OPHTHALMIC CONSEQUENCES OF MAXILLOFACIAL INJURIES seminar.pdf

Maxillofacial surgeon is often the first to assess injuries to the Head and neck, out of which the Orbital and the Eye is usually involved and hence should not be ignored. Ocular trauma may result in pathology of the ocular surface, extraocular muscles, orbital walls, eye and optic nerve. Detailed history followed by a complete ocular and, if indicated, radiological examination is therefore a crucial part of any trauma assessment.
Several vision-threatening injuries following facial trauma can ensue including retrobulbar hemorrhage (RBH), traumatic optic neuropathy (TON) and penetrating globe injury. These must be diagnosed and managed early to minimize vision loss.

1. OPTHALAMIC CONSEQUENCES OF MAXILLOFACIAL INJURIES
PAST, PRESENT & FUTURE
DR. RIYA SHAH
II MDS

2. INTRODUCTION
•Orbital fractures secondary to trauma are often complicated by ocular injuries.
•Ocular trauma may result in pathology ofthe ocular surface, extraocular muscles, orbital walls, eyeandoptic
nerve. Detailed history followed by a complete ocular and, ifindicated, radiological examination istherefore
a crucial part of any trauma assessment.
•In the case of severe trauma, ophthalmological assessment is often delayed as life-saving treatments are
performed.
•Several vision-threatening injuries following facial trauma can ensue including retrobulbar haemorrhage
(RBH), traumatic optic neuropathy (TON) and penetrating globe injury. These must be diagnosed and
managed early to minimize vision loss.
Terrill SB, You H, Eiseman H, Rauser ME. Review of Ocular Injuries in Patients with Orbital Wall Fractures: A 5-Year
Retrospective Analysis. Clin Ophthalmol. 2020 Sep

3. INCLUSIONS
❑SURGICAL ANATOMY OF ORBIT & GLOBE
❑THE PAST
❑INCIDENCE OF FACIAL FRACTURES AND OPTHALAMIC INJURIES
❑THE PRESENT
- MECHANISMS OF INJURY TO ORBIT
-OPTHALAMIC EVALUATION & ASSESSMENT
-OPTHALAMIC CONSEQUENCES OF MAXILLOFACIAL TRAUMA & THEIR
MANAGEMENT
❑CASE SCENARIOS
❑THE FUTURE
❑CONCLUSION

4. SURGICAL ANATOMY OF ORBIT & GLOBE

5. SURGICAL ANATOMY OF ORBIT & GLOBE

6. SURGICAL ANATOMY OF ORBIT & GLOBE
Normal globe anatomy on orbital MRI.
Lens (black arrow) and sclera (white arrow) show
hypointense signal on all sequences.
A.On axial T2W images, vitreous (*) and aqueous humour
in anterior chamber (**) are diffusely hyperintense. Optic
nerve is labeled (dashed black arrow).
B.Axial T1W image of right globe. Retina and choroid
appear as single hyperintense layer (white arrow) with
enhancement on fat-saturated post contrast T1W image (C,
white arrow). Ciliary bodies form part of choroid (dashed
white arrows,B, C).
D.Anotated illustration of globe for comparison with MRI
anatomy.
T1W = T1-weighted, T2W = T2-weighted
Hallinan JT, Pillay P, Koh LH, Goh KY, Yu WY. Eye Globe Abnormalities on MR and CT in Adults: An Anatomical Approach. Korean J Radiol. 2016 Sep-Oct;17.

7. Diagram of right eye demonstrating (a) the extraocular muscles
and (b) the movements they cause. (c) The fascial sheath. (SR -
Superior Rectus, IR - Inferior Rectus, MR - Medial Rectus, LR -
Lateral Rectus, SO - Superior Oblique, IO - Inferior Oblique

8. •Hippocrates was the
first person to record
the association
between facial trauma
and blindness (Latinate
from Greek: amaurosis,
or “darkening,” and
amblyopia, of “sluggish
eye, blindness”).
•In 1879, Berlin noted that
trauma could lead to fracture
of the optic canal. Blindness in
patients with maxillofacial
trauma is usually caused by
optic nerve or optic canal
injuries. It is, however, an
uncommon complication of
facial trauma, with a reported
incidence of 0.32% to 9%.
•According to Le Fort in 1901- the face resists the force
mainly because of the face’s elasticity, its periosteum, and
its soft tissues. Direct injury to the globe of the eye is
relatively rare compared with the frequency of orbital
trauma.9 This is explained by the fact that a number of
factors protect the globe from injury, including the
prominence of the bones of the orbit and the natural
reflexes of self-protection such as blinking, protecting the
eye with the hand, and averting the head.
THE PAST
Blindness After Facial Fractures: A 19-Year Retrospective Study Mohammad Hussein Ansari, DMD, BDSc 2005 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 63:229-237, 2005

