Orbital Floor Fractures (Blowout Fractures)

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Practice Essentials

Facial skeleton fractures can result from low-, medium-, or high-velocity trauma. Floor fractures may occur in combination with zygomatic arch fractures, Le Fort type II or III midface fractures, or fractures of other orbital bones.

The goal of treatment is to maintain or restore the best possible physiologic function and aesthetic appearance to the area of injury.[1] A conservative approach may be warranted in some instances, whereas more invasive intervention may be necessary in other situations.[2]

Signs and symptoms of orbital floor fractures (blowout)

Patients may describe the following after facial trauma:

Other signs and symptoms can include the following:

Workup in orbital floor fractures (blowout)

Radiographs can be used for soft tissue but are limited by their lack of ability to detect differences in tissue density of less than 10%, making evaluation of soft tissue difficult at best. Anteroposterior views of the orbit usually are obtained with varying angulation of the x-ray beam vector. The most common views are the Caldwell and Waters projections.

Computed tomography (CT) scanning has supplanted radiographs in evaluation of midfacial trauma. Magnetic resonance imaging (MRI) enables multiplanar imaging and is excellent for evaluating soft tissue masses and optic nerve pathology. However, even though MRI provides exquisite detail of the orbital region, CT scanning remains the imaging modality of choice for evaluation of orbital trauma. Of note, intraocular ferromagnetic foreign bodies can add additional insult to the eye and surrounding structures secondary to the magnetic field of the MRI scan.

Management of orbital floor fractures (blowout)

Medical therapy

Medical treatment is warranted for patients for whom surgery is not indicated. This may include patients who present without significant enophthalmos (2 mm or more), a lack of marked hypo-ophthalmos, absence of an entrapped muscle or tissue, a fracture of less than 50% of the floor, or a lack of diplopia.

The patient can be treated with oral antibiotics on an empiric basis due to the disruption of the integrity of the orbit in communication with the maxillary sinus.

A short course of oral prednisone reduces edema of the orbit and muscle, allowing for a better assessment of enophthalmos or entrapment.

Surgery

The orbital floor can be accessed through a conjunctival approach, through cutaneous exposure, or through a transmaxillary approach. Access to this region allows for exploration and release of displaced or entrapped soft tissue, thereby correcting any extraocular motility disturbances. In addition, repair of the bony defect with removal or repositioning of bony fragments allows for restoration of the partition between the orbit and maxillary antrum, thereby preserving orbital volume and geometry and eliminating impingement of soft tissue structures.

Background

Orbital floor fractures may result when a blunt object, which is of equal or greater diameter than the orbital aperture, strikes the eye. The globe usually does not rupture, and the resultant force is transmitted throughout the orbit causing a fracture of the orbital floor. Signs and symptoms can be quite varied, ranging from asymptomatic with minimal bruising and swelling to diplopia, enophthalmos, hypo-ophthalmia (ie, hypoglobus), and hypoesthesia of the cheek and upper gum on the affected side. Treatment is titrated to the degree of injury.[5]  

 See the image below.



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Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.

History of the procedure

According to Ng et al, orbital floor fractures were first described by MacKenzie in Paris in 1844.[6]  In 1957, Smith and Regan described inferior rectus entrapment with decreased ocular motility in the setting of an orbital floor fracture and used the term blowout fracture.[7]  

During the 1990s, rigid internal fixation became the most frequently used technique in repair of floor fractures. According to Patel and Hoffmann, materials employed for fixation reach back to the introduction of stainless steel wires by Dr. Buck in the 19th century.[8]  

Plating has gained widespread acceptance, eclipsing stainless steel wiring in the repair of facial fractures. Refinement of plating for the repair of long bones, microplating systems, and biocompatible implants offer the surgeon several choices for restoration of normal bony architecture.

Problem

Orbital floor fractures can increase volume of the orbit with resultant hypoglobus and enophthalmos.

The inferior rectus muscle or orbital tissue can become entrapped within the fracture, resulting in tethering and restriction of gaze and diplopia.

Significant orbital emphysema from a communication with the maxillary sinus can occur. Orbital hemorrhage is possible with risk of a compressive optic neuropathy.

