orbital-fractures- ANIMATION

Prof Dr.P.ASHOK KUMAR
RIO GOH MMC

Prof Dr.P.ASHOK KUMAR
RIO GOH MMC

Prof Dr.P.ASHOK KUMAR
RIO GOH MMC

ORBITAL FRACTURES- AN OVERVIEW

COMPLICATIONS EPIDEMIOLOGY
.
.
06
01

MANAGEMENT ORBITAL 02 PATHOPHYSIOLOGY

. FRACTURES .

05

INVESTIGATION 04 03

. EVALUATION

.

Epidemiology

Age- most orbital floor fractures occur in teenagers

or young adults.( ages 21 to 30 years of age).

assault 7 70 Etiology
motor vehicle accident 10
Falls In a study of orbital fractures in an
gunshot wounds 13 urban population, mechanism of
injury –
Sex
70% of the fractures were due to
Orbital fractures are more common in males- assault with a blunt object (eg,
81% than in females. 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

Initial Evaluation

• History

– Time and mechanism of injury

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.

– Change in appearance of eye
– State of vision immediately after injury

• Immediate loss of vision – severe damage to retina
• Loss of light perception - vascular occlusion or optic nerve

compression
• Initial good vision – compression optic neuropathy

Presentation History

Diplopia- The double vision is often vertical and worse with attempted
up or downgaze.
Pain with eye movement

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.

Pathophysiology of Orbital Fractures

In the event of Trauma  ‘Blow-In’ or ‘Blow-Out’ fractures

• The bony defect is filled with soft tissue and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped -Direct muscle damage can result

www.presentationgo.com

Pathophysiology of Orbital Fractures

In the event of Trauma  ‘Blow-In’ or ‘Blow-Out’ fractures

• The bony defect is filled with soft tissue and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped -Direct muscle damage can result

www.presentationgo.com

Pathophysiology of Orbital Fractures

In the event of Trauma  ‘Blow-In’ or ‘Blow-Out’ fractures

Orbial rim

Thick Rims protect the
Eyeball

• The bony defect is filled with soft tissue and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped -Direct muscle damage can result

www.presentationgo.com

Pathophysiology of Orbital Fractures

In the event of Trauma  ‘Blow-In’ or ‘Blow-Out’ fractures

Orbial rim Orbital rim

Thick Rims protect the Absorb shock by
Eyeball Fracturing themselves

• The bony defect is filled with soft tissue and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped -Direct muscle damage can result

www.presentationgo.com

Pathophysiology of Orbital Fractures

In the event of Trauma  ‘Blow-In’ or ‘Blow-Out’ fractures

Orbital rim

Orbial rim Absorb shock by Orbital walls
Fracturing themselves
Thick Rims protect the
Eyeball Orbital walls (especially
Medial Wall & Floor) fracture
in an isolated way

• The bony defect is filled with soft tissue and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped -Direct muscle damage can result

www.presentationgo.com

Pathophysiology of Orbital Fractures

In the event of Trauma  ‘Blow-In’ or ‘Blow-Out’ fractures

Orbital rim

Orbial rim Absorb shock by Orbital walls Orbital walls
Fracturing themselves
Thick Rims protect the Gets displaces Inwards
Eyeball Orbital walls (especially or Outwards
Medial Wall & Floor) fracture
in an isolated way

• The bony defect is filled with soft tissue and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped -Direct muscle damage can result

www.presentationgo.com

Blow out Fractures

• Blowout fractures now refer to fractures of the:

– Orbital floor
– Medial wall
– Lateral wall
– Superior wall

• “pure” blowout fractures – trap door rotation to
bone fragments involving central area of bone

• “impure” fracture – fracture line extends to orbital
rim

Blow Out Fracture

Buckling Hydraulic

Enopthalmus following Blow-Out Fracture

 Retracting action of
extraocular muscles –
Enopthalmus.

 Diplopia – Entrapment of
Inferior Rectus & Inferior
Obliqus

 Occulomotor supplies – SR , MR, IR , IO
 Abducent – LR
 Trochlear – SO

 Due to paresis of these nerves → all these
extraocular muscles undergo paralysis → eyeball
fails to move → ‘External Opthalmoplegia’

 As affected eye -immobile→ whereas
contralateral EOM-normal → focal axis gets
disturbed → two images -→ Diplopia

BLOW IN FRACTURE

 Fragmented bones of the orbital floor are displaced into
the orbit.

 Proptosis – Exopthalmous
 More commonly seen in fractures of – orbital roof

Superior Orbital Fissure Syndrome

 Also k/as – ‘Rochon Duvigneaud Syndrome’
 Hirschfeld – first described it.

