|Year : 2016 | Volume
| Issue : 2 | Page : 84-89
Orbital blowout fractures: A Survey and review
Rahul Kashyap1, Gaurav Mittal2, Gaurav Kataria2
1 Department of Oral and Maxillofacial Surgery, SGT Dental College, Gurgaon, Haryana, India
2 Department of Oral and Maxillofacial Surgery, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India
|Date of Web Publication||30-Nov-2016|
Department of Oral and Maxillofacial Surgery, Institute of Dental Studies and Technologies, Modinagar Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Orbital floor fractures make up one of the most widely discussed clinical controversies of the maxillofacial region. Many have no major consequences if left untreated, however, some may result in unacceptable functional and cosmetic defects. We present our views regarding their diagnosis, treatment planning, and management.
Patients and Methods: A postal survey was designed to assess the current concepts employed by the practicing oral and maxillofacial surgeons within the state of Kerala, India, regarding the management of these fractures, in the form of a tick box questionnaire. The questionnaire was formatted to include 18 closed questions divided into 5 different sections. The questionnaire was forwarded to 45 practicing oral and maxillofacial surgeons by post.
Results: The response rate of the postal survey was 49%. Pre and postoperative prescription of antibiotics was practiced by 72% for 5-7 days. Sixty-three percent of the respondents used steroids while 81% wait for edema resolution before making the final decision to operate. All respondents relied on plain radiography and CT scanning for the final diagnosis and treatment planning. Most surgeons (63%) considered diplopia as the mostimportant ophthalmologic parameter determining the prognosis and the final treatment outcome.
Conclusion: The following article discusses the results of this survey and reviews the past and current literature associated with these fractures. It can be very safely said that there is no real consensus regarding all the aspects of these injuries, with the management being mostly operator dependant.
Keywords: Blow out fractures, diplopia, enophthalmus, orbital imaging, orbital reconstruction
|How to cite this article:|
Kashyap R, Mittal G, Kataria G. Orbital blowout fractures: A Survey and review. Arch Int Surg 2016;6:84-9
| Introduction|| |
The orbital bones form a socket for the globe of the eye. They provide insertion to the extraocular muscles and are also intimately associated with the surrounding sinuses and the anterior cranial fossa. The structures of the eye, being very important and delicate, are protected by different mechanisms provided by nature. The presence of fascia, periorbital fat, check ligaments, and extraocular muscles, etc. also provide support and protection to the globe in various ways. In spite of these protective factors, they are not exempted from injury.
The orbital blowout fractures considered for this survey are a direct extension of an orbital rim fracture, a part of a fracture of the zygomatic complex, a component of the Lefort II or Lefort III varieties, or in isolation without fracture of the orbital rim; in this variety, it is accepted that a fracture of another wall, generally the medial wall, may coexist.
Many orbital blowout fractures have no sequelae if they are left untreated, however, others may result in diplopia, enophthalmus, or even complete loss of vision if not treated promptly and adequately. Diplopia resulting from positional changes of extraocular muscle or their entrapment is a very common complication of zygomaticomaxillary complex (ZMC) fractures in general. Blow-out fractures of the orbit comprise the most common cause of diplopia. Many studies have now described the changes that occur within the orbit from disruption of its contents due to trauma. Posttraumatic enophthalmus has been shown to be caused by displacement of orbital soft tissues within the enlarged bony orbit., There are controversies regarding use of antibiotics and steroids, type of imaging, surgical approaches, timing of intervention, and choice of implant materials used for reconstruction.
| Patients and Methods|| |
A questionnaire was formatted to include 18 questions divided into 5 sections. These sections included use of antibiotics, use of steroids, imaging, ophthalmologic consultation, and surgical technique. At the end of the questionnaire, space was provided for the participants to express their views or provide any extra information in context to any question.
