Orbital Fractures Treatment & Management
- Author: Neeraj N Mathur, MBBS, MS; Chief Editor: Arlen D Meyers, MD, MBA more...
See the list below:
Patients should avoid blowing their nose and performing Valsalva maneuvers to limit intraorbital emphysema.
Visual loss with acute orbital emphysema has been reported.
Oral antibiotic therapy may be considered. Fractures that involve the medial wall and floor may be considered open fractures, as laceration of the sinus mucosa is inevitable.
Analgesia and antiemetics may be required.
The use of oral steroids (prednisone 1 mg/kg/d) has been advocated to decrease soft-tissue edema.
The management of traumatic hyphema responds well to outpatient care and topical aminocaproic acid.
Surgical repair of orbital and maxillofacial fractures typically involves several steps, as follows:
- Exposure with degloving the facial skeleton
- Anatomic reduction
- Rigid fixation with replacement of lost or comminuted bone
- Soft-tissue resuspension
Surgical management of orbital floor and medial-wall fractures is described below.
Management of other associated injuries to globe are described in other Medscape Reference articles; however, management of traumatic cataracts has been enhanced with new iris-fixated lens implants.
A retrospective study by Scawn et al indicated that surgery for orbital blow-out fractures can be successful even when performed more than 6 weeks after injury in late-presenting patients. The study involved 20 patients, including 10 with isolated floor fractures and 10 with combined floor and medial wall fractures, with surgery performed a mean 19 months after injury. Successful resolution or reduction of enophthalmos, hypoglobus, and diplopia was reported.
However, a literature review by Damgaard et al indicated that in patients with isolated blow-out fractures, the chance of persistent postoperative diplopia is greater (odds ratio = 3.3) when surgery takes place more than 14 days after the trauma.
Orbital fracture repair generally requires general anesthesia, and the patient requires a general medical assessment with this in mind. Diagnostic imaging studies should be made available in the operating room for intraoperative guidance.
Prior to exposure of any fractures, perform forced duction testing to confirm extraocular muscle restriction and to obtain preoperative results for comparison with those obtained later in the procedure. The success of blow-out fracture repair depends on adequate exposure, visualization of posterior bony shelf, and anatomic repair of the entire defect.
A fracture of the orbital floor may be repaired through transcutaneous, transconjunctival, or endoscopic (transmaxillary or transnasal) approaches.[15, 16]
Transcutaneous techniques may involve an approach through the subciliary area, lower eyelid crease, or orbital rim. Transconjunctival approaches may be subtarsal, preseptal, or inferior fornical. The medial orbital wall may be approached via a Lynch incision or a transcaruncular approach.
With all approaches, dissection is carried down to the periosteum of the orbital rim, which may be incised and reflected. Once the orbital rim is exposed, a subperiosteal dissection completely exposes the limits of the fracture. Herniated and entrapped orbital soft tissue is reduced. Once the orbital soft tissues are repositioned, an orbital implant is placed to completely cover the orbital bony defect, preventing malpositioning of the soft tissue and restoring the native bony orbital anatomic volume. A forced duction test is performed at this point to confirm adequate relief of entrapment. Excessive pressure or traction is avoided on the globe and optic nerve during retraction.
Careful dissection is required in the posterior orbit to prevent orbital apex injury. Important anatomic landmarks include the posterior wall of the maxillary sinus and the posterior ethmoidal vessels. Closure of periosteum may help prevent implant migration. Conjunctiva or skin may be closed with a 6-0 absorbable suture.
The transmaxillary endoscopic approach offers excellent visualization of the entire orbital floor and is safe and efficacious and eliminates any postoperative eyelid complications. Trapdoor and medial blow-out fractures are the best candidates for an endoscopic approach. Dissection necessary for larger defects that extend lateral to the infraorbital nerve may place the infraorbital nerve at a greater risk for postoperative paresthesias. Complex 2-wall fractures cannot be managed endoscopically. The surgeon must discuss with the patient the possibility of using a transconjunctival/subciliary incision if the endoscopic approach fails.