 Contents of Superior Orbital Fissure :
 3rd Cranial Nerve (Occulomotor)
 4th Cranial Nerve (Trochlear)
 6th Cranial Nerve (Abducent)
 5th Cranial Nerve (Trigeminal) – Opthalmic

Branch
 Opthalmic Artery
 Opthalmic Vein

Superior Orbital Fissure Syndrome

Pathophysiology

 Raised Intraorbital Pressure (due to
Hematoma/ Displaced fractured segments)
 Compression of contents of Sup. Orbital Fissure

 Paresis of Nerve
 Neurological deficit in their distribution

Clinical Features

 Circum orbital Edema -Periorbital eccyhmosis/ Intraorbital
emphysema

 Subconjunctival Bleeding – due to fracture →
subperiosteal bleeding → escapes in subconjuctival plane.

 Enopthalmous → Increase in size of Orbit →
Eyeball sinks

 Periorbital Fat Herniates through fractured walls
 ‘Hanging- drop’Appearance
 Unilateral Epistaxis – bleeding into antrum

 Numbness in area of distribution of Infraorbital Nerve(V2)

 Diplopia or Vertical gaze – Inferior Rectus or Inferior
Obliqus gets entrapped in fracture → inability of eyeball
to move in vertical direction.

Clinical Manifestations

 External Opthalmoplegia – Eyeball fails to move

 Internal Opthalmoplegia – Fixed Dilated pupils
(parasympathetic – III cranial nerve – Occulomotor )

 Ptosis of Upper Eyelid – upper eyelid drops
down like a curtain – parasympathetic supply.

 Orbital Apex Syndrome – If Optic Nerve
Involvement is present.

Injuries associated with blow out fractures

• Ruptured globe
• Retro orbital hemorrhage
• Vitreous hemorrhage
• Retinal detachment
• Hyphema
• Dislocated lens
• Secondary glaucoma

 Initial Opthalmological evaluation –

1. Periorbital Examination- Palpation orbital rim
2. visual acuity – SNELLEN CHART
3. ocular motility – FORCED DUCTION TEST
4. Pupillary responses- size, shape & symmetry& light reactivity
5. Visual fields – HESS CHART

6. Neuro Ophthalmological evaluation -Cranial nerve examination

▪ EOM
▪ Numbness check
7. Fundus examination
8. TONOMETRY – to assess IOP (Normal10-20mmHg )

9. Hertel Exopthalmometer – measure exopthalmous

Forced Duction Test

 Prior to the performance of a forced
duction test, a cotton-tipped
applicator is soaked with topical
anesthetic drops and held against
the limbus for a few minutes.

 Fine-toothed forceps are then
used to grasp the conjunctiva and
Tenon’s capsule just posterior to
the limbus.

 The patient is then asked to look in
the direction of restriction of
movement of the eye .

HESS CHART



Workup
Evaluation

Preoperative blood work should include CBC, electrolytes, coagulation profile etc.

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--orbital floor -
a) Subcutaneous emphysema
b) Soft-tissue teardrop along the roof of the maxillary sinus
c) Air fluid level in the maxillary sinus

2. CT scan--with axial and coronal views, often reveals
a. herniation of orbital fat or the inferior rectus muscle, into the

maxillary sinus.
b. occult tears and retained foreign bodies
c. fractured segments & also helps evaluate the Intra orbital

volume
d. thin cuts (2-3 mm) -the orbital floor and optic canal.

3. MRI

34

Rt coronal –medial wall #(1)

Lt coronal –medial &
inferior walls # (2)

Lt coronal –medial,
inferior & lateral walls # (3)

CT- 3D reconstruction- Computer guided surgical planning

CT 3D
Reconst
ruction

CT- 3D reconstruction- Computer guided surgical planning

CT 3D
Reconst
ruction

CT- 3D reconstruction- Computer guided surgical planning

(DICOM) CT 3D
Reconst
Digital imaging and ruction
communications in medicine
(DICOM) data of the CT
scans
-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.

CT- 3D reconstruction- Computer guided surgical planning

3D Slicer software CT 3D
Reconst
The skull bone was segmented from ruction
DICOM volumetric data using 3D
Slicer software by Hounsfield unit
thresholding.

(DICOM)

Digital imaging and
communications in medicine
(DICOM) data of the CT
scans
-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.

CT- 3D reconstruction- Computer guided surgical planning

3D Slicer software 3D reconstruction

The skull bone was segmented from The software converts the data
DICOM volumetric data using 3D for 3D reconstruction in the
Slicer software by Hounsfield unit axial, coronal &
thresholding. sagittal views..

(DICOM) CT 3D
Reconst
Digital imaging and ruction
communications in medicine
(DICOM) data of the CT
scans
-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.

