early versus late repair of orbital blowout fractures

RepaiR of oRbital blowout fRactuRes · Ben Simon et al. 141

■ C L i n i C a L s C i e n C e ■

EarlyVersusLateRepairofOrbitalBlowoutFractures

Guy J. Ben Simon, MD; Hasan M. Syed, MD; John D. McCann, MD, PhD; Robert A. Goldberg, MD

n BACKGROUND AND OBJECTIVE:To com-pare early and late surgical repair of orbital blowoutfloorfractures.

n pATIENTs AND METHODs: A retrospective,comparative interventionalcaseseriesreviewedmedi-calrecordsof50consecutivepatientswhounderwentunilateral orbital floor fracture repair in a 4-year pe-riod.Comparativeanalysiswasperformedbetweenpa-tientsoperatedonwithin2weeksofinjuryandthoseoperatedonatalaterstage.

n REsULTs: Assault, motor vehicle accidents, andsportsinjurieswerethemostcommoncausesofinjury.Surgerywas performeddue to inferior rectusmuscleentrapment and limitations in up gaze in 20 (40%)patientsortopreventenophthalmosincaseswithsig-

nificantbonyorbitalexpansionin30(60%)patients.After surgery, enophthalmos improved an average of0.8mm.Limitationinocularmotilityimprovedaftersurgerybutwasstatisticallysignificantonlyinupgaze.Patientswhounderwentearlyrepair(within2weeks)achievedlessimprovementinenophthalmosversuspa-tientswhounderwentlaterepair(deltaenophthalmosof0.2±1.1vs1.3±1.9mm,respectively;P=.02).

n CONCLUsION: In these patients, postoperativeverticalductionsandpostoperativeenophthalmosim-provedafterfracturerepair.Surgerywasassociatedwithalowrateofpostoperativecomplications.Noapparentdifferenceinsurgicaloutcomewasseenbetweenearly(within2weeks)andlatesurgicalrepair.

[Ophthalmic Surg Lasers Imaging 2009;40:141-148.]

INTRODUCTION

Orbital blowout fractures occur in various bluntinjuries,withthemedialandinferiorwallsmostcom-

monly involved. Approximately half of the cases candeveloplateenophthalmosdependingontherangeoforbitaltissueexpansionintoadjacentsinuscavities;ap-proximatelyone-fourthofthepatientsdevelopdiplo-piaduetoischemicmuscleinjuryorrestrictionassoci-atedwithdisplacedortraumatizedmuscle.Infraorbitalnervehypoesthesiamayalsooccur.1Combinedmedialwallandfloorfracturesmaybeassociatedwithoculartraumainmorethanhalfofthecases.Inmostcases,diplopiaresolvesspontaneouslysothatenophthalmosisthemostcommonlatesequelaoforbitalfractures.

From the Jules Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California.

Accepted for publication September 3, 2008.The authors have no financial or proprietary interest in the materials

presented herein.Address correspondence to Guy J. Ben Simon, MD, Goldschleger Eye Insti-

tute, Sheba Medical Center, Tel Hashomer, Israel 52621.

142 ophthalmic suRgeRy, laseRs & imaging · maRch/apRil 2009 · Vol 40, no 2

Orbital roof fractures aremore common in chil-drenyoungerthan7years,andmorethantwo-thirdsofthecasesoccurinboys.Thismaybeaconsequenceof the lack of frontal sinus pneumatization and therelatively larger cranium in this age group. Multiplewall fractures, especially when the orbital roof is in-volved,areassociatedwithincreasedriskofconcurrentintracranial injury.2,3 Computed tomography is thepreferredimagingtechniqueforevaluatingorbitalfrac-tures,withcoronalsectionsbeingthemostsensitivefororbitalfloor involvement.4Saggital sections aremoresensitivefordemonstratingtheanteriorandposteriorextentoffloorfractures.

