SURVEY OF OPHTHALMOLOGY
VIEWPOINTS
VOLUME 35. NUMBER 4. JANUARY-FEBRUARY
1991
JONATHAN DUTTON AND THOMAS SIAMOVITS,
EDITORS
Management of Blow-out Fractures of the Orbital Floor I. Editorial.
JONATHAN
J. DUTTON,
M.D., PH.D.
II. Early Repair of Selected Injuries. AND 111.
NICHOLAS
PAUL
N. MANSON,
ILIFF, M.D.
A Conservative Approach.
ALLEN
M. PUTTERMAN,
Abstract. The management oforbital fractures has long been controversial. In some cases, repair is required, and early repair is more successful than secondary reconstruction. cases, slow resolution of diplopia over four to six months obviates surgery. In an editorial separate articles, the authors elucidate indications for and results of the early vs. late repair of orbital blow-out fractures. (Sure Ophthalmol 35:279-298, 1990)
Key words. motility
l
M.D.,
blow-out fractures hypo-ophthalmos
l
l
diplopia orbit
I. Editorial. TONATHAN 1. DUITON, M.D., ty Eye C&v-, Dwham: North Caiolina
l
enophthalmos
PH.D.,
The management of orbital fractures has been a matter of controversy for nearly fifty years, ever since Converse’ presented his techniques for surgical repair in 1944. Two schools arose: one arguing for early surgical intervention in order to restore normal orbital volume and anatomic relationships, and another favoring more conservative management for recovery of visual function. Both sides presented compelling arguments that their approach produced better longterm results. There is little question that many patients with pure orbital wall fractures and diplopia experience symptomatic improvement over several months, even without treatment.‘.’ Likewise, in many patients surgery is needed, and in these cases early repair yields better results than secondary reconstruction.7.8 The basis for the continuing controversy has lain principally with our inability to accurately evaluate the trauma patients, and to predict which ones would benefit from early surgery. In an often quoted paper, Putterman et al” presented arguments for conservative management, and went so far as to recommend that all blow-out
l
extraocular
M.D.
surgical In other and two surgical
muscle
Dejxufment ofOphthalmology,
Duke Uniuersi-
fractures be followed for four to six months before considering surgical repair. In a later paper, Putterman” discussed the techniques for late surgical correction of residual diplopia and cosmetically objectionable enophthalmos. Since Putterman’s early papers, computerized tomography (CT) has become a standard technique for orbital imaging. Manson et al,’ Gilbard et al,” and others have demonstrated the value of CT, in conjunction with the clinical examination, in more accurately predicting the need for early surgery. In the pair of papers presented below, these two approaches to orbital fractures are explored in some detail. Until now, discussions of conservative management have been concentrated in the ophthalmic literature, and ophthalmologists in general have had little appreciation for the broader problems ofaesthetic facial surgery. Similarly, the arguments for early repair have appeared primarily in the general plastic surgery literature. The result has been the drawing of an unfortunate battleline between these surgical subspecialties, with each group talking principally to its own practitioners.
