|Year : 2015 | Volume
| Issue : 2 | Page : 47-51
Influence of time on the management of complications of orbital floor fracture
Ayman Abd El-Ghafar
Department of Ophthalmology, Ophthalmic Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||11-Nov-2014|
|Date of Acceptance||29-Apr-2015|
|Date of Web Publication||23-Jul-2015|
Ayman Abd El-Ghafar
Department of Ophthalmology, Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura 35516
Source of Support: None, Conflict of Interest: None
The aim of this work is to evaluate the influence of time elapsed between the occurrence of orbital floor fracture and management on improvement of complications.
Patients and methods
This is a prospective comparative interventional study that including 17 patients with pure orbital floor fracture (without involvement of the orbital rim) who presented to Mansoura Ophthalmic Center from January 2012 to September 2012; they presented with diplopia with or without enophthalmos. For all cases, computed tomography-coronal cuts were performed. For all cases, repair of the orbital floor fracture was performed using a titanium mesh. For cases that had persistent diplopia after repair because of restrictive myopathy, adjustable inferior rectus recession was performed. Those who did not achieve correction after recession were corrected by prisms. Cases were followed for 6 months after surgery.
This study included 17 cases with pure orbital floor fracture. They were divided into two groups according to the time of presentation after trauma: group A included seven (41.2%) patients who were operated within 3 weeks of trauma and group B included 10 (58.8%) patients who were operated after 3 weeks up to 6 months of trauma. In group A, all cases presented with diplopia in up gaze; however, one (14.3%) case presented with enophthalmos more than 2 mm.
In group B, all cases presented with diplopia in up gaze and three (30%) of them presented with enophthalmos more than 2 mm. In group A, diplopia and enophthalmos were completely resolved after surgical repair of orbital floor fracture; however, in group B, diplopia improved only in two (20%) cases, but cases of enophthalmos were completely resolved. Among the remaining eight (80%) patients with persistent diplopia who underwent adjustable inferior rectus recession, seven (70%) patients improved and only one (10%) patient had persistent diplopia that was corrected with prisms.
Early repair of orbital floor fracture (within 3 weeks) leads to complete improvement in diplopia; however, late repair in most of the cases needs inferior rectus recession and sometimes prism correction. However, enophthalmos is not affected by the time of repair.
Keywords: Diplopia, enophthalmos, influence of time on floor fracture, orbital floor fracture, proptosis
|How to cite this article:|
El-Ghafar AA. Influence of time on the management of complications of orbital floor fracture. J Egypt Ophthalmol Soc 2015;108:47-51
| Introduction|| |
Blowout fractures are repaired on the basis of the clinical symptoms and signs of the patients, although reconstruction may not completely resolve the cosmetic and functional problems. Recognized sequelae of orbital blowout fractures include enophthalmos, diplopia from extraocular muscle dysfunction, infraorbital nerve anesthesia, disfiguring facial contour, and tearing because of the obstruction of the nasolacrimal duct ,,.
Pure orbital floor fractures (no inferior orbital rim involvement) have several indications for surgical intervention: diplopia secondary to soft tissue entrapment within the orbital floor defect, enophthalmos greater than 2 mm, or a clinically significant fracture . Some oculoplastic surgeons adopt a more conservative approach to the management of pure orbital floor fractures, but will intervene immediately if patients have entrapment and a nonresolving oculocardiac reflex, a trap-door fracture, early enophthalmos, or hypoglobus .
Entrapment of extraocular soft tissues (muscle, fat, and connective tissue) within the orbital floor defect can cause diplopia, restricted, and/or painful vertical gaze, which can persist without intervention .
Enophthalmos is a condition where the globe recedes posteriorly and inferiorly as extraocular support systems of the globe become disrupted and displaced bone fragments alter the boundaries of the orbital cavity. Signs may not be present initially because of soft tissue swelling and bruising, which is why surgeons will operate to prevent enophthalmos if the size of the defect is greater than or equal to 50% of the orbital floor or greater than 2 cm 2 . The high-resolution computed tomography scan can be used with a forced duction test to assess for indications to intervene. Surgical intervention, when indicated, should be prompt because subsequent scarring decreases the efficacy of future intervention .
Early repair (<2 months) yielded better results than late repair (>2 months) in terms of both enophthalmos and extraocular muscle dysfunction, and early repair of large fractures, preferably within two weeks after injury, is recommended .