Current evidence for surgical intervention oforbitalfracturesincludes“whiteeyed”blowoutfrac-tures, nonresolving oculocardiac reflex, and earlyenophthalmos. In cases of symptomatic diplopia,surgicalrepairisindicatedwithin2weeksoftraumaiftherearelargefloorfractureswithanticipatedlateenophthalmos or clinical or radiological evidenceoforbital soft tissueentrapment.Surgeryata laterstagemaybeassociatedwithseverescartissueforma-tion,leadingtoahigherpostoperativecomplicationrate.Someadvocatesurgeryatanevenearlierstageincasesofsuspectedischemicinjurytoextraocularmuscles.5

Thepurposeofthisstudyistoevaluatefunction-al and aesthetic results of patients with orbital floorfractureswhohadsurgeryatanearly stage (less than2weeks)afterinjuryversuspatientswhohadsurgerymonthstoyearsafterinjury.

pATIENTs AND METHODs

In our retrospective, comparative interventionalcase series, 50 consecutive electronic medical recordsofpatientswhounderwentunilateralorbitalfloorfrac-turerepairattheJulesSteinEyeInstitute ina4-yearperiod(January2000toDecember2003)wereevalu-ated.Dataregardingvisualacuity,intraocularpressure,ocularmotility,enophthalmos,associatedocularinju-ries,surgicalreports,andpreoperativeandpostopera-tive imaging studieswere recordedandanalyzed.Pa-tientswerethendividedintotwogroups:“earlyrepair”includedthosewhounderwentorbitalsurgeryduringthefirst2weeksaftertraumaand“laterepair”includedthosewhounderwentsurgeryupto3.5yearsaftertheorbitaltrauma.

Surgical TechniqueSurgerywasperformedbecauseof inferior rectus

muscleentrapment,limitationinupgaze,oranticipat-edenophthalmosincaseswithsignificantbonyorbitalexpansion. Orbital implants were used to bridge thefracturegap;fixationscrewswereusedwhenstabiliza-tionoftheimplantcouldnotbeachieved.Ingeneral,patientswithfractureswithanticipatedenophthalmosof1mmorlessandnoclinicalevidenceofinferiorrec-tusentrapmentwerenotoperatedon.Thestudycom-pliedwiththepoliciesofthelocalInstitutionalReviewBoard andwas compliantwith theHealth InsurancePortabilityandAccountabilityAct.

Statistical AnalysisStatisticalanalysiswasperformedusing thepaired

samplestteststoevaluatepreoperativeandpostoperativedata such as visual acuity, intraocular pressure, ocularmotility,andenophthalmos.Thechi-squarenon-para-metric testwasused toevaluate the traumahistory indifferent age groups. Pearson bivariate correlation wasusedtoexaminetheinfluenceofage,timefrominjurytosurgicalrepair,degreeofenophthalmos,number,andcross-sectionalareaofimplantsonclinicaloutcome.

Independentsamples t testswereusedtoexaminethedifferenceinenophthalmoscorrectionandmotilityimprovementbetweenearlyandlaterepairgroups.TheWilcoxonMannWhitneyrelatedsamplesnon-paramet-rictestwasusedtocomparesurgicaloutcomesbetweenpatientsyoungerthan18yearsandolderpatients,aswellas foracomparisonofpatientswhowereoperatedonwithinthefirstyearafterinjurytothosewhowereop-eratedonmore than1yearafter the injury.StatisticalanalysiswasperformedusingMicrosoftExcel2003(Mi-crosoftCorporation,Redmond,WA)andSPSSversion12.0(SPSS,Inc.,Chicago,IL)programs.

REsULTs

Fiftypatients(37men,13women;meanage=33years)underwentorbitalsurgeryforblowoutfracturesduring the follow-up period. Demographics of thestudypopulationaresummarizedinTable1.Isolatedorbitalfloorfractureswerethemostcommonpatternwith34(68%)patients,followedbyfloorandmedialwallfractureswith14(28%)patients(Table2).Assaultwas the most prevalent cause of orbital trauma with22(44%)patients,followedbymotorvehicleaccidents


andsportsinjurieswith8(16%)patientsineachcat-egory.Patientsolderthan17yearsweremorelikelytosustainorbital fractures as a result of an assault thanyoungerpatients(P<.000;x2test).

