ANATOMICAL STUDY
Visual Acuity in Orbital Floor Fractures: Does Surgical Subspecialty Management Matter? Nikisha Q. Richards, MD, Ninita H. Brown, MD, PhD, and Earl D.R. Kidwell Jr, MD Purpose: At the time of this writing, there is no consensus regarding orbital floor fracture (OFFx) management. Proper management of OFFxs is imperative to help prevent well known complications and the possibility of decreased visual acuity (VA). The VA outcomes have been largely underreported in the literature. The current study identifies the complications of the different subspecialty management including VA outcome. Methods: A retrospective chart review study was performed to identify patients who suffered an OFFx and were managed by ophthalmology alone or in conjunction with either ENT or oral maxillofacial surgery at a single hospital. The primary outcome included VA at injury and subsequent visits. Secondary outcomes included epiphora, diplopia, enophthalmos, infraorbital dysesthesia, and decreased motility. Data were analyzed using Microsoft Office Excel 2007 using the Student t-test to find a P value < 0.05. Results: There were 54 patients with OFFx. The majority were Black (83.3%) and men (77.8%) with their average age at time of injury being 37.6 (SE ¼ 17.02) years. The majority of OFFxs were secondary to assault (65%). The average follow-up was 2.84 (SE ¼ 5.38) months. The 34 patients who did not undergo surgical correction had statistically significant improvement of their VA by 1 week after injury (P ¼ 0.02). There was no statistically significant improvement in VA outcomes for surgical patients of ophthalmology (P ¼ 0.45) or oral maxillofacial surgery (P ¼ 0.12). Conclusions: Patients undergoing OFFx repair did not have improved VA. The VA of nonsurgical patients was statistically significantly improved by 1 week after injury (P ¼ 0.02). Key Words: Buckling force, hydraulic pressure, pure blowout fracture (J Craniofac Surg 2015;26: 1668–1672)
A
t the time of this writing, there is no consensus on how orbital floor fractures (OFFxs) should be managed. Orbital floor fractures are classified as pure blowout fractures if the orbital rim is not involved. Patients with OFFx are managed by plastic surgery, oral-maxillofacial surgery, ophthalmic plastic surgery, otolaryngology, cranial facial surgery, and neurosurgery. The current debate not only exists among surgical subspecialties but From the Department of Ophthalmology, Howard University Hospital, Washington, DC. Received December 11, 2014. Accepted for publication January 16, 2015. Address correspondence and reprint requests to Nikisha Richards, MD, Department of Ophthalmology, Howard University Hospital, Washington, DC; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001743
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within the ophthalmology community as well. Proper management of patients with OFFx is imperative to help prevent the dreaded well known sequelae of epiphora, persistent diplopia, enophthalmos, infraorbital dysesthesia, decreased extraocular motility (EOM), and overall unacceptable cosmesis.1 –4 In addition to the widely reported aforementioned sequelae, there exists the possibility of decreased visual acuity (VA) that is largely underreported. The current study attempted to identify the differing surgical subspecialty management of patients who suffered a pure blowout fracture and to determine their complications including VA outcome. The ophthalmologist is often the first surgical subspecialist to evaluate and provide recommendations. Most ophthalmologists follow 1 of 2 well known recommendations, either the Smith and Reagan or the Putterman recommendation.2 In 1957, Smith and Regan initiated a trend toward immediate exploratory surgery of blowout fractures. This trend was based on the assumption that unless surgery was performed within the first few weeks after trauma, the patient would experience persistent diplopia and disfiguring enophthalmos.5 In 1974, Putterman et al5 challenged this trend finding that the majority of their patients with symptoms after an OFFx improved sufficiently within approximately 6 months so that no surgery was indicated. Current ophthalmic guidelines for surgical intervention in OFFxs include any 1 of the following:
diplopia with limitation of up/downgaze within 30-degrees of primary position þ positive forced duction 7–10 days after injury þ radiologic evidence of OFFx; enophthalmos >2 mm; OFFx >50% þ medial wall fracture.6
Orbital fractures are different from all of the other facial fractures in that surgery does not typically attempt to achieve bone healing. Rather, the goal of surgery is simply to reconstitute the defect.7 The orbital floor has an architecture rendering it vulnerable to fracture.8 Isolated OFFxs make up 50% of all of the orbital fractures and are explained by either the effect on the globe (hydraulic pressure) or the effect on the infraorbital rim (buckling force).8,9 The approximate force necessary to achieve an OFFx via the buckling theory is 1.2 J and 3.0 J for the hydraulic pressure theory.8 Such injuries can be quite daunting immediately after injury and require appropriate assessment so as to avoid inapposite intervention. According to Koornneef,10 there is a complex network of fibrous septa functionally uniting the sheathes of the inferior rectus and oblique muscles, the inferior fibrofatty tissues, and the periosteum of the orbital floor.8 Displacement or incarceration of any component of this functional unit may limit ocular motility. If, however, these were the only determinants of late ocular motility, then surgical reduction should be curative, and outcome studies in addition to our own suggest otherwise.8
