Orbicular Fractures

Orbital Fractures
9
Simon Holmes, Michael Perry, Joe McQuillan,
and Steve White
9.1 Applied Anatomy
All “black eyes” associated with numbness of the

cheek and upper lip, should be assessed carefully—the
patient may have an isolated fracture of the orbital
floor, or a fracture of the zygomatic complex (see
Fig. 9.1). Nasoethmoid, midface and skull fractures
may also involve the orbit.
S. Holmes (*)
Consultant Maxillofacial Surgeon, Craniofacial Trauma Unit,
Barts Health NHS Trust, London, UK
e-mail: [email protected]
M. Perry
Regional North West London Craniomaxillofacial Unit,
Northwick Park and St Mary’s Major Trauma Service,
Northwick Park Hospital, Harrow, Middlesex, UK
Fig. 9.1 Orbital fractures commonly involve the floor and/or medial
J. McQuillan wall but it is important not to forget the two remaining walls in your
Senior Orthoptist, Craniofacial Trauma Unit, assessment
Barts Health NHS Trust, London, England, UK
S. White
Regional Eye Unit, Royal Victoria Hospital,
Belfast, Northern Ireland, UK
M. Perry, S. Holmes (eds.), Atlas of Operative Maxillofacial Trauma Surgery, 359

DOI 10.1007/978-1-4471-2855-7_9, © Springer-Verlag London 2014
360 S. Holmes et al.
The orbit is a roughly pyramidal-shaped structure. Each has The shape and structure of the orbital floor is complex and
a volume of approximately 30 mL. Both orbits are aligned in familiarity with its geometry is essential to understanding the
such a way that their medial walls are almost parallel to each treatment of orbital fractures. The four orbital walls are com-
other, while their lateral walls form lines that intersect each posed of a number of different bones that vary significantly
other at approximately 90° (see Fig. 9.2). in thickness and strength (see Fig. 9.3). The orbital floor and
medial orbital wall are particularly delicate and prone to
injury, either in isolation (blowout fractures), or in combina-
a tion with the adjacent supporting bones (zygomaticomaxil-
lary/nasoethmoid fractures). Fractures of the lateral wall are
usually seen with fractures of the zygoma. Fractures of
the orbital roof should be regarded as skull base fractures.
These rarely occur in isolation.
The floor of the orbit inclines upwards at approximately
30° as it passes from anterior to posterior and at approxi-
mately 45° from lateral to medial. Towards the back of the
orbit, the junction between the floor and medial wall becomes
less obvious as the two converge to form the “posteromedial
bulge” (see Fig. 9.4). This is an area of particular importance
in the repair of orbital fractures. The medial wall is a very
delicate structure, being composed of the ethmoid bones,
b deep to which lay the ethmoidal air cells. The ethmoidal
blood vessels pass through the orbit and into the nose. These
Fig. 9.2 A good understanding of orbital topography is essential to the Fig. 9.3 The orbit is made up from a number of different bones, all of
management of orbital, zygomatic, and nasoethmoid trauma. Precise varying thickness. E ethmoid, F frontal, G greater wing of sphenoid,
reconstruction of orbital wall geometry is required to reestablish the L(post) lesser wing of sphenoid, L(ant) anterior wing of sphenoid,
correct orbital volume. Failure to repair injuries adequately can result in M maxilla, Z zygoma. The floor and medial wall are especially thin and
considerable morbidity and enophthalmos (a, b) most commonly fractured in trauma
9 Orbital Fractures 361
are important landmarks during dissection and may bleed half of the nose and upper lip. Sometimes it passes within a
profusely following trauma. bony tunnel, other times it lays in a shallow groove directly
The infraorbital nerve passes forward along the orbital in contact with the orbital periosteum. This can make dissec-
floor, supplying sensation to most of the cheek and ipsilateral tion along the orbital floor a bit tricky (see Fig. 9.5).
Fig. 9.4 The “posteromedial” bulge is a key site in repair (a, b). Familiarity with the curvatures of the floor and medial wall is essential. The floor
is not flat, but as seen has a number of gentle curves. This has important implications in the choice of material used in the repair of large defects
a b
Fig. 9.5 The infraorbital nerve is commonly injured during trauma, but is also at risk of injury during orbital dissection. While its position along
the floor of the orbit is generally predictable, its depth can vary. It may be covered entirely by a thin sheet of bone, or it can be in direct contact
with the periosteum (usually the latter). Black arrow shows the orbital floor fracture
Coordinated movements of the eye are achieved by the pad), facilitating movement and providing support. Damage to
extraocular muscles: four recti and two oblique. These are the orbit can result in herniation of the fat and trapping of the
very delicate structures. The four recti muscles arise from the septa. This can restrict eye movements, resulting in diplopia.
tendinous ring—a fibrous band that passes around the orbital The trochlea is a cartilaginous ring that supports the supe-
apex. As the muscles pass forward they form a muscular rior oblique muscle. It is attached to the periorbita within the
“cone” before inserting into the sclera of the globe. Each fovea trochlearis, along the superior-medial orbit. Dissection
orbit therefore has an “extraconal” and “intraconal” com- in this area must be undertaken with particular care (usually
partment. These communicate with each other between the when raising a coronal flap).
edges of the recti muscles.
Orbital fat makes up the bulk of the retrobulbar contents.
Within this pass the neurovascular structures of the eye and the
extraocular muscles. Fat within the cone is termed “intra- Fractures involving the orbit often result in the classic
conal;” that surrounding the muscles is termed “extraconal.” “black eye,” as blood is contained by the orbital sep-
Throughout the fat, fine but strong fibrous septa form a com- tum. However not all black eyes are due to blowout
plex interlacing pattern of numerous, tiny fat-filled compart- fractures. Fractures to the nose, skull base and zygoma
ments. This delicate “bubble-wrap” type arrangement provides also extend into the orbit and therefore can develop
structural support for the globe and allows its free movement. similar clinical signs (see Fig. 9.6).
In a sense, retrobulbar fat acts like a bursa (cf the buccal fat
Fig. 9.6 While the well-defined

“black eye” usually means there
is a fracture of the orbit, this
gives no indication of the site or
the extent of injury (a, b)
9.2 Blowout Fractures blowout fractures can occur along the medial wall. Isolated
blowout fractures of the orbital roof or lateral wall are con-
The term “blowout fracture” refers to an isolated defect in siderably rarer. Fractures at these sites tend to be associated
one of the orbital walls, most commonly the floor or medial with other fractures in the surrounding bones.
wall. Displacement of the bone can vary from minimal (not Depending on the size of the defect and whether there is
requiring repair), to significant, requiring reconstruction. any entrapment of the orbital contents, blowout fractures can
The orbital rims and surrounding bones of the face remain result in one or two clinical problems.
intact. 1. Diplopia (from entrapment of soft tissues). Usually extra-
The classically taught mechanism of injury for a “blowout” conal fat becomes trapped within the fracture. As the
fracture is that following a direct blow to the globe (e.g., from patient tries to move the globe (usually to look upwards)
a squash ball). The globe transmits the energy posteriorly, the tethered fat prevents the inferior rectus muscle from
increasing the pressure within the bony orbit, which then freely moving. Sometimes the muscle itself can become
“gives” at its weakest spot. This is usually the floor or medial trapped in the fracture. This is a more serious problem, as
wall. However, blowout fractures may also occur following a direct injury to the muscle can result in scarring and per-
blow to the prominence of the cheek. In this mechanism the sistent diplopia (see Fig. 9.7).
bone “buckles,” resulting in deformation and fracture propa- 2. Enophthalmos. This is a “sunken-in” appearance of the
gation along the weakest lines. Bone is a “plastic” material globe. This may not be apparent when the patient is first
and therefore it tends to bend or deform before it breaks (espe- seen, due to the compensatory effects of swelling within
cially in children). Hence the zygoma itself may not fracture. the orbit. Hence patients need to be followed up for a
Most blowout fractures occur along the thin floor of the short while. Enophthalmos is a “volume problem,” in that
orbit. This is weakened further by the presence of the infraor- the volume of the orbit has expanded following displace-
bital canal. Herniation of orbital contents (usually extraconal ment of the wall, allowing the contents to sink back (see
fat) then occurs into the maxillary sinus. Less commonly, Fig. 9.23).
a b
Fig. 9.7 Blowout fracture of the right orbital floor (red circle) (a, b). There is mechanical restriction of upward gaze due to trapping of the extra-
conal fat at the fracture. This needs to be released
9.3 Clinical Assessment swelling of the eyelids, making examination of the eye dif-
ficult. In such cases, gently pressing on the eyelids (not the
This is summarised in Tables 9.1 and 9.2. Preliminary globe) for a few minutes can reduce this, although epiphora
assessment of the eye always takes priority over the frac- can make the eyelids somewhat slippery. Ideally a pair of
ture itself. With localised injuries, a dilated pupil is most Desmarres or Jaffe lid retractors should be used. These can
likely to be due to traumatic mydriasis, but always keep safely open the lids without putting pressure on the globe
in mind the possibility of a coexisting head injury or (see Fig. 9.8).
serious ocular injury. Not all serious globe injuries are If you are really struggling, a pair of clean, bent paper-
immediately obvious. Sometimes there is considerable clips do surprisingly well as makeshift Jaffe-like retractors.
Although far from ideal, these can often open even the most
Table 9.1 Initial assessment of isolated orbital injury swollen of lids, at least sufficiently to assess visual acuity,
Visual acuity
pupillary size and reaction, and to visualise the anterior
Pupil size and reaction chamber for hyphema. If a penetrating injury to the eye is
Periorbital bruising/eyelid injuries suspected from the history, pressure should be avoided (see
Subconjunctival haemorrhage Fig. 9.9).
Numb cheek
Restricted eye movements (usually upwards) with diplopia Table 9.2 Investigations
Retraction sign and forced duction test Plain radiographs
Enophthalmos (although this can be masked by swelling) Occipitomental (OM). Look for the “hanging drop” sign. This
Consider also the following: represents the herniation of orbital contents into the maxillary
Nasolacrimal dysfunction sinus. A fluid level in the sinus suggests a fracture nearby
Presence of foreign bodies Coronal/axial CT of orbits
Globe rupture Orthoptic assessment (see text for discussion)
Contact lenses and superficial foreign bodies should be removed Measurement of exophthalmos/enophthalmos
a b
Fig. 9.8 Desmarres and Jaffe lid retractors (a, b)
Fig. 9.9 Opening swollen eyelids can be very difficult. Sometimes gentle but sustained pressure on the lids can reduce swelling (note there is no
pressure being exerted on the globe). If the correct retractors are not available and examination cannot wait, a couple of bent paperclips can act as
makeshift retractors (make sure they are cleaned first) (a–c)
A significant number of injuries to the bony orbit are not sure. If a penetrating injury to the eye is suspected
associated with injuries to the globe itself. Always check from the history, pressure should be avoided (see
the visual acuity and seek ophthalmic advice if you are Fig. 9.10).
a b
Fig. 9.10 A large shard of glass can be seen in a patient who was hit in the face with a beer glass (a, b). Surprisingly he did not sustain any serious
injuries to the globe. Careful evaluation of the globe is essential before this is retrieved. Red arrow shows shows glass foreign body
Fig. 9.11 CT confirmation of an extensive fracture to the left orbital

