CRANIOMAXILLOFACIAL TRAUMA

Orbital Fractures and Ocular Injury: Is a Postoperative Ophthalmology Examination Necessary? Zachary S. Peacock, DMD, MD,* Toufic Boulos, MS,y John B. Miller, MD,z Matthew F. Gardiner, MD,x Sung-Kiang Chang, DMD, MD, DMSc,k and Maria J. Troulis, DDS, MS{ Purpose:

To determine whether formal ophthalmology evaluation is necessary after operative repair of orbital fractures and the association of an ocular injury to the severity of facial injury.

Patients and Methods:

This was a retrospective cohort study of patients with orbital fractures undergoing operative repair from 2005 to 2013. Subjects were included if they had undergone reconstruction of orbital floor fractures and had data from pre- and postoperative examinations by the oral and maxillofacial surgery and ophthalmology services available. The predictor variables included the service performing the ocular examination (oral and maxillofacial surgery or ophthalmology) and the number of fractures present. The outcome variables were the presence of pre- and postoperative ocular injuries. Logistic regression models were used to determine the relationship of the fracture number to ocular injury.

Results:

A total of 28 subjects had undergone repair of orbital fractures with preoperative and postoperative examinations performed by both services. Preoperative ocular injuries were found in 17 of the 28 subjects. Those detected by oral and maxillofacial surgeons were limited to changes in visual acuity, pupillary response, and extraocular muscle dysfunction in 11 subjects. Two subjects had new postoperative ocular findings that were considered minor and did not alter management. An increasing number of facial fractures was associated with an increased risk of ocular trauma. Those with 3 or more fractures had an odds ratio of 14.625 (95% confidence interval, 2.191 to 97.612, P = .006) for the presence of ocular injury.

Conclusions: Operative repair of orbital fractures did not lead to new ocular injuries that would change the management. Thus, those without preoperative ocular injuries will not require a formal postoperative ophthalmology examination. However, the subjects with more fractures had an increased likelihood of ocular injuries. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-8, 2014

The management of orbital injuries represents a challenging area of facial trauma treatment. The complex osseous and soft tissue anatomy of the orbit and the potential for ocular injuries requires a multidisciplinary approach. Orbital trauma can be isolated to

the walls of the orbit, but will frequently be associated with other facial injuries. The prevalence of ocular injuries in the presence of orbital fractures varies significantly within the literature.1-3 Holt and Holt2 found that 67% of patients

{Associate Professor, Department of Oral and Maxillofacial

*Assistant Professor, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA.

Surgery, Massachusetts General Hospital, Boston, MA.

yResearch Fellow, Department of Oral and Maxillofacial Surgery,

Address correspondence and reprint requests to Dr Peacock:

Massachusetts General Hospital, Boston, MA. zFellow,

Vitreoretinal

Ophthalmology,

Department of Oral and Maxillofacial Surgery, Massachusetts General Department

of

Hospital, WRN 1201, Boston, MA; e-mail: [email protected]

Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA.

Received January 28 2014

xAssistant Professor and Director, Ophthalmology Emergency Department, Department of Ophthalmology, Massachusetts Eye

Ó 2014 American Association of Oral and Maxillofacial Surgeons

and Ear Infirmary, Boston, MA.

0278-2391/14/00321-8$36.00/0

Accepted March 8 2014

jjAssociate Professor and Director, Predoctoral Education,

http://dx.doi.org/10.1016/j.joms.2014.03.008

Harvard School of Dental Medicine, Boston, MA.

1

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ORBITAL FRACTURES, OCULAR INJURY, AND POSTOPERATIVE OPHTHALMOLOGY EXAMINATION

