Approach
Advanced trauma life support (ATLS) is the initial approach in the assessment and management of any patient who may have orbital fractures. Once the patient has been stabilised, urgent referral for ophthalmological assessment of the eye and associated structures (generally to an ophthalmologist or maxillofacial surgeon) is required.
Treatment of orbital fractures is divided into:
Emergency surgical intervention
Delayed surgical intervention
Conservative treatment.
Urgent surgery is generally performed in paediatric patients with signs of soft tissue (muscle) entrapment; namely upgaze limitation and the oculovagal response (presence of vagal stimulation by pressure to intraorbital structures, which results in bradycardia, hypotension, nausea, and/or vomiting). Surgery is delayed in most adult cases to allow oedema and haemorrhage to resolve. In small, non-blow-out fractures, conservative treatment may be considered.
Urgent eye morbidity
Orbital floor blow-out fractures causing soft-tissue entrapment can exacerbate the oculovagal response and require urgent surgical intervention. The oculovagal reflex refers to the presence of vagal stimulation by pressure to intraorbital structures, which results in bradycardia, hypotension, nausea, and/or vomiting. It is generally caused by blow-out fractures in children.[11] However, it has been described in other causes of pressure on the orbital contents such as ophthalmic surgery, adult orbital fractures, zygomatic fracture management, and even cosmetic face-lifts. In extreme cases, patients may require to be treated intravenously with an antimuscarinic acetylcholine antagonist such as atropine.
In children, orbital soft-tissue floor release is ideally undertaken within 24 hours in blow-out fractures.
No urgent eye morbidity
Conservative treatment, including adequate analgesia, is initially considered in cases where urgent surgery is not indicated. Patients should be reviewed 1 week later following resolution of oedema that may overlie residual local injury. Orthoptic testing (including a Hess chart, cover test, binocular fixation test, and binocular fields of vision) may reveal that, although a fracture is present, there is no derangement of function or cosmesis and no surgery is indicated.
Surgery is delayed in most adult cases to allow oedema and haemorrhage to resolve. Delayed surgical intervention is undertaken in patients with persistent or worsening functional or cosmetic derangement. The orbit, particularly the medial wall, has a complex 3D anatomy. The reconstruction of the sigmoid shape of this is a key element of orbital reconstructive surgery.
In adults, surgery is limited to:[25]
Release of trapped orbital contents
Correction of malposition of the globe (vertical dystopia, enophthalmos)
Correction of changes in orbital volume.
Surgery is always a compromise between the optimal access to the fracture and the potential complications of each approach. It depends on the position of the defect, the age of the patient, and the existence of concomitant injuries. In adults with complex facial trauma, surgery is typically delayed at least 1 week for swelling to resolve.
Orbital floor fractures: the surgical approach is transconjunctival or through the lower eyelid at various levels. Access may be increased by combining this with a lateral cantholysis (a 'lid swing'), and medially a 'transcaruncular' incision up and behind the lacrimal drainage apparatus.
Orbital roof/complex cranio-maxillofacial fractures: coronal approach through the hair-bearing skin of the scalp is standard, to avoid facial scarring and maximise exposure.
Other incisions through facial/lid skin: repair may involve alloplastic or synthetic material.
Alloplastic: harvested cranial bone, maxillary sinus anterior wall, costochondral cartilage
Synthetic: titanium mesh, medpore (high-density polyethylene sheets), polydioxanone, and stainless steel are used. Custom-made prostheses may be required.
Cranial and facial bone fractures are usually fixed with titanium or steel miniplates.
Antibiotic prophylaxis
Little evidence exists for the use of prophylactic antibiotics in orbital fractures. Orbital cellulitis is serious but rare. A recommended approach is to prescribe oral broad-spectrum antibiotics (e.g., amoxicillin or erythromycin) in the following cases:[26]
For open fractures
When surgical emphysema is present
When open reduction and internal fixation is performed
In orbital grafting.
Antibiotics are not indicated if there is evidence of a fracture communicating with a sinus.
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