9. INCIDENCE
BLINDNESS AFTER FACIAL TRAUMA
•Blindness after facial fractures has been reported in 1996 to occur with an incidence that
ranges between 0.67% and3% depending on the reporting institution. To verify this finding
authors undertook a retrospective chart review of 5936 patients with facial fractures that
occurred over a 12 1/2-year period. They found that vision in 19 eyes were lost in 18 patients.
• Vision loss was more frequently encountered in Le Fort III level fractures (2.2%) followed
distantly by Le Fort II level fractures (0.64%), and zygomatic fractures (0.45%).
•The cause of blindness was most frequently associated with motor vehicle accidents and
gunshot injuries. Injuries of this type require immediate and prompt consultation by the
ophthalmologic surgery service.
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Nicholas Zachariades, Demetrius Papavassiliou, Panos Christopoulos,Blindness after facial trauma,
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology,Volume 81, Issue 1,1996,

10. THE PRESENT
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FRACTURES ASSOCIATED WITH LOSS OF VISION
A study by Umarane et al in 2020 stated:
The total number of recorded midface maxillofacial trauma
cases was 181. Out of 181 patients, 161 had ocular injuries.
Among 181 cases, 161 (88.95%) cases were due to road
traffic accidents, which was the prime etiologic factor
The maximum number of cases were of zygomaticomaxillary
complex fractures (44.75%) followed by nasal bone fractures
(21.5%). Periorbital ecchymosis accounted for the
maximum number of cases, amounting to 61.88%.
Loss of vision or blindness was seen in eight (4.42%)
patients.
Umarane S, Kale T, Tenagi A, Manavadaria Y, Motimath AS Sr. A Clinical Study of the Evaluation and Assessment of the Etiology and Patterns of
Ocular Injuries in Midfacial Trauma in a Tertiary Care Hospital. Cureus. 2020 Sep.

11. INITIAL ASSESSMENT
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•After initial stabilization of the patient, a thorough facial examination is performed in a way similar to any facial
fracture.
•Special consideration is given to a detailed ophthalmic evaluation followed by eliciting signs and symptoms
significant for periorbital trauma.
•The frontal area and supraorbital rim are examined first, with a logical progression downward, including the lateral
and infra-orbital rims, although extensive edema in this area may obscure any steps making the palpatory
examination difficult.
➢“8-Point” Ophthalmic Examination Advocated by the American
Association of Ophthalmology
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)

12. OPHTHALMOLOGIC EXAMINATION
on
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1. Visual acuity: Visual acuity test for each eye is recorded using
a Snellen chart and includes ability to read letters, count fingers,
perceive hand movements, and light perception.
If visual acuity is extremely poor and recording of a chart test
fails, the patient is subjected to a finger counting test or at times
even assessed for primary light perception alone.
2. Pupillary examination: Pupillary examination is done to note
the (a) size, (b) shape, (c) symmetry, (d) and direct/indirect reflex
to light.
Glaucoma, previous history of surgery, and/or injury to ocular
system may also account for anisocoria or irregular pupils.
Peaked or irregular pupils may also be indicative of perforation of
the globe. The swinging flashlight test is performed for relative
afferent pupillary defect (RAPD)
Swinging flash light test
Snellen chart
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-
Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)

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3. Extraocular motility and alignment: The patient is first screened for
all the six cardinal gazes. Diplopia and restrictions in gazes are noted.
Clinically, a forced duction test under topical anesthesia is done to
elicit mechanical impediment to movement of the globe. This may
also be performed under general anesthesia intraoperatively. A Hess
chart examination is a part of the orthoptic assessment protocol for
evaluation of ocular motility.
HESS CHART
The Hess screen test gives a pictorial record of the ocular
movements of each eye.
It is based on foveal projection, and it is essential that the patient
has normal retinal correspondence, central fixation and little or no
suppression for accurate measurements.
Demonstration of the method of
performing intraoperative forced
duction test (a) by grasping the
limbus (sclero-corneal junction)
and (b) by grasping the inferior
rectus muslce
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-
Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)