with midfacial fractures undergoing a formal ophthalmologic examination had injures to the globe; however, others have reported much lower rates. Jabaley et al3 reported that the incidence of detected ocular injuries in patients with midfacial fractures increased to 29% when an ophthalmology resident performed the examination compared with 18% when performed by plastic surgery residents. Subtle ocular findings that could have an effect on the decision for, and timing of, operative correction of orbital fractures can be missed by non-ophthalmologists.4,5 No consensus exists regarding the specific indications for, and timing of, an ophthalmologic examination in patients sustaining midfacial fractures. Although scoring systems exist to predict the likelihood of ocular injuries,6 ophthalmologic examinations are generally obtained for operative midfacial trauma and may be considered the standard of care.7 Many surgeons also obtain a formal ophthalmologic examination after repair of orbital trauma with or without preoperative ocular injury. No data exist on the outcomes of a postoperative ophthalmologic examination, and determining the utility provides an opportunity for resource and cost-containment. The purpose of the present study was to determine whether a formal ophthalmologic examination is necessary after operative repair of orbital fractures. Secondarily, we sought to compare the incidence of ocular findings detected by the oral and maxillofacial surgery (OMS) service to ophthalmology at our institution. Additionally, we assessed whether the extent of facial injury (ie, the number of fractures) would be associated with the presence of ocular injuries. Our hypothesis was that no additional ocular injuries would be detected on the postoperative ophthalmologic examination after operative repair of orbital fractures. Also, we hypothesized that the ophthalmology service would detect more ocular findings and that subjects with more facial fractures would have a greater incidence of ocular findings.

Patients and Methods STUDY DESIGN

This was a retrospective cohort study of all patients with orbital fractures undergoing operative repair within the Department of Oral and Maxillofacial Surgery at Massachusetts General Hospital (MGH) from January 2005 to December 2013. Potential subjects were identified using the ‘‘International Classification of Diseases, 9th edition’’ codes 802.6 and 802.7. The patients were included if they had had fractures that included the floor of the orbit that was reconstructed. Additional inclusion criteria were as follows: complete records including preoperative computed tomography (CT) scan and report, operative report, pre- and

postoperative (within 2 days of repair) examinations performed by both the oral and maxillofacial surgery service at MGH and the ophthalmology services at the Massachusetts Eye and Ear Infirmary (MEEI), and at least 1 follow-up examination after discharge. The subjects were excluded if the records were unavailable or inadequate. The MGH and MEEI institutional review boards approved the project (protocol no. 2010P002694 and FWA00006221, respectively). STUDY VARIABLES

Predictors The predictor variables were the service (OMS or ophthalmology) performing the pre- and postoperative facial and orbital examinations and the point at which the examination was performed (pre- and postoperative). Demographic and descriptive predictor variables for bivariate analysis included age, gender, mechanism of injury, and fracture type. The number of facial fractures was used as a predictor variable for the logistic regression model. A facial fracture was considered present if a unilateral fracture was found in the following regions: mandible, isolated maxillary sinus, Le Fort I to III, nasoorbitoethmoid, zygomaticomaxillary complex, frontal sinus, orbital floor, and medial, lateral, and superior walls of the orbit. Bilateral fractures were counted as 2 fractures, with the exception of nasal bone fractures. All CT scans were reviewed to confirm the presence of facial fractures, the fracture patterns, and the coded diagnoses. Outcomes The outcome variables were ocular injuries found on preoperative and postoperative examination by the OMS and ophthalmology service. Ocular injuries included those that affected the optic nerve, globe and its internal structures (eg, lens, iris, retina, and anterior and posterior chambers) and the extraocular muscles. Mild ocular injuries that would not generally change management (ie, chemosis and subconjunctival hemorrhage) were excluded for the purposes of the present study. Corneal abrasion was included, but superficial punctate keratitis and punctate epithelial erosion that might only indicate dryness were also excluded. Extraocular muscle dysfunction was defined as a limitation in eye movement. The secondary variables recorded included changes in the management owing to ocular findings during the pre- and postoperative examinations (eg, a delay in the operation, medications, additional referrals or follow-up visits, reoperation or readmission). DATA COLLECTION

Data were gathered from the electronic and paper medical records at both institutions and entered into

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PEACOCK ET AL

Table 1. DESCRIPTIVE STATISTICS FOR STUDY SAMPLE (N = 28)

