orbital fractures - the role of an ophthalmologist

ORBITAL FRACTURES

Dr. Ankit M. Punjabi (drankitalways@gmail.com)Kota Eye Hospital, Kota, Rajasthan, India

The Role of An Ophthalmologist

Rate of orbital involvement : 15% of all serious injuries Fracture : 78% Foreign body : 24% Hemorrhage : 1%

Males : 78%

The Place & Source of Injury

Source of InjuryPlace of Injury

Pathophysiology

Orbit’s primary role: Protect the eyeball

The combination of superior & lateral strength with medial and inferior wall weakness allows dissipation of energy when orbit is struck

Evolutionary master piece: the ability of the orbital floor to fracture selectively, similar to a safety valve

Evaluation of Orbital Trauma

Injuries to orbit are often associated with severe

neurological injuries, which are life-threatening

and take precedence over the orbital treatment

History in a case of Ocular Trauma

Evaluation of Visual Functions

CT: Best images of relationship between the bone and soft tissues Suspected orbital fractures Palpable bone step-offs Restricted extra-ocular movements Metallic orbital foreign bodies

MRI: Best at differentiating soft tissues Associated neurological damage Wooden foreign bodies

LE FORT FRACTURES

Type 1 Type 2 Type 3

Common to all Le Fort Fractures

is

involvement of Pterygoid Plates

MAXILLOFACIAL INJURY

LE FORT FRACTURESType 1 Low Transverse Maxillary Fracture

MAXILLOFACIAL INJURY

LE FORT FRACTURESType 2 Pyramidal Fracture

MAXILLOFACIAL INJURY

LE FORT FRACTURESType 3 Craniofacial Dysfunction

Most common orbital injury Typical history of a blow by blunt, may be rounded object (>5cm

in size) Fracture of the inferior medial orbit

Classical triad of: Diplopia

(restrictive strabismus) Infraorbital numbness

(interruption of infraorbital nerve) Periocular ecchymosis

(skin & muscle damage)

Left Orbital

Blow-out Fracture

Theories of Blow-Out Fracture

Direct injury (Retropulsion): Sudden compression of globe with orbital floor fracture (increased orbital

& ocular pressure)

Indirect injury (Buckling) Blow to inferior rim causes a ripple effect causing fracture

Clinical Features

• Diplopia (Defective Elevation)• Infraorbital numbness• Periocular ecchymosis & Edema• Enophthalmos• Orbital Emphysema• Hyphaema, angle recession• Commotio Retina, Retinal dialysis

• Positive forced Duction Test

• In Children:GREEN STICK FRACTUREclinically evident, absence on CT

X-Ray

Herniation of orbital contents

CT – “Tear Drop” sign

The Myth & The Truth

Patients with isolated blow-out fractures: Initially they can be followed clinically If surgery is needed, it is usually planned for 7-14 days after the trauma

Waiting allows time for: Spontaneous improvement Resolution of swelling associated with the initial trauma Precise surgical planning

Delaying surgery for over 14 days results in increased scarring of orbit

Early repair is necessary : Associated craniofacial trauma Marked enophthalmos & hypoglobus Complete disruption of the orbital floor

Causes of delayed presentation: Life-threatening injuries which took precedence Non-exploration & non-repair by craniofacial surgeons Too edematous orbit to allow effective repair

Surgical Repair

Specific Indications: Restrictive Strabismus CT evidence of muscle entrapment Enophthalmos <2mm Oculocardiac Reflex Hypo-ophthalmos Large floor fracture <50%, based on CT estimate of fracture size

Usually transconjunctival approach: Excellent exposure Conceals the incision Prevents postoperative lid retraction

Orbital Floor Implants

Autogenous materials Calverium Iliac crest Ribs

Alloplastic materials Porous polyethelene implant Titanium mesh Polymer of polylactic & polyglactic acid (resorbable)

Individualised Pre-fabricated Implants

Endoscopic Approach

Recovery

May take weeks to months Last thing to recover from is numbness

Multiple fractures in and around the orbit Can be seen in Tripod & LeFort III fractures Clinical signs & symptoms

Enophthalmos Deep superior sulcus

Extension of a floor fracture Component of naso-orbital-ethmoid (NOE) fractures Signs & symptoms:

Horizontal diplopia Orbital Emphysema Orbital Hemorrhage Enophthalmos

Distinctly uncommmon Due to moderate-high energy impact Associated with significant concomittant non-ocular injuries C/F:

Restricted up-gaze & ptosis Epistaxis, CSF Rhinorrhoea, Anosmia Depression of Supraorbital rim Hyperaesthesia of Cranial nerve V1 Hypo-ophthalmos & pulsatile exophthalmos

Indications of surgery: Depressed skull fracture (if the anterior cranial fossa is compromised, a

craniotomy is often required); Significant diplopia; Significant exophthalmos; and Frontal sinus fracture with compromise of the nasofrontal duct.

Tripod or trimalar fracture Now considered to have

4 components: ZM suture ZF suture ZT suture ZMC buttress (most important)

2nd most common fracture Varied presentations

(thus often missed)

Features of ZMC complex fracture

Highly variable Point tenderness & ecchymosis Malar flattening & increased facial width Lateral canthal dystopia Dysesthesia of Cranial Nerve V1 Trismus & malocclusion Inferior or Lateral Rim Step-off Associated floor fracture findings

Specific indications for surgical intervention include the following: Significant malar flattening Lateral canthal dystopia or lower-lid malposition Trismus or malocclusion Significant orbital enlargement, with or without orbital floor

symptoms Significant displacement or comminution

Complex multilevel injuries

Associated with extensive craniofacial trauma

Mostly due to direct high-energy frontal impact

Invariably bilateral and comminuted

Clinical features:

Facial flattening

Traumatic telecanthus

Damage to nasolacrimal system

Epistaxis, CSF rhonirrhoea, anosmia

Traumatic optic neuropathy

Associated craniofacial fractures

Presence of NOE is itself an indication of surgery

Flowchart Showing elements of Counseling