When is surgery indicated after a minimally displaced orbital floor fracture?

Surgical Timing for Minimally Displaced Orbital Floor Fractures

For minimally displaced orbital floor fractures without muscle entrapment, observation is the appropriate initial management approach, as most cases will improve spontaneously without surgical intervention. 1

Immediate Surgical Indications (Emergent)

Surgery must be performed immediately if any of the following are present:

• Oculocardiac reflex (bradycardia, heart block, nausea, vomiting, loss of consciousness) with CT/MRI evidence of entrapped muscle or periorbital tissue 1
• White-eyed blow-out fracture (trap-door fracture with muscle entrapment, typically in children) 1
• Globe subluxation into the maxillary sinus 1

These conditions are vision- and potentially life-threatening, requiring urgent intervention to prevent permanent muscle ischemia and dysfunction. 2

Surgery Within 1-2 Weeks

Repair within 1-2 weeks is indicated when:

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment showing minimal improvement over time 1
• Large floor fractures with significant displacement 1
• Hypoglobus or early enophthalmos causing facial asymmetry (these will not resolve spontaneously) 1
• Progressive infraorbital hypoesthesia 1
• Significant fat or periorbital tissue entrapment (can cause permanent strabismus even without direct muscle entrapment) 1, 2

The 1-2 week window permits adequate time for edema to subside while preventing permanent fibrotic changes and adhesions. 1

Observation Protocol for Minimally Displaced Fractures

Observation is appropriate when:

• Minimal diplopia (not present in primary position or downgaze) 1
• Good ocular motility without restriction 1
• No significant enophthalmos or hypoglobus 1

Conservative Management During Observation

• Wait 4-6 months before considering any surgical intervention, as strabismus frequently resolves spontaneously 1
• Consider a short burst of oral steroids to hasten recovery and unmask persistent strabismus after edema resolution 1
• Utilize conservative measures: occlusion, Fresnel prisms, prism glasses, or botulinum toxin injection for temporary or permanent diplopia relief 1
• Perform forced duction testing to distinguish restriction from paresis 1, 2

Delayed Repair (After 2 Weeks to Months)

Delayed repair may be beneficial for:

• Persistent restrictive strabismus after the observation period 1
• Unresolved enophthalmos causing functional or cosmetic concerns 1
• Delayed repair can be successful even years after injury, with significant improvement in enophthalmos (mean reduction 2.1 mm) and diplopia resolution in 50% of cases 3

Critical Pitfalls to Avoid

• Do not assume all diplopia indicates muscle entrapment—soft tissue swelling, hematoma, or nerve paresis can cause similar symptoms 2
• Monitor vital signs carefully for oculocardiac reflex signs, which constitute a medical emergency 1, 2
• Fat entrapment is as problematic as muscle entrapment and can cause permanent fibrotic changes if not addressed appropriately 1, 2
• Combined floor and medial wall fractures have higher rates of persistent postoperative diplopia (86% in one series) compared to isolated floor fractures 4
• Even with optimal surgical repair, 37% of patients may have persistent diplopia postoperatively 1

Re-evaluation Timeline

For patients not meeting early surgical criteria, re-evaluate at 4-6 months to ensure stability of alignment before considering any surgical intervention. 1 This approach maximizes spontaneous recovery while maintaining the option for delayed repair if symptoms persist.