- Can observe for 7–10 days for resolution of motility disturbance resulting from edema, hemorrhage, rectus muscle contusion.
- If the fracture is large and associated with early enophthalmos then a period of observation is not indicated.
- Nasal decongestants
- Oral steroids
- Oral antibiotics — infection occurred in 0.8% of orbital fractures in 1 study; 3 of the 4 patients with infection received antibiotics (Ben Simon, Ophthalmology 2005).
- Botulinum toxin injection is less effective in correcting vertical deviation from orbital fractures, compared to similar ocular deviation from other orbital pathology (Strabismus 2013; 21:165).
- Avoid nose blowing
- Ice packs for 2–3 days.
Surgical criteria should be treated more as guidelines than strict rules. Indications for repair:
- "Trap-door" or "white-eyed" floor fractures can have severe restriction, which can cause pain and vagal symptoms of nausea, vomiting and bradycardia
- Urgent surgical intervention might be required to prevent inferior rectus ischemia.
- Surgical repair more than 48 hours after injury with white eyed blowout fracture has resulted in residual limitation in upgaze, despite adequate surgical repair (Arch Dis Child 2013; 98:445).
- Typically do not have significant enophthalmos, and the degree of fracture might appear limited on orbital imaging (OPRS 1998; 14:379).
- Unresolved diplopia in useful fields of gaze suspected to be restrictive in nature or secondary to globe malposition
- Early enophthalmos > 2 mm
- Large fracture (> 50% of orbital floor on CT scan) indicates that enophthalmos is likely to occur.
- Concomitant medial orbital wall fracture can increase risk of progressive enophthalmos. Orbital floor fracture repair might be indicated in this setting for small or medium sized defects.
- Appropriate timing is based on the clinical exam and imaging.
- Oculocardiac reflex — bradycardia and nausea from traction on orbital contents with significant herniation of orbital contents; can be without clinical evidence of extraocular muscle entrapment (OPRS 2009; 25:496).
- Has been observed with clinical evidence of entrapment, bradycardia with vomiting was exacerbated by upgaze (BMJ Case Reports 2014, 2014).
- Oculocardiac reflex can also resolve spontaneously without surgery (Orbit 2014; 33:286).
- Infraorbital nerve hypesthesia — rarely an indication for surgical intervention
- Mostly resolves spontaneously
- Severe, progressive nerve pain and paresthesia can be an indication for surgery (OPRS 1994; 10:271).
Timing of surgery:
- Early intervention
- Trapdoor fractures with signs of severe restriction and nausea/pain
- Intervention should occur within first few days to prevent permanent motility deficits (Jordan DR, Ophthal Plast Reconstr Surg, 1998)
- Delayed intervention
- Typically 7–14 days after trauma to allow for edema to subside making the surgery easier and safer by decreasing the chances for a compartment syndrome.
- In a comparison of 36 orbital floor fractures with diplopia repaired early (average 9 days after injury), versus 22 late repairs (average 19 days after trauma), there was no significant difference in postoperative diplopia (OPRS 2008; 24:437).
- Late intervention
- Might be weeks to months after injury; repair more than 6 weeks after injury can still have good outcomes, but prognosis is more varied. (OPRS 2015).
- Some surgeons will wait until visually significant enophthalmos develops or diplopia remains.
- Additional reports have indicated that outcomes of fractures in which repair was delayed might be similar to those of more acutely repaired fractures among oculoplastic surgeons (Dal Canto, Ophthal Plast Reconstr Surg 2008)
- In addition to Hertel measurements, volumetric analysis of CT images can have predictive value, estimating bone displacement (BJO 1993; 77:100).
- CT images can be more helpful early after the injury, with clinical exam altered by edema and hemorrhage.
- As an approximation, volumetric expansion of 1 cm3 correlates with 0.8 mm of induced enophthalmos (BJO 1994; 78:618).
- A 1.5-cm-wide fracture, involving half the typical orbital floor, with 2 cm in depth, typical of the maxillary sinus, and 1 cm displacement, potentially creates volumetric expansion of 1.5 x 2 x 1 = 3 cm,3 presenting concern about postoperative enophthalmos.
- Because a hinged fracture creates a bisecting triangle, it might induce only half the volumetric expansion.
- When floor fractures are combined with medial wall and zygoma fractures the likelihood of enophthalmos is greater.
