Orbit Fractures: Identifying Patient Factors Indicating High Risk for Ocular and Periocular Injury

Transcription

1 The Laryngoscope VC 2015 The American Laryngological, Rhinological and Otological Society, Inc. TRIOLOGICAL SOCIETY CANDIDATE THESIS Orbit Fractures: Identifying Patient Factors Indicating High Risk for Ocular and Periocular Injury Brian T. Andrews, MD, MA; Anee Sophia Jackson, MD; Niaman Nazir, MD; Alan Hromas, MD; Jason A. Sokol, MD; Todd E. Thurston, MD Objectives/Hypothesis: Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient s history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision. Study Design: A retrospective clinical chart review was performed at a tertiary academic medical center. Methods: Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test. Results: In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P ), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P and , respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P ), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury. Conclusion: Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Subjects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment. Key Words: Orbit fracture, orbit trauma, ocular injury, globe injury, vision loss. Level of Evidence: IV. Laryngoscope, 126:S5 S11, 2016 INTRODUCTION Maxillofacial trauma often involves fractures of the orbit. Ocular injury and vision loss are rare but devastating complications related to maxillofacial trauma and From the Department of Otolaryngology and Department of Plastic Surgery (B.T.A., A.S.J., T.E.T.); the Department of Preventative Medicine and Public Health (N.N.); and the Department of Ophthalmology (A.H., J.A.S.), University of Kansas Medical Center, Kansas City, Kansas, U.S.A. Editor s Note: This Manuscript was accepted for publication November 4, The authors have no funding, financial relationships, or conflicts of interest to disclose. Computed tomography maxillofacial three-dimensional reconstruction demonstrating severe right orbit blow-in fracture involving the entire orbit (roof, lateral wall, rim, medial wall, and floor) Send correspondence to Brian T. Andrews, MD, MA, Director of Cleft and Craniofacial Surgery, Assistant Professor, University of Kansas Medical Center, Department of Otolaryngology Head and Neck Surgery, Department of Plastic Surgery, Sutherland Institute, MS 3015, 3901 Rainbow Blvd., Kansas City, KS bandrews@kumc.edu DOI: /lary orbit fractures. Vision loss may be caused by direct injury to the globe, optic nerve and/or canal injury, retinal edema or detachment, vascular compromise to the eye, and/or intracranial injury to the optic chiasm or brain. The incidence of vision loss associated with maxillofacial trauma varies widely in the literature, with published ranges of 0.32% to 10.8%. 1 5 A meta-analysis by Magarakis reported an actual vision loss rate of 1.7%. 6 Of interest, this same study demonstrated that the incidence of orbit fracture and concomitant ocular injury is much higher (range 5 9.8% 29.8%). Recognition of ocular injury is important for vision preservation. Early identification of ocular injury may change the management of maxillofacial fractures in some circumstances and possibly preserve vision. 7 As a result, a comprehensive ophthalmologic evaluation on all patients with maxillofacial trauma, and specifically those with orbital fractures, would be ideal. However, a comprehensive ophthalmologic evaluation by a trained ophthalmologist is notavailableateverymedicalinstitution. Additionally, comprehensive ophthalmologic evaluation may be hindered by S5

2 facial swelling, medications, sedation, and patient monitoring of neurologic injury. Thus, identification of patients at high risk of ocular injury by maxillofacial trauma care providers is essential but often insufficient. The objective of this study is to identify patients with orbit fractures who are at high risk for concomitant ocular injury and possible vision loss. The specific aim of this project is to stratify orbit fractures based on basic information available to most, if not all, maxillofacial care providers. This basic information consists of mechanism of injury obtained during a routine patient history, physical exam findings, and radiographic findings. The hypothesis of this study is that history, physical exam findings, and radiographic imaging can be used to identify subgroups of patients at high risk for ocular injury and vision loss. More specifically, it is hypothesized that the likelihood of concomitant ocular injury can be determined by: 1) the mechanism of injury determined from the patient history; 2) physical exam findings such as visual acuity, extraocular movements, afferent pupillary defect, and chemosis 6 subconjunctival hemorrhage; and 3) radiographic fracture patterns categorized by anatomic location and depth of injury. By using this information and identifying high risk