New Algorithm for the Management of Orbital Blowout Fracture Based on Prospective Study

Abstract

Despite extensive debate and publications in the management of blowout fracture (BOF), there are still considerable differences in the surgeons’ management of BOF due to a lack of reliable evidence-based studies. This article aimed to evaluate which BOF patients require surgical treatment due to functional and/or cosmetic deformities; evaluate which computed tomography (CT) scan findings predict these problems; and provide an algorithm in the management of BOF. Seventy-nine patients with BOF were treated conservatively and followed up prospectively regarding functional and cosmetic deformities for at least 1 year. The patients’ CT scans were analyzed and several measurements were performed. Patients’ symptoms and the clinical findings were correlated to the CT scan measurements. We found visible deformity in 37% of the patients, but only 10% chose to proceed to surgery due to cosmetic deformities. In patients with inferior BOF and a herniation < 1.0 mL, a visible deformity was found when the ratio between fracture and the fractured orbital wall areas was ≥42%, or the total area of the fracture was ≥ 2.3 cm2. In patients with inferior BOF and a herniation ≥ 1.0 mL, a visible deformity was found when the distance from the inferior orbital rim to the posterior edge of the fracture was ≥ 3.0 cm. In patients with inferomedial fracture, a visible deformity was found when the herniation was ≥ 0.9 mL. Diplopia improved significantly and remained in only 3% of the patients in nonoperated group. Hypoesthesia of the infraorbital nerve improved significantly, but 23% of the nonoperated and 50% of the operated patients still experienced loss of sensation at final control. In this prospective study, we found that not only herniated orbital volume but also other CT scan findings in BOF were crucial to predict late visible deformities. Based on these findings, we propose an algorithm for the prediction of late visible deformity with 83% accuracy. There are indications that diplopia without ocular motility disorder is due to edema and we recommend observation as long as the diplopia improves gradually.

Prospective Randomized Controlled Pilot Study on Orbital Blowout Fracture

“…0.9 mL. 18 Therefore, we hypothesize that there is a fundamental difference between inferomedial and inferior BOF.…”

“…However, in our earlier observational study, these parameters have not been shown to correlate with the development of a visible deformity. 18 In the literature, early surgical intervention in patients with BOF has been proposed to be important for patient outcome. 6 In our study, the timing of surgery naturally differed between the observational and the surgical groups.…”

“…1) is described and used again in our other study. 18 Measurements were made accordingly: Sagittal plane where the fracture was considered largest in the inferior wall:…”

Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis

“…2,8,11 Most recently, a Swedish study identified certain parameters of deformities as risk factors for late visible deformity, such as herniation of 0.9 mL or more for inferomedial wall fractures, 42% or more of the floor, and a distance from the inferior orbital rim to the posterior edge of the fracture of 3.0 cm or more. 1 Although beyond the scope of this review, CTguided repair of orbital floor fractures represents a powerful new technique that may decrease postoperative complication rates and push the risk-benefit analysis in favor of early repair. When coupled with interpretative surgical navigation, CT-guided repair can provide real-time feedback that shows the correct orbital shape and plate position, preventing adverse outcomes.…”

“…Fractures to the orbital rim and/or walls are among the most common traumatic craniofacial injuries. 1 Although a great force is required to break the thick superior or lateral orbital walls, the relatively thin bones of the medial wall and orbital floor can be injured with even mild or moderate trauma. 2 The orbital floor is composed of the maxillary, zygomatic, and palatine bones and is the shortest of the 4 walls, terminating at the posterior edge of the maxillary sinus.…”