This questionnaire was forwarded to 45 oral and maxillofacial surgeons currently practicing in the state of Kerala, India.
| Results|| |
The response rate of the postal survey was 49%. Antibiotics started 3 hours preoperatively to a maximum of 72 hours postoperatively are considered prophylactic. Those given beyond 72 hours are considered therapeutic.
None of the respondents prescribed prophylactic antibiotics only. Twenty-seven percent of the respondents prescribed antibiotics only postoperatively whereas 72% prescribed both pre and postoperatively. If given postoperatively, 63% prescribed for a period of 5 days whereas only 27% continued for 7–10 days [Table 1].
Sixty-three percent of the respondents used steroids in the management of orbital fractures whereas 36% did not. Eighty-one percent of the respondents liked to wait for edema resolution by using steroids before making the final decision to operate; only 18% said they would rely on radiographic signs alone and proceed with surgical exploration without waiting for the edema to subside. Only 9% of the respondents depended on plain radiography alone for radiological diagnosis whereas 45% relied on computed tomography (CT) scan only; rest of the responders relied on combinations, out of which 100% respondents relied on plain radiography and CT scanning for the final diagnosis and treatment planning. None of the respondents in our survey used magnetic resonance imaging (MRI) either alone or in combination [Table 2].
|Table 2: Preferred imaging technique used for diagnoses and treatment planning|
Click here to view
Visual acuity and diplopia remained equally important parameters for seeking an ophthalmologic consultation. Most surgeons (63%) considered diplopia as the most important ophthalmologic parameter determining the prognosis and the final treatment outcome while 18% considered visual acuity and enophthalmus.
None of the surgeons believed in operating immediately on orbital blowout fractures; maximum (45%) liked to wait for a period of 6–10 days whereas 36% operated within 1–5 days; 9% believed in waiting for 11–15 days or >15 days before operating [Table 3]. Most preferred surgical approach was the subciliary being used by 45% surgeons while 36% of the surgeons adopted the infraorbital approach. Nine percent of the respondents preferred the mid lower eyelid incision or the Caldwell Luc approach whereas none of the surgeons opted to use the transconjectival route [Table 4].
Iliac crest emerged as the most commonly used graft material being used by 36% of the surgeons, followed by rib which was being used by 18%; cartilage, titanium, and silastic was used by 9% of the surgeons while none of the surgeons preferred to use the calvarial bone, antral bone, polytetrafluoroethylene (PTFE), or polydioxane sheets as the graft material of choice [Table 5]. Fifty-four percent of the respondents reported never having to remove the graft due to any reasons, whereas 36% stated infection to be the most common cause in the future removal of the graft; 9% of the respondents quoted extrusion as the reason for graft removal. Ocular volume discrepancy was not given as the reason of graft removal by any surgeon [Table 6].
| Discussion|| |
According to the principles of general surgery, it is believed that antibiotic prophylaxis is not recommended for clean wounds as infection rate is very low even without prophylaxis. The orbital blowout fractures, even if isolated, are considered to be infected, due to the presence of open skin wounds, communication with the sinuses, and implantation of a foreign body or an implant put at the time of surgery. Westfall and Shore have shown that, if purulent sinusitis is present, infection rate increases up to 40%, and if fractures are approached through the oral cavity, the infection rate is expected to be approximately 15%. Our survey reveals that almost 100% surgeons preferred to give therapeutic antibiotics starting preoperatively, however, most (63%) restricted to 5 days postoperatively. Only 27% surgeons gave only postoperative antibiotics.
In orbital blowout fractures, the presence of massive periorbital edema may mask an increase in orbital volume, in effect masking an enophthalmus caused by the trauma. Also this edema may result in indirect diplopia, due to compression of periorbital tissues leading to incorrect clinical diagnosis. This edema has also been associated with an increase in complications with access incisions due to a distortion of the local anatomy. Millmann et al. did a comparative study on 38 CT proven orbital fractures with diplopia to determine the efficacy of steroids by dividing them into two groups based on steroids being used or not being used. Their study showed that cases with or without soft tissue prolapse on CT showed resolution of diplopia in both groups but at a much faster rate in the group where steroids were given. Residual diplopia was seen in all cases with CT evidence of inferior rectus entrapment irrespective of whether steroids were used or not. In addition, enophthalmus was revealed in all cases in the steroid group within 1 week of administration as compared to 5 months in the non steroid group.
