Ongoing Debate in Clinical Decision Making in Orbital Fractures



Ongoing Debate in Clinical Decision Making in Orbital Fractures




Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2021-03-01, Volume 29, Issue 1, Pages 29-39, Copyright © 2020 Elsevier Inc.



Key points

  • Trapdoor fracture in children, globe dislocation or trapdoor fracture with a nonresolving oculocardiac reflex, bradycardia, heart block, nausea, vomiting, or syncope are indications for immediate surgery.

  • Early enophthalmos, hypoglobus, and severe limitation of eye motility (<15°) are indications for early intervention.

  • If there is no enophthalmos present, and the motility of the eye significantly improves within 10 to 14 days, surgery may be not indicated, and clinical findings overrule the computed tomography scan results in all occasions.

  • If reconstruction is required, titanium is the current gold standard, because it has many advantages compared with autologous grafts and other alloplastic implants.


Introduction

The orbit is a complex area, because important and delicate anatomic structures are packed together into a small space. , With its midfacial position and its thin bony walls, the orbit is susceptible to fractures. The trauma mechanism consists of buckling forces applied to the orbital rim and/or the retropulsion of orbital content

Solitary orbital fractures are commonly caused by repulsion, leading to increased intraorbital pressure that is transmitted to all the orbital walls. The lateral wall and orbital roof are relatively strong and can sustain forces more easily, but the orbital floor and medial wall are relatively fragile. This dissipation of force through the 2 thin walls protects the globe, acting as a crumple zone, whereas the stronger roof protects the intracranial structures. In most cases, the increased periorbital pressure results in blowout fracture, where the comminuted orbital wall(s) will be dislocated to the adjacent sinuses ( Fig. 1 ). Occasionally, especially in pediatric patients, the trapdoor phenomenon is seen, wherein the periorbital contents are trapped as soon as the pressure wave decreases and the fracture snaps back into the original position. The viscosity of the bone of children contributes to this phenomenon ( Fig. 2 ). With loss of bony support, the orbital volume may increase, which can potentially result in the protrusion of the orbital contents into adjacent sinuses, with subsequent posterior displacement of the globe (enophthalmos) (arrow in Fig. 1 ). If most of the impact occurs as a buckling force to the orbital rim, the anterior part of the orbit may be fractured also. The loss of anterior support to the globe may result in vertical displacement of the globe, as well (hypoglobus) ( Fig. 3 ).

Blow-out fracture.
Fig. 1
Blow-out fracture.

Trapdoor fracture.
Fig. 2
Trapdoor fracture.

Loss of vertical support causing a hypoglobus.
Fig. 3
Loss of vertical support causing a hypoglobus.

Apart from damage to the orbital walls, soft tissues will be disrupted also. If adipose and muscle tissues herniate into the fracture, the suspension system and periorbit will be affected to some extent. Initially, the actual damage may be difficult to assess because of emphysema, swelling, contusion of muscles, and the presence of hematoma ( Fig. 4 ).

CT images of ( A ) swelling, ( B ) emphysema, ( C ) swelling of muscles, ( D ) intramuscular hematoma.
Fig. 4
CT images of (
A ) swelling, (
B ) emphysema, (
C ) swelling of muscles, (
D ) intramuscular hematoma.

For the orbital walls, the goal of reconstruction is to reposition the globe into its original position by placing an orbital implant to recontour the traumatized orbit and restore the pretraumatized anatomy as accurately as possible ( Fig. 5 ). This is mandatory for preventing volume increase of the orbit with clinical sequelae such as enophthalmos and hypoglobus and for adequate support in order to regain proper ocular function and prevent diplopia. On the soft tissue level, the incarcerated tissues also need to be released to restore orbital function. The regenerative capacities of the soft tissues (fat, muscles, septae, nerves) and the amount of damage caused by the surgery itself are highly unpredictable. This unpredictability possibly accounts for persisting debates on the various aspects of orbital fracture management. In the current literature, there is no uniformly accepted guideline for the treatment of orbital fractures.

Reconstruction of the orbital contours.
Fig. 5
Reconstruction of the orbital contours.

The shape of the bony orbit and the intricate architecture of the soft tissue pose surgical challenges. , Orbital reconstruction is performed in a confined space with limited overview in close proximity to vital and delicate structures. Iatrogenic damage and surgical complications are not uncommon. , The key to successful treatment of orbital wall fractures may be found by carefully selecting the appropriate indications. , ,

Even if anatomic reconstruction has been achieved, functional rehabilitation does not always follow automatically, as both traumatic and surgical damage to soft tissue contents may induce scarring, entrapment, and fat atrophy. Therefore, persistent diplopia and enophthalmos are believed to be common complications after orbital fracture repair.