MATERIALS AND METHODS After obtaining approval from the institutional review board of Howard University Hospital (institutional review board no.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Visual Acuity in Orbital Floor Fractures
TABLE 1. Age and Sex Distribution of Patients Age, y
All Patients, n
Male Patients, n
Female Patients, n
10 11–20 21–30 31–40 41–50 51–60 >61
1 7 15 7 11 9 4
1 7 13 6 8 7 0
0 0 2 1 3 2 4
FWA00000891), we performed a retrospective chart review of patients who had experienced an OFFx and were managed by ophthalmology solely or in conjunction with either otolaryngology (ENT) or oral maxillofacial surgery (OMFS) between January 1, 2007 and July 1, 2012. Data were collected from individual patient charts, radiographic imaging reports, and surgical dictations. Demographics included the number of patients, sex, age, concurrent eye disease, mechanism of injury, ethnicity, and additional treatment such as surgery. The time of operation after injury was also reviewed. The primary outcome was the VA of patients at injury and at follow-up of approximately 1 week, 1, 3, and 6 months after injury when available. Secondary outcomes included epiphora, persistent diplopia, enophthalmos, infraorbital dysesthesia, entropion, and ectropion. Exclusion criteria included involvement of the orbital rim, lateral orbital wall or orbital roof, other surgical intervention besides OFFx repair in the interim, optic nerve involvement, and other evident plausible VA confounding factors. The data are expressed as the mean and SE and were analyzed using Microsoft Office Excel 2007 using the Student t-test to find a P value < 0.05 that was considered statistically significant.
RESULTS Demographics The demographics of the 54 patients who met the criteria for inclusion are found in Table 1. A total of 45 patients were Black (83.3%). There was 1 patient (1.9%) under the age of 10, 7 (13%) in their teens, 15 (27.8%) in their 20s, 7 (13%) in their 30s, 11 (20.4%) in their 40s, 9 (16.7%) in their 50s, and 4 (7.4%) older than 60 years. The incidence reached the peak in the 21 to 30-year-old age group (Fig. 1). The average age at the time of injury was 37.6 (SE ¼ 17.02) years. The cause of the OFFx was most commonly secondary to an assault (65%) (Fig. 2). The right eye was the affected eye in 28 patients (52%) and the majority of patients were men (77.8%). Average time of longest follow-up was 2.84 (SE ¼ 5.38) months.
FIGURE 2. Number of the cause of injury by sex.
Cause The most common cause was violent assault, accounting for 34 patients (65%). Falling was the second-most common cause, with 13 (21%). Sports-related injury in addition to bumping into or hitting objects was responsible for 5 patients (10%). Two (4%) patients experienced bicycle-related injuries accounting for their fractures (Fig. 2).
Surgery Nonsurgical Patients There were 34 (63%) patients who did not undergo surgical correction. Their VA was statistically significantly improved by 1 week after injury (P ¼ 0.02) (Fig. 3). Of these same 34 patients, at the time of injury, 5 had diplopia, 4 had decreased ocular motility, 3 with infraorbital dysesthesia, and 1 with enophthalmos (Fig. 4). All of the aforestated symptoms had improved by the latest follow-up available that had an average of 2.84 (SE ¼ 5.38) months with the exception of enophthalmos that remained unchanged and 1 patient who developed ectropion (Fig. 5). All of these results support the Putterman recommendation and seem to obviate immediate surgical intervention.
Surgical Patients Of the 54 patients, 20 (37%) patients underwent surgical repair. The sole surgical patient of ENT has not been included in the final analysis. The average time from injury to surgical correction for all of the surgical patients was 46.4 (SE ¼ 117) days (Table 2). All 14 (70%) of the surgical patients encountered by OMFS underwent surgical correction at an average of 3.4 days after injury. In this cohort, there was only 1 patient whose surgery was performed by ENT and 5 by ophthalmology. The sole patient surgically managed by ENT experienced a compartment syndrome of the orbit with temporary loss of VA that returned nearly immediately after removing all of the sinus packing. TABLE 2. Distribution of Time of Surgical Repair from Time of Injury Patients, n (%) Interval within 3 d 4–7 d 8–14 d 15–30 d 31 d
11 4 0 1 3
(58) (21) (0) (5.3) (15.8)
FIGURE 1. Age and sex distribution of patients.
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2015 Mutaz B. Habal, MD
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Richards et al
TABLE 3. Distribution of Symptoms of Surgical Patients Preoperatively and Postoperatively
Diplopia Decreased EOM Enophthalmos Dysesthesia Ectropion Entropion Total
Before Surgery, n
After Surgery, n
7 8 1 2 0 0 18
4 3 2 2 3 1 15
The preoperative symptoms of the 19 surgical patients included 7 complaints of diplopia, 8 of decreased ocular motility, 2 of infraorbital dysesthesia, and only 1 of enophthalmos (Fig. 6 and Table 3). Figure 7 demonstrates a postoperative reduction in the percentage of surgical patients suffering from decreased motility and diplopia. Although the total number of symptoms decreased after surgical correction, with 8 patients reporting no symptoms after surgery, surgery seemed to introduce new categories of symptoms, namely ectropion and entropion. The decrease in symptoms after surgery was not statistically significant (P ¼ 0.69). All of the postoperative symptoms are reported according to longest follow-up available.
