LANDMARK: Repair of Orbital Floor Fractures

Article: Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109(7):1207-10.

Take Home Points:

  • Orbital floor fractures warranting immediate repair include patients presenting with orbital cardiac reflex and those with “white-eyed blowout fractures”. 
  • Those requiring repair within 2  weeks include patients with obvious early enophthalmos, high risk of development of enophthalmos, and those with obvious ocular motility impairment causing diplopia. 
  • Fractures involving >50% of the orbital floor and those with obvious muscle herniation into the maxillary sinus as seen on CT are patients with high risk of developing late enophthalmos/diplopia. 

The Details:

  • This paper is a review of the medical literature to assess (1) what fractures should be surgically repaired, and (2) when these fractures should be repaired. It’s worth noting that there are no prospective RCTs on the subject. 
  • Symptoms that raise concern for orbital floor fractures include: periorbital ecchymosis, lid swelling, orbital pain, V2 hypesthesia, enophthalmos, vertical diplopia, restriction of vertical extraocular movements, among others. 
  • Not all ocular movement impairment is a result of muscle impingement; extraocular movement may be limited in the setting of muscle swelling, orbital hematoma, and motor nerve palsy.
  • Oculocardiac reflex occurs when an orbital floor fracture causes orbital soft tissue entrapment, leading to increased vagal tone that can cause life threatening bradycardia and heart block. Other symptoms include nausea, vomiting and syncope. If a patient presents with these symptoms and they don’t resolve within 30 minutes, the patient should be operated on immediately. 
  • Children (<18y/o) have more elastic bones so when the orbital floor fractures it can displace back to a medial position, causing a high rate of soft tissue entrapment. This can lead to very early severe diplopia and restriction of upward gaze with minimal soft tissue swelling. This is the “white-eyed fracture”. 
  • 2 weeks is considered ideal because early soft tissue swelling is resolved, but fractured segments are still easily manipulated.
  • Some patients can have significant hypesthesia from V2 impingement at the fracture site and some authors consider this an indication for repair.

Summary Contributed by Enrique Gorbea, MD