hand book on recent update of orbital fractures management

Orbital Floor Fractures (Blowout Fractures)- Overview of
Recent updates

I. Background

Fractures of the orbital floor and the medial orbital wall (blowout fractures) are common
midface injuries. Orbital fractures have a distinct trauma mechanism and are complex,
due to the complex anatomy of the bony and soft tissue structures involved.

Knowledge of anatomy is mandatory when dealing with patients presenting with

trauma to the orbit.

Osteology-The frontal, ethmoidal, sphenoid, zygomatic, and lacrimal bones form the
bony structures of the orbit. Medially, the maxillary and the lacrimal bone form the
lacrimal fossa. Together with the lamina papyracea of the ethmoid bone, they form the
medial wall. The sphenoid bone forms the posterior wall and houses the orbital canal.
Lateral to the orbital canal lies the superior orbital fissure housing cranial nerves III, IV,
V, and VI. The zygomatic bone forms the lateral wall. Superior and inferior borders are
the frontal and maxillary bone.

Soft tissues-Located around the globe of the eye and attached to it are 6 extraocular
muscles- the 4 rectus muscles and the superior and inferior oblique muscles. The fat
and connective tissue around the globe help to reduce the pressure exerted by the
extraocular muscles.

Orbital floor fractures may result when a blunt object, which is of equal or greater in
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 (due to entrapment of inferior rectus muscle),
enophthalmos, hypo-ophthalmia (ie, hypoglobus), and hypoesthesia of the cheek and
upper gum on the affected side.

Finally, the orbital injury can also lead to retinal edema, hyphema and significant loss
of vision.

The goal of treatment is to restore aesthetics and physiological function. Treatment is
titrated to the degree of injury . While some cases may be managed with conservative
care, others may require some type of surgical intervention.

II. Pathophysiology

The orbit and its contents are affected by orbital floor fractures.

Location-Fractures of the orbital floor and the medial orbital wall are the most common
fractured site.

Direct fractures of the orbital floor can extend from orbital rim fractures, while

Indirect fractures of the orbital floor may not involve the orbital rim. A blowout
fracture is an isolated fracture of the orbital walls without compromise of the orbital
rims.

A. Mechanism- 1)adults-The common mechanisms are falls, high-velocity ball-related
sports, traffic accidents, and interpersonal violence. The cause of the fracture is thought
to be from increased intra orbital pressure, which causes the orbital bones to break at
their weakest point. This is usually the medial orbital floor.

The trauma mechanism is a blunt, directed force which may be aimed at the eye, without
a pressure component toward the eye rim leading to an increase of pressure inside the
orbit with a fracture of the bony structures (hydraulic mechanism). Alternatively, the
trauma may be directed towards the orbital rim, which then leads to a bending of the
orbital walls with consequent fracturing (buckling mechanism).

2) Child-The mechanism of entrapment is more frequently referred to as a trapdoor in
children, as opposed to the blowout or punched-out fracture present in adults.

B. Symptom & signs- pathophysiology- 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.[3]

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 is usually temporary but can last up to 6 months or longer. In severe
injuries, the hypoesthesia may be permanent.

III. Epidemiology-

Age

Because of the nature of the injury and its etiology (eg, assault), most orbital floor
fractures occur in teenagers or young adults.( ages 21 to 30 years of age).

Sex

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

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)

13% occurred due to a motor vehicle accident, usually involving striking the
dashboard

Falls accounted for 10%

gunshot wounds contributed to 6% of orbital floor fractures.

Presentation History

The patient should be queried specifically about the trauma mechanism and if he/she
has double vision, numbness to his face and/or loss of visual acuity.

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 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.
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.

Physical

Traumatized patients should be treated only after the initial assessment, according to
advanced trauma life support criteria. Examination always has to include a full
examination of the facial structures according to current guidelines published by the
relevant authority. Some patients present with extensive damage to other facial
structures for which detailed assessment is mandatory. Some limitations may exist due
to extensive soft tissue swelling or non-responsive patients.

A complete ocular evaluation is essential to ensure that no injury to the globe or optic
nerve has occurred. It is important to distinguish between fractures that need acute
surgical care and referral versus those for which simple observation is sufficient.

