ORIGINAL ARTICLE
A Clinical Analysis of Bilateral Orbital Fracture Joon Ho Roh, MD,* Jee Woong Jung, MD,Þþ and Mijung Chi, MD, PhDþ Abstract: Although bilateral orbital fracture can cause serious eyeball and facial skeletal problems, few reports have been issued on the topic. We analyzed the clinical features of bilateral orbital fracture by reviewing the medical records of 147 patients and compared bilateral and unilateral fractures by reviewing the literature. Bilateral orbital fracture was most common in men aged between 50 and 59 years. A traffic accident was the leading cause of trauma, and average time between trauma and surgery was 12.2 days. Bilateral medial fracture accompanied by nasal fracture accounted for the overwhelming majority, and impure blowout fracture in at least 1 eye occurred in 69.4% of the 147 patients. Associated ocular injuries seemed to be similar for bilateral and unilateral fracture. Thirty-five patients (23.8%) had other multiple traumas affecting other than the eyes, and this significantly increased the need for surgery (P G 0.05). Of the 48 patients who underwent surgery, including 4 cases of bilateral surgery, 21 patients who had ocular motility restriction with central diplopia within 30 degrees almost completely recovered. No significant relation between the timing of surgery and improvement was found. Although unilateral surgery was performed in most cases, facial asymmetry related to enophthalmos was unclear at 6 months postoperatively. In summary, bilateral orbital fracture was found to be clinically distinguishable from unilateral fracture in several aspects. We hope these findings provide a reference guide to the approach and management of bilateral orbital fracture. Key Words: Bilateral orbital fracture, blowout fracture, clinical feature, facial fracture, trauma (J Craniofac Surg 2014;25: 388Y392)
P
revious reports associated with orbital fracture do not provide a straightforward answer to the question as to whether bilateral What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Department of Ophthalmology, Eulji University Hospital, Daejeon; †Fine Eye Center, Osan, and ‡Department of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea. Received November 14, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Dr. Mijung Chi, Department of Ophthalmology, Gachon University Gil Hospital, 1198 Guwol-dong, Namdong-gu, Incheon 405-760, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000646
388
orbital fracture is nothing more than a unilateral orbital fracture in both eyes. Bilateral orbital fracture is clinically important to both ophthalmologists and craniofacial surgeons because the orbits contain both eyeballs and constitute the greater part of the midface. Temporary or permanent decrease in visual acuity secondary to periorbital swelling and concurrent ocular injuries in both eyes can cause serious discomfort to patients. Furthermore, bilateral orbital fractures are likely to be more complex fractures involving adjacent facial bones rather than isolated fractures of both eyes, because each orbit is connected to the frontal, maxillary, and nasal bone and thus are more likely to result in severe deformities of the facial skeleton.1 In this respect, it is reasonable to presume that arithmetically bilateral fractures are associated with more than twice as many problems as unilateral fractures. Bilateral orbital fracture is rarely encountered, but when presented compels clinicians to make hard management decisions, such as those regarding the need for orbital reconstruction; the timing of surgery; the extent of surgery, which depend on the conditions of both orbits; ocular motility dysfunction; degree of facial asymmetry; associated ocular injuries; and systemic condition of the patient. Accordingly, studies2Y8 confined to unilateral fracture appear inappropriate in terms of providing sufficient information for the management of bilateral fracture. The purposes of the current study were to analyze the clinical features of bilateral orbital fracture and to compare bilateral and unilateral orbital fracture based on a review of the literature.
MATERIALS AND METHODS We reviewed the charts of 147 patients diagnosed with bilateral orbital fracture by computed tomography at Gachon University Gil Hospital between March 2006 and February 2012. Pure blowout fractures involving solely the orbital wall and impure blowout fractures involving the orbital rim were included. Data were collected on age, sex, time between trauma and hospital visit or surgery, causes and features of fractures, concomitant facial fractures and ocular injuries, other medical problems associated with trauma, and surgical outcomes. Only patients with a follow-up period of 6 months or longer and those with complete data were included. Orbital computed tomography scans were conducted in the axial, coronal, and sagittal plane on all patients, and these scans were assessed to identify features of fractures, such as fracture location, fracture size, fracture type, and presence of concurrent facial fracture. Fracture types were classified as comminuted, hinged, trapdoor, and linear. Absolute surgical indications included restriction of extraocular muscle with symptomatic diplopia (within 30 degrees from the center), definite eyeball displacement, manifest enophthalmos of more than 2 mm, and a high possibility of facial asymmetry resulting from delayed enophthalmos. Limitations of extraocular muscle movement were graded mild, moderate, or severe based on greatest motility restriction in the 4 cardinal gazes. When it was unclear whether facial asymmetry resulting from late enophthalmos would occur, we comprehensively considered fracture size and location, number of involved walls, degree of bony displacement,
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Bilateral Orbital Fracture
TABLE 1. Times Between Trauma and Hospital Visit and Between Trauma and Surgery
Within Within Within Within 91 mo
1d 1 wk 2 wk 1 mo
Times Between Trauma and Hospital Visit
Times Between Trauma and Surgery
No. Patients (%) (n = 147)
No. Patients (%) (n = 48)
86 139 144 145 147
(58.5) (94.6) (98.0) (98.6) (100)
0 (0) 12 (25.0) 33 (68.8) 45 (93.8) 48 (100)
were female. The mean age of the patients was 46.1 (SD, 15.0) years (range, 13Y78 years), and the greatest number of patients was in the 50- to 59-year age group regardless of sex (Fig. 1). FIGURE 1. Age distribution of the patient population.
and prolapse of orbital tissue in both eyes to determine the need for and the range of surgery. One of the authors performed surgeries under general anesthesia and with endoscopic guidance. Forced duction tests were performed at the beginning and completion of surgery. Exposure of the inferior orbital wall was obtained using a transconjunctival approach and of the medial orbital wall using a transcaruncular approach. Surgical outcomes were evaluated with respect to enophthalmos and ocular motility restriction with diplopia.
