Apex Orbital Fracture Treatment & Management

Updated: May 20, 2016
  • Author: Bhupendra C K Patel, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

The management of orbital apex fractures is determined by the patient's specific functional deficits and overall status. Associated neurosurgical emergencies take precedence. Associated craniofacial skeletal and ocular injuries may require treatment. The initial radiographic trauma series may not fully elucidate the details of apex fractures, and dedicated fine-cut CT scans or an MRI may be required.

In cases where vision is decreased and optic nerve injury is suspected, consideration must be given to medical and/or surgical nerve decompression. Indirect traumatic optic neuropathy is considered the result of forces transmitted to the orbital apex and optic canal at the time of injury. Axon shearing occurring at the time of injury, contusion of the intracanalicular optic nerve axons, ischemia and microinfarction of axons due to damage to pial microvasculature, direct bony impingement with a canal fracture, and continued edema and hemorrhage within the closed space of the optic canal all have been proposed to play a role in the pathophysiology of traumatic optic neuropathy. Theoretically, reduction in optic nerve compression and edema may salvage those axons with reversible damage. However, treatment remains controversial. Currently, 3 treatment options exist, as follows: observation alone, high-dose corticosteroids, and surgical optic canal decompression. [19]

Numerous case reports and case series have described the use of steroids and optic nerve decompression surgery and the outcomes in traumatic optic neuropathy. [20]

The International Optic Nerve Trauma Study attempted to compare the visual outcome of traumatic optic neuropathy treated with corticosteroids, optic canal decompression surgery, or observation. [21] The presence of an orbital apex fracture was not discussed, although patients with orbital penetrating injuries were excluded. It was a comparative nonrandomized interventional study with concurrent treatment groups; 127 patients with unilateral optic nerve were included. Results showed that visual acuity increased by 3 or more lines in 32% of the surgery group (n = 33), 52% of the corticosteroid group (n = 85), and 57% of the untreated group. After adjustment for baseline visual acuity, there was no significant difference between any of the groups. No clear benefit was found for either steroid therapy or optic canal decompression surgery.

The management of oculomotility disturbance generally falls under the care of a strabismus specialist. In many cases of a traumatic SOF syndrome, significant recovery of extraocular muscle occurs. [11] If strabismus surgery is contemplated, a period of more than 6 months is allowed to achieve maximal spontaneous recovery.

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Surgical Care

Several methods are available for surgical decompression of the optic canal. These include a medial approach via an external ethmoidectomy; an inferomedial approach via a transantral, transethmoidal approach; a sublabial transsphenoidal approach; a supraorbital-subfrontal approach; and endoscopic transethmoidal approach. [22] The details of these surgical approaches are beyond the scope of this article.

Minimally invasive transcaruncular optic canal decompression was found to be successful in one case of traumatic optic neuropathy; however, visualization using this approach may be limited, and an adequate decompression is more difficult working down a long narrow optical cavity. [23]

Surgical decompression may have an increased role in the management of an optic neuropathy associated with optic nerve impingement from a penetrating foreign body or displaced bony fragment, and also in the presence of a MRI-confirmed subdural sheath hematoma, where an optic nerve sheath fenestration has been advocated. However, there is no definitive proof that moving bony fragments in the optic canal improves the chance of visual recovery. Indeed, it has been argued that further trauma, which is inherent in a surgical approach to the optic canal, may further risk visual integrity.

Orbital apex fractures may involve the posterior portion of the medial orbital wall, near the apex. In such cases, repair using a superomedial orbital approach or a transcaruncular approach may be successful . [24]

Nasal endoscopic approaches to traumatic orbital apex syndrome are still the most popular when decompression of the superior and medial walls of the orbital apex and optic canal are necessary. [25]

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Consultations

A multidisciplinary approach to the orbital apex injury may be warranted.

Review by the neurosurgical service is indicated to assess associated intracranial injury.

Review by an ophthalmology service is indicated to help follow indices of vision (visual acuity, color vision, visual fields), follow any globe injury, and aid in long-term management of strabismus.

Radiology should be consulted to help interpret the radiographic findings in the context of the clinical presentation. The possibility of associated carotid artery injury may require interventional radiologic review and angiographic procedures.

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