Controversies in orbital reconstruction

In orbital fracture management, the most controversial dilemmas are indication, optimal timing, and biomaterials. A scientifically substantiated answer to key questions in orbital reconstruction is therefore desired:

  • What type of fracture needs to be reconstructed?

  • What is the best timing for orbital reconstruction?

  • Which materials are most suitable for the different types of orbital fracture?


What type of fracture needs to be reconstructed?

Several publications have shown that most surgeons base their decision regarding orbital fracture repair on clinical findings, and such data are increasingly obtained from computed tomography (CT) scans. , , From a clinical perspective, the presentation of patients with orbital fractures is variable ( Fig. 6 ). The most relevant clinical (nonradiological) symptoms that influence decision making are motility restrictions/diplopia, enophthalmos, and hypoglobus. , ,

Clinical presentation of patients with orbital fractures.
Fig. 6
Clinical presentation of patients with orbital fractures.


Enophthalmos

Evident enophthalmos and hypoglobus are clear indications for surgery. Hypoglobus is caused by the loss of anterior support and is encountered in less than 5% of the patients with orbital fractures. Enophthalmos is most commonly caused by either an increase in bony orbital volume or a secondary decrease in soft tissue volume caused by fat atrophy or, rarely, a shrinking globe. Enophthalmos is only present in less than 18% of trauma patients with orbital fractures. , Spontaneous disappearance of enophthalmos can be seen in 50% of the patients with orbital fractures. This results from pseudo-enophthalmos, a phenomenon caused by swelling of the surrounding tissues, resembling an enophthalmos ( Fig. 7 ). Nevertheless, enophthalmos, which does require treatment, is frequently not present immediately after trauma but will occur over time ( Fig. 8 ). A CT scan is the gold standard in imaging for the severity assessment of orbital wall fractures. , Several studies have suggested that defects of at least 2 cm 2 can cause clinically significant enophthalmos. According to Christensen and colleagues , who performed among 442 American oral and maxillofacial surgeons, the defect size had the greatest influence on the surgeon’s decision to operate, despite absence of enophthalmos. The same trend has been shown by several systematic reviews: clinicians base their decision for surgery in almost half of the cases on CT findings. , , Specifically, a fracture greater than 50% of the surface area was the primary indication for orbital reconstruction in 19% to 30% of the cases. , , Although, other radiological observations such as herniated volume, orbital volume ratio, and location of the fracture and inferomedial strut are probably better predictors of enophthalmos ( Fig. 9 ).

Pseudo-enophthalmos caused by swelling of the surrounding tissues ( A ). 5 days after trauma ( B ). Months after trauma ( C ).
Fig. 7
Pseudo-enophthalmos caused by swelling of the surrounding tissues (
A ). 5 days after trauma (
B ). Months after trauma (
C ).

Clinical presentation of enophthalmos over time. ( A , B ) 6 days after trauma. ( C , D ) 2 weeks later.
Fig. 8
Clinical presentation of enophthalmos over time. (
A ,
B ) 6 days after trauma. (
C ,
D ) 2 weeks later.

( A ) Location of the fracture (anterior fractures), ( B ) significant herniated volume, ( C ) loss of the inferomedial strut in 2 wall fractures.
Fig. 9
(
A ) Location of the fracture (anterior fractures), (
B ) significant herniated volume, (
C ) loss of the inferomedial strut in 2 wall fractures.

Accurate quantification of size, location, and complexity of orbital defects is important in the diagnostic process. Nevertheless, accurate measurement or prediction of the defect size remains extremely difficult even on CT, , , and the average rate of overestimation is 76%. This overestimation may lead to overtreatment, because a defect size of 1.3 cm 2 is interpreted as greater than 2 cm 2 ( Fig. 10 A). Interestingly, 30% of the patients with a defect greater than 2 cm 2 have no signs of diplopia, motility disturbance, or enophthalmos. Jansen and colleagues showed that this principle is more evident in single-wall defects. In multiple-wall fractures, the third dimension is increasing the defect size by 27% ( Fig. 10 B). There seems to be a strong tendency to treat expected problems instead of those that are present. The predictability of the measurements on CT scans is highly questionable in combination with the uncertainty of occurrence of enophthalmos. In terms of indications for reconstruction, defect size should be used cautiously ( Figs. 11 ).

Illustration of discrepancies between two- and three-dimensional measurements derived from the coronal view, which affects the defect size estimation.
Fig. 10
Illustration of discrepancies between two- and three-dimensional measurements derived from the coronal view, which affects the defect size estimation.

Clinical example of large defect without enophthalmos ( A ). CT-scan ( B ). 6 days after trauma, ( C ). 1 year after trauma.
Fig. 11
Clinical example of large defect without enophthalmos (
A ). CT-scan (
B ). 6 days after trauma, (
C ). 1 year after trauma.