Statistical Analysis Statistical analysis was performed using SPSS for Windows (version 18.0; SPSS Inc, Chicago, IL). Categorical variables were compared using the W2 test when applicable, and sequential variables using the paired t test. P G 0.05 was considered statistically significant.
RESULTS Two hundred ninety-four eyes of 147 patients were included. One hundred eight (73.5%) of the patients were male, and 39 (26.5%)
Etiology A traffic accident was the leading cause of injury and accounted for 64 patients (43.5%), where the patient was a driver, passenger, or pedestrian, followed by falling down or slipping down (37 patients [25.2%]) and assault (32 cases [21.8%]). The remaining fractures resulted from industrial accidents (10 patients) and others (4 patients). Regardless of sex, the most common mechanism of injury was a traffic accident. However, there was a difference between male and female in the second most common cause (Fig. 2).
Time Between Trauma and Medical Intervention Mean time between trauma and initial hospital visit was 1.8 days. Eighty-six patients (58.5%) visited clinics within 24 hours after trauma, and 139 patients (94.6%) within 1 week. Forty-eight patients (32.7%) underwent orbital wall reconstruction surgery, although 63 patients met the surgical indications. Mean time between trauma and surgery was 12.2 days. Twelve of 48 patients (25.0%) underwent surgery within 1 week of trauma, and 33 patients (68.8%) within 2 weeks (Table 1).
Nature of Fractures Of the various fracture types, comminuted fracture (77.5%) comprised the majority, and the hinged fracture (20.4%) was the second most common. There were only 3 cases (2.0%) of trapdoor fracture and no case of the linear type. With regard to fracture location, medial fracture was observed most frequently. One hundred thirty-seven patients (93.2%) had at least 1 medial wall fracture in either eye, and 107 patients (72.8%) had bilateral medial wall fractures in both eyes. Eighty-one patients (55.1%) had at least 1 inferior wall fracture (Table 2). Seventy-eight patients (53.1%) had 2 fracture sites in both eyes, that is, a single wall fracture in each eye, likewise, 31 patients (21.1%), 3 walls; 14 patients (9.5%), 4 walls; and 24 patients (16.3%), 5 walls and more (Table 3). Pure and impure blowout fracture occurred in 136 and 158 eyes, respectively. The concurrent occurrence of pure blowout fracture TABLE 2. Location of Bilateral Orbital Fracture Location
FIGURE 2. Percentage of the cause of injury in each sex.
Medial wall Inferior wall Lateral wall Superior wall
No. Patients (%) (n = 147) 137 81 32 27
(93.2) (55.1) (21.8) (18.4)
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
No. Eyes (%) (n = 294) 244 126 47 38
(83.0) (42.9) (16.0) (12.9)
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Roh et al
TABLE 3. Number of Fractured Walls in Both Orbits No. Fractured Walls 2 3 4 5 6 7 8
TABLE 5. Associated Ocular Injuries No. Patients (%) (n = 147)
Walls Walls Walls Walls Walls Walls Walls
78 31 14 6 9 6 3
(53.1) (21.1) (9.5) (4.1) (6.1) (4.1) (2.1)
in both eyes was noted in 45 patients (30.6%), and the remaining 102 patients had at least 1 impure blowout fracture closely related to facial fracture. The coexistence of facial fracture and orbital fracture was noted in 105 patients (71.4%). Nasal bone fracture, including fracture of the naso-orbitoethmoid complex, was the most common form (58.1%) of combined facial fracture, and maxillary fracture, including Le Fort fracture and zygoma-maxilla complex fracture, was the second most common form (38.1%) (Table 4).
Associated Ocular Injuries Concomitant ocular injury was present in 231 eyes (78.6%). Subconjunctival hemorrhage was most frequently noted and accounted for 218 eyes (74.1%). This was followed by traumatic hyphema in 57 eyes (19.4%), commotio retinae in 20 eyes (6.8%), traumatic optic neuropathy in 12 eyes (4.1%), and corneal abrasion in 11 eyes (3.7%) (Table 5). Seventy-one eyes had 2 concurrent ocular injuries, and 16 eyes had 3 ocular injuries or more.
Relationship Between Multiple Trauma and Orbital Fracture In connection with trauma, 35 patients (23.8%) had medical problems in addition to orbit and midface damage. These included life-threatening problems, such as brain hemorrhage, spinal injury, internal organ damage, shock secondary to excessive bleeding, and unconsciousness. Twenty-four of these 35 patients (68.6%) needed surgical correction of the orbital fracture. However, 11 of the 24 (45.8%) could not undergo surgery because of a poor status. Thirtynine of the remaining 112 patients (34.8%) without another medical problem met surgical indications, and 4 (10.3%) could not undergo surgery because of a poor status. Furthermore, a significantly greater proportion of patients with multiple traumas were indicated for orbital reconstruction surgery than patients with localized orbital trauma (P G 0.001 by W2 test; Table 6).