14. OPHTHALMOLOGIC EXAMINATION
on
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,,
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-
Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)
4. Intraocular pressure: Tonometry should be performed to evaluate intraocular pressure either in a clinic setting
using a Goldmann applanation method or outside using a mobile/portable device. This examination is skipped if there
is a suspicion of ruptured globe. The normal IOC is a range between 10 and 21 mmHg with the mean being around
15mmHg. Low IOP may be suggestive of a ruptured globe or detached retina, while increased IOP may indicate
hyphema, glaucoma, or an orbital compartment syndrome like “retrobulbar hemorrhage.” A pressure of more than
30mmHg is an ophthalmological emergency.
Goldmann Applanation Tonometer

15. 5. Visual fields: Visual fields for each eye are checked by asking the patient to determine
movements at the periphery of the examiner’s own visual field, while at a distance of about 2ft
from each other. Loss of field may be suggestive of compressive or ischemic injuries to the
optic nerve with or without damage to the visual pathway. Goldmann visual field test can also
be employed to objectively chart binocular visual field loss wherein patient is asked to look at
a center of the chart and is required to track a point source of light.
Static Perimetry Test
Subject will be asked to keep looking at a center target throughout the test. Small, dim lights
will begin to appear in different places throughout the bowl, and he/she will press a button
whenever you see a light. The machine tracks which lights they did not see.
This is called a "static" test because the lights do not move across the screen, but blink at
each location with differing amounts of brightness. This allows the machine to find the
dimmest light the subject can see at each location in peripheral vision.
.
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-
Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)

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6.External examination/periorbital screening: A thorough clinical evaluation is
performed to note down all clinical features like periorbital edema, ecchymosis,
subconjunctival haemorrhage etc. Orbital trauma is generally associated with
possible adnexal injuries which also need to be assessed for intervention and
management.
7. Slit-lamp examination: A formal slit lamp test is performed if it may be allowed.
This provides information about the lids, lashes, lacrimal system, conjunctiva, sclera,
anterior chamber, iris, the lens, and the anterior vitreous.
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-
Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)
Slit Lamp

17. OPHTHALMOLOGIC EXAMINATION
on
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8. Fundoscopic examination: A fundoscopic examination is
performed to assess the retina, optic nerve head, and the
vessels. This is done by the use of an ophthalmoscope. It also
provides information about presence of intraocular hemorrhages
and foreign bodies.
9.Globe position: An important feature in examination of orbital
trauma from a cranio-maxillofacial perspective includes the
examination of globe positions. This is performed both clinically
and by using an exophthalmometer.
The Hertel’s exophthalmometer is used in common settings for
the evaluation of proptosis or enophthalmos. In case of injuries
involving the lateral face, like a fracture of the ZMC, the Naugle’s
exophthalmometer is used.
The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen
A. Schendel MD, DDS, FACS-Face Center Los Angeles, Pacific Palisades, CA, USA
Volume 24, Issue 4,Pages 525-720(November 2012)
Naugle’s exophthalmometer

18. CLASSIFICATION
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A modified Birmingham Eye Trauma Terminology (BETT)
classification system that incorporates both globe and periocular
injuries.
The original BETT classification did
not consider periocular injuries.

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❖EYELIDS
- Laceration
WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
When the skin is cut, suturing is generally desirable with careful
apposition of the wound edges using as fine a suture material as is
compatible with maintained closure—a 6/0silk. Wounds of the lid
margins merit special attention. A cut eyelid margin will often heal
leaving a notch or defect.
To avoid such a sequel, the lid should be repaired as indicated in
Figure.
All repairs of palpebral wounds should avoid cicatricial deformity of
the eyelids. Fibrous tissue contractions may cause
1.Inversion of the eyelid margin (entropion) with abrasion of the
eyeball by the in turned eyelashes.
2.Eversion of the eyelid (ectropion) with exposure of the cornea
and its subsequent dehydration which is so often followed by
epithelial breakdown and infection, e.g. corneal ulceration or
even perforation.

