Facial Fracture-Associated Blindness

Epidemiology of Blindness From Facial Trauma: A Multi-Centre Nigerian Study

Study Design

This is a multi-centre retrospective study.

Objective

To determine the prevalence of blindness and pattern of facial trauma associated with blindness among Nigerians.

Methods

A multi-centre retrospective study of all patients with facial trauma resulting in blindness, that were co-managed by maxillofacial surgeons and ophthalmologists in 4 Nigerian public tertiary hospitals between January 2010 and December 2019 was undertaken. Data was analysed by IBM SPSS Statistics (version 21.0 for windows, IBM© Inc, Chicago, IL).

Results

Of 2070 patients who presented with major facial injuries during the study period, 61 eyes of 56 (2.7%) patients were blind. Blindness was bilateral and unilateral in 5 (8.9%) and 51 (92.1%) patients, respectively. The mean age (SD) at presentation was 36.2 (16.6) years, and 47 (83.9%) of these patients were males. Road traffic accident (n = 27; 48%) was the commonest mechanism of facial trauma, the cheek (n = 18; 40.9%) was the commonest site of associated soft tissue injury and zygomatic complex fracture (n = 19; 24.1%) was the commonest related fracture. Globe rupture (n = 34; 55.7%) was the leading cause of blindness. Enucleation (n = 7; 13.2%) and evisceration (n = 22; 41.5%) were performed on 29 eyes of which 12 (41.4%) patients had ocular prosthesis post-operatively.

Conclusions

Blindness was recorded in 2.7% of Nigerians with facial trauma. The commonest mechanism of trauma and cause of blindness in at least one eye were road traffic accident and globe rupture, respectively. Eye removal surgery was necessary in about half of the blind eyes.

Open Globe Injuries with Concurrent Orbital Fractures - Clinical Settings and Factors Predicting Outcomes

AIM

We describe the clinical settings and the factors predicting outcomes in open globe injuries with concurrent orbital fractures.

METHODS

Retrospective, consecutive, non-comparative study. All eyes from January 2014 to January 2021 with concurrent open globe injuries with orbital fractures that underwent management were included. The clinical data of each patient who underwent a comprehensive ophthalmic examination was entered into a browser-based electronic medical records system (eyeSmart EMR) by uniformly trained ophthalmic personnel and supervised by an ophthalmologist using a standardized template. Favorable functional outcome was defined as the final best corrected visual acuity of >20/200 as per the World Health Organization (WHO) definitions of severe visual impairment and blindness. A favorable anatomic outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. Multivariate logistic regression analysis was done to assess the effect of various demographic and clinical factors and the type of orbital fracture on the final anatomic and functional outcome.

RESULTS

Ninety-one eyes of 91 patients were included in the study. Females accounted for 74/91 (81.3%) of the eyes. Modes of trauma was rupture in 67%, perforating in 5.5% and penetrating in 27.5% of the cases. Orbital rim involvement was seen in 79.1%. The most common isolated fracture seen was a medial wall (19.78%), which was followed by the orbital floor (15.38%). Favorable functional outcome was seen in 10 eyes (11%), while a favorable anatomic outcome was achieved in 45 (49.5%). Odds of a favorable functional outcome were 6.12 (95% CI 1.22 to 30.71), p = .02 for an open globe injury with orbital fracture in the absence of a concurrent retinal detachment. Odds of a favorable anatomic outcome were 55.55 (95% CI 2.43 to 1250), p = .01 when the injury did not involve zone 3, 9.94 (95% CI 2.05 to 48), p = .004 when concurrent retinal detachment was absent, 16.3 (95% CI 1.42 to 187.19), p = .02 when the orbital rim was intact and 7.83 (95% CI 1.09 to 56.19), p = .04 when only one orbital wall was involved.

CONCLUSIONS

Open globe injuries with concurrent orbital fractures result in a very poor functional outcome. Concurrent retinal detachment is a negative predictive factor. Associated fractures involving the orbital rim increase the risk of eyeball loss.

Orbital Wall Fractures and Ocular Injury: Impact on Management

Background: Orbital wall fractures are often associated with concomitant ocular injury. In some cases, detection and treatment of such injuries requires ophthalmology evaluation. Study Objective: To identify a change in ocular management as a result of ophthalmology evaluation in patients with orbital wall fractures. Materials and Methods: Retrospective cohort, patients >18 years of age with orbital wall fracture, and prompt evaluation by an ophthalmologist from 2012 to 2020 in a tertiary Level 1 trauma center. Results: Fifty percent of patients had a moderate and/or severe ocular injury. Ophthalmology evaluation led to an ocular management change in 27% of patients. Patients with eyelid laceration, extra-ocular motion (EOM) abnormality, and pupillary defect were more likely to have a change in management. There was no delay of surgical bony fracture management. Conclusion: In patients with midface trauma including orbital wall fractures those with eyelid laceration, EOM abnormality, and pupillary defect were likely to undergo ocular management change as a result of ophthalmology consultation.

Delayed-type retrobulbar hematoma caused by low temperature after reconstruction of inferior blow-out fracture

Retrobulbar hemorrhage is a disastrous condition that can lead to permanent blindness. As such, rapid diagnosis and treatment are critical. Here, we report a patient who presented with retrobulbar hemorrhage following an orbital floor fracture. Restoration of inferior orbital wall with porous polyethylene implant was underwent. Four days after the orbital floor reconstruction, the patient smoked a cigarette outdoors in –3˚C weather. Cold temperature and smoking caused an increase in his systemic blood pressure. The elevated blood pressure increased intraorbital pressure to the extent of causing central retinal artery occlusion and exacerbated oozing. During exploratory surgery, 3 mL of hematoma and diffuse oozing without arterial bleeding were observed. Prompt diagnosis and treatment prevented vision impairment. Few studies have reported on the risk factors for retrobulbar hemorrhage. This case showed that daily activities, such as exposure to cold weather or tobacco smoking, could be risk factors for retrobulbar hemorrhage.

Poor prognoses of open globe injuries with concomitant orbital fractures

PURPOSE

Orbital trauma, particularly with open globe injury, can have a wide range of visual outcomes, which can be difficult to predict at presentation. Clinical features on presentation may provide insight into visual prognosis. We hypothesized that patients with open globe injuries and concomitant orbital fractures have poorer visual outcomes than patients without orbital fractures.

METHODS

We reviewed the charts of 77 patients with isolated open globe injuries (OG) and 76 patients with open globe injuries and concomitant orbital fractures (OGOF). Multivariate regression analysis was performed to assess the relative influence of individual presenting historical and clinical features on visual outcome.

RESULTS

OGOF patients were more likely to have sustained blunt trauma than a sharp, penetrating injury compared to OG patients. Ocular wound locations were more posterior and likely to involve multiple zones in OGOF compared to OG patients. Among OGOF patients, orbital floor fractures were the most common and roof fractures were the least common, but the latter was associated with presenting NLP vision and multiple zone involvement. The presence of an orbital fracture independently increased the odds of subsequent evisceration/enucleation (OR: 4.6, 95% CI 1.3-20.1, p = .0246) and NLP vision (OR: 6.81, 95% CI 2.42-21.85, p = .0005) when controlling for zone, mechanism of injury, uveal prolapse and demographic variables.

CONCLUSIONS

The presence of an orbital fracture independently confers a worse visual and ocular prognosis in patients with open globe injuries. Patients with open globe injuries in this category should be appropriately counseled.