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 following assessments are characteristic of orbital floor fractures and mandate
further imaging:

1. The examiner should evaluate extraocular movements and document any restriction
or palsy and diplopia (on upward gaze)

2. Limited vertical movement may be due to entrapment of the perimuscular fascia of
the inferior rectus in the fracture site.

3. Trigeminal function assessment: The infraorbital nerve runs along the floor of the
orbit. Decreased sensation over the inferior orbital rim, extending to the edge of the nose
and ipsilateral upper lip should be tested.

4. Tenderness, or step-offs at the infraorbital rim

5. Subcutaneous emphysema (indicates a fracture of the maxillary sinus)

6. Oculomotor function: a) Entrapment of the inferior rectus muscle; often occurs
between fragments of the lower orbit and it is the cause of diplopia .

b) 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 help
to differentiate between the two conditions.

7. Pupillary light reflex: An absent reflex can show damage to the afferent or efferent
nerve system
8. Gross visual acuity
9. Position of the globe: A dislocated fracture can lead to enophthalmos and swelling
behind the globe to exophthalmos. Unusually severe orbital edema may be associated
with more severe fractures and can cause proptosis. Once the edema has subsided
(usually 1-2 wks), enophthalmos may be present. Hertel exophthalmometry may
demonstrate either proptosis or enophthalmos and should be documented
Carefully evaluation of the eye is important for visual acuity, hyphema, retinal
detachment, and of the nose for septal hematoma. In the presence of eye pain and
decreased visual acuity, globe rupture should be suspected, since itis associated with a
high rate of concomitant orbital floor fracture.
10. Chemosis and sub-conjunctival hemorrhage
11. Edema and periorbital ecchymosis.

Clinical examination has to eliminate the need for acute intervention under the
following conditions:
1. Large fractures with a high risk of enophthalmos
2. Entrapment of infra-orbital structures
3. Optical neuropathy

IV. Workup

Evaluation
Preoperative blood work should include CBC, electrolytes, coagulation profile, and a
pregnancy test.
Imaging should provide useful information to differentiate orbital floor fractures from
any of the following:
1. Medial or lateral wall fractures
2. Orbito-zygomatic fractures
3. LeFort I, II, and III fractures
4. Naso-orbital ethmoidal fractures (Markowitz fractures)

Imaging Studies

1. Plain Radiograph

Can help suspect an orbital floor fracture in the presence of the following:

Subcutaneous emphysema Soft-tissue teardrop along the roof of the maxillary sinus Air-
fluid level in the maxillary sinus

2. CT scan

For most orbital fractures, the imaging study of choice is CT scan. A CT scan -orbit
with axial and coronal views, often reveals herniation of orbital fat or the inferior rectus
muscle, into the maxillary sinus. Such a scan can also detect occult tears and retained
foreign bodies if any are present. Ask for thin cuts (2-3 mm) with specific attention to
the orbital floor and optic canal.

3. CT-3D reconstruction- a) 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.

b) Computer guided surgical planning & manufacturing produce passive fitting
implants customized for patient specific needs and they have revolutionized the
reconstruction of late orbital deformities.

Steps involved in creating -CT 3D Reconstuction:
1.Digital imaging and communications in medicine (DICOM) data of the CT scans
were obtained in 0.5mm layer thickness and region of interest (ROI) resolution of
512×512 corresponding to a voxel size of 0.331×0.331×0.5 mm. The skull bone was
segmented from DICOM volumetric data using 3DSlicer software by Hounsfield unit
thresholding.
2. The software converts the data for 3D reconstruction in the axial, coronal &
sagittal views.
3. The scan is adjusted by anatomical landmarks for symmetry.
4. Planning is performed by mirroring the unaffected side to the side where
reconstruction is necessary.

V. Treatment- a) Medical Care

When orbital oedema 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.

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.

b) Management- Surgical Care-
The choice of orbital fracture treatment depends on findings following a clinical
examination. Indications for surgery vary among different countries; but, there is a
consensus about several indications for surgery.
However, considerable differences in opinion may exist regarding the management of
blowout fracture due to a lack of a reliable consensus.

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

1. 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 peri muscular 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 oedema subsides.