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
•Damage to the conjunctiva itself is rarely serious, but great care should be taken during examination to ensure that the
injury does not extend into the eyeball, because penetrating injuries of the eye may be visually damaging, in contrast
to a solitary conjunctival injury which does not affect vision.
•Blunt injuries to the conjunctiva usually cause oedema (chemosis) but this should absorb without difficulty and
without treatment.
•Similar injuries to the conjunctiva may only breach one or more conjunctival capillaries giving an haematogenous
extravasation with the collection of blood under the conjunctiva, i.e. a subconjunctival haemorrhage.
• Although unsightly, these haemorrhages gradually absorb without treatment. If the haemorrhage is excessive and the
conjunctiva extrudes between the eyelids, the conjunctiva should be kept well moistened with frequent applications of
an antibioticoculate.
•Lacerations of the conjunctiva itself usually merit suturing unless they are small— the most efficacious suture
materials are 6/0 collagen, 6/0 catgut or 8/0 virgin silk.
❖CONJUCTIVA

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
❖CORNEA
Concussion injuries to the cornea follow two main pathological types:
1. The corneal tissue may suffer a concussion necrosis or laceration
2. The cornea may become oedematous and the seat of infiltrations
of both haematogenous cells and debris.
A blunt injury to the cornea may tear its epithelium, causing a
localised superficial oedema which on examination appears hazy in
the damaged area. A breach in the corneal epithelium takes up the
dye fluorescein and demarcates the extent of the damage by
imparting a green colouration to it. As the damaged area heals, the
extent of this green colouration recedes but as the damage increases
so does the spread of the colouration.
Oedema of the corneal stroma does not usually cause lasting
damage. The hazy oedematous tissue gradually absorbs without
visual upset, but severe damage may leave some residual corneal
opacities
Corneal
Abrasion

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
❖CORNEA
Lacerations of the cornea vary greatly in their extent. A small
superficial tear will often heal without further intervention but
rupture of Bowman’s membrane leaves opacification.
Deep corneal lacerations usually require suturing and this should
preferably be performed by an ophthalmologist.
First-aid treatment is simple with the application of an antibiotic
oculentura or drops and a mydriatic such as guttae mydrilate 1%
(cyclopentolate) or phenylephrine 10% to the injured eye. Steroid
applications should not be given at an early stage as impaired wound
healing results.
Perforating wounds of the cornea demand meticulous suturing of the
cornea with restitution of the anterior chamber. Prolapse of the iris
through the perforation may require excision of the prolapsed
segment of iris tissue or simply its reposition prior to suturing of the
cornea.
Corneal Laceration

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
❖IRIS
The iris, which is part of the vascular coat of the eyeball, also
contains some smooth muscle tissue which alters the pupillary
size and reactions. Blood in the anterior chamber is known as
hyphaema. Bleeding from the iris or, at its root, the ciliary body,
usually passes into the aqueous humour in the anterior chamber.
The amount of blood which collects there varies from an almost
imperceptible haze to a large bleed which may fill the anterior
chamber.
A small amount of blood in the anterior chamber will gradually
gravitate to the lower pan of the chamber and assume an
horizontal upper border.
A small hyphaema merits no local treatment or, at the most,
Betnesol eye drops three or four times a day.
Hyphaema

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
A total hyphaema should be examined by an ophthalmologist as
a large or total hyphaema may not only increase the intraocular
tension but also aid the passage of haematogenous elements
into the corneal stroma (blood staining of the cornea) which
then assumes a brownish tinge.
As a first aid treatment for total hyphaema, it may be desirable
to administer diamox tablets (acctazolamide) 250 mg twice or
three times daily and steroid eye drops or oculentum.
Blunt injuries to the eye may give rise to a traumatic miosis
(constriction) or mydriasis (dilatation) of the pupil. Such a paresis
is usually permanent.
Prolapse of the iris through a penetrating wound produces a
knuckle of iris visible at or through the perforation.
Severe trauma to the eyeball may tear the iris at its periphery
(where it is attached to the ciliary body). Here the iris is thin and
fragile; thus it tears readily and, on doing so, a dark defect or
hole in the iris pattern appears (iridodialysis) corresponding with
the area of tom iris, together with a deformed pupillary margin
which present^ axial to the iris hole. This breach in the iris
persists and usually requires no treatment.
Prolapse of Iris

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
Iritis or inflammation of the iris may follow corneal infections of
a severe nature.Treatment of such an iritis is primarily the
control of the corneal infection by local and systemic antibiotics
and dilatation of the pupil by guttae atropine 1%.
Iritis may also follow a penetrating injury of the eyeball when
infection is introduced within the eye. The pupil may soon be
deformed by adhesions between the iris and adjacent lens.
These adhesions are called posterior synechiae.
Urgent systemic antibiotics should be instituted in addition to a
subconjunctival injection of antibiotic (e.g. 40 mg gentamycin)
after anaesthetising the conjunctiva with gutt. amethocaine. This
injection may have to be repeated. The pupil should be dilated
by guttae atropine 1% (even repeated applications) with the
application of steroids to the injured eye being decided by the
ophthalmologist.
Posterior synechiae i.e adhesion
of iris to lens capsule