floor. This involves the posteromedial bulge
a b
d
c
Fig. 9.12 CT evaluation is now commonly undertaken for both pre- and postoperative assessment of the orbit following trauma (a–d). Such a
large two-wall defect as shown is a very difficult fracture to precisely repair. Postoperative clinical examination will give no indication of long-term
outcomes, but a CT showing a correctly positioned plate is certainly reassuring. If the plate is incorrectly placed, the patient may need to return to
theatre
9.3.1 The Role of the Orthoptist orthoptic assessment involves several different tests to assess
the patient’s vision, binocularity, ocular movements, and
Orthoptists are specialists in ocular motility and paediatric symptoms.
visual development. Their input into the management of
orbital fractures is valuable both pre- and postoperatively. 9.3.1.2 Visual Acuity (Vision)
The extraocular muscles are particularly susceptible to dam- In ophthalmology, visual acuity is one of the most important
age following orbital trauma, especially when fractures have measurements to make because it is generally the best mea-
occurred. Any damage to these muscles (or the cranial nerves surable indication of outcome. However, this is not the case
that innervate them) has an impact on the “laws of eye move- with orbital fractures, which usually result in mechanical-
ments” and subsequently the patient’s ability to keep their type problems (restriction of movement or volume effects).
eyes working in a coordinated fashion. Nevertheless, it is still an important monitoring tool. It is also
especially important to identify any significant ocular injury
before surgery is undertaken. Some globe injuries may con-
Limitation of eye movement following trauma has sev- traindicate exploration of the orbit.
eral varied causes and therefore does not always
require surgery. Similarly, diplopia following repair 9.3.1.3 Cover Test
does not automatically mean that surgery was per- The cover test is a quick and accurate assessment of the posi-
formed inadequately—although it can. Orthoptic input tioning and balance of the patient’s eyes in the primary posi-
in both these scenarios is therefore essential to help tion. It quickly assesses the presence and size of any
determine which cases require exploration and which strabismus (squint), which can be pre-existing (often con-
cases require nonsurgical management. genital), or secondary to the trauma.
9.3.1.4 Binocular Functions

9.3.1.1 The Orthoptic Assessment Binocular vision is when both eyes are used simultaneously
It is important to take into account the amount of periorbital to interpret one image. There are three levels of this: simul-
oedema when referring a patient. If the eye cannot open, or taneous perception, sensory/motor fusion, and stereopsis.
can only marginally open, a full ocular movement assess- 1. Simultaneous perception is the ability for a person to per-
ment will not be possible. Therefore assessment needs to be ceive simultaneously two images, one formed on each
delayed to allow the swelling to sufficiently settle. A full retina.
2. Sensory fusion: the ability for a person to perceive two sim- The extent of muscle sequelae that can develop varies
ilar images, one from each eye, and interpret them as one. among people.
3. Motor fusion is the ability for a person to maintain sensory
fusion through a range of ocular movements, or vergences
(e.g., convergence and divergence). 9.3.3 Extraocular Muscles
4. Stereopsis is the ability for a person to perceive the rela-
tive depth of an object based on binocular disparity. The six extraocular muscles are innervated by three cranial
nerves: the oculomotor nerve (IIIrd), the trochlear nerve
9.3.1.5 Ocular Movements (IVth) and the abducens nerve (VIth).
There are four groups of ocular movements: smooth pursuits, IIIrd nerve innervates
saccades, optokinetic nystagmus (OKN), and vergences. • Superior rectus: elevation (max in abduction), intor-
1. Smooth pursuits: this is a method to assess the function of sion, and adduction
all six pairs of extraocular muscles. It is tested by having • Inferior rectus: depression (max in abduction), extor-
the patient move their eyes into the nine cardinal position, and adduction
tions to isolate different muscles and assess the balance of • Medial rectus: adduction
each with its yoke muscle. (Yoke muscles are contralater- • Inferior oblique: elevation (max in adduction), extor-
ally paired extraocular muscles that work together to tion, and abduction
direct the gaze in a given direction. For example, in – Levator palpebrae superioris
directing the gaze to the right, the right lateral rectus and – Sphincter pupillary muscle
left medial rectus operate together as yoke muscles). It is IVth nerve innervates
important to be able to differentiate between a restriction • Superior oblique: depression (max in adduction),
of ocular movements and an underaction. An underaction intorsion, and abduction
will have a neurogenic cause whereby a restriction will be VIth nerve innervates
mechanical. • Lateral rectus: abduction
2. Saccades: this is a basic rapid eye movement system,
which allows rapid, accurate changes in fixation.
3. Optokinetic nystagmus: this is a refixation movement, 9.3.4 Hess Charts
most commonly noted when somebody is looking out of
the window of a moving train. The Hess chart is one part of the orthoptic assessment and is
4. Vergences: Convergence is the ability for the eyes to very useful for monitoring ocular motility. These charts are
move towards each other in conjunction with each other. used in the investigation of entrapment and strabismus. By
Divergence is the ability for the eyes to move apart from dissociating the eyes with a mirror (using the Lees screen) it
each other. is possible to locate the position of the nonfixing eye when
the other eye is fixed on specific points on the screen. Each
inner point on the screen represents 15° from the central
9.3.2 Laws of Eye Movements point and each outer point 30°. A field is plotted for each eye
(see Figs. 9.13 and 9.14).
There are certain laws that govern how the eyes move: When interpreting Hess charts and comparing the right
1. Herring’s law of equal innervation: a muscle and its yoke and left fields, the smaller field represents the affected eye.
muscle (contralateral synergist) receive equal and simul- Any difference in sizes indicates “incomitance” and recent
taneous innervation to contract so the eyes move as a onset of a problem. Similar sizes represent concomitance
pair. and therefore a more long-standing problem.
2. Sherrington’s law of reciprocal innervation: when a mus- When looking at the smaller field you need to look at:
cle receives an impulse to contract, an equal inhibitory • The deviation in the primary position
impulse is sent to its antagonist partner to relax. • The greatest inward displacement. This indicates the pri-
3. Muscle sequelae: when underaction of a primary muscle mary underacting and affected muscle.
occurs, the following sequelae develop: – Any outward displacement. This indicates an overact-
• The primary affected muscle’s yoke muscle overacts ing muscle.
• The direct antagonist of the affected muscle contracts There are three types of orbital floor blowout fractures,
to overact which can be differentiated based on whether the ocular
• The antagonist of the Yoke muscle underacts motility defect is mechanical and/or neurogenic.
Fig. 9.13 Lees screen
a b
Fig. 9.14 Example of a patient performing a Hess charting with the Lees screen (a, b)
9.3.4.1 Type 1 a “chin elevation head posture” to maintain a useful field of

This is characterised by limited elevation of the affected eye binocular single vision (BSV) (see Fig. 9.15).
due to a mechanical restriction. This can be associated with
Fig. 9.15 (a) Looking at the

a
Hess chart of the right field, you
can see the limited elevation
mainly affecting abducted
elevation (red arrows). This also
demonstrates Herring’s law by
the overaction of the contralateral
synergist (blue arrows). Forced
duction test is positive with the
greatest limitation in abducted
elevation. (b) Patients often adapt
well to a reduced field of BSV as
the defect is in the superior field,
which is not as commonly used
as the primary position and down
gaze (e.g., reading)
b
9.3.4.2 Type II either damage to its nerve supply (oculomotor) or direct

This is characterised by limited depression of the affected injury to the muscle (see Figs. 9.16 and 9.17).
eye due to an inferior rectus palsy. The palsy occurs due to
Fig. 9.16 The forced duction

test is negative for mechanical
restriction. Limited function
of the inferior rectus commonly
occurs and can last up to a year
postinjury. Blue arrows indicate
increased movements of the left
eye. Red arrows indicate
decreased movements of the
right eye
Fig. 9.17 Looking at the field of

BSV, you can see these patients
will often suffer with diplopia that
is much more troublesome than in
type I fractures. It affects
downgaze, thus having an impact
on walking, sports, reading, etc.
9.3.4.3 Type III As with type II fractures, the loss of binocularity in down
This is characterised by limited elevation and depression due gaze is the biggest problem for the patient. If this recovers
to mechanical restriction and inferior rectus palsy respec- before the upgaze problems they are usually happy.
tively (see Figs. 9.18 and 9.19).
Fig. 9.18 Type III. This is a

combination of types I and II,
so you have a positive forced
duction test mainly in abducted
elevation. Red arrows indicate
reduced movements of the left
eye. Blue arrows indicate
increased movements of the
right eye
Fig. 9.19 Looking at the field of

BSV, you can see these patients
are left with a central, often
elliptical area
9.3.4.4 Medial Wall Blowout Fractures motility than orbital floor fractures. Surgical repair usually
The medial wall of the orbit is more commonly fractured in results in significant improvements in ocular movements
association with the orbital floor than in isolation. Isolated (see Figs. 9.20 and 9.21).
medial wall fractures tend to have less of an effect on ocular
Fig. 9.20 This Hess chart

demonstrates the restrictions of
adduction and elevation found in
a typical medial wall fracture
combined with an orbital floor
fracture. Blue arrows show the
increased movements of the left
eye. Red arrows show the
reduced movement of the
right eye
Fig. 9.21 The field of BSV

shows the significant area of
diplopia and the reduced and
eccentric area of binocular single
vision. Patients will often adopt
abnormal head postures (face
turns and tilts) to try to centralise
this area
9.3.5 Measuring Globe Position position in the anteroposterior direction. Exophthalmometry

helps verify and determine the extent of any enophthalmos.
The horizontal position of the globe can be measured using It also helps evaluate the effectiveness of any repair (see
an exophthalmometer. This gives a numerical value of its Figs. 9.22, 9.23, 9.24 and 9.25 and Table 9.3).
a a
Fig. 9.22 Hertel exophthalmometer (a, b)
Fig. 9.24 The mirrors are used to take the measurements (a, b)
Fig. 9.25 Each cornea is viewed in its corresponding mirror and mea-
sured against the graduated marks. Red arrow shows the reflection of
the cornea against the scale
Table 9.3 How to use a Hertel exophthalmometer