Study Variable Demographic variables Age (yr) Male gender Fracture variables (total fractures = 94) Frontal sinus Le Fort I Le Fort II Le Fort III Mandible Maxillary sinus Nasal bone/septum Nasoorbitoethmoid Orbit, floor Orbit, lateral wall Orbit, medial wall Zygomaticomaxillary complex Base of skull Frontal bone Fractures (n) Orbital floor repair Incision type Transconjunctival Subciliary Through an existing laceration Subtarsal MEDPOR MEDPOR Titan Depuy Synthes anatomic plates Silicone sheets Titanium mesh

Table 2. BIVARIATE ANALYSIS OF PREOPERATIVE OCULAR INJURIES

Value

Ocular Injury Variable

35.0  13.7 25 (89%) 1 (1) 11 (12) 2 (2) 5 (5) 6 (6) 3 (3) 8 (9) 3 (3) 32 (34) 1 (1) 6 (6) 14 (15) 1 (1) 1 (1) 3.36  2.1

22 (71) 5(16) 3(10) 1(3) 4 (13) 5 (16) 4 (13) 2 (6) 16 (52)

Yes

No

Patients 17 (60.7) 11 (39.3%) Mechanism of injuryy Assault (n = 13) 9 (69.2) 4 (30.8) Fall (n = 7) 5 (71.4) 2 (28.6) MVC (n = 6) 4 (66.7) 2 (33.3) Other blunt trauma 1 (50) 1 (50) (n = 2) Additional fractures by type (n = 24 subjects)y Zygomaticomaxillary 6 (42.9) 8 (57.1) (n = 14) Nasal bone/septum 6 (85.7) (14.3) (n = 7) Le Fort I (n = 6) 6 (100) 0 (0) Medial orbital wall 5 (83.3) 1 (16.7) (n = 6) Mandible (n = 3) 2 (66.7) 1 (33.3) Le Fort III (n = 3) 3 (100) 0 (0)

P Value* NA .9371

.1201 .4188 .0549 .3547 1.000 .5053

Data presented as n (%). Predictor variable, service; outcome variable, ocular injuries; sample size, 28 subjects. Abbreviations: MVC, motor vehicle collision; NA, not applicable. * P # .05 considered statistically significant. y Fisher’s exact test used to determine P values. Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

Data presented as mean  standard deviation or n (%). Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

an Excel spreadsheet (Microsoft, Redmond, WA). These included age, gender, diagnoses, procedures performed, interval to repair, fixation type used to reconstruct the orbit, examination findings pre- and postoperatively by the OMS and ophthalmology services, and the latest follow-up findings. STATISTICAL ANALYSIS

The data were entered into a statistical database (Statistical Analysis Systems, version 9.3, SAS Institute, Cary, NC). Bivariate statistics were calculated using Fisher’s exact test. Univariate and multivariate logistic regression models were used to determine the relationship between the number of facial fractures and ocular injuries. P #.05 was considered statistically significant.

Results A total of 92 subjects were found with a diagnosis of orbital fracture, of which 45 had undergone operative

reconstruction. Of the 45 subjects, 28 had records of preoperative and postoperative examinations by both services available, with 3 undergoing bilateral orbital repair. Twenty-five subjects were male, with an average age of 35.0 years (range 12 to 56; Table 1). Thirteen subjects had injuries after an assault, 6 after motor vehicle crashes, 7 from falls, and 2 from other blunt trauma. Bivariate statistics are found in Table 2. Subjects had an average of 3.36 anatomic sites of fracture, including the orbit. Sixteen subjects were reconstructed with titanium mesh (Dupuy Synthes, West Chester, PA) and 9 with MEDPOR or MEDPOR Titan (Stryker, Kalamazoo, MI; Table 3). The average interval to repair after injury was 6.6 days (range 0 to 13), and the average follow-up was 23 weeks (range 1 to 156). The pre- and postoperative ocular findings are listed in Table 4. Seventeen subjects (60.7%) had preoperative ocular findings, with operative intervention delayed for 2 patients for hyphema. Two required urgent open reduction and internal fixation (ORIF) for extraocular muscle entrapment. Fifteen subjects (53.5%) had postoperative ocular findings, of whom

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ORBITAL FRACTURES, OCULAR INJURY, AND POSTOPERATIVE OPHTHALMOLOGY EXAMINATION

Table 3. INJURY MANAGEMENT

Age (yr)

