Orbital and Ocular

Trauma
Josh Coffey
PGY3
Shere et al, 2014
• evaluated 3599 midfacial and 1141 orbital blowout
fractures
• 20 year multicenter retrospective analysis
• 29.8% of orbital blowout fractures had associated ocular
injury
Development
• Average orbital volume ~30cc
• By 5 years 85% orbital growth, finalized by
puberty.
• The maxillary sinuses are present at birth and
reach the orbital floor and infraorbital canal
by age 2 years
• The frontal sinus begins to form around 6 yrs
 unilateral 5% of adults
 missing in another 5%
Basic Anatomy
Bones of the Orbit
1. Frontal
2. Zygomatic
3. Sphenoid
4. Maxilla
5. Ethmoid
6. Lacrimal
7. Palatine
• Closing:
Basic Anatomy
• orbicularis oculi (CN VII)

• Opening:
• levator palpebrae superioris (CN
III)

• Upper eyelid resting position: Superior

tarsal AKA Müller’s muscle
(sympathetic)
• Increase  “wide-eyed” look.

• Lower eyelid retractor: inferior tarsal

(sympathetic)
 Layers of the Eyelid
• skin, subcutaneous tissue
• orbicularis oculi
• orbital septum and tarsal plates
• conjunctiva
 Glands
 Lacrimal (watery)
 Meibomian/tarsal glands

(oily)
 Conjunctival goblet cells

(mucinous)

 Eyelid margin glands:

◦ Zeis: sebaceous/oily
◦ Moll: apocrine
Schirmer Test
 Orbital Fat Pads
 Five Pads
 Three fat pads
below eye
 Two pads above
eye
 Medial pads are white
 Lateral pads are
yellow
Movement of the eye
Orbital Fractures
• Isolated orbital wall fractures 4-16% of facial fractures.
 If fractures that extend outside the orbit are included, (ZMC &
NOE), then this accounts for 30 to 55% of all facial fractures.

• Assault and MVA

 Internal Orbital Fractures
• Linear internal orbital fractures maintain periosteal
attachments.

• Blow-out fractures (most common) Displacement of wall that

results in either increased or decreased volume
 Most commonly is the anteriormedial floor.
 Roof blow-in  “pulsatile globe.”

• Complex internal orbital fractures involve two or more walls,

>2cm diameter, or comminution with unretrievable segments.
 Extend posteriorly, may involve the optic canal.
 Associated with more severe trauma.
Clinical Exam
• The initial exam should include:
 periorbital examination (visual/palpation)
 visual acuity (pt should wear glasses)
 ocular motility (may need retractors)
 pupillary responses
 visual fields
 Fundoscopic examination.
 Ocular Injuries and Disturbances
• Between 0.6 and 4% of patients
suffering orbital fractures have a globe
injury or optic nerve impairment,
resulting in a significant or total loss of
vision in one eye.
• Following repair: 0.27% blindness
• 25-30% spontaneous recovery of vision
 Ocular Injuries and Disturbances
• Always evaluate for retrobulbar hematoma!
 severe pain, proptosis, loss of vision, subconjunctival hemorrhage, ophthalmoplegia,
afferent pupillary defect, V1 paresthesia, ptosis

• Treated w/ lateral canthotomy, and inferior cantholysis

 Retrobulbar Hematoma
• 1386 ER visits for orbital trauma 50 patients had retrobulbar
hemorrhage.
• RBH  blindness, incidence ~48%
• With proper and prompt treatment, the incidence of blindness was only
0.14%,

Fattahi T, Brewer K, Retana A, Ogledzki M. Incidence of retrobulbar hemorrhage in the emergency

department. J Oral Maxillofac Surg. 2014 Dec;72(12):2500-2
Ansari, M.H. Blindness after Facial Fractures: A 19 year retrospective study. J Oral Maxillofac Surg 63:229-
237, 2005.
Post-Canthotomy management
• Serial exams with IOP
• Mannitol 20% 2g/kg IV in 30 min
• Diamox 500mgIV
• Timoptic (B-blocker) and Opidine (alpha agonist) to
decrease aqueous secretions
Common findings
• Periorbital ecchymosis
• Subconjunctival hemorrhage

• Chemosis
 Globe Injuries
• The penetrating injuries should be treated emergently, or within 12 hours,
to decrease the risk of infection or ocular content herniation.
• With suspected globe perforation, pupillary dilatation and inspection by an
ophthalmologist is mandatory
Hyphema
• Hyphema is blood in the
anterior chamber of the
eye.
 Treated with
Acetazolamide and
Cycloplegics

• Blurry vision, +IOP

Diplopia
• Monocular diplopia
 lens dislocation or opacification

• Binocular diplopia
 Restricted motility, or neuromuscular paralysis

• Visual Field
 Diplopia of extremes of gaze normal in trauma setting due to
edema or hemorrhage
Forced Duction Test
• Rules out/in entrapment of orbital muscles
 Consider with diplopia, ocular muscle dysfunction, or CT
evidence of entrapment

• Procedure
 Anesthetize with topical anesthetic (tetracaine)
 Fine Toothed Adson into inferior fornix
 Grasp insertion of Inferior Rectus
 Gently pull in all directions to evaluate muscle entrapment
Lacrimal Injuries
• Occur with direct injury to medial aspect of lid or with
strong force applied to lateral lid
 Insert lacrimal probe into puncta and explore segments of duct.

• Repair involves stringing a silicone tube through duct to

the inferior turbinate
 Allow 6-12 weeks for canal to re-epithelize.
 Epiphora
• Epiphora may be due to
impaired outflow or
hypersecretion from a
corneal abrasion, lash
ptosis, foreign bodies,
or entropion
• A dye disappearance
test, Jones I or II,
nasolacrimal irrigation,
or dacryocystography
can help one determine
the precise point of
obstruction and guide
surgical planning.
Cannulating the Duct
Nonoperative Management of
Fractures
• Decision to not operate should be based on clinical and
radiographic finding.
 F/u for 2 weeks is indicated to ensure no progression of
symptoms

• Repair of isolated orbit fractures needs to be weighed

against the risk of surgery
• All patients with orbit fractures should be
 placed on sinus precautions
 given prophylactic antibiotic coverage
Urgent Repair
• Entrapment and Oculocardiac reflex
• May present as “white eye blowout fracture”
Operative Management of
Fractures
• Contraindications:
 Hyphema
 Retinal tears
 Globe perforation
 The patient sees only with the eye on the injured side

• Indications: functional and cosmetic indications

Cosmetic/Functional Indications
• Pt presents with enophthalmos or inferior dystopia
• Normal globe position: >50% of floor involved or soft
tissue prolapse
• Persistent diplopia
• Decreased visual acuity
 Surgical Landmarks
• Generally, a subperiosteal
dissection from the inferior
lateral rims can be safely
extended for 25 mm.
• An exploration distance of 30
mm from the superior orbital rim
or anterior lacrimal crest (found
on the frontal process of the
maxilla) can be safe.
• Caveat: These are averages
• Rule of Halves: 24-12-6.
 Surgical Approaches
A. Subciliary (lower
blepharoplasty)
B. Subtarsal (lower or
mideyelid)
C. Infraorbital
(inferior orbital rim)
D. Transconjunctival
Difficult Areas
• Posterior ledge of orbital floor
 Common cause of enophthalmos

• Posterior medial bulge

 Convexity
Titanium
• Difficult to bend titanium to correct contours
Preformed Orbital Implants