Journal of Cranio-Maxillofacial Surgery (2000) 28, 140±147 # 2000 European Association for Cranio-Maxillofacial Surgery doi:10.1054/jcms.2000.0138, available online at http://www.idealibrary.com on
Ophthalmic involvement in cranio-facial trauma Shantha Amrith,1 Seang Mei Saw,2 Thiam Chye Lim,3 Timothy Kam Yiu Lee4 1
Singapore National Eye Centre & Department of Ophthalmology, National University Hospital, Singapore, Department of Community Occupational and Family Medicine, 3Division of Plastic Surgery, Department of Surgery, 4Neurosurgery Division, Department of Surgery, National University of Singapore, Singapore 2
SUMMARY. Objectives: This is a retrospective descriptive case study which will look into the spectrum of ophthalmic involvement in cases with orbital and eye injuries after cranio-facial trauma and to analyse the visual and motility outcome. Material: One hundred and four cases with ophthalmic involvement after cranio-facial trauma that were referred to and seen in the eye department of a tertiary teaching hospital in Singapore between 1991±97 were included in the study. Methods: The case records of 104 such patients were traced. The demographic data, the mode of injury, the type of fracture sustained and presence of serious eye injury were noted. The details about visual acuity, signi®cant diplopia and enophthalmos at the ®rst and last visits were charted. Presence of traumatic optic neuropathy including the type of treatment given was recorded. Results: There was a male preponderance (82%). The industrial accidents were 21%, only next to road trac accidents, which constituted approximately 36.5%. The predominant types of fractures seen were blow-out orbital fractures, complex fractures comprising of Le-Fort II, III, panfacial and fronto-basilar skull fractures. Diplopia was the most common presenting feature (40%) with visual acuity disturbance (23% having 56/60) as the next most common ®nding. Traumatic optic neuropathy was seen in 20% of patients and serious eye injury was present in 9% of patients. The incidence of traumatic optic neuropathy was signi®cantly higher (p50.001) in patients with complex fractures and fronto-basilar fractures, as compared to the blow-out and zygomatico-maxillary fractures. Analysis of ®nal results indicated 15% as having signi®cant diplopia in one or more gazes and 12.5% as having a vision of 56/60. Conclusion: Diplopia and visual acuity disturbances seem to be the most common ophthalmic presentations in cranio-facial trauma. A signi®cant number of patients suer from poor vision and signi®cant diplopia despite treatment. # 2000 European Association for Cranio-Maxillofacial Surgery
INTRODUCTION
permanent diplopia. Other soft tissue involvement may result in III, IV, V, VI and VII cranial nerve palsies necessitating further management to correct the sequelae. The lacrimal drainage system can be aected in naso-ethmoidal fractures. Medial and lateral canthal positions can similarly be aected due to injury to the corresponding areas. The main objectives of the study were to examine the pattern of ophthalmic injury in a series of 104 cases with orbital and eye involvement after craniofacial trauma seen in the Eye Clinic of a tertiary teaching hospital and to analyse the visual and motility outcome.
With the ready availability of high-resolution computed tomographic (CT) scans, evaluation of craniofacial trauma has improved tremendously in recent years. The main aims of management are restoration of bony architecture and repair of any soft tissue injury. Modern day surgical practice of open reduction of facial fractures with rigid ®xation devices (Rubin et al., 1992) such as micro-plates and miniplates, has improved the cosmetic and functional results. The ophthalmic involvement is inevitable in mid-facial fractures as the soft tissues absorb more energy at the time of impact than the underlying bones (Yaremchuk, 1992). The severity and permanency will depend on the type of injury, extent of fractures and availability of expertise to manage the complex problems that arise. Singapore is a newly industrialized City State; as a result, high velocity road trac accidents and industrial accidents are common. Soft tissue injury to the eyeball and the orbital structures is a major complicating factor in such accidents and has been reported in various studies. Visual loss can ensue from perforating and concussion injuries to the eyeball, alternatively from traumatic optic neuropathy. Disabling diplopia often results from facial trauma and if not managed adequately can result in
MATERIAL AND METHODS This study was carried out to analyse the demographics and the extent of ophthalmic involvement in patients, who presented to or were referred after a cranio-facial trauma to the oculoplastic service of the Ophthalmology Department of National University Hospital, which is a tertiary teaching hospital. One hundred and four such patients seen between 1991 and 1997 were included in the study. All patients had some involvement of the orbit or the eye, or were considered high risk for ophthalmic involvement, 140
Ophthalmic involvement in cranio-facial trauma 141
