Orbital fracture, types, blow in fracture ,blow out fracture ,clinical features ,superior orbital fissure syndrome ,management ,complications ,reconstruction techniques ,Oculocardiac reflex

2. CONTENTS
❑ Anatomy of Orbit
❑ Classification of fracture
❑ Pathophysiology
❑ Blow In fracture
❑ Blow Out Fracture – Pathophysiology & Clinical features.
❑ Superior Orbital Fissure Syndrome - Pathophysiology &
Clinical features.
❑ CLINICAL EVALUATION – Forced Duction Test
❑ Management
❑ Reconstruction
❑ Complications

3. Anatomy of Orbit
❑ Orbit – conical cavity
❑ Base – Anteriorly
❑ Apex – Directed at Optic Foramen.
❑ Orbital Volume – 30cc ; Globe – 7cc
❑ Bones – 7 (Maxillary, Zygomatic, Frontal, Ethmoid,
Lacrimal, Palatine, and Sphenoid )
❑ Four Walls – roof, lateral, medial, floor
❑ Medial wall & Floor – Thin
❑ Lateral wall & Roof – Stronger.
❑ Floor weakened – due to – Infraorbital canal passing
through it.

4. ❑ Medial wall – Formed by – Lamina Papyracea of Ethmoid bone
& Lacrimal bone.
❑ 6 EXTRAOCULAR MUSCLES –
❑ Originate from Common Tendinous fibrous ring
❑ Annulus of Zinn – Fibrous ring – Common origin of 4Recti Muscle
❑ OPTIC NERVE – direct extension of Gray Matter
❑ Very sensitive to Compression and once damaged fails to regenerate.
❑ SUPERIOR ORBITAL FISSURE
❑ Transmits – 3rd , 4th & 6th Cranial Nerves
❑ Opthalmic Division of 5th Cranial Nerve
Anatomy of Orbit

5. Anatomy of Bony Orbit

6. Floor Of Orbit
❑ Extends – Rim to approx.
2/3rd of the depth of orbit.
❑ Posteromedial aspect of Orbital
floor transits into Medial Orbital Wall
– to form
post. medial bulge.
❑ Only three of four orbital wall extend
into the apex – Medial, Superior,
Lateral.
❑ Ant. 3rd – Diameter widens
behind Superior Inferior margins
‘Post Entry Concavity’ –
Saggital plane – ‘Lazy S’ shape.
Peterson’s Principles of Oral and Maxillofacial Surgery ; 2nd Edition ; Page 463- 464

7. Surface Landmarks –
❑ Infraorbital Groove –
bony sulcus
❑ Inferior Orbital Fissure
–converts into canal –
continues to Infraorbital
Foramen.
❑ Origin Of Inferior
Oblique Muscle
❑ Posterior Lateral
Promontry – Posterior
medial bulge ending in a
raised promontory shaped
lateral plateau.
Floor Of Orbit

9. Medial wall
❑ Convex Rectangular shape
❑ Runs parallel to saggital
plane
❑ Medial wall – paper thin
Lamina paprycea
– (0.2-0.4mm)
Reinforced along the Maxillary-
Ethmoidal suture --- forming an
Internal Orbital Buttress.
Peterson’s Principles of Oral and Maxillofacial Surgery ; 2nd Edition ; Page –465

10. Surface Landmarks
❖ Lacrimal Fossa –Anterior 1/3rd of MedialWall
❖ Frontoethmoidal suture – Roof of ethmoid sinus at the level of
cribriform plate.
❖ Ant. & Post. Ethmoidal Foramen – along frontoethmoidal suture in
midorbit.
❖ Distances :
❖ Medial orbital rim – Ant. Ethmoid Foramen – 22- 25mm
❖ Post. Ethmoid Foramen to Ant Ethmoid Foramen – 12mm

