Orbital bone fractures constitute a significant portion of traumatic facial injuries. Because of the frequent functional and aesthetic deformities that result, the treating physician must be knowledgeable and experienced in this area. They are most commonly seen in assaults, battery, and motor vehicle accidents. Furthermore, injuries to the eyeball, optic nerve, and extraocular muscles are always a concern. Understanding the fundamental nuances of orbital injuries includes understanding orbital examination, appropriate management, and potential complications.
In a previous publication, we retrospectively reviewed and evaluated all the characteristics of patients with orbital trauma.
The most common clinical findings in adult orbital fractures are periorbital bruising and subconjunctival hemorrhages. However, the absence of such signs does not exclude an orbital floor fracture, especially in children. Among the physical findings that should raise the suspicion of an underlying orbital fracture, the most important are the presence of periorbital ecchymoses and subconjunctival hemorrhages. Even in the absence of these physical signs, mild proptosis and eyelid swelling; orbital or eyelid tension; chemosis after blowing the nose; eyelid pressure or a "crackling" sound upon eye movement; numbness of the cheek, side of the nose, or ipsilateral front teeth; pain or nausea in a specific gaze direction; and an unexplained urge to close one eye after trauma may be present.
A person with orbital trauma will experience nasal congestion due to edema, which will cause the need to blow their nose. As a result, air may enter the eye cavity after blowing, which may lead to infection and compartment syndrome. This situation has been mentioned in a previous publication.
After a fracture, bleeding can occur suddenly around the closed area of the eye. This bleeding, in particular, can lead to compartment syndrome. This accumulated blood and increased pressure can compress the optic nerve, leading to permanent vision loss. In our previous post on this topic, I outlined the necessary steps and detailed information.
Any of these findings should raise suspicion of an orbital fracture. However, we are often consulted to see patients after an orbital fracture is diagnosed using computed tomography (CT). When this occurs, the key questions to answer are: (1) Are there any neurological or ophthalmological injuries that potentially alter the timing of orbital bone fracture repair? (2) Is fracture repair necessary?
Each wall varies in thickness, and accordingly, the medial wall (lamina papyracea) and orbital floor are the most susceptible to fracture, having the thinnest walls. Although the medial wall has the thinnest bone, the supporting effect of the ethmoid sinus laminae makes the orbital floor more susceptible to fracture. However, because impacts often come from the side, the thick frontal bones were not uncommon in fractures.
The most useful imaging modality in trauma patients is CT. We prefer slices of 1.25 mm or thinner.
Some orbital injuries require urgent surgery. However, the timing of non-urgent injuries is a matter of debate and is often treated semi-delayed for approximately 7 to 14 days, before soft tissue scarring develops but after post-traumatic edema resolves. Surgery after 21 or 22 days, particularly in young men, may cause additional damage due to soft tissue adhesions.
The most common indication for emergency repair of an orbital floor fracture is inferior ocular muscle entrapment.
Diplopia or double vision alone does not indicate extraocular muscle entrapment, as eye movement may be reduced due to edema.
After trauma, the eye may initially bulge forward due to edema, but in patients with fractures, the edema gradually decreases, and the eye shrinks and moves backward. Surgery performed within the first seven days has a high success rate, but subsequent adhesions reduce the success rate. Enophthalmos (backward protrusion of the eye) greater than 2 mm can cause significant aesthetic problems.
We urgently operated on one of our patients due to the appearance of the eyeball falling into the maxillary sinus after the base fracture, and after the repair, our patient continued his normal daily life. Delay can lead to irreversible damage.
Our surgical experience demonstrates the need for caution, and sometimes even imaging methods may fail to provide sufficient information. A tear in an eye muscle can sometimes go unnoticed on X-rays due to edema and bleeding, and the patient's urgent and painful condition can obscure this injury. Therefore, during surgery, all adjacent structures should be examined, the eye should be searched for tears, and the presence of a muscle tear should be confirmed. Orbital trauma can also be accompanied by tearing of the lacrimal ducts. While initially easier to treat, this condition can become incurable if not treated promptly.
