Orbital Wall Fracture Repair: The Results of Early and Delayed Surgery

Kyu Hwan Jang; Nam Ju Kim; Ho Kyung Choung; Sang In Khwarg

doi:10.3341/jkos.2016.57.2.181

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Jang, Kim, Choung, and Khwarg: Orbital Wall Fracture Repair: The Results of Early and Delayed Surgery

Original Article

J Korean Ophthalmol Soc 2016;57(2):181-187.

Published online: 7 September 2016

DOI: https://doi.org/10.3341/jkos.2016.57.2.181

Orbital Wall Fracture Repair: The Results of Early and Delayed Surgery

Kyu Hwan Jang, MD¹, Nam Ju Kim, MD^2,³, Ho Kyung Choung, MD^2,⁴, Sang In Khwarg, MD^1,²

¹Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea

²Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea

³Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam, Korea

⁴Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea

Address reprint requests to Sang In Khwarg, MD Department of Ophthalmology, Seoul National University Hospital, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-2879, Fax: 82-2-741-3187 E-mail: khwarg@snu.ac.kr

Received 24 September 2015 Revised 14 October 2015 Accepted 21 December 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the surgical results of early and delayed repair of orbital wall fracture after multiple subgrouping of patients by time between the operation and injury.

Methods

Eighty-eight eyes of 88 patients who underwent orbital wall fracture repair from January 2002 to December 2014 and who were followed up for more than 3 months postoperatively were included in this study. We divided the 88 patients into three groups: Early surgery group (surgery within 2 weeks after the injury), slightly delayed surgery group (surgery between 3 weeks and 2 months after the injury), delayed surgery group (surgery after 2 months of the injury). Preoperative and postoperative ocular motility, diplopia, and the degree of enophthalmos were analyzed retrospectively.

Results

The early surgery group consisted of 30 eyes; slightly delayed surgery group, 42 eyes; and delayed surgery group, 16 eyes. The mean duration between injury and surgery was 8.6 ± 22.5 weeks in all patients, 1.5 ± 0.5 weeks in the early surgery group, 3.5 ± 1.3 weeks in the slightly delayed surgery group, and 35.3 ± 44.7 weeks in the delayed surgery group. All patients were followed up for a mean of 12.9 ± 10.8 weeks. Gaze limitation in all directions showed improvement in all groups, with the most shown in up gaze limitation. There were no significant differences in the degree of improvement between preoperative and postoperative gaze limitation among the three groups. Enophthalmos improved as well, without any significant differences among the three groups.

Conclusions

Improvement in ocular motility limitation and enophthalmos after orbital wall fracture repair did not vary significantly according to the duration between the surgery and injury. Therefore, surgical repairment even for old orbital fractures may successfully treat enophthalmos or diplopia and relieve symptoms.

Keywords: Delayed surgery, Early surgery, Multiple subgrouping, Orbital wall fracture repair

REFERENCES

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Table 1.

Clinical characteristics of the orbital wall fracture patients

	Early surgery group^*	Slightly delayed surgery group^†	Delayed surgery y group^‡	Total
Number of patients	30	42	16	88
Age (years)	23.9 ± 7.7	29.0 ± 11.6	30.8 ± 11.8	27.5 ± 11.0
Male/female	21/9	36/6	5/11	62/26
Etiologies of orbital fractures
Violence	13 (43.3%)	17 (40.5%)	6 (37.5%)	36 (40.9%)
Sports injury	10 (33.3%)	9 (21.4%)	3 (18.7%)	22 (25.0%)
Slip down	5 (16.7%)	9 (21.4%)	5 (31.3%)	19 (21.6%)
Traffic accident	0 (0%)	3 (7.2%)	2 (12.5%)	5 (5.7%)
Others	2 (6.7%)	4 (9.5%)	0 (0%)	6 (6.8%)
Location of fracture
Inferior orbital wall	22 (73.3%)	21 (50.0%)	5 (31.2%)	48 (54.5%)
Medial orbital wall	4 (13.3%)	4 (9.5%)	3 (18.8%)	11 (12.5%)
Inferior and medial orbital wall	4 (13.3%)	17 (40.5%)	8 (50.0%)	29 (33.0%)
Surgical indications
Diplopia	6 (20%)	11 (26.2%)	1 (6.3%)	18 (20.5%)
Enophthalmos	12 (40%)	13 (31.0%)	8 (50.0%)	33 (37.5%)
Diplopia and enophthalmos	12 (40%)	18 (42.8%)	7 (43.7%)	37 (42.0%)
Period between trauma and surgery (weeks)	1.5 ± 0.5	3.5 ± 1.3	35.3 ± 44.7	8.6 ± 22.5

Values are presented as mean ± SD unless otherwise indicated. There is no statistically significant difference between the 3 groups with respect to age, sex, etiologies of fracture, location of fracture, or surgical indication (p > 0.05, Kruskal-Wallis test).