which is the primary reason why they were seen in the eye department. The treatment of choice for Le Fort, pan-facial, zygomatico-maxillary fractures and orbital roof fractures involving the orbital margin was open reduction and internal ®xation with mini or microplates. Bony defects in the orbit were covered with approved materials as seen appropriate at the time of surgery. These include materials like autologous bone grafts (calvarial or rib), titanium plates, lyophilized dura which in the later years has been replaced with aliphatic polyesterurethane patch (neuropatch). In blow-out fractures repaired by the ophthalmic plastic surgeon, 0.4 or 0.3 mm supramid plates were used to cover the bony defect. The records of the 104 such patients were traced. The following parameters were noted: age, sex, the nature of accident, the type of fractures sustained, visual acuity at the ®rst and the ®nal visits and the presence of eye injury. Serious eye injuries for this study were de®ned as those that are likely to result in permanent impairment of vision, such as eye ball ruptures/penetrating eye injuries, hyphaema, subluxation of the lens, angle recession, vitreous haemorrhage, retinal detachment, choroidal ruptures in the posterior pole etc. Presence of optic neuropathy was con®rmed if, in addition to poor vision, there was relative aerent pupillary defect in the absence of signi®cant pathology in the eye. In cases of optic neuropathy, the type of treatment received was also noted. Ocular motility ®ndings were based on the orthoptic check up, including the ®ndings from Lees screen. Lees screen is a device similar to Hess screening, which maps the ocular movements with each eye ®xing, as the patient tries to superimpose the ®xation target. Like the Hess screening, Lees screen also uses nine inner points and 16 peripheral points for ®xation. Initial diplopia refers to the recording done after subsidence of initial oedema (approximately 2 weeks post injury). However, for patients with multiple fractures and zygomatico-maxillary fractures who had the repair done within 5±7 days after injury, initial diplopia refers to the earliest possible recording after surgery. Final diplopia refers to the diplopia recorded at one of the last visits to the clinic (average follow-up of 11 months). Signi®cant diplopia for this study is de®ned as diplopia that is likely to interfere with daily activity. Those who had diplopia only in extreme gaze (as evidenced by restriction of movement in Lees screen charting beyond 25 degrees) were considered as not having signi®cant diplopia. However, if the patient volunteered information that the diplopia was signi®cantly aecting his/her daily activities, it was included as signi®cant diplopia. The exophthalmometry readings were noted if available. Presence of a foreign body, injury to the lacrimal system, the presence of ptosis and any abnormal positions of the canthi were also noted. Both descriptive and univariate analysis of the data were carried out. Categorical factors in dierent categories were compared using w2 or Fisher's exact test.
Table 1 ± Description of patients with cranio-facial trauma seen in Eye Clinic of National University Hospital, Singapore between 1990 and 1997 All subjects (n104) Gender Female Male Year of presentation 1991 1992 1993 1994 1995 1996 1997
Number (%) 18 (17) 86 (83) 11 16 22 10 19 15 13
(10) (15) (21) (9) (18) (14) (12)
Fig. 1 ± Age and gender distribution of 104 patients seen in Eye Clinic for ophthalmic complications after cranio-facial trauma between 1990 and 1997. &, Male; , Female.
RESULTS As in most trauma studies, there is a male predominance (82%). There was no signi®cant change in the trend or pattern of injury over the 7 year period studied (Table 1). The majority of patients were between the ages of 20 and 40 (Fig. 1). The mean age was 32 years and the median age 29 years. The follow-up ranged from 2 weeks to 86 months, a mean of 11 months. Figs 2 & 3 show the number of cases vs the nature of injury and the types of fracture. Road trac accidents followed by the industrial accidents were the most frequently seen. Blow-out fractures of ¯oor and medial wall were the most commonly seen, followed by complex fractures (Le Fort II, III, panfacial fractures, frontobasilar and some combined fractures). It is not surprising to see the blow-out fractures as the most common, as this study represents ®gures from an eye department. Thirty-®ve cases (34%) had no surgical intervention for the injury to bony skeleton. Five of these had no fracture (this includes cases with optic neuropathy due to indirect trauma and cases with diplopia, but
142 Journal of Cranio-Maxillofacial Surgery
Fig. 2 ± Various modes of injuries in 104 patients with ophthalmic complications presenting to Eye Clinic between 1990 and 1997.
without a fracture), ®ve cases had complex fractures, 13 blow-out fractures, four zygomatico-maxillary fractures, four base of skull fractures, two roof fractures and two had orbital foreign bodies. For those with complicated and zygomatico-maxillary fractures who underwent repair, it was done within one week of injury. Nine patients (9%) had more than one operation for restoration of bony architecture or for enophthalmos.
