Orbital Floor Fractures (Blowout) 

Updated: Feb 08, 2022
Author: Adam J Cohen, MD; Chief Editor: Deepak Narayan, MD, FRCS 

Overview

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. A conservative approach may be warranted in some instances, whereas more invasive intervention may be necessary in other situations.[1]

Signs and symptoms of orbital floor fractures (blowout)

Patients may describe the following after facial trauma:

  • Decreased visual acuity
  • Blepharoptosis
  • Binocular vertical or oblique diplopia (especially in upgaze)
  • Ipsilateral hypesthesia, dysesthesia, or hyperalgesia, in the distribution of the infraorbital nerve
  • Epistaxis and eyelid swelling, following nose blowing

Other signs and symptoms can include the following:

  • Pupillary dysfunction coupled with decreased visual acuity
  • Ocular misalignment
  • Hypotropia or hypertropia
  • Limitation of elevation ipsilateral to the fracture
  • Deepening of the supratarsal crease, along with narrowing of the palpebral fissure

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.

History of the Procedure

According to Ng et al, orbital floor fractures were first described by MacKenzie in Paris in 1844.[2] 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.[3]

Over the past decade, rigid internal fixation has become 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.[4]

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.[5]

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%).[6]

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

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.[7]

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.

Presentation

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 also common, being found in 20.2% of patients, while enophthalmos and reduction of extraocular movement occurred in 2.3% and 1.7% of patients, respectively.[8]

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%.[9]

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.[10]

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.[11]

Indications

The timing and requirements for surgical repair of pure orbital floor fractures has been long debated. Most literature supports a 2-week window for repair to prevent fibrosis, resulting tissue contracture and entrapment. The authors often wait 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 of residual extraocular muscle dysfunction when the fracture was repaired within 7 days.[12, 13]

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.

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.[14]

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 terminates at the posterior edge of the maxillary sinus.

The bones that contribute to the structure of the 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.

Contraindications

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

 

Workup

Laboratory Studies

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

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.

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

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

Coronal CT scan showing orbital floor fracture pos 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 flo 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).

Coronal CT scan (soft tissue window) showing 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.

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.[15]

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.[16]

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.[17]

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.

Other Tests

An ECG also may be indicated.

Diagnostic Procedures

If the CT scan is equivocal when evaluating a patient with presumed entrapment, forced ductions can be performed. Directly assessing the ability or inability to further supraduct or infraduct the eye can yield important clinical confirmation of an entrapped muscle or tissue or of a paretic muscle.

 

Treatment

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.

Discourage nose blowing to avoid creating or worsening orbital emphysema. Nasal decongestants can be used if not contraindicated.

Surgical Therapy

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.

Transconjunctival approach

The transconjunctival approach can be combined with a lateral canthotomy for exposure of the orbital floor (see image below).

Operative photo of fracture repair via transconjun Operative photo of fracture repair via transconjunctival approach.

Initiate this approach with a curvilinear incision approximately 3 mm below the tarsal plate parallel to lower lid punctum.

Carry this surgical plane forward in a fashion posterior to the orbicularis oculi muscle and anterior to lower lid retractors and orbital septum. If placed too low, orbital fat prolapse likely compromises visibility of the fracture; if placed too high, postoperative architectural distortion may ensue.

Moving in a vector anterior to the septum, approach the orbital rim and overshoot it for several millimeters. Incise the periosteum at the medial aspect of the anterior border of the inferior orbital rim and carry it laterally.

Then elevate the periosteum with a hand-over-hand technique using sharp periosteal elevators, starting nasally and moving temporally until adequate exposure is obtained.

Preserve an anterior flap to be sutured at the conclusion of the procedure and remain cognizant of the location of the infraorbital groove and foramen that encase the infraorbital neurovascular bundle.

The advantages of this approach include the absence of visible scars and reduced risk of lower eyelid retraction.

Cutaneous approach

The cutaneous approach commences with a skin-muscle flap elevation via an incision 2-3 mm below the lower lid margin. Carry this dissection anterior to the orbital septum until the orbital rim is exposed.

Incise the periosteum and release it from its bony attachments as described in the transconjunctival approach. Of note is the downward sloping of the floor immediately posterior to the rim, which can result in breach of the septum during periosteal dissection.

Transantral approach

A transantral approach allows access to the orbital floor via the maxillary sinus. This approach may be especially useful when repairing a floor fracture of the trap door variety.

Achieve exposure of the incision site with upper labial retraction exposing the buccal-gingival sulcus.

Create a horizontal incision just inferior to the buccal-gingival sulcus so that a wide mucosal band is present. This wide band allows for imbrication of the wound, avoiding oral-antral fistulization.

Use a periosteal elevator to strip the anterior maxillary wall of periosteum. The proximity of the infraorbital foramen should be kept in mind to minimize the risk of insult to the neurovascular bundle.

Create a Caldwell-Luc antrostomy with an osteotome and mallet, followed by rongeurs to increase the diameter of the antrostomy, providing access to the orbital floor, medial wall, and ethmoid sinus complex.

