What is the appropriate management of an undisplaced orbital (blow‑out) fracture without muscle entrapment, diplopia, enophthalmos, or vision‑threatening injury?

Management of Undisplaced Orbital Fracture

For an undisplaced orbital blow-out fracture without muscle entrapment, diplopia, enophthalmos, or vision-threatening injury, observation with close monitoring is the appropriate management strategy. 1

Initial Management Approach

Observation is specifically recommended for cases meeting all of the following criteria: 1

• Minimal or no diplopia (particularly not in primary gaze or downgaze)
• Good ocular motility without restriction
• No significant enophthalmos or hypoglobus
• No CT evidence of muscle or significant tissue entrapment

Monitoring Protocol

Timeframe for Observation

• Wait 4 to 6 months after the initial trauma before considering any surgical intervention, as strabismus and diplopia frequently resolve spontaneously during this period. 1
• This conservative approach can reduce the need for surgery by approximately 50% in patients with pure blow-out fractures. 2

What to Monitor During Follow-up

• Eye movement exercises should be initiated immediately and performed thoroughly throughout the observation period. 2
• Serial assessment for development of diplopia, particularly in primary position and downgaze (the most functionally important fields). 3
• Monitor for progressive enophthalmos (≥2 mm would warrant intervention). 4, 3
• Watch for development of hypoglobus causing facial asymmetry. 1
• Assess for progressive infraorbital hypoesthesia. 1

Adjunctive Conservative Measures

A short burst of oral corticosteroids can hasten recovery from orbital edema/hematoma and help uncover any persistent strabismus that may require eventual intervention. 1

If mild diplopia develops during observation, conservative treatments may provide temporary or permanent relief: 1

• Occlusion therapy
• Fresnel prisms
• Prism glasses
• Filters

When to Reconsider Surgical Intervention

Surgery should only be considered if any of the following develop during the observation period:

• Symptomatic diplopia with positive forced ductions or CT-confirmed entrapment showing minimal improvement over time (repair within 1-2 weeks). 1, 4
• Enophthalmos ≥2 mm causing facial asymmetry (repair within 2 weeks). 4, 3
• Large floor fractures causing significant orbital volume changes or hypoglobus (repair within 2 weeks). 1
• Restrictive strabismus that persists beyond 4-6 months (delayed repair). 1

Important Caveats

Forced duction testing is critical if any concern for restriction develops, as it distinguishes true mechanical restriction from paresis and guides surgical decision-making. 4, 3

The rationale for this conservative approach is based on evidence that conventional surgical repair of the orbital floor alone does not address the dysfunction of the entire orbital motility apparatus, and complications from surgery (including iatrogenic adhesions between eye muscles and orbital floor) can be difficult to treat. 2, 5

Even when surgery is eventually performed for appropriate indications, diplopia persists in approximately 37% of patients postoperatively, reinforcing the value of avoiding unnecessary intervention. 1, 4, 3