Diplopia and motility disturbances

As previously stated, radiological observations such as defect size and evidence of muscle entrapment are frequently used by most surgeons as strong indications for early intervention. , Clinical observations such as true muscle entrapment with a positive forced duction test are mainly seen in children ( Fig. 12 ) (76% <15 years) but are relatively rare in adults ( Fig. 13 ). A more common clinical symptom is motility restriction and diplopia caused by a blowout fracture ( Fig. 14 ). The survey of Christensen and colleagues and Aldekhayal and colleagues showed that approximately 4 of 5 surgeons have strong to very strong indications for surgical intervention if diplopia persisted for more than 15 days.

Clinical example of trapdoor fracture in pediatric patient.
Fig. 12
Clinical example of trapdoor fracture in pediatric patient.

Clinical example of trapdoor fracture in adult.
Fig. 13
Clinical example of trapdoor fracture in adult.

Absolute motility restriction due to blow-out fracture in adult.
Fig. 14
Absolute motility restriction due to blow-out fracture in adult.

As shown in Box 1 , there is a great variability in the extent and causes of diplopia and motility restrictions. This will be further discussed in Yvette Braaksma and Hinke Marijke Jellema’s article,“ Orthoptic Evaluation and Treatment in Orbital Fractures ,” in this issue. One of the difficulties in clinical decision making is that ocular motility disturbances are commonly caused by muscle edema, hemorrhage, and motor nerve palsy, conditions that cannot be treated surgically, and they are rarely caused by entrapment of the extraocular muscles. In time, most of these deficits may resolve spontaneously. Edema resolves within several days to weeks ( Fig. 15 ), but hemorrhage and motor nerve palsy can even take up to 12 months to recover ( Fig. 16 ). The true dilemma in clinical decision making occurs when the enophthalmos is minimal or absent and motility has improved, but diplopia persists.

Box 1
List of causes of diplopia
a Could be treated surgically.

  • Emphysema

  • Muscle edema

  • Hemorrhage

  • Hematoma formation in the extra-ocular muscles

  • Motor nerve palsy (cranial nerves III, IV, and VI, and their respective neuromuscular junctions and target muscles)

  • Entrapment of the inferior ocular muscles a

  • Entrapment of surrounding soft tissues a

  • Disruption of the orbital septae

  • Lack of support of the orbital contents a

  • Fibrosis of the orbital contents (ligaments and septae)

  • Fibrosis of the extra-ocular muscles

  • Related to neurotrauma/intracranial

Clinical example of improvement of motility restrictions caused by swelling ( A ). CT-scan ( B ). 3 days after trauma, ( C ). 2,5 week after trauma ( D ). 1 year after trauma.
Fig. 15
Clinical example of improvement of motility restrictions caused by swelling (
A ). CT-scan (
B ). 3 days after trauma, (
C ). 2,5 week after trauma (
D ). 1 year after trauma.

Clinical example of improvement of motility restrictions caused by neurologic damage (n. VI paresis) ( A ). minor dislocated fracture ( B ) 3 months after trauma ( C ). 12 months after trauma.
Fig. 16
Clinical example of improvement of motility restrictions caused by neurologic damage (n. VI paresis) (
A ). minor dislocated fracture (
B ) 3 months after trauma (
C ). 12 months after trauma.

In most studies, diplopia and motility restrictions are subjective observations occurring shortly after trauma and which are not objective or accurate standardized consecutive measurements performed by an orthoptist. , Other groups stress the importance of quantitative evaluation of ocular motility , , and the use of a Hess screen test, interpretation of ductions, and the field assessment of binocular single vision (BSV) can be extremely helpful. Using these measurements, improvement of ocular motility and diplopia can be objectively assessed over weeks or even months after trauma. , Alhamdani and colleagues and Jansen and colleagues have shown that in minor diplopia (BSV <80), orbital reconstruction can worsen the clinical outcome, and even with moderate diplopia (BSV 60–80), surgery appears to have limited effect on the amount of diplopia. Nevertheless, in severe diplopia (BSV <60), orbital reconstruction has a significant effect on the outcome.

These findings stress the importance of standard orthoptic evaluations during follow-up, especially if diplopia is the only clinical symptom.


What is the best timing for orbital reconstruction?

In many fields of trauma surgery, an increasing body of evidence is emphasizing the importance of optimal timing of surgery. The timing of orbital reconstruction is a determining factor with respect to the potential occurrence of postoperative orbital complications.

In orbital trauma surgery, a general distinction can be made among immediate (within hours), early (<2 weeks), and late surgical interventions (>2 weeks).

There is consensus on the indications for immediate repair, which include vision-threatening symptoms such as retrobulbar hematoma, significant globe displacement ( Fig. 17 ) and (pediatric) trapdoor fractures with muscle entrapment ( Fig. 18 A) with risk of ischemia and fibrosis, and oculo-cardiac reflex. Without immediate intervention in these cases, permanent damage to the orbital soft tissue and functional impairment are likely to occur. However, except for the trapdoor phenomenon in children, these indications are extremely rare.

