Orthoptic Sequelae Following Conservative Management of Pure Blowout Orbital Fractures

Abstract

The aim of this study was to prospectively assess the prevalence of orthoptic anomalies following conservative management of pure blowout orbital fractures and to evaluate their clinical relevance. Clinical and radiologic data of patients with unilateral conservatively managed pure blowout orbital fractures with a minimum follow-up of 6 months were reviewed. Eligible patients were contacted and invited to undergo an extended ophthalmologic examination as follows: distance and near visual acuities, Hertel exophthalmometry, corneal light reflex (Hirschberg test), ductions and versions in the 6 cardinal fields of gaze, eye deviation with prisms and alternate cover test in all of the 9-gaze directions with Maddox rod, degrees of incyclo/excyclotorsion with right and left eye fixation, horizontal and vertical deviation with Hess-Weiss coordimetry, degree of horizontal/vertical and incyclo/excyclotorsion deviation with Harms wall deviometry, and vertical deviation with Bielschowsky head-tilt test. Of the 69 patients contacted, 49 declined to participate given that they were asymptomatic. Twenty patients agreed to undergo the examination. One patient complained of minimal double vision limited to the extreme downgaze. Four patients had asymptomatic ocular motility disturbances limited to the extreme gaze. Seven patients had asymptomatic horizontal heterophoria. These disturbances did not interfere with daily or professional activities in any of the patients. The current study demonstrated that conservative management of pure orbital blowout fractures can result in orthoptic anomalies. These sequelae were restricted to a very limited portion of the binocular field of the vision and were not found to be clinically relevant.

Orthoptic Evaluation and Treatment in Orbital Fractures

“…Residual diplopia in conservatively treated patients is reported globally, with a significant range, from 15% to 82%. 1 Independent of the type of injury, the strabismus is likely to change in the first weeks to months as edema resolves 13 (Case 3); 7 days to 10 days after trauma, examination is performed more easily because the initial edema often is resolved partially or mostly. Through orthoptic examination, it can be determined if and to what degree diplopia is improved spontaneously and orbital reconstruction may be prevented.…”

“…There is no real consensus with regard to standardized examination or protocolled treatment to determine either the necessity or type of treatment. 1 Surgical indication, meaning possible orbital repair surgery, is predicated on criteria, such as enophthalmos, restriction of extraocular muscles, type and size of the fracture's defect, degree of diplopia, and clinicoradiological findings. 1e3…”

Are Inferior Rectus Muscle Displacement and the Fracture's Size Associated With Surgical Repair Decisions and Clinical Outcomes in Patients With Pure Blowout Orbital Fracture?

“…Thus far, studies have been primarily focused on clinical prognostic factors and have reported severe diplopia immediately after trauma and/or persisting at 10 to 14 days and patient age as the most important predictors of the decision for surgical exploration. 1,3,4,9,10,13,14,21,24,25,40 These elements strongly contributed to the generally accepted approach to wait for a 1-to 2-week observation period before deciding on a definitive management strategy, with the exception of pediatric fractures. By contrast, only a few studies have reported on the predictive value of initial diplopia for persistent long-term annoying diplopia.…”

“…By contrast, only a few studies have reported on the predictive value of initial diplopia for persistent long-term annoying diplopia. 1,3,9,10,24,25 The occurrence of the development of enophthalmos has been mainly related to orbital volume increase rather than fracture size. 26,27 A few studies have reported on fracture size measured on CT scan images and/or IRM changes (morphologic and positional) as radiologic predictors for the decision for surgery and persistence of diplopia and/or enophthalmos in patients with BOFs.…”

“…This modification seemed a wise compromise and is still used in several centers. 6,7,14,16,[20][21][22][23][24][25] The advent of the computed tomography (CT) scan provided new insights into the structure of the orbits by showing the relationship between the bony and soft tissue components. This rapidly led to a new start in the comprehension of the possible mechanism underlying the occurrence of diplopia and enophthalmos in BOFs.…”