Lipkin et al. reported a case of acute near total loss of vision secondary to orbital trauma causing compression of the optic nerve. Using detailed high resolution CT scan as a guide to surgical planning with large dose of steroids, early surgical intervention was done and resulted in a substantial recovery of vision. Majority of our respondents (63%) advocated the use of steroids in the management of orbital fractures whereas 36% did not routinely use steroids. However, 81% surgeons liked to wait for edema resolution using steroids before making the decision to operate.
In most hospital emergency departments, the patients undergo a series of plain radiographs whenever a possibility of a midface fracture is suspected. There are commonly 4 radiographs included in this “midface series.” They are PA view, lateral facial view, submentovertex view and 30° occipitomental or Water's view. Pogrel et al. in a series of 105 patients with suspected midface fractures concluded that a single 30° occipitomental radiograph, augmented with a CT scan when indicated, can accurately identify all midface fractures requiring treatment.
For orbital floor trauma, however, plain radiography can be unpredictable. Chu et al. and Cricklair et al., in separate studies, showed that the classic “tear drop” sign seen in occipitomental radiographs is unreliable. Ilankovan, in a study to compare the effectiveness of CT and MRI in diagnosing herniation and entrapment of orbital soft tissues in orbital fractures in 15 patients, concluded that CT and MRI were equally accurate in demonstrating or excluding orbital wall fractures. However, both modalities slightly underestimated the actual incidence when compared to the surgical findings. CT scanning, although quite reliable in identifying fractures and fractures defects, may not readily or accurately identify the tissues involved. By using direct coronal high resolution scans, detailed images can be produced, however, unfortunately, these thin slice protocols increase the ionizing radiation exposure, especially to sensitive structures such as the lens of the eye or the thyroid.
MRI is a noninvasive technique and its advantages include lack of ionizing radiation, direct multiplanar, imaging and high soft tissue contrast resolution. Surface coil MRI has been found to be superior to CT in the assessment of fracture site, orbital prolapse, and muscle entrapment as well as detecting paranasal sinus hemorrhages. Therefore, MRI when available should be used as the initial imaging modality and CT scanning held in reserve for confirmation because positioning in the MRI unit is easier and more comfortable for recently injured patients who may also have other associated injuries. The downside, however, of using MRI is the cost and the potential obstruction of the images in follow up cases where metallic implants were used for repair, especially where detailed imaging is a priority.
Our survey findings suggest that none of the surgeons used MRI as the preferred imaging modality either alone or in combination. One hundred percent of our respondents relied on plain radiography combined with CT images for diagnosis while CT alone was preferred by 45% and plain radiography by 9% of the respondents.
Al Qurainy et al. developed a system for detecting patients at risk of eye injury based on a prospective study on 363 patients. They divided patients into the following 3 groups based on the extent of injury:
- Nonreferral cases: Were defined as those patients without permanent visual or psychological sequelae such as corneal abrasions or subconjunctival hemorrhage. These injuries healed spontaneously
- Routine referral cases: Were those patients having ocular injuries that are unlikely to lead to permanent visual or physiological sequelae but for whom referral may be indicated for the purpose of assessment or screening for pathologies necessitating treatment
- Early referral cases comprised those cases with ocular injuries such as corneal lacerations or retinal damage likely to produce sustained visual loss as well as those patients with adnexal injuries requiring advice at an early stage concerning management or therapeutic intervention.