Surgical repair of blowout fractures within two weeks of trauma decreases the incidence of residual diplopia and enophthalmos .
| Patients and methods|| |
This is a prospective comparative interventional study that included 17 patients with pure orbital floor fracture (the orbital rim was not involved) who attended Mansoura Ophthalmic Center from January 2012 to September 2012; they presented with diplopia with or without enophthalmos at different periods after trauma ranging from 10 days to 6 months [Figure 1]a. For all cases, a full ophthalmological examination was performed including history of the cause of trauma, date of trauma, epistaxis, diplopia, loss of sensation on the cheek, fainting with eye movement, and any previous surgical interference. Visual acuity testing using Landolt's broken rings, examination of the anterior segment using the slit lamp, and posterior segment using indirect ophthalmoscopy were performed to exclude any effect of trauma on the globe.
|Figure 1: (a) Right eye shows limitation in up gaze and enophthalmos in a patient with right orbital floor fracture. (b) Computed tomography both orbits (coronal cut) shows right orbital floor fracture with entrapment of inferior rectus and surrounding tissues. (c) Intraoperative exposure of the fracture in the orbital fl oor. (d) Repair of the fracture using titanium mesh after repositioning of the prolapsed contents .|
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Examination of ocular motility was performed in all directions of the gaze to detect limitations of ocular motility that affect the up and down gaze in orbital floor fracture due to entrapment of the inferior rectus muscle or soft tissue around.
Detection of enophthalmos or proptosis in comparison with the other side using Hertl's exophthalmometer and determination of the degree of enophthalmos. The sensation on the infraorbital area was tested to detect infraorbital anesthesia because of injury of the infraorbital nerve. As all cases presented with diplopia, a forced duction test was performed to detect any restriction in the inferior rectus muscle. Topical anesthesia was used (benoxinate 0.4%), a speculum was applied, two nontoothed forceps were applied at the limbus at 3 and 9 o'clock, gentle forward traction was applied to the globe, then the globe was mobilized upward and downward, and any limitation was noted. Computed tomography was performed for all cases and we ordered thin coronal cuts (2-3 mm) slices that would detect any defect in the orbital floor [Figure 1]b. Also, axial cuts were used to detect associated medial wall fracture. In all cases, there was entrapment of the inferior rectus or surrounding tissues through the defect in the orbital floor and four of them presented with enophthalmos more than 2 mm.
After obtaining written consent and ethical approval, all cases were operated under general anesthesia. A subciliary incision was used in all cases for wider exposure, the periosteum was opened 2 mm below the inferior orbital rim and elevated posteriorly with a periosteal elevator, and all prolapsed tissues were elevated from the fracture site until the entire defect in the orbital floor became obvious [Figure 1]c.
We used titanium mesh of 0.6 mm thickness to cover the defect and we tailored the mesh to cover the defect all around and to ensure that no residual tissue was present under the mesh. Then, the mesh was fixed to the orbital floor through two holes in the anterior portion of the mesh using two self-drilling titanium screws 4 mm in length. Now, the mesh covered the entire defect and the prolapsed tissues were above the mesh [Figure 1]d.
During dissection and after application of the mesh, the pupil was examined for any dilatation, which means compression of the optic nerve that would require immediate release of that compression. Then, the periosteum was closed with polyglactin 5/0 sutures and the skin was closed with black silk 5/0 sutures.
Postoperative systemic antibiotics and analgesic were used for one week and silk sutures were removed after 5 days. Cases were followed for improvement in diplopia, limitation of ocular motility, and enophthalmos.
Patients who did not show improvement in diplopia because of restrictive myopathy were re-evaluated by the forced duction test and those with restriction were reoperated within 3 weeks by performing adjustable suture inferior rectus recession. Surgery was performed under general anesthesia after application of a speculum; a fornix-based conjunctival flap was performed and exposure of the inferior rectus as posterior as the vortex was performed. Double-armed polyglactin 5/0 sutures were applied at the insertion of the muscle then, the insertion of the muscle was severed, the muscle was over-recessed, and the suture was applied to the insertion site and tied in a bow-tie manner. The next day, the movement was evaluated and the adjustable suture was adjusted accordingly and the conjunctiva was closed with polyglactin 5/0 sutures. Postoperative topical combined steroid antibiotic combination was used and the patients were followed up for 6 months.
| Results|| |
This is a prospective comparative interventional study that included 17 patient with pure orbital floor fracture (data were analyzed using SPSS, version 16; SPSS Inc., Chicago, Illinois, USA); seven (41.2%) of these patients (group A) were diagnosed within the first 3 weeks (1-3 weeks, with a mean of 2.25 ± 0.96 weeks) after trauma and six (85.7%) of these patients were men and one (14.3%) was a woman. They ranged in age from 18 to 35 years (mean 25 ± 5.9 years), and the cause of trauma was a motor car accident in six (85.7%) cases and fall from height in one (14.3%) case. All cases presented with diplopia in up gaze; however, one (14.3%) case presented with enophthalmos more than 2 mm [Table 1].
|Table 1: Sex, age, cause, presentation, and time of presentation of the two groups|
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Ten (58.8%) cases (group B) presented after 3 weeks of trauma (4-24 weeks, with a mean of 17.6 ± 6.3 weeks); six (60%) of these patients were men and four (40%) were women. They ranged in age from 20 to 37 years (mean 29.5±6.9 years), and the cause of trauma was a motor car accident in nine (90%) cases and fall from height in one (10%) case. All cases presented with diplopia in up gaze and three (30%) of them presented with enophthalmos more than 2 mm [Table 1].