Visual Acuity During the follow-up period, there was no difference in the VA when comparing all of the surgical patients with nonsurgical patients (at injury P ¼ 0.24, at 1 week P ¼ 0.98, at 1 month P ¼ 0.21, at 3 months P ¼ 0.14, and at 6 months P ¼ 0.14) (Fig. 8). Apropos of the preceding statement, one could interpret further accordance for the Putterman approach. In addition, there was no statistically significant improvement in VA outcomes for surgical patients of ophthalmology (P ¼ 0.45) (Fig. 9) or OMFS (P ¼ 0.12) (Fig. 10). There was, however, a statistically significant improvement in the VA of the nonsurgical patients within 1 week after injury (P ¼ 0.02) (Fig. 3).
DISCUSSION The orbital floor is composed of the maxilla, palatine, and zygomatic bones. It is well known that the medial wall, specifically the lamina papyracea of the ethmoid bone, is the thinnest of the orbital bones. The fact that this is not the weakest part of the orbit is less popular, however. The posterior medial portion of the maxilla, also known as the inferomedial strut, is actually the weakest part of the orbit that likely explains why isolated OFFxs make up 50% of all of the OFFxs.9,11 In fact, according to de Silva and Rose,12 the floor is the most common site involved in orbital fractures. Blowout fractures are classified as either pure or impure based on orbital rim involvement.4 The definition of blowout fracture is orbital fractures secondary to traumatic force to the orbital rim or soft tissues involving any internal orbital wall causing decreased extraocular motility, enophthalmos, or diplopia. Only patients with pure isolated OFFx were included in the current study. According to Tong et al,13 physical assault is strongly associated with blowout fracture. The current retrospective analysis was conducted on 54 patients who had experienced an OFFx and were managed either with observation or surgical repair. Ophthalmology seemed more dedicated to a watch-and-wait approach, whereas OMFS was keener on surgical intervention. Reconstructing the orbital floor is a unique surgery because the primary objective is not to promote bone
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healing, but rather to release entrapped soft tissue contents and to restore the original anatomy and orbital volume.7,14,15 The authors recognize that there are absolute and immediate indications for surgical intercession for those cases requiring exigent attention and they include retrobulbar hematoma with induced compartment syndrome of the optic nerve and muscle entrapment with possible ischemia causing a ‘‘white globe’’ presentation.7,14,16 In 2011, the degree of protrusion of the inferior rectus muscle into the maxillary sinus relates closely to the prognosis of OFFxs and may behoove surgical intervention.17 It is equally important, however, to note the incidence of visual loss as a complication of surgery of OFFxs ranges from 0.24% to 3.1% with blindness being ascribed to retrobulbar hemorrhage nearly 50% of that time.14 The previous statement highlights the necessity to approach OFFx surgery punctiliously on a patient-to-patient basis. This is a reasonable approach considering symptoms such as diplopia in upgaze will be more bothersome for some patients, athletes for instance, than it will for others who are more sedentary.16 Of the 54 patients in our study, 100% of them had radiologic evidence of OFFx via computed tomography (CT) scan. It has been postulated that more orbital operations are being undertaken, perhaps even unnecessarily as a direct consequence of the increased number of CT investigations.18 Furthermore, there is a commonly held view that CT images do not correspond very well to intraoperative fracture findings.19,20 The current study found a greater than 4:1 ratio of male-tofemale patients with the highest risk group being the 21 to 30-yearold group. The most common cause of OFFx was assault as many other studies have reported. The main injury causation was gender dependent with assault being the most common cause in men, and falls the most common in women. Among all of the patients, decreased extraocular motility along with diplopia were the most common symptoms at time of injury. Visual acuity can be altered by many factors after OFFx injury. It is for this reason that we excluded patients found at any point in their follow-up period to have any VA compromising confounding factors such as optic neuropathy, traumatic iritis, or cataract. Additionally, we compared surgical patients’ outcomes with the outcomes of nonsurgical patients. Furthermore, we compared the VA outcomes of surgical patients of ophthalmology with OMFS and found no statistically significant improvement or difference. It is worth further investigation in a larger study with more surgical subspecialties compared with succor in finding if such a difference exists. There were few postoperative complications with 1 hyphema and 1 canalicular laceration. Most notably there was 1 compartment syndrome that developed after surgical correction by ENT and was discovered relatively quickly by ophthalmology allowing the prompt recommendation to remove surgical packing after which the patient’s VA returned nearly immediately. Some of the limitations of our study include the design being a retrospective study and lack of documentation inducing a small sample size. In addition, inconsistent follow-up of the patients posed a challenge and also contributed to the small cohort. The main strength of our study is the fact that VA indeed improved within 1 week after injury in the nonsurgical patients. There does not seem to be a statistically significant correlation between surgical subspecialty (OMFS P ¼ 0.12, eye P ¼ 0.45) surgical management and VA outcome in patients who have experienced an OFFx. As it relates to VA, however, patients undergoing OFFx repair did not fare better than those who did not have surgery. Although the Putterman approach was in reference to patient symptoms after an OFFx, it seems that the watchand-wait approach may be applicable to VA. In our cohort, the VA of nonsurgical patients was statistically significantly improved by 1 week after injury (P ¼ 0.02) (Fig. 3). #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Visual Acuity in Orbital Floor Fractures
FIGURE 3. Visual acuity at injury versus at 1 week after injury of all of the nonsurgical patients. FIGURE 6. Symptoms at time of injury of all of the patients undergoing surgical correction.
