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Orbital Fractures Treatment & Management

  • Author: Neeraj N Mathur, MBBS, MS; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 23, 2016
 

Medical Therapy

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.

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Surgical Therapy

Surgical repair of orbital and maxillofacial fractures typically involves several steps, as follows:

  1. Exposure with degloving the facial skeleton
  2. Anatomic reduction
  3. Rigid fixation with replacement of lost or comminuted bone
  4. Soft-tissue resuspension
  5. Closure

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.[12]

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.[13]

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.[14]

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Preoperative Details

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.

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Intraoperative Details

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)
  • Alloplastic materials
    • Nonabsorbable titanium,[17] silicon, porous polyethylene, and Teflon
    • Absorbable - Polydioxanone, polylactide, and polyglactin
  • Allogenic dura

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.

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Postoperative Details

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.

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Follow-up

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.

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Complications

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
  • Orbital hemorrhage

Postoperative complications include, but are not limited to, the following:

  • Blindness
  • Persistent diplopia
  • 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
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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.[18] 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.

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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.

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Contributor Information and Disclosures
Author

Neeraj N Mathur, MBBS, MS Director-Professor, Department of ENT and Head Neck Surgery, Vardhman Mahavir Medical College and Associated Safdarjang Hospital; Professor, Delhi University and Indraprastha University, India

Neeraj N Mathur, MBBS, MS is a member of the following medical societies: Royal Society of Medicine, Indian Medical Association, Association of Otolaryngologists of India, Cochlear Implant Group of India, National Academy of Medical Sciences (India), Neuro-Otological and Equilibriometric Society of India

Disclosure: Nothing to disclose.

Coauthor(s)

Bhupendra Patel, MD, FRCS Professor of Ophthalmic Plastic and Facial Cosmetic Surgery, Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah School of Medicine

Bhupendra Patel, MD, FRCS is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Simon F Taylor, MBBS FRANZCO, FRACS, Clinical Senior Lecturer, Oculoplastic Surgery, Save Sight Institute, University of Sydney, Australia

Simon F Taylor, MBBS is a member of the following medical societies: Australian Medical Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Erik Kass, MD Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern Virginia

Erik Kass, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Association for Cancer Research, American Rhinologic Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

M Abraham Kuriakose, MD, DDS, FRCS Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences

M Abraham Kuriakose, MD, DDS, FRCS is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, British Association of Oral and Maxillofacial Surgeons, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

References
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  15. 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].

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  17. 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].

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Minimally displaced orbital floor fracture.
Left orbital floor fracture. This patient presented with little motility disturbance; however, because of the large defect in the orbital floor, late enophthalmos was predicted. Surgical repair was undertaken. Note the pneumo-orbitum.
Medial-wall fracture with significant herniation of the orbital contents into the ethmoid sinus. Horizontal diplopia was evident.
Orbital floor fracture with significant soft-tissue entrapment, a so-called trapdoor fracture. Note the relatively small amount of herniated tissue and the air-fluid level in the maxillary sinus. This patient had a significant vertical ocular motility disturbance.
This lateral-wall fracture is part of a zygomaticomaxillary complex fracture that was classified as a tripod fracture.
 
 
 
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