What specialty fixes orbital fractures?

Orbital Fracture Management: Specialty Involvement

Orbital fractures require a multidisciplinary approach involving oculoplastic surgeons (ophthalmologists with orbital surgery training), facial plastic surgeons, oral and maxillofacial surgeons, and neurosurgery when indicated, with oculoplastic surgeons typically leading management of the orbital components and associated ocular complications. 1

Primary Specialties Involved

Oculoplastic Surgery (Ophthalmology Subspecialty)

• Oculoplastic surgeons are the primary specialists for managing orbital fractures with associated ocular complications, including diplopia, enophthalmos, and extraocular muscle entrapment. 1, 2
• These surgeons handle both the orbital reconstruction and subsequent strabismus surgery when diplopia persists after fracture repair. 1
• The American Academy of Ophthalmology guidelines emphasize that orbital trauma management requires ophthalmologic expertise, particularly for addressing vision-threatening complications and muscle entrapment. 1

Facial Plastic Surgery and Oral-Maxillofacial Surgery

• Facial plastic surgeons and oral-maxillofacial surgeons commonly manage isolated orbital floor fractures, particularly when ocular complications are minimal. 3, 2
• Survey data shows both oculofacial and facial plastic surgeons actively manage these fractures, with similar indications for surgery (motility restriction, enophthalmos, diplopia at 2 weeks). 2
• Significant interdisciplinary differences exist in approach timing and implant selection, with facial plastic surgeons more likely to operate earlier (4-7 days vs 8-14 days). 3, 2

Neurosurgery

• Neurosurgery involvement is essential for orbital roof fractures, which occur in 5% of orbital/skull base fractures and frequently involve dural lacerations (10% requiring operative repair), cerebrospinal fluid leaks, and traumatic brain injury (65% with intracranial hemorrhage). 4
• An interdisciplinary approach with plastic surgery, ophthalmology, and neurosurgery is crucial for orbital roof fractures given the high rate of concomitant neurologic injury. 4, 5

Clinical Decision Algorithm

Immediate Ophthalmologic Evaluation Required

• All orbital fractures require specialized ophthalmologic examination as soon as possible, particularly when signs and symptoms of severity are present. 6
• In one prospective study of 64 orbital fractures, 8 injuries (12.5%) required specialized ophthalmologic intervention, including 4 emergency eye surgeries. 6
• Critical findings requiring immediate ophthalmologic assessment include vision loss, pupillary abnormalities, globe injury, and signs of muscle entrapment with oculocardiac reflex. 1, 7

Surgical Timing and Specialty Coordination

• Immediate repair (within 24 hours) requires oculoplastic or orbital surgery expertise for entrapped muscle with nonresolving oculocardiac reflex, white-eyed blowout fracture in children, or globe subluxation into maxillary sinus. 1, 7
• Repair within 1-2 weeks is indicated for symptomatic diplopia with positive forced ductions, large floor fractures with hypoglobus, or early enophthalmos causing facial asymmetry. 1, 7
• For patients without muscle entrapment, waiting 4-6 months is advised before strabismus surgery, as spontaneous resolution occurs frequently. 1, 8

Common Pitfalls to Avoid

Delayed Ophthalmologic Consultation

• Non-ophthalmologist surgeons must have basic knowledge to provide primary ophthalmologic care and discern injury severity, but should not delay specialized consultation. 6
• Failure to recognize muscle entrapment early can result in permanent ischemic injury and restrictive strabismus. 7

Premature Strabismus Surgery

• Operating on persistent diplopia before 4-6 months post-trauma is premature, as strabismus may resolve spontaneously in many cases. 1, 8
• Only 7-24% of orbital floor fracture patients ultimately require strabismus surgery. 1, 8

Underestimating Soft Tissue Entrapment

• Orbital fat and periorbital tissue entrapment can cause permanent strabismus even without direct muscle entrapment, and may be as challenging to manage as muscle entrapment. 1, 7

Missing Concurrent Injuries

• Orbital roof fractures have 87% concomitant craniofacial skeletal fractures, 47% ophthalmologic injuries, and 65% traumatic brain injury—requiring coordinated multidisciplinary care. 4