What is the treatment for an orbital fracture?

Treatment of Orbital Fractures

The treatment of orbital fractures is determined by the presence of muscle entrapment, oculocardiac reflex, and degree of functional impairment, with immediate surgical repair required for entrapped tissue causing oculocardiac reflex, repair within 2 weeks for symptomatic diplopia with entrapment, and observation for minimal symptoms without significant anatomical disruption. 1

Initial Assessment and Life-Threatening Conditions

Before addressing the fracture itself, all life-threatening and vision-threatening conditions must be treated first, as serious ocular injury occurs in 24% of orbital fracture cases, with complete vision loss occurring in 5.5% of patients with facial fractures 1.

Monitor vital signs closely for bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness—these indicate an entrapped muscle causing oculocardiac reflex, which can be life-threatening and requires urgent medical and surgical intervention 1.

Imaging

• CT scan is the preferred imaging modality and is required if there is any concern about ferrous-metallic foreign bodies 1, 2
• MRI provides more precise imaging of extraocular muscles and surrounding tissues but is contraindicated with metallic foreign bodies 1

Surgical Timing Algorithm

Immediate Repair (Emergency)

Proceed to surgery immediately for:

• CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1
• White-eyed blowout fracture (trapdoor fracture with muscle entrapment and oculocardiac reflex, typically in children) 1
• Globe subluxation into the maxillary sinus 1

Repair Within 1-2 Weeks (Urgent)

Surgery within 2 weeks is indicated for:

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

Delayed Repair (After 2 Weeks)

Consider delayed surgical repair for:

• Restrictive strabismus that persists beyond 4-6 months 1
• Unresolved enophthalmos after observation period 1

Observation Only

Observation is appropriate for:

• Minimal diplopia not affecting primary position or downgaze 1
• Good ocular motility without significant enophthalmos or hypoglobus 1

Conservative Management During Observation Period

Wait 4-6 months after orbital trauma before considering strabismus surgery, as many cases resolve spontaneously unless there is substantial fat and orbital pulley entrapment suggesting earlier intervention 1.

Conservative treatments include:

• Short burst of oral steroids to hasten recovery and reveal persistent strabismus after edema resolution 1
• Occlusion, filters, Fresnel prisms, and prism glasses for temporary or permanent diplopia relief 1
• Botulinum toxin injection may provide symptomatic relief 1

Critical Pitfalls to Avoid

Do not delay surgery in patients with oculocardiac reflex—this is a medical emergency that can be life-threatening 1. The presence of bradycardia with orbital trauma should trigger immediate surgical consultation.

Do not assume minimal initial symptoms mean no intervention needed—early enophthalmos and hypoglobus will not resolve spontaneously and require repair within 2 weeks to prevent permanent deformity 1.

Perform forced duction testing to distinguish muscle restriction from paresis, as this fundamentally changes surgical planning 1.

Surgical Considerations

When surgery is indicated:

• Preoperative and intraoperative forced duction testing is essential 1
• Fat entrapment can be as challenging as muscle entrapment, causing fibrotic adhesion syndromes 1
• Multiple surgeries may be required, and complete elimination of diplopia is often not achievable 1
• Adjustable sutures are helpful in these complex cases 1

The goal is to eliminate diplopia in primary position and downgaze while enlarging the field of binocular single vision 1.