^* Early surgery group: the group of patients who underwent surgery within 2 weeks after injury;

^† Slightly delayed surgery group: the group of patients who underwent surgery between 3 weeks and 2 months after injury;

^‡ Delayed surgery group: the group of patients who underwent surgery after 2 months from injury.

Table 2.

Comparison of postoperative improvement of duction limitation of extraocular muscles between three groups in all orbital wall fractures

Limited duction in all fracture		Early surgery group					Slightly delayed surgery group					Delayed surgery group
		(N = 30)					(N = 42)					(N = 16)
		Grade of duction limitation					Grade of duction limitation					Grade of duction limitation
		0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Elevation	Preop	8	10	5	4	3	11	19	9	3	0	4	6	5	0	1
	Postop	13	14	3	0	0	24	18	0	0	0	7	7	1	1	0
Depression	Preop	18	7	4	1	0	24	11	5	2	0	13	2	0	1	0
	Postop	28	2	0	0	0	35	6	1	0	0	15	1	0	0	0
Abduction	Preop	26	2	2	0	0	36	4	1	1	0	14	0	2	0	0
	Postop	29	1	0	0	0	42	0	0	0	0	15	0	1	0	0
Adduction	Preop	29	1	0	0	0	39	3	0	0	0	15	1	0	0	0
	Postop	29	1	0	0	0	41	1	0	0	0	16	0	0	0	0

Grade of duction limitation: 0, Full motility without restriction; -1, mild restriction of motility (about 30-35° movement); -2, moderate restriction (about 20-25° movement); -3, severe restriction (about 10-15° movement); -4, Complete restriction, no movement. The preoperative grades of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test). The postoperative grades of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test).

Preop = preoperative; Postop = postoperative.

Table 3.

Comparison of postoperative improvement of duction limitation of extraocular muscles between three groups in inferior orbital wall fracture

Limited duction in inferior orbital wall fracture		Early surgery group					Slightly delayed surgery group					Delayed surgery group
		(N = 22)					(N = 21)					(N = 5)
		Grade of duction limitation					Grade of duction limitation					Grade of duction limitation
		0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Elevation	Preop	2	9	4	4	3	2	13	5	1	0	1	2	2	0	0
	Postop	10	10	2	0	0	12	9	0	0	0	2	3	0	0	0
Depression	Preop	10	8	3	1	0	9	7	4	1	0	5	0	0	0	0
	Postop	21	1	0	0	0	17	4	0	0	0	5	0	0	0	0
Abduction	Preop	20	1	1	0	0	19	1	1	0	0	5	0	0	0	0
	Postop	22	0	0	0	0	21	0	0	0	0	5	0	0	0	0
Adduction	Preop	22	0	0	0	0	18	3	0	0	0	5	0	0	0	0
	Postop	22	0	0	0	0	20	1	0	0	0	5	0	0	0	0

Preop = preoperative; Postop = postoperative.

Table 4.

Comparison of postoperative improvement of duction limitation of extraocular muscles between three groups in medial orbital wall fracture

Limited duction in medial orbital wall fracture		Early surgery group					Slightly delayed surgery group					Delayed surgery group
		(N = 4)					(N = 4)					(N = 3)
		Grade of duction limitation					Grade of duction limitation					Grade of duction limitation
		0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Elevation	Preop	3	0	1	0	0	3	0	1	0	0	3	0	0	0	0
	Postop	4	0	0	0	0	3	1	0	0	0	3	0	0	0	0
Depression	Preop	4	0	0	0	0	3	0	1	0	0	3	0	0	0	0
	Postop	4	0	0	0	0	4	0	0	0	0	3	0	0	0	0
Abduction	Preop	2	1	1	0	0	1	2	0	1	0	3	0	0	0	0
	Postop	2	2	0	0	0	4	0	0	0	0	3	0	0	0	0
Adduction	Preop	3	1	0	0	0	3	1	0	0	0	3	0	0	0	0
	Postop	3	1	0	0	0	4	0	0	0	0	3	0	0	0	0

Grade of duction limitation: 0, Full motility without restriction; -1, mild restriction of motility (about 30-35° movement); -2, moderate restriction (about 20-25° movement); -3, severe restriction (about 10-15° movement); -4, Complete restriction, no movement. The pre-operative grades of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test). The postoperative grades of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test).