Surgical Outcomes Forty-eight (32.7%) of the 147 patients underwent reconstruction surgery, but only 4 (8.3%) required surgery in both eyes. Preoperatively, 21 (43.8%) of the 48 had ocular motility restriction in more than 1 gaze and were classified by extent as follows. Based on greatest motility restriction in the 4 cardinal gazes, mild restriction was identified in 12 patients, moderate restriction in 7, and severe restriction in 2 patients. Postoperatively, 19 of the 21 patients achieved almost complete or completely recovery from
Nasal fracture Maxillary fracture Zygomatic fracture Frontal fracture
390
Injuries
No. Eyes
Subconjunctival hemorrhage Traumatic hyphema Commotio retinae Traumatic optic neuropathy Corneal abrasion Vitreous hemorrhage Retinal hemorrhage Lens dislocation Globe rupture
218 57 20 12 11 6 3 3 2
restriction, whereas the remaining 2 (9.5%) had residual diplopia within 30 degrees from the center. Although surgery significantly improved ocular movement restriction with diplopia, no significant relationship was found between timing of surgery (surgery within 2 weeks or at 92 weeks after trauma) and improvement (P = 0.519 by W2 test; Table 7). The occurrence of facial asymmetry related to enophthalmos was unclear in most cases. In exophthalmometer examination, 8 of 48 patients had differences greater than 2 mm between both eyes preoperatively, and the differences decreased from 3.18 (SD, 1.55) to 1.3 (SD, 0.45) at 6-month follow-up after surgery. Likewise, the differences decreased from 1.44 (SD, 0.85) to 0.87 (SD, 0.42) postoperatively in 40 patients having differences less than 2 mm preoperatively. Furthermore, these improvements were statistically significant (P G 0.03 by the paired t test).
DISCUSSION Orbital fracture can result in a wide range of functional disabilities and aesthetic deformities unless timely and proper treatment is provided. Unfortunately, in uncommon cases, orbital fracture can occur concurrently bilaterally. According to Greenwald et al,2 bilateral orbital fracture accounts for approximately 2% of all orbital fracture cases, but published values depend on study inclusion criteria. The definition of orbital fracture in the current study included impure blowout fracture involving the orbital rim as well as pure blowout fracture involving solely the orbital wall. Actually, orbital fractures involving only pure blowout fractures in both eyes were relatively uncommon. Thus, we thought that the study confined to pure blowout fracture was inappropriate for representing a variety of forms of bilateral orbital fracture. In our previous study9 on unilateral blowout fracture, the most common cause was assault, which concurred with the results of many other studies.2,4,7,8,10 On the other hand, Converse et al5 and others11,12 found that a traffic accident was the leading cause. This difference between the causes was probably due to differences between geographic region, socioeconomic status, culture, era, and inclusion criteria.13 With regard to bilateral orbital fracture, however, there will be relative consistency in determining the leading cause because of its mechanism. To produce bilateral fracture, an external TABLE 6. Relationship Between Trauma Site and Reconstruction Surgery of Orbital Fracture
TABLE 4. Concomitant Facial Fractures Facial Fracture
& Volume 25, Number 2, March 2014
No. Patients (%) (n = 105) 61 40 29 21
(58.1) (38.1) (27.6) (20.0)
Patients requiring surgery (n = 63) Patients not requiring surgery (n = 84)
Multiple Trauma (n = 35)
Localized Orbital Trauma (n = 112)
P
24
39
G0.001
11
73
* 2014 Mutaz B. Habal, MD
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The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
TABLE 7. Relationship Between Timing of Surgery and Ocular Motility Restriction Preoperative (n = 21) Postoperative (n = 2) Operated within 2 wk (n = 33) Operated after 2 wk (n = 15)
13/33 (39.4%) 8/15 (53.3%)
1/33 (3.0%) 1/15 (6.7%)
P 0.519
force has to strike both orbits at once, or each orbit at different times. A traffic accident or a fall down is mostly related to simultaneous blows to both orbits because of high possibility of panfacial trauma, whereas assault is related to a sequential injury from multiple blows in an altercation, which is less likely to occur. It was interesting to find that the more affected age group in this study was older than those in other studies,2,8Y10 which found that those in their third and fourth decades were more at risk. The higher average age found in the current study might be due to the relatively low proportion of assaults, which tend to be more common in younger age groups. In addition, we found that it took less time to visit a hospital for trauma treatment and more time to undergo the surgery than in our prior report9 on unilateral fracture, which was probably due to the presence of multiple other injuries. Concurrent multiple injuries can occasionally be serious and potentially life-threatening and delay surgical intervention, which is likely to adversely affect prognosis.14 Furthermore, we observed that surgery was more necessary in patients with other medical problems than in patients with a localized fracture of the periorbital area (Table 6). These findings suggest that the severity of orbital fracture is positively associated with the presence of other medical problems. In this study, medial wall fracture with nasal bone fracture was found to be the most common type of bilateral fracture. Facial fracture appears to be strongly associated with the mechanism of bilateral orbital fracture caused by widespread orbital and midfacial injury. The nose is the most