Abstract
The timing of orbital reconstruction is a determinative factor with respect to the incidence of potential postoperative orbital complications. In orbital trauma surgery, a general distinction is made between immediate (within hours), early (within 2 weeks), and late surgical intervention. There is a strong consensus on the indications for immediate repair, but clinicians face challenges in identifying patients with minimal defects who may actually benefit from delayed surgical treatment. Moreover, controversies exist regarding the risk of late surgery-related orbital fibrosis, since traumatic ocular motility disorders sometimes recover spontaneously and therefore do not necessarily require surgery. In this study, all currently available evidence on timing as an independent variable in orbital fracture reduction outcomes for paediatric and adult patients was systematically reviewed. Current evidence supports guidelines for immediate repair but is insufficient to support guidelines on the best timing for non-immediate orbital reconstruction.
Introduction
Clinical decision-making in the management of patients with orbital fractures is challenging, and various aspects of orbital fracture management are still debated. Controversies exist regarding the indications for surgery, the timing of surgery, and the best reconstruction material. To date, no uniformly accepted guidelines have been developed for the maximal interval between trauma and reconstructive surgery. However, in many other fields of trauma surgery, an increasing body of evidence is stressing the importance of the optimal timing of surgery.
Early revision and repair of blowout fractures has been considered the first-line treatment for optimal surgical outcome. The major clinical outcome parameters in patients with orbital fractures include functional impairment (vision, extraocular muscle motility disorders, and diplopia), cosmetic disturbance (enophthalmos), and infraorbital hypaesthesia. Ocular motility disturbances due to orbital fractures are often related to contused ocular muscles and post-traumatic oedema. In the 1970s, it was observed that contused ocular muscles usually recover spontaneously within 1 or 2 weeks, thus a conservative approach was suggested in order to avoid surgery-related complications. The introduction of computed tomography (CT) provided increasingly accurate information on the extent of the fractures and the presence of herniated tissue, and resulted in CT-based treatment protocols in the 1980s and 1990s. The focus of the debate on optimal timing has since then shifted from the indications for early intervention towards the question of which patients are eligible for delayed repair. In general, a distinction needs to be made between immediate (within hours), early (within 2 weeks), and delayed late orbital reconstruction.
There is consensus on the indications for immediate surgery. An emergency situation in orbital trauma exists if a retrobulbar haematoma develops with apical compression of the globe or the optic nerve in combination with impaired vision. These conditions are an indication for immediate surgery within 6 h after presentation. Another indication for urgent surgical intervention is muscle incarceration and possible ischaemia in the paediatric patient. New light was shed on the timing issue by Jordan et al. in 1998, who found that although children under the age of 16 years presenting with diplopia and vertical gaze restriction (‘white-eyed blowout fractures’) might show little or no radiological evidence of muscle entrapment, this patient category is vulnerable to the development of eye motility disorders that are highly resistant to surgery. Parbhu et al. found that CT evidence for soft tissue entrapment in children is easily missed or underestimated by radiologists because of the trapdoor mechanism. Minor muscle entrapment in children may rapidly result in muscle fibrosis followed by persistent diplopia, and requires intervention within 2–4 days. In addition, the oculocardiac reflex, due to orbital wall fractures and vagal stimulation in children, causes serious bradycardia with potential life-threatening complications.
Indications for early intervention within 2 weeks have also been reported in the literature, and include enophthalmos larger than 2 mm with significant hypoglobus or diplopia. Large displaced fracture defects generally require surgery within 2 weeks, since the development of enophthalmos is anticipated. Enophthalmos may be obvious at the time of presentation, but may be masked by oedema or haematoma. However, if surgery is delayed until enophthalmos is apparent, fibrosis may develop between orbital soft tissues, the sinus mucosa, and bone fragments. To prevent fibrosis of the injured orbital tissue, early repair within 2 weeks has been proposed for patients who have clinically unimproved diplopia with radiological evidence of orbital tissue compression. Delaying the operation further may increase the complexity of the reconstruction and introduce the risk of additional complications, such as sinusitis, dacryocystitis, late ptosis, and functional deficits (e.g. enophthalmos, hypoglobus, and diplopia).
Delayed reconstructions are commonly indicated in patients who have developed aesthetically disturbing enophthalmos or persistent diplopia 2 weeks after trauma. In these patients, the indication for surgical intervention may be uncertain in the early stages after trauma. This uncertainty applies specifically to small orbital defects, e.g. in patients with orbital fractures who have good ocular motility and only slight displacement of the orbital content. In a retrospective study, Dal Canto and Linberg found similar complication rates between orbital floor and/or medial wall fracture repairs conducted within 14 days and those performed 15–29 days after trauma. However, the majority of studies support early reconstruction because of the better postoperative results and a decreased incidence of diplopia and enophthalmos. These outcomes are thought to result from reduced scarring of soft tissue. The initial contusion, shearing, and laceration cannot be prevented; however, early reversal of an ongoing tissue crush or severe stretch might limit late fibrosis, especially in cases of fractures with disproportionate soft tissue displacement.