11. Lateral wall
❑ Forms – Triangle with an ant. base.
❑ Forms 450
angle to its medial wall
counterpart.
❑ SURFACE LANDMARKS –
❑ Whitnall’s tubercle – small bony
projection – actual insertion is
‘Common lateral retinaculum’.
❑ Superior & Inferior Orbital Fissure
❑ Zygomaticosphenoid suture –
imp. landmark to verify proper
reduction of complex ZMC fracture.
Peterson’s Principles of Oral and Maxillofacial Surgery ; 2nd Edition ; Page –465

12. Roof Of Orbit
❑ Domed contour
❑ Comprised of – Orbital plate of Frontal Bone
❑ Extremely thin
❑ In apex – Roof terminates into Lesser Wing of Sphenoid
– where Oval shaped Optic foramen forms Optic canal.
❑ SURFACE LANDMARKS:
❑ Trochlear fossa : Zone of attachment of tendon of
Superior Oblique muscle
❑ Lacrimal Gland Fossa

13. Apex of Orbit
❑ Post. 3rd – made by sphenoid
bone
❑ Superior Orbital Fissure –
separates the Lesser wing of
sphenoid & Greater Wing of
Sphenoid
❑ Optic Canal – within the lesser
wing of sphenoid
❑ Annulus of Zinn – All Extraocular
muscles except Inf. Oblique arises
from this tendinous ring.

15. Limit of Dissection
❑ Inferiorly(Floor) – Upto 28-30mm (safe limit) –optic canal
is at around 40mm.
❑ Laterally – Superior Orbital Fissure
❑ Superiorly – Orbital roof dissection is stopped at periorbital
surrounding Recurrent Meningeal Artery – passing through
bony canal within the Sphenofrontal suture line
❑ Medially – Posterior extent – Posterior Ethmoidal vessels,
running in the Fronto-Ethmoidal Suture line Anterior to Optic
foramen.

16. Distance of Vital Orbital Structures
from Bony landmark
STRUCTURE REFERENCE
LANDMARK
MEAN DISTANCE (mm)
Midpoint of
inferior orbital
fissure
Infraorbital foramen 24
Anterior
Ethmoidal
Foramen
Anterior Lacrimal crest 24
Superior Orbital Fissure Zygomaticofrontal
suture
35
Superior orbital Fissure Supraorbital Notch 40
Optic Canal
(medial aspect)
Anterior Lacrimal Crest 42
Optic Canal (Superior
Aspect)
Supraorbital notch 45

17. Pathophysiology of Orbital
Fractures
Trauma
Thick Rims protect the Eyeball
Absorb shock by Fracturing themselves
Orbital walls (especially Medial Wall & Floor) fracture
in an isolated way
Gets displaces Inwards or Outwards
Called as ‘Blow-In’ or ‘Blow-Out’fractures

18. Classification
 ORBITAL WALL FRACTURES
1. Blow Out Fracture
2. Pure Blow Out Fracture
3. Impure Blow Out Fracture
4. Blow In Fracture
 ISOLATED ORBITAL WALL FRACTURE :
1. Roof
2. Floor
3. Medial wall
4. Lateral wall

19. ❑ ISOLATED FRACTURES OF THE ORBITAL
RIM:
1. SUPERIOR RIM
2. INFERIOR RIM
3. MEDIAL RIM
4. LATERAL RIM
❑ COMPLEX COMMINUTED FRACTURES :
Nasoethmoidal and fronto-naso-orbital
fractures

20. ❑ PURE Blow Out OR Blow In –
Orbital Walls fracture in Isolation
❑ IMPURE Blow Out or Blow In Fracture –
Walls + Rim

21. Blow Out Fracture

22. Blow Out Fracture
❑ Term coined by – Smith and Regan – 1957
❑ First described by MacKenzie in 1844
❑ PATHOPHYSIOLOGY
❑ Buckling Theory –
❑ If a force strikes at any part of orbital rim,
❑ it will cause walls to undergo a rippling effect &
the force striking the rim will transfer to weaker
portion especially floor & cause them to distort
& eventually fracture

23. Pathophysiology of blow out fracture
of the orbit
❑ Hydraulic Theory (Pfeiffer in
1943) – A generalized increase
in orbital content pressure
results in direct compression and
fracture of the thin orbital bone.
❑ Therefore direct injury to globe
forcing it into the orbit is
necessary.
❑ Medial Wall & Floor –Thin &
Fragile
❑ Fracture readily – Provide
natural compensation.