1. Position yourself opposite the patient at the same eye height
2. Make sure the patient is looking straight at the bridge of your nose
3. Position the feet of the exophthalmometer accurately at the
patient’s outer canthae with gentle pressure backwards so that the
Fig. 9.23 Correct positioning is important. Measurement will be dif- feet are resting on the orbital rim
ficult if there is coexisting displacement of the zygoma (a, b) 4. Align the parallax eliminating mark on the exophthalmometer
appropriately
5. Read off the position of the anterior most cornea on the scale
6. When recording the findings, make sure you record the
intercanthal distance as well as the exophthalmometry reading to
allow future comparisons
9.4 Management of Orbital Fractures a
Whenever an injury to the globe or its associated structures

is suspected, an ophthalmic opinion should always be sought.
Initial management is similar to patients with fractures of the
zygomaticomaxillary complex and is detailed in that
chapter.
Patients should be advised not to blow their nose. The
concern here is not the surgical emphysema per se, but asso-
ciated contamination in the orbit and soft tissues. This can
result in orbital cellulitis, both a sight- and life-threatening b
condition (see Fig. 9.26).
9.4.1 Surgical Repair
When orbital fractures coexist with other fractures of the

midface (zygoma, nasoethmoid, frontal bone), these must be
repaired first. This is because safe orbital dissection and suc-
cessful repair of orbital defects are dependent on key land-
marks and a correctly positioned infraorbital rim to support
the implant. This will not be possible if the peripheral bones
are significantly displaced.
Fig. 9.26 “Don’t blow your nose”: two cases of orbital cellulitis (a, b).
9.4.1.1 Indications for Repair Infection can spread rapidly throughout the orbit and extend intracrani-
ally and into the face. When it is as extensive as this, the prognosis is
“Clinically Signiﬁcant” and the Risks of Surgery extremely poor. Often patients are immunocompromised in some way.
Surgical repair is a controversial area of practice. While Fortunately this is very rare
some fractures clearly require repair and others clearly do
not, there remains a “grey area” in which the need for sur- Table 9.4 Indications and relative contraindications in orbital repair
gery is largely a matter of opinion. This is partly due to the Indications Relative contraindications
problems of defining what is “clinically significant” enoph- Significant restriction of eye Visual impairment
thalmos, and in accurately predicting when it will occur in movement with CT confirmation of Anticoagulant medication
any particular patient. In some patients there may be an entrapment
obvious orbital floor defect, yet the amount of enophthal- Significant dystopia Patient not concerned
mos they eventually develop is less than anticipated. Significant enophthalmos Proptosis
Furthermore, in many cases the patients themselves are not “Large” blowout “At risk” globe
even aware of this. Therefore the need for surgery has to be
balanced against the small risks of potentially major How “Big” Is Big?
complications. If a defect is large enough it will inevitably result in enoph-
In the absence of any significant diplopia, surgical repair thalmos once swelling has fully settled. However, the precise
becomes largely a cosmetic procedure (i.e., to prevent or dimensions of a “large” blowout fracture (as measured on
treat enophthalmos). In these patients the concern is that any CT imaging) are unclear from the literature. A number of
repair itself could result in complications such as significant studies have looked into the relationship between orbital vol-
diplopia or injury to the visual pathway. Although these risks ume expansion and enophthalmos, each with different find-
are very small, should either occur, the patient will be con- ings. Some clinicians feel that any defect greater than
siderably worse off. This needs to be clearly discussed with 1 × 1 cm will result in “significant” enophthalmos. However,
the patient before surgery is agreed on. The final decision in the site of the defect will probably have as much bearing (if
such “borderline” cases is therefore largely a matter of per- not more) than the actual size. Defects involving the postero-
sonal/patient preference, taking into account the risks and medial bulge are more likely to have greater effect on globe
benefits of operating (or not). Indications and relative contra- position than similar sized defects sited more anteriorly (see
indications for surgery are shown in Table 9.4. Fig. 9.27).
a b
Fig. 9.27 Before the advent of CT, defining the size of an orbital floor defect was impossible. The “hanging drop” sign (a) gave no indication of
size and tomograms (now obsolete) gave little more information. CT has without doubt significantly improved diagnosis. Defects involving the
posteromedial bulge (green line/red arrow) are most likely to have a significant effect on orbital volume and globe position (b, c). The blue arrow
on the axial view illustrates how the convexity of this “bulge” supports the forward position of the globe. Fractures of the posteromedial bulge
should be considered as fractures of both the orbital floor and medial wall. Anterior-sited defects below the globe (blue line) are more likely to
have an effect on the vertical position of the globe. This effect is lessened if Lockwood’s suspensory ligament is intact
Today, orbital volumes can be measured using appropri- When Is Diplopia Signiﬁcant?
ate software after CT scanning. This can provide a valuable Similarly, opinions vary over what constitutes “significant”
tool in the prediction of enophthalmos and evaluation of diplopia. This is a relatively common clinical finding,
repair (see Figs. 9.28 and 9.29). although in many patients it occurs only at the extremes of
gaze. Diplopia is usually more of a clinical problem when Deciding when (and when not) to operate is therefore not
looking downwards (for example to read), but in some pro- always that simple. In some cases a period of close follow-up
fessions diplopia on looking up can be just as much a prob- may be necessary to determine if any of the initial symptoms
lem (e.g., for a heavy goods vehicle, or bus driver, or and signs are resolving (diplopia) or getting worse (enoph-
professional snooker/pool player). Fortunately, in many thalmos). Since surgical repair always carries the small (but
cases this will resolve if managed nonsurgically and eye devastating) risk of blindness and causing diplopia, a clear
movements are encouraged. indication for surgery should always be established.
9.4.1.2 Timing
a
Timing of surgery is dependent on a number of factors.
Immediate exploration and repair is rarely required. However,
many authorities believe that indications for urgent repair
include significant entrapment of the muscles. In most
“blowouts” it is the orbital fat that is trapped. However, mus-
cle entrapment (which can be seen on coronal CT views) can
b potentially result in ischaemic injury to the muscle and sub-
sequent fibrosis. Inappropriately severe pain is considered by
some to be a sign of this. The pain is severe because of isch-
aemia (cf pain in myocardial infarction, or an ischaemic leg).
For similar reasons, blowout fractures in children may need
to be repaired urgently if they are accompanied by severe
pain (and often vomiting). Due to the greater elasticity in
young bone, children are more likely to experience entrap-
ment (since the bones recoil back into place). This can result
Fig. 9.28 A two-wall defect involving the lateral orbital floor and in severe restriction in eye movements. Entrapment in the
medial wall (a, b). Enophthalmos is already apparent
a b
Fig. 9.29 The dimensions of the defects have been measured. Appropriate software can calculate the volume change at both sites separately and
collectively. This helps in predicting the extent of enophthalmos and in planning repair (a–c)
absence of external signs of trauma has been termed the In the absence of indications for urgent repair, most
“white-eyed blowout fracture” (WEBOF). blowout fractures can be left safely for up to 7–10 days if
necessary. Swelling should be allowed to resolve to enable
further assessment. Repairing a blowout fracture in the
Diagnosis of WEBOF is important and can be easily presence of significant swelling may put the patient at risk
overlooked. Attempts to examine the eye may generate of developing orbital compartment syndrome postopera-
significant pain and a parasympathetic autonomic tively. While the orbital wall defect is present, oedema can
response, resulting in nausea, vomiting, and bradycar- leak out of the orbit and fat can herniate if the pressure is
dia. These symptoms can be easily misinterpreted, high (effectively decompressing the orbit). However, once
especially if there is a history of head injury and there repaired this natural compensation is lost.
are no external signs of orbital trauma.
a c
Fig. 9.30 Postoperative CT images with successful correction of enophthalmos (a–c)

9.4.1.3 Infraorbital Access

Access to the infraorbital margin is commonly required dur-
ing repair of midface fractures, fractures of the zygoma, or
in the exploration and repair of orbital floor fractures and
some fractures of the medial wall. A number of approaches
Brow
are well described in the literature and which approach is
taken depends on a number of factors (surgeon’s and
patient’s preference, overlying lacerations, access required, Upper lid
Medial blepharoplasty
presence of suitable skin creases, to name a few). Collectively
canthal Subcilliary
these can all be considered as falling into two groups: trans-
cutaneous or transconjunctival. Both are relatively quick
procedures (see Figs. 9.31 and 9.32). Midtarsal
Transcutaneous Approaches Rim

Transcutaneous approaches have a number of advantages and
disadvantages and arguably may be a safer approach for the
novice. A number of skin incisions have been described, rang-
Fig. 9.31 Transcutaneous approaches to the orbit. Variations of these
ing from the “subciliary” incision, which is placed just below exist. Some may be made “straight down to bone,” or the approach may
the eyelashes, to the lower “subtarsal” (or rim) incision, which be stepped, with the incision of each successive layer at a different level
is placed along the lower edge of the eyelid. Much has been
written about the relative merits of each (see Fig. 9.31).
Midtarsal Approach
In the first two cases shown, an incision approximately mid-
way between the subciliary and subtarsal levels has been
made: “midtarsal.” This has been sited in a suitable skin
crease. Meticulous haemostasis is required during this proce-
dure. Not only does this help with the dissection of the tis-
sues, but it also minimises postoperative bruising and
swelling of the eyelids. Following an initial full-thickness
skin incision, the wound edges are gently retracted with skin
hooks. Forceps should not be used to grasp the skin as it is
easily damaged. Using fine tenotomy scissors, the muscle
fibres of the underlying orbicularis muscle fibres are gently
separated, proceeding towards the infraorbital margin. (Some
surgeons approach the orbit through a “stepped” incision.
This is reported to improve scarring.) In most cases this is a
“muscle splitting” type procedure, in that the muscle fibres
can be separated without being divided. Consequently there
is usually very little bleeding. However, with medial or lat-
eral extensions of the incision, some division of muscle
fibres may be necessary due to their circular configurations.
Fig. 9.32 Transconjunctival approach to the orbit. These can be ‘retro-
This should be kept to an absolute minimum and is usually septal’ (as shown here) or ‘preseptal’
avoidable with careful retraction of the muscle fibres.
Splitting of the muscle fibres exposes the underlying encountered during periosteal elevation, both within the orbit
orbital septum and periosteum. These are then incised with a as well as exiting from its foramen. The position of the nerve
scalpel along the entire length of the infraorbital rim, a few can vary, so it must be carefully looked for during this part of
millimetres below the crest. Care is required at this stage, the procedure. Deep orbital dissection is described later.
particularly in the presence of multiple bone fragments, as Following repair of the rim and/or orbital defect, the peri-
these can be mobile and easily displaced by pressure from osteum is carefully closed with a resorbable suture. If exten-
the scalpel blade. Using a sharp periosteal elevator, the peri- sive exposure of the midface has been undertaken, the soft
osteum is then gently lifted. Care is also required during this tissues need to be resuspended. This can often be achieved
part of the procedure as the infraorbital nerve is often using the fixation plates as a point of anchorage.
Case 1
a b
c d
e f
g h
Fig. 9.33 (a–h) Mid tarsal approach to the orbit. Following a temporary tarsorrhaphy, the midtarsal incision is made. Upward traction stretches
the lower eyelid skin and helps placement of the incision. The skin is gently separated with skin hooks and the muscles split (either directly below
or in a stepped fashion). Following periosteal incision and elevation, the defect can be defined
Case 2
a b
c d
e f
Fig. 9.34 (a–f) Mid tarsal approach to the orbit. Following skin incision the edges are gently retracted using skin hooks. Muscle splitting with fine
tenotomy scissors is usually quick and causes very little bleeding. The periosteum in the incised and elevated
Case 3 through the laceration itself follows the same principles as

