orthoptic approach to blowout fracture

1. ORBITAL INJURIES
By
Siraj Safi

2. Orbital injuries
• Orbital injuries usually arise following blunt
trauma, either from an object striking the
face, for example
• a fist, or through the patient being thrown
against a hard surface, as occurs in road traffic
accidents.
• Limitation of ocular movement and diplopia
are common consequences

3. Blow out Fractures
• Are classified in two groups
1. Pure Blow-out Fractures:
In which the orbital rim remain intact. They
are generally caused by the objects which
are same in size of the globe.
2. Impure Blow-out Fractures:
In which the orbital rim is fractured

4. Features of Blow out fractures
• Diplopia:
is a main symptom of blow out fracture.
It will be vertical, if fracture is of floor.
will be horizontal if fracture is of medial or lateral
wall.
• Pain: On movement away from site of lession.

5. Features of Blow out fractures
• Loss of Vision: The trauma to the eye involving the
optic nerve will result in loss of vision.
• Limitation: May be due to
1. Oedema may be due to orbital hemorrhage
2. Incarceration or entrapment of tissue if the fracture is
linear.
3. Myogenic or Neurogenic (I.R).

6. Features of Blow out fractures
• Displacement of Globe: It is commonly
backward known as “Enophthalmos”
• Retraction of Globe: Which occurs when the
eye moves away from the site of entraped
muscle.
• Facial Asymmetry: Which occurs in “Impure
Blow-Out fractures”.

7. Features of Blow out fractures
• A Large subconjunctival Hamerrhage
• Subcutaneous emphysema: It results due to
entrapment of air in the underlying tissues,
this condition worsens when the patient blow
his nose which is seen following fracture of
medial wall.

8. Investigation
1. Visual Acuity
2. Examination of the ocular media
3. Recording of AHP
4. Recording of EOM
5. Measurement of deviation
6. Hess chart
7. IOP in direction of restriction
8. FDT

9. Radiological Investigations
1. Plain radiography (X-ray)
2. CT Scan
3. MRI Scan

10. Management of BOF
• Conservative:
• Encouraging adaptation of AHP to achieve BSV
• The use of Fresnel prism if effective.
• Occlusion if diplopia is troublesome.

11. Management of BOF Conti….
• Surgical:
• If the motility dose not improve in 14-21 days
• If the radiological investigation prove the
fracture and herniation or incarceration of
orbital contents.

12. Classification of Blow out fracture
1. Orbital Floor blow-Out Fracture
2. Medial Wall blow-out Fracture.

13. Classification of Orbital floor
blow-out fractures.
Based on ocular movement restriction it has
three types
1. Type I: Limited elevation of affected eye
because of mechanical restriction
2. Type II: Limited depression of affected eye
because of I.R Palsy.
3. Type III: Limited elevation and depression of
the affected eye because of the mechanical
restriction and I.R palsy, respectively.

14. Type I Orbital floor
blow out fractures
Features:
• Limitation of ocular movements on up-gaze
• FDT is +ve, with greater limitation in elevation and
abduction.
• Field of BSV is reduced, especially in vertical
direction.
• Orbital surgery is fruitful if the elevation is
significantly restricted.

15. Management
• Many patients adapt to the condition and
therefore avoid any surgical intervention.
• The incidence of these patients is very high.

16. Surgical Treatment
It is done for two main reasons
1. To increase the range of movement of the
affected eye on up-gaze.
2. To correct the defect produced by the over-
action of the muscles of the fellow eye.
Restriction of the movement is categorized
in three main groups.

17. Categories of restriction
1. Mild restriction
2. Moderate restriction
3. Marked restriction

19. Surgical Treatment of
Mild Restriction
• Recession of I.O of the unaffected eye is done.
• if there is any paresis of the I.R of the affected
eye, then there will be overaction of the S.O in
the contralateral eye.
• This will result in loss of binocular single vision
in the down gaze, therefore this approach is
avoided in such cases.

