|Year : 2012 | Volume
| Issue : 2 | Page : 152-158
A prospective study on ophthalmic injuries related to maxillofacial trauma in Indian population
Gaurav Mittal1, Neeraj Singh2, Suraj Suvarana3, Shimona R Mittal1
1 Department of Dentistry, VCSGGMS and RI, Srinagar, Pauri, Garhwal, Uttarakhand, India
2 Department of Oral and Maxillofacial Surgery, NIMS, Jaipur, India
3 Department of Prosthodontics, Bankey Bihari Dental College, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||4-May-2013|
Department of Dentistry, VCSGGMS and RI, Srinagar, Pauri, Garhwal, Uttarakhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background : Ophthalmic injuries commonly occur in patients with facial fractures. This study was set up to determine the incidence of ophthalmic injuries as assessed by an ophthalmologist, in patients who had sustained maxillofacial fractures. Objective: To determine the incidence of ophthalmic injuries in maxillofacial fractures in Indian population. Materials and Methods : A study of 136 patients who had sustained facial trauma sufficient to lead to a facial bone fracture was undertaken and the patients received a comprehensive examination by an ophthalmologist and an orthoptist within one week of injury. All the patients sustaining confirmed maxillofacial fractures were examined by an ophthalmologist for any associated ocular injury. The ophthalmic injuries were classified into three categories-mild, moderate, severe. Results : Ninety-three patients (68.3%) examined sustained eye injuries of various types. Of these, 61.2% were temporary or minor, 29.03% were moderate, and 9.6% were serious. The highest incidence was found in association with mid face fractures, i.e., 95.7%. Fifty-seven patients sustained 176 minor ophthalmologic injuries; 27 patients suffered moderately; 33 had severe ophthalmic injuries. Nine patients sustained severe eye injuries. Conclusion: It is suggested that all traumas to the face, particularly above the level of the mouth, require a careful eye examination, including an estimation of visual acuity of each type.
Keywords: Mandibular fracture, maxillofacial trauma, mid face fracture, ophthalmic injuries
|How to cite this article:|
Mittal G, Singh N, Suvarana S, Mittal SR. A prospective study on ophthalmic injuries related to maxillofacial trauma in Indian population. Natl J Maxillofac Surg 2012;3:152-8
|How to cite this URL:|
Mittal G, Singh N, Suvarana S, Mittal SR. A prospective study on ophthalmic injuries related to maxillofacial trauma in Indian population. Natl J Maxillofac Surg [serial online] 2012 [cited 2020 Jun 5];3:152-8. Available from: http://www.njms.in/text.asp?2012/3/2/152/111370
| Introduction|| |
The orbit, like the maxillary antrum, is an anatomical region which is of clinical and surgical interest to many disciplines. It may be regarded as crossroads where the signposts, in the more complex injuries, clearly indicate the necessity for additional expertise, which can be provided by other specialties.  Ocular injuries often accompany the facial trauma. Injuries to and around the eye vary in severity. All traumas to the face, particularly above the level of the mouth, require a careful ocular examination, including an estimation of the visual acuity of each eye. Some ophthalmic injuries may be clearly apparent. However, other potentially blinding complications can easily be missed unless they are actively sought. Inadequate care can result in blindness, with its attendant social and medicolegal implications.  The initial examinations may be the only time that the physician is able to observe the damage to such structures such as the retina and optic nerve that may later become obscured by continued hemorrhage and cataract formation. Ophthalmic injuries in relation to maxillofacial trauma may be non-occupational domestic injuries, injuries in travel and sports, industrial hazards, assaults, self-inflicted injuries, and so on. The injuries vary from lacerations of the lids and abrasions of the cornea to wounds or ruptures of the sclera, intraocular hemorrhages, dislocation of the lens, and detachment of the retina.Accidents involving the injury to the eyes and their adnexal incurred in traveling are common. In all traveling accidents, whether incurred in trains, airplanes, or car, the injury tends to be severe, as a rule contusion leading to fracture of the orbit and rupture of the globe or penetrating injuries due to glass is associated with considerable facial damage, particularly lacerations of the eyelids and cheek. The treatment of facial trauma is generally reported separately from the management of specific ocular trauma due to the fact that many surgeons who manage facial injuries are not ophthalmologists. Therefore, they are not aware of many types of ocular injuries that may occur as well as their diagnosis, appropriate therapy, and ultimate prognosis. Some ocular injuries may require concomitant surgical treatment with facial injuries, while in other circumstances the presence of an ocular injury would contraindicate immediate surgery to repair the facial fractures.  The objective of this study was to determine the incidence and types of ocular and motility disorders, as assessed by ophthalmologist, in patients who had sustained maxillofacial fractures and who were under the care of a maxillofacial surgeon.