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
•The healthy lens is a transparent structure. However,
perforation of the lens invariably causes opacification which
initially is small but which slowly extends.
• A penetrating injury of the lens should be treated by an
ophthalmologist.
• A blunt injury of the eyeball may cause no apparent change
in the lens.
•Partial displacement (subluxation) may result from injury to
the eyeball, or total dislocation of the lens frequently results
from more serious or severe trauma.
• All lens injuries should be referred to the ophthalmologist,
there being no particular urgency for treatment of pure
lenticular injuries.
❖LENS

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
•Oedema of the choroid per se is not of importances neither is a rupture or tear of the choroid except when it
involves the macular area where a diminution of central vision results.
• Haemorrhage of the choroid after trauma is especially variable in size and position. Initially red, the haemorrhage
quickly assumes a greyish-blue colouration which is irregular in outline, although generally more or less round. With
an open wound of the sclera and choroid, bleeding from the choroid may result in a collection of blood within the
eye or the blood may escape outside the eyeball.
•Choroidal haemorrhage at the macula characteristically has a devastating effect on vision as macular function is
disrupted.
•Profuse bleeding from the choroid occurs when one of the large choroidal vessels is ruptured during the injury. No
treatment is needed, as the bleeding is self-limiting and eventually becomes organized.
❖CHOROID

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
Rupture of the choroid may be:
1) Direct and due to an outside force involving the eyeball. Such
an injury is rare in contusion injuries and is peripherally situated
with exposure of the white sclera visible with the
ophthalmoscope through the choroidal tear
2) Indirect when the choroidal tears appear as crescentic narrow
pale lines concentric with the optic disc and lying between the
disc and the macula, with retinal vessels coursing over the
choroidal rupture. No treatment is usually needed.

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
Concussion injury of the retina causes oedema known as commotio
retinae which is transient and reversible. The oedematous retina is milky-
white, with an ill-defined periphery and, although the oedema is
preferentially posterior, it may be situated anywhere in the fundus
according to the site of the trauma. Spontaneous absorption of the
oedema occurs but sometimes the oedema is followed by cystic
degeneration at the macula and by pigment degeneration.
Haemorrhage may be small or large, single or multiple and varied in
position. The extravasated blood may burst forwards into the vitreous
where it absorbs slowly either spontaneously or with proliferative
neovascularisations from the retina into the vitreous haemorrhage.
Treatment generally fails to influence the position. The majority of
traumatic retinal haemorrhages absorb spontaneously but, when a tear of
the retina is also present, ophthalmic treatment may be needed.
Detachment of the retina is a late complication of ocular trauma which
usually necessitates planned ophthalmic surgery.
❖RETINA

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
Optic atrophy is a common sequel to indirect injuries of the skull
but the atrophy may also follow injury to the eyeball.
Trauma may cause haemorrhage into the nerve, or a bone
fragment, for example, may lacerate the nerve and,following the
breach of optic nerve fibrils, Atrophy ensues. Severe intra-orbital
haemorrhage may result in a posttraumatic atrophy of the optic
nerve but it should be noted that such atrophy is a rare sequel to
orbital haemorrhage.
When osseous fracture severs the optic nerve in the optic canal,
the eye is blind but the optic disc initially maintains a good
colour for about two weeks until the Wallerian degeneration
reaches the globe and the blanching of the disc commences.
❖OPTIC NERVE

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
.Traumatic optic neuropathy
TON refers to any insult to the optic nerve secondary to trauma and occurs inbetween 2.5% of midface fractures and
10% of craniofacial fractures. Of those affected, approximately 50% have permanent vision loss.
The patient presents with a RAPD in the affected eye accompanied by varying loss of visual acuity.
Visual acuity is typically 20/400 or less in the affected.
Most commonly, the optic nerve is damaged posterior to the entry point of the central retinal vessels presenting a
normal optic disk appearance; however, if damaged anterior to this point, the disk will appear swollen with associated
retinal haemorrhages. Optic atrophy is a late sign, usually becoming evident 6 weeks after injury.
The concept of primary and secondary injury in TON has been proposed by Steinsapir and Goldberg in 2005 .TON can
be either direct or indirect. Direct TON results from anatomical disruption of the optic nerve whereas indirect TON is
caused by the transmission of forces from a distant site to the optic nerve.
Mechanisms and management of vision loss following orbital and facial trauma F.C. McClenaghana , D.G. Ezrab,c,d and S.B. Holmesa Current Opinion in
Ophthalmology 2011, 22:426–431

