Orbit Fractures

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Orbit Fractures

Trauma
Author Credentials 

Jared M. Theler, MD
Chief Facial Plastics and Reconstructive Surgery
Department of Otolaryngology
Tripler Army Medical Center
​1 Jarrett White Road
Tripler AMC, Hawaii 96859-5000
Jared.m.theler.mil@mail.mil

Module Summary

Orbital Fractures are the third most common facial fracture with numerous pre, intra and post-operative complications associated with them. Early recognition and treatment of orbital compartment syndrome is paramount to saving eyesight via canthotomy and cantholysis intervention in close consultation with ophthalmology when possible. Diplopia and enophthalmos are the two most common indications for repair and are ideally treated within 14 days of injury, but can be treated successfully even years later. Detailed understanding of the orbital anatomy is paramount in safely approaching and treating this common traumatic injury.

Module Learning Objectives 
  1. Explain the basic anatomy of orbit and how it relates to orbital trauma and reconstruction.
  2. Define the different layers of the upper and lower eyelid (Lamella) and how to recognize injury to these layers to allow proper re-approximation after injury.
  3. Perform a comprehensive exam of the orbit and recognize the clinical and radiological indications for surgical treatment.
  4. Distinguish between the need for emergent surgical intervention, delayed surgery and close observation based on the clinical picture.
  5. Review the different surgical approaches to the orbit and their distinct advantages and disadvantages.
  6. Recognize the different pitfalls within surgery that can compromise vision and post-operative lid and globe position.
  7. Review the most feared post-operative complications from orbital surgery and how to recognize and treat them.

Anatomy

Learning Objectives 
  1. Describe the bony anatomy of the orbit and recognize the significance of the 3 dimensional orbito-sphenoid suture line in assuring proper alignment of ZMC fractures of the orbit.
  2. Understand the relationship of the medial canthal ligament and the lacrimal system.
  3. Describe the function and contents of the orbital apex.
  4. Be able to differentiate the different layers of the upper and lower eyelid (also known as the anterior and posterior lamella).
References 
  1. PMID: 15710133 Aviv RI, Casselman J: Orbital imaging: Part 1. Normal anatomy.Clin Radiol. 2005 Mar;60(3):279-87.
  2. PMID: 17097776 B.T. Evans, A.A.C. Webb: Post-traumatic orbital reconstruction: Anatomical landmarks and the concept of the deep orbit. British Journal of Oral and Maxillofacial Surgery. 2007 April;45(3);183-189.
  3. PMID: 9413359 Burns JA, Park SS: The zygomatic-sphenoid fracture line in malar reduction. A cadaver study. Arch Otolaryngol Head Neck Surg. 1997 Dec;123(12):1308-11.
  4. PMID: 27888891. Chambers CB, Moe KS: Periorbital Scar Correction. Facial Plast Surg Clin North Am. 2017 Feb;25(1):25-36.
  5. PMID: 27105794. Sand JP, Zhu BZ, Desai SC: Surgical Anatomy of the Eyelids. Facial Plast Surg Clin North Am. 2016 May;24(2):89-95.

Pathogenesis

Learning Objectives 
  1. Understand the basic concept of the crumple zone and sinus’s within the face.
  2. Describe the hydraulic principle and how it relates to orbital floor fractures.
References 
  1. PMID: 10658130 Waterhouse N1, Lyne J, Urdang M, Garey L: An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg. 1999 Dec;52(8):607-12.

Incidence

Learning Objectives 
  1. Majority of Orbital Trauma is associated with blunt force trauma.
  2. Concomitant zygomatic, Lefort II and III and NOE fractures need to be assessed.
References 
  1. Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of 727 cases. Otolaryngol Head Neck Surg. 1983 Jun;91(3):276-9.

