Ocular Injuries in Patients of Zygomatico-Complex (ZMC) Fractures

Abstract

Purpose

Mid face injuries commonly destroy the integrity of the orbital skeleton, and are frequently complicated by injury to the eye, ranging between 2.7 and 90.6 % as reported in literature. The eye injuries range from simple subconjunctival haemorrhage to globe rupture. The paper aims to study the types of ocular injuries in patients with ZMC fractures.

Patients and Methods

A study of 67 patients, who had sustained facial trauma sufficient to lead to a facial bone fracture, was undertaken in the department of Oral and Maxillofacial Surgery, Govt Dental College, Srinagar from 2008 to 2014 and the patients received a comprehensive examination by an ophthalmologist within 1 week of injury. All the patients sustaining confirmed ZMC fracture were examined by an ophthalmologist for any associated ocular injury. A thorough ophthalmologic examination included assessment of visual acuity, pupillary reactivity, anterior and posterior segment examination and extraocular motility. The variables reviewed included patient’s gender, mechanism of injury, visual acuity, pupillary reactivity, extra ocular motility, presence or absence of diplopia, ocular and orbital findings, and intraorbital hypoesthesia.

Results

The most common etiology of trauma was RTA (64.1 %), followed by falls (14.9 %) in our study. In our study 83.5 % of the patients were males. Minor ocular injuries such as subconjunctival haemorrhage and corneal injury accounted for most of the cases. Subconjunctival haemorrhage was the most common injury, present in 86.5 % of the cases. Hyphema was present 13.4 %, vitreous haemorrhage 2.98 %, retinal haemorrhage 1.49 %, corneal abrasion 4.47 %, mydriasis 1.49 %, choroidal rupture 5.97 %, retinal detachment 2.98 %, decreased visual activity 13.4 %, retinal tear and angle recession was present 7.46 % times.

Conclusion

ZMC fractures are associated with higher incidence of ocular injuries. The incidence of traumatic optic neuropathy and other ocular injuries warrants a prompt ophthalmologic examination of all patients with ZMC fractures as quickly as possible to prevent morbidity.

Introduction

Zygomatico complex (ZMC) fractures are one of the commonest fractures of face after nasal fractures [1, 2]. The prominent convex shape of the zygoma makes it vulnerable to traumatic injury. Even minimally displaced zygomatic-complex fractures can result in functional and aesthetic deformities. The frequency of injury to eye ranges from 2.7 to 96 % as these injuries destroy the orbital skeleton [2, 3]. Jelks described a 14–40 % incidence of major intraocular injury in patients with zygomatic fractures involving the orbital floor [4]. The bony architecture of this bone is rather unique, which enables it to withstand blows with significant impact without being fractured. At the most it gets disarticulated along its suture lines. The factors protecting the globe include the prominence of the orbital bones themselves, as well as natural reflexes such as blinking and head aversion [5]. Fractures of the ZMC may occur alone known as isolated ZMC (iZMC) fracture or in association with the fractures of other bones of the craniofacial complex [6]. Ocular injuries often accompany the facial trauma. Injuries to and around the eye vary in severity. All traumas to the face, particularly above the level of the mouth, require a careful ocular examination, including an estimation of the visual acuity of each eye. Some ophthalmic injuries may be clearly apparent. However, other potentially blinding complications can easily be missed unless they are actively sought. Inadequate care can result in blindness, with its attendant social and medicolegal implications [7]. Ocular complications like diplopia, enophthalmos, hyphema, vitreous hemorrhage, retinal hemorrhage, choroid rupture, traumatic mydriasis, commotio retinae may also occur in patients with ZMC fractures, so the optimum ophthalmic evaluation of the patients who sustained ZMC fractures is mandatory [8]. Blindness is an uncommon complication of facial trauma with a reported incidence of 2–5 % [9, 10]. Though there are many studies in literature which have discussed the ophthalmic injuries in relation to facial fractures but there is very less literature correlating ZMC fractures and ophthalmic injuries. The aim of this study is to study ophthalmic injuries in relation to ZMC fractures.

Materials and Methods

A prospective study was carried out in the department of Oral and Maxillofacial Surgery, Govt Dental College, Srinagar from March 2008 to August 2014. Patients with facial injuries were studied but only patients with isolated ZMC fractures were included in the study. An informed consent for the same was obtained. A total of 67 patients were diagnosed with isolated ZMC fracture after clinical and radiological examination. The patients were sent for an opthalmological examination to assess ocular injuries. The patients were screened for diplopia, enophthalmos, hyphema, vitreous hemorrhage, retinal hemorrhage, traumatic mydriasis, retinal detachment, corneal abrasion, choroidal rupture, decrease visual acuity, retinal tear, angle recession, canthal laceration, corneal laceration and commotio retinae. The data was entered into a master chart and SPSS software was used for analysis of data.

Results

In this study only ZMC fractures were studied and out of 67 subjects studied 56 (83 %) were males and 11 (16.41 %) were females (Table 1). In this study about 64.17 % of patients had ZMC fracture due to road traffic accident, 14.9 % had ZMC fracture due to falls, about 19.4 % fractures were due to interpersonnel fights and only 1 patient had suffered firearm injury (Table 2). Table 3 shows that the commonest ocular injury was subconjunctival haemorrhage 86.6 % (Fig. 1) followed by corneal injury in 32.83 % and diplopia in 20.89 % of patients. The frequency of other injury in this study was hyphema 13.4 %, vitreous haemorrhage 2.98 %, retinal haemorrhage 1.49 %, corneal abrasion 4.47 %, mydriasis 1.49 %, choroidal rupture 5.97 %, retinal detachment 2.98 % (Figs. 2, 3), decreased visual activity 13.4 %, and retinal tear and angle recession 7.46 % each. The frequency of cantheal laceration, commotio retinae and enophthalmos was (4.47 %). There was no evidence of optic nerve injury in our study.