FIGURE 4. Symptoms at time of injury of all of the surgical and nonsurgical patients.
When one thinks of an ophthalmologist, one thinks of arguably the most paramount of the 5 senses, sight. We feel it is important to note that although there was no statistically significant difference in VA among those managed surgically via OMFS versus ophthalmology, it is equally important if not more, to note the fact that VA
FIGURE 7. Symptoms after surgery of all of the patients undergoing surgical correction at longest follow-up available.
FIGURE 5. Symptoms at longest follow-up available of all of the surgical and nonsurgical patients.
FIGURE 8. Average logMAR visual acuity of all of the patients at time of injury, approximately 1week, 1, 3, and 6 months after injury.
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2015 Mutaz B. Habal, MD
did not decline among the nonsurgical patients. This finding should help ophthalmologists feel more secure in knowing their watch-andwait approach is unlikely to compromise their most vital responsibility of nonmaleficence and upholding their responsibility to preserve vision.
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Richards et al
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REFERENCES
FIGURE 9. Visual acuity at time of injury versus best-corrected visual acuity at longest follow-up available of the patients undergoing surgical correction by ophthalmology.
FIGURE 10. Visual acuity at time of injury versus best-corrected visual acuity at longest follow-up available of the patients undergoing surgical correction by oral maxillofacial surgery.
To the best of our knowledge based on our PubMed search, this was the first study to review OFFxs and specifically evaluate VA unrelated to traumatic optic neuritis or other VA compromising confounding factors2 (Figs. 3–10).
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1. Tang DT, Lalonde JF, Lalonde DH. Delayed immediate surgery for orbital floor fractures: less can be more. Can J Plast Surg 2011;19:125–128 2. Tsai HH, Jeng SF, Lin TS, et al. Predictive value of computed tomography in visual outcome in indirect traumatic optic neuropathy complicated with periorbital facial bone fracture. Clin Neurol Neurosurg 2005;107:200–206 3. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 4. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg 2013;24:703–707 5. Putterman AM, Stevens T, Urist MJ. Nonsurgical management of blowout fractures of the orbital floor. Am J Ophthalmol 1974;77:232–239 6. Hawes M, Dortzbach RK. Surgery on orbital floor fractures: influence of time of repair and fracture size. Ophthalmology 1983;90:1066–1070 7. Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg 2007;120:57S–63S 8. Harris GJ, Garcia GH, Logani SC, et al. Correlation of preoperative computed tomography and postoperative ocular motility in orbital blowout fractures. Ophthal Plast Reconstr Surg 2000;16:179–187 9. Birkenfeld F, Steiner M, Becker ME, et al. Forces charging the orbital floor after orbital trauma. J Craniofac Surg 2012;23:953–956 10. Koornneef L. Orbital septa: Anatomy and function. Ophthalmology 1979;86:876–880 11. Birkenfeld F, Steiner M, Kern M, et al. Maximum forces applied to the orbital floor after fractures. J Craniofac Surg 2012;23:1491–1494 12. de Silva DJ, Rose GE. Orbital blowout fractures and race. Ophthalmology 2011;118:1677–1680 13. Tong L, Bauer RJ, Buchman SR. A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center. Plast Reconstr Surg 2001;108:612–621 14. Gosau M, Schoneich M, Draenert FG, et al. Retrospective analysis of orbital floor fractures: complications, outcome, and review of literature. Clin Oral Investig 2011;15:305–313 15. Dutton JJ, Manson PN, Putterman AM, et al. Management of blow-out fractures of the orbital floor. Surv Ophthalmol 1991;35:279–298 16. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003;14:236–240 17. Higashino T, Hirabayashi S, Eguchi T, et al. Straightforward factors for predicting the prognosis of blow-out fractures. J Craniofac Surg 2011;22:1210–1214 18. Folkestad L, Granstrom G. A prospective study of orbital fracture sequelae after change of surgical routines. J Oral Maxillofac Surg 2003;61:1038–1044 19. Ilankovan V, Hadley D, Moos K, et al. A comparison of imaging techniques with surgical experience in orbital injuries. A prospective study. J Craniomaxillofac Surg 1991;19:348–352 20. Alinasab B, Beckman MO, Pansell T, et al. Relative difference in orbital volume as an indication for surgical reconstruction in isolated orbital floor fractures. Craniomaxillofac Trauma Reconstr 2011;4:203–212
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Visual Acuity in Orbital Floor Fractures: Does Surgical Subspecialty Management Matter? Nikisha Q. Richards, MD, Ninita H. Brown, MD, PhD, and Earl D.R. Kidwell Jr, MD Purpose: At the time of this writing, there is no consensus regarding orbital floor fracture (OFFx) management. Proper management of OFFxs is imperative to help prevent well known complications and the possibility of decreased visual acuity (VA). The VA outcomes have been largely underreported in the literature. The current study identifies the complications of the different subspecialty management including VA outcome. Methods: A retrospective chart review study was performed to identify patients who suffered an OFFx and were managed by ophthalmology alone or in conjunction with either ENT or oral maxillofacial surgery at a single hospital. The primary outcome included VA at injury and subsequent visits. Secondary outcomes included epiphora, diplopia, enophthalmos, infraorbital dysesthesia, and decreased motility. Data were analyzed using Microsoft Office Excel 2007 using the Student t-test to find a P value < 0.05. Results: There were 54 patients with OFFx. The majority were Black (83.3%) and men (77.8%) with their average age at time of injury being 37.6 (SE ¼ 17.02) years. The majority of OFFxs were secondary to assault (65%). The average follow-up was 2.84 (SE ¼ 5.38) months. The 34 patients who did not undergo surgical correction had statistically significant improvement of their VA by 1 week after injury (P ¼ 0.02). There was no statistically significant improvement in VA outcomes for surgical patients of ophthalmology (P ¼ 0.45) or oral maxillofacial surgery (P ¼ 0.12). Conclusions: Patients undergoing OFFx repair did not have improved VA. The VA of nonsurgical patients was statistically significantly improved by 1 week after injury (P ¼ 0.02). Key Words: Buckling force, hydraulic pressure, pure blowout fracture (J Craniofac Surg 2015;26: 1668–1672)