Globe dislocation. ( A , B ) Extreme proptosis. ( C , D ) Dislocated globe into adjacent maxillary sinus.
Fig. 17
Globe dislocation. (
A ,
B ) Extreme proptosis. (
C ,
D ) Dislocated globe into adjacent maxillary sinus.

Trapdoor with ( A ) and without ( B ) muscle entrapment (CT).
Fig. 18
Trapdoor with (
A ) and without (
B ) muscle entrapment (CT).

Delayed reconstruction (>2 weeks) has some theoretic disadvantages. As a result of the trauma mechanism, there is some initial contusion, hematoma formation, and disruption of the intraorbital tissues. As delayed reconstruction can be considered a second trauma to contents of the orbit, some authors believe that early correction may prevent fibrosis.

However, which fractures require early intervention? Diplopia and motility disturbances tend to resolve over time, and enophthalmos mainly occurs in due time. Hence, it is prudent to conclude that small asymptomatic fractures do not need surgery, whereas larger fractures with early enophthalmos require early orbital reconstruction. Most authors agree that a trapdoor fracture without muscle entrapment ( Fig. 18 B) but with significant motility restrictions requires early surgery. What is the effect on the clinical outcome if surgery in large blowout fractures with proper ocular function that develop enophthalmos over time is postponed? Is it possible to predict the cause of early post-traumatic diplopia (fracture-related, edema, hematoma formation, scarring, motor nerve palsies), and when and how does surgery affect the postoperative clinical outcome? The answers to these questions will help in determining the type of orbital fractures suitable for delayed surgery. If the delay itself of an orbital reconstruction does not affect the clinical outcome, it is surely safer to wait and observe if enophthalmos will occur and if diplopia will resolve, rather than risk complications because of surgery. The size of the fracture does not necessarily correlate to late enophthalmos, and severe diplopia could still resolve without intervention. , , A systematic review revealed that even if an early surgical approach was chosen, enophthalmos still persists in 30% of the cases. As a consequence of this, overtreatment of patients with early surgery may be the case, and spontaneous recovery might have occurred over time. Several systematic reviews showed that the literature is not conclusive on whether early surgery is better than delayed surgery for orbital wall fractures. Some authors reported good outcomes after late orbital reconstructions. Hence, the focus of the debate on optimal timing has shifted from the indications for early intervention toward the question of which patients are eligible for delayed repair or may be better treated with nonsurgical treatment. The proposed treatment schedule, which is based on the literature, is presented in Table 1 .

Table 1
Indications for reconstruction
Immediate Early Delayed
Timeframe Within 24 h 1–14 d <14 d
Indications Diplopia with CT evidence of an entrapped muscle or periorbital tissue associated with a nonresolving oculocardiac reflex: bradycardia, heart block, nausea, vomiting, or syncope
White-eyed blow-out fracture. Young patients (<18 y), history of periocular trauma, little ecchymosis or oedema (white eye), marked extraocular motility vertical restriction, and CT examination revealing an orbital floor fracture with entrapped muscle or perimuscular soft tissue
Significant globe displacement with vision-threatening emergency
Early enophthalmos/hypoglobus causing facial asymmetry
Symptomatic diplopia with positive forced ductions, evidence of an entrapped muscle or perimuscular soft tissue on CT examination
Symptomatic diplopia without proven entrapment on CT examination, negative forced ductions, and insignificant clinical improvement over time
Late-onset enophthalmos/hypoglobus