frequently injured part of the face because of its central prominent positioning and thin cartilaginous skeleton.15,16 Depending on the striking angle and the magnitude of the force, fractures of the zygoma, maxilla, and frontal bone, which are thicker and harder than nasal bone, can occur unilaterally. We suppose that impact of the nasal bone causing nasal fracture can be transmitted to the thin medial orbital walls through the medial orbital rim and thus produce various other fractures, such as pure blowout fracture, impure blowout fracture involving the orbital rim, or nasoorbitoethmoid complex fracture. The main findings of this study, that is, the most common type of bilateral fracture was bilateral medial wall fracture, the most combined facial fracture was a nasal bone fracture or combined fracture of bony complex adjacent to the nasal bone, and orbital fractures involving only pure blowout fractures in both eyes were relatively uncommon, are in line with the above supposition. Our results also concur with those of He et al,17 regarding the common coexistence of nasal bone fracture and medial wall fracture in cases of bilateral fracture. Regarding ocular injuries concomitant with orbital fracture, the reported prevalence varies widely, from 2.7% to 90%, largely because of the different category definitions used.10,12,18Y22 For example, subconjunctival hemorrhage frequently occurs in ocular trauma, but in many studies, it was not included as a significant ocular finding. In the current study, the proportion of the eyes with other ocular injuries, excluding subconjunctival hemorrhage, was 27.6%, which is similar to other investigations.19Y22 Obviously, the prevalence rate had been expected to be higher, considering the clinical features of bilateral orbital fracture. If the hydraulic theory was more attractive, the prevalence of ocular injuries such as traumatic hyphema should have been much higher because of the force
Bilateral Orbital Fracture
required to produce fracture. Thus, we believe that this discrepancy is better explained by the bone conduction theory, whereby the fracture is produced by impact of the infraorbital rim rather than the globe. It is unreasonable to compare surgical outcomes directly because of differences of surgical indications and skills among surgeons as well as differences of epidemiologic findings. Thus, in the current study, the surgical outcomes of our prior investigation9 were simply considered reference data. Unexpectedly, no meaningful difference in recovery rate was found between the current study and our previous study regarding unilateral fracture. The distinctive characteristics of impact in bilateral fracture, that is, extensiveness and severity, appear to have little effect on recovery from ocular motility restriction after surgery. Furthermore, surgical timing was also found to have little effect on postoperative recovery from ocular motility restriction. Overall, early reconstruction surgery is accepted as a virtue, but delayed surgery performed by a well-experienced surgeon with thorough preparation and correction of systemic issues appears to have little adverse effect on outcomes as compared with early surgery. The estimation of enophthalmos in bilateral orbital fracture requires careful consideration. It should be noted that problems, such as severe edema secondary to facial fracture, orbital lateral rim displacement, and variable patient positioning, can reduce the accuracy of exophthalmometer measurement. In addition, it should be borne in mind that relative difference between both eyes is more significant than change in the absolute value of enophthalmos in individual eye. In the current study, after carefully considering fracture size and location, the number of involved walls, the degree of bony displacement, and the presence of prolapsed orbital tissue in both eyes, we conducted only unilateral surgery in most cases to correct or prevent facial asymmetry due to enophthalmos. In general, bilateral surgery is highly stressful to patients and to the surgeon because of considerations of recovery and rehabilitation issues and the possibilities of rare but devastating complications, such as blindness, caused by compressive optic neuropathy. Thus, bilateral surgery is unwarranted in patients without functional disabilities in both eyes. Furthermore, it should be realized that facial asymmetry can be minimized by leaving the less fractured orbit uncorrected. In the current study, we had difficulty evaluating other potentially significant data because of the retrospective study design. Although in view of the rarity of bilateral orbital fracture, this study includes a reasonable sample size, a larger-scale study of patients who have undergone surgery would undoubtedly increase the reliability of surgical outcomes. In addition, this study had limitations because it was based on indirect comparison by reviewing the literature rather than on direct comparison. Thus, we suggest that further prospective investigations be conducted to confirm the differences observed between these 2 fracture types in the current study.
CONCLUSIONS Bilateral orbital fracture was clinically distinguished from unilateral fracture in several respects. The results in the current study also reflected the extensiveness and severity of trauma causing bilateral orbital fracture. Furthermore, we realized that unilateral surgery can be effective at preventing facial asymmetry due to enophthalmos when functional disabilities are not present in both eyes. We hope these findings serve as reference guide for the approach and management of bilateral orbital fracture.
