Long-term Vision Outcomes after Pediatric Orbital Fractures
Christopher D. Lopez1, Pooja Yesantherao2, Joseph Lopez3, Paul N Manson1, Richard J Redett1, Robin Yang1
1Johns Hopkins School of Medicine, Baltimore, MD, 2Stanford University School of Medicine, Palo Alto, CA, 3Yale School of Medicine, New Haven, CT
Background: Orbital fractures in pediatric patients are morbid due to bony elasticity of the pediatric craniofacial skeleton increasing risk of soft tissue incarceration. Furthermore, young children cannot accurately describe their visual symptoms, making diagnosis and correction of defects challenging. Prior investigations have identified predictors of adverse outcomes in adults, but longitudinal vision outcomes in pediatric patients with orbital fractures have not been well-characterized.
Methods: This was a 30-year (1990-2020) retrospective, longitudinal cohort study of pediatric patients who presented to a single institution with orbital fractures. Patient data were abstracted from medical and imaging records. Patients without adequate clinical data regarding fracture/treatment outcomes and at least 1 year of follow-up data were excluded. Fracture severity was determined using clinical reports and imaging data. Demographic variables, injury characteristics and treatment variables were analyzed using multivariable regression to identify predictors of outcomes/complications. Statistical analyses were conducted using Stata MP v.13 (StataCorp, College Station, Texas). The threshold for statistical significance was set at an alpha value of 0.05.
Results: 168 had sufficient clinical data available for study inclusion. Median follow-up time was 2.1 years (interquartile range: 1.4-3.3 years). 48% had orbital floor fractures, 5% had orbital roof fractures, 20% had medial wall fractures, and the remainder had more than one type of orbital fracture type. Approximately 10% of patients had ocular muscle incarceration on presentation. At the time of presentation, 44% of patients had reports of limited ocular motility, while 41% reported diplopia. Across the study population, 38% of fractures were operatively managed, while the remainder were managed conservatively with serial outpatient follow-up. At 12-month follow-up, 92% of patients presenting with visual complications (diplopia, limited ocular motility) had recovered, while 8% continued to experience visual symptoms. Upon multivariable logistic regression adjusting for patient age and injury/treatment characteristics, fracture severity significantly predicted presence of visual complications (adjusted odds ratio: 1.4, 95% confidence interval 1.1-1.8, p=0.03). Additionally, presence of incarcerated ocular muscles was significantly associated with continued symptoms of diplopia upon one-year follow up (chi square: p=0.02).
Conclusions: Risk factors for adverse visual outcomes include fracture severity and ocular muscle incarceration. In fact, incarcerated ocular muscles at fracture presentation was associated with delayed resolution of visual complications. Thus, when managing children with these challenging injury types, it is important to identify patients with these risk factors and to ensure they receive regular follow-up/visual evaluations.
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