Table 2 shows percentages of various ophthalmic involvements seen in this series. Table 3 shows the details of the serious eye injuries (nine cases). Eyeball rupture or penetrating injury was seen in ®ve eyes of four patients, two of them were severe enough to warrant enucleation. Minor eye injuries such as corneal abrasions, microscopic hyphaema, traumatic mydriasis, orbital haematoma, ecchymosis and lid lacerations were not included. Traumatic optic neuropathy was classi®ed separately. Visual acuity results are given in Table 4. In 12.5% of all cases, the ®nal vision remained less than 6/60, seven of which had no light perception. None of the blow-out fractures was associated with loss of vision. The incidence of traumatic optic neuropathy was signi®cantly higher (p50.001) in patients with complex fractures and fronto-basilar fractures grouped together, as compared to the blow-out and zygomatico-maxillary fractures together (Table 5). Traumatic optic neuropathy was present in 23 eyes of 21 patients. The treatment outcome is shown in Table 6. The prognosis appears to be poor in patients, who had no perception of light to begin with. There were eight eyes (eight patients) with traumatic optic neuropathy who had no light perception on presentation. Two of them received no treatment, three cases received megadose steroids and three had steroid and decompression of the optic canal. Of these eight eyes, only one eye (one patient) who had received megadose steroids initiated within 24 h, showed improvement in vision (6/12). All the others remained without perception of light.
Fig. 3 ± Dierent types of injuries in 104 patients with ophthalmic complications presenting to the Eye Clinic between 1990 and 1997.
Ophthalmic involvement in cranio-facial trauma 143 Table 2 ± Ophthalmic involvement in patients with cranio-facial trauma at presentation to the Eye Clinic between 1990 and 1997 Type of involvement
All subjects (n104)
Comment
Number (%) 9 (9) 21 (20)
Serious eye injury Traumatic optic neuropathy Diplopia Signi®cant diplopia Missing data Not tested due to poor vision Enophthalmos Enophthalmos 42 mm Missing data Ptosis Orbital foreign body Lacrimal involvement Medial canthal dystopia Lateral canthal dystopia
Bilateral for one patient Bilateral for two patients
42 (40) 19 (18) 10 (10) 19 55 5 3 7 7 6
(18) (53) (5) (3) (7) (7) (6)
3 (3%) due to III nerve palsy
Table 3 ± Details of serious eye injuries in patients with ophthalmic complications after cranio-facial trauma seen in Eye Clinic between 1990 and 1997 Age/Sex
Type of injury
Initial vision
Final vision
Other ®ndings
1.
27/M
Choroidal rupture
2.
29/M
Choroidal rupture
6/12 or better 6/60 ± 6/18
6/12 or better 6/12 or better
3.
58/M
PL/HM
PL/HM
4. 5.
21/M 20/M
6.
19/M
7.
39/M
Vit. haemorrhage, macular scar Perforation of eyeball Bilateral perforation of eyeballs Subluxated lens, Retinal detachment Vit. haemorrhage
Blow-out # I.O. underaction Complex # Enophthalmos, diplopia in down gaze Complex #
8. 9.
29/M 20/M
PL/HM NPL (bilateral) 6/60 ± 6/18 6/60 ± 6/18 NPL NPL
PL/HM NPL (bilateral) 6/12 or better 6/12 or better NPL NPL
Perforation of eyeball Posterior eyeball rupture
Roof # Complex # Complex # Complex # Complex #,* Complex #, *
# ± Fracture, Vit. ± Vitreous, I.O. ± Inferior oblique, NPL ± No perception of light, PL ± Perception of light, HM ± Hand movements, * eye enucleated as part of treatment.