In group A, diplopia and enophthalmos were completely resolved after surgical repair of the orbital floor fracture [Figure 2]a and b.
|Figure 2: (a) Preoperative photo of a patient with left orbital floor fracture showing limitation in up gaze in the left eye. (b ) Postoperative photo of the same patient after repair of the fracture using a titanium mesh within 3 weeks of trauma .|
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In group B, diplopia improved only in two (20%) cases and eight (80%) cases did not improve because of restrictive myopathy of inferior rectus muscle; however, three cases of enophthalmos were completely resolved. Among the remaining eight patients with persistent diplopia who underwent adjustable inferior rectus recession, seven (70%) patients improved and only one (10%) patient had persistent diplopia that was corrected with prisms [Table 2].
| Discussion|| |
Isolated orbital wall fractures represent 5% of all mid-facial fractures . Folkestad and Westin , in a series of 107 patients, found that in 55% of cases, traumas resulted from domestic or street violence, 18% from accidental falls, 13% from vehicle accidents, and 11% from accidents during sports activity. Men were more prone to orbital floor fracture (62%) than women (38%) .
Kamath et al.  reported that the most common age group of orbital floor fracture was between 20 and 40 years. Among the causes of injury, 71.43% of patients had been involved in road traffic accidents, 20% of patients had a history of falls, and 5.7% of patients had sustained an injury with a blunt object.
In this study, we found that 85.7% of cases were involved in motor car accidents in group A and 90% in group B, which is more common than other studies; however, 14.3% of patients in group A and 10% of patients in group B had sustained injuries as a result of fall from a height. Males were affected in 85.7% in group A and 60% in group B; however, females were affected in 14.3% in group A and 40% in group B and this is in agreement with other studies in which men were more prone to orbital floor fracture. The age of the affected patients ranged from 18 to 35 years in group A and from 20 to 37 years in group B, which is in agreement with the Kamath et al.'s  study.
According to Lester et al. , limitation of ocular motility and vertical diplopia occurred in 90% of cases and enophthalmos in 5.75% of cases of orbital floor fracture.
In our study, diplopia was present in 100% of cases; however, enophthalmos occurred in 14.3% of cases in group A and 30% in group B.
Hawes and Dortzbach , in a series of 51 patients with orbital floor fractures who were studied retrospectively to evaluate results in relation to time of surgical repair and fracture size, had reported that early repair (<2 months) yielded better results than late repair (>2 months) in terms of both enophthalmos and extraocular muscle dysfunction. They recommended early repair of large fractures preferably within two weeks after injury. Patients with significant extraocular muscle dysfunction because of tissue entrapment, irrespective of fracture size, should undergo early repair, preferably within 2 weeks after injury, if improvement does not occur spontaneously by that time .
To prevent fat atrophy and scarring of the orbital fat to the maxillary antrum, surgical repair should be performed within 2 weeks. Orbital soft-tissue entrapment may generate the oculocardiac reflex (bradycardia, heart block, nausea, vomiting, and syncope), warranting an immediate surgical intervention .
Matteini et al.  performed early surgery within 3 days in children with diplopia and within 7 days in adults with diplopia.
Ceylan et al.  reported that there was no significant difference in postoperative primary gaze diplopia when comparing early versus delayed repair. Among seven patients with persistent diplopia, three (7.6%) required strabismus surgery to correct persistent diplopia, although they had previously undergone orbital wall reconstruction; however, in four (10.2%) patients, strabismus surgery was performed without fracture repair because of a history of trauma 28 months ago.
In this study, we found that, after early repair (within 3 weeks) of orbital floor fracture, diplopia had resolved in all cases; however, in cases with delayed repair (after 3 weeks), only 20% of cases had improved and 80% did not improve (statistically significant, P = 0.015). For nonimproved cases, adjustable inferior rectus recession enabled correction in seven (70%) cases and only one (10%) case did not improve and was corrected by prisms.
In contrast, there was no difference between early and late repair in improvement in enophthalmos as all cases had improved after repair of orbital floor fracture.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]