Orbital trauma and surgical management

1. Orbital blowout
fracture.

2. An orbital blowout fracture is a traumatic
deformity of the orbital floor or medial wall,
typically resulting from impact of a blunt
object larger than the orbital aperture, or eye
socket.
Etiology:

3. Anatomical
considerations:
3-Optic nerve foramen
III = Oculomotor nerve (Motor)
IV = Trochlear nerve (Motor)
VI = Abducens nerve
V1 = Ophthalmic (Sensory)
1-Superior orbital fissure
2-Inferior orbital fissure
V2 = Infra-orbital nerve.
II = Optic nerve.
Intra-orbital neurovascular structures.
1
2
3

4. Fronta
l
Sphenoi
d
Zygomatic
Maxillary
Ethmoid Lacrimal
Anatomical
considerations:
The medial
wall is
slightly
thinner
(0.25 mm vs
0.50 mm) of
floor
thickness

5. Anatomical
considerations:
 Lateral rectus muscle
 Medial rectus muscle
 Superior rectus muscle
 Inferior rectus muscle
 Superior oblique muscle
 Inferior oblique muscle
Ocular muscles:

6. Extra-ocular muscles
Eye movement of lateral rectus muscle,

7. Extra-ocular muscles
Eye movement of superior oblique muscle,

8. II- Optic (vision)
III = Oculomotor nerve (Motor)
double vision (diplopia)
eyelid drooping (ptosis)
pupil dilation (mydriasis)
IV = Trochlear nerve (Motor)”Sup. Obliq. M
double vision (diplopia)
Squint.lateral sup
VI = Abducens nerve.
double vision (diplopia)”Lat. Rec. M
Squint.-medial
V1 = Ophthalmic (Sensory)
Corneal anesthesia.
V2 = Infra-Orbital (Sensory)
Skin of lower eye lid-nose-upper lip.
Clinical significance of intra-orbital structures:

9. Orbital trauma:
 Edema or hematoma within the internal
orbit.
 Orbital blowout fracture.
Clinical significance of intra-orbital structures:
Increase the intra-orbital
pressure, compromising
the intra-orbital
neurovascular
structures.

10. Signs and symptoms:
 Loss of sensation due to infraorbital nerve injury
 Diplopia and enophthalmos.
 Orbital pain
 Limitation of eye movement.
 Orbital and lid subcutaneous ecchymosis or
emphysema.
Diagnosis:

11. Diagnosis:
Clinical examination:
Ocular motility:
Test eye movements in all possible directions.
Presence of squint or improper eye movement
denoting muscle entrapment or neural damage.
Forced duction test used for differentiation.

12. Pupil function:
Pupillary light reflex provides a useful
diagnostic tool for testing the integrity of the
sensory (CN II) and motor (CN III) functions
of the eye.
 Direct reflex.
 Consensual reflex
Diagnosis:
Clinical examination:

13. Diagnosis:
Imaging:
Plain radiographs do not
sensitively capture blowout fractures.
C.T: (coronal cut) teardrop sign, polypoid mass
consists of herniated orbital contents, periorbital fat
and inferior rectus muscle.
The affected sinus is partially
opacified on radiograph. Air-fluid
level in maxillary sinus due to
presence of blood.

14. Diagnosis:
Imaging:
Medial wall fracture is less common
than floor fracture due to presence
of honey comb ethmoid bone.

15. Inflammatory myopathy
Vitreous
hemorrhage
Diagnosis:
Imaging:
MRI : Detection of
 Inflammatory myopathy
 Optic nerve condition
 Vitrous hemorrhage.
Optic nerve
damage

16.  All patients should follow-up with
an ophthalmologist within one week of
the fracture (Retinal examination,
Intra-ocular pressure).
 To prevent orbital emphysema, patients
 are advised to avoid blowing of the nose.
 Nasal decongestants are commonly used. It is also
common practice to administer prophylactic antibiotics
when the fracture enters a sinus.(Amoxicillin-clavulanate
and azithromycin)
 Corticosteroids are used to decrease swelling.
 Surgical repair of a "blowout" is safely postponed for up to
two weeks, if necessary, to let the swelling subside.
Pre-operative preparation:

17. Surgery is indicated if there is :
Enophthalmos greater than 2 mm.
Double vision on primary or inferior gaze.
Entrapment of extraocular muscles.
Fracture involves greater than 50% of the orbital floor.
Most blowout fractures heal spontaneously without significant
consequence.
Surgical management
It can be safely postponed for up to two weeks

18. Reconstruction is
usually performed
through a
Transconjunctival
incision.
Surgical management
Transconjunctival

19. Reconstruction
through a
Subciliary incision.
Surgical management

20. Reconstruction is usually performed
with Titanium mesh or porous
polyethylene or polydioxanone .
Surgical management
polydioxanone
polyethylene

21. Complications:
More recently, there has been success
with endoscopic, or minimally invasive,
approaches.
partial relief from double vision or a
sunken eye.
Ectropion of lower eye lid.
Graft morbidity.
Sunken eye
Ectropion
Graft