They concluded by putting visual acuity at the time of presentation as the principle predictor in detecting patients with the risk of eye injury; pure blowout fractures, comminuted facial trauma, diplopia, and amnesia also emerged as significant factors in determining ocular injury.
In our survey, diplopia emerged as the most significant prognostic indicator (63%) whereas visual acuity and enophthalmus remained a distant second at 18% as the criteria for seeking ophthalmology consolation.
The timing of treatment is probably the most controversial in the management of orbital blowout fractures. Dulley and Fells  have reported that 72% of the patients operated upon greater than 6 months after the injury developed residual enophthalmus. In contrast, only 20% of the patients operated within 14 days of trauma developed enophthalmus. Of the early treated patients, 31% of those treated nonsurgically due to lack of symptoms or signs were left with permanent enophthalmus or diplopia.
Jordan et al. have reported lower complication rates in patients operated upon 7 days or more after the injury once circumorbital edema has subsided. On the contrary, Emery et al. reported that only 20% of the case were managed nonsurgically where diplopia resolved within the first 15 days after injury and developed enophthalmus, whereas 49% of the patients treated surgically developed persistent diplopia.
Our survey findings correlate well with the literature as almost 54% of our respondents operated in the 6–15 day window (45% in 6–10 days and 9% in 11–15 days).
No consensus exists on the choice of implant material for orbital reconstruction, and a plethora of materials are currently available and used according to the surgeon's preference. Chowdhary and Krausse  in a Medline literature research on orbital reconstruction from 1966 to 1997 concluded that autologous bone grafts in general and specifically calvarial bone grafts are currently the material of choice. Their advantages include stability because of inherent strength, vascularization, and incorporation of the graft material within the surrounding bone, leading to a decreased incidence of postoperative infections. Over banked bone, there is less bone resorption, allowing a more stable long-term outcome; in addition, the risk of transmission of infectious agents is lesser.
Alloplastic materials such as gel film, PTFE, and polyamide are too soft in a moist environment; furthermore, fibrous tissue proliferation and encapsulation occurs to some extent without replacement by bone. Titanium, vitallium, and other metallic alloy meshes allow tissue ingrowths that may cause tethering of the globe or make them difficult to remove if required later; moreover, the risk of direct injury to the optic nerve in case of future trauma due to posterior displacement of the graft exists.
Disadvantages associated with the use of autogenous grafts are mainly the need for a graft donor site, resulting in increased operative timing and complications intrinsic to donor site morbidity. Iliac crest and rib have substantial donor site morbidity and are of endochondral origins, which have been suggested to have a greater rate of resorption than bone of intramembranous origin, especially without internal fixation. Anterior maxillary wall and septal or auricular cartilage may not provide adequate graft material for larger fractures.
Potter and Ellis  in a recent review of literature pointed out the factors influencing the choice of biomaterials for use in orbit, namely, size of defect, involvement of multiple walls, adaptation to internal contours, restoration of proper volume, presence of adjacent sinus cavity, prevention of displacement, risk of further trauma, adhesions/restriction of ocular movement, early versus late repair, and ease of availability in case of an alloplastic material.
Our survey produced contrasting results compared to the literature as most of the respondents used iliac crest as the graft material of choice (36%) followed by rib (18%), whereas 9% used cartilage, titanium mess and silastic. Calvarial bone was not the material of choice for any of the respondents of our survey.
Although transconjectival approach produces an invisible scar, it provides only a limited access unless a lateral canthotomy is performed. Subciliary incision is associated with a high incidence of ectropion and persistent scleral show; however, it has been suggested that, if soft tissue dissection is carried out in a postorbicularis plane, the incidence of these complications significantly decreases. The infraorbital incision is associated with an unsightly scar and also persistent orbital edema. Holtman et al. reported that the mid lower eyelid incision combined the advantages of both the subciliary and the infraorbital incisions with minimum scarring, a rapid approach, and very less incidence of ectropion; moreover, it also gave very good access to both the orbital floor as well as the medial orbital wall.
