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Orbital Fracture Treatment

An orbital fracture, also known as an orbital blowout fracture, is frequently found in patients who experience trauma to their faces or skulls. The impact may be mild or severe, causing the eye socket (the bony cup that surrounds and protects the eye) to become fractured or even damaging the eye itself. The extent of the damage depends on the intensity of the trauma and the direction of the impact to the bone and eye.

Injury can occur to the globe (eyeball), eyelid, lacrimal system, bones around the eye, sinuses, and/or the brain. Thus, it is very important to carefully examine the patient’s eyes after an accident to understand the full extent of the injuries.

Sometimes after an accident it is difficult to assess the extent of injury because the area around the affected eye may be bruised and swollen (eyelid and orbital edema). The doctor will need to wait for the swelling to go down before they can properly examine the eye. This should be done by a specialist, such as an oculoplastic specialist (ophthalmic plastic and reconstructive surgery).

Symptoms
  • Numbness in the cheek.
  • Double vision.
  • Swelling and bruising of the eyelid.
  • Difficulty opening the eye or inability to open the eye completely due to muscles being compressed by the fractured bone.
  • After the swelling goes down, the eyeball appears smaller than normal or looks “collapsed.”
Please see a doctor immediately if you experience any of these symptoms. In some patients, after a traumatic injury to the face, they may not experience any symptoms of a fracture at all, even if the bone has broken.
 
  • To correct abnormality and return normal function.
  • To minimize the impact to vision.
  • To minimize the impact to other organs within the eye.
Many orbital fractures do not lead to enophthalmos, diplopia or ocular motility dysfunction so the decision to observe a fracture or proceed with surgery is based on the clinical exam findings, orbital imaging and assessment of the risk and benefit of either option. If there is a clear sign of muscle entrapment, surgery should be performed within 48 hours to prevent the death of tissue that is essential for the normal functioning of the eye. If symptoms occur, such as cheek numbness, double vision, blurry vision, uneven eyes (the affected eye looks lower than the healthy eye), difficulty moving the eye around, or the affected eye is more “sunken” or if computed tomography (CT) scans show that the eye tissue has been displaced into the sinus cavity or has become trapped, treatment can be delayed for no more than two weeks. This is because scar tissue or adhesions may form, making surgery more difficult and, in the long-term, causing the affected eye to become sunken (enophthalmos).
 
  1. A thorough examination by an ophthalmologist is necessary to rule out any other injuries or conditions, such as hyphema (blood in the anterior chamber of the eye), retinal detachment, vitreous hemorrhage, lens subluxation, or fractures of the skull or facial bones. Specific equipment is required to diagnose and rule out each condition.
  2. Imaging studies.
  3. A computed tomography (CT) scan may be necessary to check for injury to nearby muscle and tissue.
There are three to four surgical approaches, but the most popular are:
  1. Subciliary approach, under the eye, as seen in (A) of the image on the right.
  2. Transconjunctival approach, as seen in (A) of the second image on the right. The advantage to this approach is there is no visible scarring, but it also means limited visibility for the doctor, which may require extension of the incision (as in B and C).
Fixation Materials for Orbital Fracture
  1. Autogenous material, which is the patient’s own bone, such as cartilage from the rib or nasal septum or bone from the skull, hip, rib, or chin.
Advantage: Low risk of infection and rejection
Disadvantage: Additional surgery is necessary, which means more time and more pain
  1. Allogenic material, which is donor bone/material, such as lyophilized dura/cartilage or fascia lata. This option is rarely used due to risk of cross contamination.
  2. Alloplastic material, which can be divided into two categories:
    1. Non-resorbable materials, such as titanium plate, polyethylene polymer, and hydroxyapatite (artificial bone)
    2. Resorbable materials, such as polydioxanone (PDS) polymer, polyglactin polymer (Vicryl), and Lactasorb (combination of polylactic and polyglycolic)
  3. Xenograft, which is material from animals, such as collagen; rarely used due to the risk of infection and rejection.
 
Factors for Choosing Fixation Material
  1. The size of the fracture: A small fracture (less than 5 millimeters) may require a soft material like polydioxanone (PDS) polymer while a bigger fracture may require Lactosorb; a very big fracture/enphthalmos may require a stronger material like titanium plates or bone from the skull or hip.
  2. Patient’s preference, such as whether or not they would like to use their own cartilage/bone.
  3. Experience and expertise (with the material) of the doctor.
  1. After the procedure you will need to stay in the hospital so the doctor can monitor and assess your vision.
  2. You will be prescribed pain medication and antibiotics. Please use the eye drops as instructed and take all medication prescribed.
  3. Please keep all follow-up appointments.
  4. Do not let the incisions come into contact with water for at least one month after the procedure.
  • Loss of vision
  • Bleeding
  • Permanent enophthalmos
  • Inflammation
  • Infection
Complications can be avoided by choosing the appropriate method and technique for surgery and the right fixation material.
 
Before the Procedure
  • Please plan to stay in Thailand for at least one week through the duration of treatment.
  • It is recommended that you stay in a hotel close to the hospital for convenience in traveling to the hospital before and after the procedure.
  • You will undergo a health screening when convenient for you before the procedure as the procedure is done using general anesthesia. You will likely need to fast before the health screening. You will be given detailed instructions by your medical team.
After the Procedure
  • The doctor will schedule a follow-up appointment for the day after the procedure.
  • If you have no abnormal symptoms after the procedure you can usually return to your home country. The final decision will depend on your doctor’s recommendation.
  • After the follow-up appointment the day after the procedure you will need to see your doctor one month after the procedure, three months after the procedure, and six months after the procedure. If you cannot return to Thailand for these appointments, please see an ophthalmologist in your home country.
The success of this procedure depends on the injury and timely and correct medical attention from an ophthalmologist when the injury/trauma occurs.
 
What if the procedure is not performed?
Complications can occur from death of tissue around the eye.
 
Treatment options will depend on the type and severity of the condition. In some cases, the doctor may choose to simply monitor symptoms before making a decision about surgery, such as if the fracture does not affect any important areas or if the fracture is not too big or if symptoms improve on their own within 1-2 weeks after the swelling subsides.
 

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