Children-A subclass of orbital fracture with entrapment is the so-called white-eye
fracture in children.
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.

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.

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

3. 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.

A. Early surgical-intervention (preferably within 24 hours) is necessary when other
injuries threaten the eye such as nerve incarceration, acute enophthalmos or hypoglobus,
and limitation of gaze caused by extraocular muscle or periorbital tissue entrapment.
Many clinicians have recommended that orbital volume increases be treated, as an
indication for early reconstructive surgery. However, the increased post-traumatic
orbital volume is not particularly useful in predicting late enophthalmos or diplopia.

1. Entrapment of muscle or periorbital fat which leads to diplopia and/or the initiation
of the oculo cardiac reflex with bradycardia, nausea, and vomiting. These can be life-
threatening and indicate a need for immediate surgery.
2. Retrobulbar hematoma with a progressive loss in visual acuity
3. Enophthalmos (more than 2 mm) on first clinical examination
4. High risk fractures for enophthalmos, which involve over one-half of the orbital floor
or lateral orbital wall.

B. Delayed- In general, surgery should be undertaken within 14 days to prevent fibrosis.
Most surgeons wait 24-72 hours to allow the oedema to subside before undertaking
surgery. If the patient's only complaint is infraorbital nerve dysfunction, then the
decision to repair requires judgment and experience. Some surgeons report good results
with an early repair.

C. Children with orbital fracture and oculomotor dysfunction tend to have a more
favourable outcome if the repair is done within the first 7 days

D. observation- with possible intervention within 1 to 2 weeks in all other cases of
confirmed orbital floor fractures.
Patients with fractures where the orbital floor fragments are not displaced, and the
orbital volume remains unchanged, can be addressed without any surgical intervention.

Relative contraindications for surgery according to Kim et al. include the following
conditions:
1. Hyphema
2. Retinal tears
3. Globe perforation
4. Medical instability [15]

Pre OP Medications-1. Begin prophylactic antibiotic treatment for oral organisms in
all types of fractures of the orbit. Corticosteroids may help reduce the oedema in some
cases.
2. At the same time, the patient should be discouraged from blowing the nose or
performing a Valsalva manoeuvre because this may worsen the orbital emphysema.

Procedures -Pre op

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 he has completely reduced
the herniated tissue and that any residual motility deficit is neurologic and not
mechanical.

Enhancing Healthcare Team Outcomes
An interprofessional approach to blow-out fracture is recommended.
Management is relevant from a number of surgical specialties, such as otolaryngological
(ENT) surgery, plastic surgery, facial plastic surgery, ocular plastic surgery, and oral
maxillofacial surgery.

1.Ophthalmologist: All patients suspected of orbital fractures must see an
ophthalmologist on presentation to the emergency department and before surgery

2. Otolaryngologist and/or facial plastic surgeon and/or maxillofacial surgeon
depending on the institutional practice.

3. Nursing care is critical both during and after surgery. The patient should be pain-free
and should be told to avoid blowing the nose. Nurses should monitor the patients in the
ICU or the surgical floor, depending on the extent of the injury.

At all times, the nurse should closely monitor the vitals, pupillary function, visual
acuity, Glasgow coma score (GCS) score and assess the patient for mental status
changes. Any change in visual or mental status should be immediately reported to the
surgeon.

Close communication with all the staff is vital to improve patient outcomes. The
outcomes of most blow out fractures is reasonable but some patients may have altered
eye function and cosmetic changes of the face.

Approach- The goal of surgery is to restore herniated structures into the orbital cavity.
The surgery may be done via a

a) Trans conjunctival -. Access to the orbital floor usually is made through an inferior
fornix approach. This allows the surgeon to avoid a cutaneous incision and scar.

b) Trans maxillary approach- Alternatively, a lower eyelid sub ciliary 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.

c) Endoscopic techniques-. Today there are endonasal approach to manage the orbital
fracture

Implants & Bone Grafts- Multiple implant options are available for the repair of
orbital floor fractures.
An implant is placed over the fracture site.