| Materials and Methods|| |
This prospective study was conducted involving patients with a history of mechanical injury to the facial region. All the patients with persistent pathology were followed up to a period of two years. The study included 136 patients with confirmed facial fractures who presented during a seven-month period. These included 71 midfacial fractures, 55 mandibular fractures, four nasal fractures, and six frontal fractures.
All the patients sustaining confirmed maxillofacial fractures were examined by an ophthalmologist for any associated ophthalmic injury. All data accruing from each ophthalmic consultation were as follows:
All routine information
All ocular injuries sustained and their functional consequences, complications, treatment, and recovery.
Examination of Ocular motility comprised assessment of movement in all directions of gaze and elicitation of diplopia. All motility abnormalities were quantified by means of prism cover test, the synoptophore, the field of binocular single vision, and/or the Hess chart, as appropriate for the type of motility disorder detected. Enophthalmos was detected using the Keeler frame in those patients in whom the orbital margin was intact. Examination from above with careful delineation of the position of the globe with respect to the supraorbital margin was carried out in all other patients. In almost all the cases, classical signs and symptoms of facial fractures were present and particular diagnosis was arrived at after a thorough examination following first aid, and was in most cases supported by X-rays and/or CT scans. Following category of patients were excluded: Where due to the patient's serious general conditions following severe injuries, an adequate clinical and radiographic examination was not possible and often not required, patients with solitary fractures of the alveolar process (inferior and/or superior) or pure dental injuries (subluxation, luxation, avulsion), patients with soft tissue injuries of the facial region, and patients with fractures who were treated as outpatients. Facial injuries were grouped as fractures of the facial skeleton involving mandible, mid-face, nasal, and frontal region. Ophthalmic injuries were classified into three categories after a thorough examination as mild, those injuries without permanent visual or physiologic sequelae, moderate, defined as those producing sustained visual loss or adnexal sequelae requiring subsequent reconstruction and severe to those injuries with no light perception. 
| Results|| |
The study included 136 patients with confirmed facial fractures. These included 71 mid-face fractures, 55 mandibular fractures, four nasal fractures, and six frontal bone fractures.
Mid-face fractures included 36 zygomatic complex fractures-the fractures involving the malar bone in isolation or in combination with other mid face fractures. Only six patients sustained isolated fractures of the LeFort type while 18 others sustained LeFort fractures in combination with other facial fractures. Eleven patients had orbital fractures and four had nasal fractures. Fifty-five mandibular fractures included seven symphysis, 22 parasymphysis, 19 body, three angle, and four condylar fractures. Six patients with frontal bone fractures were also included in this study.
Patients having facial fractures ranged in age from an 8-year-old boy to a 72-year-old male. Males accounted for 67.7% (n = 92) of all facial fractures and females, 32.3% (n = 44). The majority of the patients were between the ages of 10 and 50 years, with the peak incidence occurring in the 20- to 30-year-age group for both the sexes. The major cause of maxillofacial trauma in this study was road traffic accidents, which accounted for 71.3% of all patients (97/136). The second most common cause was falls (15.4% or 21 patients), followed by assault-5.8% or eight patients. This was followed by sports (4.4% or six patients), industrial (1.4% or two patients). [Table 1] shows the incidence of ophthalmic disorder in relation to the etiology of maxillofacial trauma after ophthalmological examination.
|Table 1: Incidence of ophthalmic disorders in relation to the etiology of maxillofacial trauma|
Click here to view
Formal ophthalmologic examination
Fifty-five patients who sustained mandibular fractures were examined and 34.5% (19 of 55) sustained eye injuries. Twelve were males and seven were females. Four patients who sustained nasal fractures were examined and one (25%) sustained eye injury. Seventy- one patients with mid-facial fractures were examined and 95.7% (68 of 71) had eye injuries-54 were males and 14 were females. Six patients with frontal fractures were examined and 83.3% (5 of 6) had eye injuries-three were males and two were females.