Patient Evaluation

Learning Objectives 
  1. Be able to assess normal extraoccular movements, diplopia, entrapment, trapdoor blowout fracture, hyper/hypoglobus, ex/enopthalmos and normal lid positions.
  2. Basic grasp of how intraocular pressure is measured and that this is only an indirect measure of intra-orbital pressure.
References 
  1. PMID: 10371897 Patel BC,Hoffmann J: Management of complex orbital fractures. Facial Plast Surg. 1998;14(1):83-104.
  2. PMID: 25880995 Mohammadi F, Rashan A, Psaltis A, Janisewicz A, Li P, El-Sawy T, Nayak JV: Intraocular pressure changes in emergent surgical decompression of orbital compartment syndrome. JAMA Otolaryngol Head Neck Surg. 2015 Jun;141(6):562-5.

Measurement of Functional Status

Learning Objectives 
  1. Consult Ophthalmology in all cases to assess baseline gross vision and understand other ophthalmologic causes that can complicate treatment.
    1. Glaucoma
    2. Hyphema
    3. Ant/Poster Chamber Injury
    4. Retinal Detachment
    5. Orbital Apex Syndrome
  2. Diplopia can be elicited in healthy normal patient past 30 degrees off axis.

Imaging

Learning Objectives 
  1. Be able to assess different methods for determining need for orbital floor fracture repair:
    1. Greater than 50% floor fracture
    2. Rectus muscle entrapment
    3. Herniation of orbital fat into the ethmoid and maxillary sinus
    4. Occulocardiac Reflex
  2. Recognize the posterior slope of the orbital floor and how this can complicate implant placement.
References 
  1. PMID: 24756375 Betts AM, O'Brien WT, Davies BW, Youssef OH: A systematic approach to CT evaluation of orbital trauma. Emerg Radiol. 2014 Oct;21(5):511-31.
  2. PMID: 28005760 Bruneau S, De Haller R, Courvoisier DS, Scolozzi P: Can a Specific Computed Tomography-Based Assessment Predict the Ophthalmological Outcome in Pure Orbital Floor Blowout Fractures? J Craniofac Surg. 2016 Nov;27(8):2092-2097.

Pathology

Learning Objectives 
  1. Recognize Orbital Compartment syndrome and it’s need for urgent intervention.
    1. Rapid decrease in vision
    2. Pain out of proportion to injury
    3. Fixed globe and minimal extraoccular movements
    4. Tight Globe with decreased retropulsion on palpation
    5. Exophthalmos
  2. Understand how enophthalmos is measured and when to intervene.
References 
  1. PMID: 19539832 Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D: Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol. 2009 Jul-Aug;54(4):441-9.
  2. PMID: 15062312 Kellman RM, Bersani T: Delayed and secondary repair of posttraumatic enophthalmos and orbital deformities. Facial Plast Surg Clin North Am. 2002 Aug;10(3):311-23.

Treatment

Learning Objectives 

Understand ideal timing of treatment.

References 
  1. PMID: 26275096. Scawn RL1, Lim LH, Whipple KM, Dolmetsch A, Priel A, Korn B, Kikkawa DO: Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury. Ophthal Plast Reconstr Surg. 2016 Jul-Aug;32(4):296-301.
  2. PMID: 27165680 Damgaard OE, Larsen CG, Felding UA, Toft PB, von Buchwald C: Surgical Timing of the Orbital "Blowout" Fracture: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2016 Sep;155(3):387-90.

Medical Therapies

Learning Objectives 

Protocol use of diuretics/osmotic agents and steroids in the treatment of orbital compartment syndrome refractory to surgical management.

References 
  1. PMID: 25844506 Johnson D, Winterborn A, Kratky V: Efficacy of Intravenous Mannitol in the Management of Orbital Compartment Syndrome: A Nonhuman Primate Model. Ophthal Plast Reconstr Surg. 2016 May-Jun;32(3):187-90.