Preop = preoperative; Postop = postoperative.

Table 5.

Comparison of postoperative improvement of duction limitation of extraocular muscles between three groups in the combined inferior and medial orbital wall fracture

Limited duction in combined inferior and medial orbital inferior and wall fracture		Early surgery group (N = 4)					Slightly delayed surgery group (N = 17)					Delayed surgery group (N = 8)
		Grade of duction limitation					Grade of duction limitation					Grade of duction limitation
		0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Elevation	Preop	0	2	2	0	0	4	8	3	2	0	0	4	3	0	1
	Postop	0	4	0	0	0	9	8	0	0	0	2	4	1	1	0
Depression	Preop	2	0	2	0	0	12	4	0	1	0	5	2	0	1	0
	Postop	3	1	0	0	0	13	3	1	0	0	7	1	0	0	0
Abduction	Preop	4	0	0	0	0	17	0	0	0	0	6	0	2	0	0
	Postop	4	0	0	0	0	17	0	0	0	0	7	0	1	0	0
Adduction	Preop	4	0	0	0	0	17	0	0	0	0	7	1	0	0	0
	Postop	4	0	0	0	0	17	0	0	0	0	8	0	0	0	0

Grade of duction limitation: 0, Full motility without restriction; -1, mild restriction of motility (about 30-35° movement); -2, moderate restriction (about 20-25° movement); -3, severe restriction (about 10-15° movement); -4, Complete restriction, no movement. The pre-operative grades of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test). The postoperative grades of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test).

Preop = preoperative; Postop = postoperative.

Table 6.

Comparison of postoperative grade changes of the duction limitations of the extraocular muscles which were present pre-operatively between three groups in all orbital wall fractures

Limited duction in all fracture	Early surgery group (N = 30)					Slightly delayed surgery group (N = 42)					Delayed surgery group (N = 16)
	Postoperative changes of grade of duction limitation					Postoperative changes of grade of duction limitation					Postoperative changes of grade of duction limitation
	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Elevation	7	9	7	1	1	10	16	6	2	0	5	6	1	0	0
Depression	0	10	3	1	0	6	8	3	1	0	0	2	1	0	0
Abduction	0	1	0	0	0	1	3	0	0	0	0	1	0	0	0
Adduction	0	3	1	0	0	0	4	1	1	0	0	0	1	0	0

The postoperative grade changes of limitation of all ductions (elevation, depression, abduction, and adduction) were not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test).

Table 7.

Comparison of improvement of enophthalmos between the three groups

Enophthalmos (mm)	Early surgery group (N = 30)		Slightly delayed surgery group (N = 42)		Delayed surgery group (N = 16)
Enophthalmos (mm)	Preop	Postop	Preop	Postop	Preop	Postop
<-1	0	3	0	1	0	0
-1	3	1	2	4	1	2
−0.5	1	7	2	4	0	0
0	11	11	7	10	1	9
+0.5	3	4	4	9	0	3
+1	6	2	6	8	3	1
+1.5	1	0	5	0	0	0
+2	4	1	5	6	3	1
>+2	1	1	11	0	8	0
Average (mm)	0.5	−0.1	1.3	0.4	2.0	0.2
Total (n)	30	30	42	42	16	16

The preoperative enophthalmos was significantly different between the 3 groups (p < 0.05, Kruskal-Wallis test). The postoperative enophthalmos was not significantly different between the 3 groups (p > 0.05, Kruskal-Wallis test).

Preop = preoperative; Postop = postoperative.

Table 8.

Postoperative complication of three groups

Postoperative complication	Early surgery group	Slightly delayed surgery group	Delayed surgery group
Postoperative complication	(N = 30)	(N = 42)	(N = 16)
Cheek numbness	2 (6.6%)	2 (4.8%)	0
Epiphora	1 (3.3%)	0	0
EOM pain	1 (3.3%)	0	0
Corneal erosion	0	1 (2.3%)	0

Values are presented as n (%) unless otherwise indicated.

EOM = extraocular muscle.

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