280
Surv Ophthalmol
35 (4) January-February
DUTTON,
1991
In the first article, Drs. Manson and Iliff present an historical overview of ideas on the etiology of orbital fractures, and the causes of diplopia and enophthalmos. They discuss the development ofarguments for early repair versus conservative management. These authors now recognize that there is a subgroup of patients with resolving diplopia, minimal enophthalmos, and small pure orbital wall fractures in whom CT shows no evidence of entrapment. These patients do not require surgery. However, they correctly stress the unreliability of some clinical examinations, such as the evaluation of early post-traumatic enophthalmos. Drs. Manson and Iliff argue that with CT evidence of inferior orbital tissue entrapment, orbital volume expansion even without enophthalmos, or associated rim fractures, early surgical repair offers the best chance for a successful outcome. They emphasize the need to reconstruct normal orbital contour to allow soft tissues to heal in appropriate anatomic relationships. In the companion article, Dr. Putterman discusses his experience with pure orbital wall fractures. He has tempered his earlier enthusiasm for conservative management, and now agrees that appropriate CT evaluation can help in the assessment of surgical necessity. Like Drs. Manson and Iliff, Dr. Putterman recognizes the need for early reconstruction in some patients. However, he differs in his continued belief that a significant proportion of patients can be managed conservatively, even in the face of entrapment of nonmuscular orbital soft tissue. He correctly points out that some clinical tests, such as the forced duction test, can be misleading, and a positive result does not always correlate with entrapment. He also feels that residual diplopia and late enophthalmos can be satisfactorily managed secondarily after four to six months. In an attempt to summarize the conclusions of both papers, the indications for early surgery (within one to two weeks) are: symptomatic diplopia with positive forced ductions and CT evidence of muscle entrapment, and showing no clinical improvement over one to two weeks; early enophthalmos of 3 mm or more; significant hypo-ophthalmos; a large or-
MANSON, ILIFF, PUTTERMAN
bital wall defect likely to result in late enophthalmos; or associated rim or facial fractures. The indications for conservative observation without treatment are: minimal diplopia with good motility that shows evidence of clinical improvement over several weeks, and without CT evidence of muscle entrapment; absence of significant enophthalmos or hypo-ophthalmos; and small bony defects not likely to result in late enophthalmos. The authors differ primarily in their evaluations of the degree of fracture that requires repair, in the importance of always releasing nonmuscular tissue incarceration, and in the need to restore the bony orbit to normal volume and contour. It is clear that the differences between these two approaches to orbital blow-out fractures is growing less distinct as our ability to evaluate orbital trauma becomes more precise. Hopefully, this set of papers will increase our mutual understanding of the complex issues involved in managing these patients, and will allow more open communication and cooperation between the various subspecialists dealing with these problems.
References 1.
2.
3. 4.
5.
6.
7.
8.
Converse JM: Two plastic operations for repair of the orbit following severe trauma and extensive comminuted fracture. Arch Ophthalmol 31:323, 1944 Emory JM, VanNoorden GK, Sclernitzauer DA: Orbital floor fractures: long-term follow-up of cases with and without surgical repair. Trans Am Acad Ophthalmol Otolaryngol 75:802, 1971 Gilbard S, Mafee M, Lagouros P, et al: Orbital blow-fractures. Ophthalmology 92:1523-1528, 1985 Manson PN, Grivas A, Rosenbaum A, et al: Studies on enophthalmos. II. The measurement of orbital injuries and their treatment by quantitative computed tomography. Plast Reconstr Surg 77:203, 1985 Putterman AM, Stevens T, Urist MJ: Non-surgical management of blow-out fractures of the orbital floor. Am J Ophthalmol 77:232-239, 1974 Putterman AM: Late management of blow-out fractures of the orbital floor. Trans Am Acad Ophthalmol Otolaryngol 83: 650-659, 1977 Tajima S, Sugimoto C, Tanino R, et al: Surgical treatment of malunited fractures of zygoma with diplopia and with comments on blow-out fractures./ Maxillofucial Surg 2:201, 1974 Wilkins R, Havins W: Current treatment of blow-out fractures. Ophthalmology 89:464-466, 1982
II. Early Re air for Selected Injuries. PAUL N. MANSON, M.D.,‘,’ AND NICHOLAS ILIFF, M.D.,’ iF lustic Surgery, The Maryland Institutefor Emergency Medical Services Systems,and 2The Johns Hopkins Medical Institutions, Baltimore, Maryland Fractures involving the orbit are common injuries and multiple surgical specialties provide their treatment. The orbital rim and globe occupy a prominent place on the facial skeleton; as such, they are a frequent recipient of traumatic injury. Because the orbital cavity contains the ocular globe and extraocular structures, injuries in this area
have profound functional and aesthetic implications. The magnitude of fractures within the orbital region varies considerably. One may see a simple linear fracture, a circular “blow-out” fracture (Figs. 1 and 2), or a “blow-in” (Fig. 3) fracture. Portions of the orbit may be involved in a complex craniofacial
VIEWPOINTS
VOLUME 35. NUMBER 4. JANUARY-FEBRUARY
1991
JONATHAN DUTTON AND THOMAS SIAMOVITS,
EDITORS
Management of Blow-out Fractures of the Orbital Floor I. Editorial.
