Rethinking blowout orbital fractures

It is always a pleasure to attend our national meeting and have the opportunity to see old friends and reassess one's educational experience. The subspecialty day is most valuable, as it discusses controversial topics and allows the physician to be challenged from his or her past experience with what is the new thinking on the subject. The interactive response is very interesting, especially when the speaker presents his or her thoughts about the best way to manage a problem, and surprisingly almost half the audience disagrees and is not planning on incorporating it into their practice.

Dr. Robert Kersten, however, spoke on timing and indications of orbital fractures. What I guess I liked about it was really not only that I strongly agree with what he said, but I too over 38 years have changed my position on who needs to be operated on. Subsequently, over the years, I have operated much less often on blowout fractures.

The prevailing recommendations for surgical repair of blowout fractures within 2 weeks of the trauma are:

1. Symptomatic diplopia within 30° of primary gaze.

2. Evidence of muscle entrapment on CT and/or a positive force duction test.

3. Large fractures encompassing greater than 50% of the entire orbital floor surface area.

4. Clinically significant hypothalamus.

I do not believe anybody disputes operating immediately, within hours, when the globe herniates into the orbital sinuses, or as soon as possible when a white blowout fracture is identified in a young patient. The latter is characterized by little or no clinical evidence of soft tissue trauma but reduced superduction deficit accompanied by pain, nausea, vomiting and bradycardia. In addition, there may be minimal to no evidence of bone displacement and/or tissue herniation into the maxillary sinus. In these cases, there is a trap-door fracture incarcerating the inferior rectus that may be very difficult to see radiographically and may lead to muscle ischemia and fibrosis with a poor outcome.

On the other hand, generally excellent results can be obtained when operating on patients with persistent diplopia or enophthalmos well beyond the 2-week post-traumatic period. In many instances, the orbital floor is comminuted unlike in children, and there may be a traumatic component to the inferior rectus or a paresis that may take a month or so to clear.

In addition, late enophthalmos is not very common, and it is difficult to predict radiographically who is going to go on to develop it. Moreover, surgical intervention with fat manipulation may lead to fat atrophy and a degree of enophthalmos. It seems reasonable, therefore, to operate urgently on patients with globe subluxation and white blowout fractures. On the other hand, adults with vertical diplopia and evidence of blowout fracture on coronal CT scanning, which does not show frank muscle entrapment but muscle and/or fat within the bony defect, may be watched for progressive improvement beyond 2 weeks.

The natural course of the traumatic event can be shortened with a short course of systemic steroids of 30 to 40 mg a day for 10 days. If there is cessation in improvement and vertical diplopia is still problematic, surgical intervention is considered. Remember that there is no guarantee that diplopia will resolve following surgery, as it depends a lot on the free energy release transmitted within the orbit by the specific type of injury.

Large orbital fractures may be monitored with exophthalmometry readings every 2 weeks, looking for signs of progression of the enophthalmos, which may then be operated on at the appropriate time.

In summary, it has become apparent that the large majority of blowout fractures do not require surgical intervention. Patient counseling and good patient rapport are of paramount importance.