Mechanism of Injury

1 2

51 31

MVC Fall

3 4

16 52

5 6 7 8

53 23 52 37

Assault Other blunt trauma Fall Fall Fall MVC

9 10

49 23

Assault Assault

L OF, L ZMC, L Max sinus R OF L OF, B LF I, L ZMC B OF, L Lat OW, B LF I & II, open frontal bone defect L OF, L Med OW, nasal L OF, nasal

11

48

Assault

L OF

12

50

Assault

R OF, nasal, R Max sinus

13 14 15

19 53 34

Assault MVC Assault

16 17 18 19 20 21 22 23

27 30 18 12 24 33 41 29

Assault Assault Assault Assault MVC MVC Fall Assault

R OF, R ZMC B OF, B LF I, B LF III, L NOE L OF, L Med OW, L ZMC, L LF I R OF, R ZMC R OF, R ZMC L OF, L ZMC R OF B OF, L ZMC, B LF I, Md (3) L OF, L ZMC, nasal L OF, L ZMC L OF, L Med OW

24 25 26 27

24 56 44 35

Assault Fall MVC Fall

28

17

Other blunt trauma

Pt. No.

Interval to Repair (days)

Latest FollowUp (wk)

MEDPOR MEDPOR

5 6

5 18

Titanium mesh Titanium mesh

8 9

52 14

Titanium mesh MEDPOR Titan Titanium mesh MEDPOR Titan, R

1 0 2 12

6 4 78 14

MEDPOR Titan Dupuy Synthes anatomic plate Dupuy Synthes anatomic plate Dupuy Synthes anatomic plate MEDPOR Titan Titanium mesh, B Titanium mesh

13 12

4 39

5

1

11

14

8 7 1

1 21 130

Titanium mesh MEDPOR Titanium mesh Titanium mesh Silicone sheets, B Titanium mesh MEDPOR Titan Dupuy Synthes anatomic plate Titanium mesh Titanium mesh Titanium mesh, B Titanium mesh

0 7 6 2 11 10 9 9

4 6 6 2 2 3 4 4

12 7 9 3

4 4 156 39

0

3

Injuries R OF, R nasal L OF, L Med OW, L ZMC, L frontal sinus, nasal, R base of skull L OF, L NOE, L Max sinus L OF, L ZMC, L Md

R OF, R ZMC L OF, L Med OW B OF, NOE, B LF I, B LF III L OF, L LF III, R ZMC, nasal, L Md (2) L OF, L Med OW, nasal

Repair

MEDPOR

Abbreviations: B, bilateral; F, female; L, left; Lat, lateral; LF, Le Fort; M, male; Md, mandibular; Max, maxillary; Med, medial; MVC, motor vehicle collision; NOE, nasoorbitoethmoidal; OF, orbital floor; OW, orbital wall; Pt. No., patient number; R, right; ZMC, zygomaticomaxillary complex. Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

2 (7.1%) had new postoperative ocular findings. One subject underwent ORIF of a medial wall fracture with medial rectus entrapment and was found to have a new corneal abrasion that resolved with topical antibiotics. The other patient had had a limitation in the downgaze that had resolved after 1 week. Of the subjects with preoperative commotio retinae, retinal

hemorrhage, macular edema, optic neuropathy, and intraocular pressure abnormalities, none were worsened by ORIF of associated fractures. Ocular trauma was detected by the OMS service in 11 of the 17 subjects with preoperative ocular findings and was limited to decreased visual acuity, pupillary light reaction, and extraocular muscle dysfunction.

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PEACOCK ET AL

Table 4. OCULAR FINDINGS

Ocular Findings by Ophthalmology*

Pt. No.