Althoughconcomitantocularinjurywasnotcom-mon,thereweretwocasesofgloberupture,oneresult-ingineviscerationandtheotherresultinginafinalvi-sualacuityofhandmotions.Eightadditionalcaseshadminorcorneallacerationsthatresultedinnodecreaseinvisualacuityafterprimaryrepair.

Twenty (40%) patients had clinical and radio-graphicevidenceofinferiorrectusmuscleentrapment(Figs. 1 and 2); they exhibited severe limitations inverticalductionscomparedtopatientswithnoentrap-ment(P<.001,independentsamplesttest).Theyalsoachieved better improvement in ocular motility aftersurgery(P=.05)(Table3;Figs.3and4).Ofthe34(68%)patientswhohadenophthalmospreoperatively,20patientshadenophthalmosof2mmorgreater.Pa-tientswithmoresevereenophthalmoswerelesslikelytohaveseverelimitationsinverticalductionscomparedtopatientswithoutenophthalmos(r=-0.7,P= .04,Pearsonbivariatecorrelation).

Surgerywasperformedbecauseof either inferiorrectus muscle entrapment or limitations in up gazein20(40%)patientsoranticipatedenophthalmosincaseswithorbitaltissueexpansionintothemaxillaryorethmoidalsinusesin30(60%)patients.

Averagetime(±standarddeviation)elapsedfrominjurytoorbitalsurgerywas4months(±8.5months)(range=1day to3.5 years), althoughmost patients(27;54%)wereoperatedonwithin2weeksoforbitaltrauma.Overall,40(80%)patientswereoperatedonwithin thefirstyearafter injury, and theotherswereoperatedonupto3.5yearsaftertheorbitalfracture.

Following surgery, visual acuity remained un-changed (mean = 20/25 preoperatively and 20/30postoperatively). Intraocular pressure increased aftersurgerybutremainedwithinnormallimits(Table4).Enophthalmos markedly improved an average of 0.8mm(±1.6mm)fromapreoperativemeanof1.6mm

Table1

Demographics of 50 Consecutive Patients Who Underwent Orbital Blowout

Fracture Repair at the Jules Stein Eye Institute in a 4-Year Period

Variable No. ± sD (range)

No.ofpatients 50(37men,13women)age(y) 33±18(range:6to85)SideoffractureRight 21(42%)left 29(58%)Historyassault 22(44%)MVa 8(16%)Sports/recreation 8(16%)Trauma/other 5(10%)Fall 5(10%)FeSS 2(4%)Timetosurgery 4±8.5mo.(range:1day

to3.5years)Follow-up(mo.) 3.6±1.9(3to12)SD = standard deviation; MVA = motor vehicle accident; FESS = functional endoscopic sinus surgery.

Table2

Orbital Fracture Characteristics and Type of Implant Used in Surgical Repair

Characteristics No. (%)

Concomitanteyeinjury

Globerupturea 2Cornealaceration 8No.ocularinjury 40Fracturetypeb

Floor 34(68%)Floor/medialwall 14(28%)Floor/lateralwall 2(4%)ImplantNoimplant 2(4%)Medpore 22(44%)lactasorb 12(24%)Other 8(16%)bone 4(8%)Titaniummesh 2(4%)No.ofimplants1 34(68%)2 12(24%)3 2(4%)4 2(4%)aOne patient underwent primary repair but visual acuity remained at no light perception due to optic nerve avulsion or traumatic optic neuropathy; the other patient underwent evisceration with implant along with orbital fracture repair. bThree patients had bilateral orbital fracture but had surgery on just one side.


(±1.7mm)toapostoperativemeanof0.8mm(±1.4mm)(P=.002,pairedsamplesttest;Fig.5).Olderagewasassociatedwithmoreseverepostoperativeenoph-thalmos(r= .4,P= .03,Pearsoncorrelation).Largerimplants were used in patients with more severe en-ophthalmos(r=.7,P=.001).Positivecorrelationwasfound between the number of implants and implantsizetothechangeinenophthalmos(r=.4,P=.007,andr=.5,P=.02,respectively).Surgeryatalaterstagewasassociatedwithalargernumberofimplants(r=.5,P=.02).Limitationsinglobemotilityimprovedaftersurgery,butthiswasonlystatisticallysignificantinupgaze(ascoreof-1.4preoperativelyto-0.7postopera-tively,P<.001)(Fig.6).