In the transmaxillary endoscopic approach, a sublabial incision is made over the canine fossa to expose the maxillary face in the subperiosteal plane; a maxillary osteotomy is performed and enlarged to approximately 1 X 2 cm about 1-2 mm below the infraorbital foramen and 1-2 mm lateral to the nasomaxillary buttress, thus avoiding injury to nerve, nasal aperture, and dental roots. An endoscope notch is then created at the central portion of the antrostomy; this helps in giving tactile feedback while the eyes of the surgeon are on the monitor.
In trapdoor fractures (the most common type of orbital blow-out fracture), a stable hinge that consists of greenstick fracture and the sinus mucoperiosteum is usually present. Implant placement is usually not required, and a 1- to 1.5-mm malleable retractor passed through the maxillary sinus antrostomy can reduce the orbital contents.
In medial blow-out fractures, a circumferential dissection is first made and, after the margins are defined, a 3- to 5-mm dissection is made on the orbital side of the defect. This releases more periorbita into the sinus and increases the prolapse of the orbital contents into maxillary sinus but is essential for placement of the implant.
Endoscopic endonasal reduction of a blow-out fracture is possible using endonasal sinus surgery. This depends on the endoscopic view of orbital floor via middle meatus; in a few patients, a supplemental septoplasty and submucous conchotomy of inferior turbinate may be required to obtain such a view.
The following implants have been used to reconstruct the orbital wall:
Autogenous materials (eg, bone [cortical and cancellous], cartilage, fascia)
- Nonabsorbable titanium, silicon, porous polyethylene, and Teflon
- Absorbable - Polydioxanone, polylactide, and polyglactin
All implants have advantages and disadvantages, and the choice of implant is usually determined by the preference of the institution, surgeon, and patient. Autogenous bone grafts are the criterion standard to provide framework for facial skeleton and orbital walls. Cancellous bone grafts are preferred over cortical because cancellous bone grafts revascularize rapidly and completely, have an initial appositional bone formation followed by resorption (the opposite of a cortical bone graft), and repair completely, whereas the cortical graft remains an admixture of necrotic and viable bone.
Repair of a complex orbital fracture, such as orbital rim, zygomaticomaxillary (ZMC), and naso-orbito-ethmoid (NOE) fractures, requires additional incisions for adequate exposure (eg, coronal, brow, upper eyelid crease, lateral canthus, transoral). Periosteal elevation and adequate exposure of the fracture is required to ensure anatomic alignment. The skeleton is rigidly fixated with miniplate and microplate systems. Soft-tissue resuspension at the time of primary reconstructive surgery may prevent early and late soft-tissue deformity.
Posttraumatic enophthalmos is a relatively common problem following orbitozygomatic fractures. Bony-volume expansion and soft-tissue atrophy are considered the main etiological causes of this condition. Making fine adjustments to soft-tissue volume and orbital size during the same actual surgery is extremely difficult, if not impossible, which constitutes the biggest challenge in the treatment of enophthalmos. A novel protocol of one-stage treatment for correction of disfiguring enophthalmos has been described by Lee (2008), in which (in addition to the standard fracture-reduction methods) the author uses an autologous, 3.0-5.5 mL diced-cartilage graft to augment the orbital-tissue volume.
Applying an eye patch after orbital surgery to protect the cornea and to reduce conjunctival edema in the postoperative period is common practice. However, signs that indicate orbital hemorrhage or optic nerve compression (eg, visual loss, proptosis, chemosis, ocular motility disturbance, pupil abnormalities) progress unnoticed under an eye patch. The authors' policy is never to apply an eye patch after orbital surgery. The orbital surgeon should be familiar with the short-term management of an evolving orbital compartment syndrome. Recording the patient's visual acuity when the patient has regained consciousness is prudent.