CT- 3D reconstruction- Computer guided surgical planning

3D Slicer software 3D reconstruction Symmetricity

The skull bone was segmented from The software converts the data The scan is adjusted by
DICOM volumetric data using 3D for 3D reconstruction in the anatomical landmarks for
Slicer software by Hounsfield unit axial, coronal & symmetry.
thresholding. sagittal views..

(DICOM) CT 3D
Reconst
Digital imaging and ruction
communications in medicine
(DICOM) data of the CT
scans
-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.

CT- 3D reconstruction- Computer guided surgical planning

3D Slicer software 3D reconstruction Symmetricity

The skull bone was segmented from The software converts the data The scan is adjusted by
DICOM volumetric data using 3D for 3D reconstruction in the anatomical landmarks for
Slicer software by Hounsfield unit axial, coronal & symmetry.
thresholding. sagittal views..
Mirroring
(DICOM) CT 3D
Reconst Planning is performed by
Digital imaging and ruction mirroring the unaffected
communications in medicine side to the side where
(DICOM) data of the CT reconstruction is necessary..
scans
-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.

3D CT-reconstruction
of Orbital fracture



Management

▪ ABC Non surgical
▪ C-Spine Analgesia
▪ Nurse Head up
▪ Ice affected area

▪ Broad spectrum antibiotics - Elderly patients -antibiotics

given preoperatively and continued for 2 weeks

postoperatively

▪ Steroids- to decrease severe orbital edema

▪ to avoid nose blowing for several weeks - to prevent

orbital emphysema and possible visual compromise.

Indications for Surgery

• Retrobulbar haematoma
• Diplopia
• Enophthalmos >2 mm
• Substantial soft tissue herniation into

maxillary sinus
• Displaced fracture esp if palpable step at rim

Contraindications to surgery

• Hyphema
• Retinal detachment
• Globe perforation
• Only seeing eye
• Medically unstable patient

Three important apertures at the apex of bony orbit
1.Optic canal
2.Superior orbital fissure
3.Inferior orbital fissure

Connects to pterygopalantine fossa
Located between floor and lateral
wall Transmits:

1. Infra orbital Artery
2. Maxillary division Trigeminal N
3. Zygomatic Nerve
4. Sphenopalatine Ganglion Br

5.Ophthalmic Vein Branches

Distance of Vital Orbital Structures from Bony Landmarks

STRUCTURE REFERENCE MEAN DISTANCE (mm)
LANDMARK 24
Midpoint of inferior
orbital fissure Infraorbital foramen
Anterior Ethmoidal
Foramen Anterior Lacrimal crest 24
Optic Canal (medial Anterior Lacrimal Crest 42
aspect)
Optic Canal (Superior Supraorbital notch 45
Aspect)
Superior orbital Fissure Supraorbital Notch 40

Superior Orbital Fissure Zygomaticofrontal suture 35

Peterson’s Principles of Oral and Maxillofacial Surgery ; 2nd Edition ; Page – 465

Limit of Dissection

 Inferiorly(Floor) – Upto 28-30mm (safe limit) –
optic canal is at around 40mm

 Laterally – Superior Orbital Fissure

 Superiorly – Orbital roof dissection is stopped at
periorbital surrounding Recurrent Meningeal
Artery – passing through bony canal within the
Sphenofrontal suture line

 Medially – Posterior extent – Posterior Ethmoidal
vessels , running in the Fronto-Ethmoidal Suture
line Anterior to Optic foramen.

Limit of Dissection

Medial & inferior wall- section
with vital structures

Superior, lateral & inferior wall- section
with vital structures

ORBITAL # -Surgical process- Flow Diagram

5 Immediate post op
1.Immediate- vision, no afferent pupil, proptosis or increased IOP
2. 1st post op- vision, pupils, motility, and intraocular pressure.

4 Orbital implants

implants based on degree of
comminution & size of fracture

3 Orbital floor dissection

subperiosteal dissection of anterior maxilla &
orbital floor.
adequate exposure of the fractured area

2 Surgical approach

1.LowerEyelid –a)Subciliary, b)Subtarsal,
c) Infraorbital
2.Transconjuctival Approach – Lower Eyelid
.

1 Pre op-Medical

steroids - decrease severe orbital edema
Elderly patients -antibiotics given
preoperatively (2 weeks).

Surgical Approaches

SURGICAL MANAGEMENT :
1. Transconjunctival approach

2.Transcutaneous
• Subciliary

3.CLOSED REDUCTION –
 Trans antrally.- Caldwell Luc Procedure
 Trans nasally – Through inferior turbinate – foley’s catheter

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..

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