Orbital Floor Fractures (Blowout Fractures) Treatment & Management

When orbital edema is severe, steroids may be used to decrease orbital edema. However, most cases do not require any medical intervention. In addition, most cases are managed on an outpatient basis. ^{[8, 5]} Elderly patients may require antibiotics given preoperatively and continued for 2 weeks postoperatively. Patients should be advised to avoid nose blowing for several weeks after the injury to prevent orbital emphysema and possible visual compromise.

The criteria for surgical intervention in blowout fractures are controversial; however, 3 general guidelines exist for surgical intervention. ^[9]

• Diplopia due to limitation of upgaze and/or downgaze with a positive forced duction test and radiologic confirmation of an orbital floor fracture is an indication of entrapment of the inferior rectus or the perimuscular tissues surrounding the inferior rectus. If diplopia is still present 10-14 days after trauma, a need for release and repair is indicated. Diplopia may be present initially after trauma but may resolve as the neuropraxia and/or orbital edema subsides.

  • A subclass of orbital fracture with entrapment is the so-called white-eye fracture in children. ^[10]

  • Several studies have shown that children may be more prone to pure trap door fractures than adults and incarceration of the muscle in such fractures can lead to permanent damage of the neuromuscular complex. ^[11]

  • Several studies have demonstrated more complete resolution of diplopia if these cases are operated on very early or as soon as the diagnosis is made. Careful examination of the CT scan is essential since there is often no loss of the floor and a lack of blood in the maxillary sinus.

• Enophthalmos of greater than 2 mm 10-14 days after trauma is cosmetically significant and is an indication for surgery. Orbital edema that is present initially may mask any enophthalmos. Therefore, measurements must be rechecked once the orbital edema has subsided. This usually occurs 10 days to 2 weeks after injury.

• A fracture involving one third or more of the orbital floor usually leads to a cosmetic and/or functional deformity. If left unattended, these fractures tend to result in significant enophthalmos.

When surgery is indicated, it is usually best performed as close to 2 weeks from the trauma date as possible. This allows the swelling to subside and a more accurate examination of the orbit to be performed. Additionally, the scarring usually has not advanced enough to prohibit adequate surgical correction.

Access to the orbital floor usually is made through an inferior fornix approach. This allows the surgeon to avoid a cutaneous incision and scar. Alternatively, a lower eyelid subciliary incision can be used but will result in a cutaneous scar. Both approaches allow easy elevation of the periorbita along the floor and release of entrapped orbital contents. An implant (eg, MEDPOR, calvarial bone, Supramid, silicone) is placed over the fracture site. The surgeon must ensure that adequate ledges of stable bone are present for the implant to sit on. Then, the periorbita is closed over the implant along the orbital rim. If the orbital rim is involved and unstable, microplates may be screwed directly into the floating bone segment to anchor it to stable bone.

• Multiple implant options are available for the repair of orbital floor fractures. Some surgeons harvest split-thickness calvarium for an implant, although this significantly lengthens the surgical time and increases the potential complications.

• Allograft materials, such as Supramid or silicone sheets, have been commonly used and are easy to work with. However, these implants can migrate or form capsules and may need to be removed later.

• More recently, many surgeons are using porous polyethylene (MEDPOR) because of its ease of use (moldable and easily shaped) and its ability to become incorporated in the soft tissue. Its porosity, like other integrated implants such as hydroxyapatite, allows this material to remain firmly fixated in the position that the surgeon places it. ^[12]

Physical activity is limited for about 3-6 weeks after surgery to prevent re-injury. This may involve restricting gym class for students. Any contact sports should be avoided for this period.

Nose blowing should also be avoided for about 4-6 weeks to prevent orbital emphysema.

Surgical complications may include loss of vision, traumatic optic neuropathy, diplopia, overcorrection or undercorrection of enophthalmos, lower eyelid retraction, bleeding, infection, extrusion of the implant, infraorbital nerve damage with resultant hypoesthesia, orbital congestion, and epiphora.

Most complications are the result of either malpositioning the implant or using the wrong size implant.

Occasionally, trauma to the inferior rectus occurs during the attempt to release it from the fracture site. Palsy may result. This usually resolves spontaneously but may take as many as 3 months to resolve.

The use safety glasses in all contact sports may prevent many eye injuries. The lenses should be made of polycarbonate, and the frames should be larger than the orbital entrance.

The surgeon should evaluate the patient's vision in the recovery room postoperatively as soon as the patient is alert enough to cooperate.

The vision after surgery should be essentially the same as preoperative vision, and no afferent pupil should be present (assuming no afferent pupil was present preoperatively).

The surgeon should inspect for signs of excessive retrobulbar hemorrhage, such as proptosis or increased intraocular pressure.

Patients should be seen the next day in the office and evaluated for vision, pupils, motility, and intraocular pressure.

Start patients on a combination steroid/antibiotic ointment on the wound 4 times per day and have them follow up in 1 week.

A broad-spectrum antibiotic is used postoperatively in elderly or immune-compromised patients along with analgesics of choice.