individuals early, patient management can be tailored to prevent further ocular injury and aid in vision preservation. MATERIALS AND METHODS After institutional review board approval (13059) was obtained, a retrospective clinical chart review was performed. Patients with maxillofacial trauma were identified by reviewing the trauma registry at a tertiary academic medical center. All subjects between January 1, 2007, and December 31, 2012, who were diagnosed with an orbital fracture were included. Inclusion criteria for this study included maxillofacial trauma with an associated orbit fracture, comprehensive ophthalmologic examination, and computed tomography (CT) radiographic imaging. Subjects were excluded from this study when this information was not available. History Assessment The mechanism of injury was determined from the documented patient history and was categorized into five groups. These groups included: motor vehicle accident (MVA), blunt trauma, penetrating trauma, fall, and unknown. The unknown group consisted of a small number of patients (n 5 5) who had an undocumented etiology in their medical records. Physical Examination Assessment Clinical notes and ophthalmologic records were reviewed to assess key physical exam findings. Four key physical exam findings were utilized in this study. These included: 1) extraocular movements, 2) afferent pupillary defect, 3) chemosis 6 subconjunctival hemorrhage, and 4) decreased visual acuity. Visual acuity was based on a comparison with the noninjured eye in unilateral injuries and was consider normal if it was 20/40 or better in bilateral patients. Physical exam findings were measured independently of each other. Therefore, a single subject could present with a single or multiple abnormal physical exam findings. S6 Radiographic Assessment Maxillofacial CT scans were used to assess radiographic fracture patterns for all subjects. When possible, CT images in the axial, coronal, and sagittal plane were reviewed, as well as three-dimensional computer-generated reconstructions. Two groupings of orbital fractures were utilized: 1) anatomic orbit fracture patterns and associated facial fractures, and 2) depth of eye socket involvement. The first grouping assessed the anatomic orbit fracture pattern. In this grouping, orbit fractures were classified as either isolated single-wall fractures (floor, medial wall, lateral wall, and roof), multiwall fractures isolated to the orbit alone, and orbit fractures associated with other facial fractures. These fractures included nasal or naso-orbital-ethmoid (NOE) fractures, zygomaticomaxillary complex (ZMC) fractures, frontal bone fractures, and/or multiple panfacial bone fractures. The second orbit fracture grouping was based on depth of eye socket involvement. This classification method is most readily visualized on sagittal CT images; however, all planes were utilized for fracture identification. Type 1 (superficial type) fractures are isolated to the orbital rim and anterior maxilla; type 2 (intermediate type) fractures extend from the anterior to the posterior globe; and type 3 (posterior type) fractures are located posterior to the globe. Ocular Injury Assessment All clinical evaluations and ophthalmologic records were reviewed. All subjects underwent a comprehensive eye examination by an ophthalmologist. Ocular injury was defined as any injury determined to be unrelated to preexisting conditions and those that threatened or caused vision loss. Four groups of ocular or periocular injury were established, including anterior segment injury, a posterior segment injury, globe rupture, and retrobulbar hematoma. Anterior segment injuries included those involving structures such as the conjunctiva, sclera, cornea, anterior chamber, iris, ciliary body, and lens. Posterior segment injuries involved the retina, macula, choroid, fovea, optic nerve, and vitreous humor. For the purpose of this study, periocular injury such as retrobulbar hematoma was reported as an ocular injury, although technically it is not one. Statistical Analysis Statistics were performed on mechanism of injury, physical exam findings, and CT radiographic imaging. A chi-square analysis and a Fisher exact test were used to assess the association of these variables with ocular injury. A P value of 0.05 was used to determine statistical significance. RESULTS Three hundred and ninety-six subjects who sustained maxillofacial trauma during the study period were identified through the institutional trauma registry. Two hundred and seventy-nine were identified to have orbit fractures and met inclusion criteria for this study. There were 209 males (74.9%) and 70 females (25.1%) in the study. The average age was 42.1 years, and the range was 8 to 95 years of age. One hundred thirty-six of the 279 subjects (48.7%) required surgical repair of their orbit fracture 6 other associated facial fractures. Seventy-seven of the 279 subjects (27.6%) were identified to have an ocular injury that threatened visual acuity or caused vision loss in this study (Table I). Ocular