REFERENCES 1. Casto AL, Priolo GD, Garufi A, et al. Imaging evaluation of facial complex strut fractures. Semin Ultrasound CT MRI 2012;33:396Y409 2. Greenwald HS, Keeney AH, Shannon GM. A review of 128 patients with orbital fractures. Am J Ophthalmol 1974;78:655Y664 3. Smith B, Regan WF. Blowout fracture of the orbit. Am J Ophthalmol 1957;44:733Y739
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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4. Cunningham JD, Marden PA. Blowout fractures of the orbital floor. Arch Ophthalmol 1962;68:492Y497 5. Converse JM, Smith B, Obear MF, et al. Orbital blowout fractures: a ten year survey. Plast Reconstr Surg 1967;39:20Y35 6. Wilkins RB, Havins WE. Current treatment of blowout fractures. Ophthalmology 1982;89:464Y466 7. Miyaguchi M, Ishida M, Hori T, et al. Blow-out fracture. Rhinology 1983;21:315Y319 8. Bartkowski SB, Krzystkowa KM. Blow-out fracture of the orbit. Diagnostic and therapeutic consideration, and results in 90 patients treated. J Maxillofac Surg 1982;10:155Y164 9. Chi MJ, Ku M, Shin KH, et al. An analysis of 733 surgically treated blowout fractures. Ophthalmologica 2010;224:167Y175 10. Barry C, Coyle M, Idrees Z, et al. Ocular findings in patients with orbitozygomatic complex fractures: a retrospective study. J Oral MaxillofacSug 2008;66:888Y892 11. Tong L, Bauer RJ, Buchman SR. A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center. Plast Reconstr Surg 2001;108:612Y621 12. Al-Qurainy IA, Stassen LF, Dutton GN, et al. The characteristics of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral Maxillofac Surg 1991;29:291Y301
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13. Cruz AA, Eichenberger GC. Epidemiology and management of orbital fractures. Curr Opin Ophthalmol 2004;15:416Y421 14. Seider N, Gilboa M, Miller B, et al. Orbital fractures complicated by late enophthalmos: higher prevalence in patients with multiple trauma. Ophthal Plast Reconstr Surg 2007;23:115Y118 15. Kim JJ, Huoh K. Maxillofacial (midface) fractures. Neuroimaging Clin N Am 2010;20:581Y596 16. Bremke M, Wiegand S, Sesterhenn AM, et al. Digital volume tomography in the diagnosis of nasal bone fractures. Rhinology 2009;47:126Y131 17. He D, Blomquist PH, Ellis E. Association between ocular injuries and internal orbital fractures. J Oral Maxillofac Surg 2007;65:713Y720 18. Luce EA, Tubb TD, Moore AM. Review of 1000 major facial fractures and associated injuries. Plast Reconstr Surg 1979;63:26Y30 19. Jabaley ME, Lerman M, Sanders HJ. Ocular injuries in orbital fractures. A review of 119 cases. Plast Reconstr Surg 1975;56:410Y418 20. Ioannides C, Treffers W, Rutten M, et al. Ocular injuries associated with fractures involving the orbit. J Craniomaxillofac Surg 1998;16:157Y159 21. Amrith S, Saw SM, Lim TC, et al. Ophthalmic involvement in craniofacial trauma. J Craniomaxillofac Surg 2000;28:140Y147 22. Cook T. Ocular and periocular injuries from orbital fractures. J Am Coll Surg 2002;195:831Y834
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
A Clinical Analysis of Bilateral Orbital Fracture Joon Ho Roh, MD,* Jee Woong Jung, MD,Þþ and Mijung Chi, MD, PhDþ Abstract: Although bilateral orbital fracture can cause serious eyeball and facial skeletal problems, few reports have been issued on the topic. We analyzed the clinical features of bilateral orbital fracture by reviewing the medical records of 147 patients and compared bilateral and unilateral fractures by reviewing the literature. Bilateral orbital fracture was most common in men aged between 50 and 59 years. A traffic accident was the leading cause of trauma, and average time between trauma and surgery was 12.2 days. Bilateral medial fracture accompanied by nasal fracture accounted for the overwhelming majority, and impure blowout fracture in at least 1 eye occurred in 69.4% of the 147 patients. Associated ocular injuries seemed to be similar for bilateral and unilateral fracture. Thirty-five patients (23.8%) had other multiple traumas affecting other than the eyes, and this significantly increased the need for surgery (P G 0.05). Of the 48 patients who underwent surgery, including 4 cases of bilateral surgery, 21 patients who had ocular motility restriction with central diplopia within 30 degrees almost completely recovered. No significant relation between the timing of surgery and improvement was found. Although unilateral surgery was performed in most cases, facial asymmetry related to enophthalmos was unclear at 6 months postoperatively. In summary, bilateral orbital fracture was found to be clinically distinguishable from unilateral fracture in several aspects. We hope these findings provide a reference guide to the approach and management of bilateral orbital fracture. Key Words: Bilateral orbital fracture, blowout fracture, clinical feature, facial fracture, trauma (J Craniofac Surg 2014;25: 388Y392)
P
revious reports associated with orbital fracture do not provide a straightforward answer to the question as to whether bilateral What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Department of Ophthalmology, Eulji University Hospital, Daejeon; †Fine Eye Center, Osan, and ‡Department of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea. Received November 14, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Dr. Mijung Chi, Department of Ophthalmology, Gachon University Gil Hospital, 1198 Guwol-dong, Namdong-gu, Incheon 405-760, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000646
388
orbital fracture is nothing more than a unilateral orbital fracture in both eyes. Bilateral orbital fracture is clinically important to both ophthalmologists and craniofacial surgeons because the orbits contain both eyeballs and constitute the greater part of the midface. Temporary or permanent decrease in visual acuity secondary to periorbital swelling and concurrent ocular injuries in both eyes can cause serious discomfort to patients. Furthermore, bilateral orbital fractures are likely to be more complex fractures involving adjacent facial bones rather than isolated fractures of both eyes, because each orbit is connected to the frontal, maxillary, and nasal bone and thus are more likely to result in severe deformities of the facial skeleton.1 In this respect, it is reasonable to presume that arithmetically bilateral fractures are associated with more than twice as many problems as unilateral fractures. Bilateral orbital fracture is rarely encountered, but when presented compels clinicians to make hard management decisions, such as those regarding the need for orbital reconstruction; the timing of surgery; the extent of surgery, which depend on the conditions of both orbits; ocular motility dysfunction; degree of facial asymmetry; associated ocular injuries; and systemic condition of the patient. Accordingly, studies2Y8 confined to unilateral fracture appear inappropriate in terms of providing sufficient information for the management of bilateral fracture. The purposes of the current study were to analyze the clinical features of bilateral orbital fracture and to compare bilateral and unilateral orbital fracture based on a review of the literature.
