduction of right eye.
119
Fig. 2. Diffuseright orbital and ethmoidal sinus shadowing. Silastic plate in medial orbital wall. (Day 1 post-operatively).
wall fractures and 3 had combined orbital floor and medial wall fractures. The aetiology of these injuries were: assault (9 cases), accidents (4 cases) and sport (4 cases). The timing of orbital repair
ranged from 5 to 21 days in 13 cases and 4 to 6 weeks in 2 cases. The 2 remaining patients (cases 1 and 11) were operated on at 6 and 24 months, respectively. Further surgery was required in 2 pa-
Fig.?. Case 9. Post-operative Hess chart showing improved ocular motility.
120
. result had poor vision from commotio retinae. On
Fig.4. Case 9. Post-operative field of binocular single vision (hatched lines correspond to diplopia).
tients, case 9 required silastic plate removal, while case 1 required an ipsilateral inferior rectus resection. Selected cases Case 9. A 25-year-old male was punched in the right eye while playing rugby. Ten years previously he had injured the left eye playing rugby, and as a
admission, his visual acuity measured O.D. 616, and O.S. counting fingers. He was complaining of diplopia. He had periorbital swelling with crepitus and 360 degrees of subconjunctival haemorrhage. Ocular .movementsof the right eye were grossly restricted with no adduction and limited abduction. There was no field of binocular single vision. A diagnosis of medial wall blowout fracture was confirmed by tomography. Eight days later surgical repair was undertaken with release of the trapped tissues and insertion of a silastic plate. At first dressing, the following day, acuity measured no light perception and there was a right afferent pupillary defect. An orbital computed tomographic scan showed some bony fragments close to the insertion of the articifkal orbital wall posteriorly, possibly reducing the dimensions of the bony optic canal. In addition there was diffuse orbital shadowing which was presumed haemorrhagic in nature. The orbit was re-explored and the silastic plate removed. Six weeks later the vision had returned to 619 and improved to 616 by 4 months. At discharge (2.5 years later) the vison was 616 and there was mild optic disc pallor. The ocular motility had improved substantially and there was a good field of binocular single vision. Case 11. A 32-year-old man presented 18 months following a road traffic accident with right hypo-
HESSSCREEN CHART FIELDOF LEFTEYEII~mngw~lh righieye)
i.mP
-
DIAGNOSIS
Green belore t e l l Eye
Green brlorr Righi Eye
Fig 5. Case 11. Post-operativeHess chart showing gross limitation of elevation of right eye. 121
Fig. 6. Case 11. Post-operative Hess chart showing persisting limitation of elevation.
tropia and enophthalmos. At presentation his visual acuity measured O.D. 6/18, O.S. 6/9. There was 5 mm of right enophthalmos with retraction on adduction and on attempted downgaze. Ocular movements were grossly restricted in all positions of elevation with downdrift on abduction. The right eye suffered from longstanding amblyopia and diplopia while appreciated, was not the major
complaint. Tomography confirmed a blowout fracture of the posterior orbital floor. Surgical repair revealed a large fracture involving the posterior orbital floor and medial wall. The incarcerated tissues were freed and a double thickness stainless steel mesh was fashioned and covered with a 3 nun silastic plate. Symptomatic motility problems persisted 2 years post-operatively and were related to restricted upgaze and limited abduction and adduction. The field of binocular single vision remains poor even though a small field centrally and in depression has been achieved. The cosmesis is excellent with no residual enophthalmos.
Discussion
Fig. 7. Case 11. Post-operative field of binocular single vision (hatched lines correspond to diplopia).
122
In this study 17 patients had orbital blowout fractures surgically repaired. Sixteen (94%)were satisfied in that any residual diplopia was not troublesome. At the time of injury 11 patients were aged 21 years and younger while 3 were over 26 years. The management, indications for and timing of surgery for orbital blowout fractures is controversial (Hornblass 1984; Dulley & Fells 1975; Putterman et al. 1974; Helveston 1977; Roper-Hall 1989; Wilkins & Havens 1982; Holt & Holt 1988). Dulley & Fells argue that a decision regarding surgical intervention can be made within 14 days of the injury. They found that the results of surgery were
good for a period of up to 2 months after injury, but may be poor thereafter. More than 213 of the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were operating within 2 weeks of the injury when their individual criteria, whatever those criteria for surgery were, was present (Wilkins & Havens 1982).Thirteen of the 17 cases in our series (76%)had surgery within 3 weeks of injury for diplopia that failed to resolve ‘significantly’ and in whom tissue incarceration was believed to exist. All of these patients are now free of troublesome diplopia. The single patient with troublesome diplopia (aged 32 years) presented 18 months after his injury with significant enophthalmos, diplopia and tissue incarceration. Some studies suggest (Waddell et al. 1982; McCarry et al. 1984) that young patients (
