Acute Treatment of Inferior Orbital Wall Fractures
Treatment decisions for inferior orbital wall fractures depend critically on the presence of muscle entrapment, oculocardiac reflex, and degree of functional impairment, with immediate surgery required for entrapped tissue causing bradycardia or persistent nausea, repair within 2 weeks for symptomatic diplopia with positive forced ductions or large fractures, and observation for minimal symptoms without significant enophthalmos. 1
Immediate Life-Threatening Assessment
Before addressing the fracture itself, rule out vision-threatening conditions, as 24% of blowout fractures have serious ocular injury and 5.5% result in complete vision loss in one eye. 2 Monitor vital signs for bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness—these indicate oculocardiac reflex from muscle entrapment requiring urgent intervention. 1, 2
Obtain CT imaging (not MRI if metallic foreign body is possible) to assess fracture extent and tissue entrapment. 1, 2
Surgical Timing Algorithm
Immediate Repair (Within 24-48 Hours)
Proceed directly to surgery for: 1
- CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1, 2
- White-eyed blowout fracture (trapdoor fracture with muscle entrapment, particularly in children) 1
- Globe subluxation into the maxillary sinus 1
Repair Within 1-2 Weeks
Schedule early surgical repair for: 1
- Symptomatic diplopia with positive forced ductions or CT evidence of entrapment showing minimal improvement over time 1
- Large floor fractures with hypoglobus 1
- Progressive infraorbital hypoesthesia 1
- Early enophthalmos or hypoglobus causing facial asymmetry (will not resolve spontaneously) 1
- Significant fat or periorbital tissue entrapment (can cause permanent strabismus even without muscle entrapment) 1
The 1-2 week window allows edema to subside while preventing permanent fibrotic changes. 1
Observation Without Surgery
Conservative management is appropriate for: 1
- Minimal diplopia not affecting primary position or downgaze 1
- Good ocular motility 1
- No significant enophthalmos or hypoglobus 1
- Fracture defects less than 3 cm² with enophthalmos less than 2mm and no tissue entrapment 3
Conservative Management During Observation
Administer a short burst of oral corticosteroids to hasten recovery and unmask persistent strabismus that will remain after edema resolves. 1, 2 This is a key early intervention that can clarify the need for delayed surgery.
Wait 4-6 months before considering strabismus surgery, as many cases resolve spontaneously unless substantial fat and orbital pulley entrapment is present. 1, 2
During the observation period, use: 1, 2
- Occlusion for diplopia management 1, 2
- Fresnel prisms for temporary relief 1, 2
- Prism glasses for temporary or permanent diplopia relief 1, 2
- Botulinum toxin injection in select cases 1, 2
Critical Pitfalls and Caveats
Even with optimal surgical repair, 37% of patients have persistent postoperative diplopia, so set realistic expectations. 1, 2 Preoperatively, 86% had diplopia; this only improves to 63% being diplopia-free postoperatively. 1
Perform forced duction and forced generation testing to distinguish restriction from paresis—this is critical for surgical planning. 1, 2 This testing should be done both preoperatively and intraoperatively. 1
Fat entrapment is nearly as problematic as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection. 1, 2 Adhesions may extend deep into the orbit beyond surgical reach. 1
Fractures of the anterior orbit (anterior third of medial wall) cause more severe diplopia than posterior fractures, even when the posterior defect is larger. 3 This means defect size alone should not drive surgical decisions.
The degree of enophthalmos correlates well with fracture size, but diplopia and ocular motility do not. 3 Therefore, functional assessment trumps radiographic measurements.