Orbital Floor Fractures (Blowout) Treatment & Management

Medical treatment is warranted for patients for whom surgery is not indicated. This may include patients who present without significant enophthalmos (2 mm or more), a lack of marked hypo-ophthalmus, absence of an entrapped muscle or tissue, a fracture less than 50% of the floor, or a lack of diplopia.

The patient can be treated with oral antibiotics on an empiric basis due to the disruption of the integrity of the orbit in communication with the maxillary sinus.

A short course of oral prednisone reduces edema of the orbit and muscle, allowing for a better assessment of enophthalmos or entrapment.

Discourage nose blowing to avoid creating or worsening orbital emphysema. Nasal decongestants can be used if not contraindicated.

The orbital floor can be accessed through a conjunctival approach, through cutaneous exposure, or through a transmaxillary approach. Access to this region allows for exploration and release of displaced or entrapped soft tissue, thereby correcting any extraocular motility disturbances. In addition, repair of the bony defect with removal or repositioning of bony fragments allows for restoration of the partition between the orbit and maxillary antrum, thereby preserving orbital volume and geometry and eliminating impingement of soft tissue structures.

Transconjunctival approach

The transconjunctival approach can be combined with a lateral canthotomy for exposure of the orbital floor (see image below).

Initiate this approach with a curvilinear incision approximately 3 mm below the tarsal plate parallel to lower lid punctum.

Carry this surgical plane forward in a fashion posterior to the orbicularis oculi muscle and anterior to lower lid retractors and orbital septum. If placed too low, orbital fat prolapse likely compromises visibility of the fracture; if placed too high, postoperative architectural distortion may ensue.

Moving in a vector anterior to the septum, approach the orbital rim and overshoot it for several millimeters. Incise the periosteum at the medial aspect of the anterior border of the inferior orbital rim and carry it laterally.

Then elevate the periosteum with a hand-over-hand technique using sharp periosteal elevators, starting nasally and moving temporally until adequate exposure is obtained.

Preserve an anterior flap to be sutured at the conclusion of the procedure and remain cognizant of the location of the infraorbital groove and foramen that encase the infraorbital neurovascular bundle.

The advantages of this approach include the absence of visible scars and reduced risk of lower eyelid retraction.

Cutaneous approach

The cutaneous approach commences with a skin-muscle flap elevation via an incision 2-3 mm below the lower lid margin. Carry this dissection anterior to the orbital septum until the orbital rim is exposed.

Incise the periosteum and release it from its bony attachments as described in the transconjunctival approach. Of note is the downward sloping of the floor immediately posterior to the rim, which can result in breach of the septum during periosteal dissection.

Transantral approach

A transantral approach allows access to the orbital floor via the maxillary sinus. This approach may be especially useful when repairing a floor fracture of the trap door variety.

Achieve exposure of the incision site with upper labial retraction exposing the buccal-gingival sulcus.

Create a horizontal incision just inferior to the buccal-gingival sulcus so that a wide mucosal band is present. This wide band allows for imbrication of the wound, avoiding oral-antral fistulization.

Use a periosteal elevator to strip the anterior maxillary wall of periosteum. The proximity of the infraorbital foramen should be kept in mind to minimize the risk of insult to the neurovascular bundle.

Create a Caldwell-Luc antrostomy with an osteotome and mallet, followed by rongeurs to increase the diameter of the antrostomy, providing access to the orbital floor, medial wall, and ethmoid sinus complex.

Strip the mucosa from the maxillary antrum and cauterize the remnants.

Following repair of the fracture, attention to hemostasis is followed by closing the buccal-gingival mucosa with fast-absorbing suture material.

This approach results in inferior orbital floor exposure and is not favored for floor fracture repair.

Some authors have advocated an endoscopic transantral approach for improved visualization of fractures and to eliminate the need for eyelid incisions.^[8]

Other approaches

Tessier described vertical osteotomies of an intact orbital rim for exposure of the orbital floors. This myringotomy is essentially 2 vertical osteotomies on either side of the infraorbital foramen conjoined by a horizontal osteotomy. Two osteotomies of the orbital floor originating at the inferior rim and extending past the infraorbital groove origins are created, allowing for removal of this segment, which can be replaced at the conclusion of surgery.

Endoscopic-assisted approaches via a transmaxillary and transnasal route have been described.^{[9, 10, 11, 12]}

Implants

Several types of implants are available for reconstructive use. The ideal implant should be easy to insert and manipulate, inert, not prone to infection or extrusion, easily anchored to surrounding structures, and reasonably priced. It should not rouse fibrous tissue formation. Most orbital floor defects can be repaired with synthetic implants composed of porous polyethylene, silicone, metallic rigid miniplates, Vicryl mesh, resorbable materials, or metallic mesh. Autogenous bone from the maxillary wall or the calvaria can be used, as can nasal septum or conchal cartilage. Each material has advantages and disadvantages that are not within the realm of this article. The surgeon should have a certain comfort level and familiarity with his or her choice of material.