Table 4 ± Initial and ®nal visual acuity of patients seen in the Eye Clinic for ophthalmic complications after cranio-facial trauma between 1990 and 1997
Initial visual acuity 6/12 and better 6/18 to 6/60 56/60 to CF HM/ PL NPL Missing data Final visual acuity 6/12 and better 6/18 to 6/60 56/60 to CF HM/ PL NPL Missing data
Total (n104)
Total (n104)
Number (%)
Number (%) with 56/60
60 (58) 13 (12.5) 12 (11.5) 4 (4) 7 (7) 8 (8)
24 (23)
81 (78) 8 (8) 4 (4) 2 (2) 7 (7) 2 (2)
13 (12.5)
NPL ± No perception of light, PL ± Perception of light, HM ± Hand movements. CF ± Counting ®ngers.
Table 5 ± Proportion of patients with traumatic optic neuropathy with blow-out or zygoma fractures compared to patients with complex, base of skull or orbital roof fractures among the 104 seen with cranio-facial trauma between 1990 and 1997 Traumatic optic neuropathy Blow-out and zygoma fractures (n51) Complex, base of skull and roof fractures (n48)
Number (%) 3 (6)
p value (w2)
p50.001
17 (35)
Table 7 shows diplopia for all fractures and blow-out fractures in primary and in dierent positions of gaze. In 10 patients (10%) diplopia could not be elicited due to poor vision in one or both eyes. The ®nal results for all fractures and the subgroup of blow-out fractures are very similar. However, the point of interest is that none had ®nal diplopia in primary
144 Journal of Cranio-Maxillofacial Surgery
position for blow-out fracture. Four patients (4%) persisted to have diplopia in primary position in the `all patients' group. Three of the four had complex fractures (two had surgery more than once for this problem and one was lost to follow-up). The fourth patient with diplopia in primary position had a foreign body near the medial rectus insertion and an attempt to remove the foreign body resulted in a failure. Of the 37 cases of blow-out fracture, 24 cases (65%) were repaired surgically. The indications for surgery were, persistent diplopia with evidence of muscle or tissue entrapment, large fractures and or enophthalmos of more than 2 mm. Two of those were done by plastic surgeons, the rest by an ophthalmic plastic surgeon. Two of them were pure medial wall fractures. Repair of blow-out fractures was carried out between 1 and 4 months of injury, except for one case where it was delayed by one year. The results are tabulated in Table 8. Of the operated cases, none had diplopia in primary position postoperatively as Table 6 ± Treatment of traumatic optic neuropathy in 23 eyes of 21 patients with cranio-facial trauma seen in the Eye Clinic between 1990 and 1997 Type of treatment
Number of eyes (n23 eyes)
Number of eyes improved
No treatment Megadose steroids Megadose steroids decompression optic canal
6 8 9
Number (%) 2 (33) 5 (62) 5 (55)
against nine preoperatively. Seventeen percent of patients operated, remained with signi®cant diplopia in one or more gazes on follow up (an average period of 10 months). The patient who underwent repair a year later showed signi®cant improvement in diplopia in all gazes except in downgaze. Data for enophthalmos is incomplete, as it was not recorded for 52% of patients at the preoperative period. Most of the missing data is from patients who had severe trauma and complex fractures. The initial measurements were not possible as most underwent repair before the subsidence of initial oedema and haemorrhage, i.e. within 2 weeks of injury. However, by the last visit, six patients (6%) had enophthalmos of 4±6 mm. Of the six patients, four were after complex fractures and all of them had subsequent surgery to correct their late enophthalmos. The time interval between surgical procedures was between 6 months and 5 years. The other two were after a zygomatico-maxillary fracture and blow-out fracture respectively. Five patients (5%) had ptosis, three of the ®ve were due to palsy of the oculomotor nerve, one was due to a blow-out fracture (ptosis recovered after ®xing the fracture) and one was due to orbital roof fracture. There were three cases of orbital foreign body; one was removed from under the optic nerve by a lateral orbitotomy, and another from the trochlea. Removal in the third case from near the medial rectus insertion failed. There were seven (7%) cases of lacrimal involvement, seven cases (7%) of medial canthal dystopia and six cases (6%) of lateral canthal dystopia. Of the