3 TABLE I. Types of Ocular Injury. Ocular Injury Type No. Ocular Injury Type No. Posterior Chamber Injury Type 47 Anterior Chamber Injury Type Commotio retinae 16 Hyphema 1 Retinal hemorrhage 7 Traumatic iritis 1 Optic neuropathy 11 Traumatic mydriasis 3 Retinal detachment 2 Corneal abrasion/scar 5 Optic nerve avulsion 2 Iris tear 1 Optic nerve edema 2 Retinal pigment 2 epithelial atrophy Macular hole 1 Orbital apex syndrome 1 foveal lesion 1 Purtscher s retinopathy 1 Cilioretinal artery 1 occlusion Retrobulbar Hemorrhage 10 Ruptured globe 10 * One subject had both a retrobulbar hematoma and an optic neuropathy. TABLE II. Incidence of Ocular Injury Associated With Mechanism of Injury. Mechanism of Injury (history) 11 With Ocular Injury (%) Motor vehicle accident (24.8%) Blunt trauma (34.7%) Fall 39 4 (10.3%) Penetrating trauma 23 9 (39.1%) Unknown 3 1 (33.3%) TABLE III. Incidence of Ocular Injury Associated With Key Physical Exam Findings. Physical Exam Finding No. Subjects With Ocular Injury (%) Visual acuity deficits (42.2%) Extraocular movements (32.6%) Afferent pupillary defect (73.9%) Chemosis 6 subconjunctival hemorrhage (31.6%) injuries included posterior segment (n 5 47), retrobulbar hematoma (n 5 10), anterior segment (n 511), and ruptured globe (n 510). One of the 77 subjects had both a posterior chamber injury and a retrobulbar hematoma, accounting for 78 injuries reported in Table I. The most common posterior segment injury were commotion retinae (n 5 16) and optic neuropathy (n 5 11). The most common anterior segment injuries were corneal abrasion/scar (n 5 5) and traumatic mydriasis (n 5 3). The most common mechanism of injury documented in the patient history causing orbital fracture was motor vehicle accident (n 5 113), followed by blunt trauma (n 5 101), fall (n 5 39), penetrating trauma (n 5 23), and unknown (n 5 3). Concomitant ocular injury was identified in 77 of the 279 subjects (27.5%). Concomitant ocular injury was reported in 39.1% (9 of 23) of the subjects who suffered penetrating trauma, 34.7% (35 of 101) who suffered blunt trauma, 10.3% (4 of 39) who sustained a fall injury, 24.8% (28 of 113) who had a motor vehicle accident, and 33.3% (1 of 3) who had an unknown mechanism of injury (Table II). A chi-square analysis demonstrated a statistically significant association between mechanism of injury and ocular injury (P ), with penetrating trauma being the most likely cause of ocular injury. Four key physical exam findings at the time of presentation were examined and the incidence of ocular injury was assessed. Of the 279 subjects, 114 had chemosis 6 subconjunctival hemorrhage, 86 had extraocular movement restriction, 65 had visual acuity deficits, and 23 had afferent papillary defects. The incidence of concomitant ocular injury was 73.9% (17 of 23) for subjects with an afferent papillary defect, 42.2% (27 of 64) for subjects with visual acuity deficits, 31.6% (36 of 114) for subjects with chemosis 6 subconjunctival hemorrhage, and 32.6% (28 of 86) with extraocular movement restriction on physical exam (Table III). More than one abnormal physical exam finding was found in 81 subjects, and 35 (43.2%) of these subjects had an associated ocular injury. Using a chi-square analysis, ocular injury was statistically associated with visual acuity deficits and an afferent pupillary defect (P and , respectively). Chemosis 6 subconjunctival hemorrhage and extraocular movement restrictions were not associated with ocular injury (P and , respectively). Maxillofacial CT scans were assessed by two methods to study the incidence of ocular injury based on radiographic imaging. Of the 279 subjects in this study, 269 had CT imaging available for review and were included in the anatomic fracture pattern group, and 209 subjects were included in orbital fracture depth group. Table IV describes the association of anatomic fracture patterns with ocular injury. Within this grouping, 41 subjects had a single isolated orbital wall fracture (floor 5 19, medial wall 5 15, lateral wall 5 4, roof 5 3). Isolated single wall orbit fractures had an associated ocular injury of 31.7% (13 of 41). Isolated lateral wall fractures were most commonly associated with ocular injury (2 of 4; 50%). An additional nine subjects had an isolated orbit fracture that involved more than one wall. Interestingly, isolated orbit fractures with multiwall involvement were less likely to have concomitant ocular injury than lateral wall alone (4 of 9; 44.4%). Two hundred twenty-nine subjects had an orbit fracture associated with other facial fractures, and 26% of these subjects had concomitant ocular injury (60 of 229). These same 229 subjects were further subcategorized. Fifty-six had ZMC fractures, 40 had nasal/noe fractures, 13 had frontal bone fractures, and 119 had multiple or panfacial fractures. Concomitant ocular injury was observed in 27.5% (11 of 40) of S7