MATERIALS AND METHODS We reviewed the charts of 147 patients diagnosed with bilateral orbital fracture by computed tomography at Gachon University Gil Hospital between March 2006 and February 2012. Pure blowout fractures involving solely the orbital wall and impure blowout fractures involving the orbital rim were included. Data were collected on age, sex, time between trauma and hospital visit or surgery, causes and features of fractures, concomitant facial fractures and ocular injuries, other medical problems associated with trauma, and surgical outcomes. Only patients with a follow-up period of 6 months or longer and those with complete data were included. Orbital computed tomography scans were conducted in the axial, coronal, and sagittal plane on all patients, and these scans were assessed to identify features of fractures, such as fracture location, fracture size, fracture type, and presence of concurrent facial fracture. Fracture types were classified as comminuted, hinged, trapdoor, and linear. Absolute surgical indications included restriction of extraocular muscle with symptomatic diplopia (within 30 degrees from the center), definite eyeball displacement, manifest enophthalmos of more than 2 mm, and a high possibility of facial asymmetry resulting from delayed enophthalmos. Limitations of extraocular muscle movement were graded mild, moderate, or severe based on greatest motility restriction in the 4 cardinal gazes. When it was unclear whether facial asymmetry resulting from late enophthalmos would occur, we comprehensively considered fracture size and location, number of involved walls, degree of bony displacement,
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Bilateral Orbital Fracture
TABLE 1. Times Between Trauma and Hospital Visit and Between Trauma and Surgery
Within Within Within Within 91 mo
1d 1 wk 2 wk 1 mo
Times Between Trauma and Hospital Visit
Times Between Trauma and Surgery
No. Patients (%) (n = 147)
No. Patients (%) (n = 48)
86 139 144 145 147
(58.5) (94.6) (98.0) (98.6) (100)
0 (0) 12 (25.0) 33 (68.8) 45 (93.8) 48 (100)
were female. The mean age of the patients was 46.1 (SD, 15.0) years (range, 13Y78 years), and the greatest number of patients was in the 50- to 59-year age group regardless of sex (Fig. 1). FIGURE 1. Age distribution of the patient population.
and prolapse of orbital tissue in both eyes to determine the need for and the range of surgery. One of the authors performed surgeries under general anesthesia and with endoscopic guidance. Forced duction tests were performed at the beginning and completion of surgery. Exposure of the inferior orbital wall was obtained using a transconjunctival approach and of the medial orbital wall using a transcaruncular approach. Surgical outcomes were evaluated with respect to enophthalmos and ocular motility restriction with diplopia.
Statistical Analysis Statistical analysis was performed using SPSS for Windows (version 18.0; SPSS Inc, Chicago, IL). Categorical variables were compared using the W2 test when applicable, and sequential variables using the paired t test. P G 0.05 was considered statistically significant.
RESULTS Two hundred ninety-four eyes of 147 patients were included. One hundred eight (73.5%) of the patients were male, and 39 (26.5%)
Etiology A traffic accident was the leading cause of injury and accounted for 64 patients (43.5%), where the patient was a driver, passenger, or pedestrian, followed by falling down or slipping down (37 patients [25.2%]) and assault (32 cases [21.8%]). The remaining fractures resulted from industrial accidents (10 patients) and others (4 patients). Regardless of sex, the most common mechanism of injury was a traffic accident. However, there was a difference between male and female in the second most common cause (Fig. 2).
Time Between Trauma and Medical Intervention Mean time between trauma and initial hospital visit was 1.8 days. Eighty-six patients (58.5%) visited clinics within 24 hours after trauma, and 139 patients (94.6%) within 1 week. Forty-eight patients (32.7%) underwent orbital wall reconstruction surgery, although 63 patients met the surgical indications. Mean time between trauma and surgery was 12.2 days. Twelve of 48 patients (25.0%) underwent surgery within 1 week of trauma, and 33 patients (68.8%) within 2 weeks (Table 1).
Nature of Fractures Of the various fracture types, comminuted fracture (77.5%) comprised the majority, and the hinged fracture (20.4%) was the second most common. There were only 3 cases (2.0%) of trapdoor fracture and no case of the linear type. With regard to fracture location, medial fracture was observed most frequently. One hundred thirty-seven patients (93.2%) had at least 1 medial wall fracture in either eye, and 107 patients (72.8%) had bilateral medial wall fractures in both eyes. Eighty-one patients (55.1%) had at least 1 inferior wall fracture (Table 2). Seventy-eight patients (53.1%) had 2 fracture sites in both eyes, that is, a single wall fracture in each eye, likewise, 31 patients (21.1%), 3 walls; 14 patients (9.5%), 4 walls; and 24 patients (16.3%), 5 walls and more (Table 3). Pure and impure blowout fracture occurred in 136 and 158 eyes, respectively. The concurrent occurrence of pure blowout fracture TABLE 2. Location of Bilateral Orbital Fracture Location
FIGURE 2. Percentage of the cause of injury in each sex.
Medial wall Inferior wall Lateral wall Superior wall
No. Patients (%) (n = 147) 137 81 32 27
(93.2) (55.1) (21.8) (18.4)
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No. Eyes (%) (n = 294) 244 126 47 38
(83.0) (42.9) (16.0) (12.9)
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TABLE 3. Number of Fractured Walls in Both Orbits No. Fractured Walls 2 3 4 5 6 7 8
TABLE 5. Associated Ocular Injuries No. Patients (%) (n = 147)
Walls Walls Walls Walls Walls Walls Walls
78 31 14 6 9 6 3
(53.1) (21.1) (9.5) (4.1) (6.1) (4.1) (2.1)
in both eyes was noted in 45 patients (30.6%), and the remaining 102 patients had at least 1 impure blowout fracture closely related to facial fracture. The coexistence of facial fracture and orbital fracture was noted in 105 patients (71.4%). Nasal bone fracture, including fracture of the naso-orbitoethmoid complex, was the most common form (58.1%) of combined facial fracture, and maxillary fracture, including Le Fort fracture and zygoma-maxilla complex fracture, was the second most common form (38.1%) (Table 4).
