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Facial Fractures with Concomitant Globe Rupture: Injury Mechanisms and Fracture Patterns Associated with Blindness
Gerhard S. Mundinger, M.D1, Elbert Vaca, B.S.2, Joseph A. Kelamis, M.D.1, Amir H. Dorafshar, M.B.ChB1, Branko Bojovic, M.D.1, Michael R. Christy, M.D.1, Paul N. Manson, M.D.3, Eduardo D. Rodriguez, M.D., D.D.S.1.
1Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA, 2Johns Hopkins University School of Medicine, Baltimore, MD, USA, 3Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital,, Baltimore, MD, USA.
Purpose: Treatment of facial fractures in the setting of open-globe injuries poses a particular reconstructive challenge. At the expense of aesthetic outcomes, reconstructive procedures are often delayed in the hopes of visual recovery, yet many patients do not show signs of visual improvement following open-globe injuries. A predictive algorithm for anticipated visual recovery following open-globe injuries could therefore minimize unnecessary delay in reconstruction and improve aesthetic outcomes.
Methods: Electronic medical records contained in the University of Maryland Shock Trauma Registry were reviewed to identify patients who had sustained facial fractures with concomitant open globe injuries from January 1998 - August 2010.Fracture patterns were confirmed by author review of patient radiographic studies. Charts were reviewed to record patient demographics, injury type (i.e. blunt vs. penetrating), and mechanisms of injury. To assess for ultimate visual outcome, admission ophthalmology reports, including zone of rupture, discharge summaries, and follow-up visit records were reviewed. Rupture zones were defined as follows: full-thickness injury of the cornea and/or limbus (zone 1); full-thickness injury of the anterior 5mm of the sclera (zone 2); full-thickness scleral injury greater than 5mm posterior to the limbus (zone 3). Patients were segregated into 2 groups (blind vs. non-blind), and statistical comparisons were made between these groups.
Results: A total of 99 patients were identified with 105 open-globe injuries. Globe rupture spanning all 3 eye zones was significantly associated with blindness (odds ratio [OR] 9.15; 95% confidence interval [CI] 1.17 - 71.7), while globe rupture limited to eye zone 1 or zone 1+2 was associated with visual acuity of light perception or better at follow-up (OR 22.9; CI 2.58 - 203 and OR 9.56; CI 1.70 - 53.6, respectively). The average number of facial fractures among the blind and non-blind groups was 5.42 (+/-5.16) and 3.05 (+/- 2.80), respectively (p= 0.007). Among the non-blind group, there were 20 patients with a total of 20 open-globe injuries, with blunt trauma accounting for the majority of ruptures (18/20, or 90%). Among the blind group, there were 79 patients with a total of 83 open globe injuries, with blunt trauma accounting for a smaller proportion of injuries (39/79, or 49%). Penetrating trauma was significantly associated with increased likelihood of blindness (OR 4.81; CI 1.07-21.6). Fracture of the maxillary sinus was most significantly associated with blindness (OR 9.11; CI 1.18 - 70.6), and remained significant in the blunt trauma sub-population (OR 8.23; CI 1.01 - 67.1). Any fracture to the contralateral orbit or contralateral maxillary sinus was also associated with ipsilateral blindness (OR 4.65; CI 1.31 - 16.5).
Conclusions: Blindness following globe rupture was associated with penetrating facial trauma, maxillary sinus fracture, contralateral orbital fractures, and globe rupture spanning all three eye zones. Better prediction of poor visual outcomes in the setting of open-globe injuries with concomitant facial fractures will permit earlier interventions allowing for improved reconstructive outcomes.
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