Plastic Surgery Research Council

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Fracture Patterns Predictive Of Traumatic Optic Neuropathy
Adekunle Elegbede, MD, PhD1, Camille Bulte, BS2, Macey Yates, BS2, Sashank Reddy, MD, PhD1, Ryan Dunlow, BS2, LediBabari Ngaage, BS3, Yvonne Rasko, MD3, Fan Liang, MD4, Arthur Nam4, Paul Manson, MD1, Michael Grant4.
1Johns Hopkins Hospital, Baltimore, MD, USA, 2University of Maryland School of Medicine, Baltimore, MD, USA, 3University of Maryland Medical Center, Baltimore, MD, USA, 4R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.

PURPOSE: Traumatic optic neuropathy (TON) is a rare but devastating complication of craniofacial trauma. Approximately half of those affected develop permanent vision loss. Here we identify the most common fracture patterns associated with TON to alert treating surgeons to this fraught complication.
METHODS: We performed a retrospective review of all patients presenting with orbital fractures to R Adams Cowley Shock Trauma Center from 2015 to 2017. Patients with fractures secondary to penetrating trauma were excluded. Craniomaxillofacial CT Scans were reviewed to identify fracture patterns. Visual status was abstracted from formal ophthalmologic examination at the time of presentation. Multivariable regression was performed to identify patterns predictive of TON.
RESULTS: Six hundred patients met inclusion criteria. Thirty-seven of the 600 patients (6.2 %) were diagnosed with TON. Fracture patterns most predictive of TON were: (1) sphenotemporal buttress fractures (OR= 5.8, p< 0.05) (2) naso-orbito-ethmoid (NOE) fractures (OR= 5.5, p < 0.05), (3) Lefort III fractures (OR 3.8, p< 0.05), and (4) zygomaticomaxillary complex fractures (OR= 2.8, p< 0.05). Pure (rim-sparing) orbital fractures were less frequently associated with TON (OR= 0.5, p<0.05) than rim-involving orbital fractures. The majority (63%) of patients who developed TON from pure orbital (rim-sparing) fractures had two wall fractures involving the floor and medial orbital wall.
CONCLUSIONS: Patients who sustain sphenotemporal buttress, NOE or Lefort III fractures are at highest risk for traumatic optic neuropathy. Surgeons treating these injuries should have heightened awareness of TON and seek ophthalmologic guidance accordingly to afford the greatest chance of visual preservation.


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