The globe can be ruptured or suffer less severe forms of trauma, resulting in hyphema, retinal edema, and profound visual loss. A study by Gaier et al indicated that the visual and ocular prognosis is worse in patients in whom open globe injury is concomitant with orbital fracture than in those with isolated open globe injury. The investigators reported, for example, that the presence of an orbital fracture is an independent risk factor for subsequent evisceration/enucleation, with an odds ratio of 4:6. Orbital floor fractures were the most common orbital fractures in the study.[9]

Pathophysiology

Etiology

Pure orbital floor fractures, referred to as isolated floor fractures, result from impact injury to the globe and upper eyelid. The object is usually large enough not to perforate the globe and small enough not to result in fracture of the orbital rim.

Pathophysiology

The orbit and its contents are affected by orbital floor fractures. Direct fractures of the orbital floor can extend from orbital rim fractures, whereas indirect fractures of the orbital floor may not involve the orbital rim. The cause of the fracture is thought to be from increased intraorbital pressure, which causes the orbital bones to break at their weakest point. This is usually the medial orbital floor. Another theory is that compression of the inferior orbital rim causes direct buckling of the orbital floor. In either case, if the intraorbital pressure is great enough at the time of injury, orbital contents can be forced into the fracture site and possibly into the maxillary sinus.[10]  

Orbital floor fractures are secondary to a sudden increase in intraorbital hydraulic pressure. A high-velocity object that impacts the globe and upper eyelid transmits kinetic energy to the periocular structures. This energy results in pressure with a downward and medial vector usually targeting the infraorbital groove. Most fractures occur in the posterior medial region that is comprised of the thinnest bones.[11]

Another proposed mechanism that is less favored describes buckling of the orbital floor without displacement of orbital contents following high-velocity trauma.

Although most pure orbital fractures affect the region medial to the infraorbital groove, any fracture type, size, or geometry is possible.

Epidemiology

Frequency

Orbital floor fractures alone or in conjunction with other facial skeletal fractures are the most commonly encountered midfacial fractures, second only to nasal fractures.

The frequency of orbital floor fractures depends on demographics and socioeconomic conditions. Trauma centers and urban facilities encounter a higher prevalence of this injury type.

A retrospective, cross-sectional study by Iftikhar et al found that between 2001 and 2014, of an estimated 671,324 US inpatient admissions for ophthalmic disorders, orbital floor fractures were among the three most prevalent diagnoses (9.6%), together with orbital cellulitis (14.5%) and eyelid abscesses (6.0%).[12]   

Mortality/Morbidity

With simple blowout fractures, there may be no morbidity at all, or the patient may complain of diplopia, enophthalmos, or hypoesthesia of the cheek and gum. Edema and ecchymosis of the eyelids and periorbital region usually are seen but are temporary. With any injury that involves a sinus, air may escape into the orbit or subcutaneous tissues. This is called orbital emphysema.

Vertical diplopia may be caused by entrapment of the perimuscular tissue surrounding the inferior rectus muscle in the fracture site. This results in limited upgaze and may cause pain on attempted upgaze as well. Damage to the third nerve branch to the inferior rectus muscle also may cause limited vertical motility. Severe pain with limited horizontal and vertical movements can be indicative of more severe orbital hemorrhage or edema.[13]

Enophthalmos may result when large orbital floor fractures occur and orbital contents prolapse into the maxillary sinus. If a medial wall fracture also has occurred, the enophthalmos may be compounded due to prolapse of orbital contents into the ethmoid sinus. Orbital edema that occurs at the time of injury initially may mask the enophthalmos, but the sunken eye appearance will become more apparent over the following 1-2 weeks as the edema subsides.

Fractures along the floor usually affect the infraorbital groove and therefore the infraorbital nerve. The resultant neuropraxia causes hypoesthesia of the cheek and upper gum on the affected side. This usually is temporary but can last up to 6 months or longer. In severe injuries, the hypoesthesia may be permanent.

Sex

Because the usual mechanism of injury is assault with a blunt object, the vast majority of cases occur in males. In a study of facial fractures in an urban population, 81% of the patients were males.

Age

Because of the nature of the injury and its etiology (eg, assault), most orbital floor fractures occur in teenagers or young adults.[14]  

Prognosis

Most cases do well, and most patients obtain resolution of diplopia and correction of enophthalmos.