- Hess screen can confirm restriction of muscle movement and isolate involved muscle (AJO 2006; 142:1019).
- Hess area ratio (HAR) is defined as percentage of total measured ocular motility on the affected side compared to movement on the unaffected side.
- In a study of 30 patients with orbital fractures and diplopia undergoing repair within 7 days after injury, 13 (43%) with HAR > 85% had no postoperative diplopia while 5/8 (52%) with HAR <65% had postoperative diplopia at four months (OPRS 2009; 25:123).
- Stop anticoagulants if possible.
- Transconjunctival approach (Figure 5).
- Probably the most common approach used by oculofacial surgeons.
- Without or with lateral canthotomy ("swinging eyelid") for better exposure.
- Conjunctival incision
- Can be extended for access to medial and lateral orbital walls.
- No visible scar
- Wide access to the inferior orbit
- Less chance for postoperative lid retraction
- No damage to the orbicularis or its innervation
- Less direct approach
- Higher learning curve
- Transcutaneous (Figure 6).
- Less commonly used by oculofacial surgeons
- Skin incision
- Orbital rim
- More direct approach
- Less of a learning curve
- Visible scar
- Higher chance of cicatricial lower lid retraction
- Transantral endoscopic
- Rarely used
- Requires endoscopic equipment
Figure 5. Illustration of the transconjunctival approach to the orbit.
Figure 6. Illustration of the transcutaneous approach to the orbit.
- General anesthesia, lidocaine with epinephrine into the lower lid.
- Perform forced ductions. (Figure 7).
- Evert the lower lid.
- Open conjunctiva (e.g., with monopolar knife) with or without release of the lateral canthus.
- Sharply and bluntly dissect posterior to the orbicularis and anterior to the orbital septum.
- Blunt retractor in lower lid and conjunctiva/lower lid retractors on bridle suture over cornea.
- Open the periosteum of the rim and dissect in the plane inferior to the periosteum posteriorly in the orbit.
- Careful release of entrapped tissue from the fracture.
- Placement of implant to reproduce the anatomic position of the orbital floor.
- Posterior aspect of the implant must rest on the posterior ledge.
- Perform forced ductions and ensure release of any entrapped tissue.
- Close periosteum over the rim.
- Close conjunctiva and repair lateral canthus if it was released.
- No patch.
Figure 7. Illustration of forced duction testing.
Orbital floor implants:
- Autologous material
- Anterior maxillary wall
- Nasal septal
- Fascia lata
- Allogenic material
- Irradiated bone
- Lyophilized dura
- Lyophilized cartilage
- Fascia lata
- Bovine bone
- Alloplastic material
- Titanium mesh (Figure 8 and Figure 9)
- Vitallium mesh
- Silastic (silicone) sheet
- Marlex mesh (crystalline polypropylene)
- Bioactive glass (glass/ceramic)
- Porous polyethylene — with titanium reinforcement (Figure 8) and without
- Polylactic/polyglycolic (PLA/PGA) acid copolymer
- Polydioxanone (PDS)
- Seprafilm — carboxymethylcellulose and hyaluronate hybrid (OPRS 2009; 25:2011).
- Polyglactin 910 polydioxanone (OPRS 1993; 9:191).
Figure 8. Illustration of various titanium implants used for orbital fracture repair. A. Titanium fan-shaped plate. B. Porous polyethylene covered titanium fan-shaped plates. C. Titanium floor and medial wall plate. D. Preformed right and left anatomic titanium floor plates.
Figure 9. Illustration of titanium implant placed on the floor of the left orbit.
- Typically the surgery is outpatient and the patient is allowed to go home after the surgery.
- Pain control medication
- Lubricating ointment
- Antibiotic ointment with or without steroid (e.g., Tobradex)
- Possibly antinausea medication
- Possibly oral steroids
- No nose blowing
- No contact sports
- No patch
- The patient might develop a hematoma with optic nerve compromise, and the patch can mask this.
- Ice packs for the first 2–3 days, then heat packs
- Instructions to call the surgeon ASAP at any hour if uncontrolled bleeding or vision loss is experienced
- Note: Some surgeons will place a drain in the orbit and admit the patient overnight.
- Follow-up in the surgeon's office in a few days to 1–2 weeks