In some cases, access to the infraorbital margin may be previously described. However, the anatomy can sometimes
possible through a preexisting laceration. The dissection be more confusing due to the presence of soft tissue injury.
a b
c d
e f
Fig. 9.35 The laceration is extended medially within a suitable subtarsal skin crease (a, b). Following skin incision the muscle fibres are bluntly
separated as previously described (c, d). This provides extensive exposure of the underlying bones (midface and orbital fractures in this case). The
periosteum is then incised (e, f)
a b
Fig. 9.36 The periosteum must be elevated carefully, avoiding “buttonholes” in the process. Once in the correct plane it usually elevates easily (in
areas remote from the fractures). Start laterally (a, b)
a b
Fig. 9.37 The defect is then defined and repaired. With such extensive exposure careful resuspension of midface tissues is important during clo-
sure (a, b)
Transconjunctival Approaches important here. The lower eyelid is retracted and a malleable
A number of transconjunctival approaches to the orbit have flat retractor is used to gently retract the globe and conjunc-
been described in the literature. These can be considered as tiva, such as to stretch the conjunctiva over the infraorbital
either “preseptal;” that is, part of the dissection proceeds rim. Very often a thin layer of orbital fat can be seen and felt
superficial to the orbital septum and tarsal plate, or “retrosep- bulging into the fornix. In younger patients this can some-
tal” where the entire dissection proceeds deep to the tarsal times be gently “milked” back into the orbit, although a
plate. Even retroseptal approaches have variants (see Fig. 9.32). small amount commonly herniates through the incision (this
is not a clinical or technical problem). To minimise this from
Retroseptal Approach occurring, the first incision can be made through the con-
The retroseptal approach is one of the simplest and most junctiva only, not straight down to bone. Conjunctiva is sur-
direct approaches to make. A low conjunctival incision can prisingly thicker than often thought. Any bleeding is stopped
be placed deep in the fornix, just above the orbital rim. and the malleable retractor then replaced, retracting any fat
Alternatively, an incision can be placed at a slightly higher that is now clearly visible.
level and a conjunctival flap raised. This can be used to pro- A second incision is then made through the remaining tis-
tect the globe. Each has advantages and disadvantages over sues and periosteum. This incision can be a little bit difficult
the other, and which is used is largely a matter of personal if the orbital rim is comminuted and there are “floating” frag-
choice. ments. However, if the bone is well supported, this is an easy
In the examples shown, access to the orbit has been gained approach to make. Once the periosteum is incised, it is ele-
through an incision placed low in the fornix. A protective eye vated along the length of the rim (see Figs. 9.38, 9.39, 9.40
shield is required for this approach. Gentle retraction is and 9.41).
Case 1
a b
Fig. 9.38 Gentle retraction of the lower eyelid and globe stretches the conjunctiva over the rim. Local anaesthetic is infiltrated. Haemostasis
greatly facilitates dissection (a, b)
a b
Fig. 9.39 The conjunctiva is incised, either directly “down to bone” or as a full-thickness conjunctival incision only (as here) (a, b)
a b
Fig. 9.40 The underlying soft tissues and fat are gently “milked” into the orbit and a second full-thickness incision made to include periosteum.
This is then gently elevated (a, b)
Fig. 9.41 The retroseptal approach is very quick, but only gives lim-
ited access (depending on how lax the lower eyelid is). This is consider-
ably improved when combined with a lateral canthotomy (described
later)
Case 2
a b
Fig. 9.42 Injection of local anaesthetic and incision (a, b)
a b
Fig. 9.43 Second periosteal incision and elevation of periosteum (a, b)

a b
Fig. 9.44 Without a lateral canthotomy, small defects can usually be repaired (a, b). Note protective eye shield. These can easily displace
Depending on the extent of periosteal elevation, the peri-

osteum may be sutured at the end of the procedure or not.
Suturing the periosteum would be recommended if extensive
dissection onto the cheek has been required (to help resus-
pend tissues), or if an implant has been placed, but not
securely fixed (e.g., silastic sheeting). The conjunctiva can
either be sutured or not (see Fig. 9.45).
The retroseptal approach has the merits of being very
quick and providing reasonably good access. However,
orbital fat can sometimes herniate into the wound and irritat-
ingly get in the way. The lower eyelid retractors can also be
affected by this approach if the wound is poorly designed or
closed. For this reason some surgeons prefer not to suture the
conjunctiva.
Fig. 9.45 The conjunctiva can be closed with a resorbable suture (6.0
Vicryl in this case). The knots should be buried
Preseptal Approach globe. The dissection is continued inferiorly between the

In the preseptal approach, an incision is made through the orbital septum and the overlying orbicularis oculi muscle.
conjunctiva, below the tarsus. A plane of dissection is then This is a relatively avascular plane. It is important to keep the
developed between the more superficial orbicularis muscle orbital septum intact as this prevents herniation of orbital fat
and the orbital septum. or injury to the inferior oblique muscle. Once the orbital rim
The initial incision can be done with a scalpel or a is exposed, the periosteum is incised and elevated. Following
guarded monopolar cautery needle (Colorado needle). The exploration, the wound can be sutured or left.
plane of dissection deep to conjunctiva is developed with Left transconjunctival incision with secondary can-
scissors and a retraction suture placed through the free mar- tholysis and McCord lid swing (see Figs. 9.46 to 9.49 and
gin of the flap. This is gently retracted superiorly over the 9.51 to 9.53).
a b
Fig. 9.46 The initial incision is made using cutting diathermy, using a “postage stamp” technique (a, b)
a b
Fig. 9.47 A conjunctival flap is raised (a). As the dissection proceeds, any vessels in the conjunctival connective tissue are readily displayed. Both
sharp dissection with scissors and/or cutting diathermy may be used. The conjunctival flap is used to protect the globe (b)
a b
Fig. 9.48 Once the periosteum is clearly exposed, it is incised with a cutting diathermy. If any thickness or “sponginess” of the soft tissue is
observed, continue with the blunt dissection (a, b). Otherwise the skin flap, which is very thin, may be buttonholed
a b
Fig. 9.49 The rim is fully exposed and the orbital periosteum then elevated, commencing laterally and working across the rim and deep towards
the inferior orbital fissure (a, b)
Improving Access: Lateral Canthotomy (See Fig. 9.50) Most small to medium-sized blowout fractures can be
accessed comfortably through either of the transconjunctival
incisions just described. However, with large or complex
defects, greater exposure maybe required. This can be achieved
by extending the transconjunctival incision laterally, with a
lateral canthotomy. Some surgeons prefer to do this part of the
procedure before the transconjunctival incision and dissec-
tion. Others extend the conjunctival incision as required.
The cutaneous incision of the lateral canthotomy is made
using either scalpel or scissors. This is placed at the junction
of the upper and lower lids, extending approximately 5 mm
laterally, in a suitable “crows-foot” wrinkle. The skin is
gently dissected, exposing the inferior crus of the lateral
canthal tendon. This is then divided using scissors or scal-
pel and the deeper conjunctiva incised to join with the
orbital incision (see Figs. 9.51–9.57).
This simple procedure improves access considerably, as
Fig. 9.50 The addition of a lateral canthotomy to either of the trans-
the lower lid hinges downwards. Although it is simple to
conjunctival approaches considerably improves access. In experienced make, it is very important to accurately realign the tendon
hands it is a quick procedure with minimal morbidity. Meticulous when closing the wound.
closure is required, however
a b
Fig. 9.51 Once the lateral aspect of the conjunctival incision is reached, a small skin incision is made (a). It is important to only cut skin at this
point. Often there is a small amount of conjunctival oedema (b). This can cause some confusion with the anatomy
a b
Fig. 9.52 A curved mosquito clip is placed across the tendon; the curve of the clip should point upwards. The aim is to section the lower limb
only, thereby leaving the superior limb intact to suture to, minimising lid malposition (a, b)
a b
Fig. 9.53 The cut end of the tendon is usually clearly seen (a). The Desmarres retractor is now pulled inferolaterally and any remaining vestiges
of the tendon displayed and incised. There should be a visible “give” as the tendon parts and the lid swings down (b). Without this movement, the
procedure is not complete
a b
Fig. 9.54 A second Desmarres retractor can now aid the swinging of the lid inferiorly (a). A malleable retractor is then placed on the bone edge
and rolled posteriorly (b). If the rim is broken, then the bone is elevated and supported prior to periosteal incision. Initial dissection should ideally
proceed from a solid segment of bone, otherwise there can be considerable fat herniation
a b
Fig. 9.55 This additional procedure facilitates direct access to the back of the orbit and visualisation of most of the medial and lateral orbital wall
as required (a, b)
a b
Fig. 9.56 Meticulous closure of the tendon is essential (a, b)

a b
Fig. 9.57 If the tendon has been accurately repositioned and supported, the skin incision can be left or lightly sutured (a–c)
Preseptal Cantholysis • Lateral orbital margin fractures

With experience, surgical access may be planned to include • Large floor defect
cantholysis from the outset. There are distinct advantages in • Young patients: nondistendible lids
this approach, access is considerably improved, and the con- • Asian eyes
junctival incision is much easier (see Figs. 9.58–9.66). • Associated repaired lower lid laceration
Indications for cantholysis include: • Repaired intraocular damage
• Medial wall fractures • Retrobulbar haematoma
• Comminution of infraorbital margin
Fig. 9.58 The incision is marked in a crow’s foot. It is important to dry Fig. 9.59 The incision is just through skin only, just short of the con-
the skin thoroughly, as there is a tendency for tears to spill and blur the junctival edge medially. Bleeding is usually minimal. The index finger
marking. The length of the incision is a matter of experience, and and thumb can be used to spread the skin incision to aid development of
depends on the volume of surgical exposure. In practice the incision can the cut
be quite short, as long as the lateral canthal tendon is fully released.
Usually around 4–5 mm is all that is required
Fig. 9.60 Following skin incision, a mosquito haemostat is placed Fig. 9.61 Following removal of the clip, the canthal tendon is incised
across the canthal tendon. This is used to crush the tissues for around with a pair of sharp tenotomy scissors, or curved Aufrecht scissors. It is
30 s to ensure that the marginal artery of the lid goes into spasm. Be important that the sharpest scissors are used. If the cut is not achieved
careful not to let the clip drop over the cornea easily, it is better to open another instrument set rather than to simply
chew away with blunt ones. Or use a scalpel
Fig. 9.62 Invariably there is a troublesome vessel in the bed of the Fig. 9.64 Cutting diathermy greatly facilitates bloodless dissection.
incision. Bipolar diathermy is used to arrest this. However, if bleeding However, conventional micro-scissors may also be used. Further dis-
is minor, it may be easier to carry out haemostasis once the conjunctiva section proceeds as previously described
has been raised
a b
Fig. 9.63 The lid is then everted over a Desmarres retractor. In contrast to secondary cantholysis, the lid is much easier to evert. It is also more
straightforward to maintain an even cuff of conjunctiva. Postage stamp incisions are made. Leave a cuff below the tarsal plates to suture back, and
finish medially just behind the caruncle (a, b)
a b
Fig. 9.65 Traction sutures facilitate conjunctival dissection. As the incision is developed, the lid moves gently caudally (a, b)
Fig. 9.66 Whilst meticulous closure essential, a small gap is useful to

allow egress of blood following extubation
Other Approaches
Historically, the “antral pack” was a commonly employed
technique in the management of isolated blowout frac-
tures. A “transantral” approach provided access to the
undersurface of the orbital floor via the maxillary sinus.
Packing the sinus reduced and supported the floor, allow-
ing it to heal. An incision was made in the upper labial
sulcus to expose the anterior maxillary wall. Through this,
a Caldwell-Luc antrostomy was made using a drill or
osteotome. The antrostomy was then enlarged (remember-
ing to protect the infraorbital nerve), until it was large
enough to provide access to the orbital floor. The antrum
was then gently packed. Following repair of the fracture,
the mucosa was closed with a resorbable suture (see
Figs. 9.67 and 9.68).
Unfortunately, this was a very imprecise technique, best Fig. 9.68 Antral packing following support of the zygomatic fracture
with an external fixator
suited for small defects with no entrapment. Leaving the
packs in situ for several weeks carried the risk of infection.
Packs were removed several weeks later, through the same Successful use of endoscopic-assisted approaches via
incision. Due to these limitations, this technique has now a transmaxillary and transnasal route has also been
largely been replaced by open techniques, but it is still worth reported.
knowing about.
9.4.1.4 Deep Orbital Dissection and Placement
of Implants/Grafts
Be aware of the oculocardiac reflex when manipulat-

