Effect of Timing of Surgery in Patients Undergoing Correction for Post-Traumatic Diplopia

Background and objective: Major clinical outcomes related to orbital fractures are impaired vision, compromised ocular motility and diplopia, cosmetic disturbances like enophthalmos& hypoglobus and infraorbital paresthesia. Clinical decision making in patients with orbital fracture is always challenging and it has been debated for many decades. Specific guidelines for the interval between trauma and surgery has not been established and is controversial. Early recognition and treatment has been considered optimal for orbital reconstruction in patients with clinical and radiological features of fracture. Laceration and traumatic contusion of extra-ocular muscles and associated post traumatic oedema lead to limited or restricted ocular motility. In 1970s it was believed that these contusion and oedema will subside within 2 weeks and conservative approach of treatment was practiced. Moreover risk of late surgery related orbital fibrosis will result in unfavourableoutcome of treatment. Sometimes conditions may not be conducive for early treatment like medical status, socio-economic standards, available operating room time, legal matters, insurance related matters etc which may influence clinicians in decision making for surgery. Advancements in diagnosis with CT scan made accurate assessement of the extent of fractures possible and to assess presence or absence of herniated tissue. This lead to CT based treatment protocols in 1980s and 1990s. After this period focus of the debate has shifted towards surgery for those patients who may benefit from early intervention. Objective: To assess the effect of timing of surgery ( within 1 week and after 1 week) on correction of post-traumatic diplopia as measured by HESS chart. . Methods: Patients undergoing correction for post traumatic diplopia are included in our study. Patients are divided into two groups, early and late. Early group patients going correction of post traumatic diplopia within 1st week of trauma and late group are those patients going correction after 1st week of trauma. Diplopia is evaluated by diplopia charting and muscle overaction& underaction evaluated by HESS chart method. Results and discussion: Out of 37 patients surgically treated 14 patients out of 16 patients in early group have complete resolution of diplopia and one patient had palsy of orbital muscles and one patient did not recover. In late group out of 21 patients 16 patients had compelte resolution of diplopia and 4 patients did not show complete recovery and one patients had mild improvement in diplopia without complete recovery. On the basis of available data the present study suggest that surgical intervention in early group patients have more postoperative improvement in diplopia and enophthalmos compared to late group, but still it is insufficient to support guidelines of early surgical intervention in cases were late treatment is advisable due to slow resolving diplopia, traumatic brain injury or other morbidities that lead to late report to health setup. Conclusion: In comparison with diplopia improvement post operatively early group patients have more number of patients of complete recovery after surgical correction than late group and also its same for enophthalmos. But still there is insufficient data due to limited time bound study and require more research and studies in this subject.