Incidence of ophthalmic disorder in the population of study
The type of ophthalmic injury with respect to the location of the fracture, the seriousness of the injury, and the extent of visual disability were analyzed. [Table 2] illustrates the incidence of eye abnormalities, according to their severity in the population of study. [Table 3] illustrates the same in relation to the type of mid-facial fracture sustained. [Table 4] shows the incidence of ocular injuries in other facial fractures. Ninety-three of the patients (68.3%) examined sustained eye injuries of various types. Of these, 61.2% were temporary or minor, 29.03% were moderate, and 9.6% were serious. Fifty-seven patients sustained 176 minor ophthalmologic injuries. Minor ophthalmic injuries like eyelid swelling/bruising may cause subcutaneous palpebral hemorrhages which gradually absorb. Similarly, subconjunctival hemorrhages gradually absorb without treatment. [Figure 1] shows a patient with subconjunctival hemorrhage.Even superficial corneal abrasions often heal without further intervention. Twenty-seven patients (29.3%) suffered moderately severe ophthalmologic injuries (33 in number), examples of which include minor eyelid and conjunctival lacerations and enophthalmos. Eyelid and conjunctival lacerations require suturing with careful apposition of the wound edges using a fine suture material. All lens injuries should be referred to the ophthalmologist, there being no urgency for treatment of pure lenticular injuries. Nine patients (9.6%) sustained severe eye injuries such as retinal or vitreous injury or optic nerve damage. Of those nine patients, six patients (66.6%) lost vision in the affected eye. Right eye was affected in 48 patients (48/93 = 51.6%). Left eye was affected in 49 patients (49/93 = 52.6%). When a tear of the retina is present, specialized ophthalmic treatment is usually needed. Similarly, detachment of retina is accompanied by a corresponding visual field defect and requires specialist attention. All blunt ophthalmic injuries require fundus examination within a week of the injury to exclude retinal tear and/or detachment. Severe injuries such as proptosis give little damage to the eye itself, provided it is reduced early.
|Table 3: Incidence of ophthalmic disorder in relation to midfacial trauma|
Click here to view
Two-third of all the patients with orbital fracture suffered a severe ophthalmic injury (7/11 = 63.6%). [Figure 2] shows CT scan of a patient with orbital fracture.Three of eight patients with LeFort II level fracture had severe ophthalmic injury, whereas LeFort I level fracture was not associated with any severe ophthalmic injury. Sixteen mandibular fractures were associated with mild ophthalmic injury, whereas three were associated with moderate complications. No severe or blinding complications were seen in relation to the mandibular fractures. Of the five frontal fractures, three were associated with severe complications.
Twenty-seven of 93 patients (29.09%) had suffered transient or permanent visual loss. Causes of impaired vision varied from minor self-healing corneal abrasions to optic nerve avulsion. Permanent loss of vision ensued in six cases and was due to traumatic optic neuropathy in each case-one in association to zygomatico maxillary complex fracture, two with orbital fractures, and three with frontal fractures. No treatment is currently available to arrest traumatic optic atrophy.
The type of facial fracture was found to be an important factor in relation to visual deterioration. Five of eleven patients with orbital fractures were associated with visual impairment. Nine of thirty-six patients with zygomatico maxillary complex fractures were associated with visual impairment.
Enophthalmos following facial fracture occurred in 9.6% of the patients. All patients with enophthalmos had sustained some form of orbital fracture, either a pure blow out fracture or a medial wall fracture. [Figure 3] shows a patient with enophthalmos. Where enophthalmos is accompanied by diplopia that is not resolving, surgery should be taken at the earliest opportunity.
One patient had ptosis, which was due to a blow out fracture.
A total of five patients (5/93 = 5.37%) complained of diplopia in one or more directions of gaze-three associated with orbital fractures, one with LeFort III level fracture, and one with zygomatic complex fracture. Follow up showed resolution of visual symptoms within 6 months of the injury with early surgical repair.