Associated Ocular Injuries Concomitant ocular injury was present in 231 eyes (78.6%). Subconjunctival hemorrhage was most frequently noted and accounted for 218 eyes (74.1%). This was followed by traumatic hyphema in 57 eyes (19.4%), commotio retinae in 20 eyes (6.8%), traumatic optic neuropathy in 12 eyes (4.1%), and corneal abrasion in 11 eyes (3.7%) (Table 5). Seventy-one eyes had 2 concurrent ocular injuries, and 16 eyes had 3 ocular injuries or more.
Relationship Between Multiple Trauma and Orbital Fracture In connection with trauma, 35 patients (23.8%) had medical problems in addition to orbit and midface damage. These included life-threatening problems, such as brain hemorrhage, spinal injury, internal organ damage, shock secondary to excessive bleeding, and unconsciousness. Twenty-four of these 35 patients (68.6%) needed surgical correction of the orbital fracture. However, 11 of the 24 (45.8%) could not undergo surgery because of a poor status. Thirtynine of the remaining 112 patients (34.8%) without another medical problem met surgical indications, and 4 (10.3%) could not undergo surgery because of a poor status. Furthermore, a significantly greater proportion of patients with multiple traumas were indicated for orbital reconstruction surgery than patients with localized orbital trauma (P G 0.001 by W2 test; Table 6).
Surgical Outcomes Forty-eight (32.7%) of the 147 patients underwent reconstruction surgery, but only 4 (8.3%) required surgery in both eyes. Preoperatively, 21 (43.8%) of the 48 had ocular motility restriction in more than 1 gaze and were classified by extent as follows. Based on greatest motility restriction in the 4 cardinal gazes, mild restriction was identified in 12 patients, moderate restriction in 7, and severe restriction in 2 patients. Postoperatively, 19 of the 21 patients achieved almost complete or completely recovery from
Nasal fracture Maxillary fracture Zygomatic fracture Frontal fracture
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Injuries
No. Eyes
Subconjunctival hemorrhage Traumatic hyphema Commotio retinae Traumatic optic neuropathy Corneal abrasion Vitreous hemorrhage Retinal hemorrhage Lens dislocation Globe rupture
218 57 20 12 11 6 3 3 2
restriction, whereas the remaining 2 (9.5%) had residual diplopia within 30 degrees from the center. Although surgery significantly improved ocular movement restriction with diplopia, no significant relationship was found between timing of surgery (surgery within 2 weeks or at 92 weeks after trauma) and improvement (P = 0.519 by W2 test; Table 7). The occurrence of facial asymmetry related to enophthalmos was unclear in most cases. In exophthalmometer examination, 8 of 48 patients had differences greater than 2 mm between both eyes preoperatively, and the differences decreased from 3.18 (SD, 1.55) to 1.3 (SD, 0.45) at 6-month follow-up after surgery. Likewise, the differences decreased from 1.44 (SD, 0.85) to 0.87 (SD, 0.42) postoperatively in 40 patients having differences less than 2 mm preoperatively. Furthermore, these improvements were statistically significant (P G 0.03 by the paired t test).
DISCUSSION Orbital fracture can result in a wide range of functional disabilities and aesthetic deformities unless timely and proper treatment is provided. Unfortunately, in uncommon cases, orbital fracture can occur concurrently bilaterally. According to Greenwald et al,2 bilateral orbital fracture accounts for approximately 2% of all orbital fracture cases, but published values depend on study inclusion criteria. The definition of orbital fracture in the current study included impure blowout fracture involving the orbital rim as well as pure blowout fracture involving solely the orbital wall. Actually, orbital fractures involving only pure blowout fractures in both eyes were relatively uncommon. Thus, we thought that the study confined to pure blowout fracture was inappropriate for representing a variety of forms of bilateral orbital fracture. In our previous study9 on unilateral blowout fracture, the most common cause was assault, which concurred with the results of many other studies.2,4,7,8,10 On the other hand, Converse et al5 and others11,12 found that a traffic accident was the leading cause. This difference between the causes was probably due to differences between geographic region, socioeconomic status, culture, era, and inclusion criteria.13 With regard to bilateral orbital fracture, however, there will be relative consistency in determining the leading cause because of its mechanism. To produce bilateral fracture, an external TABLE 6. Relationship Between Trauma Site and Reconstruction Surgery of Orbital Fracture
TABLE 4. Concomitant Facial Fractures Facial Fracture
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No. Patients (%) (n = 105) 61 40 29 21
(58.1) (38.1) (27.6) (20.0)
Patients requiring surgery (n = 63) Patients not requiring surgery (n = 84)
Multiple Trauma (n = 35)
Localized Orbital Trauma (n = 112)
P
24
39
G0.001
11
73
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TABLE 7. Relationship Between Timing of Surgery and Ocular Motility Restriction Preoperative (n = 21) Postoperative (n = 2) Operated within 2 wk (n = 33) Operated after 2 wk (n = 15)
13/33 (39.4%) 8/15 (53.3%)
1/33 (3.0%) 1/15 (6.7%)
P 0.519
force has to strike both orbits at once, or each orbit at different times. A traffic accident or a fall down is mostly related to simultaneous blows to both orbits because of high possibility of panfacial trauma, whereas assault is related to a sequential injury from multiple blows in an altercation, which is less likely to occur. It was interesting to find that the more affected age group in this study was older than those in other studies,2,8Y10 which found that those in their third and fourth decades were more at risk. The higher average age found in the current study might be due to the relatively low proportion of assaults, which tend to be more common in younger age groups. In addition, we found that it took less time to visit a hospital for trauma treatment and more time to undergo the surgery than in our prior report9 on unilateral fracture, which was probably due to the presence of multiple other injuries. Concurrent multiple injuries can occasionally be serious and potentially life-threatening and delay surgical intervention, which