A
t the time of this writing, there is no consensus on how orbital floor fractures (OFFxs) should be managed. Orbital floor fractures are classified as pure blowout fractures if the orbital rim is not involved. Patients with OFFx are managed by plastic surgery, oral-maxillofacial surgery, ophthalmic plastic surgery, otolaryngology, cranial facial surgery, and neurosurgery. The current debate not only exists among surgical subspecialties but From the Department of Ophthalmology, Howard University Hospital, Washington, DC. Received December 11, 2014. Accepted for publication January 16, 2015. Address correspondence and reprint requests to Nikisha Richards, MD, Department of Ophthalmology, Howard University Hospital, Washington, DC; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001743
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within the ophthalmology community as well. Proper management of patients with OFFx is imperative to help prevent the dreaded well known sequelae of epiphora, persistent diplopia, enophthalmos, infraorbital dysesthesia, decreased extraocular motility (EOM), and overall unacceptable cosmesis.1 –4 In addition to the widely reported aforementioned sequelae, there exists the possibility of decreased visual acuity (VA) that is largely underreported. The current study attempted to identify the differing surgical subspecialty management of patients who suffered a pure blowout fracture and to determine their complications including VA outcome. The ophthalmologist is often the first surgical subspecialist to evaluate and provide recommendations. Most ophthalmologists follow 1 of 2 well known recommendations, either the Smith and Reagan or the Putterman recommendation.2 In 1957, Smith and Regan initiated a trend toward immediate exploratory surgery of blowout fractures. This trend was based on the assumption that unless surgery was performed within the first few weeks after trauma, the patient would experience persistent diplopia and disfiguring enophthalmos.5 In 1974, Putterman et al5 challenged this trend finding that the majority of their patients with symptoms after an OFFx improved sufficiently within approximately 6 months so that no surgery was indicated. Current ophthalmic guidelines for surgical intervention in OFFxs include any 1 of the following:
diplopia with limitation of up/downgaze within 30-degrees of primary position þ positive forced duction 7–10 days after injury þ radiologic evidence of OFFx; enophthalmos >2 mm; OFFx >50% þ medial wall fracture.6
Orbital fractures are different from all of the other facial fractures in that surgery does not typically attempt to achieve bone healing. Rather, the goal of surgery is simply to reconstitute the defect.7 The orbital floor has an architecture rendering it vulnerable to fracture.8 Isolated OFFxs make up 50% of all of the orbital fractures and are explained by either the effect on the globe (hydraulic pressure) or the effect on the infraorbital rim (buckling force).8,9 The approximate force necessary to achieve an OFFx via the buckling theory is 1.2 J and 3.0 J for the hydraulic pressure theory.8 Such injuries can be quite daunting immediately after injury and require appropriate assessment so as to avoid inapposite intervention. According to Koornneef,10 there is a complex network of fibrous septa functionally uniting the sheathes of the inferior rectus and oblique muscles, the inferior fibrofatty tissues, and the periosteum of the orbital floor.8 Displacement or incarceration of any component of this functional unit may limit ocular motility. If, however, these were the only determinants of late ocular motility, then surgical reduction should be curative, and outcome studies in addition to our own suggest otherwise.8
MATERIALS AND METHODS After obtaining approval from the institutional review board of Howard University Hospital (institutional review board no.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Visual Acuity in Orbital Floor Fractures
TABLE 1. Age and Sex Distribution of Patients Age, y
All Patients, n
Male Patients, n
Female Patients, n
10 11–20 21–30 31–40 41–50 51–60 >61
1 7 15 7 11 9 4
1 7 13 6 8 7 0
0 0 2 1 3 2 4
FWA00000891), we performed a retrospective chart review of patients who had experienced an OFFx and were managed by ophthalmology solely or in conjunction with either otolaryngology (ENT) or oral maxillofacial surgery (OMFS) between January 1, 2007 and July 1, 2012. Data were collected from individual patient charts, radiographic imaging reports, and surgical dictations. Demographics included the number of patients, sex, age, concurrent eye disease, mechanism of injury, ethnicity, and additional treatment such as surgery. The time of operation after injury was also reviewed. The primary outcome was the VA of patients at injury and at follow-up of approximately 1 week, 1, 3, and 6 months after injury when available. Secondary outcomes included epiphora, persistent diplopia, enophthalmos, infraorbital dysesthesia, entropion, and ectropion. Exclusion criteria included involvement of the orbital rim, lateral orbital wall or orbital roof, other surgical intervention besides OFFx repair in the interim, optic nerve involvement, and other evident plausible VA confounding factors. The data are expressed as the mean and SE and were analyzed using Microsoft Office Excel 2007 using the Student t-test to find a P value < 0.05 that was considered statistically significant.