Sixteen patients (16/93 = 17.2%) were confirmed to have infraorbital nerve disorders on initial examination-seven of them were associated with orbital fractures and the rest were associated with zygomatic complex fractures and other maxillary fractures. On subsequent follow up, it was noted that 13 patients had completely recovered from infraorbital paresthesia after successful surgical management. Two patients lost follow up and one patient refused to undergo any surgical management.
Two male patients had orbital emphysema-one in association with orbital blow out fracture and other in relation to zygomatic maxillary complex fracture. Although alarming to the patient, the emphysema disappears in a few days and its only significance is that a communication has been established between the orbit or the periorbital tissues and potential source of infection, so that antibiotic cover is desirable. One patient had a globe rupture concomitant with blow out fracture of the orbit. A 34-year-old patient was diagnosed as retrobulbar haemorrhage based on the signs and symptoms shown in [Figure 4]. This complication occurred in association with a zygomatico complex fracture. Retrobulbar hemorrhage is unpredictable and variable in its effects upon retinal circulation but will, if progressive and untreated, irreversible ischemia of the retinal cells and permanent blindness. If the papillary response to stimulation by direct light becomes diminished and is accompanied by progressive dilatation and reduced visual acuity, immediate action is indicated.
| Discussion|| |
Injuries to globe and adnexal structures occur frequently during blunt facial trauma.  In the present study, 34.5% of the mandibular fractures, 25% of the nasal fractures, 95.7% of the mid face fractures, and 83.3% of the frontal fractures were associated with ophthalmic injury of some severity. Holt et al. (1983), after formal ophthalmologic examination of patients with blunt facial trauma, found the following incidence of eye injuries-29% mandibular fractures, 59% nasal fractures, 76% mid-face fractures, and 89% frontal fractures.  Al Qurainy et al. (1991) found an overall incidence of 90.6% ophthalmic injury in 363 patients with mid-facial injury. 
Gordon R. Miller and Tenzel(1967) reported five patients of 30 with mid-facial fractures to have serious ophthalmic complications.  Jean Edwards Holt et al. (1983) reported 79% temporary injuries in 382 patients (680 in number), 18% moderate injuries in 90 patients (401 in number), and 3% blinding injuries in 22 patients.  Al-Qurainy et al. (1991) presented 230 patients (230/363 = 63.4%) with temporary injuries, 57 patients (57/363 = 15.7%) with moderate injuries, and 42 patients (42/363 = 11.6%) with blinding injuries .  Shantha Amrith et al. (2000) showed a 9% incidence of severe injury in a retrospective evaluation 104 patients with maxillofacial trauma.  Jamal et al. (2009) reported that 66.6% had minor ocular injuries such as subconjunctival hemorrhage, iris sphincter tear, and corneal abrasion; 10% had major injuries like ruptured globe and retinal hemorrhage.  The present study shows 57 patients with minor or temporary injuries (57/93 = 61.2%), which were totally 176 in number. Twenty-seven patients (27/93 = 9.6%) suffered moderately severe injuries, which were totally 33 in number. Nine patients (9/93 = 9.6%) sustained severe eye injuries, totally 24 in number. Our figure of 9.6% severe injuries is high as compared to 3% incidence shown by Holt et al. (1983), but similar to the above mentioned studies.
Holt et al. (1983) found that 90 patients had moderately severe eye injuries. Amongst them, 3% had mandibular fractures, 7% had nasal fractures, 70% mid-face fractures, and 20% frontal sinus and supra orbital fractures.  In the present study of total patients with moderately severe injuries, 11.2% were associated with mandibular fractures, 3.7% had frontal fractures, and 85.1% were found in mid-facial fractures.
Diplopia is a common complain among the patients with maxillofacial trauma.  Kai Lund (1971) reported diplopia in six patients of a total of 62 patients with fractures of zygoma.  El Attar et al. (1985) gave an incidence of 74.5% of diplopia in pure blow out fractures.  Jamal et al. (2009) reported an incidence of 16% symptomatic diplopia.  In the present study, a total of five patients had signs and symptoms of diplopia-three were associated with orbital fractures and two were associated with zygomatico maxillary complex fractures.