Fractures (n)

New Postoperative Finding

Change in Management Because of Ocular Findings

Preoperative

Postoperative Ø OD: IRH OS: IRH, EOMD Ø EOMD

Ø Ø

Ø Ø

Ø EOMD

Ø Ø

1 2

2 6

3 4

3 3

Ø OD: IRH OS: IRH, EOMDy EOMDy Ø

5

3

ON

ON

Ø

Ø

6 7 8

1 4 8

CA OHT OD: NLPy (fixed dilated pupil), EOMDy OS: Ø

CA Ø OD: NLPy (fixed dilated pupil), EOMDy OS: Ø

Ø Ø Ø

9

3

EOMD,y CR

EOMDy

Ø

10

2

EOMDy

EOMDy

Ø

Ø Ø OD: Ø OS: orbital defect not treated because of loss of vision in OD Additional ophthalmology follow-up Ø

11

1

OD: Ø OS: OHT, CR

Ø

ORIF delayed 1 week due to MH

12 13 14

3 2 7

CA, DR, VH Ø OD: IRH, SRH, PRH, ON, ME OS: Ø

Ø Ø Ø

Ø Ø Ø

15

4

OD: OHT OS: YVA,y OHT, SRH, CR, CA, MH CA, DR, VH Ø OD: YVA,y IRH, SRH, PRH, ON, ME OS: Ø CA, PRH, IRH, MH, EOMDy (IR entrapmenty)

CA, PRH, IRH, MH

Ø

Ø

16 17 18 19 20

2 2 2 1 8

Ø Ø Ø Ø TI, H, EOMDy

Ø Ø Ø Ø TI, EOMD

Ø Ø Ø Ø Ø

21 22 23

3 2 2

Ø Ø I, MH, CA

Ø Ø CA

Ø Ø Ø

24

2

Ø

Ø

Ø

Ø Ø Ø Ø ORIF delayed 11 days due to H Ø Ø MH resolved after 4 days Ø

Notes

EOMD resolved 4 wk postop EOMD resolved 1 wk postop Neuroophthalmology referral postop; improved monocular diplopia 6 wk postop

ORIF delayed 12 days because of intracranial injury EOMD resolved 4 wk postop EOMD resolved 4 wk postop

Repaired emergently due to muscle entrapment

TI resolved at 2 wk follow-up

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ORBITAL FRACTURES, OCULAR INJURY, AND POSTOPERATIVE OPHTHALMOLOGY EXAMINATION

Table 4. Cont’d

Ocular Findings by Ophthalmology*

Pt. No.

Fractures (n)

Preoperative

Postoperative

New Postoperative Finding

25

2

Ø

Ø

Ø

26

7

OD: [IOP OS: [IOP

OD: [IOP OS: [IOP

Ø

27 28

6 3

EOMDy IOP, EOMDy (MR entrapmenty)

Ø EOMD,y CA

Ø CA

Change in Management Because of Ocular Findings Additional ophthalmology follow-up for asymmetric IOP preoperatively Brimodidine for [IOP

Ø Erythromycin ointment for 3 days; emergency repair for entrapment

Notes

[IOP resolved 2 wk postop; required skeletal revision CA resolved after 3 days, EOMD resolved 10 days postop

Abbreviations: CA, corneal abrasion; CR, commotio retinae; DR, diabetic retinopathy; EOMD, extraocular muscle dysfunction; H, hyphema; IR, inferior rectus; IOP, intraocular pressure; IRH, intraretinal hemorrhage; ME, macular edema; MH, microhyphema; MR, medial rectus; NLP, no light perception; OD, right eye; OHT, ocular hypertension; ON, optic neuropathy; OS, left eye; postop, postoperatively; PRH, preretinal hemorrhage; SRH, subretinal hemorrhage; VA, visual acuity; VH, vitreous hemorrhage. * Bilateral cases have side delineated. y OMS findings. Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

The comparison between services is summarized in Table 5. Injuries or abnormalities of the cornea, lens, iris, retina, or intraocular pressure were only detected by the ophthalmology service. The OMS service did not perform an examination with fluorescein or pupillary dilation or use instruments such as the slit-lamp or ophthalmoscope. In the univariate logistic regression model, increasing numbers of facial fractures were associated with an increased risk of ocular findings (Table 6). Subjects with 3 or more facial fractures had a 14.6-fold (1,363%) increased risk of ocular injury (P = .0056). Each additional fracture increased the chance of ocular injury by 2.8-fold (184%; P = .0374). Including age and gender in a multivariate logistic regression model did not change the significant findings (Table 7).