Table 7 ± Types of diplopia in patients with ophthalmic complications after cranio-facial trauma seen in Eye Clinic between 1990 and 1997 Signi®cant diplopia
All patients (n104)
Patients with blow-out fracture (n37)
Initial diplopia
Final diplopia
Initial diplopia
Final diplopia
Any position No Yes Missing data
Number (%)
Number (%)
Number (%)
Number (%)
43 (41) 42 (40) 19 (18)
83 (80) 16 (15) 5 (5)
11 (30) 26 (70) 0 (0)
29 (78) 6 (16) 2 (5)
Primary Position No Yes Missing data
65 (62) 20 (19) 19 (18)
94 (89.5) 4 (4) 5 (5)
26 (70) 11 (30) 0 (0)
35 (95) 0 (0) 2 (5)
Up gaze No Yes Missing data
59 (56) 26 (25) 19 (18)
92 (88) 7 (7) 5 (5)
19 (51) 18 (49) 0 (0)
32 (86.5) 3 (8) 2 (5)
Down gaze No Yes Missing data
59 (56) 26 (25) 19 (18)
88 (84) 11 (10.5) 5 (5)
21 (57) 16 (43) 0 (0)
31 (84) 4 (11) 2 (5)
Horizontal gaze No Yes Missing data
70 (67) 15 (14) 19 (18)
96 (91) 3 (3) 5 (5)
33 (89) 4 (11) 0 (0)
35 (95) 0 (0) 2 (5)
Ophthalmic involvement in cranio-facial trauma 145 Table 8 ± Signi®cant diplopia in patients with blow-out fractures who underwent repair (n24) Signi®cant diplopia
Preop
Postop
Any gaze Primary position Up gaze Down gaze Horizontal gaze
Number (%) 21 (87.5) 9 (37.5) 17 (71) 14 (58) 4 (17)
Number (%) 4 (17) 0 (0) 1 (4) 3 (12.5) 0 (0)
seven cases of medial canthal dystopia, three cases had lacrimal involvement too.
DISCUSSION This series was evaluated retrospectively and brings out the demographic data relevant to our setting and highlights the visual morbidity that is associated with cranio-facial trauma. As in most trauma studies, we also found that the most vulnerable for orbital trauma are the young male adults. al-Qurainy et al. (1991a) prospectively analysed the eects of facial trauma, which included all the complex, roof and nasoethmoidal fractures. They found that assaults ranked the highest (49.9%) followed by falls (19%), and then road trac accidents and sports (12.4% each). Our study showed road trac accidents (36.5%) followed by industrial accidents (21%) to be among the top oenders in our country. Industrial accidents tend to be higher if safety regulations are not strictly observed and if the hospital is situated near an industrial area of the city, as in our case. Similarly, the mode of injury is very much dependent on the local culture and society. An example of this is evident in a study from Iran (Taher, 1993) where ®rearms were responsible for the highest number of injuries. Two studies (Covington et al., 1994; Jayamanne and Gillie, 1996) from dierent regions show contradictory ®gures for the orbitozygomatic fractures. In the ®rst study (Covington et al., 1994) road trac accidents were responsible for 80% of fractures and assaults for 5%, whereas in the second study (Jayamanne and Gillie, 1996), assaults accounted for 73% and road trac accidents for only 3% of the zygomatic fractures. This dierence again can be due to regional and cultural variation. The term `severe eye injury' is used in dierent studies to denote various types of eye injuries. alQurainy et al. (1991a) de®ned the severe injury as gross proptosis, retrobulbar haemorrhage, corneal laceration, angle recession, reduced visual acuity (6/ 36 or less), visual ®eld loss, and choroidal tear involving macula and optic nerve injury. Osguthorpe (1991) de®ned severe eye injury as those having hyphaema, laceration of the globe, and detachment of the retina and optic nerve injury. We included only those with eyeball lacerations, gross hyphaema, vitreous haemorrhage, choroidal ruptures, subluxated lens and retinal detachments. The above
studies (al-Qurainy et al., 1991a; Osguthorpe, 1991) found serious eye injuries in 12% and 17% respectively. Lim et al. (1993) found an incidence of 3.9% eye injury that included three penetrating injuries and ®ve optic nerve injuries among 839 patients with facial fractures. The comparative ®gure for our study is 9%. Patients with traumatic optic neuropathy were included with serious eye injuries in the other studies, while we classi®ed them separately. This is one of the reasons for the lower ®gure in our study. Covington et al. (1994) found that out of 243 cases of zygoma fractures, there were 15 globe ruptures. Our corresponding ®gure was 0 among the small number of only 19 cases with zygoma fractures. Severe ocular injuries such as retinal detachment, dialysis etc. were found to be rare in orbito-zygomatic fractures compared to multiple facial fractures (Jayamanne and Gillie, 1996). Of the four cases of globe rupture in our series, three occurred in cases with complicated facial fractures and one with an orbital roof fracture. Visual acuity results of our study compare quite favourably with a few other studies. al-Qurainy et al. (1991a) found the visual acuity to be impaired in 15.4% at presentation. Osguthorpe (1991) observed that 5% had permanent loss of vision and another 5% had permanent impairment in vision. We found that, even though 23% of patients had a vision of less than 6/60 at the time of injury, only 12.5% had permanent impairment (56/60). 