If an orbital wall defect needs reconstruction, several decisions need to be made on the timing of surgery. The aim of the present study was to systematically review all the available controlled clinical trials on post-traumatic orbital reconstruction with a focus on the timing, or delay of surgery.
Methods
A systematic literature search in PubMed (updated 14 September 2013; all indexed years) with multiple search terms was performed, combining the subjects ‘orbital fracture’, ‘timing’, and ‘delay’. The search excluded case series with 10 or fewer subjects, and the language was restricted to English, German, and Dutch. All prospective and retrospective human clinical studies reporting comparative data regarding the interval between the injury and the reconstructive orbital surgery and also the outcome of the orbital fracture treatment met our entry criteria; these studies could include either adults or children. During the primary review process (performed in accordance with the PRISMA criteria, (preferred reporting items for systematic reviews and meta-analyses) for systematic reviews ), two authors (SS and LD) assessed the relevance of the retrieved articles based on the abstracts. In a secondary review, full articles were retrieved and relevant articles were included. Any disagreements were resolved through discussions with a third person (PG). Fig. 1 shows a flow diagram of the inclusion process.
The PubMed search terms (all indexed years) were as follows: ((((“Orbital Fractures”[Mesh] OR orbital fracture*[tiab] OR orbit fracture*[tiab] OR orbital trauma*[tiab] OR orbit trauma*[tiab] OR orbital injur*[tiab] OR orbit injur*[tiab] OR orbital wall fracture*[tiab] OR orbital wall injur*[tiab] OR orbital wall trauma*[tiab] OR orbital floor fracture*[tiab] OR orbital floor injur*[tiab] OR orbital floor trauma*[tiab] OR blow-out fracture*[tiab] OR blowout fracture*[tiab] OR supraorbital fracture*[tiab] OR trapdoor fracture*[tiab] OR malar fracture*[tiab] OR tripod fracture*[tiab] OR orbitozygomatic fracture*[tiab] OR orbito-zygomatic fracture*[tiab] OR zygomatico-orbital fracture*[tiab] OR tripartite fracture*[tiab] OR (le fort[tiab] AND fracture*[tiab]) OR (lefort[tiab] AND fracture*[tiab]))) AND (“Time”[Mesh] OR time[tiab] OR timing[tiab] OR delay*[tiab] OR moment[tiab] OR wait*[tiab] OR early[tiab] OR late[tiab] OR week*[tiab] OR day[tiab] OR days[tiab])) NOT (case reports[pt] NOT (cases[tiab] OR series[tiab] OR group[tiab] OR patients[tiab] OR review[tiab] OR retrospective[tiab]))) AND (English[la] OR Dutch[la] OR German[la]).
Methods
A systematic literature search in PubMed (updated 14 September 2013; all indexed years) with multiple search terms was performed, combining the subjects ‘orbital fracture’, ‘timing’, and ‘delay’. The search excluded case series with 10 or fewer subjects, and the language was restricted to English, German, and Dutch. All prospective and retrospective human clinical studies reporting comparative data regarding the interval between the injury and the reconstructive orbital surgery and also the outcome of the orbital fracture treatment met our entry criteria; these studies could include either adults or children. During the primary review process (performed in accordance with the PRISMA criteria, (preferred reporting items for systematic reviews and meta-analyses) for systematic reviews ), two authors (SS and LD) assessed the relevance of the retrieved articles based on the abstracts. In a secondary review, full articles were retrieved and relevant articles were included. Any disagreements were resolved through discussions with a third person (PG). Fig. 1 shows a flow diagram of the inclusion process.
The PubMed search terms (all indexed years) were as follows: ((((“Orbital Fractures”[Mesh] OR orbital fracture*[tiab] OR orbit fracture*[tiab] OR orbital trauma*[tiab] OR orbit trauma*[tiab] OR orbital injur*[tiab] OR orbit injur*[tiab] OR orbital wall fracture*[tiab] OR orbital wall injur*[tiab] OR orbital wall trauma*[tiab] OR orbital floor fracture*[tiab] OR orbital floor injur*[tiab] OR orbital floor trauma*[tiab] OR blow-out fracture*[tiab] OR blowout fracture*[tiab] OR supraorbital fracture*[tiab] OR trapdoor fracture*[tiab] OR malar fracture*[tiab] OR tripod fracture*[tiab] OR orbitozygomatic fracture*[tiab] OR orbito-zygomatic fracture*[tiab] OR zygomatico-orbital fracture*[tiab] OR tripartite fracture*[tiab] OR (le fort[tiab] AND fracture*[tiab]) OR (lefort[tiab] AND fracture*[tiab]))) AND (“Time”[Mesh] OR time[tiab] OR timing[tiab] OR delay*[tiab] OR moment[tiab] OR wait*[tiab] OR early[tiab] OR late[tiab] OR week*[tiab] OR day[tiab] OR days[tiab])) NOT (case reports[pt] NOT (cases[tiab] OR series[tiab] OR group[tiab] OR patients[tiab] OR review[tiab] OR retrospective[tiab]))) AND (English[la] OR Dutch[la] OR German[la]).