1. Natural bone & cartilage grafts – a) Autografts ( calvarial bone,), autogenous bone
grafts from clavicle, mandible, iliac crest etc, are considered as the best. Autogenous
materials provide rigidity & moulding capacity, vascularity, biocompatibility &
minimal immune reactivity. They have osteo conductive and Osteo inductive properties.
Apart from bone grafts, cartilage grafts from auricular concha & nasal septum can also
be used

b) Allografts-Alloplastic cancellous bone 'Genesis Sponge' employs the demineralized
cancellous bone to induce proliferation of mesenchymal cells & osteoblast
differentiation to help normal bone formation. It has high osteo conduction and osteo
induction properties.

Some surgeons harvest split-thickness calvarium for an implant, although this
significantly lengthens the surgical time and increases the potential complications. 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.
.

2. Synthetic/Artificial Implants- A) Non Porous- Osteo Conductive Materials (titanium,
Supramid, silicone)-
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.
Surgical intervention for orbital fractures involving the medial wall and floor can be
done with synthetic implants like silastic sheeting, and Titanium .

The extrusion rates for silastic sheeting is minimal as a capsule forms around the implant
and hence chances of diplopia post operatively is decreased due to less fibrovascular
ingrowth. Pliability, ease of shaping and conforming to the fracture site is an advantage
with these implants. They are cost effective and biocompatible as well.

1. For fractures not involving the orbital rim and that lesser than 2.5cm square,
silastic sheeting and Titanium/ porous polyethylene gives good result.

2. For fractures involving orbital rim and greater than 2.5 cm square, titanium mesh
is advocated , the disadvantages of which are the sharp edges that need to be
burred down and tissue ingrowth through the holes.

3. For very large reconstructions, titanium mesh covered with porous polyethylene
can be used.

B) Porous- Osteo inductive grafts- eg, MEDPOR- More recently, many surgeons
are using wide variety of allogeneic materials like hydroxyapatite, 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.

Osteo inductive bioabsorbable copolymer Hydroxyapatite PolyLactide Caprolactone
can assist good bone formation for bone defects <15mm with linear or trapdoor types
of fracture.
Resorbable meshed plate implant 'Osteomesh' made of Polycaprolactone which will
degrade & resorb fully in vivo by hydrolysis supports bone In growth. It degrades as
new bone regenerates & is replaced by autologous bone.
.

C) 3D Printed Grafts – A great variety of printing materials allows for mechanical
properties, cheaper, easily accessible, less time-consuming and appearance accustomed
to specific applications. More importantly, accessibility of robust 3D modelling
software and powerful computer processors enables 3D models to be created at ease
with typical desktop workstations.

a) Digital-3d Design- skull model - A 3D skull model was created in standard triangle
language (STL) format and refined with 3D modelling software

b) Area Specific Mesh Optimization -The relevant area including the orbital floor
defect and the contralateral intact orbital floor was cropped from the skull.

Afterwards, mesh reduction (decimation), smoothing and defect filling techniques
were applied to the 3D models to reduce its triangular complexity. These mesh
optimization steps were aimed at reducing the computational burden and time
required for printing.

c) 3D Print Models- are produced with medically designated Acrylonitrile Butadiene
Styrene using an Industrial Grade fused deposition modelling (FDM) printer. The
model are created at a layer thickness of 0.178mm and sterilized by low temperature
hydrogen peroxide gas plasma following published recommendations before
operation

d) Actual Custom Implant- A porous polyethylene sheet (0.85mm thick) is trimmed
and molded to fit the size of defect according to the sterilized 3D printed model and
inserted to reconstitute the orbital floor

The time required to prepare the digital 3D models at the computer workstation will be
< 1 hour and the 3DP turnover time will be three working days. Logistically, this
enables 3DP models to be used for semi-elective situations where surgery may be
performed in 1–2 weeks.

Dis advantages of conventional implants & its placement- conventionally-

size and shape of defect of orbital floor blow out fracture was estimated from the two-
dimensional CT scan images. And with the small trans-conjunctival incision, the bony
defect especially the posterior landing zone will be difficult to be visualized clearly
during the operation.

The implant had to be repeatedly retrieved from the subperiosteal plane after insertion
for trimming and moulding for more precise placement which could theoretically
increase implant fatigue, increase soft tissue handling, worsen tissue oedema and
prolong operative time.