24. Clinical Features
❑ Circumorbital Edema
❑ Subconjunctival Bleeding – due to fracture →
subperiosteal bleeding → escapes in subconjuctival
plane.
❑ Enopthalmous → Increase in size of Orbit →
Eyeball sinks
❑ Periorbital fat herniates through fractured walls-‘Hanging-
drop’Appearance
❑ Unilateral Epistaxis – bleeding into antrum
❑ Numbness in area of distribution of Infraorbital Nerve
❑ Diplopia or Vertical gage – Inferior Rectus or Inferior
Obliqus gets entrapped in fracture → Inability of eyeball
to move in vertical direction.

25. Enopthalmus following Blow-Out
Fracture
❑ Retracting action of
extraocular muscles
– Enopthalmus.
❑ Diplopia –
Entrapment of
Inferior Rectus &
Inferior Obliqus

26. Superior Orbital Fissure
Syndrome
k/a – ‘Rochon Duvigneaud Syndrome’
Hirschfeld – first described it.

27. Pathophysiology
Raised Intraorbital Pressure (due to
Hematoma/Displaced fractured segments)
Compression of contents of Sup. Orbital Fissure
Paresis of Nerve
Neurological deficit in their distribution

28. ❑ Due to paresis of these nerves → all these
extraocular muscles undergo paralysis →
eyeball fails to move → ‘External
Opthalmoplegia’
❑ As affected eye does not move → whereas
contralateral normal eyeball moves → focal
axis gets disturbed → two images -→
Diplopia

29. Clinical Manifestations
❑ External Opthalmoplegia – Eyeball fails to move
❑ Diplopia – Two images of one object
❑ Internal Opthalmoplegia – Fixed Dilated pupils
(parasympathetic – III cranial nerve –
Occulomotor )
❑ Ptosis of Upper Eyelid – upper eyelid drops
down like a curtain – parasympathetic supply.
❑ Orbital Apex Syndrome – If Optic Nerve
involvement is present.

30. BLOW IN FRACTURE
Fragmented bones of the orbital floor are
displaced into the orbit.
Proptosis – Exopthalmous.
More commonly seen in fractures of orbital roof.

31. CLINICAL EXAMINATION
 Initial Opthalmological evaluation –
1. Periorbital Examination
2. Visual acuity – SNELLEN CHART
3. Ocular motility – FORCED DUCTION TEST
4. Pupillary responses ,- pupillary size, shape & symmetry,
light reactivity,
5. Visual fields – HESS CHART
6. Fundoscopic examination -TONOMETRY – to assess Intraocular
pressure (Normal 10-20mmHg)
7. Hertel Exopthalmometer – measure exopthalmous

32. Forced Duction Test
❑ Prior to the test, a cotton-
tipped applicator soaked
with topical anesthetic
drops and held against
the limbus for few
minutes.
❑ Fine-toothed forceps
are then used to grasp
the conjunctiva and
Tenon’s capsule just
posterior to the limbus.
❑ The patient is then
asked to look in the
direction of restriction of
movement of the eye .

33. Snellen Chart
• To assess visual
acuity of the eye
Tonometer
• Measures IOP
• Greatly increased IOP
causes pulsatile optic
disk
Hess Chart

34. Opthalmoscopy
 Examination of the fundus
 TYPES:
Direct --- General examination
Indirect--- Better view of the eye
Pressure – eye ball – blunt instrument—edges
of fundus -- examination
 Retinal detachment requires
ophthalmologic attention.