Discussion The purpose of this study was to investigate the role of the formal postoperative ophthalmology examination after ORIF of orbital floor fractures. The hypotheses were that patients would not have devel-

oped new ocular findings on the postoperative examination and that more ocular findings would be detected by the ophthalmology service. Finally, we also believed that ocular injuries would be more likely in patients with multiple facial fractures. Our study results have confirmed that patients generally do not develop new ocular findings after reconstruction of orbital floor fractures. Of the 28 subjects undergoing 31 orbital fracture repairs, 2 (7.1%) were found to have new postoperative ocular injuries that were considered minor. One subject developed a corneal abrasion, which can result from inadvertent mechanical stress on the ocular surface during operative repair. However, like most corneal abrasions, it resolved without sequelae. The other subject developed a limited downgaze 1 day after ORIF that resolved after 1 week. Subjects (n=17) who did have ocular findings preoperatively did not have worsening of these signs on postoperative examination. As such, it can be reasonably stated that for patients without preoperative ocular injury, a routine postoperative ophthalmology examination is not required. When preoperative ocular findings are present or new

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PEACOCK ET AL

Table 5. BIVARIATE ANALYSIS OF DETECTION OF OCULAR INJURIES BY SERVICE

Table 7. LOGISTIC REGRESSION MODEL FOR OCULAR INJURIES (MULTIVARIATE)

Variable

Variable

Sample size Preoperative ocular injuries Postoperative ocular injuries

OMS

Ophthalmology P Value*

28 11 (35.7)

28 17 (60.7)

NA .1810

4 (14.3)

15 (53.6)

.0041y

Data presented as number of subjects with percentages in parentheses. Abbreviations: NA, not applicable; OMS, oral and maxillofacial surgery. * Fisher’s exact test used to determine P values. y Statistically significant. Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

postoperative findings such as a disturbance in visual acuity are detected, an ophthalmology examination should be obtained. The OMS service detected far fewer ocular findings than ophthalmology. Although changes in visual acuity, pupillary response, and eye movements were detected by the OMS service, other ocular injuries were missed. These additional findings were identified by the ophthalmology service, which performed a complete examination, including the use of the slit lamp with fluorescein staining and dilated ophthalmoscopy. While OMS residents receive training in these examination methods, the availability of ophthalmologists at many institutions has precluded the development of these skills as routine. Clinical practice in settings in which ophthalmologists are less available still dictates a through ocular examination, because more than one half of our patients had ocular injuries detected on the preoperative examination. Table 6. LOGISTIC REGRESSION MODEL FOR OCULAR INJURIES (UNIVARIATE)

Variable Male gender (binary, n = 25) Age (yr) No. of fractures (n $ 3) Fracture number (per unit increase)

OR* (95% CI)

P Value

0.750 (0.060-9.418)

.8237

1.019 (0.962-1.079) 14.625 (2.191-97.612)

.5215 .0056y

2.706 (1.001-7.317)

.0498y

Abbreviations: CI, confidence interval; OR, odds ratio. * ORs > 1 indicate associations with increased odds of ocular injury. y Statistically significant. Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

No. of fractures (n $ 3), age, gender Fracture number (per unit increase), age, gender

OR* (95% CI)

P Value

16.093 (2.112-122.640)

.0073y

2.883 (1.066-7.791)

.0369y

* ORs > 1 indicate associations with increased odds of ocular injury. y Statistically significant. Peacock et al. Orbital Fractures, Ocular Injury, and Postoperative Ophthalmology Examination. J Oral Maxillofac Surg 2014.

