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Early surgery and late surgery for repair of orbital fractures yield similar results
Ophthal Plast Reconstr Surg. 2008:24(6):437-443.
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Ocular motility, diplopia and frequency of strabismus surgery postoperatively were comparable in patients undergoing repair of orbital fracture within 14 days of trauma and in those undergoing surgery 15 to 29 days after trauma.
In a retrospective review of patients with orbital floor or medial wall fracture, a study found that ocular motility was equivalent in 36 patients who underwent early fracture repair and in 22 patients who underwent delayed fracture repair. Large tripod fractures and complex orbital fractures were excluded from study. Thirteen patients delayed presentation, which constituted the most common reason for delayed surgery.
Patients who had improving diplopia and were at low risk of enophthalmos can be observed for 3 to 4 weeks before surgery, preventing unnecessary surgery in some cases. However, delayed repair is more technically challenging, so patients who present early and will require surgery because of large fractures or significant restrictions should undergo surgery in a timely manner, the study authors said.
This retrospective study of early (less than 14 days) vs. “delayed” (15 to 29 days) orbital fracture repair showed no significant difference in motility, diplopia, hypesthesia or complications. Postoperative increased difference in Hertel measurements could be from thickness of the implants used. Patients who presented later likely had fewer symptoms and restriction immediately after injury. Thus, less soft entrapment and outcome of delayed surgery would be less affected compared to patients with more severe clinical findings. Increased operative technical difficulty occurred with delayed repair, which must be taken into consideration for clinical management. The authors add objective data for clinical management of orbital fractures, but orbit trauma variability makes a universal treatment algorithm unlikely. From my perspective, orbital fracture management needs to be individualized. Patients with muscle ischemia or globe dystopia should have urgent surgery. Most orbital fractures can be repaired at around 2 weeks to allow for swelling and clinical improvement to occur and to intervene when minimal scarring would not increase intraoperative technical difficulty. With equivocal indications/symptoms or patients with potential medical contraindications for surgery, delayed repair should not affect postoperative outcomes. Late repair where enophthalmos correction is the main indication is also an option.
– John D. Ng, MD, MS, FACS
OSN Oculoplastic and Reconstructive Surgery Section Member
Although many surgeons prefer to perform orbital fracture repair within 2 weeks of trauma, orbital fracture repair performed up to 1 month after trauma appears to offer similar results as earlier surgery. Patients with improving diplopia who are at low risk for enophthalmos may be observed for up to 1 month after trauma to determine the need for surgery. This larger time window may allow some patients to avoid surgery if they do not develop significant enophthalmos during the observation period. Patients with obvious entrapment still require early surgery, and patients with larger fractures who suffer from significant enophthalmos on presentation likely benefit from earlier surgery as well.
– Julian D. Perry, MD
OSN Oculoplastic and Reconstructive Surgery Section Member