35. Hyphaema
❑ Layering of blood in the anterior chamber.
❑ Direct blow to eye --fist or squash ball
❑ C/F: Pain
Blurred vision
Photophobia
Visual acuity decreased
Pupil dilated
❑ Vision worse supine, clears upright
❑ Can cause increased IOP

36. ❑ Head of bed elevated
❑ Atropine –dilates pupil– prevents iris movements
❑ Mannitol
❑ Anti fibrinolytic agent 50mg/kg every 4 hrs reduces
recurrent bleeding.

37. IMAGING
❑ Caldwell view
❑ Waters view
❑ Lateral skull
❑ CT Scan – Orbit
- To visualize the fractured segments
- Also helps evaluate the Intraorbital volume.
By using a software to compare the normal
orbital volume to the affected.
❑ MRI

38. Imaging
 Ultrasound
 High resolution CT is used the
management of enophthalmos
 Sinuscopy
 3D reconstruction volumetric
assessment

39. Management
Management

41. Indications for surgical
managment
Unresolving soft tissue entrapment with disabling
diplopia
Enopthalmous greater than 2mm
CT scan evidence of a large fracture
SURGICAL MANAGEMENT :
1.CLOSED REDUCTION –
Transantrally.- Caldwell Luc Procedure
Trannasally – Through inferior turbinate – foley’s
catheter

42. Incisions
❑ Existing lacerations
❑ Lower Eyelid –
1)Subciliary
2) Subtarsal
3) Infraorbital approaches
❑ Transconjuctival Approach

43. SAGITAL SECTION THROUGH ORBIT &
GLOBE
C- Palpebral
Conjuntiva
IO- Inferior Oblique
muscle
IR- Inferior Rectus
Muscle
OO- Orbicularis Oculi
OS – Orbital Septum
P -
Periosteum/Periorbita TP-
Tarsal Plate.

44. Orbicularis Oris Muscle
Innervated by Cranial Nerve VII
Upper Eyelid – Levator
Palpebral Superioris – Cranial
Nerve III
Orbicularis Oculi -
Orbital and
Palpebral Portions
Palpebral Portion is divided into
fibers -
Pretarsal Portion
Preseptal Portion

45. Subciliary
Incision
The incision is approximately 2 mm below eyelashes, can be
extended laterally as necessary (top dashed line). It is made
through skin only.

46. Subcutaneous dissection of skin, leaving
pretarsal portion of orbicularis muscle
attached to tarsus. Dissection 4-6mm
inferiorly in this plane is adequate.
Subcutaneous dissection
through lid margin

47. Use scissors to dissect through orbicularis oculi muscle
over lateral orbital rim to identify periosteum.

48. Incision through the bridge of orbicularis
oculi muscle.
Saggital plane through orbit showing
incision of the bridge of orbicularis oculi
muscle.

49. ❑ Incision through periosteum
along ant. maxilla, 3 to 4 mm
inferior to infraorbital rim.
❑ Note the pretarsal muscle still
remaining on the inferior tarsus
and orbital septum, which restricts
orbital fat from entering field.
❑ Subperiosteal dissection of anterior
maxilla and orbital floor. Periosteal
elevator entering the orbit is
placed almost vertically as
dissection proceeds behind rim.
❑ In ant. region, floor of the orbit is at a
lower level than crest of the rim,
necessitating dissection inferiorly.

50. Sagital plane through orbit showing subperiosteal dissection of
the anterior maxilla and orbital floor.

51. Transconjuctival approach
•Fig.1 - Incision of conjuctiva below the tarsalplate.
•Fig 2 - Incision through periosteum. To facilitate this maneuver, a traction
suture is placed through the cut end of conjunctiva to retract the tissueand
maintain the position of corneal shield.
• Small retractors are placed so that lower lid is retracted to the level of ant.
surface of infraorbital rim.
• Intervening tissue along infraorbital rim is the periosteum. Theincision
is made through the periosteum just post. to infraorbitalrim.

52. •Saggital plane through the orbit and globe demonstrating
level and plane of incision. The conjunctiva and lower lid
are incised with scissors.

53. SUBPERIOSTEAL DISSECTION OF THE ORBITAL FLOOR.
Note the traction suture placed through the cut end of the
conjunctiva, which assists in retracting the conjunctiva and
maintains the corneal shield in place.

