orbital fractures - the role of an ophthalmologist
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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
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