Results
In the systematic search, a total of 17 studies including 1579 patients with orbital injuries were identified ( Tables 1–3 ).
| Study [Ref.] | Design | Fracture type | Surgical technique | Number of patients | Interval from injury to surgery (delay) | Follow-up | Results |
|---|---|---|---|---|---|---|---|
| Bayat et al. | Randomized controlled clinical trial | Blowout fractures | Nasal septal cartilage (11) vs. conchal cartilage (11) | 22 | <4 weeks: n = 8 >4 weeks: n = 13 |
3–6 Months | At baseline, differences in the mean values of the enophthalmos between patients treated within or after 4 weeks of injury were non-significant (mean (SD), 4.8 (0.89) vs. 5.1 (0.8) mm, respectively; P = NS). However, the mean correction of the enophthalmos (and residual enophthalmos) was significantly higher (and lower) at each follow-up visit in patients who were treated within 4 weeks of injury ( P = N/A) |
| Kontio et al. | Cohort study | Isolated floor (11) and floor with associated facial fracture (13) | Autogenous iliac cortical graft | 24 | 7 Days (range 0–26) | 5–13 Months | Timing of the operation did not affect the occurrence of diplopia ( P = N/A) |
| Study [Ref.] | Design | Fracture type | Number of patients | Interval from injury to surgery (delay) | Follow-up | Results |
|---|---|---|---|---|---|---|
| Hawes and Dortzbach | Consecutive case series | Orbital floor fractures (either with diplopia or enophthalmos) | 51 | <2 Months ( n = 43) vs. >2 months ( n = 8) | >6 weeks | ‘Early’ vs. ‘late’ repair Enophthalmos postoperative: 7% vs. 50% ( P < 0.002) Motility ‘satisfactorily’ corrected: 88% vs. 40% ( P < 0.02) |
| Verhoeff et al. | Chart review | Orbital trauma with subsequent motility disorders needing repair | 28 | <2 Weeks vs. >2 weeks <2 Months vs. >2 months |
>6 months | Higher complete recovery rate in earlier repair (73% <2 weeks vs. 40% <2 months vs. 25% >6 months); P = N/A |
| Harris et al. | Cohort study | Orbital floor fracture with or without medial wall extension, and diplopia | 30 | Mean 16/24 days Range 1–2920 days |
4–10 weeks postop. | Higher than median ocular motility outcome in patients treated < 1 week; P = N/A |
| Matteini et al. | Chart review | Pure orbital fractures | 108 | <2 h, 2–24 h, 1–3 Days, 3–7 days, 7–12 days | 2–6 months (mean 4 months) | ‘Strong relation’ between timing of surgery and the variables ‘functional impairment or muscle entrapment’ and ‘serious conditions of compression or ischaemia’; P = N/A |
| Dal Canto and Lindberg | Chart review | Orbital fractures (floor and/or medial wall) | 58 | <14 Days ( n = 36) vs. 15–29 days ( n = 22) | >3 weeks | No significant difference between ocular motility (preop. and postop.), self-reported diplopia, and strabismus between ‘early’ and ‘delayed’ groups. Time to resolution or stability of diplopia postop. independent of the time to surgery |
| Simon et al. | Consecutive case series | Orbital floor fracture with entrapment or enophthalmos | 50 | <2 Weeks vs. >2 weeks | No apparent difference between early and late repair. Repair <2 weeks was associated with less improvement in enophthalmos vs. >2 weeks (delta 0.2 ± 1.1 vs. 1.3 ± 1.9 mm, P = 0.02) | |
| Shin et al. | Chart review | Orbital fractures with diplopia or motility restriction | 233 | <14 Days vs. 15–30 days | >6 months | No significant difference in degree of preop. and postop. diplopia, motility restriction, and enophthalmos between the two groups |
| Brucoli et al. | Chart review | Blowout fractures without orbital rim involvement | 51 | <2 Weeks vs. >2 weeks | 6–81 months (mean 39 months) | Timing of surgery at <2 weeks vs. >2 weeks was significantly associated with a positive influence on diplopia at long-term follow-up ( P < 0.05), on postop. enophthalmos ( P < 0.05), and on infraorbital hypaesthesia ( P < 0.05) |
| Shin et al. | Chart review | Pure blowout fractures | 952 | <3 Days, 4–7 days, 8–14 days, 15–30 days, >1 month | There was no significant difference in the improvement of diplopia according to timing of surgery ( P < 0.05, McNemar test), but timing of surgery (operated after 1 week) was significantly related to postoperative extraocular movement limitation and enophthalmos ( P > 0.05, McNemar test) |
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