21. Surgical treatment of
Moderate restriction
• Moderate restriction is characterized by overaction
of both the elevators of the contralateral eye.
• Recession of S.R with PFS in contralateral eye is the
method of choice.
• Recession of both the elevators should be avoided if
possible.

23. Surgical management of
Marked Restriction
• Marked restriction of movement of the
affected eye on up-gaze, preventing fixation in
the primary position.
• Surgery should be done to free the
incarcerated tissue and to explore the orbital
floor.
• Surgery on unaffected eye cannot give fruitful
results.

24. Note: -
• Ipsilateral I.R recession is not advocated for
the improvement of movement on up gaze in
all type I blow fractures as this will result
limitation of movement in down gaze without
any improvement in elevation.

25. Type II orbital Floor blow-out Fractures
• Limitation of E.O.M on down gaze.
• The FDT is negative for mechanical restriction
on depression.
• The etiology is a palsy of the inferior rectus
muscle either because of direct myogenic
injury to the muscle or from damage to its
nerve supply.
• Recovery may take up to 6-12 months.

28. Management of
Type II Blow out Fracture
Conservative
Prisms are very ineffective in long term
management of Type II BOF.
Conservative management should continue
until there is no recovery seen.

29. Management of
Type II Blow out Fracture
Surgical treatment
There are two basic principles of surgery
1. Surgery to the affected eye to improve EOM
– A resection of I.R and recession of S.R
– Inverse Knapp procedure.

30. Management contd:
Surgical treatment
2. Surgery to the fellow eye to balance the defect
• Recession of the contralateral S.O
• A recession of the contralateral I.R with or without
PFS.

31. Note:
• I.R resection of the ipsilateral eye should be
avoided in Blow Out Fracture may cause
restriction of elevation or worsen any pre-
existing tendency to it.

32. Type III orbital floor Blow Out Fracture
Features
• Combine features of Type I & Type II
• Limitation of movement on up gaze with FDT
positive in Elevation
• Limitation of Movement on down gaze with FDT
negative on depression.
• Central island of BSV

34. Management
Conservative
There is some spontaneous improvement in
EOM specially in down gaze, but prisms have
no significant role in this case.

35. Management
Surgical Management
Very difficult to manage the type III out orbital
floor blow out fracture.
There is always a danger that I.R will under act,
producing a vertical deviation.
Surgical management is carried out in two stages

36. Surgical Management
• Stage one:
• A large recessoin of Both the vertical recti of the
unaffected eye. (SR, IR)
• Aim is to balance the limited depression of the
affected eye with a large I.R Recession of the
contralateral eye.
• S.R recessoin is required to prevent postoperative
hypertropia of the operated eye.

37. Surgical Management
• Stage two:
• carried out if these procedures have been
successful in enlarging the field of BSV.
• A PFS to the two recessed muscles can obtain
further expansion of the field.

38. Classification of Medial wall orbital wall
Blow-out fractures
• More commonly seen with an association with
Floor fractures rather then medial wall
isolated.
• Less disabling then floor fractures.
• Responds well to the surgical intervention
• M.R is involved
• Optic nerve involvement is also very frequent
in Medial wall blow-out fractures.

39. Medial wall orbital blow-out fracture.
EOM imbalance includes
• Limitation of Abduction due to mechanical
restriction
• Limitation of Adduction due to mechanical
restriction due to entrapment or a neurogenic
palsy.

42. Management
Conservative management
Spontaneous improvement is seen in most of
the cases. Long term use of the prisms are
usually ineffective.

43. Management
Surgical Management
• In case of mechanical restriction medial wall
and medial rectus should be explored and all
abnormal adhesions should be removed.

44. Management
Surgical Management
• If the palsy is partial then simple M.R
resection and L.R recession will do the work.
• If the palsy is total then transposition of the
vertical recti should be accompanied with the
weakening of L.R.

45. Thank You