What is the acute management of a left orbital fracture?

Acute Management of Left Orbital Fracture

Immediately assess for life-threatening oculocardiac reflex and vision-threatening injuries, obtain CT imaging, and proceed to urgent surgical repair if muscle entrapment with nonresolving oculocardiac reflex is present; otherwise, follow a time-based surgical algorithm based on specific clinical findings. 1

Initial Emergency Assessment

Rule Out Life-Threatening Conditions First

• Monitor vital signs continuously for bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness, which indicate entrapped muscle causing oculocardiac reflex requiring urgent medical and surgical intervention 1, 2
• Perform immediate vision testing, pupillary examination, IOP measurement, confrontational visual fields, slit-lamp examination, and dilated fundus examination (if safe) to rule out globe injury 1
• Note that serious ocular injury occurs in 24% of blowout fractures, with complete vision loss in 5.5% of one eye and 0.8% of both eyes in facial fracture patients 2

Obtain Appropriate Imaging

• Order CT imaging rather than MRI as the initial study, as CT provides sufficient information about fracture presence and entrapment while ruling out ferrous-metallic foreign bodies 1, 2
• MRI can be considered later for more precise imaging of extraocular muscles and surrounding tissues if needed for surgical planning 1

Detailed Ophthalmologic Examination

Sensorimotor Testing

• Perform detailed sensorimotor examination including versions, ductions, saccades, pursuit, vergence, and near reflex 1
• Conduct forced duction and forced generation testing to distinguish restriction from paresis, which is critical for surgical planning 1, 2
• Test alignment in multiple gaze positions with attention to primary and secondary deviations 1
• Consider Double Maddox rod, Lancaster red-green, or Hess screen testing 1

Additional Assessments

• Test facial sensation for infraorbital nerve involvement 1
• Perform exophthalmometry to document any enophthalmos or proptosis 1
• Note that examination findings will change from the acute setting when edema and hemorrhage may limit ductions and obscure enophthalmos 1

Surgical Timing Algorithm

Immediate Repair (Within Hours)

Proceed to immediate surgical repair for: 1, 2

• CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1, 2
• White-eyed blow-out fracture (trap-door fracture with muscle entrapment and oculocardiac reflex, typically in children) 1
• Globe subluxation into the maxillary sinus 1

Repair Within 2 Weeks

Schedule surgical repair within 1-2 weeks for: 1, 2

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment with minimal improvement over time 1, 2
• Significant fat or periorbital tissue entrapment (can cause permanent strabismus even without muscle entrapment) 1
• Large floor fractures 1, 2
• Hypoglobus 1, 2
• Progressive infraorbital hypoesthesia 1, 2
• Early enophthalmos or hypoglobus causing facial asymmetry (will not resolve spontaneously) 1

Note: Early surgical repair within 2 weeks reduces the incidence of diplopia, enophthalmos, and infraorbital nerve dysfunction compared to delayed repair 3

Observation Period (4-6 Months)

Observe without immediate surgery for: 1, 2

• Minimal diplopia (not in primary or downgaze) 1, 2
• Good ocular motility without significant enophthalmos or hypoglobus 1, 2

Conservative Management During Observation

Medical Management

• Consider a short burst of oral corticosteroids to hasten recovery and reveal persistent strabismus that will remain after orbital edema/hematoma resolution 1, 2
• Wait 4-6 months after orbital trauma before considering strabismus surgery, as many cases resolve spontaneously 1, 2

Symptomatic Relief Options

• Occlusion for diplopia management 2
• Fresnel prisms for temporary relief 2
• Prism glasses for temporary or permanent diplopia relief 2
• Botulinum toxin injection in select cases 2

Critical Pitfalls and Caveats

Set Realistic Expectations

• Even with proper surgical repair, diplopia persists in 37% of patients postoperatively, so counsel patients accordingly 2
• Complete elimination of diplopia is difficult or impossible in most cases due to multifactorial etiology and incomitant misalignment 1

Technical Considerations

• Fat entrapment can be nearly as challenging as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection 1, 2
• Adhesions may extend deep into the orbit, beyond the reach of standard surgical approaches 1
• For delayed strabismus surgery, wait until alignment is stable and consider adjustable sutures 2

Antibiotic Prophylaxis

• Prophylactic antibiotics for orbital fractures have no proven benefit in preventing orbital infection 4
• If antibiotics are prescribed, use shorter courses (5-7 days) and avoid broad-spectrum agents to prevent antibiotic resistance 4

Delayed Presentation

• Surgical repair can still achieve marked improvement in enophthalmos and diplopia even when performed months to years after injury, with low likelihood of induced diplopia 5