Pattern and Significance of Ocular Injuries Associated with Orbito- Zygomatic Fractures
Abstract
Introduction: The face, orbit, and eyes have a relatively
prominent position in the human body making
this area more susceptible to trauma. A variety
of ophthalmic injuries associated with mid-facial
fractures has been reported in the literature [1]. Motor-
vehicle accidents, as sault, falling down injuries,
occupational, and sport accidents are generally considered
as common etiologies of maxillofacial fractures
[2].
Zygomatic fractures are the most common facial
fractures second only to nasal fractures and these
fractures are also the most commonly occurring fractures
of the orbit [3]. There is a recognized association
between orbitozygomatic fractures and ocular
injuries. The reported incidence of ocular injuries in
patients with orbital fractures varies widely, ranging
from 2.7% to 90% [1,4]. Al-Qurainy et al. developed
criteria for appropriate referral to an ophthalmologist.
The authors proposed the acronym “BAD ACT,”
to represent Blowout, Acuity, Diplopia, Amnesia, and
Comminuted Trauma, as a method for easy recall.
However, the system is not commonly used in clinical
practice [5]. The severity of an injury is related to
the site of the fracture and direction of the incoming
force. The outcome may range from mild injury
such as sub-conjunctival hemorrhage (SCH) to severe
damage like globe rupture or permanent visual loss
[1,4].
Early diagnosis of potentially serious ophthalmic injuries
is paramount not only in minimizing long-term
complications of midfacial fractures but also from
a medico-legal standpoint. The management of the
ophthalmic injuries must be considered as the first
priority. Repairing the fractures before treatment of
ophthalmic injuries may further compromise visual
outcomes, leading to visual loss [5].
Patients and Methods: This is a retrospective study
of patients presenting with orbitozygomatic bone
fractures admitted to Maxillofacial Surgery Department
at King Fahad Hospital in Almadinah Almunawara,
Saudi Arabia from 2012 to 2017. Patients with
isolated zygomatic arch fractures or concomitant
midfacial fractures were excluded from the study.
Fractures were diagnosed clinically. The extent of the
bony injury was confirmed with computerized tomographic
scans (CT). Patient demographics, date of
injury, date of presentation to the hospital, fracture
etiology, brain injuries status and clinical ocular signs
were recorded.
All patients were examined by the ophthalmologist
preoperatively, and if needed were also followed up
postoperatively. On the basis of clinical examination
and pre-treatment, radiograph/CT scan result, the
study population was divided into 3 subgroups based
on the extent of the bony injury.
Results: The study population included 156 patients
(142 male and 14 female). There was a peak in incidence
for adult compared to female accounting for
91% of the fractures as shown in Table 1.
Road traffic accident was the most commonly documented
mechanism of injury, accounting for 79.5%
(n=124) of the fractures, followed by fall down injuries
(18%, n=11.5), explosion (0.6%, n=1), assault
(4.5%, n=7), and gunshot (0.6%, n=1). This is summarized
in Table 2.
Variables Frequency Percentage (%)
Road traffic accident 129 82.7
Explosion 1 0.6
Assault 7 4.5
Fall down 18 11.5
Gun shot 1 0.6
Total 156 100
Table 2: Details about road traffic accidents.
Group-1 (“simple” fractures) accounted for 67.3%
(n=105) of the patients, Group-2 (“comminuted”
fractures) accounted for 23.7% (n=37), and Group-3
(“orbital blowout”) for 9% (n=14). All orbitozygomatic
fractures were unilateral.
There were 2 ocular findings in Group-1 (1.9%). Complete
visual loss occurred in one patient. The other
patient had mild diplopia. There were 15 ocular findings
(n=37, 40.5%) in Group-2.
Resolution occurred in 10 patients. Three patients
had permanent visual loss. One has mild exophthalmos
and one patient presented with oculomotor
nerve neuropathy. There were 7 ocular findings
(n=14, 46.6%) in Group-3.
Resolution occurred in 6 patients. One had persistent
non disabling diplopia at the extremes of visual field.
The data is represented in both Table 3 and 4.
Variables Sample size (n) Percentage (%)
Zygomatico-maxillary complex fracture 3 7
23.7
Isolated orbital floor fracture 14 9
Simple non comunuted zygomatico-maxillary fracture
105 67.3
Total 156 100
Table 3: Subgroups of zygomatic fractures frequency.
Category of ocular injury Type of zygomatic fracture
Total
Zygomatico-maxillary complex fracture Isolated
orbital floor fracture Simple noncomunuted zygomatico-
maxillary fracture
Blindness 3 0 1 4
Free 22 8 103 133
Occulomotor injury 5 0 0 5
Rupture globe 1 0 0 1
Enophthalmos 5 0 0 5
Diplopia 0 6 1 7
Exfliated globe 1 0 0 1
Total 37 14 105 156
Table 4: Frequency of ocular injury associated with
zygomatic fracture.
Discussion
Analysis of the data from this retrospective study allows
examination of demographic patterns, etiology
of injuries, and highlights the ocular morbidity associated
with orbitozygomatic trauma. There were no
patients in the study population presenting with bilateral
orbitozygomatic fractures.