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Ongoing Debate in Clinical Decision Making in Orbital Fractures Leander Dubois DDS, MD, DMD, PhD , Jasjit Dillon MD, DMD, PhD , Jesper Jansen MD, DMD, PhD and Alfred G. Becking DDS, MD, DMD, PhD, FEBOMS Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2021-03-01, Volume 29, Issue 1, Pages 29-39, Copyright © 2020 Elsevier Inc. Key points Trapdoor fracture in children, globe dislocation or trapdoor fracture with a nonresolving oculocardiac reflex, bradycardia, heart block, nausea, vomiting, or syncope are indications for immediate surgery. Early enophthalmos, hypoglobus, and severe limitation of eye motility (<15°) are indications for early intervention. If there is no enophthalmos present, and the motility of the eye significantly improves within 10 to 14 days, surgery may be not indicated, and clinical findings overrule the computed tomography scan results in all occasions. If reconstruction is required, titanium is the current gold standard, because it has many advantages compared with autologous grafts and other alloplastic implants. Introduction The orbit is a complex area, because important and delicate anatomic structures are packed together into a small space. , With its midfacial position and its thin bony walls, the orbit is susceptible to fractures. The trauma mechanism consists of buckling forces applied to the orbital rim and/or the retropulsion of orbital content Solitary orbital fractures are commonly caused by repulsion, leading to increased intraorbital pressure that is transmitted to all the orbital walls. The lateral wall and orbital roof are relatively strong and can sustain forces more easily, but the orbital floor and medial wall are relatively fragile. This dissipation of force through the 2 thin walls protects the globe, acting as a crumple zone, whereas the stronger roof protects the intracranial structures. In most cases, the increased periorbital pressure results in blowout fracture, where the comminuted orbital wall(s) will be dislocated to the adjacent sinuses ( Fig. 1 ). Occasionally, especially in pediatric patients, the trapdoor phenomenon is seen, wherein the periorbital contents are trapped as soon as the pressure wave decreases and the fracture snaps back into the original position. The viscosity of the bone of children contributes to this phenomenon ( Fig. 2 ). With loss of bony support, the orbital volume may increase, which can potentially result in the protrusion of the orbital contents into adjacent sinuses, with subsequent posterior displacement of the globe (enophthalmos) (arrow in Fig. 1 ). If most of the impact occurs as a buckling force to the orbital rim, the anterior part of the orbit may be fractured also. The loss of anterior support to the globe may result in vertical displacement of the globe, as well (hypoglobus) ( Fig. 3 ). Fig. 1 Blow-out fracture. Fig. 2 Trapdoor fracture. Fig. 3 Loss of vertical support causing a hypoglobus. Apart from damage to the orbital walls, soft tissues will be disrupted also. If adipose and muscle tissues herniate into the fracture, the suspension system and periorbit will be affected to some extent. Initially, the actual damage may be difficult to assess because of emphysema, swelling, contusion of muscles, and the presence of hematoma ( Fig. 4 ). Fig. 4 CT images of ( A ) swelling, ( B ) emphysema, ( C ) swelling of muscles, ( D ) intramuscular hematoma. For the orbital walls, the goal of reconstruction is to reposition the globe into its original position by placing an orbital implant to recontour the traumatized orbit and restore the pretraumatized anatomy as accurately as possible ( Fig. 5 ). This is mandatory for preventing volume increase of the orbit with clinical sequelae such as enophthalmos and hypoglobus and for adequate support in order to regain proper ocular function and prevent diplopia. On the soft tissue level, the incarcerated tissues also need to be released to restore orbital function. The regenerative capacities of the soft tissues (fat, muscles, septae, nerves) and the amount of damage caused by the surgery itself are highly unpredictable. This unpredictability possibly accounts for persisting debates on the various aspects of orbital fracture management. In the current literature, there is no uniformly accepted guideline for the treatment of orbital fractures. Fig. 5 Reconstruction of the orbital contours. The shape of the bony orbit and the intricate architecture of the soft tissue pose surgical challenges. , Orbital reconstruction is performed in a confined space with limited overview in close proximity to vital and delicate structures. Iatrogenic damage and surgical complications are not uncommon. , The key to successful treatment of orbital wall fractures may be found by carefully selecting the appropriate indications. , , Even if anatomic reconstruction has been achieved, functional rehabilitation does not always follow automatically, as both traumatic and surgical damage to soft tissue contents may induce scarring, entrapment, and fat atrophy. Therefore, persistent diplopia and enophthalmos are believed to be common complications after orbital fracture repair. Controversies in orbital reconstruction In orbital fracture management, the most controversial dilemmas are indication, optimal timing, and biomaterials. A scientifically substantiated answer to key questions in orbital reconstruction is therefore desired: What type of fracture needs to be reconstructed? What is the best timing for orbital reconstruction? Which materials are most suitable for the different types of orbital fracture? What type of fracture needs to be reconstructed? Several publications have shown that most surgeons base their decision regarding orbital fracture repair on clinical findings, and such data are increasingly obtained from computed tomography (CT) scans. , , From a clinical perspective, the presentation of patients with orbital fractures is variable ( Fig. 6 ). The most relevant clinical (nonradiological) symptoms that influence decision making are motility restrictions/diplopia, enophthalmos, and hypoglobus. , , Fig. 6 Clinical presentation of patients with orbital fractures. Enophthalmos Evident enophthalmos and hypoglobus are clear indications for surgery. Hypoglobus is caused by the loss of anterior support and is encountered in less than 5% of the patients with orbital fractures. Enophthalmos is most commonly caused by either an increase in bony orbital volume or a secondary decrease in soft tissue volume caused by fat atrophy or, rarely, a shrinking globe. Enophthalmos is only present in less than 18% of trauma patients with orbital fractures. , Spontaneous disappearance of enophthalmos can be seen in 50% of the patients with orbital fractures. This results from pseudo-enophthalmos, a phenomenon caused by swelling of the surrounding tissues, resembling an enophthalmos ( Fig. 7 ). Nevertheless, enophthalmos, which does require treatment, is frequently not present immediately after trauma but will occur over time ( Fig. 8 ). A CT scan is the gold standard in imaging for the severity assessment of orbital wall fractures. , Several studies have suggested that defects of at least 2 cm 2 can cause clinically significant enophthalmos. According to Christensen and colleagues , who performed among 442 American oral and maxillofacial surgeons, the defect size had the greatest influence on the surgeon’s decision to operate, despite absence of enophthalmos. The same trend has been shown by several systematic reviews: clinicians base their decision for surgery in almost half of the cases on CT findings. , , Specifically, a fracture greater than 50% of the surface area was the primary indication for orbital reconstruction in 19% to 30% of the cases. , , Although, other radiological observations such as herniated volume, orbital volume ratio, and location of the fracture and inferomedial strut are probably better predictors of enophthalmos ( Fig. 9 ). Fig. 7 Pseudo-enophthalmos caused by swelling of the surrounding tissues ( A ). 5 days after trauma ( B ). Months after trauma ( C ). Fig. 8 Clinical presentation of enophthalmos over time. ( A , B ) 6 days after trauma. ( C , D ) 2 weeks later. Fig. 9 ( A ) Location of the fracture (anterior fractures), ( B ) significant herniated volume, ( C ) loss of the inferomedial strut in 2 wall fractures. Accurate quantification of size, location, and complexity of orbital defects is important in the diagnostic process. Nevertheless, accurate measurement or prediction of the defect size remains extremely difficult even on CT, , , and the average rate of overestimation is 76%. This overestimation may lead to overtreatment, because a defect size of 1.3 cm 2 is interpreted as greater than 2 cm 2 ( Fig. 10 A). Interestingly, 30% of the patients with a defect greater than 2 cm 2 have no signs of diplopia, motility disturbance, or enophthalmos. Jansen and colleagues showed that this principle is more evident in single-wall defects. In multiple-wall fractures, the third dimension is increasing the defect size by 27% ( Fig. 10 B). There seems to be a strong tendency to treat expected problems instead of those that are present. The predictability of the measurements on CT scans is highly questionable in combination with the uncertainty of occurrence of enophthalmos. In terms of indications for reconstruction, defect size should be used cautiously ( Figs. 11 ). Fig. 10 Illustration of discrepancies between two- and three-dimensional measurements derived from the coronal view, which affects the defect size estimation. Fig. 11 Clinical example of large defect without enophthalmos ( A ). CT-scan ( B ). 6 days after trauma, ( C ). 1 year after trauma. Diplopia and motility disturbances As previously stated, radiological observations such as defect size and evidence of muscle entrapment are frequently used by most surgeons as strong indications for early intervention. , Clinical observations such as true muscle entrapment with a positive forced duction test are mainly seen in children ( Fig. 12 ) (76% <15 years) but are relatively rare in adults ( Fig. 13 ). A more common clinical symptom is motility restriction and diplopia caused by a blowout fracture ( Fig. 14 ). The survey of Christensen and colleagues and Aldekhayal and colleagues showed that approximately 4 of 5 surgeons have strong to very strong indications for surgical intervention if diplopia persisted for more than 15 days. Fig. 12 Clinical example of trapdoor fracture in pediatric patient. Fig. 13 Clinical example of trapdoor fracture in adult. Fig. 14 Absolute motility restriction due to blow-out fracture in adult. As shown in Box 1 , there is a great variability in the extent and causes of diplopia and motility restrictions. This will be further discussed in Yvette Braaksma and Hinke Marijke Jellema’s article,“ Orthoptic Evaluation and Treatment in Orbital Fractures ,” in this issue. One of the difficulties in clinical decision making is that ocular motility disturbances are commonly caused by muscle edema, hemorrhage, and motor nerve palsy, conditions that cannot be treated surgically, and they are rarely caused by entrapment of the extraocular muscles. In time, most of these deficits may resolve spontaneously. Edema resolves within several days to weeks ( Fig. 15 ), but hemorrhage and motor nerve palsy can even take up to 12 months to recover ( Fig. 16 ). The true dilemma in clinical decision making occurs when the enophthalmos is minimal or absent and motility has improved, but diplopia persists. Box 1 List of causes of diplopia a Could be treated surgically. Emphysema Muscle edema Hemorrhage Hematoma formation in the extra-ocular muscles Motor nerve palsy (cranial nerves III, IV, and VI, and their respective neuromuscular junctions and target muscles) Entrapment of the inferior ocular muscles a Entrapment of surrounding soft tissues a Disruption of the orbital septae Lack of support of the orbital contents a Fibrosis of the orbital contents (ligaments and septae) Fibrosis of the extra-ocular muscles Related to neurotrauma/intracranial Fig. 15 Clinical example of improvement of motility restrictions caused by swelling ( A ). CT-scan ( B ). 