JONATHAN
J. DUTTON,
M.D., PH.D.
II. Early Repair of Selected Injuries. AND 111.
NICHOLAS
PAUL
N. MANSON,
ILIFF, M.D.
A Conservative Approach.
ALLEN
M. PUTTERMAN,
Abstract. The management oforbital fractures has long been controversial. In some cases, repair is required, and early repair is more successful than secondary reconstruction. cases, slow resolution of diplopia over four to six months obviates surgery. In an editorial separate articles, the authors elucidate indications for and results of the early vs. late repair of orbital blow-out fractures. (Sure Ophthalmol 35:279-298, 1990)
Key words. motility
l
M.D.,
blow-out fractures hypo-ophthalmos
l
l
diplopia orbit
I. Editorial. TONATHAN 1. DUITON, M.D., ty Eye C&v-, Dwham: North Caiolina
l
enophthalmos
PH.D.,
The management of orbital fractures has been a matter of controversy for nearly fifty years, ever since Converse’ presented his techniques for surgical repair in 1944. Two schools arose: one arguing for early surgical intervention in order to restore normal orbital volume and anatomic relationships, and another favoring more conservative management for recovery of visual function. Both sides presented compelling arguments that their approach produced better longterm results. There is little question that many patients with pure orbital wall fractures and diplopia experience symptomatic improvement over several months, even without treatment.‘.’ Likewise, in many patients surgery is needed, and in these cases early repair yields better results than secondary reconstruction.7.8 The basis for the continuing controversy has lain principally with our inability to accurately evaluate the trauma patients, and to predict which ones would benefit from early surgery. In an often quoted paper, Putterman et al” presented arguments for conservative management, and went so far as to recommend that all blow-out
l
extraocular
M.D.
surgical In other and two surgical
muscle
Dejxufment ofOphthalmology,
Duke Uniuersi-
fractures be followed for four to six months before considering surgical repair. In a later paper, Putterman” discussed the techniques for late surgical correction of residual diplopia and cosmetically objectionable enophthalmos. Since Putterman’s early papers, computerized tomography (CT) has become a standard technique for orbital imaging. Manson et al,’ Gilbard et al,” and others have demonstrated the value of CT, in conjunction with the clinical examination, in more accurately predicting the need for early surgery. In the pair of papers presented below, these two approaches to orbital fractures are explored in some detail. Until now, discussions of conservative management have been concentrated in the ophthalmic literature, and ophthalmologists in general have had little appreciation for the broader problems ofaesthetic facial surgery. Similarly, the arguments for early repair have appeared primarily in the general plastic surgery literature. The result has been the drawing of an unfortunate battleline between these surgical subspecialties, with each group talking principally to its own practitioners.