Merrill J. Reeh and Tsujinmura(1966) evaluated 12 cases of blow out fractures of the orbit and recorded the ophthalmic complications of diplopia and enophthalmos.  El attar et al. (1985) reported an almost similar incidence of enophthalmos as diplopia in blow out fractures of the orbit.  Al-Qurainy (1991) reported 8% incidence of enophthalmos in midfacial fractures.  Amrit et al. (2000) reported 6% of patients to have enophthalmos of 4-6 mm.  In the present study, 9.6% (9 of 93) had enophthalmos and most of them were males. All the nine patients had orbital fractures, i.e., 9 of 11 (81.8%) had enophthalmos.
Fractures of the mid-facial region, especially zygoma usually affect the infraorbital foramen, which is the weakest point of the malar complex and sensory disturbances of the infraorbital nerve are practically always present in the acute stage.  Kai Lund (1971) reported sensory disturbances in the infraorbital region in 41 patients of the 62 patients with fractures of the zygoma.  Liebston et al. (1976) reported 55 patients with infraorbital paresthesias of 365 orbital floor fractures.  Amin El-Attar (1985) showed a 50% incidence of infraorbital nerve anesthesia in all zygomatico-orbital fractures.  Peter Jugell and Lindqvist (1987) told 81% incidence of paresthesia of the infraorbital nerve in 68 patients with the fractures of zygomatic complex.  The present study shows 16 patients with infraorbital nerve disorders-seven of them (63.6%) had orbital fractures and nine (25% of all patients) were in conjunction with zygomaticomaxillary complex fractures. The present study shows a low incidence of infraorbital nerve disorders in comparison to the previous mentioned studies.
Retrobulbar hemorrhage is a rare complication of the facial fractures.  Huang et al. (1977) reviewed 10 patients with retrobulbar hemorrhage in eight years.  Al-Qurainy et al. (1991) reported an incidence of 1.5% in 393 patients.  The present study also reports a case of retrobulbar hemorrhage in a 34-year-old male patient with zygomaticomaxillary complex fracture.
Transient or permanent visual loss has been reported in previous studies in relation to maxillofacial trauma. Al-Qurainy et al. (1991) reported a 15.4% (56 of 393) decrease in visual acuity.  In a retrospective analysis by Ashar et al.(1998), of 49 patients admitted with mid-facial fractures, ten patients lost vision in one eye.  Shantha Amrith (2000) reported 23% patients with decrease in visual acuity, with 12.5% having permanent visual impairment.  The present study shows 29.09% (27 of 93) with transient or permanent visual loss. The statistics is significantly comparable with the above studies.
The concomitant occurrence of globe rupture and blow out fracture of the orbit is a rare occurring situation. Dodick et al. (1970) reported two cases of concomitant blow out fractures of the orbit and globe rupture.  Paul M. cherry (1972) reported 34 patients with direct or indirect rupture of the globe.  Amrith et al. (2000) reported four cases of globe rupture-three with complicated fractures and one with orbital fracture.  In the present study, simultaneous occurrence of a blow out fracture and globe rupture was found.
Al-Qurainy et al. (1991) reported four cases of orbital emphysema in relation to midfacial fractures.  The present study shows two cases of orbital emphysema in two young males-one in relation to blow out fracture of the orbit and one in relation to zygomaticomaxillary complex fracture.
Facial fractures have been reported to increase the risk of developing an ocular injury by a factor of 6.7 when compared with major trauma in patients with no facial fractures.  The very low incidence of ophthalmic injury in previous studies probably indicates that significant ophthalmic pathology may have gone undetected, or only the more serious ocular injuries were reported while mild and moderate injuries were neglected.  The overall incidence of ophthalmic injury of any severity in the present study is 68.3% with the highest incidence in relation to midfacial trauma, i.e., 95.7%. The results of this present study reinforce the contention that road traffic accidents cause more severe ocular injuries than any other cause of facial trauma. Similarly, complex facial fractures are related with highest incidence of visual dysfunction. Two-third of all the patients with orbital fractures were associated with severe ocular disorder, followed by frontal fractures. Then came the zygomaticomaxillary complex fractures, whereas no severe ocular complication was reported in mandibular or nasal fractures.