Successful repair of orbital blowout fractures may be complicated by persistent problems. Neuralgia in the distribution of the infraorbital nerve may worsen after surgery. Improvement of this problem, if any, may take 6 months or more.

More troubling is persistent diplopia. If isolated to extreme positions of gaze, it may go unnoticed or may not be bothersome to the patient. However, if the diplopia affects functional positions of gaze, corrective prisms can be tried. Ultimately, eye muscle surgery may be required to address this problem with repositioning of the extraocular muscles to allow for orthophoric fixation of images.

A study by Su et al of 83 pediatric patients with orbital blowout fractures found that the length of time for postoperative recovery from diplopia was associated with age, with the younger patients taking longer to recover than the older ones.[15]

Enophthalmos can worsen over time. Despite adequately repairing the fracture, atrophy of the orbital fat can occur, resulting in further enophthalmos.

Patient Education

Warn patients to avoid strenuous activity and to use common sense when determining their postoperative activity level.

Warn patients to avoid nose blowing for several weeks after the injury and repair.[3, 4]

Educate patients about nerve damage recovery. An injured motor nerve (third nerve branch) or sensory nerve (infraorbital nerve) can take weeks or months to return to normal. In some cases, the damage may be permanent.

 

History

Patients may relay a history of the eye being struck by an object larger than the diameter of the orbital entrance. Fists, balls, or car dashboards are examples.

Patients may have no complaints. However, they may complain of vision loss or diplopia. The double vision is often vertical and worse with attempted up or downgaze.

Numbness (hypoesthesia) of the cheek and gum on the affected side may be present. Ecchymoses, ptosis (droopiness of the eyelid), and swelling around the eye may be noted.

The examiner should obtain a past ocular history to assess whether any loss of vision or diplopia is due to the present accident or was established prior to this incident.

After facial trauma, patients may describe decreased visual acuity, blepharoptosis, binocular vertical or oblique diplopia (especially in upgaze), and ipsilateral hypesthesia, dysesthesia, or hyperalgesia (in the distribution of the infraorbital nerve). In addition, patients may complain of epistaxis and eyelid swelling, following nose blowing.

Periorbital ecchymosis and edema accompanied by pain are obvious external signs and symptoms, respectively. Enophthalmos is possible but initially can be obscured by surrounding tissue swelling. This swelling can restrict ocular motility, giving the impression of soft tissue or inferior rectus entrapment. Retrobulbar or peribulbar hemorrhage may be heralded by proptosis. A bony step-off of the orbital rim and point tenderness are possible during palpation.

Examination of the globe is essential, albeit difficult because of soft tissue edema. Desmarres retractors may be helpful to spread edematous eyelids.

Pupillary dysfunction coupled with decreased visual acuity should alert one to the possibility of a traumatic or compressive optic neuropathy.

Ocular misalignment, hypotropia or hypertropia, and limitation of elevation ipsilateral to the fracture are possible. Forced duction testing can differentiate entrapment versus neuromyogenic etiologies of muscle underaction.

There may be a deepening of the supratarsal crease, along with narrowing of the palpebral fissure stemming from enophthalmos or fibrous tissue contraction. Although the palpebral fissure may in fact narrow, the geometric shape is preserved, since dehiscence or disruption of the canthal tendons is uncommon.

A retrospective study by Bartoli et al of 301 orbital floor fractures found the most common symptom to be hypesthesia extending through the region of the maxillary nerve (32.9% of patients). Diplopia was common, being found in 20.2% of patients, whereas enophthalmos and reduction of extraocular movement occurred in 2.3% and 1.7% of patients, respectively.[16]  

A study by Firriolo et al indicated that in pediatric patients with orbital floor fracture, the presence of nausea and/or vomiting is indicative of tissue entrapment, with a sensitivity of 83.3% and a negative predictive value of 98.1%.[17]  Wilkins and Havins reported a 30% incidence of a ruptured globe in conjunction with orbital fractures, supporting the notion that a thorough and complete ophthalmic examination is needed.[18]  A study by Boffano et al of patients with blow-out fractures indicated that the characteristics of diplopia vary according to the position of the fracture. In the report, in which just over 50% of 447 patients with pure blow-out fractures presented with evidence of diplopia, statistically significant associations were found between orbital floor fractures and diplopia on eye elevation, and between medial wall fractures and horizontal diplopia. The investigators suggested, therefore, that the form of diplopia that a patient presents with may offer clues to the type of orbital fracture sustained.[19]  

Physical

A complete ocular evaluation is essential to ensure that no injury to the globe or optic nerve has occurred.

