Outcomes and Impacts of Blow-out Fractures of The Orbit Faaiz Y. Alhamdani A thesis submitted for the degree of Doctor of Philosophy at Newcastle University Supervisors Dr. Ian Corbett Prof. Mark Greenwood Dr. Nick Strong Dr. Justin Durham Prof. Jimmy Steele Outcomes and Impacts of Blow-out Fractures of The Orbit Acknowledgment I cannot thank enough Dr. Ian Corbett for his continuous support. I have been privileged by the way he helped me to handle the research question in the best possible way along the study journey. I am deeply grateful to his kind guidance. I would like to express my deep gratitude to Dr. Justin Durham, who provided me with the best of his knowledge and experience in the field of quality life and qualitative research. He was keen to guide me through every step in these fields of research to ensure the highest possible standards. I would like to thank Professor Mark Greenwood for being there whenever I wanted his support, guidance and invaluable feedback. I would like, also, to express my highest regards to Dr. Nick Strong and Professor Jimmy Steele for their support, and useful comments on this work. I would like to express my gratitude to Kat Taylor who gave me from her time and effort to have the knowledge about the necessary orthoptic tests. My thanks to all the staff in Oral and Maxillofacial department; the consultants, the senior house officers, the receptionists and nursing staff who kept me informed about all new patients and updated me with their treatment courses. I would like to thank all the patients who participated in this study and provided me with their insight and experience, and I wish them the best in their future life. I would like to express my deep gratitude to my family, friends and colleagues who supported me from the beginning of this journey in Baghdad and along the way through in Newcastle. I will be always thankful for their unlimited support and prayers. Finally, I would like to thank my beloved wife Areej for her dedication, commitment, all the support and help I wished for. I hope that she benefited from this long journey as much I hope for myself. i Outcomes and Impacts of Blow-out Fractures of The Orbit Abstract A blow-out fracture of the orbit is defined as one with orbital wall and or floor fracture without orbital rim involvement. The management of this injury and its timing continue to be a matter of some debate. One of the main reasons for this debate is the lack of unifying objective, quantitative, clinical measures of diplopia severity that encompass both the clinical and patient perspectives. This thesis consists of two distinct studies: one study examines the factors associated with outcome of blow-out fractures, whilst the other examines the patient perspective and experience of this type of fracture. The aim of this thesis is to study the impacts and determine the factors that influence management outcomes with regard to diplopia. A combination of retrospective data and qualitative data was used to help achieve this aim. The retrospective study demonstrated binocular single vision assessment to be a valuable tool in assessing management outcome. In addition, the data demonstrate it has a significant prognostic value in blow-out fractures of the orbit: lower pre-operative diplopia scores, the more chance of improvement in diplopia scores after surgery. Lower pre-operative diplopia scores were associated with a longer follow up time and a greater number of follow up visits required. Demographic factors, surgical timing, type of surgical approach and surgical implant material were shown to have no significant influence on diplopia. Orbital fat herniation in the absence of orbital muscle involvement, as determined by CT scan interpretation, appears to have no significant influence on diplopia when compared to fractures where no tissue herniation was observed on diplopia scores in blow-out fractures. The impact of blow-out fractures from the patient’s perspective was reflected through distress and frustration which negatively influence patients’ daily activities, including their employment. This distress and frustration was reported to centre around the individual’s fear of losing their vision. This misconception appears to be due to potentially ineffective patient- clinician communication. ii Outcomes and Impacts of Blow-out Fractures of The Orbit Table of Contents Acknowledgment ........................................................................................................................ i Abstract ...................................................................................................................................... ii Table of Contents ..................................................................................................................... iii List of Figures ........................................................................................................................... ix List of Tables ............................................................................................................................ xi Introduction .............................................................................................................................. 12 Chapter 1 Surgical anatomy of the orbit ............................................................................. 14 1.1 The bony orbit ........................................................................................................... 15 1.2 Soft tissues of the orbit .............................................................................................. 16 1.2.1 Muscles of the orbit: .......................................................................................... 18 1.2.2 Nerves of the orbit ............................................................................................. 19 1.2.3 Vessels of the orbit............................................................................................. 20 1.2.4 The globe of the eye ........................................................................................... 20 Position of the globe ..................................................................................................... 21 Ocular movements ........................................................................................................ 21 Chapter 2 Literature Review............................................................................................... 22 2.1. Mechanism of blow-out fractures ................................................................................. 23 2.2. Classification of blow-out fractures: ............................................................................. 29 2.2.1. Medial wall blow-out fracture: .............................................................................. 30 2.3. Incidence of blow-out fractures .................................................................................... 31 2.4. Diagnosis and clinical findings of blow-out fracture .................................................... 33 iii Outcomes and Impacts of Blow-out Fractures of The Orbit 2.4.1. Binocular diplopia .................................................................................................. 35 2.4.2. Enophthalmos ........................................................................................................ 38 2.4.3. Subconjunctival haemorrhage and circumorbital ecchymosis: .............................. 43 2.4.4. Infraorbital paraesthesia: ........................................................................................ 44 2.4.5. Periorbital emphysema: ......................................................................................... 44 2.4.6. Ophthalmic injuries associated with blow-out fractures (intraocular injuries): ..... 44 2.5. Radiographic examination ............................................................................................ 47 2.5.1. Plain radiography: .................................................................................................. 47 2.5.2. Computed tomography (CT scan) .......................................................................... 48 2.6. Investigations for ocular motility disturbances ............................................................. 51 2.6.1. Clinical investigations (forced duction and forced generation test) ...................... 51 2.6.2. Quantitative assessment of diplopia: ..................................................................... 52 2.6.3. Assessment of ocular motility defects ................................................................... 54 2.7. Management of blow-out fractures ............................................................................... 55 2.7.1. General considerations ........................................................................................... 55 2.7.2. Conservative management ..................................................................................... 57 2.7.3. Surgical management ............................................................................................. 59 Orbital Surgical approach ............................................................................................. 65 Materials used for reconstruction of the orbital floor ................................................... 72 2.7.4. Late management ................................................................................................... 77 2.8. Postoperative diplopia ..................................................................................................