In our survey, 45% of the surgeons used the subciliary approach whereas 36% adopted the infraorbital approach. Nine percent of the surgeons preferred the mid lower eyelid incision or the Caldwell Luc approach whereas none of the surgeons opted to use the transconjectival route.
| Conclusion|| |
Although much has been said and written about the management of orbital fractures, it can be very safely said that there is no real consensus regarding all the aspects of these injuries, with the management being mostly operator dependant. Prescribing both preoperative and postoperative antibiotics, advocating steroids, using plain radiographs and CT for imaging, using diplopia as the guide for ophthalmic consultation, operating 6–10 days after the trauma, using subciliary as access incision, and using iliac crest as the graft material of choice are some of the management options.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
al-Qurainy IA1, Stassen LF, Dutton GN, Moos KF, el-Attar A. Diplopia following midface fractures. Br J Oral Maxillofac Surg 1991;29:302-7.
Manson PN, Grivas A, Rosenbaum A, Vannier M, Zinreich J, Iliff N. Studies on enophthalmus II. The measurement of orbital injuries by quantitative computed tomography. Plast Reconstr Surg 1986;77:203.
Potter JK, Ellis E. Biomaterials for reconstruction of the internal orbit. J Oral Maxillofac Surg 2004;62:1280-97.
Wittmann D. Prophylaxis in general surgery. Infect Surg 1983;825-9.
Westfall CT, Shore JW. Isolated fractures of the orbital floor: Risk of infections and the role of antibiotics prophylaxis. Opthalmic Surg 1991;22:409-11.
Millman AL, Della Rocca RC, Spector S, Leibeskind AL, Messina A. Steroids and orbital blowout fractures – A new systematic concept in medical management and surgical decision making. Adv Opthalmic Plast Reconstr Surg 1987;6:291-300.
Alan F. Lipkin, MD; Gayle E. Woodson, MD; Robert H. Miller, MD. Visual Loss due to Orbital Fracture: The Role of Early Reduction. Arch Otolaryngol Head Neck Surg 1987;113:81-3.
Pogrel MA, Podlesh SW, Goldman KE. Efficacy of a single occipitomental radiograph to screen for midfacial fractures. J Oral Maxillofac Surg 2000;58:24-6.
Ng P, Chu C, Young N, Soo M. Imaging of orbital floor fractures. Australas Radiol 1996;40:264-8.
Crikelair GF, Rein JM, Poter GD. A critical look at the 'blow out' fractures. Plast Reconstr Surg 1972;49:374-9.
Ilankovan V Hardley D, Moos K, El Attar A. A comparison of imaging techniques with surgical experience in orbital injuries. J Craniomaxillofac Surg 1991;19:348-52.
al-Qurainy IA, Titterington DM, Dutton GN, Stassen LF, Moos KF, el-Attar A. Midfacial fractures and the eye: The development of a system for detecting patients at risk of eye injury. Br J Oral Maxillofac Surg 1991;29:363-7.
Dulley B, Fells P. Long-term follow-up of orbital blow out fractures with and without surgery. Mod Probl Opthalmol 1975;14:467-70.
Jordan DR1, Allen LH, White J, Harvey J, Pashby R, Esmaeli B. Intervention within days for some orbital floor fractures: The white-eyed blowout. Opthalmic Plast Reconstr Surg 1998;14:379-90.
Emery JM, van Noorden GK, Schlernitzauer DA. Orbital floor fractures: Long term follow up of cases with and without surgical repair. Trans Am Opthalmol Otolaryngol 1971;75:802-12.
Chowdhury K, Krause G. Selection of materials for orbital floor reconstruction. Arch Otolaryngol Head Neck Surg 1998;124:1398-401.
Holtmann B, Wray CR. A randomised comparison of four incisions for orbital fractures. Plast Reconstr Surg 1981;67:731-5.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]