Table 1.

Gender distribution of subjects

Total no patients	67
Males	56 = 83.5 %
Females	11 = 16.4 %

Table 2.

Etiological distribution of patients

Etiology	%Age (n = 67)
Road traffic accidents	64.17 % (n = 43)
Falls	14.92 % (n = 10)
Interpersonal fights	19.40 % (n = 13)
Firearm injuries	1.49 % (n = 1)
Occupational	(N = 0)

Table 3.

Ocular injuries in the studied subjects

Type of ocular injury	Number	%Age
Subconjunctival haemorrhage	58	86.56
Hyphema	9	13.4
Diplopia	14	20.89
Corneal injury	22	32.83
Vitreous haemorrhage	2	2.98
Retinal haemorrhage	1	1.49
Corneal abrasion	3	4.47
Mydiarasis	1	1.49
Choroidal rupture	4	5.97
Retinal detachment	2	2.98
Decreased visual activity	9	13.4
Retinal tear	5	7.46
Angle recession	5	7.46
Canthal laceration	3	4.47
Commotio retinae	3	4.47
Enophthalmos	3	4.47
Optic nerve injury	0	–

Fig. 1.

Subconjunctival haemorrhage in a patient of ZMC fracture

Fig. 2.

Canthal ligament detachment

Fig. 3.

ZMC fracture on a coronal CT

Discussion

The zygomatic complex gives the cheek prominence, and it is the second most common mid-facial bone that is fractured (Fig. 3) after the nasal bone and overall it represents 13 % of craniofacial fractures [11]. The globe and adnexal structures are frequently injured during blunt facial trauma. Ophthalmic opinion is mandatory in most of the zygomatic complex fractures. As mentioned by Grey et al. [12] delayed retro-bulbar haemorrhage and transient blindness can be the result of fracture. The higher frequency of ZMC fractures in our study in males (83.5 %) is consistent with the other studies, the reasons being cultural and socioeconomic characteristic where males participate more in outdoor activities compared to females [11].

Our study showed greater frequency of ZMC fractures due to road traffic accidents (64.17 %) which is true of developing countries and is consistent with the other studies which show higher frequency of these fractures due to road traffic accidents [13–15].

Facial fractures have been reported to increase the risk of developing an ocular injury by a factor of 6.7 when compared with major trauma in patients with no facial fractures [16]. The ocular complication due to facial fractures has been investigated by many authors [16–18]. The reported incidence of ocular injuries in facial fractures ranges from 2.7 to 90.6 % [2, 3, 19, 20]. In our study subconjunctival injury was present in 86.56 % of patients which is consistent with other studies which have reported about a frequency of 60–74 % cases [3, 5]. Our study notices corneal injury in 32 % of cases and diplopia in 20.89 % of cases; similar findings were noticed in the study of Al-Qurainy et al. [2] and Jamal et al. [21] who reported an incidence of 16 % symptomatic diplopia and found 66.6 % had minor ocular injuries such as subconjunctival hemorrhage, iris sphincter tear, and corneal abrasion; 10 % had major injuries like ruptured globe and retinal haemorrhage. Our study observed a frequency of impaired visual acuity of 13.4 % and similar finding of 15.4 % was reported in the study of Al-Qurainy et al. [2]. Amrith et al. [3] reported 12.4 % of patients with decreased visual acuity. About 13.4 % patients in our study had hyphema which is due to tearing of blood vessels at the base of iris. Enophthalmos was present in 4.47 % of patients which is in conformity with the study of Amrith et al. [3] and Al-Qurainy et al. [2]. In our study vitreous haemorrhage was present in 2.98 %, retinal haemorrhage in 1.49 %, corneal abrasion in 4.49 %, mydiarasis in 1.49 %, choroidal rupture in 5.97 %, retinal detachment in 2.98 %, retinal tear in 7.46 %, angle recession in 7.46 % and canthal laceration in 4.47 % of cases (Fig. 4). Similar findings were reported by Nabeela et al. [22] in their study. Commotio retinae was found in 4.47 % of patients in our study and similar findings were reported by Jayamanne and Gillie [23] who reported about 6.7 % of frequency whereas Brown et al. [24] found the frequency of commotio retinae to be about 13.7 % in their study. The ocular complications except traumatic optic neuropathy are thought to be associated with direct injury to globe during trauma so negating the concept that the magnitude of forces in the hydraulic and globe-to-wall theories would also be damaging to the ocular globe. Al-Qurainy et al. [2], Ansari [25], Wood [26] reported that ZMC fractures are associated with higher ocular complications of about 41 % compared to other fractures, whereas Dilip et al. [27] reported an incidence of 61 % of ocular injuries in ZMC fractures.

Fig. 4.

Patient with canthal injury and hypoglobus

Conclusion

Ocular complications are very common in ZMC fractures. It is suggested that all traumas to the face, particularly above the level of the mouth, require a careful eye examination, including an estimation of the visual acuity of each type. Considerable care should be taken to ensure that all patients who may have sustained eye injuries in association with ZMC fractures are managed appropriately to prevent any blinding complications. This study highlights the importance of evaluating the ocular complications which can be then managed appropriately by the concerned specialist and recommends that ophthalmologic examination is mandatory in patients who have sustained ZMC fractures and it would be wise to educate the general public about the impact of maxillofacial trauma and how some accidents can be prevented.

Compliance with Ethical Standards

Conflict of interest

None.

Ethical Standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional/departmental research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

A proper informed consent was obtained from the patients on an approved consent form.