ing the contents of the orbit. This is a neurogenic reflex
that can result in profound bradycardia and hypoten-
sion. It occurs when pressure is applied to the globe or
when the extraocular muscles are stretched (notably
during a forced duction test). When performing this
test during surgery, always notify the anaesthetist.
Entire circumferential exposure of a defect in the orbital

floor or walls can vary in difficulty, depending on a number
of factors (size and site of defect, adherence of the infraorbital
nerve to the periosteum, timing of repair, and the presence of
swelling/bleeding). As a general rule, surgery is technically
easier the sooner it is done, but this has to be balanced against
other factors, such as swelling.
Whatever the choice of access, dissection within the orbit
should always proceed in the subperiosteal plane. This can be
difficult in the vicinity of the fractures, as the periosteum is
Fig. 9.67 The antral pack was once a popular method of treating often torn or shredded and the bones can be mobile. For this
orbital floor fractures. However, it lacked precision and packs could get
infected. This is now largely an obsolete technique, but is still worth reason it is often helpful to start raising the periosteum at a site
knowing relatively remote (and therefore less injured) from the defect.
Some authorities recommend commencing the dissection subperiosteal layer cleanly and custom made retractors are
along the lateral part of the floor of the orbit. This is because also available (see Fig. 9.70).
most blowout fractures involve the medial side of the floor. Of Care is required with the infraorbital nerve. In some cases,
course this can be adjusted should the fracture pattern be dif- the periosteum lifts off relatively easily, but in others, sharp
ferent (see Fig. 9.69). dissection may be required to develop the plane between the
Appropriate instrumentation is important: a slightly nerve and periosteum.
sharpened elevator (or something similar) helps raise the A general approach to deep dissection is outlined in
Table 9.5.
Table 9.5 Orbital exploration (a few tips and traps)

Know your anatomy (or have a skull in theatre)
Sagittal views on the CT scan will show how far back the defect
goes (i.e., how close it is to the orbital apex)
Consider the use of steroids at the time of surgery and for a short
period after
Use a headlamp and correct instruments
Inform the anesthetist when starting (reflex bradycardia)
Start laterally and dissect on a broad front
Contents passing though the inferior orbital fissure can be cauterised
and divided—there are no important structures here. This will
greatly improve access
The infraorbital nerve can have a variable relationship with the bone.
Sometimes it needs to be carefully dissected free as the orbital
contents are elevated
Define the periphery of the defect
Fig. 9.69 Orbital dissection commences laterally, at a site remote from A thick sheet of silastic makes a good retractor with large defects
the fractures. Here subperiosteal dissection off robust bone is easiest An orbitotomy can improve access for “deep” defects
Implants often need to be secured
Do a forced duction test at the beginning and at the end (for
comparison)
Don’t panic if the pupil becomes dilated—this can be common. It is
not a sign of blindness (know your cranial nerves)
Fig. 9.71 A suddenly dilated pupil is always a little worrying, but it is

usually not a serious clinical problem. The commonest cause is trau-
matic mydriasis. Always check the pupil sizes and do a forced duction
Fig. 9.70 Orbital retractor. This instrument is specifically designed to test before commencing surgery. Sometimes dilation may be pre-
aid in the retraction of contents during exposure of the orbital floor existing (if noted, get an ophthalmic opinion before surgery)
9.4.1.5 Deep Dissection siderably. This should always be considered with deeper or
In principle, the aim of repair is to define the edges of the more complex defects. Transcutaneous approaches also pro-
defect, return any herniated contents back into the orbit, and vide excellent access but are becoming less popular due to
then cover the defect with a suitably strong material. The the success and superior aesthetics of the transconjunctival
deepest edge of the defect (best seen on the sagittal views of approach. Division of the tissues passing through the inferior
the CT) is often called the “posterior ledge.” With large orbital fissure also greatly facilitates the lateral dissection
defects this can be very close to the orbital apex. With small along the orbital floor. If you are really struggling, an orbi-
“trap-door” defects, repair is usually straightforward, the totomy may help access to the deepest recesses of the orbit.
contents are reduced relatively easily, and the fracture This is described later.
realigns itself, often without the need for a graft (although The more one dissects, the more tissue there is to retract.
some surgeons may prefer to place one anyway). Such Choice of instrumentation is important, although what feels
defects can usually be accessed through a relatively small best for one surgeon may not necessarily be best for another.
incision (see Figs. 9.72, 9.73, 9.74 and 9.75).
With larger defects, dissection and access becomes more
difficult. If a transconjunctival approach has been used, add-
ing a lateral canthotomy will certainly improve access con-
Fig. 9.73 Trap-door left orbit. The soft tissues (yellow arrows) are
seen herniating through the defect (blue arrows). To reduce the con-
tents, the hinged part of the trap door must be gently opened enough so
that the contents can be gently teased back into the orbit. This must be
Fig. 9.72 A small trap-door defect. This can be approached through a done carefully; otherwise it may completely fracture, requiring a larger
relatively small incision. Yellow arrows indicate margins of fracture, implant
red arrow indicate herniated orbital contents
Fig. 9.74 As the contents reduce, the trap door becomes more obvious.
Sometimes the fracture reduces completely, sometimes there is a small
residual defect that may or may not need an implant. Small defects do Fig. 9.75 The herniated contents can be seen returning to the orbit. The
not. Yellow arrows indicate margins of fracture, light blue arrow indi- sooner surgery is done, the easier this is. With long delays (weeks) the
cate trapdoor defect hingeing down contents become adherent and friable, making surgery technically harder
An element of trial and error is often required when learning when dissecting upwards along the medial wall (through an
this technique. Because the orbit narrows the further back you infraorbital approach), good retraction is essential to avoid
go, broad retractors cannot be placed deeply and sometimes a trapping the soft tissues between the bone and the leading
narrower one is a better choice. Good visualisation of the (upper) edge of the implant. Makeshift retractors can be sur-
depths of the dissection is essential. Not only is it important to prisingly useful sometimes. A thick (2-mm) sheet of silastic
make sure you are not too deep (potentially damaging the cut to size can often help in difficult cases where the perios-
optic nerve), but it is also important to ensure that the tissues teum is shredded and fat keeps herniating into the field of
at the back do not get trapped between the implant and the view. Needless to say, good assistance and a headlamp will
posterior ledge (on which the implant should sit). Similarly, also make this a lot easier (see Figs. 9.76, 9.77 and 9.78).
Fig. 9.77 The contents of the inferior orbital fissure can be safely
Fig. 9.76 Large defect seen on sagittal view. The defect starts at the divided. These often bleed, so bipolar cautery is best undertaken before
blue arrow and extends to the red arrow—the posterior ledge. This division. Dividing these tissues will greatly facilitate retraction of the
needs to be completely spanned by the implant. Careful evaluation of contents and exposure of the orbital floor. The fissure can now be seen
the CT scan is important. Dissection at the back of the orbit will prob-
ably come close to the orbital apex. Double yellow arrow shows the
increased orbital volume
a b
Fig. 9.78 Left orbital blowout (a, b). Once the orbital contents have been repaired, the graft/implant is placed over the entire defect
9.4.1.6 Repair of Defects also included cartilage, harvested from both the pinna and
Once the orbital contents have been successfully reduced, nasal septum. Being autogenous, the reported risks of infec-
they need to be supported to prevent them from re-herniating. tion and extrusion with bone and cartilage are very low, but
Orbital defects can be repaired or reconstructed using a num- they do require a second procedure to harvest the material.
ber of allogenic or autogenous materials. Ideally the material Alternatively, allogenic materials can be used. Today there are
should be supported by the entire periphery of the defect, many different materials available, including titanium sheets,
although this can sometimes be very difficult to achieve if mesh, polymers and newer resorbable materials. Each has its
the defect extends too close to the orbital apex. own advantages and disadvantages compared to the others and
Bone was once a very popular choice of material and many the final choice is often largely one of personal preference and
donor sites have been described in the literature. These include cost. Titanium is currently a popular choice. A small selection
antral wall, cranium (calvarial), rib or iliac crest. Reports have of materials available is shown (see Figs. 9.79–9.87).
a b
Fig. 9.79 Iliac crest bone (a) used to repair a right orbital floor defect (b)
a b
Fig. 9.80 Although mostly superseded by titanium, silastic still has a useful role in the management of small trap-door defects (a). The defect is
shown following release of the trapped tissues (b). Red circle represents the fractured orbital floor
a b
Fig. 9.81 A thin sheet of silastic is then cut to shape (a) (here it is approximately 1 cm in diameter). This is used to cover the defect (b). Silastic
has very little intrinsic strength and therefore offers no structural support. Its role here is simply to prevent the soft tissues from catching on the
bone edges. The bones themselves are still supporting the orbital contents
a b
Fig. 9.82 Titanium has gained popularity in the repair of orbital defects (a, b). It is generally inert and much more rigid than silastic. This comes
in many forms (sheets, mesh). Thin titanium mesh also can be coated with a thin layer of silastic (reinforced silastic)
Fig. 9.83 Titanium mesh

a b
Fig. 9.84 Various configurations of titanium sheets exist. These are designed to reconstitute orbital anatomy (a, b)
Fig. 9.85 Medpor (high-density porous polyethylene) is another material commonly used. It is reported to integrate with the soft tissues, reducing
the incidence of infection (a, b)
Fig. 9.86 Resorbable materials are also available
a b
c
d
Fig. 9.87 Repair using titanium has the advantage of allowing critical evaluation on postoperative scans (a–d)
Whatever the choice of material, the aim is to accurately orbital contents and span the entire defect, the complex
restore the shape (and hence the volume) of the orbit. This curvatures of the orbital walls means that a flat sheet of
can be difficult, especially when two or more walls are material may not necessarily restore the shape. The com-
fractured (most commonly the floor and medial wall). monest site where this problem occurs is at the posterome-
Although it may be possible to completely reduce the dial bulge (see Fig. 9.88).
a b
Fig. 9.88 Repair of two-wall defect with titanium (a–c). Difficult aspects in repair are precise placement of the implant in the deepest recesses of
the dissection (red arrows) and in reproducing the posteromedial bulge (blue arrow). Yellow rectangle represents the optic nerve
Precontoured (preformed) titanium plates are now avail- compared with flat sheets. Ideally, navigational surgery should
able for the repair of floor and medial wall defects. These are be available for this, but in reality not all centres can afford this
designed to reproduce the orbital contours at these sites. expensive equipment. Endoscopic-assisted surgery is another,
Unfortunately, this means greater precision is required when slightly less costly method to help improve precision (see
placing these plates as there is considerably less room for error Figs. 9.89–9.97).
Fig. 9.89 Precontoured (preformed) orbital plates are designed to reproduce the complex geometry of the orbital floor and medial wall. They
come in two sizes (small and large) (a, b)
a b
Fig. 9.90 Preformed orbital plate (a, b)
Fig. 9.91 These can be very difficult to place accurately, but currently
offer the best chance of restoring orbital geometry. They are placed in a
specific manner with the medial wall as the leading edge. Good access,
lighting, and assistance is essential with large defects
a b
Fig. 9.92 Viewed from different directions (a–d). The implant is secured to the infraorbital rim. When positioned accurately it will reconstruct
the sloping surfaces of the orbital floor and posteromedial bulge
a d
Fig. 9.93 (a–d) Postoperative imaging is recommended with these plates. Precise placement is very technique sensitive. In these cases, plain films
have been taken
a b
c d
Fig. 9.94 Left orbital blowout repair with preformed titanium (a–d) (see text and previous case)
Fig. 9.95 Remember to do a forced duction test at the end of the pro-
cedure. A poorly positioned plate can trap tissues, both inferiorly and
medially
a b
Fig. 9.96 Postoperative CT showing satisfactory plate position (a–c)
a b
Fig. 9.97 Further examples (a, b)