Whencomparingsurgicaloutcomesamongearlyrepair(1dayto2weeksaftertheinjury)andlaterepair(1monthtoyearsaftertheinjury),patientswithearlyrepairhadlesspreoperativeenophthalmoscomparedtopatientswithlaterrepair(1±1mmvs2.3±2.1mm,P=.008,independentsamplesttest).Thisisprobablybecauseorbital swellinghadnot resolvedcompletely;therefore,thesepatientsachievedlessimprovementinenophthalmos (deltaenophthalmosof0.2±1.1mmvs1.3±1.9mm,P= .02,WilcoxonMannWhitneyindependent samples t test). There were similar im-provements in supraductions and infraductionspost-

operativelyinbothgroups.Postoperativevisualacuity,intraocular pressure, and lateral ocular duction werealsosimilarinbothgroups(Table5).Surgicaloutcomewasnotdifferentbetweenthevarioustypesofimplants.However,duetosmallnumbersineachgroup,adefini-tiveconclusioncannotbemade.Clinicaloutcomewassimilarinpatientsyoungerthan18yearscomparedtoolderpatients(WilcoxonMannWhitneytest).

Forty(80%)patientswereoperatedoninthefirstyearafterorbitalinjury.Therewasnodifferenceinanyoftheclinicalparameters,suchasenophthalmoscor-rection, visual acuity, or postoperative limitations ofocularductions,comparedtopatientswhowereoper-atedonatalaterstage.

Complicationsincludedonecaseofpostoperativeoptic neuropathy with decreased visual acuity from20/25preoperativelyto20/80with+2afferentpupil-larydefect3monthspostoperatively.Ofnote,thispa-tientsustainedabrainconcussionandwasunconscious

Figure 1.a6-year-oldchildafterbluntorbitaltraumawhileplayingasport.(a)Clinicaland(b)radiographicevidenceofrightorbitaltrapdoorfracturewithinferiorrectusmuscleentrapment.

a

B

Figure 2.(a)Computedtomographyscanofthecoronalsectionoftheorbitsofan11-year-oldboywithleftorbitalfloorfracture.(b)Intraoperativephotographofinferiorrectusmuscleentrapmentintheorbitalfloorfracture.

a

B


for1weekfollowingtheheadtraumaandhadpreoper-ativebilateralcentralscotomasincomputerizedcentral10-2visualfields.Onecaseofpostoperativeperiorbitalcellulitisthatresolvedwithanoralantibioticandonecase of postoperative orbital apex syndrome that re-solvedspontaneouslywereobserved.

DIsCUssION

Inourpatients, surgery fororbitalblowout frac-turesresultedinsimilaroutcomesregardlessofthetim-ingoftherepair.Patientswhowereoperatedonatanearlystagehadsimilarimprovementinenophthalmosandocularductionswhencompared topatientswhowereoperatedonlater.Assaultandinterpersonalvio-lencewereamongthemostcommoncausesoforbital

floorfracture,althoughsportsandrecreationalactivi-tieswerealsoresponsibleforasizableportionofinju-ries in youngerpatients,which is similar topreviousreports.6 Surgical timing of orbital fractures remainscontroversial.Someinvestigatorsadvocateaconserva-tiveapproachtoblowoutfractures,7-9especiallyincasesoffloorfractureswithintactperiorbita,10whereasoth-ersadvocateearlyrepair.5,6,11-17

Puttermanetal.7observed57patientswithorbitalfloorfractureswithoutsurgery(28patientswereevalu-atedretrospectivelyand29patientsprospectively).Atthetimeoftheir lastexamination,almostallpatientswere free of visually disturbingdiplopia in the func-tionalpositionofgaze,althoughtwo-thirdsofthepa-tientshadprimarygazediplopiaandlimitationinverti-calductionsattheinitialexamination.Twentypercentof thepatientshaddiplopia in the extremepositions

Figure 3.Preoperativeandpostoperativelimitationsinupgazeinpatientswithclinicalandradiographicevidenceofmuscleentrap-ment.Yaxis ismotilityscore(0 to-4),each line isoneormorepatients.

