Menu

  1. Home
  2. /
  3. Orbit & Oculoplasty–II
  4. /
  5. FP1390 : Assessment of...

Share this post

Dr.Nayana Nagesh, Dr.Raghuraj S Hegde,Dr.H Niveditha

ABSTRACT:

PURPOSE-To list out clinico-radiological factors considered to decide mode of management in 60 patients-prospective study.

METHOD-Patients with CT proven orbital fractures were included in the study. A detailed ophthalmological examination was done. Ct scan was ordered for each patient and decision of surgery or conservative management was made

RESULTS– In our study 35 patients were managed surgically.25 patients were managed conservatively because of minimal displacement, no diplopia, enophthalmos and restrictions. Surgically managed patients either had diplopia, restriction, enophthalmos or complex fractures.

CONCLUSION: Though radiological factors (site, severity, entrapment) are important, it is the clinical factors which play a major role in deciding treatment. A 10-day observation period-reduces oedema and improves ocular motility. It prevents unnecessary early interventions. Key words: orbital fractures, conservative approach, surgical approach, orbital floor, medial orbital wall, lateral orbital wall, orbital roof fracture

INTRODUCTION–

Orbital fractures are a common sequelae of blunt trauma to the face.[1]Their management is challenging and deserves special consideration as not all ct proven orbital fractures need a surgical repair.[2] Their treatment differs from other facial bone fractures as the basic objective here is not just primary bone healing but adequate support to the globe as well. An inappropriate decision of conservative or surgical approach can result in compromise in vision, extraocular movements, diplopia and enophthalmos and thus have an impact not only on ocular function but also on facial aesthetics.[2,12] The  optimal management plan is often variable and the proper choice regarding what to choose rests entirely upon the clinical scenario. On one hand, there are studies which have highlighted that early repair of fractures drastically improves the functional and aesthetic outcomes, while on the other hand there are studies which recommend conservative treatment for blowout fractures as well.

This puts the surgeon in a dilemma whether to operate or not. Adding on to this is the risks associated with surgery like infection of the implanted material, implant migration, epiphora, worsening of diplopia, ectropion and blindness. Nonetheless, conservatively managed patients can also present with delayed onset of diplopia and enophthalmos as these might not be immediately evident in some cases. Thus, considering all of this, this prospective study aims at highlighting all the  clinical and radiological factors we considered while deciding if an orbital fracture needed to be repaired or not

MATERIALS AND METHODS:

60 facial trauma patients presenting to the emergency and outpatient department with orbital fractures confirmed by a CT scan were taken up for this study. CT-Scan orbits (1mm cuts, zero gantry, bone windows coronal, saggital and axial view with 3D-reconstruction) were done for all patients to localise the fractures. A thorough ophthalmic evaluation was done which included visual acuity testing, anterior segment evaluation like examination of the eyelids and adnexa, conjunctiva, cornea, anterior chamber, iris, pupils to rule out any relative afferent pupillary defect, lens and the posterior segment by indirect Ophthalmoscopy. B-Scan was done to rule out posterior segment pathology in cases of suspected retinal detachment or vitreous haemorrhage. Extraocular movements were checked to see for any restriction of ocular movements. Diplopia charting was done. Forced duction test was done to differentiate whether restriction is due to entrapment or nerve palsy. All the patients were given tetanus injection and started on broad spectrum antibiotics, intravenous/oral steroids to reduce the swelling and inflammation, intravenous analgesics and topical antibiotic eye drops. Neurosurgical consultation was taken for patients with associated head injury and was put on intravenous Mannitol and antiepileptic. Patients with traumatic optic neuropathy were started on intravenous methyl prednisolone

1 gram once daily for 3 days. Patients which we thought could be managed conservatively were put on oral broad spectrum antibiotics, steroids to reduce inflammation, analgesics and antibiotic eye drops and were asked to review regularly on an OPD basis. All the patients whether treated surgically or conservatively were asked to come for follow up at 1week, 1 month, 3 months and 6 months. Patients who needed intervention because of orbital fractures were admitted whereas sometimes patient who didn’t need admission for intervention from ophthalmology side had to be admitted because of other ailments mainly neurosurgical and maxillofacial. While taking this important decision of whether to operate or not we assessed several factors after which we made the final decision. All the surgeries were done within 10 days of the injury. In this study, none of the patients were taken up for immediate repair. Post trauma, patients present with chemosis, ecchymosis, and periorbital swelling which gives a false impression of no enophthalmos and might not allow one to assess how much ocular movement restriction and diplopia the patient actually has. Factors which were considered for surgical or conservative management are:

1.Primary factors

2.Secondary factors.