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
TON has a high spontaneous visual recovery rate of 40–60% when managed conservatively. Most studies of TON have shown
a significant correlation between initial and final visual acuities, patients with direct TON or no light perception at
presentation have a poorer prognosis. Lee et al. found that there was no statistically significant difference in improvement in
visual acuity between those patients treated with steroids and/or surgery and the untreated group. There is no good
evidence that either corticosteroids or surgery have any benefit in terms of long-term visual acuity and both may carry the
risk of significant morbidity. This is reflected in the finding be Lee et al. of a trend towards conservative management of TON
in the UK.
❖SCLERA
The opaque posterior % of the eyeball coat largely performs a protective role in maintaining the functional integrity of the
internal ocular contents.
Partial-thickness wounds of the sclera do not usually merit suturing but any full-thickness breach of the sclera should be
carefully repaired by an ophthalmologist—so often, perforation of the sclera involves damage to the underlying choroid and
the visually important retina. 4/0 white silk is very effective as a scleral suture material. It is only necessary to place the suture
in the external 0.5 mm of the sclera.
Mechanisms and management of vision loss following orbital and facial trauma F.C. McClenaghana , D.G. Ezrab,c,d and S.B. Holmesa Current Opinion in
Ophthalmology 2011, 22:426–431

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WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
.❖Retrobulbar hemorrhage
Retrobulbar hemorrhage (RBH) is a rapidly progressive, sight-threatening emergency that results in an accumulation of
blood in the retrobulbar space.
The blood accumulation can lead to proptosis and an increased IOP that may result in stretching of the optic nerve and
blockage of ocular perfusion leading to venous and/or arterial occlusive process.
Retrobulbar haemorrhage RBH is a rare consequence of blunt facial trauma affecting 0.3% of patients presenting with
zygomatic complex fractures . Perry et al have suggested that patients should be assessed for RBH when assessing the
pupils of any trauma patient as part of the Glasgow Coma Scale (GCS). In those with a high GCS, Popat et al have
suggested that the presence of three or more of pain, proptosis, chemosis, diplopia, subconjunctival haemorrhage,
increased intraocular pressure, tense globe, decreasing visual acuity, loss of direct pupillary light reflex and
ophthalmoplegia is a strong indication of RBH. However, in an unconscious patient when visual acuity cannot be
assessed then a tense orbit, proptosed globe and a dilated pupil may be the only diagnostic aids.
Mechanisms and management of vision loss following orbital and facial trauma F.C. McClenaghana , D.G. Ezrab,c,d and S.B. Holmesa Current Opinion in
Ophthalmology 2011, 22:426–431

34. ,,
,,
.
Erickson BP, Garcia GA. Evidence-based algorithm for the management of acute traumatic retrobulbar haemorrhage. Br J Oral Maxillofac Surg. 2020 Nov

35. ,,
,,
WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
❖Ptosis
Ptosis
or drooping of the upper eyelid may be unilateral or bilateral.
Haemorrhage or oedema of the eyelid may cause ptosis; this is
essentially a mechanical problem which, by virtue of the extra
bulk or weight of the involved eyelid, causes it to droop. With
spontaneous absorption of the oedema and haemorrhage, the
eyelid should gradually rise to its normal level without
treatment. Ptosis due to nerve paresis requires no immediate
treatment but should be left for about 6 months, as spontaneous
recovery ensues in many instances. Treatment should be
controlled by an ophthalmologist.