Figure 4.Preoperativeandpostoperativelimitationsinupgazeinpatientswithoutmuscleentrapment.Yaxisismotilityscore(0to-4),eachlineisoneormorepatients.

Table3

Preoperative and Postoperative Vertical Ductions in Patients Operated on for Orbital Blowout Fracture at the Jules Stein Eye Institute in a 4-Year Perioda

Muscle Entrapment (n = 20) No Muscle Entrapment (n = 30)

Up Down Up Down

Motility preop postop preop postop preop postop preop postop

0 0 10 13 13 16 22 23 24-1 6 5 2 3 4 4 5 3-2 8 2 4 2 8 2 2 3-3 5 2 1 2 2 2 0 0-4 1 1 0 0 0 0 0 0Preop = preoperative; Postop = postoperative; 0 = normal motility; -1 = mild restriction; -2 = moderate; -3 = severe; -4 = no motility. aPatients are divided into those with inferior rectus muscle entrapment and those without inferior rectus muscle entrapment (the number of patients in each category is shown in the table). Motility was graded on a scales of 0 to -4 , with 0 indicating normal motility and -4 indicating no motility.


ofgaze.Noneof thepatientsdesired surgical correc-tionforenophthalmos.Theauthorsconcludedthatthebasiccauseofsymptomsishemorrhagicedemaoftheorbitalfatwithorwithoutprolapseintothemaxillarysinusandnotatrappedinferiorrectusmuscle.How-ever,atthetimeoftheirwork,computedtomographyoftheorbitswasnotperformedandtheagedistribu-tionofpatientswasnotreported.

Ellis and Reddy18 published a series on 58 pa-tientswhowereoperatedonforzygomaticomaxillarycomplex(ZMC)fractureswithoutinternalorbitalre-construction.Theyconcluded that, incasesofZMCfractureswithminimalornosofttissueherniationandwithminimaldistortionoftheinternalorbit,ZMCre-ductionisadequateinrealigningtheorbitalfractures,withnopostoperativeorbitalexpansionorsoft tissuesagging.

Most investigators advocate for early fracture re-pair,especiallyinyoungpatientswithseverelyrestrict-edocularmotility.Bansagietal.17foundthattrapdoorfractureswithclinicalevidenceofentrapmentmaybeassociated with minimal findings on computed to-mographyscans.Itwasalsoshownthatearlyrepairisimportanttoreducetherateofcomplicationsandim-proveocularmotility.Delayedsurgerywasassociatedwithpostoperativediplopia.15

Matteini et al.19 investigated 108 consecutivecasesoforbitalfracturesandrecommendedearlysur-geryinchildrenandadultswithdiplopiaorincasesof associated injuries such as orbital apex fracture,cerebrospinal fluid leak, and penetrating injuries.Delayed surgery can be performed on orbital wallfracturesthatdonotinvolvetheorbitalrim.Otherinvestigators,however,didnotfindanydifferencein

Table4

Preoperative and Postoperative Data for 50 Patients Undergoing Orbital Blowout Fracture Repair at the Jules Stein Eye Institute in a 4-Year Period

Variablepreoperative (Mean ± sD)

postoperative (Mean ± sD) Pa

Visualacuity 20/25 20/30 NSIntraocularpressure(mmHg) 9.1±7.6 13.8±5.5 .036enophthalmos(mm) 1.6±1.7 0.8±1.4 .002Motilityb

Up -1.4±1.2 -0.7±1.1 <.001Right -0.4±0.8 -0.3±0.8 NSDown -0.4±0.8 -0.4±0.8 NSleft -0.3±0.9 -0.3±0.9 NSSD = standard deviation; NS = not significant. aP was calculated using paired-samples t test. bOcular duction limitations were evaluated on a scale of 0 to -4, with 0 indicating normal motility and -4 indicating no motility.