7% had permanent loss of vision. Jayamanne and Gillie (1996) found that 74% of multiple facial fractures had 6/9 or better vision and our observation showed a comparable ®gure of 81% who had a vision of 6/12 or better. al-Qurainy et al. (1991a) included optic nerve injuries along with severe eye injuries and quoted a ®gure of 2.5%. Covington et al. (1994) noted 19 out of 243 patients (8%) and Jayamanne and Gillie (1995) one out of 45 (2%) to have traumatic optic neuropathy. In the studies mentioned above, the reason for a low incidence of optic neuropathy may be because of the preponderance of zygomaticomaxillary fractures and blow-out fractures and our analysis shows that the optic neuropathy is signi®cantly lower in zygomatico-maxillary and blow-out fractures compared to orbital roof or base of skull or other complex fractures. On the contrary, Karesh et al. (1991) found that in seven cases of orbital roof blow-in fractures there were varying degrees of optic nerve involvement in all the seven cases. Similarly, Burstein et al. (1997) analysed fronto-basilar trauma and found that two of the 14 patients were bilaterally blind due to optic nerve trauma. Stanley et al. (1998) found that nine out of 11 cases with impacted lateral orbital wall fractures had traumatic optic neuropathy, however, they conjectured that the traumatic optic neuropathy that accompanied this type of fracture is distinct from the indirect optic nerve trauma that may have responded to steroids or optic canal decompression. Since our case series included all types of fractures, our ®gure (20%) for traumatic optic neuropathy does not appear to be high.
146 Journal of Cranio-Maxillofacial Surgery
The treatment of traumatic optic neuropathy is controversial. Most treatment trials were non-randomized. However, it is useful to know the observation made by some with respect to treatment outcome. There are some reports on the bene®cial use of megadose steroids (Sei, 1990) and optic canal decompression (Joseph et al., 1990; Li et al., 1999; Maurer et al., 1999). A meta-analysis of a large number of patients by Cook et al. (1996) showed that treatment with megadose steroids alone or in combination with optic canal decompression was better than no treatment and that between two modalities of treatment there was no statistical dierence. However, Levin et al. (1999) concluded after an international optic nerve trauma study on 133 patients that there is no clear bene®t with steroid therapy or optic canal decompression. Steinsapir (1999) made a similar observation. Our results are similar to Cook et al. (1996), though our numbers are too small for any statistical conclusion. Treatment outcome seemed to be uniformly poor in cases whose initial vision was no light perception and this observation is in concurrence with that made by Mine et al. (1999). Comparison of diplopia between dierent studies is dicult as there is no objective parameter by which diplopia can be quanti®ed. al-Qurainy et al. (1991b) included all those having diplopia close to midline and within 15 degrees of gaze. Biesman et al. (1996) de®ned signi®cant diplopia as the one `apparent while performing normal daily activities'. In our study, all those having restriction of eye movement in the recordings of Lees screen up to almost 25 degrees were considered as signi®cant. We have also included patients who complained of diplopia as interfering with normal daily activities even if the recordings showed minimal restriction of movement in extreme gaze. Table 9 summarizes the diplopia ®gures in dierent studies. Except in blow-out fractures, where the surgery is usually delayed until subsidence of oedema and haemorrhage, the true incidence of diplopia is dicult to assess. Most patients with complex fractures and zygomatico-maxillary fractures undergo repair within a week of injury when they still have limitation of eye movements due to oedema and
