What is the recommended treatment for an orbital floor fracture, specifically regarding Open Reduction and Internal Fixation (ORIF)?

ORIF of Orbital Floor Fracture: Treatment Recommendations

The decision to perform ORIF of an orbital floor fracture depends critically on specific clinical and radiographic findings, with timing stratified into immediate repair (for muscle entrapment with oculocardiac reflex), repair within 1-2 weeks (for symptomatic diplopia with entrapment, large fractures, or enophthalmos), delayed repair (for persistent restrictive strabismus), or observation (for minimal symptoms without significant functional impairment). 1

Immediate Surgical Repair (Emergent)

Proceed with immediate ORIF for the following life-threatening or vision-threatening conditions:

• Entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex (bradycardia, heart block, nausea, vomiting, loss of consciousness) confirmed on CT or MRI 1, 2
• White-eyed blow-out fracture (trap-door fracture with muscle entrapment and oculocardiac reflex, particularly in children with elastic cancellous bone) 1, 2
• Globe subluxation into the maxillary sinus (rare but demands immediate repair) 1

Critical pitfall: The oculocardiac reflex can be life-threatening and requires urgent medical and surgical intervention—monitor vital signs closely in all orbital trauma patients 1, 2

Repair Within 1-2 Weeks (Urgent)

Perform ORIF within 1-2 weeks for patients with:

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

The 1-2 week window permits adequate time for edema to subside while allowing re-evaluation of globe position and motility before permanent fibrotic changes occur 1

Delayed Repair (After 2 Weeks to 4-6 Months)

Consider delayed ORIF for:

• Persistent restrictive strabismus after the acute phase 1
• Unresolved enophthalmos 1

For patients without muscle entrapment, wait 4-6 months after orbital trauma before considering strabismus surgery, as spontaneous resolution may occur unless substantial fat and orbital pulley entrapment is present 1, 2

Important consideration: A short burst of oral steroids can hasten recovery and unmask persistent strabismus after orbital edema/hematoma resolution 1

Observation (No Surgery)

Observation is appropriate for:

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

Conservative management includes occlusion, filters, Fresnel prisms, botulinum toxin injection, and prism glasses for temporary or permanent diplopia relief 1

Surgical Approach and Materials

When ORIF is indicated:

• Transconjunctival approach with lateral canthotomy is the most commonly used and effective method, minimizing ectropion risk compared to subciliary approaches 3, 4
• Titanium mesh is used for larger fractures 3, 4
• Porous polyethylene (Medpor) or polydioxanone sheets are effective for smaller defects 3, 4
• Combined open reduction with transantral endoscopy provides superior visualization of the posterior bony shelf and confirms adequate soft tissue reduction in complex cases 5

Essential Preoperative Evaluation

Before any surgical decision:

• CT imaging is the gold standard for detecting fractures and muscle entrapment (MRI provides better soft tissue detail but requires exclusion of metallic foreign bodies) 1, 2
• Forced duction testing distinguishes restriction (positive test) from paresis (negative test) 1, 2
• Rule out globe injury or sight-threatening conditions before addressing strabismus (5.5% complete vision loss in one eye, 0.8% bilateral vision loss in facial fracture series) 1

Expected Outcomes and Realistic Expectations

• Even with optimal repair, 37% of patients have persistent diplopia postoperatively (compared to 86% preoperatively) 1, 2
• Fat entrapment can be as challenging as muscle entrapment, resulting in fibrotic adhesion syndromes not easily relieved by dissection 1, 2
• Multiple operations and supplementation with prism glasses may be required 1
• Goals should focus on eliminating diplopia in primary position and downgaze while enlarging the field of binocular single vision 1