Visual acuity and pupils should be evaluated to ensure that no loss of vision or traumatic optic neuropathy has occurred.[20]

The examiner should evaluate extraocular movements and document any restriction or palsy.

A complete slit lamp evaluation and measurement of intraocular pressures should be performed.

Most posterior segment injuries can be ruled out with a dilated funduscopic examination.

The physical findings may involve only periorbital edema and ecchymosis; however, more severe cases may demonstrate limited vertical movement, enophthalmos, ptosis, and possibly proptosis.

Unusually severe orbital edema may be associated with more severe fractures and can cause proptosis. Once the edema has subsided (usually 1-2 wk), enophthalmos may be present.

Limited vertical movement may be due to entrapment of the perimuscular fascia of the inferior rectus in the fracture site. However, traumatic palsy of the third nerve branch to the inferior rectus also may cause decreased extraocular movements. If a question exists, forced duction testing may differentiate between the two conditions.

Hertel exophthalmometry may demonstrate either proptosis or enophthalmos and should be documented.

Causes

In a study of orbital fractures in an urban population, 70% of the fractures were due to assault with a blunt object (eg, fist, baseball bat), and 13% occurred due to a motor vehicle accident, usually involving striking the dashboard. Falls accounted for 10%, and gunshot wounds contributed to 6% of orbital floor fractures.

Laboratory Studies

The only lab studies are those needed for clearance for surgery (eg, CBC count, sequential multiple analysis, chest x-ray, bleed times).

If alcohol or illicit drug use is suspected, obtain and document serum levels.

As with most surgical patients, appropriate preoperative laboratory tests (eg, complete blood count, metabolic panels, activated partial thromboplastin time) and an international normalized ratio level are necessary. Obtain a pregnancy test when warranted.

Imaging Studies

For most orbital fractures, the imaging study of choice is CT scan. A CT scan with axial and coronal views is optimal. Ask for thin cuts (2-3 mm) with specific attention to the orbital floor and optic canal.[11, 21] See the image below.



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Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.

When the patient has severe head and neck trauma, the radiologist may have difficulty positioning the patient to obtain coronal views. Because these views are generally the most helpful for evaluating the integrity of the orbital floor, the surgeon may ask the radiologist to obtain very thin axial cuts to allow reconstructed coronal views to be obtained.

Radiography

Radiographs can be used for soft tissue but are limited by the lack of ability to detect differences in tissue density of less than 10%, making evaluation of soft tissue difficult at best. Anteroposterior views of the orbit usually are obtained with varying angulation of the x-ray beam vector.

The most common views are the Caldwell and Waters projections. The Caldwell projection allows for visualization of the orbital floor and orbital zygomatic process above the dense petrous pyramids. A more extended view of the orbit is afforded by the Waters projection. This angle of x-ray trajectory places the petrous pyramids below the maxillary sinus, allowing evaluation of the orbital floor, prolapsed orbital contents, and air-fluid levels in the maxillary sinus. Ng et al found a poor correlation between soft tissue opacities below the inferior orbital rim and inferior rectus muscle entrapment with a Waters view.[6]

Lateral views often are confusing because of overlapping anatomic structures and offer little in the assessment of floor fractures.

CT Scanning and MRI

Computed tomography (CT) scanning has supplanted radiographs in evaluation of midfacial trauma (see images below).



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Coronal CT scan showing orbital floor fracture posterior to the globe. A fracture of the lateral maxillary sinus wall also is present.



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Coronal CT scan showing posterior extension of floor fracture.

A gray-scale image is created based on various soft tissue linear coefficients that are assigned a particular shade of gray. Direct axial, coronal, or sagittal images can be obtained with proper positioning of the patient. CT scanning without contrast provides views of high-density bone. Obtain both axial and direct coronal 1.5- to 2.0-mm cuts to properly evaluate the orbit and the floor. If the patient cannot be manipulated into proper position for direct coronal images, coronal views also may be obtained indirectly by reformatting thin axial windows. However, direct coronal images are preferable. Coronal orbital views provide bony and soft tissue windows, allowing for excellent detail of orbital floor fractures, adjacent sinuses, and soft tissue entrapment (see image below).