3 days after trauma, ( C ). 2,5 week after trauma ( D ). 1 year after trauma. Fig. 16 Clinical example of improvement of motility restrictions caused by neurologic damage (n. VI paresis) ( A ). minor dislocated fracture ( B ) 3 months after trauma ( C ). 12 months after trauma. In most studies, diplopia and motility restrictions are subjective observations occurring shortly after trauma and which are not objective or accurate standardized consecutive measurements performed by an orthoptist. , Other groups stress the importance of quantitative evaluation of ocular motility , , and the use of a Hess screen test, interpretation of ductions, and the field assessment of binocular single vision (BSV) can be extremely helpful. Using these measurements, improvement of ocular motility and diplopia can be objectively assessed over weeks or even months after trauma. , Alhamdani and colleagues and Jansen and colleagues have shown that in minor diplopia (BSV <80), orbital reconstruction can worsen the clinical outcome, and even with moderate diplopia (BSV 60–80), surgery appears to have limited effect on the amount of diplopia. Nevertheless, in severe diplopia (BSV <60), orbital reconstruction has a significant effect on the outcome. These findings stress the importance of standard orthoptic evaluations during follow-up, especially if diplopia is the only clinical symptom. What is the best timing for orbital reconstruction? In many fields of trauma surgery, an increasing body of evidence is emphasizing the importance of optimal timing of surgery. The timing of orbital reconstruction is a determining factor with respect to the potential occurrence of postoperative orbital complications. In orbital trauma surgery, a general distinction can be made among immediate (within hours), early (<2 weeks), and late surgical interventions (>2 weeks). There is consensus on the indications for immediate repair, which include vision-threatening symptoms such as retrobulbar hematoma, significant globe displacement ( Fig. 17 ) and (pediatric) trapdoor fractures with muscle entrapment ( Fig. 18 A) with risk of ischemia and fibrosis, and oculo-cardiac reflex. Without immediate intervention in these cases, permanent damage to the orbital soft tissue and functional impairment are likely to occur. However, except for the trapdoor phenomenon in children, these indications are extremely rare. Fig. 17 Globe dislocation. ( A , B ) Extreme proptosis. ( C , D ) Dislocated globe into adjacent maxillary sinus. Fig. 18 Trapdoor with ( A ) and without ( B ) muscle entrapment (CT). Delayed reconstruction (>2 weeks) has some theoretic disadvantages. As a result of the trauma mechanism, there is some initial contusion, hematoma formation, and disruption of the intraorbital tissues. As delayed reconstruction can be considered a second trauma to contents of the orbit, some authors believe that early correction may prevent fibrosis. However, which fractures require early intervention? Diplopia and motility disturbances tend to resolve over time, and enophthalmos mainly occurs in due time. Hence, it is prudent to conclude that small asymptomatic fractures do not need surgery, whereas larger fractures with early enophthalmos require early orbital reconstruction. Most authors agree that a trapdoor fracture without muscle entrapment ( Fig. 18 B) but with significant motility restrictions requires early surgery. What is the effect on the clinical outcome if surgery in large blowout fractures with proper ocular function that develop enophthalmos over time is postponed? Is it possible to predict the cause of early post-traumatic diplopia (fracture-related, edema, hematoma formation, scarring, motor nerve palsies), and when and how does surgery affect the postoperative clinical outcome? The answers to these questions will help in determining the type of orbital fractures suitable for delayed surgery. If the delay itself of an orbital reconstruction does not affect the clinical outcome, it is surely safer to wait and observe if enophthalmos will occur and if diplopia will resolve, rather than risk complications because of surgery. The size of the fracture does not necessarily correlate to late enophthalmos, and severe diplopia could still resolve without intervention. , , A systematic review revealed that even if an early surgical approach was chosen, enophthalmos still persists in 30% of the cases. As a consequence of this, overtreatment of patients with early surgery may be the case, and spontaneous recovery might have occurred over time. Several systematic reviews showed that the literature is not conclusive on whether early surgery is better than delayed surgery for orbital wall fractures. Some authors reported good outcomes after late orbital reconstructions. Hence, the focus of the debate on optimal timing has shifted from the indications for early intervention toward the question of which patients are eligible for delayed repair or may be better treated with nonsurgical treatment. The proposed treatment schedule, which is based on the literature, is presented in Table 1 . Table 1 Indications for reconstruction Immediate Early Delayed Timeframe Within 24 h 1–14 d <14 d Indications Diplopia with CT evidence of an entrapped muscle or periorbital tissue associated with a nonresolving oculocardiac reflex: bradycardia, heart