9.4.2 Medial Orbital Fractures resulting in proptosis and ocular dystopia. For a number of
reasons, these are a difficult group of fractures to repair—
Fractures of the medial orbital wall can occur in isolation, or access is somewhat limited and deep dissection along the
as a medial extension of orbital floor defects. Isolated frac- medial orbital wall comes into very close contact with the
tures are common. These can either be “blowout” or “blow- orbital apex. Significant bleeding can also occur due to the
in” in nature. In the latter case, the mobile fragment is proximity of the ethmoidal vessels (see Figs. 9.98, 9.99,
displaced into the orbit (as opposed to the ethmoid sinuses), 9.100 and 9.101).
a b
Fig. 9.98 Medial wall “blow-in” fracture with proptosis and ocular dystopia. Preoperative (a, b). Post operative (c, d)
a b
Fig. 9.99 Isolated medial wall blowout fracture (a, b)
Fig. 9.101 Complex injury involving medial wall and floor of orbit.
There is significant emphysema from nose blowing (yellow arrows).
Note depth of posterior limit and its relationship with the orbital apex
b
Fig. 9.100 Extensive medial wall blowout fracture with gross hernia-
tion of tissues (a–b). Red arrows indicate margins of fracture, yellow
arrows extent of displacement of the lamina papyracea, blue arrows
indicate posterior margin of fracture next to optic canal
9.4.2.1 Surgical Repair Transcutaneous Approach to the Medial Wall

Access to the medial orbital wall is possible through a The transcutaneous approach requires a suitably sized skin inci-
number of approaches. It may be possible to access the sion placed alongside the medial canthus. A zig-zag design
lower half of the wall through any of the infraorbital minimises unsightly scarring. Through this incision, the under-
approaches previously described. However, this is some- lying periosteum is incised and subperiosteal dissection along
what limited and clear visualisation of the entire wall can the medial wall undertaken. The obvious limitation here is the
be very difficult. The coronal flap is reported to provide attachment of the medial canthus, which restricts access and
good access to the upper half of the medial wall, but may prevents passage of any sizeable implant. Nevertheless, com-
be an excessive approach for isolated defects. More direct bined with an infraorbital approach, this incision is relatively
access is possible transcutaneously, or through a “transcar- easy to do, facilitating exposure of the upper part of the defect
uncular” approach. and manipulation of the leading edge of any implant. The can-
thus should not be detached. These incisions generally heal well
with acceptable scarring (see Figs. 9.102, 9.103 and 9.104).
a b
Fig. 9.102 This approach has been combined with a transconjunctival approach to the orbital floor. A zig-zag design minimises scar contraction (a, b)
a b
Fig. 9.103 Initial dissection identifies the medial canthal attachment. This is left undisturbed. The external angular vein is shown prior to division
(a, b)
Fig. 9.104 Although limited, this does allow access and visualisation
of the medial wall and leading edge of the titanium plate. Repair is not
possible through this approach alone. The wound is closed in layers
Transcaruncular Approach far back as the orbital apex (although such an extensive expo-
More recently the transcaruncular approach has gained sure is not recommended routinely). The anterior and poste-
increasing popularity. In a sense, this can be thought of as a rior ethmoid foramina lie along the medial wall, through
medial transconjunctival approach, with elements similar to which the anterior and posterior ethmoid arteries pass. These
the retroseptal dissection. Following incision of the conjunc- are important surgical landmarks, marking the level of the
tiva, blunt dissection (using tenotomy scissors) is progressed cribriform plate and the anterior cranial fossa. Grafts may or
behind the medial canthal attachment onto the posterior lac- may not need securing, depending on how they lay passively.
rimal crest on the medial wall. It is here that the periosteum is If a graft is secured with a screw anteriorly, make sure it does
then incised and elevated, leaving the medial canthus and lac- not “kick out” at the back (into the orbit) as the screw is tight-
rimal sac undisturbed. Through this incision the periosteum ened. Following repair, sutures are often not required for clo-
can be widely elevated exposing most of the medial wall as sure (see Figs. 9.105, 9.106, 9.107 and 9.108).
Lacrimal sac
Horner’s muscle
Pretarsal orbicularis
Tarsus
Fig. 9.105 The transcaruncular incision is shown here. Passing through the conjunctiva, the dissection proceeds deep to the lacrimal apparatus
and medial canthal attachment. The periosteum is incised behind the posterior lacrimal crest
a b
c d
e f
Fig. 9.106 Transcaruncular approach. Think of this as a medial transconjunctival approach. The line of incision is shown (a, b). The incision is
marked and the conjunctiva incised (c, d). Tenotomy scissors develop the plane, heading toward the bone, posterior to the posterior lacrimal crest
(e, f). The plane of dissection is shown in (g). Once the periosteum is reached (arrow in h), it is incised along the length of the wound (i). The
periosteum is then elevated, working on a broad front (j, k). Starting on firm bone, the periosteum is gradually elevated to define the periphery
of the defect. Care is required with deep defects. Deep dissection here will come onto the orbital apex (l). Therefore check your scans preopera-
tively (m)
g h
i j
k l
Fig. 9.106 (continued)

a b
c d
Fig. 9.107 In this case the incision is marked (a, b). Following tenotomy dissection to bone the periosteum is incised and elevated (c, d). The
medial wall can be clearly seen (the defect is more posterior) (e, f). A strip of thick silastic cut to shape, makes a good retractor if your instruments
are not the right size (g, h). Plate position is marked on a dry skull to aid understanding. Note that it tapers posteriorly. Also note the ethmoidal
foramina (red arrows). Bleeding is common during this procedure. The plate can be seen (not fully seated yet) (i, j)
e f
g h
i j

a b
Fig. 9.108 Postoperative plain films show a satisfactory position (a, b). Red circles show the plate
9.4.2.2 Endoscopic-Assisted Repair a

Transnasal endoscopic-assisted repair is a very useful tech-
nique that greatly assists the repair of medial wall fractures.
This provides excellent visualisation of the defect, particu-
larly in areas that are difficult to see through the approaches
previously described. By combining transorbital access with
an endoscopic-assisted transnasal approach, precise recon-
struction of large orbital defects is possible. Needless to say,
this requires skills in the operating of an endoscope and a
good working knowledge of intranasal anatomy (see
Figs. 9.109, 9.110, 9.111, 9.112 and 9.113).
Fig. 9.109 Precise placement of plates in large defects can be very

difficult without assisted techniques (a, b). Note malposition
a b
Fig. 9.110 Endoscopic techniques are a valuable adjunct if available. Visualisation of the medial wall and repair greatly facilitates accuracy (a, b)
a b
Fig. 9.111 Endoscopic view showing plate and elevator (a, b)

a b
Fig. 9.112 Pre- and postoperative CT images (a–c)

Fig. 9.113 Further example of precise repair possible using endoscopic-assisted techniques (a, b)
9.4.3 Orbitotomy nerve. The orbital ends of each cut pass along the orbital
floor to meet each other (again taking care not to damage
Access osteotomy is a familiar concept, particularly in head the nerve). The cuts are then completed with a fine osteo-
and neck cancer surgery. The excellent blood supply to the tome and the fragment gently lifted. This must be done
head and neck region gives us the opportunity to physically carefully. The nerve may not be completely free and can
detach bone from its soft tissues, thereby gaining access to sometimes run in a tunnel within the centre of the frag-
the deeper structures. Following management of these deeper ment. If so, the bone needs to be gently nibbled away to
structures (resection if malignant, clipping if vascular, repair free the nerve. The free bone fragment is then wrapped in a
if traumatic), the removed bone is then replaced and secured damp gauze swab and set aside (see Figs. 9.115, 9.116,
with plates. 9.117 and 9.118).
In facial trauma, access osteotomy is not often required. Following orbital repair, the fragment is then replaced and
However, occasionally it may facilitate the dissection and secured using the previously prepared relocation plates.
repair of large orbital fractures, particularly those that Prior to this, any bony spicules on the undersurface of the
extend posteriorly, close to the orbital apex. By removing fragment should be removed using bone nibblers and the
a segment of the orbital rim (usually the inferior rim), foramen enlarged slightly. This hopefully reduces the likeli-
retractors can be better positioned and dissection less hood of any nerve compression during healing (see
hindered. Fig. 9.119).
Care is required when carrying out an orbitotomy of the
infraorbital rim. The infraorbital nerve runs at a variable
depth along the floor of the orbit and can easily be
damaged.
In the case shown, the orbit has been accessed through a
midtarsal incision. Following periosteal elevation, the rim is
clearly defined. The infraorbital nerve should be clearly
identified as it exits through its foramen. This can vary in
position. The ends of the osteotomy are marked; the bigger
the osteotomy, the better the access.
Prior to osteotomy, a relocation plate or plates can be pre-
pared. These are placed along the rim, spanning the ends of
the osteotomy line and then secured with one or two screws.
The plates and screws are then removed and put aside. This
technique should ensure that the fragment is returned pre-
cisely to its correct position (see Fig. 9.114).
Initial bone cuts are then made using a fine saw or burr.
The cuts should be as thin as possible so that the bone fits
precisely back into position at the end of the procedure.
Using an apicecectomy burr, or some other suitable instru-
ment, the lower (facial) end of each cut is continued into Fig. 9.114 Inferior orbitotomy. The rim has been marked prior to bone
the infraorbital foramen, taking care not to damage the cuts. Prelocation plates may be placed at this stage
a b
Fig. 9.115 Vertical bone cuts are made through the rim with a fine saw and joined to the foramen with an apicectomy burr (a, b)
a b
Fig. 9.116 The bone cuts are joined along the orbital floor (a, b)
a b
Fig. 9.117 These are completed with a fine osteotome and the fragment elevated carefully (a, b)
a b
Fig. 9.118 Fragment and infraorbital nerve (a, b)
a b
Fig. 9.119 The osteotomised rim has been returned and secured prior to wound closure (a, b)
9.5 The Forced Duction Test will result in an abrupt cessation of rotation. The test may be
performed in a number of ways. In the first example, fine
The forced duction test is an important part of the assessment tooth forceps are used to grasp the sclera in the 6 o’clock
of orbital fractures. It is often undertaken to determine if position just below the iris. The globe is then gently rotated
there is any soft tissue entrapment resulting in restricted upwards, as if the patient was looking up. This is the most
movements of the globe. The test can be carried out in the common direction for entrapment, but the globe can also be
clinic under local anaesthetic if there is uncertainty regarding rotated laterally with medial wall fractures (the sclera is
mechanical or neurological pathology. It should also be car- grasped medially). Alternatively, the forceps may be passed
ried out following orbital floor exploration and repair, before deep into the lower fornices and the tendon of the inferior
the patient is woken up, to ensure there is no residual entrap- rectus muscle grasped. This needs to be carried out carefully
ment of soft tissues. to avoid damage to the eye or conjunctiva. The anaesthetist
The principle of the forced duction test is very straightfor- should also be warned beforehand, as pulling on the globe
ward. The globe is gently rotated away from the suspected can result in profound bradycardia (see Figs. 9.120, 9.121
site of entrapment. Any residual tethering of the soft tissues and 9.122).
a b
Fig. 9.120 Force duction test following repair of the orbital floor. The sclera is gently grasped and rotated up (a–c)
Fig. 9.121 Alternatively the inferior rectus tendon can be grasped
a b
Fig. 9.122 Avoid repeated attempts at this (a–c). The conjunctiva can be damaged
9.6 Fractures of the Orbital Roof With larger fractures, access may require a coronal flap.
and Superior Orbital (Supraorbital) Rim However, such an extensive exposure may be difficult to jus-
tify for smaller fractures, which may just as easily be repaired
These are mentioned for completeness here, but depending through discretely sited local incisions, as shown.
on their size represent a “watershed” area between the skull
base and frontal sinus. Various combinations of fractures
therefore exist:
• Isolated supraorbital rim
• Supraorbital rim extending into the frontal sinus recess
• Surpaorbital rim extending into the anterior cranial fossa
(orbital roof)
• Fractures involving all these sites.
Fractures involving the frontal sinus and skull base
are discussed elsewhere. Needless to say, the extent of
these fractures needs to be clearly defined if bone frag-
ments are to be manipulated during repair. CT scanning
is therefore essential. This also helps identify whether
the fracture involves the supratrochlear or supraorbital
Fig. 9.123 Vertical dystopia following cranio-orbital fracture. These
foramina.
serious injuries are discussed elsewhere
9.6.1 Repair of Supraorbital Rim
Fig. 9.124 Isolated rim fractures with displacement, pressing on the globe (a, b). There was mild dystopia. The fragments and lateral incision
were marked. Initial exploration was through the overlaying laceration (c, d). Surprisingly good access and exposure of the fragments was possible
(e, f). Subperiosteal dissection exposed the fragments (g, h). The main fragment was removed for extracorporal repair (i, j). The fragment was
returned and secured. Closure was in layers (k, l)
b c