Pan facial and midfacial/nasoethmoid fractures were
excluded in order to examine ocular morbidity specifically
related to orbitozygomatic fractures. Similar
to other studies addressing maxillofacial trauma,
there was a peak in incidence for orbitozygomatic
fractures in adult males compared to children as
shown in Table 1 [7]. Road traffic accident was the
most commonly documented mechanism of injury in
this study, accounting for 82.7% of patients, followed
by fall down (11.5%), and assault (4.5%). This corresponds
with other urban trauma studies [8].
The etiology of injury varies geographically: in Western
countries with large urban populations, alcohol
related assault remains the primary etiologic factor
in maxillofacial trauma. However, motor vehicle accidents
predominate in many developing countries, in
the absence of seat belt legislation and where alcohol-
related assault is uncommon [9].
The reported incidence of ocular injuries in patients
with orbital fractures varies widely, ranging from
2.7%1 to 90% [2]. The incidence in this study was
14.7%, which is consistent with many other studies.
Lower levels reported where ophthalmologic input is
absent or only sporadic may indicate that some ocular
findings were undetected [3]. On the other hand,
variation in reported incidence between studies may
represent differences in inclusion criteria.
For example, the 90.6% incidence reported by Al-
Qurainy et al. includes subconjunctival hemorrhage
as ocular pathology. This is not counted as a significant
ocular finding in many other studies, including
this study. Furthermore, Al-Qurainy’s study includes
all midfacial/ nasoethmoid fractures that were excluded
in this study [3].
BAD ACT, scoring system proposed by Al-Qurainy et
al. to predict ocular injury risk and therefore allow
appropriate referral, is not widely used in clinical
practice [6,7]. An estimation of the ocular injury risk
associated with specific orbitozygomatic fractures
may be useful for assessment of risk. Based on data
from this study, “simple fractures” have 2% risk of
concomitant ocular finding or injury. However this
complication arises from severe brain injuries associated
with simple orbito-zygomatic bone fracture.
Comminuted fractures have 40.5% risk (over one
third); and blowout fractures a 42.8% risk (over one
thirds of patients). We postulate that the varying
incidence of ocular finding or injury in the fracture
groups (“simple” “comminuted’’, “blow out’’) is related
to the mechanism of injury. The higher velocity
of impact required to generate a comminuted orbitozygomatic
fracture leads to an increased number of
ocular findings and injuries in this group when compared
with the “simple” fracture group.
The mechanism of injury in orbital blowout fractures
has been a source of discussion, but may explain the
increased incidence of ocular findings and injuries in
the “Blow Out” group. There are 2 main theories, as
follows:
Table 5: Illustration of the level of significance of
Group-1, 2 and 3.
We propose that orbitozygomatic fractures be divided
into “simple”/ “noncomminuted” fractures, “comminuted”
fractures, and “blowout” fractures, based
on clinical and conventional radiographic findings. CT
scan should be used to confirm the extent of bony
injury, allowing estimation of ocular injury risk.
Ophthalmology consultation is recommended for
Group-2 and 3 presenting with orbitozygomatic fractures.
Where constraints in available ophthalmology
resources exist, preferential referral for comminuted
and blowout fractures is recommended based on the
high incidence of ocular findings and injuries in these
patient subgroups.
Statistical analysis: This study revealed statistically
significant made by Group-2 and 3 as predictor for
ocular injury as summarized in Table 5.
Analysis of predictors (head injuries and gender) as
a contribution factors to ocular injuries are summarized
in Tables 6 and 7 using linear regression test.
The independent variable as a set accounts for 7%
of variance in ocular injuries. The overall regression
model was significant. F (1.5.11)=6.4, P value less
than 0.05, R square is 0.077. This is illustrated in Table
7.
Table 6: Model Summary.
The role of Pharmacological treatment for orbito-zygomatic
bone fracture
Ice packs and head elevation are recommended for
the Patient with orbital floor fracture for 48 hours
to reduce the swelling [10,11]. Moreover, Patient
should be informed not to blow the nose to prevent
the emphysema for 4 to 6 weeks after the injury.
Patient with limited ocular movements may benefit
from short term use of steroids (0.75-1 mg/kg per
day of prednisone) if not contraindicated. Steroids
treatment helps for peri orbital and extra ocular
muscle edema to subside quickly and helps to decide
whether this limited ocular movement is transient or
if surgery is needed. Nasal decongestant and antibiotics
are advised for one week.
Conclusion: Ocular injuries are a relatively common
complication of orbitozygomatic fractures occurring
in 23 of patients (14.7%) in this study. These injuries
are more frequently seen in patients with comminuted
orbito-zygomatic fractures 15 (44%) followed by
orbital blowout fractures 6 (42.9%). Although simple
zygomatic complex fractures has low incidence (n=2,
1.9%), it associated with major ocular complication
if brain injuries present. Ophthalmology consultation
and ocular examination of at least three components;
visual acuity, ocular movement, and pupil reaction to
light are strongly recommended for Group-2 and 3
presenting with orbito-zygomatic fractures.