As expected, more severe facial injuries correlated with an increase in ocular injuries. Subjects with 3 or more facial fractures had a 14.6-fold increased risk of ocular injury (P = .0056). Each additional fracture increased the chance of ocular injury by 2.7-fold (P = .0498). These findings are in agreement with those from previous studies documenting an increased incidence of ocular injury in the presence of comminuted facial fractures.3,8,9 Ocular trauma was found in 17 of the 28 subjects (60.7%) in the present study. Within the published data, ocular injuries have been reported in 2 to 90% of midface injuries.4 The wide range resulted from the variability in the definition of ocular injury and the lack of formal examination by an ophthalmologist in studies with a lower incidence. In the largest survey of patients with midfacial injuries, al-Qurainy et al8 reported that 90% of subjects with midfacial trauma had ocular injuries; however, their study had included those with injuries to structures surrounding the globe (eg, skin ecchymosis, edema, laceration of the eyelids, and enophthalmos).8 The definition in the present study of ocular injury was more restrictive and, therefore, might have decreased the rate of detection by the OMS service. A multidisciplinary approach to the management of orbital fractures remains the standard of care.10 The current study and literature support the need for preoperative ophthalmology evaluation for patients with orbital fractures.2,3,11-14 Although only a few will require immediate intervention,4 the consequences of undetected ocular injuries can be devastating. To our knowledge, ours is the first study to assess the need for a postoperative ophthalmology evaluation and provides an opportunity for cost-containment. The present study had several limitations. The retrospective nature relies on what was actually recorded in the records; thus, findings might have been present and found, but not necessarily documented. Only 28

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ORBITAL FRACTURES, OCULAR INJURY, AND POSTOPERATIVE OPHTHALMOLOGY EXAMINATION

of the 45 subjects who underwent reconstruction of orbital fractures had examinations by both services and complete records available. The small sample size limited the conclusions, although the rarity of new ocular findings after orbital fracture repair supports our hypothesis. The short duration of followup in many cases may underestimate potential longer term ocular injuries. In conclusion, uncomplicated repair of orbital floor fractures does not appear to result in new ocular injuries. A routine postoperative ophthalmology examination may not be necessary if a formal preoperative ophthalmology examination failed to identify ocular injury.

References 1. Luce EA, Tubb TD, Moore AM: Review of 1000 major facial fractures and associated injures. Plast Reconstr Surg 63:26, 1979 2. Holt GR, Holt JE: Incidence of eye injuries in facial fractures: An analysis of 727 cases. Otolaryngol Head Neck Surg 91:276, 1983 3. Jabaley ME, Lerman M, Sanders HJ: Ocular injuries in orbital fractures: A review of 119 cases. Plast Reconstr Surg 56:410, 1975

4. Cook T: Ocular and periocular injuries from orbital fractures. J Am Coll Surg 195:831, 2002 5. Barry C, Coyle M, Idrees Z, et al: Ocular findings in patients with orbitozygomatic complex fractures: A retrospective study. J Oral Maxillofac Surg 66:888, 2008 6. al-Qurainy IA, Titterington DM, Dutton GN, et al: Midfacial fractures and the eye: The development of a system for detecting patients at risk of eye injury. Br J Oral Maxillofac Surg 29:363, 1991 7. American Association of Oral and Maxillofacial Surgery: Parameters of care. J Oral Maxillofac Surg 70:e182, 2012 8. al-Qurainy IA, Stassen LF, Dutton GN, et al: The characteristics of midfacial fractures and the association with ocular injury: A prospective study. Br J Oral Maxillofac Surg 29:291, 1991 9. Jamal BT, Pfahler SM, Lane KA, et al: Ophthalmic injuries in patients with zygomaticomaxillary complex fractures requiring surgical repair. J Oral Maxillofac Surg 67:986, 2009 10. Anderson OA, Lee V, Singh R, et al: Orbital fractures: Ophthalmic or maxillofacial? Br J Oral Maxillofac Surg 45:90, 2007 11. Guly CM, Guly HR, Bouamra O, et al: Ocular injuries in patients with major trauma. Emerg Med J 23:915, 2006 12. Beirne OR, Schwartz HC, Leake DL: Unusual ocular complications in fractures involving the orbit. Int J Oral Surg 10:12, 1981 13. Ioannides C, Treffers W, Rutten M, et al: Ocular injuries associated with fractures involving the orbit. J Craniomaxillofac Surg 16:157, 1988 14. Jayamanne DG, Gillie RF: Do patients with facial trauma to the orbito-zygomatic region also sustain significant ocular injuries? J R Coll Surg Edinb 41:200, 1996

Orbital fractures and ocular injury: is a postoperative ophthalmology examination necessary?

To determine whether formal ophthalmology evaluation is necessary after operative repair of orbital fractures and the association of an ocular injury ...
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