What is the treatment for an orbital fracture?

Treatment of Orbital Fractures

Treatment of orbital fractures depends critically on the presence of muscle entrapment, oculocardiac reflex, and timing—immediate surgery is required for life-threatening oculocardiac reflex or muscle entrapment, repair within 2 weeks for symptomatic diplopia with entrapment, and observation for minimal symptoms without entrapment. 1, 2

Immediate Life-Threatening Assessment

Before addressing the fracture itself, rule out all vision-threatening and life-threatening conditions first, as 24% of blowout fractures have serious ocular injury and 5.5% result in complete vision loss in one eye 1, 2. Monitor vital signs carefully for:

• Bradycardia or heart block indicating oculocardiac reflex from entrapped muscle—this is life-threatening and requires immediate medical and surgical intervention 1, 2
• Symptoms of dizziness, nausea, vomiting, or loss of consciousness 1, 2
• Globe injury, traumatic cataract, optic neuropathy, or retinal damage 1

Essential Diagnostic Workup

Obtain CT imaging as the primary modality, particularly if any concern exists about ferrous-metallic foreign body, as CT provides sufficient information about fracture presence and muscle entrapment 1, 2. MRI can be used secondarily for more precise extraocular muscle imaging and reduces radiation exposure 1.

Perform a comprehensive examination including:

• Vision testing, refraction, pupillary exam, IOP measurement, and confrontational visual fields 1
• Detailed sensorimotor exam with versions, ductions, saccades, pursuit, and vergence 1
• Forced duction and forced generation testing to distinguish restriction from paresis—this is critical for surgical planning 1, 2
• Exophthalmometry to assess enophthalmos 1

Surgical Timing Algorithm

Immediate Repair (Within 24-48 Hours)

Proceed to immediate surgical repair for: 1, 2

• CT 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)
• Globe subluxation into the maxillary sinus

Repair Within 2 Weeks

Schedule surgical repair within approximately 2 weeks for: 1, 2, 3

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

Early surgical intervention within 2 weeks significantly reduces the incidence of persistent diplopia, enophthalmos, and infraorbital nerve dysfunction 3.

Delayed Repair (After 4-6 Months)

Consider delayed repair for: 1, 2

• Restrictive strabismus persisting beyond 4-6 months
• Unresolved enophthalmos after observation period

Observation Without Surgery

Observe without surgical intervention for: 1, 4

• Minimal diplopia (not in primary or downgaze)
• Good ocular motility without significant enophthalmos or hypoglobus
• Normal extraocular movements with no signs of muscle entrapment

Conservative Management During Observation

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 2. During this observation period:

• Use occlusion for diplopia management 2, 4
• Apply Fresnel prisms for temporary relief 2, 4
• Consider prism glasses for temporary or permanent diplopia relief 2
• A short burst of oral steroids can hasten recovery and reveal persistent strabismus that will remain after orbital edema/hematoma resolution 2, 4
• Botulinum toxin injection in select cases 2

Critical Pitfalls and Caveats

Set realistic expectations with patients: even with proper surgical repair, diplopia persists in 37% of patients postoperatively 2, 4. Additional important considerations:

• Fat entrapment can be nearly as challenging as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection around the involved muscle 2
• Diplopia may develop as edema resolves, occurring in up to 86% of orbital fracture patients, emphasizing the need for close ophthalmology follow-up within 1-2 weeks 4
• For patients requiring delayed strabismus surgery after fracture repair, wait until alignment is stable and use adjustable sutures when possible 2
• Complete elimination of diplopia may not be achievable due to multifactorial etiology 2
• Do not assume a normal initial exam means no future problems—delayed complications can occur 4