36. ,,
,,
WHAT ARE THE POSSIBLE OPTHALAMIC INJURIES THAT CAN OCCUR POST FACIAL TRAUMA?
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
❖LACRIMAL PASSAGES
Disorders of the lacrimal passages are not uncommon in crushing injuries. Displacements of the lower lacrimal
punctum may result from lid trauma Ophthalmic surgery to replace the punctum in good position is usually required
but it should be remembered that careful repair of the original wound should obviate the cicatricial eversion.
Avulsion of the medial palpebral (canthal) ligament gives rise to displacement of the lower lacrimal punctum. The
everted punctum may be properly replaced by suturing the lacerated ligament in the correct position as soon as is
convenient after the trauma.
Osseous fracture in the naso-maxillary region may damage the lacrimal passages. When the lacrimal sac is damaged,
the tear is usually small and the passages retain their patency.
On the other hand, a breach of the nasolacrimal duct causes an accumulation of tears in the sac which then enlarges
to form a mucocoele.

37. ,,
Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
❖DIPLOPIA
In normal fixation and projection, the fovea is the point on the retina used for fixation.
All images falling on the foveae are interpreted as being ‘straight-ahead i.e. projected
back along the visual axes.
Binocular diplopia results from a manifest ocular deviation, and is simultaneous
appreciation of two images from one object.
THE DIPLOPIA TEST
Diplopia is investigated by using a linear light and questioning the patient about the
separation of the two.
Diplopia is investigated by using a linear light and questioning the patient about the
separation of the two images in the cardinal positions of gaze. If suppression is
present, and the patient is not appreciating diplopia spontaneously ,red and green
filters are used. A white light is viewed with a red filter before one eye and a green
filter before the other eye. As the eyes are dissociated, the light falling on the fovea of
one eye and a disparate retinal point of the other eye, is projected to two points in
space and diplopia is appreciated.
The diplopia is always opposite to the position of the affected eye so that the higher
image is related to the lower eye. In the case of a right superior rectus palsy, the right
eye will be hypotropic (depressed) but the image from the right eye will be higher.

38. ,,
• Oculocardiac Refex (Trigeminocardiac Refex) First described by Dagnini and Aschner in 1908, oculocardiac refex is
bradycardia on manual compression of the eyes. The most common traumatic etiology is the incarceration of inferior
rectus muscle in trap-door fractures of the orbital floor
•Post-traumatic superior orbital fissure syndrome may be attributed to pressure exerted on the contents of the superior
orbital fissure due to hemorrhage or impingement by fractured fragments. Superior orbital fissure syndrome was first
described by Hirschfeld in 1858 and symptoms include: (i) Ophthalmoplegia due to involvement of III, IV, and VI cranial
nerves. (ii) Paresthesia over the forehead due to involvement frontal nerve of first division of trigeminal nerve. (iii) Ptosis
due to impeded action of levator palpebrae superioris and Muller’s muscle. (iv) Pupillary dilatation due to paresis of circular
sphincter muscle and unrestricted action of dilator pupillae. (v) Impairment of direct pupillary reflex due to blocked
ipsilateral efferent arc, whereas consensual reflex is preserved due to intact ipsilateral efferent and contralateral efferent
arcs
•Orbital Apex Syndrome
•In severe orbital trauma, optic nerve may also be implicated due its close proximity to the superior orbital fssure . The term
orbital apex syndrome was first coined by Kjaer in 1945 , and the symptoms include all features of superior orbital fssure
syndrome along with partial or loss of vision.

39. •There are two more widely accepted mechanisms of orbital wall fractures, namely, the: (i)
Retropulsion theory (ii) Buckling mechanism
•First proposed by King in 1944, retropulsion theory suggests that sudden increase in intra-
orbital pressure caused by direct hit from a large object creates stresses along the orbital walls
resulting in fractures at the areas of least thickness. The buckling theory or transmission
theory explains the injury through a ripple effect created in the foor. The ripple thus created
causes compression in an anteroposterior direction and resultant fracture at the
posteromedial part of the orbital floor commonly.
Biomechanics
ofInjury
•One of the first mechanisms of orbital wall fractures was suggested by Pfeiffer in
1943, called globe-to-wall theory or hydraulic theory , wherein posterior
displacement of the globe after sustaining a direct hit was propounded to transmit
force along the walls resulting in fracture of the thinner walls.