haemorrhage. The ®rst recording of diplopia in such patients is usually possible only after 3 or 4 weeks of injury. So, one will never know the true incidence of diplopia in such cases. Among the blow-out fractures, Biesman et al. (1996) found that the prognosis was worse in combined ¯oor and medial wall fractures. In our study we did not analyse diplopia according to fracture site and size and hence direct comparison with the above study is not possible. Sei and Good (1994) reported loss of binocular ®eld as a universal ®nding in all blow-out fractures resulting from sports injuries. Persistent diplopia with evidence of muscle and tissue entrapment and large fractures causing signi®cant enophthalmos are some of the indications for repair in blow-out fractures. Rounding of inferior rectus (Levine et al., 1998) in the absence of a fracture in the CT scans may indicate a small fracture that may not be apparent in 3 mm cuts and therefore an indication for surgery. Similarly, in small fractures with entrapment of inferior rectus, the CT scan may show missing muscle in some frames (Wachler and Holds, 1998). This calls for an early intervention as was illustrated in one of our patient's with similar CT ®ndings. The repair was delayed by 4 months and the postoperative improvement in diplopia was less dramatic despite release of the trapped muscle. Stanley et al. (1998) studied impacted lateral wall fractures and found that the ocular motility improved in all patients after repair due to removal of mechanical restriction. There were limitations to the assessment of enophthalmos in our study. This is a universal limitation similar to diplopia assessment because some of the cases undergo open reduction and internal ®xation before subsidence of initial oedema and haemorrhage, at which stage the eye may be proptotic rather than enophthalmic. Besides, the measurements are dicult if there is severe lid ecchymosis. Therefore, it was only possible for us to see how many cases remained with enophthalmos despite treatment as a late sequel. Yeatts (1992) reported that enophthalmos occurs in almost 90% of the patients with comminuted (Le Fort) fractures when the measurements were taken with the modi®ed external auditory canal ®xated device. Fat atrophy
Table 9 ± Comparison of diplopia from various studies Author
Type of fracture
No. of cases
Initial diplopia
Covington et al., 1994 Osguthorpe, 1991 Jayamanne and Gillie, 1995 al-Qurainy et al., 1991b
Zygoma Orbital walls Blow-out Mid-facial Blow-out
243 92 45 363 36
69.2% 23% 84% 19.8% 58.3%
Biesman et al., 1996
Blow-out (surgical cases) Cranio-facial Blow-out Blow-out (surgical cases)
Present study
54 104 37 24
Final diplopia
86%
82% recovered in 6 m 6.9% diplopia at 1 year 37%
40.4% 70.3% 87.5%
15% 16% 17%
Ophthalmic involvement in cranio-facial trauma 147
was once thought to be the cause. But lately, various factors have been blamed, such as, increase in orbital bony volume (Whitehouse et al., 1994; Yab et al., 1997), involvement of more than one wall of the orbit (Rubin et al., 1992) and increase in volume at the orbital rim area (Grant et al., 1997). An expansion of 513% of orbital volume can be a predictive factor for the development of late enophthalmos (Raskin et al., 1998). Though correction of enophthalmos is a dicult task, restoring the orbital anatomy by orbital augmentation can reverse a symptomatic diplopia (Rubin and Rumelt, 1999). This was evident in six of our cases, where there was substantial improvement in diplopia after a repeat surgery in all cases. Canthal dystopia and lacrimal injuries are frequently seen in cranio-facial injuries requiring further operations for this problem. Osguthorpe (1991) quotes approximately 13% lacrimal injury (7% in our series). The study highlights some of the permanent visual disabilities caused by cranio-facial trauma. As the trauma aects the economically viable, it would be wise to educate the public about the impact of craniofacial trauma and how some accidents can be prevented. References al-Qurainy IA, Stassen LF, Dutton GN, Moos KF, el-Attar A: The characteristics of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral & Maxillofac Surg 29: 291±301, 1991a al-Qurainy IA, Stassen LF, Dutton GN, Moos KF, el-Attar A: Diplopia following midfacial fractures. Br J Oral Maxillofac Surg 29: 302±307, 1991b Biesman BS, Hornblass