block, nausea, vomiting, or syncope White-eyed blow-out fracture. Young patients (<18 y), history of periocular trauma, little ecchymosis or oedema (white eye), marked extraocular motility vertical restriction, and CT examination revealing an orbital floor fracture with entrapped muscle or perimuscular soft tissue Significant globe displacement with vision-threatening emergency Early enophthalmos/hypoglobus causing facial asymmetry Symptomatic diplopia with positive forced ductions, evidence of an entrapped muscle or perimuscular soft tissue on CT examination Symptomatic diplopia without proven entrapment on CT examination, negative forced ductions, and insignificant clinical improvement over time Late-onset enophthalmos/hypoglobus Which materials are most suitable for the different types of orbital fracture? Various implant materials are used to reconstruct an orbital wall fracture. The goal of orbital reconstruction is to restore the pretraumatized orbital anatomy and function primarily for the correction of enophthalmos, hypoglobus, and diplopia. Implant materials must have certain material characteristics to achieve this. The ideal material should have good stability and fixation, should have an ideal architecture or have contouring abilities to restore volume and shape, is biocompatible, is able to facilitate fluid drainage, has no donor site morbidity, is radiopaque, and is readily available at acceptable costs. However, there is no perfect material available. Autologous bone grafts have long been considered the gold standard based on their biocompatibility; however, the use of autologous bone grafts has disadvantages, with donor site morbidity, difficulty of shaping the graft, and unpredictable resorption rates being the major ones. Resorbable materials have been suggested as alternatives because of their more predictable resorption rates, lack of donor site morbidity, and high levels of customizability and control (thermoplastics), but several studies showed lack of rigidity and stability over time, particularly in larger fractures. Titanium implants have become widely used and accepted as favorable material because of their high compliance to most of the previously demands mentioned. Titanium implants are available as titanium meshes for intraoperative bending as well as preformed 3-dimensional plates, and lately, they can be customized to patient specifications ( Fig. 19 ). To date, most research are focused on the clinical outcome of allogenic and (non-)resorbable alloplastic materials. Table 2 presents the main groups of biomaterials used for implants as well as their main advantages and disadvantages. Fig. 19 Shape factor of the orbital implant a. free-handed bending, b. preformed, c patient specific implant. Table 2 Advantages and disadvantages of commonly used biomaterials Stability Contouring Biological Behavior Drainage Donor-Site Morbidity Radiopacity Availability Cost-Effectiveness Titanium meshes (flat) Stability +++ Fixation ++ ++ Contouring - Possible sharp edges ++ Allows tissue ingrowth - Poor dissection of periorbita in secondary reconstruction + Permeable + + + + Bone graft Stability ++ Fixation + + Variability in thickness/smooth surface adequate in 3-wall fractures - Remodelling/difficult to shape +++ Maximal biocompatibility/periorbita readily dissects off bone in secondary reconstruction - - Donor site needed: Harvest time/pain/scarring/complications + +/− +/− Porous polyethylene sheets Stability +/− Lack of rigidity when thin fixation +/− + Eased by artificial sterile skull/smooth edges ++ Allows tissue ingrowth - + - Not visible on postoperative imagery + + Composite of porous polyethylene and titanium mesh Stability ++ Fixation ++ + Eased by artificial sterile skull adequate in 3-wall fractures ++ Allows tissue ingrowth - + + + +/− Resorbable materials Stability +/− Stable over time? Fixation +/− + Smooth surface and edges/handling (thermoplastics) - Nonthermoplastics - Degradation of material with risk of contour loss +/− Sterile infection/inflammatory response - In case nonperforated: less drainage than uncovered titanium mesh + - Not visible on postoperative imagery + + Preformed orbital implant Stability +++ Fixation ++ ++ + Minimal contouring Necessary/smooth surface ++ Allows tissue ingrowth + Permeable + + + +/− Summary There is consensus that a trapdoor fracture in a pediatric patient, a severely dislocated globe and a trapdoor fracture with a nonresolving oculocardiac reflex, bradycardia, heart block, nausea, vomiting, or syncope are strong indications for immediate surgery. Most authors agree that early reconstruction is required when there is entrapment of the orbital contents with an absolute motility restriction (adult) or early significant enophthalmos or hypoglobus (>2 mm), but others recommend expectative policy for other uncertain indications. Hence, if the motility of the eye significantly improves within 10 to 14 days, surgery may be not indicated. Favorable results of using a nonsurgical approach have been published over the years. , , , Clinical findings should overrule CT results. The soft tissues are the unpredictable factor in fracture management. An anatomic orbit does not automatically become a perfectly functioning orbit. Surgery will not necessarily heal the already inflicted damage to the soft tissues. If surgery is required, then preoperative planning, navigation, and intraoperative imaging may be help in improving the anatomic bony outcome. Treat what harms, not what is expected to occur. The clinical outcome of each patient whose treatment is guided by a protocol provides accurate feedback for reconstructive decisions (“Evidence-Based Decision Making in Orbital Fractures: Implementation of a Clinical Protocol” by Peter J. J. Gooris, Jesper Jansen, J. E. Bergsma, Leander Dubois). 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