Orbital Floor Fracture
An orbital floor fracture refers to the deformity of the bones of the eye socket, usually caused by facial trauma. In order to understand orbital floor fractures, it is important to understand the underlying anatomy of the orbital floor. The orbital floor (inferior wall or base of the eye socket) is made up of the intercalating maxillary, zygomatic and palatine bones. The orbital floor measures 35-40 mm and contains a small section of bone wall which is only 0.23 mm thick, thus predisposing the orbital floor to fractures.
What are the different kinds of orbital floor fractures?
Orbital floor fractures are of two types:
- Open door fractures – An open door fracture is said to have occurred when the bones are fractured into several fragments, significantly displaced from their normal positions.
- Trapdoor fractures – In the case of trapdoor fractures, the orbital floor bones are fractured in a hinged manner, with minimal
What causes orbital floor fractures?
In most cases, orbital floor fractures are caused by medium or high-velocity trauma to the orbital floor. Orbital floor fractures often occur in conjunction with other facial fractures such as nasal fractures as a result of physical trauma or motor accidents. It may also be caused by accidental sports injuries from high-velocity objects such as squash and tennis balls.
What are the consequences of an orbital floor fracture?
Due to the fracture of the orbital floor, the volume of the orbit increases. This may lead to displacement of the eye in the backward (enophthalmos) or downward direction (hypoglobus). Muscles or tissue within the eye can get enmeshed in the fracture which may cause an obstruction in gaze and double-vision. Orbital haemorrhage and damage to the optic nerve may occur. Rupture of the eyeball, swelling in the retina and varying degrees of vision loss could take place.
How is an orbital floor fracture treated?
- Medical therapy – Treatment with drugs unaccompanied by surgery can be employed for patients who do not present with significant displacement of the eye, patients who do not appear to have any muscle entrapment in the fracture, have greater than 50% of the orbital floor intact and do not experience double vision. A short course of antibiotics and steroid medication can be used to reduce the chances of infection and suppress any swelling or oedema.
- Surgical therapy – The aim of surgical procedures in the treatment of orbital floor fracture is to examine the affected area and restore any displaced or enmeshed tissue to its correct location in order to correct any extraocular motility. Removal and replacement of bony fragments can also be carried to re-establish the correct orbital volume and shape. The most preferred method for orbital floor reconstruction surgery is the transconjunctival approach. The advantages of this procedure are the lack of visible scarring and the decreased possibility of retraction of the lower eyelid. Other surgical approaches include the cutaneous and transantral Minimally invasive endoscopic methods via transnasal and transmaxillary routes have also been reported. In many cases, orbital implants can also be used by the oculoplastic surgeon in order to reconstruct the orbit. These implants can be fabricated from materials such as vicryl mesh, porous polyethylene, metallic mesh and metallic plates. In certain cases, autologous bone from the maxillary wall and calvaria can also be employed.
What are the complications in the surgical treatment of orbital floor fractures?
- Performing the corrective operation too early – In several cases of orbital floor fracture, the resulting double vision may resolve itself in a few days or may cease to interfere with the normal activities of the patient. In such cases, deciding to wait for one or two weeks before surgery is the most promising course of action.
- Severe postoperative scarring of the eyelid – Malposition of the lower eyelid in case a subciliary incision is performed for the fracture may result in postoperative complications which may be very difficult to treat or correct.
- Incomplete posterior coverage of the bony defect with the implant – The orbital implant material should be placed such that the entire defect is covered. This prevents herniation of the orbital tissue from any gaps remaining in the orbital floor, which may cause further complications.
- Visual loss – One of the complications of the surgical procedure is indirect damage to the optic nerve, thereby causing postoperative visual deficiency.
- Other complications such as double vision, enophthalmos may persist well after surgery.
Orbital floor fracture or orbital blowout fracture is a type of facial fracture caused due to trauma from injuries or motor vehicle accidents. The impact of the trauma results in the fracture of the bones of the eye socket, resulting in the increased volume of the orbit. This results in a range of complications ranging from double vision to displacement of the eye. Medical treatment may provide relief to certain patients; however, surgical repair is necessary in most cases.
Due to the fragile nature of the eye socket and the sensitive location, there are risks and complications involved in orbital floor fracture repair. Patients must be careful to seek treatment from highly experienced and skilled oculoplastic surgeons with prior exposure to orbital surgery.
Dr. Debraj Shome is a highly experienced oculoplastic surgeon based in India. He has various accolades and medical distinctions to his name.