Management of Orbital Exophthalmos with Blowout Fractures
The management of orbital exophthalmos with blowout fractures requires a tiered approach based on clinical presentation, with immediate surgical repair indicated for muscle entrapment with oculocardiac reflex, while most other cases should be repaired within 2 weeks to prevent permanent complications. 1
Initial Assessment and Triage
Immediate Life-Threatening and Vision-Threatening Conditions
- Rule out and address life-threatening conditions first
- Assess for oculocardiac reflex (bradycardia, heart block, dizziness, nausea, vomiting, loss of consciousness) which requires urgent intervention 1
- Check for serious ocular injury (present in 24% of blowout fractures) 1
Imaging Studies
- CT scan is the first-line imaging (94.9% sensitivity for detecting fractures) 2
- Avoid MRI if metallic foreign body suspected
- MRI provides better visualization of extraocular muscles and pulley system when needed 1
Clinical Examination
- Detailed sensorimotor examination:
- Versions, ductions, saccades, pursuit, vergence, near reflex
- Alignment in multiple gaze positions
- Forced duction and forced generation testing to distinguish restriction from paresis 1
- Double Maddox rod, Lancaster red-green, or Hess screen tests as needed
Surgical Management Algorithm
1. Immediate Surgical Repair (Emergency)
- CT evidence of entrapped muscle/periorbital tissue with nonresolving oculocardiac reflex 1
- White-eyed blowout fracture with muscle entrapment and oculocardiac reflex (particularly in children) 1
- Globe subluxation into maxillary sinus 1
- "Missing muscle syndrome" where the inferior rectus muscle cannot be visualized on contiguous CT cuts 3
2. Early Repair (Within 2 Weeks)
- Symptomatic diplopia with positive forced ductions or entrapment on CT with minimal improvement 1
- Large floor fractures with hypoglobus 1
- Progressive infraorbital hypoesthesia 1
- Early enophthalmos or hypoglobus causing facial asymmetry 1
- Significant fat or periorbital tissue entrapment (can cause permanent strabismus even without muscle entrapment) 1
3. Delayed Repair (After 2 Weeks)
- Restrictive strabismus that persists after initial observation 1
- Unresolved enophthalmos 1
- For enophthalmos correction, over 60% of operations can be performed after 1 month 4
4. Observation Only
- Minimal diplopia not affecting primary gaze or downgaze 1
- Good ocular motility 1
- No significant enophthalmos or hypoglobus 1
Post-Surgical Management
Immediate Postoperative Care
- Most patients require overnight observation (64% of surgeons practice this) 5
- Monitor for retrobulbar hematoma (1.3% incidence), which requires emergency intervention 5
- Short course of oral steroids (e.g., dexamethasone) to reduce postoperative swelling and uncover persistent strabismus 1, 2
Long-Term Management of Residual Issues
- Even with optimal repair, diplopia may persist in 37% of patients postoperatively 1, 6
- For persistent strabismus:
Important Caveats
- Surgical timing significantly impacts outcomes - repair within two weeks decreases residual diplopia 6
- Older patients are more likely to have residual postoperative diplopia 6
- Orbital fat entrapment can be as challenging as muscle entrapment, causing fibrotic and adhesion syndromes 1
- Adhesion of extraocular muscles to porous implants can complicate recovery 1
- Forced duction testing both preoperatively and intraoperatively is critical for optimal outcomes 1
- The burst-type floor fracture has the highest likelihood of requiring surgical intervention 4
Remember that clinical examination of ocular motility is more crucial than CT findings alone in determining the presence of motility limitations requiring intervention 7.