e f
g h
i j

k l
Isolated orbital roof fractures are rare. In adults they may are also skull base fractures, risk-benefit analysis of any
be managed nonsurgically, as the bone remodels, although repair must be carefully considered and the advice of a neu-
some surgeons may elect to repair them using titanium or rosurgeon sought. If the bone fragments are significantly dis-
bone grafts. Patients can rarely develop pulsatile exophthal- placed, a dural tear is likely.
mos. This may require repair if it does not settle. Since these
9.7 Orbital Apex Fractures tethered and is therefore at risk of shearing forces. For this
reason blindness can be associated with blunt forehead
Fractures of the orbital apex commonly occur in association trauma, even in the absence of any fractures.
with fractures of the zygoma and orbit. They are also seen in The superior orbital fissure (SOF) lies between the greater
association with other craniofacial fractures. Either way, and lesser wings of the sphenoid, i.e., between the orbital roof
these occur following high-energy injuries and as such may and lateral wall of the orbit. A ligamentous ring, the annular
also be associated with injuries to the cervical spine, brain, ligament (or common tendon) of Zinn, spans the fissure and
or globe. The orbital apex is the deepest part of the orbit and passes around the optic canal. From this ligament the four
forms part of the craniofacial junction. recti muscles arise. The ligament therefore divides the fissure
into an intraconal and an extraconal portion, through which
different cranial nerves and vessels pass (see Fig. 9.125).
9.7.1 Applied Anatomy These structures are:
Superior and inferior divisions of the oculomotor nerve (III)
The anatomy in this region is complex due to the neurovas- Trochlear nerve (IV)
cular structures that pass through the optic canal (OC) and Lacrimal, frontal and nasociliary branches of the ophthalmic
superior orbital fissure (SOF). These are two separate chan- nerve (V1)
nels, between which lays a thick strip of bone, sometimes Abducens nerve (VI)
referred to as the optic strut. Superior and inferior divisions of ophthalmic vein
Medially, the optic canal has a close relationship to the Orbital apex fractures commonly occur following high-
sphenoid sinus. In some patients the sinus can be enlarged to energy blunt trauma or penetrating orbital trauma.
such an extent that it almost engulfs the canal, increasing the Radiographically, three types of injury have been described:
risks of fractures. Through the optic canal pass the optic 1. Linear without displacement of fragments
nerve and ophthalmic artery. Since the optic nerve is essen- 2. Comminuted with fracture displacement
tially an extension of the brain it is enveloped by pia mater, 3. Apex avulsion with an intact optic foramen.
arachnoid, and dura mater. These collectively form a nerve Since the sphenoid sinus is also usually fractured, these
sheath. Although this is generally mobile throughout most of are technically open fractures and therefore at risk of
its length, within the canal itself the nerve sheath is relatively contamination.
a b LPS Frontal nerve

SR
Lacrimal nerve
SO
SOV
Optic nerve
IV
MR
Nasociliary III sup
nerve LR
Annulus of Zinn III inf
VI
IR
IOF
Fig. 9.125 The orbital apex: a complex anatomical site (a, b)

9.7.2 Clinical Features Traumatic optic neuropathy is believed to occur when

energy is transferred towards the orbital apex and optic canal
Symptoms and signs vary, depending on which neurovascu- at the time of injury. Due to the narrowness of the canal and
lar structures are damaged and their severity. Various syn- tethering of the nerve within it, only a small amount of elastic
dromes have been described (see Table 9.6). deformation is required to result in nerve injury and swelling,
Visual impairment from traumatic optic neuropathy can etc. Shearing forces result in contusion, ischemia, and micro-
occur and may be partial or total, with variable recovery. An infarction of the axons, followed by oedema. If there is a frac-
afferent pupillary defect is highly suggestive of optic nerve ture at the apex, bony impingement followed by oedema and
injury and this may be the only clue in the unconscious hemorrhage occur. Hence management can vary. The pres-
patient. It is important to remember that these syndromes can ence of associated intracranial injuries also has a major impact
occur in the absence of fractures—fractures of the optic on management. Investigations are shown in Table 9.7.
canal are reported to be present in only half of patients with
traumatic optic neuropathy. Injury may therefore arise from Table 9.7 Investigations of orbital apex injuries
one of several mechanisms. These include: CT scan
• Optic nerve transection Fine cuts are required to assess the orbital apex (specifically for
nerve transection or compression). Associated intracranial injury,
• Nerve sheath hematoma
facial fractures, and cervical spine injuries should be screened for
• Optic nerve compression Angiography
• Microhaemorrhages within the nerve (cf diffuse axonal This may be considered in patients with orbital apex fractures. Such
haemorrhage) high-energy injuries can also result in carotid and cavernous sinus
injury. Carotid artery dissection, spasm, or caroticocavernous fistula
should be considered
Table 9.6 Clinical syndromes MRI
Superior orbital fissure syndrome (also known as Rochon- This is rarely undertaken acutely. However it can have a role in
Duvigneaud’s syndrome) identifying hemorrhage within the optic nerve or sheath
Injury to the cranial nerves passing through the fissure results in Visual field assessment
diplopia, paralysis of the extraocular muscles, proptosis, and ptosis Visual-evoked potentials (VEP)
If blindness or visual impairment is also present with these features, These can assess the integrity of the visual pathway. They are
it is called an orbital apex syndrome particularly useful in patients with altered level of consciousness
9.7.3 Management effectively a form of compartment syndrome, and this