Surgical Therapies

Learning Objectives 
  1. Understand advantages and disadvantages of the following approaches to the orbit:
    1. Orbital Floor
      1. Lower Lid
        1. Transconjunctival
          1. Fornix /Retroseptal approach
          2. Preseptal Approach
        2. Subcilliary
        3. Subtarsal
      2. Endoscopic/Trans-antral
    2. Medial Wall Fractures
      1. Transcaruncular/Retrocaruncular
      2. Endoscopic/Trans-nasal
    3. Orbital Roof Fractures and Orbitofrontal
      1. Superior Lid Crease Incision
      2. Coronal
      3. Lateral Brow
    4. Canthotomy/Cantholysis
References 
  1. ISBN-13: 978-0781754996 Surgical Approaches to the Facial Skeleton, Second Edition. Edward Ellis III DDS MS, Michael F. Zide DDS.
  2. PMID: 19467402 Ducic Y, Verret DJ: Endoscopic transantral repair of orbital floor fractures. Otolaryngol Head Neck Surg. 2009 Jun;140(6):849-54
  3. PMID: 25954840 Kempton SJ, Cho DC, Thimmappa B, Martin MC: Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study. Ann Plast Surg. 2016 Mar;76(3):295-300.

Case Studies

  1. A 24 year-old male presents to your ER department with significant right orbital pain after blunt force trauma to the eye during a fight 2 hours previous. He has significant swelling of the right periorbital soft tissue with 4mm of exophthalmos compared to the contralateral eye. He has only light perception in the eye when holding the eyelid open and no extraoccular movements upon testing. His orbit feels tense and he has decreased retropulsion and significant pain when pushing on the orbit. He noted normal vision prior to the fight and 10/10 pain currently. What is your initial diagnosis? What would your next step in treatment be (Urgent CT scan, Urgent Surgical Intervention, Medical therapy, Bedside Canthotomy and Cantholysis)?
  2. A 51 year old female presents to you clinic status post fall after a loss of consciousness of unknown cause two weeks prior. She was noted to have significant swelling, pain and bruising of her left eye with a small laceration noted under the left orbital rim initially. Most of this has resolved, but she notes that she currently has double vision that does not appear to be getting better. She would like to know if this will be permanent and what if anything can be done for her? What would you expect to see on CT scan? What risks would you counsel her for in regards to surgical intervention? What surgical approach would you like to pursue?

Complications

Learning Objectives 
  1. Recognize retro bulbar hematomas and know how to treat them emergently.
  2. Understand the incidence and cause of pre/post-operative diplopia and when to intervene.
  3. Recognize postoperative entropion, extropion, lacrimal system dysfunction.
  4. Understand the pitfalls of improper implant placement that can cause:
    1. Optic nerve compression
    2. Exophthalmos
    3. Hyperglobus
References 
  1. PMID: 24874836 Harris. GJ: Avoiding complications in the repair of orbital floor fractures. JAMA Facial Plast Surg. 2014 Jul-Aug;16(4):290-5.
  2. PMID: 27162565 Kesselring AG, Promes P, Strabbing EM, van der Wal KG, Koudstaal MJ. Lower Eyelid Malposition Following Orbital Fracture Surgery: A Retrospective Analysis Based on 198 Surgeries. Craniomaxillofac Trauma Reconstr. 2016 Jun;9(2):109-12.
  3. PMID: 27899021 Ramphul A, Hoffman G: Does Preoperative Diplopia Determine the Incidence of Postoperative Diplopia After Repair of Orbital Floor Fracture? An Institutional Review. J Oral Maxillofac Surg. 2017 Mar;75(3):565-575.
  4. PMID: 20466466 Ethunandan M1, Evans BT: Linear trapdoor or "white-eye" blowout fracture of the orbit: not restricted to children. Br J Oral Maxillofac Surg. 2011 Mar;49(2):142-7.

Review

Review Questions 
  1. How do you recognize and treat orbital compartment syndrome?
  2. What are the different indications for repair of orbital fractures?
  3. What are the different approaches to the orbit for surgical repair of the floor, rim and medial wall?
  4. What are common post-operative complications?
  5. What is the optima timeframe for intervention?
Resources 

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  1. Annual Meeting Webcast (AMW):