54. Surgical Exposure
❑ After periorbital
dissection is performed,
adequate exposure and
illumination of the
fractured area is
imperative.
❑ Malleable retractors,
spoons and special
orbital retractors
designed for the globe.

55. ❑ Transition between anterior
mid orbit , the orbital floor
slopes upwards giving rise to
posterior medial bulge &
slightly convex bony platform.
❑ Elevator passes transversely
along inferior orbital fissure.
❑ Infraorbital neurovascular
bundle can be visualized first
shining through the thin bony
roof of its canal.
❑ Then it becomes directly visible
in infraorbital groove.

56. EXTENT OF DISSECTION
❑ Taking into account extent of
fracture, the periorbital dissection
stops at medial border of the
inferior orbital fissure leaving
the soft tissue invagination intact.
❑ Laterally, the dissection is
continued to posterior edge of
the floor to orbital process of
the palatine bone. The suture
between the maxilla and the
palatine bone is indistinguishable
in the adult skull.
❑ Medially the periorbital
dissection extends to the zone
over the internal orbital
buttress.

57. ❑ For an EXTENDED ACCESS
to posterior orbital floor, the
contents of the inferior orbital
fissure must be addressed
and transected to allow for
this additional access.
❑ The transsection is prepared
with a dissection along the
inferior portion of the lateral
orbital wall in order to create a
second tunnel alongside the
vertical soft tissue.

58. ❑ The intervening soft tissue
invagination is transected in a
stepwise fashion using
bipolar electrocautery and
sharp dissection across the
fissure above the level of
Müller’s muscle, stripping
the periorbita along the
lateral edge of the inferior
orbital fissure.

59. Limit of Dissection
❑ Inferiorly – Upto 28-30mm.
❑ Laterally – Superior Orbital Fissure
❑ Superiorly – Orbital roof dissection is stopped
at periorbital surrounding Recurrent Meningeal
Artery – passing through bony canal within the
Sphenofrontal suture line
❑ Medially – Posterior extent – Posterior
Ethmoidal vessels , running in the Fronto-
Ethmoidal Suture line Anterior to Optic
foramen.

60. ❑ The subperiosteal dissection is
continued using a periosteal or
freer elevator in a lateromedial
direction and lifted up and
retracted by and by with the
ribbon retractor until the
entrance of apex is reached.
❑ Closure (layer-by-layer)

61. Reconstruction Material

62. Autogenous Material
• Graft transferred from one part
of patient’s body to another
• Ex. –1. Septal cartilage
2. Ear cartilage
3. Maxillary wall bone
4. Iliac crest
5. Rib
6. Split calvaria

63. Bone Graft
Advantages:
1. Provides strength and stability to the orbital
floor
2. Relative resistance to infection
3. Lack of host response against the graft
4. Lack of concern for late extrusion
5. Long term efficacy and reliability
6. Can be easily accessed and harvested from
same operative area ( cartilage – ear, nose;
bone- maxilla, mandible )

64. Disadvantages :
1. Need for graft donor site
2. Increased operative time
3. Complications related to donor site wound
4. Donor site morbidity ( rib – pneumothorax,
infection; calvarial – dural tears,
subarachnoid haemorrhage, etc)
5. Unpredictable graft resorption
6. Limited ability to contour same type of bone
7. Limited availability

65. Allogenic Materials
 Graft transferred from another
person (homogenic/ allogenic) or
from any animal of different
species (xenograft)
 Ex. 1. Lyophilized dura
2. Lyophilized cartilage
3. Banked bone
Advantages:
1. No need for graft donor site
2. Decreases operative time
3. Eliminates complications
related to donor site wound
morbidity
4. Inertness
5. Resistant to resorption

66. Alloplastic Materials
 Grafts derived from non-living source, synthetic
 Ex. 1. Gelfilm
2. Medpor
3. Polytetrafluoroethylene
4. Methylmethacrylate
5. Polyamide mesh
6. Titanium, vitallium, other metallic meshes
7. Hydroxyapatite – block, granular
8. Hydroxyapatite – cement, vicryl mesh

67. Pre-formed Orbital Implant
ADVANTAGES :
•Radiopacity
•Smooth Surface
•Minimal or no countouring necessary
DISADVANTAGE :
•Cost

68. Porous Polyethylene
Sheet (PPE)
Disadvantages :
• Not Radiopaque (Not visible on Post OP Radiographs)
•Lack of Rigidity when very thin wafer of PPE is used. When a
more thick rigid wafer is used there is a risk of causing
dystopia.