Advantages- 1) implants (porous polyethylene) can be precisely shaped with ease using
a 3DP orbital floor bone model under direct visualization.

2) the technique has considerably shortened the operative time and the duration of
anaesthesia and could potentially decrease implant fatigue.

3) 3DP models are effectively being used in patient education and communication where
surgeons can better explain the patho anatomy and the surgical procedure. Patients
benefit from a deeper understanding via visual and tactile feedback using their own
anatomical model.
.

The optimal material for customizable orbital floor implants should be cheap while
providing permanent stability via fibrovascular in-growth with low complication rates.

Materials used:
1)Titanium mesh
2)Medpor-Titanium composite mesh with additional effects of the porous structure for

better tissue in growth
3)Porous polyethylene
4)Poly ether ether ketone(PEEK)

Titanium vs polymer implant- 3DP patient specific titanium implants as an alternative
in craniofacial bone defect reconstruction. Advantges of 3DP template shaped polymer
implant over titanium metal are

1) its porosity allows for fibrovascular tissue in-growth and very low extrusion rate
2) the current FDM printed ABS polymer model remains far more economical than 3DP
titanium implants.
3) metallic implants placed critically near the eye are unnecessary hazards that preclude
any future MRI studies.

3. orbital rim involvement- If the orbital rim is involved and unstable, microplates may
be screwed directly into the floating bone segment to anchor it to stable bone.

Per op procedures-Prior to any procedure, the patient's visual acuity, extraocular motor
function, diplopia, degree of enophthalmos and dysesthesia should be documented.
During surgery, the function of the pupil must be serially assessed.

The anesthesiologist- should be told to avoid medications that cause pupillary
constriction or dilatation. When manipulating the extraocular muscles, the
anesthesiologist should be warned about bradycardia secondary to the oculo cardiac
reflex.

VI. Immediate post op 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 haemorrhage, 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.

Postoperative and Rehabilitation Care
During postoperative care, the examiner should watch out for postoperative
complications such as infection, visual, or central nervous system (CNS) symptoms.
The patient's head should be elevated to reduce the oedema and cool compresses can be
placed over the closed eyelid to reduce pain and swelling.
The patient's visual acuity and pupillary function should be periodically assessed; if any
changes are noticed, the surgeon should be immediately notified.

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.

VII. Complications

1. Acute surgical complications include loss of vision due to retrobulbar hematoma
or impingement of the orbital apex.

2. Delayed surgical complications depend on the surgical procedure used and
include entropion, ectropion, diplopia, infraorbital paresthesia, enophthalmos,
and blindness.

Surgical complications may include loss of vision, traumatic optic neuropathy, diplopia,
overcorrection or under correction 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.

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

Following the repair of a blowout fracture, the outcomes are not always guaranteed and
the recovery is often prolonged. Some patients may have neuralgia of the infraorbital
nerve for 6-9 months. Others may have diplopia, which may require REDO surgery.
Finally, enophthalmos may worsen with time.

IX. 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.

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.

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.

.

X. Prevention

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.

Vertical enophth
diplopia almous

Hypoaes Loss of Soft tissue
thesia vision edema/
H’age
Intial signs
FDT

Inferior CT ORBIT/
rectus DICOM/3D
entrap
recons
Positive
Radiology

FDT POSITIVE acute

CT ORBIT/3D
RECONS

INTERVENTION

Child trap door # R

Optic nerve invol

IR muscle entrap with
oculo cardiac reflex

Vertical diplopia Soft tissue
Hypoaesthesia edema/H’age
enophthalmous undisplaced #

Muscle entrapment/ Observation/
complex orbital # Medical rx

Enopthalmous >2mm

Delayed
(10-14 days)

Large # More than 1/3rd fracturs
Incr orbital volume
Retro bulbar heamatoma

<1/3rd # /
no Rim

adult Young & children

early late

Bone/cartilage 3d porous implant
Silastic sheet Poly lact aprolate
Titanium mesh
osteomesh

CT ORBIT
Floor #

>1/3rd #/
complex # /Rim

early late

Titanium mesh Medpor mesh
/silastic sheet
3d P –PEEK/Titanium
composite mesh