A, Lisman R, Kazlas M: Diplopia after surgical repair of orbital ¯oor fractures. Ophthalmic Plast Reconstr Surg 12: 9±16, 1996 Burstein F, Cohen S, Hudgins R, Boydston W: Frontal basilar trauma: classi®cation and treatment. Plast Reconstr Surg 99: 1314±1321, 1997 Cook MW, Levine LA, Joseph MP, Pinczower EF: Traumatic optic neuropathy. A meta-analysis. Arch Otolaryngol Head Neck Surg 122: 389±392, 1996 Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH: Changing patterns in the epidemiology and treatment of zygoma fractures: 10 year review. J Trauma 37: 243±248, 1994 Grant MP, lli NT, Manson PN: Strategies for treatment of enophthalmos. Clin Plast Surg 24: 539±550, 1997 Jayamanne DG, Gillie RF: Orbital blow-out fractures: long-term visual outcome of associated ocular injuries. J Accid Emerg Med 12: 273±275,1995 Jayamanne DG, Gillie RF: Do patients with facial trauma to the orbito-zygomatic region also sustain signi®cant ocular injuries? J R Coll Surg Edinb 41: 200±203 1996 Joseph MP, Lessel S, Rizzo J, Momose KJ: Extracranial optic nerve decompression for traumatic optic neuropathy. Arch Ophthalmol 108: 1091±1093, 1990 Karesh JW, Kelman SE, Chirico PA, Mirvis SE: Orbital `blow-in' fractures Ophthalmic Plast Reconstr Surg 7: 77±83, 1991 Levin LA, Beck RW, Joseph MP, Sei S, Kraker R: The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study: Ophthalmology 106: 1268±1277, 1999 Levine LM, Sires BS, Gentry LR, Dortzbach RK: Rounding of inferior rectus muscle: a helpful radiologic ®nding in the
management of orbital ¯oor fractures. Ophthalmic Plast Reconstr Surg 14: 141±143, 1998 Li KK, Teknos TN, Lai A, Lauretano AM, Joseph MP: Traumatic optic neuropathy: result in 45 consecutive surgically treated patients. Otolaryngol Head and Neck Surg 120: 5±11, 1999 Lim LH, Lam LK, Moore MH, Trott JA, David DJ: Associated injuries in facial fractures: review of 839 patients. Br J Plast Surg 46: 635±638, 1993 Maurer J, Hinni M, Mann W, Pfeier N: Optic nerve decompression in trauma and tumor patients. Eur Arch Otolaryngol 256: 341±345, 1999. Mine S, Yamakami I, Yamaura A, Hanawa K, Ikejiri M, Mizota A, Adachi-Usami E: Outcome of traumatic optic neuropathy. Comparison between surgical and nonsurgical treatment. Acta Neurochir (Wien) 141: 27±30, 1999 Osguthorpe JD: Orbital wall fractures: evaluation and management. Otolaryngol Head Neck Surg 105: 702±707, 1991 Raskin EM, Millman AL, Lubkin V, Della Rocca RC, Lisman RD, Maher EA: Prediction of late enophthalmos by volumetric analysis of orbital fracture. Ophth Plast Reconst Surg 14: 19±26, 1998 Rubin PA, Shore JW, Yaremchuk MJ. Complex orbital fracture repair with rigid ®xation of internal orbital skeleton. Ophthalmology 99: 553±559, 1992 Rubin PA, Rumelt S: Functional indications for enophthalmos repair 15: 284±292, 1999 Sei SR: High dose corticosteroids for treatment of vision loss due to indirect injury to optic nerve. Ophthalmic Surg 21: 389±395, 1990 Sei SR, Good WV: Orbital blow-out fractures in sport. Br J Sp Med 28: 272±275, 1994 Stanley RB Jr, Sires BS, Funk GF, Nerad JA: Management of displaced lateral orbital wall fractures associated with visual and ocular motility disturbances. Plast Reconstr Surg 102: 972±979, 1998 Steinsapir KD: Traumatic optic neuropathy. Curr Opin Ophthalmol 10: 340±342; 1999 Taher AA: Management of complications of middle- and upperthird facial compound injuries: an Iranian experience. J Craniofac Surg 4: 153±161, 1993 Wachler BS, Holds JB: The missing muscle syndrome in blow-out fractures: an indication for urgent surgery. Ophthalmic Plast Reconstr Surg 14: 17±18, 1998 Whitehouse RW, Batterbury M, Jackson A, Noble JL: Prediction of enophthalmos by computed tomography after `blow-out' orbital fractures. Br J Ophthalmol 78: 618±620, 1994 Yab K, Tajima S, Ohba S: Displacements of eyeball in orbital blowout fractures Plast Reconstr Surg 100: 1409±1417, 1997 Yaremchuk MJ: Changing concepts in the management of secondary orbital deformities. Clin Plast Surg 19: 113±124, 1992 Yeatts RP: Measurement of globe position in complex orbital fractures. II. Patient evaluation utilising a modi®ed exophthalmometer. Ophthalmic Plast Reconstr Surg 8: 119±125, 1992
Dr. Shantha Amrith MD, FRCS Department of Ophthalmology National University Hospital 5, Lower Kent Ridge Road Singapore-119074 Tel: 65 7725318 Fax: 65 7777161 E-mail:
[email protected] Paper received 14 December 1999 Accepted 26 June 2000
