The Ophthalmological Consequences of Midfacial Trauma

Ocular injuries commonly occur in patients with facial fractures. A study was carried out of 363 patients presenting during a 2-year period with midfacial fractures. Patients underwent ophthalmological examination within one week of injury. The characteristics of the eye injuries sustained were related to the aetiology and type of fracture, and the sex and age of each patient. Ninety-one percent of patients sustained ocular injuries of various severities. Sixty-three percent sustained minor injuries, 16% suffered moderately severe injury and 12% experienced severe injuries. Road traffic accident was associated with the highest incidence of severe ocular disorder at 20% (9/45) followed by assaults at 11% (20/181). One third of all patients with comminuted malar fracture suffered a severe ocular disorder (9/27) whilst blow-out fracture came second at 16.7% (6/36). Fifty-six patients (15.4%) had a decrease in visual acuity and 9 (2.5%) sustained significant traumatic optic neuropathy. Decrease in visual acuity accompanied the majority of significant eye injuries. Road traffic accidents and assaults associated with alcohol abuse showed the highest incidence of major ocular dysfunction. Motility disorder was also common. Seventy-two patients (19.8%) developed diplopia which was most common following road traffic accidents (31%) and least common with simple falls (10%). Blow-out fractures of the orbit (n=36) led to double vision in 58% of cases (n=21). Eighty-two percent of patients recovered from diplopia within six months of injury, 11% recovered within 6-12 months and 7% of patients took more than one year to recover including one patient who required squint surgery for double vision. The principal risk factors for diplopia comprise road traffic accidents, blow-out fractures and comminuted malar fractures. Early surgical reconstruction with conservative management of ocular motility disorders has, in this series, resulted in very few patients having diplopia in the long term. Ocular injuries following facial trauma may be difficult to detect by the maxillofacial surgeon and may therefore be missed. Fifty-four parameters comprising maxillofacial, radiological and ophthalmic data were coded and recorded for each patient. These data were divided into predictors (the data potentially available to the maxillofacial surgeon) and outcome (the data potentially available to the ophthalmologist). Statistical methods of regression, and analysis of contingency tables, led to the identification of the principal predictors indicative of ophthalmic injury and thence to a scoring system which predicts the severity of such injuries. Impaired visual acuity was the principal predictor and when employed alone gave a sensitivity value of 80%. Pure blow-out fracture or comminuted facial fracture, double vision and amnesia, emerged as additional factors which yielded an efficient scoring system with a sensitivity of 89% and specificity of 90% for the population upon which it was based. This scoring system was tested in a pilot study upon a new population of 100 similar individuals. The sensitivity value was 94.4% and the specificity value was 89%. Only one patient, warranting ophthalmic referral, was missed by the system whilst nine were incorrectly classified as warranting referral. Defects of convergence and accommodation are common sequels of head injuries, the two functions failing usually to a commensurate degree although either may occasionally be separately deficient. A prospective evaluation of patients who have sustained midfacial trauma was carried out in order to determine the prevalence of impaired 23 convergence and accommodation and to establish the risk factors for such defects. Of 52 patients in this study, 11 suffered accommodation and/or convergence disturbances. They included 6 males (17% of the male population) and 5 females (29% of the female population) whose ages ranged from 13 to 72 years with a mean age value of 30.2 years. Nine of these 11 patients sustained their injuries due to alleged assaults (24.3% of all assaulted patients) and 2, following simple falls (25% of all fall victims). Five patients complained of diplopia at near (5/11=45.5%) and another 4 of blurred vision and/or difficulty with reading (4/11=36.4%). The remaining 2 patients were asymptomatic. Six patients were randomly selected to receive orthoptic exercises/treatment while the other five were monitored for signs of spontaneous recovery. Within six months of injury/surgery, 83% of the treated patients (n=5) and 80% of the non-treated patients (n=4) recovered to within the normal values of accommodation and convergence. No significant statistical relationship was found between the incidence of accommodation and/or convergence failure, and the cause or the type of fracture sustained. It may, however, be related to the severity of impact and the associated closed head trauma. (Abstract shortened by ProQuest.)