Fortunately, many of the ocular injuries were transient and of no permanent consequence. However, the incidence of 9.6% (9 of 93) with blinding and serious injuries is significant. Of particular importance are those of optic nerve injury (6.4% or 6 patients).
| Conclusion|| |
The results of eye examination while they do not often alter the type of fracture repair may influence the indications and timing of the repair because treatment of certain ophthalmic injuries, such as optic nerve compression, must be instituted at once. It is suggested that all traumas to the face, particularly above the level of the mouth, require a careful eye examination, including an estimation of the visual acuity of each type. The study indicates that all patients with reduced visual acuity and those with complex facial fractures are likely to have sustained ocular injury that warrants referral to an ophthalmologist. The index of suspicion for ocular injury must also be high in patients with mid-facial fractures caused by road traffic accidents. Considerable care should be taken to ensure that all patients who may have sustained eye injuries in association with facial fractures are managed appropriately to prevent any blinding complications. At the same time, it would be wise to educate the general public about the impact of maxillofacial trauma and how some accidents can be prevented.
| References|| |
|1.||Rowe NL, WilliamsJ. Ll. Maxillofacial Injuries. 2 nd ed. Edinburgh: Churchill Livingstone; 1994. |
|2.||Dutton GN, Al-Qurainy. Oral and Maxillofacial trauma. 2 nd ed. FonsecaRJ, Walker RV, editors. Pennsylvania: W. B. Saunders Company; 1997. |
|3.||Holt GR, Holt JE. Incidence of eye injuries in facial fractures: An analysis of 727 cases. Otolaryngol Head Neck Surg 1983;91:276-9. |
|4.||al-Qurainy, Titterington DM, Dutton GN, Stassen LF, Moos KF, el- Attar A. The characteristics of mid facial fractures and the association with ocular injury: A prospective study. Br J Oral Maxillofac Surg 1991;29:291-391. |
|5.||Miller GR, Tenzel RR. Ocular complications of midfacial fractures.Plast Reconstr Surg 1967;39:37-42. |
|6.||AmrithS, Saw SM, Lim TC, Lee TK. Ophthalmic involvement in craniofacial trauma. J Craniomaxillofac Surg 2000;28:140-7. |
|7.||Jamal BT, Pfahler SM, Lane KA, Bilyk JR, Pribitkin EA, DiecidueRJ, et al. Ophthalmic injuries in patients with zygomaticomaxillary complex fractures requiring surgical repair. J Oral Maxillofac Surg 2009;67:986-9. |
|8.||Lund K. Fractures of the zygoma: A follow up study on 62 patients. JOral Surg 1971;29:557-60. |
|9.||Ellis E 3 rd , el-Attar A, Moos KF. An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 1985;43:417-28. |
|10.||Reeh MJ, tsujinmura JK. Early detection and treatment of blow out fractures of the orbit.Am J Ophthalmol 1966;62:79-82. |
|11.||Nordgard JO. Persistent sensory disturbances and diplopia following the fractures of zygoma. Arch Otolaryngol 1976;102:80-2. |
|12.||Leibsohn J, Burton TC, Scott WE. Orbital floor fractures: A retrospective study. Ann Ophthalmol 1976;1057-62. |
|13.||Jungell P, Lindqvist C. Paraesthesia of the infraorbital nerve following fracture of the zygomatic complex. Int J Oral MaxillofacSurg 1987;16:363-7. |
|14.||Ord RA, El Attar A. Acute retrobulbar hemorrhage complicating a malar fracture.J Oral Maxillofac Surg 1980;234-6. |
|15.||Huang TT, Horwitz B, Lewis SR. Retrobulbarhaemorrahge. Plast Reconstr Surg 1977;59:39-44. |
|16.||Ashar A, Kovacs A, Khan S, Hakim J. Blindness associated with mid facial fractures. J Oral Maxillofac Surg 1998;56:1146-51. |
|17.||Dodick JM, Galin MA, Kwitko ML. Concomitant blow out fracture of the orbit and rupture of the globe. Arch Ophthalmol 1970;84:707-9. |
|18.||Cherry PM. Rupture of the globe. Arch Ophthalmol 1972;88:498-507. |
|19.||Guly CM, Guly HR, Bouamra O, Gray RH, Lecky FE. Ocular injuries in patients with major trauma. Emerg Med J 2006;23:915. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]