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Coronal CT scan (soft tissue window) showing right orbital floor fracture, vertical elongation of right orbit, reduction in size of right maxillary si....

A study by Huang et al indicated that in patients with head trauma, lack of maxillary hemosinus on conventional head CT scanning predicts the absence of orbital floor fracture, the negative predictive value being 99.7%. Maxillary hemosinus with high-attenuation opacity mixed with mottled gas was found to be the only type of maxillary hemosinus to independently predict orbital floor fracture.[22]

A study by Bruneau et al indicated that CT scan–based evaluation for pure orbital floor blowout fractures can be used to predict ophthalmologic outcomes, with, for example, the area ratio of the fractured orbital floor and the maximum height of periorbital tissue herniation being predictive for enophthalmos and diplopia, respectively.[23]

A study by Goggin et al indicated that the defect size of orbital floor fractures may be overestimated if simple, rapid geometric formulas are used to calculate the value from CT scans. Such formulas are highly sensitive but lack specificity, according to the investigators, who recommended instead that more time-consuming analysis, employing coronal CT scans and taking into account the thickness and number of image slices, be used to derive the defect size.[24]

Magnetic resonance imaging (MRI) uses a magnetic field and the activity of hydrogen atoms within this field to produce detailed images of the orbit. MRI enables multiplanar imaging and is excellent for evaluating soft tissue masses and optic nerve pathology.

Even though MRI provides exquisite detail of the orbital region, CT scanning remains the imaging modality of choice for evaluation of orbital trauma. Of note, intraocular ferromagnetic foreign bodies can add additional insult to the eye and surrounding structures secondary to the magnetic field of the MRI scan.

Procedures

Forced duction testing may be performed in the office to confirm that limited extraocular movements are due to restriction of the inferior rectus muscle instead of third nerve branch palsy. Testing should be performed after the orbital edema subsides, usually 10 days to 2 weeks after the trauma.

Testing should be performed at the beginning of a surgery to repair the floor fracture as well as at the end of the case. This will assure the surgeon that they have completely reduced the herniated tissue and that any residual motility deficit is neurologic and not mechanical.

Other Tests

An ECG also may be indicated.

Medical Care

Most cases do not require any medical intervention. In addition, most cases are managed on an outpatient basis.[7, 20] Patients for whom surgery is not indicated may include those who present without significant enophthalmos (2 mm or more), a lack of marked hypo-ophthalmos, absence of an entrapped muscle or tissue, a fracture of less than 50% of the floor, or a lack of diplopia.

Patients should be advised to avoid nose blowing for several weeks after the injury to prevent orbital emphysema and possible visual compromise. Nasal decongestants can be used if not contraindicated.

When orbital edema is severe, steroids may be used to decrease orbital edema.

The patient can be treated with oral antibiotics on an empiric basis due to the disruption of the integrity of the orbit in communication with the maxillary sinus.

Elderly patients may require antibiotics given preoperatively and continued for 2 weeks postoperatively.

Surgical Care

Indications

The timing and requirements for surgical repair of pure orbital floor fractures have been long debated. Consider waiting several days to allow dissipation of edema and hemorrhage in order to better assess enophthalmos and extraocular muscle function. In the event of tense inferior rectus incarceration, more immediate action is taken.

Pediatric patients with an orbital floor fracture, nausea, vomiting, and extraocular muscle dysfunction experienced rapid improvement of these signs and symptoms and less risk for residual extraocular muscle dysfunction when the fracture was repaired within 7 days.[25, 26]  

A pure orbital floor fracture involving more than 50% of the floor, with orbital tissue prolapse, usually results in significant enophthalmos (>2 mm). These 2 findings indicate the need for timely repair.[1, 27, 28]

Diplopia within 30° of primary gaze, positive forced-duction testing, and CT scan confirmation of a fracture warrant an early repair. Trapdoor or anteroposterior fractures can have clinical findings that are out of proportion to radiologic studies.