RESULTS Demographics The demographics of the 54 patients who met the criteria for inclusion are found in Table 1. A total of 45 patients were Black (83.3%). There was 1 patient (1.9%) under the age of 10, 7 (13%) in their teens, 15 (27.8%) in their 20s, 7 (13%) in their 30s, 11 (20.4%) in their 40s, 9 (16.7%) in their 50s, and 4 (7.4%) older than 60 years. The incidence reached the peak in the 21 to 30-year-old age group (Fig. 1). The average age at the time of injury was 37.6 (SE ¼ 17.02) years. The cause of the OFFx was most commonly secondary to an assault (65%) (Fig. 2). The right eye was the affected eye in 28 patients (52%) and the majority of patients were men (77.8%). Average time of longest follow-up was 2.84 (SE ¼ 5.38) months.
FIGURE 2. Number of the cause of injury by sex.
Cause The most common cause was violent assault, accounting for 34 patients (65%). Falling was the second-most common cause, with 13 (21%). Sports-related injury in addition to bumping into or hitting objects was responsible for 5 patients (10%). Two (4%) patients experienced bicycle-related injuries accounting for their fractures (Fig. 2).
Surgery Nonsurgical Patients There were 34 (63%) patients who did not undergo surgical correction. Their VA was statistically significantly improved by 1 week after injury (P ¼ 0.02) (Fig. 3). Of these same 34 patients, at the time of injury, 5 had diplopia, 4 had decreased ocular motility, 3 with infraorbital dysesthesia, and 1 with enophthalmos (Fig. 4). All of the aforestated symptoms had improved by the latest follow-up available that had an average of 2.84 (SE ¼ 5.38) months with the exception of enophthalmos that remained unchanged and 1 patient who developed ectropion (Fig. 5). All of these results support the Putterman recommendation and seem to obviate immediate surgical intervention.
Surgical Patients Of the 54 patients, 20 (37%) patients underwent surgical repair. The sole surgical patient of ENT has not been included in the final analysis. The average time from injury to surgical correction for all of the surgical patients was 46.4 (SE ¼ 117) days (Table 2). All 14 (70%) of the surgical patients encountered by OMFS underwent surgical correction at an average of 3.4 days after injury. In this cohort, there was only 1 patient whose surgery was performed by ENT and 5 by ophthalmology. The sole patient surgically managed by ENT experienced a compartment syndrome of the orbit with temporary loss of VA that returned nearly immediately after removing all of the sinus packing. TABLE 2. Distribution of Time of Surgical Repair from Time of Injury Patients, n (%) Interval within 3 d 4–7 d 8–14 d 15–30 d 31 d
11 4 0 1 3
(58) (21) (0) (5.3) (15.8)
FIGURE 1. Age and sex distribution of patients.
#
2015 Mutaz B. Habal, MD
1669
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Richards et al
TABLE 3. Distribution of Symptoms of Surgical Patients Preoperatively and Postoperatively
Diplopia Decreased EOM Enophthalmos Dysesthesia Ectropion Entropion Total
Before Surgery, n
After Surgery, n
7 8 1 2 0 0 18
4 3 2 2 3 1 15
The preoperative symptoms of the 19 surgical patients included 7 complaints of diplopia, 8 of decreased ocular motility, 2 of infraorbital dysesthesia, and only 1 of enophthalmos (Fig. 6 and Table 3). Figure 7 demonstrates a postoperative reduction in the percentage of surgical patients suffering from decreased motility and diplopia. Although the total number of symptoms decreased after surgical correction, with 8 patients reporting no symptoms after surgery, surgery seemed to introduce new categories of symptoms, namely ectropion and entropion. The decrease in symptoms after surgery was not statistically significant (P ¼ 0.69). All of the postoperative symptoms are reported according to longest follow-up available.
