What Is Orbital Fracture?

An orbital fracture is a common type of facial fracture which occurs around the eye socket. The injury usually happens when blunt force trauma hits the thin bone of the orbit or socket in the eyes. The different types of fracture include orbital floor, orbital roof, lateral wall and medial wall fractures based on anatomical positions.¹ It is seen that most orbital fractures occur due to accidents or assaults in adults and falls or sports in pediatrics.²

Initial cause and Symptoms of Orbital fracture

Patients with a history of trauma in the periorbital region have to be evaluated for orbital fractures.³ If you have faced any accidents or seen someone injured in the facial region it is important to look for orbital fracture. Orbital fracture can cause many symptoms, mostly periorbital swelling, pain upon eye movement, and bleeding due to broken blood vessels in the eyes. Patients may also experience diplopia, which is double vision of a single object and numbness of the cheek on the affected side.¹

Evaluation of Orbital fracture

Generally it is safe to perform a complete ophthalmic examination for patients with periocular or ocular trauma. A detailed eye examination provides a clear image of globe trauma or orbital fracture in the injured region.⁴ It includes examining pupil size, shape, and reactivity to light, extraocular movement, visual acuity, colour vision to red, visual field, presence of hyphema, intraocular pressure, chemosis, and bleeding in the eyes.³ A study shows that in up to 29% of individuals with orbital fractures, connected ocular injuries are evident. To reduce the risk of vision loss or compromise, an eye exam must be performed as soon as possible. Blindness from orbital fractures is approximately 0.7%-10%. The most reliable method for identifying and characterising orbital fractures remains CT imaging. Since concurrent fractures are frequently seen, imaging of the entire face is suggested.² Compared to other imaging modalities, the CT scan has several advantages. It is possible to ascertain the fracture's size and form, which helps with both clinical assessment and surgical planning. If the optic canal is affected by the fracture, this can be confirmed by a CT scan.⁵

Treatment and Management of Orbital Fracture

To prevent introducing air into the orbital region and potentially causing visual impairment, patients should be instructed not to blow their nose for a few weeks following the accident. Sprays that decongest the nose are frequently used. Prophylactic antibiotics are also often used by doctors to stop the spread of bacteria that could cause orbital cellulitis in the case where a fracture results in a direct orbital connection with the sinuses. Regardless of whether surgery is necessary, steroids can be administered to reduce severe orbital oedema.⁶

The clinical exam findings, orbital imaging, and assessment of the risk and benefit of each choice are used to decide whether to observe a fracture or proceed with surgery. There are two types of surgical indications: immediate and delayed repair.²

Surgical procedure

Many orbital fractures may not result in long-term functional or cosmetic losses and do not necessitate surgical intervention. However, in an acute context with soft tissue oedema, it is difficult to anticipate the result. There are two types of indications for orbital fracture surgery: emergent/urgent and delayed. Entrapment, which may or may not be coupled with oculocardiac reflex, causes nausea, vomiting, bradycardia (slower heart rate), syncope (fainting), hemodynamic instability (abnormal blood pressure), and even asystole (lack of heart rhythm). This is the only rationale for emergent/urgent orbital fracture repair. Trapdoor orbital fractures, in which a piece of bone is displaced with tissue protrusion and then bends back to a more normal position, are said to be more common causes of the oculocardiac reflex, especially in pediatric patients with inferior rectus muscles.⁷

Decisions to recommend operative repair for patients who do not require emergent/urgent operative interventions for orbital fractures should be based on the presence of deficits in form and/or function, as indicated by globe malposition or diplopia on repeat evaluation 7-10 days after initial injury. Patients should inquire about diplopia, visual changes, and eye position changes during this visit and a thorough eye exam should be performed. There are four widely acknowledged indications for surgical orbital fracture repair: enophthalmos (>2 mm), more than 50% floor involvement, diplopia, and entrapment.³

Various Surgical Techniques

The goal of orbital fracture surgery is to rebuild the skeletal architecture while also releasing any imprisoned periorbital tissue. The globe will be able to restore its normal position after restoring the original orbital volume, resolving any diplopia. To repair orbital bone tissue, a range of materials, including autologous bone, cartilage, and muscle, as well as synthetic materials, have been employed. Today's most common materials are pure titanium plates, titanium mixed with polyethylene, or resorbable polydioxanone plates. For significant or difficult orbital fractures, patient-specific 3D-printed reconstructive plates are acceptable. These are manufactured by duplicating the opposing orbit onto the fracture side and then fabricating an anatomically suitable implant. A 3D-printed replica of the patient can also be utilised to personalise the reconstruction plate.¹

Complications

Any orbital surgery has the possibility of problems. Failure to detect fractures that require immediate treatment may result in intra- or post-operative problems owing to fibrosis, contracture, and inadequate union. Loss of vision, traumatic optic neuropathy, diplopia over-correction or under-correction, enophthalmos, lower eyelid retraction, bleeding, infection, extrusion of an orbital implant, infraorbital nerve damage with resultant hypoesthesia, orbital congestion, and epiphora are all possible postoperative complications. A comprehensive eye examination is required following surgery to appropriately assess the consequences of these problems. The majority of issues are caused by implant misalignment or the use of the incorrect implant size. Persistent or medically caused diplopia, the most prevalent consequence, can cause severe postoperative morbidity in patients.⁵

Post Operative Care

When steroids are used to reduce oedema postoperatively, diplopia should resolve after 5 to 7 days of adequate orbital reconstruction. Persistent diplopia following predicted clearance of intra-orbital oedema and hematoma should be investigated further. Ophthalmology should be consulted for a thorough examination, evaluation, and diagnosis.⁶

Summary

• Orbital fracture is a common type of facial fracture which occurs around the eye socket. The injury usually happens when blunt force trauma hits the thin bone of the orbit or socket in the eyes
• The patients with a history of trauma in the periorbital region have to be evaluated for the orbital fracture. Orbital fracturse can cause many symptoms, mostly periorbital swelling, pain upon movement of the eye, and bleeding due to broken blood vessels in the eyes
• Generally it is safe to perform a complete ophthalmic examination for patients with periocular or ocular trauma. A detailed eye examination provides a clear picture of the globe trauma or orbital fracture in the injured region
• The most reliable method for identifying and characterising orbital fractures remains CT imaging. Since concurrent fractures are frequently seen, imaging of the entire face is suggested
• The clinical exam findings, orbital imaging, and assessment of the risk and benefit of each choice are used to decide whether to observe a fracture or proceed with surgery. There are two types of surgical indications: immediate and delayed repair
• The goal of orbital fracture surgery is to rebuild the skeletal architecture whilst also releasing any imprisoned periorbital tissue. The globe will return to  its right position after restoring the original orbital volume, resolving any diplopia
• A comprehensive eye examination is required following surgery to appropriately assess the consequences of any problems