4 TABLE IV. Incidence of Ocular Injury Associated With CT Anatomic Fracture Patterns. CT Fracture Location With Ocular With Ocular Injury (%) Isolated Single Wall Only (31.7%) Medial 15 6 (40.0%) Floor 19 4 (21.1%) Lateral 4 2 (50.0%) Roof 3 1 (33.3%) Multiwall Orbit Only 9 4 (44.4%) Involved Other Facial Bones (26.2%) Nasal/NOE (27.5%) Frontal 13 0 (00.0%) ZMC (30.4%) Multiple panfacial bones (26.9%) NOE 5 naso-orbital-ethmoid; ZMC 5 zygomaticomaxillary complex. nasal/noe fractures, 30.4% (17 of 56) of ZMC fractures, and 26.9% (32 of 119) of panfacial fractures. Ocular injury was not identified in any of the 13 subjects with orbit fractures combined with frontal bone fractures. Statistical analysis using a chi-square test demonstrated no association among fracture patterns and ocular injury (P ). Furthermore, there was no statistically significant association between individual isolated wall fractures or orbit fractures that involved other facial bones and ocular injury using a Fisher exact test (P and , respectively) Depth of fracture penetration within the orbit was also investigated independently. Complete radiographic data was available for comparison in 209 subjects in this group. Orbit fracture depth was classified into three types: anterior (type I), intermediate (type II), and posterior (type III). This data is reported in Table V. Eight subjects had type I (anterior) fractures, 78 had type II (intermediate) fractures, and 123 subjects had type III (posterior) fractures. Ocular injury was associated with 25% (2 of 8) of type I fractures, 15.4% (12 of 78) of type II fractures, and 38.2% (47 of 123) of type III fractures. A statistically significant association between depth of fracture and ocular injury was demonstrated using a chi-square analysis (P ). S8 DISCUSSION Hippocrates described the association of maxillofacial trauma with vision loss more than 2,000 years ago. 8,9 Fortunately, direct ocular injury associated with maxillofacial trauma is rare. When it does occur, damage to the eye varies from mild injuries (i.e., subconjunctival hemorrhage and corneal abrasion) to severe injuries (i.e., traumatic enucleation and globe rupture). MacKinnon demonstrated a 0.8% severe visual impairment or blindness in their review of 2,516 patients with maxillofacial trauma. 10 They hypothesized that this is because the eye possesses several protective mechanisms, including the natural blink reflex of the eyelids, the bony prominence of the eye socket surrounding the globe, and the rigidity of the globe sclera. 10 Interestingly, Kreidel et al. demonstrated that the incidence of significant intraocular sequelae was decreased in patients who had severe orbital trauma (29.4%) as compared with those with mild (41.2%) or moderate (59.5%) injuries. 11 They suggested that the orbit maintains a protective mechanism and prevents ocular injury in severe maxillofacial traumas. Orbit fractures are managed by a multitude of specialties, including otolaryngology, ophthalmology, plastic surgery, trauma surgery, and oral surgery. Each of these specialties has its own expertise, and a surgeon s training often influences their management of maxillofacial trauma. Weymuller presented specialists from ophthalmology, otolaryngology, and plastic surgery with a clinical scenario regarding the treatment of Lefort III fractures with acute vision loss in one eye and normal vision in the other eye. 12 Weymuller found that the majority of ophthalmologic surgeons would defer surgical intervention in hopes of vision preservation in the only seeing eye, whereas the majority of plastic surgeons would proceed with surgical correction to improve facial aesthetics in a similar patient. Otolaryngologists were split in their management. This dissimilarity in surgical decision making highlights a difference in the understanding of ocular injury and indicates that different surgical specialists have various goals that define successful patient outcomes. The specific aim of this study is to identify highrisk patients who may have ocular injury upon presenting with maxillofacial trauma and an orbit fracture. It is the author s opinion that any patient who sustains maxillofacial trauma with an associated orbit fracture requires a comprehensive evaluation by an ophthalmologist to assess for globe injury. However, this is not possible at many medical institutions, and certainly not at the time of initial presentation. Therefore, surgeons with nonophthalmologic backgrounds need to be able to identify patients at high risk for ocular injury. At minimum, these high risk patients need a comprehensive ophthalmologic evaluation because ocular injury has been associated with fractures of the orbit in roughly one-quarter of all maxillofacial trauma patients. 13 Recognizing that not all surgeons who manage maxillofacial trauma are trained in ophthalmology, it would be beneficial to establish clinical clues that might suggest an underlying ocular injury. By interpreting clues, such as mechanism of TABLE V. Incidence of Ocular Injury Associated With Depth of Orbit Fracture. Orbital Depth of Fracture With Ocular Injury Type I (anterior) 8 2 (25.0%) Type II (intermediate) (15.4%) Type III (posterior) (38.2%)