Visual Acuity During the follow-up period, there was no difference in the VA when comparing all of the surgical patients with nonsurgical patients (at injury P ¼ 0.24, at 1 week P ¼ 0.98, at 1 month P ¼ 0.21, at 3 months P ¼ 0.14, and at 6 months P ¼ 0.14) (Fig. 8). Apropos of the preceding statement, one could interpret further accordance for the Putterman approach. In addition, there was no statistically significant improvement in VA outcomes for surgical patients of ophthalmology (P ¼ 0.45) (Fig. 9) or OMFS (P ¼ 0.12) (Fig. 10). There was, however, a statistically significant improvement in the VA of the nonsurgical patients within 1 week after injury (P ¼ 0.02) (Fig. 3).
DISCUSSION The orbital floor is composed of the maxilla, palatine, and zygomatic bones. It is well known that the medial wall, specifically the lamina papyracea of the ethmoid bone, is the thinnest of the orbital bones. The fact that this is not the weakest part of the orbit is less popular, however. The posterior medial portion of the maxilla, also known as the inferomedial strut, is actually the weakest part of the orbit that likely explains why isolated OFFxs make up 50% of all of the OFFxs.9,11 In fact, according to de Silva and Rose,12 the floor is the most common site involved in orbital fractures. Blowout fractures are classified as either pure or impure based on orbital rim involvement.4 The definition of blowout fracture is orbital fractures secondary to traumatic force to the orbital rim or soft tissues involving any internal orbital wall causing decreased extraocular motility, enophthalmos, or diplopia. Only patients with pure isolated OFFx were included in the current study. According to Tong et al,13 physical assault is strongly associated with blowout fracture. The current retrospective analysis was conducted on 54 patients who had experienced an OFFx and were managed either with observation or surgical repair. Ophthalmology seemed more dedicated to a watch-and-wait approach, whereas OMFS was keener on surgical intervention. Reconstructing the orbital floor is a unique surgery because the primary objective is not to promote bone
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healing, but rather to release entrapped soft tissue contents and to restore the original anatomy and orbital volume.7,14,15 The authors recognize that there are absolute and immediate indications for surgical intercession for those cases requiring exigent attention and they include retrobulbar hematoma with induced compartment syndrome of the optic nerve and muscle entrapment with possible ischemia causing a ‘‘white globe’’ presentation.7,14,16 In 2011, the degree of protrusion of the inferior rectus muscle into the maxillary sinus relates closely to the prognosis of OFFxs and may behoove surgical intervention.17 It is equally important, however, to note the incidence of visual loss as a complication of surgery of OFFxs ranges from 0.24% to 3.1% with blindness being ascribed to retrobulbar hemorrhage nearly 50% of that time.14 The previous statement highlights the necessity to approach OFFx surgery punctiliously on a patient-to-patient basis. This is a reasonable approach considering symptoms such as diplopia in upgaze will be more bothersome for some patients, athletes for instance, than it will for others who are more sedentary.16 Of the 54 patients in our study, 100% of them had radiologic evidence of OFFx via computed tomography (CT) scan. It has been postulated that more orbital operations are being undertaken, perhaps even unnecessarily as a direct consequence of the increased number of CT investigations.18 Furthermore, there is a commonly held view that CT images do not correspond very well to intraoperative fracture findings.19,20 The current study found a greater than 4:1 ratio of male-tofemale patients with the highest risk group being the 21 to 30-yearold group. The most common cause of OFFx was assault as many other studies have reported. The main injury causation was gender dependent with assault being the most common cause in men, and falls the most common in women. Among all of the patients, decreased extraocular motility along with diplopia were the most common symptoms at time of injury. Visual acuity can be altered by many factors after OFFx injury. It is for this reason that we excluded patients found at any point in their follow-up period to have any VA compromising confounding factors such as optic neuropathy, traumatic iritis, or cataract. Additionally, we compared surgical patients’ outcomes with the outcomes of nonsurgical patients. Furthermore, we compared the VA outcomes of surgical patients of ophthalmology with OMFS and found no statistically significant improvement or difference. It is worth further investigation in a larger study with more surgical subspecialties compared with succor in finding if such a difference exists. There were few postoperative complications with 1 hyphema and 1 canalicular laceration. Most notably there was 1 compartment syndrome that developed after surgical correction by ENT and was discovered relatively quickly by ophthalmology allowing the prompt recommendation to remove surgical packing after which the patient’s VA returned nearly immediately. Some of the limitations of our study include the design being a retrospective study and lack of documentation inducing a small sample size. In addition, inconsistent follow-up of the patients posed a challenge and also contributed to the small cohort. The main strength of our study is the fact that VA indeed improved within 1 week after injury in the nonsurgical patients. There does not seem to be a statistically significant correlation between surgical subspecialty (OMFS P ¼ 0.12, eye P ¼ 0.45) surgical management and VA outcome in patients who have experienced an OFFx. As it relates to VA, however, patients undergoing OFFx repair did not fare better than those who did not have surgery. Although the Putterman approach was in reference to patient symptoms after an OFFx, it seems that the watchand-wait approach may be applicable to VA. In our cohort, the VA of nonsurgical patients was statistically significantly improved by 1 week after injury (P ¼ 0.02) (Fig. 3). #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015
Visual Acuity in Orbital Floor Fractures
FIGURE 3. Visual acuity at injury versus at 1 week after injury of all of the nonsurgical patients. FIGURE 6. Symptoms at time of injury of all of the patients undergoing surgical correction.