40. MANAGEMENT
,,
,,
Accepted indications for immediate surgical repair include
diplopia and unresolving oculocardiac reflex with CT
evidence of muscle/periorbita entrapment, ‘white-eyed
blow-out fractures’, a large floor defect, and significant
enophthalmos or hypoglobus causing facial asymmetry

41. MANAGEMENT
,,
,,
Bone Irradiated bone Nonmetallic, permanent
Cartilage Lyophilized dura Silastic sheets
Fascia lata Lyophilized cartilage Bioactive glass
Periosteal Fascia lata Porous polyethylene
Bovine bone Titanium
Vitalium
Resorbable materials
Polylactic/polyglycolic acid
copolymer
Autologous materials Allogenic materials Alloplastic materials
Chowdhury K, Krause GF. Selection of materials for orbital floor reconstruction.Arch Otolaryngol Head Neck Surg.1998;124:1398–401

42. MANAGEMENT
,,
,,
•A 37Y/M Patient presented to casualty with an a/h/o RTA skid and fall and
sustained injuries on face.
•On presentation the patient had periorbital edema and ecchymosis with CT
features suggestive of Left ZMC Fracture.

43. MANAGEMENT
,,
,,
1 WEEK FOLLOW UP

44. ,,
,,

45. Case
•a) Coronal CT scan: right orbital floor fracture
with severe diplopia
•.(b) Coronal CT scan: unsuccessful repair of the
orbital floor with resorbable patch.
• (c) Sagittal CT scan: unsuccessful repair of the
orbital floor with resorbable patch.
A 22-year-old male was hit by a water
barrel causing a massive injury of the
right orbit and globe. He sustained a
severe orbital floor and medial orbital
fracture. He underwent orbital floor
repair with a resorbable patch.

46. • (e) Surgical approach.
• (f) Removal of resorbable
mesh.
• (g) Insertion of titanium
mesh.
(d) 3D Navigation planning

47. (j) Eye movements to the left.
(k) Upward eye movement
(l) Eye movements to the right
(m) Downward eye movement.
(n) Trauma-induced wider right
pupil.
(o) Higher positioning of right
globe
(h) Coronal CT scan: anatomic repair of the
orbital floor with titanium mesh.
(i)Sagittal CT scan: anatomic repair of the
orbital floor with titanium mesh
.

48. CONCLUSION
,,
,,
It can be concluded that mid-facial fractures, especially the ZMC fractures, showed the majority of the
ophthalmic complications, followed by orbit, NOE, and Le Fort II and III fractures. Severe complications
leading to blindness are very less, yet can be demotivating and devastating for the patient.
So, every patient with mid-facial trauma should undergo a thorough ophthalmic evaluationandwhen in
need or suspected of major morbidity, should undergo a complete examination by an ophthalmologist for
proper timely treatment.

49. REFERENCES
,,
,,
1.Ophthalmic injuries by I. M . Duguid With a contribution by A. MacLeod ROWE & WILLIAMS VOL II
2.The Orbit, clinics of north America oral & maxillofacial surgery. Edited byStephen A. Schendel MD, DDS, FACS-Face Center Los Angeles, Pacific
Palisades, CA, USA
3.Hallinan JT, Pillay P, Koh LH, Goh KY, Yu WY. Eye Globe Abnormalities on MR and CT in Adults: An Anatomical Approach. Korean J Radiol. 2016
Sep-Oct;17
4.Erickson BP, Garcia GA. Evidence-based algorithm for the management of acute traumatic retrobulbar haemorrhage. Br J Oral Maxillofac Surg. 2020
Nov
5.Terrill SB, You H, Eiseman H, Rauser ME. Review of Ocular Injuries in Patients with Orbital Wall Fractures: A 5-Year Retrospective Analysis. Clin
Ophthalmol. 2020 Sep
6.Blindness After Facial Fractures: A 19-Year Retrospective Study Mohammad Hussein Ansari, DMD, BDSc 2005 American Association of Oral and
Maxillofacial Surgeons J Oral Maxillofac Surg 63:229-237, 2005
7.Nicholas Zachariades, Demetrius Papavassiliou, Panos Christopoulos,Blindness after facial trauma, Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontology,Volume 81, Issue 1,1996
8.Umarane S, Kale T, Tenagi A, Manavadaria Y, Motimath AS Sr. A Clinical Study of the Evaluation and Assessment of the Etiology and Patterns of
Ocular Injuries in Midfacial Trauma in a Tertiary Care Hospital. Cureus. 2020 Sep.Volume 24, Issue 4,Pages 525-720(November 2012)
9.Erickson BP, Garcia GA. Evidence-based algorithm for the management of acute traumatic retrobulbar haemorrhage. Br J Oral Maxillofac Surg. 2020
Nov
10. Chowdhury K, Krause GF. Selection of materials for orbital floor reconstruction.Arch Otolaryngol Head Neck Surg.1998;124:1398–401

50. THANK YOU