results in ischaemia and infarction of the axons.
These are serious and difficult injuries to manage and require Theoretically, decompression may salvage those nerves
a multidisciplinary approach. Neurosurgical input is indi- with reversible injury. However, there is no clear evidence
cated if there is any intracranial injury and ophthalmology that removing bony fragments will improve the chance of
input if there are any signs of globe injury or visual impair- recovery. Surgery itself may result in further trauma and
ment. The advice of a radiologist should also be sought to damage. Several techniques exist:
determine the best imaging and screening protocol for occult • Medial approach via an external ethmoidectomy
injuries (e.g., caroticocavernous injury). • Inferomedial access via a transantral/transethmoidal
Management is a controversial area and depends on the approach
patient’s specific injuries, presence of any functional deficits, • Transfrontal craniotomy
and their overall condition. Clearly any neurosurgical emer- • Endoscopically
gencies take precedence and this may restrict specific mea- Recent advances in endoscopic techniques now mean that
sures directed at the orbital apex. decompression can be undertaken intranasally via a transeth-
Three main treatment options exist. These include obser- moidal or transsphenoidal approach. This clearly has advan-
vation, high-dose steroids, and surgical decompression. tages over the more invasive external approaches, with
However, currently there appears to be no clear evidence that decreased morbidity and faster recovery time.
supports one modality over the others. Since spontaneous Management of ocular motility problems falls under the care
visual recovery has been shown to occur in a significant of specialists in strabismus. In many cases of superior orbital
number of patients (approximately 40–60 %), the decision to fissure syndrome, significant recovery of the muscles often
treat these injuries surgically or with high-dose corticoste- occurs, although this can take many months (see Fig. 9.126).
roids therefore requires clinical judgment.
High-dose corticosteroids have been used with variable
effect in the treatment of traumatic optic neuropathy. Care is
required in certain patients (e.g., diabetics, or those with pep-
tic ulcers, osteoporosis). Furthermore, there is now evidence
to suggest that the use of corticosteroids in patients with
acute traumatic brain injury increases mortality. In those
patients suitable for steroid treatment, the type and optimal
dose is still unclear.
Outcomes from surgery are very technique-dependent, as
access to the orbital apex is difficult. In cases where vision
is decreased (or decreasing) from optic nerve injury, decom-
pression may be indicated if steroids have failed. Progressive
swelling in the canal (from oedema and bleeding) is Fig. 9.126 Superior orbital fissure syndrome
Selected Reading Johnson PE, Raftopoulos I. In situ splitting of a rib graft for reconstruction
of the orbital floor. Plast Reconstr Surg. 1999;103:1709–11.
Kelly CP, Cohen AJ, Yavuzer R, Jackson IT. Cranial bone grafting for
Appling WD, Patrinely JR, Salzer TA. Transconjunctival approach vs.
orbital reconstruction: is it still the best? J Craniofac Surg.
subciliary skin-muscle flap approach for orbital fracture repair.
2005;16:181–5.
Arch Otolaryngol. 1993;119:1000–7.
Kontio R. Treatment of orbital fractures: the case for reconstruction
Buchel P, Rahal A, Seto I, Iizuka T. Reconstruction of orbital floor frac-
with autogenous bone. J Oral Maxillofac Surg. 2004;7:863–8.
ture with polyglactin 910/polydioxanon patch (Ethisorb): a retro-
Kontio RK, Laine P, Salo A, Paukku P, Lindqvist C, Suuronen R.
spective study. J Oral Maxillofac Surg. 2005;63:646–50.
Reconstruction of internal orbital wall fracture with iliac crest free
Burm JS. Internal fixation in trapdoor-type orbital blowout fracture.
bone graft: clinical, computed tomography, and magnetic resonance
Plast Reconstr Surg. 2005;116:962–70.
imaging follow-up study. Plast Reconstr Surg. 2006;118:1365–75.
Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture, new con-
Krishnan V, Johnson JV. Orbital floor reconstruction with autogenous
cepts and importance of medial orbital blowout fracture. Plast
mandibular symphyseal bone grafts. J Oral Maxillofac Surg.
Reconstr Surg. 1999;103:1839–49.
1997;55:327–30.
Burnstine MA. Clinical recommendations for repair of orbital facial
Lai A, Gliklich RE, Rubin PA. Repair of blow-out fractures with naso-
fractures. Curr Opin Ophthalmol. 2003;14:236–40.
septal cartilage. Laryngoscope. 1998;5:645–50.
Castellani A, Negrini S, Zanetti U. Treatment of orbital floor blowout
Lal D, Stankiewicz JA. Endoscopic optic nerve decompression. Oper
fractures with conchal auricular cartilage graft: a report on 14 cases.
Tech Otolaryngol. 2009;20:96–100.
J Oral Maxillofac Surg. 2002;60:1413–7.
Lee S, Maronian N, Most SP, Most SP, Whipple ME, McCulloch TM,
Chang EL, Bernardino CR. Update on orbital trauma. Curr Opin
et al. Porous high-density polyethylene for orbital reconstruction.
Ophthalmol. 2004;15:411–5.
Arch Otolaryngol Head Neck Surg. 2005;131:446–50.
Cheong EC, Chen CT, Chen YR. Endoscopic management of orbital
Manolidis S, Weeks BH, Kirby M, Scarlett M, Hollier L. Classification
floor fractures. Facial Plast Surg. 2009;25:8–16.
and surgical management of orbital fractures: experience with 111
Converse JM, Firmin F, Wood-Smith D, Friedland JA. The conjunctival
orbital reconstructions. J Craniofac Surg. 2002;13:726–38.
approach in orbital fractures. Plast Reconstr Surg. 1973;52:656–7.
Mathog RH. Repair of orbital floor fractures with bioactive glass
Cunningham LL, Peterson GP, Haug RH. The relationship between enoph-
implants. J Oral Maxillofac Surg. 2001;59:1390–5.
thalmos, linear displacement, and volume change in experimentally
Metzger MC, Schön R, Weyer N, Rafii A. Anatomical 3-dimensional
recreated orbital fractures. J Oral Maxillofac Surg. 2005;63:1169–73.
pre-bent titanium implant for orbital floor fractures. Ophthalmology.
Ellis III E, Tan Y. Assessment of internal orbital reconstructions for
2006;113:1863–8.
pure blowout fractures: cranial bone grafts versus titanium mesh.
Nagasao T, Miyamoto J, Nagasao M, Ogata H, Kaneko T, Tamaki T,
Nakajima T. The effect of striking angle on the buckling mechanism
Evans BT, Mourouzis C. Lateral orbitotomy: a useful technique in the
in blowout fracture. Plast Reconstr Surg. 2006;117:2373–80; dis-
management of severe traumatic disruption of the lateral orbital
cussion 2381.
skeleton. Int J Oral Maxillofac Surg. 2009;38:984–7.
Nagasao T, Hikosaka M, Morotomi T, Nagasao M, Ogawa K, Nakajima
Forrest CR, Lata AC, Marcuzin DW, Bailey MH. The role of orbital
T. Analysis of the orbital floor morphology. J Craniomaxillofac
ultrasound in the diagnosis of orbital fractures. Plast Reconstr Surg.
Surg. 2007;35:112–9.
1993;92:28–34.
Nolasco FP, Mathog RH. Medial orbital wall fractures: classification
Francis DO, Kaufman R, Yueh B, Mock C, Nathens AB. Air bag-induced
and clinical profile. Otolaryngol Head Neck Surg. 1995;112:549–56.
orbital blow-out fractures. Laryngoscope. 2006;116:1966–72.
O’Regan MB, Macleod SPR. Miniantrostomy for the reduction of frac-
Fujino T, Sugimoto C, Tajima S, Moribe Y, Sato TB. Mechanism of
tures in the orbital floor. Br J Oral Maxillofac Surg. 2000;38:191–2.
orbital blowout fracture: II. Analysis by high speed camera in two
Parsons GS, Mathog RH. Orbital wall and volume relationships. Arch
dimensional eye model. Keio J Med. 1974;23:115–24.
Otolaryngol Head Neck Surg. 1988;114:743–7.
Gellrich NC, Schramm A, Hammer B, Schmelzeisen R. The value of
Patel PC, Sobota BT, Patel NM, Green JS, Millman B. Comparison of
computer-aided planning and intraoperative navigation in orbital
transconjunctival versus subciliary approaches for orbital fractures:
reconstruction. Int J Oral Maxillofac Surg. 1999;28 Suppl 1:52.
a review of 60 cases. J Craniomaxillofac Trauma. 1998;4:17–21.
Goldberg RA, Garbutt M, Shorr N. Oculoplastic uses of cranial bone
Persons BL, Wong GB. Transantral endoscopic orbital floor repair
grafts. Ophthalmic Surg. 1993;24:190–6.
using resorbable plate. J Craniofac Surg. 2002;13:483–8.
Habal MB. Bone grafting the orbital floor for posttraumatic defects.
Potter JK, Ellis E. Biomaterials for reconstruction of the internal orbit.
J Craniofac Surg. 1992;3:175–80.
Hayter JP, Sugar AW. An orbital observation chart. Br J Oral Maxillofac
Reymond J, Kwiatkowski J, Wysocki J. Clinical anatomy of the supe-
Surg. 1991;29:77–9.
rior orbital fissure and the orbital apex. J Craniomaxillofac Surg.
He D, Blomquist PH, Ellis III E. Association between ocular injuries and
2008;36:346–53.
internal orbital fractures. J Oral Maxillofac Surg. 2007;65:713–20.
Rhee JS, Kilde J, Yoganadan N, Pintar F. Orbital blowout fractures:
Hosal BM, Beatty RL. Diplopia and enophthalmos after surgical repair
experimental evidence for the pure hydraulic theory. Arch Facial
of blowout fracture. Orbit. 2012;21:27–33.
Plast Surg. 2002;4:98–101.
Hundepool AC, Willemsen MAP, Koudstaal MJ, van der Wal KG. Open
Schön R, Metzger MC, Zizelmannn C, Weyer N, Schmelzeisen R.
reduction versus endoscopically controlled reconstruction of orbital
Individually preformed titanium mesh implants for true-to-original
floor fractures: a retrospective analysis. Int J Oral Maxillofac Surg.
repair of orbital fractures. Int J Oral Maxillofac Surg. 2006;35:990–5.
2012;41:489–93.
Tessier P. Inferior orbitotomy: a new approach to the orbital floor. Clin
Jank S, Emshoff R, Schuchter B, Strobl H, Brandlmaier I, Norer B.
Plast Surg. 1982;9:569–75.
Orbital floor reconstruction with flexible Ethisorb patches: a retro-
Warwar RE, Bullock JD, Ballal DR, Ballal RD. Mechanisms of orbital
spective long-term follow-up study. Oral Surg Oral Med Oral Pathol
floor fractures: a clinical, experimental, and theoretical study.
Oral Radiol Endod. 2003;95:16–22.
Ophthal Plast Reconstr Surg. 2000;16:188–200.
Jank S, Emshoff R, Etzelsdorfer M, Strobl H, Nicasi A, Norer B. The
Waterhouse N, Lyne J, Urdang M, Garey L. An investigation into the
diagnostic value of ultrasonography in the detection of orbital floor
mechanism of orbital blowout fractures. Br J Plast Surg. 1999;52:
fractures with a curved array transducer. Int J Oral Maxillofac Surg.
607–12.
2004;33:13–8.
Wilson S, Ellis III E. Surgical approaches to the infraorbital rim and
Jin HR, Yeon JY, Shin SO, Choi YS, Lee DW. Endoscopic versus exter-
orbital floor: the case for the subtarsal approach. J Oral Maxillofac
nal repair of orbital blowout fractures. Otolaryngol Head Neck
Surg. 2006;64:104–7.
Surg. 2007;136:38–44.

Orbicular Fractures

Uploaded by

Copyright:

Available Formats

Orbicular Fractures

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Orbicular Fractures

Uploaded by

Copyright:

Available Formats

Orbital Fractures

9.1 Applied Anatomy

All “black eyes” associated with numbness of the

M. Perry, S. Holmes (eds.), Atlas of Operative Maxillofacial Trauma Surgery, 359

Fig. 9.6 While the well-defined

Fig. 9.8 Desmarres and Jaffe lid retractors (a, b)

Fig. 9.11 CT confirmation of an extensive fracture to the left orbital

9.3.1.4 Binocular Functions

Fig. 9.13 Lees screen

9.3.4.1 Type 1 a “chin elevation head posture” to maintain a useful field of

Fig. 9.15 (a) Looking at the

9.3.4.2 Type II either damage to its nerve supply (oculomotor) or direct

Fig. 9.16 The forced duction

Fig. 9.17 Looking at the field of

Fig. 9.18 Type III. This is a

Fig. 9.19 Looking at the field of

Fig. 9.20 This Hess chart

Fig. 9.21 The field of BSV

9.3.5 Measuring Globe Position position in the anteroposterior direction. Exophthalmometry

Fig. 9.22 Hertel exophthalmometer (a, b)

Table 9.3 How to use a Hertel exophthalmometer

9.4 Management of Orbital Fractures a

Whenever an injury to the globe or its associated structures

9.4.1 Surgical Repair

When orbital fractures coexist with other fractures of the

Fig. 9.30 Postoperative CT images with successful correction of enophthalmos (a–c)

9.4.1.3 Infraorbital Access

Transcutaneous Approaches Rim

Case 3 through the laceration itself follows the same principles as

Fig. 9.42 Injection of local anaesthetic and incision (a, b)

Fig. 9.43 Second periosteal incision and elevation of periosteum (a, b)

Depending on the extent of periosteal elevation, the peri-

Preseptal Approach globe. The dissection is continued inferiorly between the

Fig. 9.56 Meticulous closure of the tendon is essential (a, b)

Preseptal Cantholysis • Lateral orbital margin fractures

Fig. 9.66 Whilst meticulous closure essential, a small gap is useful to

Be aware of the oculocardiac reflex when manipulat-

Entire circumferential exposure of a defect in the orbital

Table 9.5 Orbital exploration (a few tips and traps)

Fig. 9.71 A suddenly dilated pupil is always a little worrying, but it is

Fig. 9.83 Titanium mesh

Fig. 9.86 Resorbable materials are also available

Fig. 9.90 Preformed orbital plate (a, b)

Fig. 9.96 Postoperative CT showing satisfactory plate position (a–c)

Fig. 9.97 Further examples (a, b)

Fig. 9.99 Isolated medial wall blowout fracture (a, b)

9.4.2.1 Surgical Repair Transcutaneous Approach to the Medial Wall

Fig. 9.106 (continued)

Fig. 9.106 (continued)

Fig. 9.107 (continued)

9.4.2.2 Endoscopic-Assisted Repair a

Fig. 9.109 Precise placement of plates in large defects can be very

Fig. 9.111 Endoscopic view showing plate and elevator (a, b)

Fig. 9.112 Pre- and postoperative CT images (a–c)

Fig. 9.118 Fragment and infraorbital nerve (a, b)

Fig. 9.121 Alternatively the inferior rectus tendon can be grasped

9.6.1 Repair of Supraorbital Rim

Fig. 9.124 (continued)