Figure 5.Scattergramofpreopera-tive and postoperative enophthal-mos (mm) in 50 patients operatedon for orbital blowout fractures atthe Jules Stein eye Institute. Pa-tients were divided according to(a) early repair (within 2 weeks ofinjury) and(b) laterepair.Mostofthepatientsinbothgroupshadlessthan 2 mm enophthalmos postop-eratively (green area). Marker sizeis a count indicator for number ofpatientsineachpoint.

a B


ophthalmologicfindingsandocularmotilityincasesof isolated orbital floor fractures between patientsundergoing surgery and those who did not after 3months.20

Ingeneral,immediateinterventionisindicatedincasesofdiplopiawithimagingevidenceofentrappedmuscleorperiorbitaltissue.Otherindicationsincludethe “white-eyed blowout fracture” in young patientswith marked limitation in extraocular motility, non-resolving oculocardiac reflex, minimal ecchymosis oredema, and imaging evidence of floor fracture withentrapment.6,21Earlyinterventionisrecommendedtoavoiddifficultrepairassociatedwithsofttissuescarringintofracturesites.Mostadvocateinterventionwithin2weeksinpatientswithsymptomaticdiplopiaandposi-tiveforced-ductiontestwithevidenceofentrapmentor

largefloorfracturewithanticipatedlatentenophthal-mosoncomputedtomographyscans.21

Adult patientswith restriction in ocularmotilityafterorbital fracturemay showgradual improvementovertimebecauserestrictionisoftencausedbynervedamage,orbitaledema,orhemorrhageratherthantruemuscle entrapment.However,when there is imagingevidenceofinferiorrectusmuscleentrapment,resolu-tionwithconservativetreatmentandsteroidsisunlike-lyandpromptsurgeryisrequired.22,23

Pitfallsofourstudystemfromitsretrospectivede-sign.Allpatientsinthestudywereoperatedon,sowecannotdecipherthenaturalhistoryoffracturehealing.Themeanageofourpatientswas33years;therefore,ourconclusionsmayapplymoreaptlytoyoungadultsandnottothepediatricpopulation.

Table5

Comparison of Early (Within 2 Weeks) Versus Late Repair of Orbital Fracture in 50 Patients Who Were Operated on at the Jules Stein Eye Institute in a 4-Year Period

Variable Early Repair (n = 27) Late Repair (n = 23) P

Deltavisualacuitya -0.06 -0.03 NSDeltaIOP(mmHg)b 4.3±7.2 5.6±10.7 NSDeltaenophthalmos(mm)c 0.2±1.1 1.3±1.9 .02Deltamotilityd

Up 0.6±1.3 0.7±1.2 NSRight 0±1.3 0.2±0.8 NSDown -0.4±1.0 0.4±0.6 NSleft -0.4±1.0 0.1±0.6 NSIOP = intraocular pressure; NS = not significant. aCalculated as logarithm of the minimum angle of resolution (postoperative visual acuity) – logarithm of the minimum angle of resolution (preop-erative visual acuity). bCalculated as IOP (postoperative) – IOP (preoperative). cCalculated as enophthalmos (postoperative) – enophthalmos (preoperative). dOcular duction limitations were evaluated on a scale of 0 to -4, with 0 indicating normal motility and -4 indicating no motility.

Figure 6.Scattergramofpreopera-tiveandpostoperativelimitationsinsupraduction in 50 patients oper-atedonfororbitalblowoutfracturesat the Jules Stein eye Institute.Patientsweredividedaccording to(a) early repair (within 2 weeks ofinjury)or(b)laterepair.limitationsinsupraductionweregradedona0to-4scale,with0indicatingnormalmotilityand-4indicatingnomotility.Patientsinbothgroupshadsimilarimprovement in supraductionpost-operatively. Marker size is a countindicator for number of patients ineachpoint. a B


It is important not to defer surgery in orbitalfractureswithinferiorrectusentrapment,especiallyifthemuscleistightlyentrappedinasmallfracture.Inyoung adults, ocular ductions limitations that resultfrombluntmuscleandsofttissuetraumawithoutevi-denceoffrankentrapmentmayresolve6to9monthsfollowing the injury. Late surgery seems to result insimilar outcomes as early surgery. In caseswithmildorbitalvolumeexpansion,especiallywhenthemaxillo-ethmoidal strut and the fronto-ethmoidal struts areintact, one may consider deferring surgery to a laterstage.

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early versus late repair of orbital blowout fractures

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