Dexamethasone for Swelling After Orbital Floor Fracture Repair
A short course of oral steroids like dexamethasone (Decadron) can effectively reduce postoperative swelling after orbital floor fracture repair and help uncover any persistent strabismus that may remain after edema resolution. 1
Mechanism and Benefits of Dexamethasone
Dexamethasone works by:
- Reducing inflammatory response
- Decreasing capillary permeability
- Inhibiting inflammatory mediators
This leads to several clinical benefits:
- Faster resolution of orbital edema and hematoma
- Earlier assessment of true ocular alignment
- Potentially reduced risk of fibrosis and adhesion formation
- Improved patient comfort during recovery
Dosing and Administration
Based on current guidelines, a tapering course of dexamethasone is recommended:
- Day of surgery: 8 mg once daily
- First day after surgery: 6 mg once daily
- Second day after surgery: 4 mg once daily
- Third day after surgery: 2 mg once daily 1
Timing Considerations for Orbital Floor Fracture Management
The timing of surgical intervention and steroid administration is critical:
Immediate Surgical Repair (No Delay)
- Entrapped muscle or periorbital tissue with oculocardiac reflex
- White-eyed blowout fracture with muscle entrapment (especially in children)
- Globe subluxation into maxillary sinus 1
Early Repair (Within 2 Weeks)
- Symptomatic diplopia with positive forced ductions or entrapment
- Large floor fractures with hypoglobus
- Progressive infraorbital hypoesthesia
- Early enophthalmos or hypoglobus causing facial asymmetry 1
Delayed Repair or Observation
- Minimal diplopia (not affecting primary gaze or downgaze)
- Good ocular motility without significant enophthalmos
- Cases without muscle entrapment may be observed for 4-6 months as strabismus may resolve spontaneously 1
Post-Operative Care and Recovery
- Patients should avoid strenuous physical activity for 7-10 days
- Avoid sudden pressure changes (e.g., air travel)
- If sneezing is unavoidable, do so with mouth open
- Continue antibiotic therapy as prescribed
- Follow-up within 10-14 days for suture removal and assessment 1
Potential Complications to Monitor
- Persistent diplopia (occurred in 37% of patients postoperatively in one series) 1
- Inferior rectus muscle swelling (may mimic persistent entrapment) 2
- Adhesion of extraocular muscles to implants 1
- Subacute sinusitis (rare but serious complication) 1
Return to Normal Activities
Orbital floor strength is typically regained approximately 24 days after repair, regardless of the material used for reconstruction. Patients can generally resume normal activities about 3 weeks after uncomplicated orbital floor fracture repair 3.
Important Caveats
- If postoperative imaging shows enlargement of the inferior rectus muscle but no evidence of residual entrapment, conservative management with steroids may be warranted before considering reoperation 2
- Steroids should be used with caution in patients with diabetes, hypertension, or other contraindications
- Steroid therapy should not replace proper surgical technique and anatomical reduction of fractures
- CT imaging remains the gold standard for evaluating orbital trauma with 94.9% sensitivity for detecting fractures and foreign bodies 1, 4