Pearls of Orbital Trauma Management

Abstract

Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.

Inadequate Management of Multiple Orbital Fractures and Traumatic Optic Neuropathy

“…Ptosis, lid retraction, lateral canthal dystopia, flattening of the malar eminence, and trismus, gaze restriction, lagophthalmus, proptosis, exophthalmos are other indications for surgical repair in zygomatico-maxillary fractures and orbital roof fractures. The only urgent indication for surgical repair in all type of orbital fracture is entrapment that causes an oculo-cardiac reflex with bradycardia and cardiovascular instability [3][4][5][6][7].…”

“…Orbital fractures are caused by blunt trauma and may result from motor vehicle accidents, sport injuries, industrial accidents, falls, fighting, assault with a blunt object, explosion and rarely orbital or endonasal surgeries [3,4]. Incidence of orbital fracture accounts for roughly 10-25% of all cases of facial fractures [3]. Incidence is higher in third decade of life with male predominance and orbital floor is commonest bone involved [5].…”

“…Incidence is higher in third decade of life with male predominance and orbital floor is commonest bone involved [5]. Clinical presentations, complications and management have been described by several authors [3][4][5][6][7][8].…”

Postoperative CT of the Orbital Skeleton After Trauma: Review of Normal Appearances and Common Complications

“…Routine postoperative radiography is unnecessary after surgical treatment of facial trauma in patients without symptoms because it does not affect decisions on whether revision is needed [24]. Many surgeons, on the other hand, routinely perform postoperative CT to ensure adequate reconstructive positioning [18]. Although CT is the dominant modality for postoperative imaging of facial trauma, MRI is indicated in select scenarios.…”

“…It is now recognized that the medial wall contributes significantly to maintaining orbital volume, and the resulting increased volume associated with displaced or comminuted fractures poses a risk of enophthalmos [17]. The risk of enophthalmos is not necessarily equivalent with orbital floor fractures of identical size because the force of gravity displacing orbital contents sideways into the ethmoid sinuses is absent [18]. Operative indications for medial wall fractures include medial rectus muscle entrapment, either clinically or on CT, enophthalmos greater than 2 mm, persistent diplopia in primary gaze that persists for 2-4 weeks after injury, and large defects (using the same definition as for orbital floor fractures described already) [2].…”