FIGURE 4. Symptoms at time of injury of all of the surgical and nonsurgical patients.
When one thinks of an ophthalmologist, one thinks of arguably the most paramount of the 5 senses, sight. We feel it is important to note that although there was no statistically significant difference in VA among those managed surgically via OMFS versus ophthalmology, it is equally important if not more, to note the fact that VA
FIGURE 7. Symptoms after surgery of all of the patients undergoing surgical correction at longest follow-up available.
FIGURE 5. Symptoms at longest follow-up available of all of the surgical and nonsurgical patients.
FIGURE 8. Average logMAR visual acuity of all of the patients at time of injury, approximately 1week, 1, 3, and 6 months after injury.
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2015 Mutaz B. Habal, MD
did not decline among the nonsurgical patients. This finding should help ophthalmologists feel more secure in knowing their watch-andwait approach is unlikely to compromise their most vital responsibility of nonmaleficence and upholding their responsibility to preserve vision.
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Richards et al
The Journal of Craniofacial Surgery
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REFERENCES
FIGURE 9. Visual acuity at time of injury versus best-corrected visual acuity at longest follow-up available of the patients undergoing surgical correction by ophthalmology.
FIGURE 10. Visual acuity at time of injury versus best-corrected visual acuity at longest follow-up available of the patients undergoing surgical correction by oral maxillofacial surgery.
To the best of our knowledge based on our PubMed search, this was the first study to review OFFxs and specifically evaluate VA unrelated to traumatic optic neuritis or other VA compromising confounding factors2 (Figs. 3–10).
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1. Tang DT, Lalonde JF, Lalonde DH. Delayed immediate surgery for orbital floor fractures: less can be more. Can J Plast Surg 2011;19:125–128 2. Tsai HH, Jeng SF, Lin TS, et al. Predictive value of computed tomography in visual outcome in indirect traumatic optic neuropathy complicated with periorbital facial bone fracture. Clin Neurol Neurosurg 2005;107:200–206 3. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 4. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg 2013;24:703–707 5. Putterman AM, Stevens T, Urist MJ. Nonsurgical management of blowout fractures of the orbital floor. Am J Ophthalmol 1974;77:232–239 6. Hawes M, Dortzbach RK. Surgery on orbital floor fractures: influence of time of repair and fracture size. Ophthalmology 1983;90:1066–1070 7. Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg 2007;120:57S–63S 8. Harris GJ, Garcia GH, Logani SC, et al. Correlation of preoperative computed tomography and postoperative ocular motility in orbital blowout fractures. Ophthal Plast Reconstr Surg 2000;16:179–187 9. Birkenfeld F, Steiner M, Becker ME, et al. Forces charging the orbital floor after orbital trauma. J Craniofac Surg 2012;23:953–956 10. Koornneef L. Orbital septa: Anatomy and function. Ophthalmology 1979;86:876–880 11. Birkenfeld F, Steiner M, Kern M, et al. Maximum forces applied to the orbital floor after fractures. J Craniofac Surg 2012;23:1491–1494 12. de Silva DJ, Rose GE. Orbital blowout fractures and race. Ophthalmology 2011;118:1677–1680 13. Tong L, Bauer RJ, Buchman SR. A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center. Plast Reconstr Surg 2001;108:612–621 14. Gosau M, Schoneich M, Draenert FG, et al. Retrospective analysis of orbital floor fractures: complications, outcome, and review of literature. Clin Oral Investig 2011;15:305–313 15. Dutton JJ, Manson PN, Putterman AM, et al. Management of blow-out fractures of the orbital floor. Surv Ophthalmol 1991;35:279–298 16. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003;14:236–240 17. Higashino T, Hirabayashi S, Eguchi T, et al. Straightforward factors for predicting the prognosis of blow-out fractures. J Craniofac Surg 2011;22:1210–1214 18. Folkestad L, Granstrom G. A prospective study of orbital fracture sequelae after change of surgical routines. J Oral Maxillofac Surg 2003;61:1038–1044 19. Ilankovan V, Hadley D, Moos K, et al. A comparison of imaging techniques with surgical experience in orbital injuries. A prospective study. J Craniomaxillofac Surg 1991;19:348–352 20. Alinasab B, Beckman MO, Pansell T, et al. Relative difference in orbital volume as an indication for surgical reconstruction in isolated orbital floor fractures. Craniomaxillofac Trauma Reconstr 2011;4:203–212
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2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