Review and carefully document the patient's complete medical status and pertinent signs and symptoms pertaining to the injury.

The procedure and the risks, benefits, and alternatives should be explained clearly and documented. The patient should be aware of the possibility of persistent, worsening, or new-onset diplopia, hypesthesia, and enophthalmos and of the risk of visual loss secondary to the procedure. Assess the patient's expectations to avoid a successful surgical outcome coupled with a poor outcome perceived by the patient.

Clearly document visual acuity, degree of enophthalmos, pupillary and extraocular muscle function, and the amount of diplopia in all fields of gaze.

Meticulous review of imaging is essential for planning the surgical approach and identifying surrounding structures that may serve as anchoring sites for an implant.

Secure the appropriate implant several days prior to surgery.

During the repair, periodically assess pupillary function. Assessing the pupil size prior to general anesthesia, after general anesthesia is induced, and after any periorbital injections containing epinephrine (prior to manipulating the globe) is worthwhile. Narcotics can cause pupillary constriction (miosis), and epinephrine can cause pupillary dilation (mydriasis). If not assessed before orbital content manipulation, the cause of a dilated pupil can be obscured when the pupil is checked.

Perform a thorough exploration of fracture for bony fragments and occult fractures involving the medial wall. Inspection of soft tissue for necrosis is also necessary once freed from the fracture. Forced duction tests may be performed to confirm that tissues have been released completely.

Following floor restoration, assess the fit and stability of the implant. Take special care to be sure the implant is not protruding, which can result in an aesthetically poor result, patient discomfort, and soft tissue breakdown, which can invite infection. If a titanium implant is used and anchored to the orbital, the implant may be covered with AlloDerm to reduce visibility.

As for any surgical procedure, the surgeon should be made aware of the patient's overall status as monitored by the anesthesiologist. If extraocular muscle manipulation is forthcoming inform the anesthesia staff, so that bradycardia secondary to the oculocardiac reflex can be identified and communicated. The bradycardia should abate with release of the extraocular muscles.

Elevate the patient's head to 30°.

Gently place gauze soaked in iced saline over the closed eyelids.

Assess visual acuity and pupillary function every 15 minutes for the first hour and every 30 minutes until discharge. Nose blowing, strenuous activity, and straining should be avoided in the immediate postoperative period.

Instruct the patient to use cool compresses for 48 hours, to finish all prescribed oral antibiotics, and to use analgesics sparingly. Postoperative oral steroids may help reduce swelling.

Any change in visual acuity or increase in pain should prompt the patient to contact the surgeon immediately.

Follow-up examinations should assess and document visual acuity, pupillary and extraocular muscle function, neuralgia, and the amount of enophthalmos and diplopia.

As with any surgical procedure, bleeding, infection, and the need for additional surgery are risks. The possible loss of vision is the most ominous complication associated with floor repair.

Residual or new-onset diplopia, neuralgia, and extraocular muscle dysfunction are potential complications. The patient should understand these risks completely, and no promises are to be made concerning resolution of any presurgical neuralgia.

Implant extrusion and residual enophthalmos are postoperative sequelae requiring additional surgery.

Although the surgery may be a complete success in the eyes of the surgeon, the patient may view the outcome as unsatisfactory. To minimize this, the surgeon and patient should be in mutual agreement regarding the realistic outcome of the repair.

Successful repair of orbital blowout fractures may be complicated by persistent problems. Neuralgia in the distribution of the infraorbital nerve may worsen after surgery. Improvement of this problem, if any, may take 6 months or more.

More troubling is persistent diplopia. If isolated to extreme positions of gaze, it may go unnoticed or may not be bothersome to the patient. However, if the diplopia affects functional positions of gaze, corrective prisms can be tried. Ultimately, eye muscle surgery may be required to address this problem with repositioning of the extraocular muscles to allow for orthophoric fixation of images.

Enophthalmos can worsen over time. Despite adequately repairing the fracture, atrophy of the orbital fat can occur, resulting in further enophthalmos.

The timing and indications for reconstruction of orbital floor fractures remain controversial.

Early repair (within the first 2 wk) often is indicated when criteria discussed within this article are met. However, these are at best broad guidelines and not absolute criteria for management.

Patients who demonstrate significant improvement without signs of entrapment can be treated conservatively. Delayed repair is also an option in select patients. Even after the fracture is repaired, further surgery may be needed for persistent diplopia.