Strip the mucosa from the maxillary antrum and cauterize the remnants.

Following repair of the fracture, attention to hemostasis is followed by closing the buccal-gingival mucosa with fast-absorbing suture material.

This approach results in inferior orbital floor exposure and is not favored for floor fracture repair.

Some authors have advocated an endoscopic transantral approach for improved visualization of fractures and to eliminate the need for eyelid incisions.[18]

Other approaches

Tessier described vertical osteotomy of an intact orbital rim for exposure of the orbital floor. This osteotomy is essentially 2 vertical osteotomies on either side of the infraorbital foramen conjoined by a horizontal osteotomy. Two osteotomies of the orbital floor originating at the inferior rim and extending past the infraorbital groove origins are created, allowing for removal of this segment, which can be replaced at the conclusion of surgery.

Endoscopic-assisted approaches via a transmaxillary and transnasal route have been described.[19, 20, 21, 22]  Suzuki et al described a modified transnasal endoscopic approach designed to address problems with repairing anterior and lateral orbital floor fractures that have been encountered with previous transnasal endoscopic techniques. The modified approach involves going through the anterior space to the nasolacrimal duct, with surgeons removing the medial maxillary bone, shifting the lateral wall of the nose medially to provide greater access to the maxillary sinus, carefully removing bone fragments entrapping the orbital content, and correcting the periorbita (orbital periosteum).[23]

Implants

Several types of implants are available for reconstructive use. The ideal implant should be easy to insert and manipulate, inert, not prone to infection or extrusion, easily anchored to surrounding structures, and reasonably priced. It should not rouse fibrous tissue formation. Most orbital floor defects can be repaired with synthetic implants composed of porous polyethylene, silicone, metallic rigid miniplates, Vicryl mesh, resorbable materials, or metallic mesh. Autogenous bone from the maxillary wall or the calvaria can be used, as can nasal septum or conchal cartilage. Each material has advantages and disadvantages. The surgeon should have a certain comfort level and familiarity with his or her choice of material.

A study by Holtmann et al found better results with resorbable 0.15-mm diameter polydioxanone foil than with titanium mesh in the repair of median orbital floor defects of 250-300 mm2 in size. Using the foil, diplopia was reduced from 16% of patients preoperatively to 4.9% postoperatively. Fifty percent of patients who underwent reconstruction with titanium mesh reported foreign body sensations and a cold feeling in the operative region during weather changes, compared with just 4.7% of patients reconstructed with the 0.15-mm foil.[24]

A retrospective study by Kronig et al indicated that good functional and aesthetic results can be achieved 1 year after the repair of pure orbital floor fractures with autogenous bone. In patients with both orbital floor and medial wall fractures, reconstruction of both walls resulted in an absence of enophthalmos, while in those in whom the medial wall was not reconstructed, 29% still had enophthalmos after a year.[25]

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 of 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.

Follow-up

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

Complications

As with any surgical procedure, bleeding, infection, and the need for additional surgery are risks. The possible loss of vision is the most ominous complication associated with floor repair.

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.[26]

Implant extrusion and residual enophthalmos are postoperative sequelae requiring additional surgery.

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, while 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.[27]

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.

Outcome and Prognosis

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.[28]

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

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.

 

Questions & Answers

Overview

What are orbital floor fractures?

What are the surgical options for treatment of orbital floor fractures?

What are the possible complications of orbital floor fractures?

What is the prevalence of orbital floor fractures?

What causes orbital floor fractures?

What is the pathophysiology of orbital floor fractures?

Which clinical history findings are characteristic of orbital floor fractures?

What are the signs and symptoms of orbital floor fractures?

How is diplopia characterized in orbital floor fractures?

When is surgical repair of orbital floor fractures indicated?

What is the anatomy of the orbital floor relevant to orbital floor fractures?

What are contraindications for surgical repair of orbital floor fractures?

Workup

What is the role of lab testing in the evaluation of orbital floor fractures?

What is the role of imaging studies in the diagnosis of orbital floor fractures?

What is the role of forced ductions in the workup of orbital floor fractures?

Treatment

How are orbital floor fractures medically treated?

What are the surgical approaches to treatment for orbital floor fractures?

What is the transconjunctival approach to the surgical treatment of orbital floor fractures?

What is the cutaneous approach to the surgical treatment of orbital floor fractures?

What is the transantral approach to the surgical treatment of orbital floor fractures?

What is the role of vertical osteotomy in the treatment of orbital floor fractures?

What is the role of endoscopic-assisted surgery for the treatment of orbital floor fractures?

What is the role of implants in the surgical treatment of orbital floor fractures?

What is included in preoperative care for orbital floor fractures?

How is surgical repair of orbital floor fractures performed?

What is included in postoperative care following surgical repair of orbital floor fractures?

What is included in the long-term monitoring of orbital floor fractures?

What are the possible surgical complications of orbital floor fractures?

What is the prognosis of orbital floor fractures?

What is the optimal timing for surgical repair of orbital floor fractures?