Nursing the patient in a head-up position and applying cool compresses may be useful to reduce postoperative edema. Analgesia and antiemetics are frequently required after orbital surgery.
The nursing staff, the patient, and the family must be informed of the symptoms and signs of vision-threatening elevated orbital pressure. Emergency management of increased intraorbital pressure may prevent the loss of vision. The patient should promptly report symptoms of decreasing vision, increasing pain, and increasing nausea and vomiting and signs of increasing proptosis, eyelid ecchymosis, and decreasing motility.
Diplopia secondary to neurapraxia and extraocular muscle contusion should be monitored for at least 6 months. This diplopia should be stable prior to surgical intervention.
Complications may result from the initial trauma or from the surgical repair. Complications due to the latter may be intraoperative or postoperative, and postoperative complications may be early or late.
Intraoperative complications include, but are not limited to, the following:
Globe and optic nerve injury caused by direct trauma, excessive retraction, or vascular compromise (eg, central retinal artery occlusion)
Injury to the infraorbital nerve
Inadequate reduction of prolapsed tissue
Postoperative complications include, but are not limited to, the following:
Globe malpositioning, particularly enophthalmos or hypoglobus
Infection that presents as orbital cellulitis
Infraorbital nerve dysfunction in an orbital floor repair
Lid malpositioning, especially lower-lid retraction or entropion
Implant infection, migration, or extrusion
Epistaxis or cerebrospinal fluid (CSF) leakage in medial wall repairs
Sinus disease, especially sinusitis
Outcome and Prognosis
The management of orbital fractures has been a source of controversy over the last century, particularly regarding indications for surgery and the optimal timing of surgery. More recently, high-resolution CT scanning has enabled assessment of the relationships between the bony orbital and orbital soft tissues. This imaging technique has also been a significant factor in determining which patients may benefit from surgery. The combination of the clinical examination and CT scanning facilitates surgical evaluation.
The decision for early surgery should be balanced against possible perioperative complications, including blindness. The decision against early intervention should be balanced against the difficulties encountered when late reconstructive surgery for diplopia or enophthalmos is required. Although 14 days after trauma is commonly cited as a timeline target for orbital blow-out repair, Dal Canto and Linberg (2008) believe that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia who are at low risk for enophthalmos can be observed for 3-4 weeks prior to surgery. This may help prevent unnecessary surgery in some cases.
The risk of loss of vision with orbital exploration has been reported as 1 event in 500 cases. Despite surgery, 5-30% of patients have residual diplopia and may require other forms of strabismus management. This percentage is higher with combined medial-wall and floor fractures.
Remember that endophthalmitis after ocular trauma carries a significantly worse prognosis, which may be reduced by early referral and intervention.
Future and Controversies
Internal fixation devices and techniques have evolved rapidly over the past decades and will continue to do so. Bioabsorbable polymers (eg, polyglycolic acid and polydioxanone) have been used in plates and screws, with the advantage of their absorption after the fracture has healed. Minimally invasive endoscopic techniques have found applications in the treatment of blow-out fractures.
The management of orbital fractures and their complications have benefited from a multidisciplinary approach. The continued relationship between facial plastic surgeons, maxillofacial surgeons, plastic surgeons, craniofacial surgeons, ophthalmic surgeons, and others will contribute to the progression of orbital reconstruction techniques.
Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. 2008 Feb. 26(1):97-123, vi-vii. [Medline].
Kim SM, Jeong YS, Lee IJ, Park MC, Park DH. Prediction of the development of late enophthalmos in pure blowout fractures: delayed orbital tissue atrophy plays a major role. Eur J Ophthalmol. 2016 May 13. [Medline].
de Man K, Wijngaarde R, Hes J, de Jong PT. Influence of age on the management of blow-out fractures of the orbital floor. Int J Oral Maxillofac Surg. 1991 Dec. 20(6):330-6. [Medline].
