What is the treatment for an orbital wall fracture?

Treatment of Orbital Wall Fractures

The treatment of orbital wall fractures is determined by the presence of muscle entrapment, oculocardiac reflex, and the degree of functional impairment—with immediate surgical repair required for entrapped muscle with oculocardiac reflex, repair within 2 weeks for symptomatic diplopia with entrapment or large fractures, and observation for minimal symptoms without significant enophthalmos. 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 blowout fractures and complete vision loss occurs in 5.5% of one eye and 0.8% of both eyes in facial fracture patients. 1

Monitor vital signs carefully 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

Obtain CT imaging rather than MRI if any concern exists about ferrous-metallic foreign body; CT provides sufficient information about fracture presence and entrapment. 1 MRI provides more precise imaging of extraocular muscles and surrounding tissues when needed for surgical planning. 1

Surgical Timing Algorithm

Immediate Repair (Emergent)

Proceed to immediate surgical repair for: 1

• CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex
• White-eyed blowout fracture (trapdoor fracture with muscle entrapment and oculocardiac reflex, particularly in children) 1, 2
• Globe subluxation into the maxillary sinus (rare but demands immediate repair) 1

Repair Within 1-2 Weeks

Schedule surgical repair within 2 weeks for: 1

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment with minimal improvement over time (allows edema to subside for proper assessment) 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, 3

Delayed Repair (After 2 Weeks)

Consider delayed repair for: 1

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

Observation Only

Observe without surgery for: 1

• Minimal diplopia (not in primary position or downgaze) 1
• Good ocular motility without significant enophthalmos or hypoglobus 1
• Nondisplaced fractures without entrapment 2

Conservative Management During Observation Period

Wait 4-6 months after orbital trauma before considering strabismus surgery, as many cases resolve spontaneously—unless substantial fat and orbital pulley entrapment is present, which benefits from earlier repair. 1

A short burst of oral steroids can hasten recovery and reveal persistent strabismus that will remain after orbital edema/hematoma resolution. 1

Conservative treatments during the observation period include: 1

• Occlusion for diplopia management 1
• Fresnel prisms for temporary relief 1
• Prism glasses for temporary or permanent diplopia relief 1
• Botulinum toxin injection in select cases 1

Important Caveats and Pitfalls

Even with proper surgical repair, diplopia persists in 37% of patients postoperatively (compared to 86% preoperatively), so set realistic expectations with patients. 1

Perform forced duction and forced generation testing to distinguish restriction from paresis—this is critical for surgical planning. 1

Fat entrapment can be nearly as challenging as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection around the involved muscle. 1

Patients with eyelid laceration, extraocular motion abnormality, and pupillary defect are more likely to require changes in ocular management, warranting ophthalmology consultation. 4

Early surgical treatment within 2 weeks significantly reduces the incidence of postoperative diplopia, enophthalmos, and infraorbital nerve dysfunction compared to delayed repair. 3

For patients requiring delayed strabismus surgery after fracture repair, wait until alignment is stable (typically 4-6 months) and use adjustable sutures when possible, as complete elimination of diplopia may not be achievable due to multifactorial etiology. 1