Although diplopia within 30° of primary gaze, extraocular muscle entrapment, and enophthalmos greater than 2 mm are discussed in the context of large floor fractures, each on its own can be an indication for repair.

Infraorbital nerve dysfunction occurs and is often the only complaint following pure orbital floor fracture. This sensory disturbance traditionally has not been an indication for repair. Some authors have reported improvement of this neuropathy following repair and nerve decompression.[29]  

The criteria for surgical intervention in blowout fractures are controversial; however, 3 general guidelines exist for surgical intervention.[30]

When surgery is indicated, it usually is best performed as close to 2 weeks from the trauma date as possible.[28] 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.

Transconjunctival approach



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Operative photo of fracture repair via transconjunctival approach.

The transconjunctival approach can be combined with a lateral canthotomy for exposure of the orbital floor (see image above) as follows:

Cutaneous approach

The cutaneous approach should proceed as follows:

Transantral approach

The transantral approach should proceed as follows:

Other approaches

Other approaches include the following:

Implants

Considerations regarding the use of implants include the following:

​Relevant Anatomy

The adult orbital floor is composed of the maxillary, zygomatic, and palatine bones (see image below). The orbital floor is the shortest of all the walls; it does not reach the orbital apex, measures 35-40 mm, and it terminates at the posterior edge of the maxillary sinus. 



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The bones that contribute to the structure of the orbit.

The bones that contribute to the structure of the orbit.  

The infraorbital groove, canal, and foramen are contiguous and tunnel through the maxilla, encasing the maxillary branch of the trigeminal nerve. The maxillary branch of cranial nerve V exits as the infraorbital nerve, providing sensory innervations to the ipsilateral orbital floor, mid face, and posterior upper gingival. The infraorbital artery, a branch of the maxillary artery, and the infraorbital vein also are found within the infraorbital groove, flanking the infraorbital nerve and exiting the infraorbital canal.

Preoperative Details

Review and carefully document the patient's complete medical status and pertinent signs and symptoms pertaining to the injury.

The procedure and the risks, benefits, and alternatives should be explained clearly and documented. The patient should be aware of the possibility of persistent, worsening, or new-onset diplopia, hypesthesia, and enophthalmos and of the risk for visual loss secondary to the procedure. Assess the patient's expectations to avoid a successful surgical outcome coupled with a poor outcome perceived by the patient.

Clearly document visual acuity, degree of enophthalmos, pupillary and extraocular muscle function, and the amount of diplopia in all fields of gaze.

Meticulous review of imaging is essential for planning the surgical approach and identifying surrounding structures that may serve as anchoring sites for an implant.

Secure the appropriate implant several days prior to surgery.

Intraoperative Details

During the repair, periodically assess pupillary function. Assessing the pupil size prior to general anesthesia, after general anesthesia is induced, and after any periorbital injections containing epinephrine (prior to manipulating the globe) is worthwhile. Narcotics can cause pupillary constriction (miosis), and epinephrine can cause pupillary dilation (mydriasis). If not assessed before orbital content manipulation, the cause of a dilated pupil can be obscured when the pupil is checked.

Perform a thorough exploration of fracture for bony fragments and occult fractures involving the medial wall. Inspection of soft tissue for necrosis is also necessary once freed from the fracture. Forced duction tests may be performed to confirm that tissues have been released completely.

Following floor restoration, assess the fit and stability of the implant. Take special care to be sure the implant is not protruding, which can result in an aesthetically poor result, patient discomfort, and soft tissue breakdown, which can invite infection. If a titanium implant is used and anchored to the orbital, the implant may be covered with AlloDerm to reduce visibility.

As for any surgical procedure, the surgeon should be made aware of the patient's overall status as monitored by the anesthesiologist. If extraocular muscle manipulation is forthcoming inform the anesthesia staff, so that bradycardia secondary to the oculocardiac reflex can be identified and communicated. The bradycardia should abate with release of the extraocular muscles.

Postoperative Details

Elevate the patient's head to 30°.

Gently place gauze soaked in iced saline over the closed eyelids.

Assess visual acuity and pupillary function every 15 minutes for the first hour and every 30 minutes until discharge. Nose blowing, strenuous activity, and straining should be avoided in the immediate postoperative period.