280
Surv Ophthalmol
35 (4) January-February
DUTTON,
1991
In the first article, Drs. Manson and Iliff present an historical overview of ideas on the etiology of orbital fractures, and the causes of diplopia and enophthalmos. They discuss the development ofarguments for early repair versus conservative management. These authors now recognize that there is a subgroup of patients with resolving diplopia, minimal enophthalmos, and small pure orbital wall fractures in whom CT shows no evidence of entrapment. These patients do not require surgery. However, they correctly stress the unreliability of some clinical examinations, such as the evaluation of early post-traumatic enophthalmos. Drs. Manson and Iliff argue that with CT evidence of inferior orbital tissue entrapment, orbital volume expansion even without enophthalmos, or associated rim fractures, early surgical repair offers the best chance for a successful outcome. They emphasize the need to reconstruct normal orbital contour to allow soft tissues to heal in appropriate anatomic relationships. In the companion article, Dr. Putterman discusses his experience with pure orbital wall fractures. He has tempered his earlier enthusiasm for conservative management, and now agrees that appropriate CT evaluation can help in the assessment of surgical necessity. Like Drs. Manson and Iliff, Dr. Putterman recognizes the need for early reconstruction in some patients. However, he differs in his continued belief that a significant proportion of patients can be managed conservatively, even in the face of entrapment of nonmuscular orbital soft tissue. He correctly points out that some clinical tests, such as the forced duction test, can be misleading, and a positive result does not always correlate with entrapment. He also feels that residual diplopia and late enophthalmos can be satisfactorily managed secondarily after four to six months. In an attempt to summarize the conclusions of both papers, the indications for early surgery (within one to two weeks) are: symptomatic diplopia with positive forced ductions and CT evidence of muscle entrapment, and showing no clinical improvement over one to two weeks; early enophthalmos of 3 mm or more; significant hypo-ophthalmos; a large or-
MANSON, ILIFF, PUTTERMAN
bital wall defect likely to result in late enophthalmos; or associated rim or facial fractures. The indications for conservative observation without treatment are: minimal diplopia with good motility that shows evidence of clinical improvement over several weeks, and without CT evidence of muscle entrapment; absence of significant enophthalmos or hypo-ophthalmos; and small bony defects not likely to result in late enophthalmos. The authors differ primarily in their evaluations of the degree of fracture that requires repair, in the importance of always releasing nonmuscular tissue incarceration, and in the need to restore the bony orbit to normal volume and contour. It is clear that the differences between these two approaches to orbital blow-out fractures is growing less distinct as our ability to evaluate orbital trauma becomes more precise. Hopefully, this set of papers will increase our mutual understanding of the complex issues involved in managing these patients, and will allow more open communication and cooperation between the various subspecialists dealing with these problems.
References 1.
2.
3. 4.
5.
6.
7.
8.
Converse JM: Two plastic operations for repair of the orbit following severe trauma and extensive comminuted fracture. Arch Ophthalmol 31:323, 1944 Emory JM, VanNoorden GK, Sclernitzauer DA: Orbital floor fractures: long-term follow-up of cases with and without surgical repair. Trans Am Acad Ophthalmol Otolaryngol 75:802, 1971 Gilbard S, Mafee M, Lagouros P, et al: Orbital blow-fractures. Ophthalmology 92:1523-1528, 1985 Manson PN, Grivas A, Rosenbaum A, et al: Studies on enophthalmos. II. The measurement of orbital injuries and their treatment by quantitative computed tomography. Plast Reconstr Surg 77:203, 1985 Putterman AM, Stevens T, Urist MJ: Non-surgical management of blow-out fractures of the orbital floor. Am J Ophthalmol 77:232-239, 1974 Putterman AM: Late management of blow-out fractures of the orbital floor. Trans Am Acad Ophthalmol Otolaryngol 83: 650-659, 1977 Tajima S, Sugimoto C, Tanino R, et al: Surgical treatment of malunited fractures of zygoma with diplopia and with comments on blow-out fractures./ Maxillofucial Surg 2:201, 1974 Wilkins R, Havins W: Current treatment of blow-out fractures. Ophthalmology 89:464-466, 1982
II. Early Re air for Selected Injuries. PAUL N. MANSON, M.D.,‘,’ AND NICHOLAS ILIFF, M.D.,’ iF lustic Surgery, The Maryland Institutefor Emergency Medical Services Systems,and 2The Johns Hopkins Medical Institutions, Baltimore, Maryland Fractures involving the orbit are common injuries and multiple surgical specialties provide their treatment. The orbital rim and globe occupy a prominent place on the facial skeleton; as such, they are a frequent recipient of traumatic injury. Because the orbital cavity contains the ocular globe and extraocular structures, injuries in this area
have profound functional and aesthetic implications. The magnitude of fractures within the orbital region varies considerably. One may see a simple linear fracture, a circular “blow-out” fracture (Figs. 1 and 2), or a “blow-in” (Fig. 3) fracture. Portions of the orbit may be involved in a complex craniofacial