5 injury, basic physical exam findings, and CT radiographic fracture patterns, a surgeon may identify simultaneous ocular injury and possibly delay intervention until a comprehensive evaluation by an ophthalmologist is completed. Using this concept, Al-Qurainy developed the acronym BAD ACT to be used to assess high-risk patients. 14 This system used blowout fracture, acuity problems, diplopia, amnesia, and comminuted trauma as high-risk indicators for ocular trauma. This same group later published a scoring system that indicated all patients with impaired visual acuity with a blowout or comminuted fracture, a motility abnormality, and facial fractures combined with a head injury causing amnesia required a comprehensive ophthalmologic evaluation. 15 The mechanism of injury causing maxillofacial trauma and orbit fracture is often easily obtained in a patient history. This information is the first clinical clue that a surgeon is presented with when encountering such a patient. Magarakis meta-analysis demonstrated that high-impact zygomatic fractures with orbital involvement were most commonly associated with blindness. 6 Guly et al. reviewed 4,082 patients with maxillofacial fractures and found that 398 (9.8%) had an ocular injury, including corneal abrasion (31%), optic nerve injury (13.2%), and conjunctiva injury (12.9%). 16 This group found no difference in the incidence of ocular injury with the type or location of the facial fracture sustained; however, 57.3% of ocular injuries were the result of an MVA. Rosado 17 found MVA to be the most common cause of orbit fracture, and MacKinnon 10 found that MVA was most likely to cause vision impairment when compared with assault, fall, and other etiologies. Smith et al. suggested that there was a geographic bias toward MVA (47%) as the mechanism of injury in their study. 18 This study was conducted in a medium-sized city within the United States as compared to other studies conducted in larger metropolitan cities such as Chicago and Detroit, which demonstrated assault to be the most common etiology. 18 Vaca et al. studied the mechanism of injury associated with open globe injury and found a significant increase associated with penetrating trauma. 19 Despite these published reports, a knowledge gap still exists in the literature pertaining to mechanism of injury for orbit fractures and concomitant eye injury. Not surprisingly, this study demonstrates the highest incidence of ocular injury associated with penetrating trauma (47.6%). However, 47.6% is surprisingly low given the extreme amount of force sustained during penetrating trauma. Upon further review of this group of patients, 100% were blind when the penetrating injury occurred at the orbit itself. All patients who did not demonstrate an ocular injury associated with penetrating trauma sustained an injury to the lower face or midface and not to the orbit itself. These injuries transmitted a fracture that involved a nondisplaced or minimally displaced fracture of the orbit and no ocular injury. Gonul et al. demonstrated similar findings of visual outcomes among patients with similar orbitocranial projectile injuries. 20 A major aim of this study is to identify high-risk individuals based on their mechanism of injury. Statistical analysis indicates that there is a significant association between the mechanism of injury and concomitant ocular trauma. Penetrating trauma was the most likely mechanism of injury to cause ocular injury. Therefore, based on this study it is recommended that all individuals who sustain an orbit fracture as a result of penetrating trauma require an ophthalmologic consultation prior to any nonurgent surgical procedure. Physical examination findings are another important indicator of ocular injury. There is little doubt that someone trained in ophthalmology is more qualified to perform a comprehensive ophthalmologic examination. However, any surgeon who manages maxillofacial trauma should be qualified and comfortable documenting four key physical exam findings: visual acuity, extraocular movements, afferent pupillary defects, and chemosis 6 subconjunctival hemorrhage. Several studies have limitedly assessed the significance of certain physical exam findings in orbit fracture patients. Al-Qurainy et al. attempted to predict high-risk eye injury patients and found that decreased visual acuity is the best predictor with a sensitivity of 80%. 14 Petro et al. confirmed these findings by showing that 14 of 26 orbit fracture patients with ocular injury reported decreased visual acuity. 