Instruct the patient to use cool compresses for 48 hours, to finish all prescribed oral antibiotics, and to use analgesics sparingly. Postoperative oral steroids may help reduce swelling.

Any change in visual acuity or increase in pain should prompt the patient to contact the surgeon immediately.

Contraindications

Surgical correction is contraindicated in patients who are medically unstable and unable to tolerate anesthesia.

Activity

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.[3, 4]

Complications

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.

Residual or new-onset diplopia, neuralgia, and extraocular muscle dysfunction are potential complications. The patient should understand these risks completely, and no promises are to be made concerning resolution of any presurgical neuralgia.[42]

A retrospective study by Borghol et al indicated that in patients with orbital floor fractures, the transcutaneous approach results in a higher rate of ectropion and of increased scleral show and a lower rate of entropion, compared with the transconjunctival approach. In patients undergoing transconjunctival surgery, the rates of entropion, increased scleral show, and ectropion were 6.6%, 6.6%, and 4.4%, respectively, whereas in the transcutaneous group, the rates were 5%, 10%, and 25%, respectively. The presence of a complex fracture, the use of conjunctival sutures, and a greater time period prior to surgery were among the factors linked to a higher complication rate. Patients in the study had either isolated orbital floor fractures, zygomaticomaxillary complex fractures, or Le Fort pattern fractures.[43]

Although orbital floor fracture surgery may be a complete success in the eyes of the surgeon, the patient may view the outcome as unsatisfactory. To minimize this, the surgeon and patient should be in mutual agreement regarding the realistic outcome of the repair.

Prevention

The use of 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.

Further Outpatient Care

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.

Follow-up examinations should assess and document visual acuity, pupillary and extraocular muscle function, neuralgia, and the amount of enophthalmos and diplopia.

Inpatient & Outpatient Medications

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.

Future and Controversies

The timing and indications for reconstruction of orbital floor fractures remain controversial.

Early repair (within the first 2 wk) often is indicated when criteria discussed within this article are met. However, these are at best broad guidelines and not absolute criteria for management.

Patients who demonstrate significant improvement without signs of entrapment can be treated conservatively. Delayed repair is also an option in select patients. Even after the fracture is repaired, further surgery may be needed for persistent diplopia.

Author

Geoffrey M Kwitko, MD, FACS, FICS, Clinical Associate Professor, Department of Ophthalmology, University of South Florida College of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

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.

Chief Editor

Hampton Roy, Sr, MD, † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Adam J Cohen, MD, Physician/CEO, Eyelid and Facial Plastic Surgery and Aesthetic Lounge MedSpa

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Triad Inc.<br/>Serve(d) as a speaker or a member of a speakers bureau for: Mimedx; InMode.

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice

Disclosure: Received none from Allergan for speaking and teaching; Received none from LifeCell for consulting; Received grant/research funds from GID, Inc. for other.

James F Thornton, MD, Associate Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Disclosure: Nothing to disclose.

James Neal Long, MD, FACS, Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Michael Mercandetti, MD, MBA, FACS, Private Practice

Disclosure: Nothing to disclose.

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado

Disclosure: Nothing to disclose.

References

  1. Koenen L, Waseem M. Orbital Floor Fracture. 2023 Jan. [View Abstract]
  2. Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015. 9:2127-37. [View Abstract]
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Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.

Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.

Coronal CT scan showing orbital floor fracture posterior to the globe. A fracture of the lateral maxillary sinus wall also is present.

Coronal CT scan showing posterior extension of floor fracture.

Coronal CT scan (soft tissue window) showing right orbital floor fracture, vertical elongation of right orbit, reduction in size of right maxillary sinus, and soft tissue swelling of the right maxillary sinus mucosa.

Operative photo of fracture repair via transconjunctival approach.

The bones that contribute to the structure of the orbit.

Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.

Coronal CT scan (soft tissue window) showing right orbital floor fracture, vertical elongation of right orbit, reduction in size of right maxillary sinus, and soft tissue swelling of the right maxillary sinus mucosa.

Coronal CT scan showing orbital floor fracture posterior to the globe. A fracture of the lateral maxillary sinus wall also is present.

Coronal CT scan showing posterior extension of floor fracture.

Operative photo of fracture repair via transconjunctival approach.

The bones that contribute to the structure of the orbit.