What is the non-operative management for a Subdural Hematoma (SDH) orbital fracture?

Non-Operative Management of Orbital Fractures

Non-operative management is appropriate for orbital fractures with minimal diplopia (not affecting primary or downgaze), good ocular motility, and without significant enophthalmos or hypoglobus. 1

Initial Assessment and Monitoring

• Perform a thorough examination including vision testing, pupillary examination, IOP measurement, visual field testing, slit-lamp examination, fundus examination, facial sensation testing, and exophthalmometry to rule out globe injury or sight-threatening conditions 1
• Conduct detailed sensorimotor examination with attention to versions, ductions, saccades, pursuit, vergence, and alignment in multiple gaze positions 1
• Use forced duction and forced generation testing to distinguish restriction from paresis of extraocular muscles 1
• Monitor vital signs for bradycardia or heart block, which may indicate oculocardiac reflex requiring urgent intervention 1
• Obtain appropriate imaging - CT scan is preferred if there's concern about metallic foreign bodies; MRI provides better visualization of extraocular muscles and surrounding tissues 1

Conservative Treatment Approach

• A short burst of oral steroids can hasten recovery and help identify strabismus that will persist despite resolution of orbital edema/hematoma 1
• Watchful waiting for 4-6 months is recommended as many cases of strabismus after orbital trauma will improve with time 1
• For symptomatic diplopia, use conservative measures such as:
  • Occlusion therapy 1
  • Filters 1
  • Fresnel prisms 1
  • Botulinum toxin injection 1
  • Prism glasses for temporary or permanent relief of diplopia 1

Monitoring Protocol

• Post-injury observation is important - most surgeons (64%) observe patients overnight following surgical repair, though selected patients may be managed as outpatients 2
• Regular follow-up examinations to assess for:
  • Resolution of diplopia 1
  • Improvement in ocular motility 1
  • Development of enophthalmos or hypoglobus 1
  • Changes in infraorbital sensation 1

Special Considerations

• Patients with orbital fractures can continue normal fitness activities but should avoid contact or collision sports during the healing period 3
• For patients on anticoagulants like apixaban who may eventually need surgery, medication should be managed appropriately - typically stopping 48 hours before surgery for those with normal renal function 4
• Be vigilant for rare complications such as retrobulbar hematoma, which occurs in approximately 1.3% of surgical cases but can also occur with non-operative management 2

Indications for Surgical Intervention

• Non-operative management should be reconsidered if the following develop:
  • Persistent symptomatic diplopia in primary or downgaze position 1
  • Positive forced ductions or entrapment on CT with minimal improvement 1
  • Large floor fractures causing functional or cosmetic issues 1
  • Progressive infraorbital hypoesthesia 1
  • Development of enophthalmos or hypoglobus causing facial asymmetry 1
  • Oculocardiac reflex (bradycardia, nausea, vomiting) indicating muscle entrapment 1

Expected Outcomes

• Even with appropriate management (surgical or non-operative), strabismus and diplopia can persist - one study showed 37% of patients had diplopia even after surgical repair 1
• The prognosis for isolated orbital fractures without muscle entrapment or significant displacement is generally good with conservative management 3