21 Gonul et al. demonstrated a poor visual prognosis was predicted for patients with a relative afferent pupillary defect positive injury. 20 The results of these three studies are supported by the data presented in this study. Individuals with either a visual acuity deficit and/or an afferent pupillary defect require a comprehensive ophthalmologic evaluation as a statistically significant association with concomitant ocular injury. Extraocular movement restriction still remains an important exam finding because it may indicate muscle entrapment, which is a surgical emergency and may cause vision impairment if not treated appropriately. Chemosis is also an important exam finding, especially when it is circumferential, because it may indicate a globe rupture. However, neither finding was statistically associated with ocular injury in this dataset. Fractures involving the orbit may occur in isolation or involve concomitant factures of the frontal, zygomatic, maxillary, nasal, and/or sphenoid bones. Different fracture locations within the orbit alone and those associated with other maxillofacial injuries indicate different vectors and degrees of force that caused the orbit fracture. Different forces and different vectors may predispose certain patients to concomitant ocular injury. Rowe and Williams suggested classifying orbital fractures as isolated orbit fractures, ZMC, and complex maxillofacial fractures. 22 However, to date no classification system has been routinely utilized by surgeons who manage maxillofacial trauma and orbit fractures. The most likely reason for this is that no current classification system provides useful clinical information. Based on this knowledge gap in the literature, the current study tries to more precisely categorize orbit fractures based on their anatomic location on CT scan and other associated maxillofacial injuries. Commonly, orbit fractures are limited to one wall (medial, lateral, roof, or floor) or involve a combination of two or more walls without involvement of other bones. Karabekir et al. found that 50% of orbit fractures were isolated to one wall, 29% to two walls, 16% to three S9

6 walls, and 5% involved all orbital walls simultaneously. 23 Several studies have assessed the significance of fractures of each orbital wall. Jank et al. assessed the significance of medial wall involvement and concluded that these patients had statistically significant increases in exophthalmos and diplopia at the time of initial evaluation. 24 However, this study included only patients evaluated at 12 hours postinjury, which most likely biases their results secondary to swelling. Associated ocular injuries with roof fractures were studied by Fulcer and Sullivan. 25 They found that five of 21 (23.8%) patients with roof fractures had ocular injuries and another five patients had periorbital problems such as ptosis, intraorbital foreign body, and oculomotor nerve palsy. He et al. studied floor fractures and found that 22% of 240 orbit floor fractures had associated ocular injuries, thus concluding that the ocular bone-buckling theory is the most likely mechanism of globe protection in these patients. 26 Stanley et al. studied lateral wall fractures and described a triad of a lateral blow-in fracture, decreased visual acuity, and ocular motility limitations. 27 They suggested that early surgical management could correct this triad in cases such as this. Many studies have described the incidence of ocular injury with concomitant maxillofacial trauma. Read and Sires studied the relationship between anatomic location and ocular injury. 28 They published results showing that ocular injury is statistically associated with orbit apex fractures, lateral wall fractures, and Lefort III fractures. Several publications have studied the location of maxillofacial fractures with the incidence of ocular injury or blindness. Shere et al. compared the incidence of eye injuries in U.S. Army soldiers presenting with ZMC fractures (3,599 soldiers) or orbital floor blowout fractures (1,141 soldiers). 29 In their study, blowout fractures were significantly more likely to sustain concomitant eye injury than ZMC fractures (29.8% and 7.6%, respectively). Barry et al. described a 20% incidence of ocular injury and 2% incidence of vision loss in patients with ZMC fractures. 30 Jamal et al. demonstrated retinal hemorrhage (4%) and retinal detachment (2%) as the most likely ocular injury associated with ZMC fractures. 