ORBITAL FRACTURES

Brig Amer Yaqub

FCPS, FRCSEd

ANATOMY OF ORBIT

ROOF OF THE ORBIT Roof is formed by two bones 1) Lesser wing of Sphenoid 2) Orbital plate of the Frontal It is located subjacent to the anterior

cranial fossa and frontal sinus A defect in orbital roof may cause

pulsatile proptosis

LATERAL WALL OF THE ORBIT Lateral wall is formed by two bones 1) Greater wing of Sphenoid 2) ZygomaticAnterior half of the globe is vulnerable to

lateral trauma since it protrudes beyond the lateral orbital margin

FLOOR OF THE ORBITFloor is formed by three bones 1) Zygomatic 2) Maxillary 3) PalatineThe posteromedial portion of the Maxillary bone

is relatively weakMay be involved in a blowout fracture

MEDIAL WALL OF THE ORBITIt is formed by four bones 1) Maxillary 3) Ethmoid 2) Lacrimal 4) Sphenoid

Orbital cellulitis is therefore frequently secondary to Ethmoidal sinusitis

OPTIC CANALOptic canal lies in the lesser wing of

sphenoidIt is situated close to the apex of the

orbitIt connects the middle cranial fossa with

the orbital cavityIt is 4-10 mm longIt transmits, 1) Optic nerve 2) Ophthalmic artery

SUPERIOR ORBITAL FISSUREIt is a slit between the greater and lesser wing of

sphenoid boneStructures which passes through are, Superior portion contains1.Lacrimal nerve2.Frontal nerve 3.Trochlear nerve4.Superior ophthalmic vein

Inferior portion contains1.Superior & Inferior division of Oculomotor nerve2.Abducent nerve3.Nasociliary nerve4.Sympathetic fibers

INFERIOR ORBITAL FISSUREThe lateral wall and the floor of the orbit are

separated posteriorly with the inferior orbital fissure.

Which transmites.1.Maxillary nerve & its Zygomatic branch2.Ascending branches from the Sphenopalatine

ganglion3.Inferior ophthalmic vein

ORBITAL FRACTURES

BLOW-OUT ORBITAL FLOOR FRACTUREA 'pure' blow-out fracture of the orbit does not

involve the orbital rim

Whereas an 'impure' fracture involves the orbital rim and adjacent facial bones

It is caused by a sudden increase in the orbital pressure by a striking object which is greater than 5 cm in diameter

Fracture most frequently involves the floor of the orbit

Occasionally, the medial orbital wall may also

be fractured.

Periocular signsEcchymosis Oedema Subcutaneous emphysema.Infraorbital nerve anaesthesia Involving the lower lidCheekSide of noseUpper lipUpper teeth and gums

Diplopia

EnophthalmosManifest after a few

days, as the initial oedema resolves

Ocular damage

HyphaemaAngle recession Retinal dialysis

CT ScanExtent of the

fractureProlapsed

orbital fatExtraocular

musclesHaematoma

Hess test Useful in assessing and monitoring the

progression of diplopia

INITIAL TREATMENTAntibiotics SteroidsNo nose blowing

SURGICAL TREATMENTSurgery recommended for symptomatic

fractures DiplopiaMuscle entrapmentEnophthalmosExtensive fracture (>50% of floor)

Ideally surgery should be done within two weeks

GOALS OF SURGERYRestore normal extraocular

muscle movementsReplace orbital contents into the

orbitRestore normal orbit volume

TECHNIQUE OF SURGICAL REPAIRA transconjunctival or subciliary incision

The periosteum is elevated from the floor of the orbit and orbital contents are removed from the antrum

The defect in the floor is repaired using

synthetic material such as Supramid, silicone or Teflon

The periosteum is sutured

COMPLICATIONS

Diplopia (up to 75%)Exophthalmos HemorrhageEyelid malpositionSurgical trauma to

OrbitNerveLacrimal apparatus

Blow-out medial wall fractureMost medial wall orbital fractures are

associated with floor fractures.

SIGNSPeriorbital haematoma

Defective ocular motility involving abduction and adduction.

CT will show the extent of damage

TREATMENTInvolves release of the entrapped tissueRepair of the bone defect

ROOF FRACTURECaused by trauma such as

Falling on a sharp objectBlow to the brow or foreheadMost common in young children

Complicated fractures caused by major trauma commonly affect adults

PresentationHaematoma of the

upper eyelid

Periocular ecchymosis

SIGNSInferior or axial displacement of the globe.Large fractures may be associated with

pulsation of the globe unassociated with a bruit

Best detected on applanation tonometry.

TREATMENTSmall fractures may not require treatment

Observe the patient for the possibility of a CSF leak which may lead to meningitis

Sizeable bony defects with downwardly displaced fragments usually require reconstructive surgery

LATERAL WALL FRACTURERareBecause the lateral wall of the orbit is more

solid than the other wallsFracture is usually associated with extensive

facial damage

Sympathetic ophthalmia<0.5% of penetrating injurySevere bilateral granulomatous uveitisAnterior chamber inflammation, multiple yellow spots in peripheral fundus

Injured eye is called exciting eye

Fellow eye which also develops uveitis iscalled sympathizing eye

Predisposing factorsPenetrating wound ( less commonly

intraocular surgery)Wounds in the ciliary region Wounds with incarceration of the iris, ciliary

body or lens capsule More common in children than in adults

Clinical PictureExciting (injured) eye

Persistent low grade plastic uveitis, which include ciliary congestion, lacrimation and tenderness

Keratic precipitates (dangerous sign)

Sympathizing (sound) eyeUsually involved after 4-8 weeks of injury in the

other eyeMost of the cases occur within the first yearAlmost always, manifests as acute iridocyclitisRarely it may manifest as neuroretinitis or

choroiditis

Complications

Cataract Glaucoma Optic atrophy Exudative detachments Subretinal fibrosis

TreatmentProphylaxis

Early enucleation of the injured eye (best prophylaxis when there is no chance of saving useful vision)

When there is hope of saving useful vision, following steps should be taken: Meticulous repair of the wound using microsurgical

technique should be carried out, taking great care that uveal tissue is not incarcerated in the wound

Immediate treatment with topical as well as systemic steroids and antibiotics along with topical atropine should be started

Late enucleation if uveitis not settled for 2 wks

Systemic immunosuppression

CorticosteroidsMostly good prognosis >6/18However, enucleate only if no visual potential

SYMPATHETIC OPHTHALMIA(BILATERAL granulomatous panuveitis after

trauma)

Onset: 5 days to 66 years after penetrating trauma

Onset: 33% at 3 mo., <50% after 1 year

Removal of injured eye after onset does not help

Cause: antigen-antibody interaction

Risk: 0.015-1.9% (lowest after planned surgery)

Treatment: immunosuppressive therapy