Jordan DR, Allen LH, White J, Harvey J, Pashby R, Esmaeli B. Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998 Nov. 14(6):379-90. [Medline].
Büttner M, Schlittler FL, Michel C, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg. 2014 Jul. 52(6):518-22. [Medline].
Kim YS, Kim JH, Hwang K. The Frequency of Decreased Visual Acuity in Orbital Fractures. J Craniofac Surg. 2015 Jul. 26 (5):1581-3. [Medline].
Boffano P, Roccia F, Gallesio C, et al. Diplopia and orbital wall fractures. J Craniofac Surg. 2014 Mar. 25(2):e183-5. [Medline].
Ilankovan V, Hadley D, Moos K, el Attar A. A comparison of imaging techniques with surgical experience in orbital injuries. A prospective study. J Craniomaxillofac Surg. 1991 Nov. 19(8):348-52. [Medline].
Lane K, Penne RB, Bilyk JR. Evaluation and management of pediatric orbital fractures in a primary care setting. Orbit. 2007 Sep. 26(3):183-91. [Medline].
Vicinanzo MG, McGwin G Jr, Allamneni C, Long JA. Interreader Variability of Computed Tomography for Orbital Floor Fracture. JAMA Ophthalmol. 2015 Oct 8. 1-4. [Medline].
Kubal WS. Imaging of orbital trauma. Radiographics. 2008 Oct. 28(6):1729-39. [Medline].
Salvin JH. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007 Sep. 18(5):366-72. [Medline].
Scawn RL, Lim LH, Whipple KM, et al. Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury. Ophthal Plast Reconstr Surg. 2015 Aug 13. [Medline].
Damgaard OE, Larsen CG, Felding UA, Toft PB, von Buchwald C. Surgical Timing of the Orbital "Blowout" Fracture: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2016 May 10. [Medline].
Yan Z, Zhou Z, Song X. Nasal Endoscopy-Assisted Reconstruction of Orbital Floor Blowout Fractures Using Temporal Fascia Grafting. J Oral Maxillofac Surg. 2012 Feb 25. [Medline].
Shi W, Jia R, Li Z, He D, Fan X. Combination of transorbital and endoscopic transnasal approaches to repair orbital medial wall and floor fractures. J Craniofac Surg. 2012 Jan. 23(1):71-4. [Medline].
Lieger O, Schaller B, Kellner F, Messmer-Schai B, Iizuka T. Low-profile titanium mesh in the use of orbital reconstruction: A pilot study. Laryngoscope. 2012 Feb 28. [Medline].
Dal Canto AJ, Linberg JV. Comparison of orbital fracture repair performed within 14 days versus 15 to 29 days after trauma. Ophthal Plast Reconstr Surg. 2008 Nov-Dec. 24(6):437-43. [Medline].
Burm JS. Internal fixation in trapdoor-type orbital blowout fracture. Plast Reconstr Surg. 2005 Sep 15. 116(4):962-70. [Medline].
Chang EW, Manolidis S. Orbital floor fracture management. Facial Plast Surg. 2005 Aug. 21(3):207-13. [Medline].
Hinohira Y, Yumoto E, Shimamura I. Endoscopic endonasal reduction of blowout fractures of the orbital floor. Otolaryngol Head Neck Surg. 2005 Nov. 133(5):741-7. [Medline].
Kontio R. Treatment of orbital fractures: the case for reconstruction with autogenous bone. J Oral Maxillofac Surg. 2004 Jul. 62(7):863-8. [Medline].
Lee JW. Treatment of enophthalmos using corrective osteotomy with concomitant cartilage-graft implantation. J Plast Reconstr Aesthet Surg. 2008 Nov 25. [Medline].
Strong EB. Endoscopic repair of orbital blow-out fractures. Facial Plast Surg. 2004 Aug. 20(3):223-30. [Medline].