PRIMARY FACTORS
1.Positive forced duction test corroborated with clinically assessed ocular motility restriction
2. Diplopia in primary or extremes of gazes.
3. Significant enophthalmos when compared to the other eye.

 

SECONDARY FACTORS
1. CT-Scan evidence of muscle entrapment, scarring or loss of muscle mass.
2.Severity of the fracture, amount of displacement
3.which wall is fractured
4.patient is willing or not for surgery

CT-scan might show entrapment but many times clinically the patient might not have discernable ocular motility restriction. In such cases it is always advisable to wait. Diplopia in primary gaze is an indication for surgery whereas in extremes of gazes can be ignored and managed conservatively. CT-scan showing loss of muscle mass or scarring because of entrapment or impingement is always an indication to operate or else the patient might end up with persistent diplopia or restriction. Significant enophthalmos in comparison to the other eye is a criteria for surgery. Isolated undisplaced lateral wall fracture, roof fracture with no herniation or CSF leak and even blow out medial wall fractures

with no clinical evidence of restriction or diplopia doesn’t warrant surgery. In cases of multiple comminuted fractures distorting the anatomy as well as orbital emphysema causing optic nerve compression surgery is necessary. Post operatively patients treated surgically were regularly examined for vision, any persisting motility restrictions, persistent diplopia or worsening of diplopia and pupillary reaction. All patients were given broad spectrum antibiotics, intravenous steroids, analgesics and one antibiotic steroid eye drop. Post operative CT-scan was done for all patients to see whether the implant is in place or not. Conservatively treated patients were also followed up in a similar fashion during every visit. All the surgeries were done by a single surgeon through the transconjunctival route and under general anaesthesia.

 RESULTS:

35 patients in this prospective underwent surgery whereas 25 were managed conservatively. 45 patients (75%) were male and 15(25%) were female. 56(93.3%) patients suffered road traffic accident(RTA) which is the most common mode of injury in our study. 3(5%) patients had self fall whereas

1patient suffered a bull gore injury.

PATIENTS MANAGED CONSERVATIVELY:

TYPE OF FRACTURE/SYMPTOMS NUMBER OF PATIENTS
Lateral wall undisplaced fracture 9
Declined surgery 2
Medial wall fractures with no symptoms 6

 
Undisplaced floor fracture with no symptoms 3
Roof fracture with no other complications 3
Multiple undisplaced fractures with no symptoms 3

PATIENTS MANAGED SURGICALLY:

TYPE OF FRACTURE/SYMPTOMS NUMBER OF PATIENTS
Fracture displacement more than 2 cm2 31
Enophthalmos 30
Ocular motility restriction 7
Diplopia 8
Multiple comminuted orbital fractures along with other facial fractures. 5

In our study 8 patients had diplopia preoperatively. After surgery 3 had persistent diplopia whereas one patient had diplopia in extreme down gaze which resolved with time. 3 patients who had persistent diplopia at 6 months follow up underwent strabismus surgery following which their diplopia mainly in the primary gaze resolved. Out of 7 patients with ocular motility restriction preoperatively 2 patients had persistent restriction after surgery one is because of scarring and another one because of nerve palsy. For the patient with scarring restrictions resolved after scar release surgery.  Out of 30 patients with significant enophthalmos in our study only two patients had persistent enophthalmos mainly because of the severity of fracture suffered by them. Patients managed conservatively had uneventful recovery without any functionally or cosmetically hampering sequelae. 

DISCUSSION:

Orbital fractures are common facial injuries with potential anatomic and functional complications. Since its first description by Regan and Smith in 1957 its management has evolved over the years. It is important to determine the mode of treatment and explain the prognosis to the patient. While many articles state that large fractures always warrants surgical intervention it is the mild to moderate fractures which remain controversial. In our study we usually waited around 10 before doing surgery

which is similar to what Kirthi Nath Jha et al reported in his article where surgery if needed was done within 2 weeks of the injury.[3] The guidelines followed by Kirthi Nath Jha et al for surgical repair is similar to what we followed in our study like diplopia with limitation of up or down gaze, positive forced duction test, radiological confirmation of atleast half of floor fracture, significant enophthalmos and cosmetically unacceptable to the patient.[3] In our study we didn’t operate on any of the patients with orbital roof fractures and preferred conservative management because it was not associated with any other complication like CSF leak, functional deficits like vertical diplopia, lagophthalmos and impingement of bone fragments onto orbital structure which is similar to the suggestions of Kirthi Nath Jha et al and to the treatment algorithm proposed by Connon et al in their article on orbital roof fracture classification and treatment.[3,14] In our study we choose conservative management for those with minimal or no symptoms like diplopia, motility restriction, undisplaced or very minimally displaced fractures and patients unwilling for surgery which is similar to the guidelines followed by C.P.N Back et al in their study.[17]Emery et al in their study reported that the diplopia and motility restriction that resolved within 14 days need no surgery because it is mainly due to swelling or intramuscular haematoma which is similar to what

we did before taking up any patient for surgery.[5] We waited for 10 days started the patients on steroids so that oedema resolves and re-evaluated the patient for functional deficits again. Diplopia and restriction which persists beyond 10-14 days needs intervention is what suggested by C. Kunz et al in their article.[13] One more thing which is of utmost importance during decision making is to evaluate the amount of enophthalmos possible with the present displacement of the orbital floor fracture. C.Kunz et al found that there is a correlation between enophthalmos and size of fracture. The importance of this is that enophthalmos might not be very prominent in the initial few days and the patient might have significant and cosmetically unacceptable enophthalmos after probably 3 weeks or 4 weeks following injury.[13] At that time surgery is also difficult as bone healing would have already started and one has to break it to proceed with the surgery. Correlation between enophthalmos and size of fracture is also stated by Ploder et al.[1,8,13] In our study we closely followed the criteria suggested by Burnstine while selecting patients for surgery or conservative management. Burnstine as well as Hawes MJ et al suggested an observational period of 14 days before taking up the patient for surgery as within this period most of the oedema will resolve. [1,5,11,13]Hawes and Dortzbach reported CT is useful in predicting whether the patient

will have significant post injury enophthalmos and also recommended surgery in patients with half of the orbital floor depressed.[1,8,13]Roth A et al suggested late repairs are unsatisfactory as there will be fibrosis, fat atrophy and scarring.[12] Boush GA et al suggested infraorbital nerve hypaesthesia that is progressive is an indication for surgery which is also reported by Tengtrisorn et al.[2] C.Kunz et al in their study reported isolated medial wall fractures without any entrapment or diplopia had functionally uneventful outcome when managed conservatively which is similar to the findings of our study. They also suggested mild to moderate orbital wall fractures with enophthalmos less than 2mm and with no clinical signs of herniation of soft tissue and muscle entrapment can be managed conservatively which is also similar to our protocol. Initial diplopia is not an indication for surgery which is similar to what Emery et al and Putterman et al suggested. [5,13] In the study conducted by Young et al where they have treated orbital blowout fractures conservatively and then used CT scan imaging to demonstrate improvement reported that there was smoothening of bony contour, joining of bony edges, orbital content herniation reduction, new bone formation and reduction of orbital and fracture volumes.[4] These findings are really encouraging as this will reduce the need for surgery as any surgery has its limitations and is associated with complications.

They also reported improvement of ocular motility, diplopia and infraorbital hypoesthesia but they haven’t commented on how much each improved. But the drawback of the study is that they considered patients with minimal diplopia, restriction and enophthalmos. So it can be considered as bias towards patients with minimal symptoms. Nonetheless these findings are good and should be kept in mind while decision making. Tang et al also reported resolution of diplopia and ocular motility in all of their patients. Catone et al also reported complete resolution of diplopia, motility restriction and enophthalmos in patients

with untreated orbital blowout fractures.[6,10] Also studies comparing outcomes between surgically treated group and conservatively treated groups, conservatively treated groups had better outcomes as reported by Dulley B et al and Cole HG et al. Similar findings were also reported by Emery JM et al.[5,7,9] Young et al also said new bone formation is more common in young patients and it is quite significant as orbital fractures are common in the youngsters.[4] Raskin et al reported that immediate enophthalmos is usually seen in medial wall fracture of more than two

thirds involvement along with floor fracture which is similar to what we have told in our study that the type of fracture as well as which wall is fractured plays a role in decision making. Similarly Pearl et al reported that posterior orbital floor fracture produced more enophthalmos than anterior orbital floor fracture. H.H.Chen et al reported that enophthalmos treated < 2 weeks following trauma yields lower improvement rate than ated between 2-4 weeks which is different from what we followed in our study but can be kept in mind while taking decisions for surgical or conservative management. This is why decision making whether to operate or not becomes all the more important because one has to also keep in mind about the outcome of surgery or conservative management.  