is likely to adversely affect prognosis.14 Furthermore, we observed that surgery was more necessary in patients with other medical problems than in patients with a localized fracture of the periorbital area (Table 6). These findings suggest that the severity of orbital fracture is positively associated with the presence of other medical problems. In this study, medial wall fracture with nasal bone fracture was found to be the most common type of bilateral fracture. Facial fracture appears to be strongly associated with the mechanism of bilateral orbital fracture caused by widespread orbital and midfacial injury. The nose is the most frequently injured part of the face because of its central prominent positioning and thin cartilaginous skeleton.15,16 Depending on the striking angle and the magnitude of the force, fractures of the zygoma, maxilla, and frontal bone, which are thicker and harder than nasal bone, can occur unilaterally. We suppose that impact of the nasal bone causing nasal fracture can be transmitted to the thin medial orbital walls through the medial orbital rim and thus produce various other fractures, such as pure blowout fracture, impure blowout fracture involving the orbital rim, or nasoorbitoethmoid complex fracture. The main findings of this study, that is, the most common type of bilateral fracture was bilateral medial wall fracture, the most combined facial fracture was a nasal bone fracture or combined fracture of bony complex adjacent to the nasal bone, and orbital fractures involving only pure blowout fractures in both eyes were relatively uncommon, are in line with the above supposition. Our results also concur with those of He et al,17 regarding the common coexistence of nasal bone fracture and medial wall fracture in cases of bilateral fracture. Regarding ocular injuries concomitant with orbital fracture, the reported prevalence varies widely, from 2.7% to 90%, largely because of the different category definitions used.10,12,18Y22 For example, subconjunctival hemorrhage frequently occurs in ocular trauma, but in many studies, it was not included as a significant ocular finding. In the current study, the proportion of the eyes with other ocular injuries, excluding subconjunctival hemorrhage, was 27.6%, which is similar to other investigations.19Y22 Obviously, the prevalence rate had been expected to be higher, considering the clinical features of bilateral orbital fracture. If the hydraulic theory was more attractive, the prevalence of ocular injuries such as traumatic hyphema should have been much higher because of the force
Bilateral Orbital Fracture
required to produce fracture. Thus, we believe that this discrepancy is better explained by the bone conduction theory, whereby the fracture is produced by impact of the infraorbital rim rather than the globe. It is unreasonable to compare surgical outcomes directly because of differences of surgical indications and skills among surgeons as well as differences of epidemiologic findings. Thus, in the current study, the surgical outcomes of our prior investigation9 were simply considered reference data. Unexpectedly, no meaningful difference in recovery rate was found between the current study and our previous study regarding unilateral fracture. The distinctive characteristics of impact in bilateral fracture, that is, extensiveness and severity, appear to have little effect on recovery from ocular motility restriction after surgery. Furthermore, surgical timing was also found to have little effect on postoperative recovery from ocular motility restriction. Overall, early reconstruction surgery is accepted as a virtue, but delayed surgery performed by a well-experienced surgeon with thorough preparation and correction of systemic issues appears to have little adverse effect on outcomes as compared with early surgery. The estimation of enophthalmos in bilateral orbital fracture requires careful consideration. It should be noted that problems, such as severe edema secondary to facial fracture, orbital lateral rim displacement, and variable patient positioning, can reduce the accuracy of exophthalmometer measurement. In addition, it should be borne in mind that relative difference between both eyes is more significant than change in the absolute value of enophthalmos in individual eye. In the current study, after carefully considering fracture size and location, the number of involved walls, the degree of bony displacement, and the presence of prolapsed orbital tissue in both eyes, we conducted only unilateral surgery in most cases to correct or prevent facial asymmetry due to enophthalmos. In general, bilateral surgery is highly stressful to patients and to the surgeon because of considerations of recovery and rehabilitation issues and the possibilities of rare but devastating complications, such as blindness, caused by compressive optic neuropathy. Thus, bilateral surgery is unwarranted in patients without functional disabilities in both eyes. Furthermore, it should be realized that facial asymmetry can be minimized by leaving the less fractured orbit uncorrected. In the current study, we had difficulty evaluating other potentially significant data because of the retrospective study design. Although in view of the rarity of bilateral orbital fracture, this study includes a reasonable sample size, a larger-scale study of patients who have undergone surgery would undoubtedly increase the reliability of surgical outcomes. In addition, this study had limitations because it was based on indirect comparison by reviewing the literature rather than on direct comparison. Thus, we suggest that further prospective investigations be conducted to confirm the differences observed between these 2 fracture types in the current study.
CONCLUSIONS Bilateral orbital fracture was clinically distinguished from unilateral fracture in several respects. The results in the current study also reflected the extensiveness and severity of trauma causing bilateral orbital fracture. Furthermore, we realized that unilateral surgery can be effective at preventing facial asymmetry due to enophthalmos when functional disabilities are not present in both eyes. We hope these findings serve as reference guide for the approach and management of bilateral orbital fracture.
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