69. Polyethylene and titanium mesh
❑ By combining titanium mesh with
porous polyethylene –
❑ Material becomes radioopaque
❑ More rigid than porous PPE.
❑ ADVANTAGE :
❑ Stability
❑ Contouring
❑ Adequate in large three wall
fractures
❑ Radiopacity
❑ No Donor Site Needed
❑ DISADVANTAGES : Less
drainage from orbit.

70. Resorbable materials
❑ Thermoplastic and Non
thermoplastic materials.
❑ Advantages :
❑ Availability Handling/
❑ Contourability (only for
thermoplastics)
❑ Smooth surface and smooth edges
❑ Disadvantages:
❑ No radiopacity
❑ Degradation of material with possible
contour loss Sterile infection /
inflammatory response
❑ Difficult to shape according to patients
anatomy (only for non- thermoplastics)
❑ Less drainage from the orbit.

71. COMPLICATIONS
EARLY COMPLICATIONS :
1. Hemorrhagic or orbital hematoma – treated by
-lateral cathotomy immediately, lateral canthal
Tendonlysis ,
Lateral canthotomy – indicated when –
- Decreased visual acuity
- Intarocular pressure more than 40mmHg
- Proptosis
- Opthalmoplegia

72. Retrobulbar hemorrhage
❑ Rare, rapidly progressive
life threatening emergency
that results in accumulation
of blood in the retrobulbar
space
❑ Increased IOP → stretching
of the optic nerve &
blockage of ocular
perfusion
❑ Proptosis , marked
subconjuctival ecchymosis
& edema.

73. Symptoms– Pain , decreasing visual acuity, diplopia.
Treatment includes
• I.v mannitol(200 ml of 20% solution)
• i.v acetazolamide 500 mg
• i.v papaverine 40 mg
• i.v hydrocortisone 100 mg
• Dexamethasone sodium phosphate-3-4mg/kg body
weight followed by 1-3 mg /kg 6th hourly.
• If no evidence of improvement stop after 48 hours.
3. Blindness

74. OCULOCARDIAC REFLEX/ TRIGEMINOCARDIAC/
TRIGEMINOVAGAL REFLEX
- The oculocardiac reflex pathway begins with the
- afferent fibres of the long & short ciliary nerves that
travel with
- the opthalmic division of the trigeminal nerve to
- the gasserion ganglion via
- the sensory nucleus of the trigeminal nerve.
- In the floor of the 4th ventricle short internuncial
fibres in the reticular formation connect them with the
efferent pathway from the motor nucleus of the
vagus nerve to the depressor nerve ending in the
mucle tissue of the heart.

75. CLINICAL FEATURES –
- Bradycardia
- Faintness
- Further stimulation can lead to cardiac
dysrhythmias
- Atrioventricular blocks
- Asystole
- Bradycardia has been attributed to Trigeminal
derived vagal reflex

76. LATE COMPLICATIONS
❑ Altered vision
❑ Diplopia
❑ Ectropion – Lower eyelid turns outwards.
❑ Epiphora – Overflow of tears onto the face
❑ Enopthalmous

77. References
❑ Rowe & William’s Maxillofacial Injuries
❑ Maxillofacial Surgery-Peter Ward Booth
Vol-1
❑ Peterson’s Principles of Oral and
Maxillofacial Surgery ; 2nd Edition
❑ Textbook of Oral & Maxillofacial Surgery –
R.M. Borle