CONCLUSION:

Orbital fracture management is challenging as well as the decision making of whether to go for surgery or manage conservatively. Over the years with the evolution of management of orbital fractures various studies have quoted the need for surgery within a period of 2 weeks to correct diplopia, motility  restrictions and enophthalmos.

But surgery does have its fair share of anaesthesia related risks and complications as well as it might cause complications like vision loss, worsening of diplopia, postoperative implant related infections, scarring, ectropion and epiphora. Keeping all these side effects in mind one should not shy away from managing orbital fractures conservatively as recent articles and studies have shown that at times conservatively managed orbital fracture patients do have better outcomes and thus provide a valuable alternative especially in patients who decline surgery.  Mild to moderate orbital fractures with minimal symptoms can be managed conservatively whereas severe and complex fractures with distorted anatomy and symptoms do need surgery and this is why a judicious decision making is important to achieve optimum results.  

REFERENCES:

  1. Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures. Influence of time of repair and fracture size. Ophthalmology.1983; 90(9):1066–1070.
  2. Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: Challenges and solutions. Clin Ophthalmol.2015; 9:2127-37.
  3. Jha KN, Rajalakshmi A R. Evaluation and management of orbital trauma. J Clin Ophthalmol Res.2018; 6:77-82.
  4. Stephanie Ming Young, FAMS, FRCOphth, Yoon-Duck Kim, MD, PhD, Sang Wook Kim, BSc, Han Byeol Jo, MSE, Stephanie S. Lang, MSc, Kyuyeon Cho, MD, Kyung In Woo, MD, PhD. Conservatively Treated Orbital Blowout Fractures. Ophthalmology Volume 125, Number 6, June 2018.
  5. Emery JM, von Noorden GK, Schlernitzauer DA. Orbital floor Fractures: long-term follow-up of cases with and without surgical Repair.Trans Am Acad Ophthalmol Otolaryngol.1971; 75:802-812.
  6. Catone GA, Morrissette MP, Carlson ER. A retrospective study of untreated orbital blow-out fractures. J Oral Maxillofac Surg.1988; 46:1033-1038.
  7. Dulley B, Fells P. Orbital blow-out fractures: to operate or not to operate, that is the question. Br Orthop J. 1974; 31:47-54.
  8. Ploder O, Klug C, Backfrieder W, et al. 2D and 3D-based measurement of orbital floor fractures from CT scans. J Carniomaxillofac Surg. 2002; 30:153-159.
  9. Cole HG, Smith B. Eye muscle imbalance complicating orbital floor fractures. Am J Ophthalmol. 1963; 55:930-935.
  10. 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.
  11. Burnstine MA. Clinical recommendations for repair of isolated orbital   floor fractures: an evidence-based analysis. Ophthalmology 2002; 109:1207–1213.
  12. S.Roth, John C. Koshy, Jonathan S.Goldberg, Charles N.S Soparkar. Pearls of Orbital Trauma Management. Semin Plast Surg. 2010;24:398-410.
  13. Christoph Kunz, Guido R.Sigron, Claude Jaquiery. Functional outcome after non –surgical management of orbital fractures- the bias of decision making according to size of defect: critical review of 48 patients. British Journal of Oral and Maxillofacial Surgery. 2013; 51:486-492.
  14. Felicity Victoria Connon, S.J.B. Austin, A.L.Nastri. Orbital Roof Fractures: A Clinically Based Classification and Treatment Algorithm. Craniomaxillofac Trauma Reconstruction.2015;8:198-204.
  15. Jason Liss, Tonya Stefko, William L Chung. Orbital Surgery: State of the Art. Oral Maxillofacial Surg Clin N Am.2010;22:59-71
  16. P.N.Back, N.R.Mclean, P.J.Anderson, D.J.David. The conservative management of facial fractures: indications and outcomes. Journal of plastic, Reconstructive and Aesthetic Surgery.2007; 60:146-151.

 

 

 

 

 

Leave a Comment