31 This study included only subjects requiring ZMC fracture repair, and the selection bias for more severe injuries explains their different ocular injury patterns. In this current study, isolated lateral orbit fractures (66.7%) were the most common anatomic location on CT imaging to be associated with ocular injury, followed by isolated medial wall fractures (42.9%). Surprisingly, isolated multiwall injuries had a much lower association with ocular injury and most likely can be explained by a disbursement of energy by the eye socket protecting the globe. Orbit fractures associated with other facial fractures similarly demonstrated a lower association of concomitant eye injury and possibly a similar phenomenon of globe protection when multiple facial bones absorb maxillofacial trauma. Neither orbit fractures isolated to a specific wall nor those in conjunction with other facial fractures were statistically associated with ocular injury in this study. S10 The location and depth of the fracture within the orbit may also predict the relative risk of ocular injury. In general, fractures of the anterior orbit involve less energy than fractures of the posterior orbit. Lauer et al. developed a classification system based on the fractures anatomic location relative to the infraorbital nerve. 32 They described three types of fractures: 1) fractures medial to the infraorbital nerve, 2) floor fractures lateral to the infraorbital nerve, and 3) fractures on both sides of the infraorbital nerve. Unfortunately, no clinical relevance was reported with this classification system. Tsai et al. established two groups of orbit fractures: those that involve the anterior two-thirds of the orbit and fractures involving the posterior third of the orbit. 33 They found a significant relationship between visual acuity improvement and anterior fractures, and that posterior orbit fractures are associated with a worse visual outcome. These findings are supported by the current study because it demonstrates a statistical significance of associated ocular injury when the orbit fracture extends to the posterior third of the orbit. This intuitively makes sense because posterior orbit injuries indicate the exertion of high energy forces and an anatomic approximation to the entire globe, subjecting it to injury. Several studies have looked at the specific ocular injury leading to vision loss in patients with concomitant facial fractures. Dancey et al. determined that vision loss most commonly results from traumatic optic nerve injury when an associated facial fracture was present. 34 In contrast, Ansari 35 reported retrobulbar hemorrhage, and Ugboko et al. 4 reported globe rupture as the leading cause of vision loss in their studies involving motor vehicle accident and penetrating trauma, respectively. Table I demonstrates that a wide variety of ocular injuries were identified, and every group studied had an associated globe injury in at least one patient. Many of these ocular injuries can only be documented by a trained ophthalmologist. A major take-home message of this article is that all maxillofacial trauma patients with an orbit fracture require an ophthalmologic evaluation. This dataset does not have the power to investigate which ocular injuries are most common with specific mechanisms, physical exams, or radiographic patterns of injury. However, this study does demonstrate that certain orbit fracture patients are statistically more likely to have a globe injury, and thus the suspicion of injury should be highest in these individuals. There are several limitations of this study. First, this study is a retrospective review and does not demonstrate prospective data. As such, preinjury ophthalmologic evaluations are not present for any of the patients included in this study. Therefore, it is possible that ocular injuries described in this study existed prior to the subject s maxillofacial trauma and orbit fracture. Additionally, the power of this study does not allow for the assessment of specific ocular injuries with either mechanism of injury, physical exam findings, or radiographic imaging. The concept of this study is to identify highrisk maxillofacial trauma patients who absolutely require ophthalmologic consultation prior to surgery. By identifying patients as high risk, it is hoped that long-

7 term vision preservation will result by earlier identification and treatment of ocular injury. CONCLUSION Concomitant ocular injury associated with orbit fracture is present in more than one-quarter of maxillofacial trauma patients. Therefore, a comprehensive ophthalmologic evaluation is recommended for all maxillofacial trauma patients. If ophthalmologic consultation is not available for every maxillofacial trauma patient, clues can be gathered from the history, physical exam, and radiographic images to elicit patients most likely to be at risk for globe injury. Patients who have a penetrating trauma mechanism of injury, a visual acuity deficit, an afferent pupillary defect, or a radiographic depth of fracture that involves the posterior third of the orbit are at highest risk for ocular injury. Ensuring that these patients in particular receive an ophthalmologic consultation is essential because they are at highest risk for globe injury. 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