Orbital Fractures - The Role of an Ophthalmologist
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Transcript of Orbital Fractures - The Role of an Ophthalmologist
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ORBITAL FRACTURES
Dr. Ankit M. Punjabi ([email protected])Kota Eye Hospital, Kota, Rajasthan, India
The Role of An Ophthalmologist
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Rate of orbital involvement : 15% of all serious injuries Fracture : 78% Foreign body : 24% Hemorrhage : 1%
Males : 78%
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The Place & Source of Injury
Source of InjuryPlace of Injury
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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
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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
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History in a case of Ocular Trauma
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Evaluation of Visual Functions
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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
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LE FORT FRACTURES
Type 1 Type 2 Type 3
Common to all Le Fort Fractures
is
involvement of Pterygoid Plates
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MAXILLOFACIAL INJURY
LE FORT FRACTURESType 1 Low Transverse Maxillary Fracture
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MAXILLOFACIAL INJURY
LE FORT FRACTURESType 2 Pyramidal Fracture
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MAXILLOFACIAL INJURY
LE FORT FRACTURESType 3 Craniofacial Dysfunction
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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
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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
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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
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X-Ray
Herniation of orbital contents
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CT – “Tear Drop” sign
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The Myth & The Truth
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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
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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
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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
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Orbital Floor Implants
Autogenous materials Calverium Iliac crest Ribs
Alloplastic materials Porous polyethelene implant Titanium mesh Polymer of polylactic & polyglactic acid (resorbable)
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Individualised Pre-fabricated Implants
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Endoscopic Approach
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Recovery
May take weeks to months Last thing to recover from is numbness
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Multiple fractures in and around the orbit Can be seen in Tripod & LeFort III fractures Clinical signs & symptoms
Enophthalmos Deep superior sulcus
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Extension of a floor fracture Component of naso-orbital-ethmoid (NOE) fractures Signs & symptoms:
Horizontal diplopia Orbital Emphysema Orbital Hemorrhage Enophthalmos
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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
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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.
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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)
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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
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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
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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
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Flowchart Showing elements of Counseling
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