Orbital

Fractures

DR. MALIHA TAHIR

SECOND YEAR RESIDENT

1
 Topics for
Discussion
• Orbital anatomy
• Types of fractures
• Signs and
symptoms
• Management

2
 Orbital
Anatomy
• The bony orbit refers to the shell of
bone which surrounds and protects the
eye.
• The bony orbit is a pyramidal cavity with
an elliptical base presenting anteriorly
and the apex posteriorly

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 Bony
• Orbit
Seven bones form the bony
orbit
– Maxilla
– Zygoma
– Lacrimal
– Ethmoid
– Palantine
– Sphenoid
– Frontal

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 Superior Orbital
• Wall
Formed by:
– Frontal bone
– Lesser wing of sphenoid
• Functions as:
– Floor anterior fossa
• Important structures:
– Supraorbital notch which transmits
the supraorbital nerve

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 Medial Orbital
Wall
• Formed by (from anterior to
posterior):
– Maxilla
– Lacrimal bone
– Ethmoid
– Sphenoid
• Important structures:
– Lamina papyracea

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 Lamina Papyracea

• Thin segment of the medial orbital wall

• Separates the orbit from the ethmoid air
cells

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 Lateral Orbital
• Wall
Formed by:
– Zygomatic bone
– Greater wing of
sphenoid

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 Orbital
• Formed by: Floor
– Maxilla
– Palatine
• Important structures:
– Infraorbital groove
• Transverses floor from lateral to medial
• Location of infraorbital nerve which supplies
sensation to check and ipsilateral upper alveolus and
teeth

12
 Orbital
Floor
• Forms roof of maxillary sinus
• Location of more blow out fractures due to
inherent weakness of bone overlying
maxillary sinus

13
Three important apertures at
the apex of bony orbit
• Optic canal
• Superior orbital
fissure
• Inferior orbital fissure

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4
 Optic
• Contains:
Canal
– Optic nerve
– Ophthalmic artery
• In Lesser wing of
sphenoid

1
5
 Superior Orbital
•
Fissure
Separates lateral wall from roof
• Transmits the following
structures:
– Oculomotor nerve (CN III)
– Trochlear nerve (CN IV)
– Abducens nerve (CN VI)
– Ophthalmic division of trigeminal
nerve
• Lacrimal, frontal and nasociliary
Branches
– Ophthalmic vein
– Sympathetics from cavernous sinus 16
 Inferior orbital
•
Fissure
Connects to pterygopalantine fossa
• Located between floor and lateral
• wall Transmits:
– Maxillary division Trigeminal
– nerve Infra orbital Artery
– Zygomatic Nerve
– Sphenopalatine Ganglion
– Branches Ophthalmic Vein
Branches
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7
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Orbital Fissures/Canals and Their
Contents
 Distance of Vital Orbital
Structures
STRUCTURE
from
REFERENCE
Bony
MEAN DISTANCE (mm)
Landmarks
Midpoint of inferior
LANDMARK
Infraorbital foramen 24
orbital fissure
Anterior Ethmoidal Anterior Lacrimal crest 24
Foramen
Superior Orbital Fissure Zygomaticofrontal suture 35

Superior orbital Fissure Supraorbital Notch 40

Optic Canal (medial Anterior Lacrimal Crest 42

aspect)
Optic Canal (Superior Supraorbital notch 45
Aspect)

Peterson’s Principles of Oral and Maxillofacial Surgery ; 2nd Edition ; Page –

465
 Clinical
Correlation
• Superior orbital fissure syndrome
– Ptosis
– External Ophthalmoplegia ( III, IV
– &VI ) Anaesthesia of cornea
– (Nasociliary)
Ipsilateral Numbness forehead, lateral
• orbitalApex
Orbital skin
– Syndrome
– All of the
above Visual
Loss

23
Pathophysiology of Orbital
Fractures
  In the event of Trauma

 Thick Rims protect the Eyeball

 Absorb shock by Fracturing themselves

 Orbital walls (especially Medial Wall & Floor) fracture

in an isolated way

 Gets displaces Inwards or Outwards

 Called as ‘Blow-In’ or ‘Blow-Out’ fractures

 PURE Blow Out OR Blow In –
 Orbital Walls fracture in
Isolation
 IMPURE Blow Out or Blow In Fracture –
 Walls + Rim
Blow Out Fracture
 Blowout
•
Fractures
Blowout fractures now refer to fractures of the:
– Orbital floor
– Medial wall
– Lateral wall
– Superior wall
• “pure” blowout fractures – trapdoor rotation
to bone fragments involving central area of
• bone
“impure” fracture – fracture line extends to
orbital rim

28
 Physiology of Blowout
Fracture
• The bony defect is filled with soft tissue
and fat from the orbit
• Alters support mechanisms for EOM
• EOM can become entrapped
• Direct muscle damage can result

29
 Common causes of orbital
fractures
• Falling
• Aggression
• Sporting
events
• MVAs

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 Initial
• History
Evaluation
– Time and mechanism of injury
– Change in appearance of eye
– State of vision immediately after injury
• Immediate loss of vision – severe damage to retina
• Loss of light perception - vascular occlusion or optic
nerve compression
• Initial good vision – compression optic neuropathy

33
 Initial
•
Evaluation
Physical Exam
– Cranial nerve examination
• EOM
• Numbness check
– Palpation orbital rim
– Papillary function
– Visual acuity
– Fundus examine
– Ophthalmologic
evaluation

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 Visual
• Light
Acuity
perception
• Finger counting
• Visual acuity

35
 Consultatio
n

Do not hesitate to obtain an

ophthalmologic consultation

36
 Common physical
signs
• Periorbital eccyhmosis
• Impaired extraocular muscles
• Hypoesthesia in V2
distribution
• Intraorbital emphysema

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1
 Common
Symptoms
• Diplopia
• Pain with eye
movement

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 Radiographic
Evaluation
• CT scan of the orbits
• Plain films not useful due to a high rate
of false negatives and non-diagnostic
studies

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5
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 Injuries associated with blow
out fractures
• Ruptured globe
• Retroorbital
hemorrhage
• Vitreous hemorrhage
• Hyphema
• Dislocated lens
• Secondary glaucoma
• Retinal detachment
43
BLOW IN FRACTURE
 Fragmented bones of the orbital floor are
displaced into the orbit.
 Proptosis – Exopthalmous
 More commonly seen in fractures of –
orbital roof
 CLINICAL EXAMINATION
 Initial Opthalmological evaluation –
1.Periorbital Examination
2. visual acuity – SNELLEN CHART
3. ocular motility – FORCED DUCTION TEST
4.Pupillary responses ,- pupillary size, shape&
symmetry, light reactivity,
5. Visual fields – HESS CHART
6.Fundoscopic examination
- TONOMETRY – to assess Intraocular pressure
(Normal 10-20mmHg)
7. Hertel Exopthalmometer – measure
exopthalmous
Forced Duction Tes
 Prior to the performance
of a forced duction test,
t
a cotton-tipped
applicator is soaked
with topical anesthetic
drops and held against
the limbus for a few
minutes.
 Fine-toothed forceps
are then used to grasp
the conjunctiva and
Tenon’s capsule just
posterior to the limbus.
 The patient is then
asked to look in the
direction of restriction of
movement of the eye .
 Tonometer
Snellen chart
HESS
CHART
 Treatment
Options
• Nonsurgic
al
• Surgical

49
 Initial
• ABC
Management
• C-Spine
• Analgesia
• Nurse Head
• up
• Ice affected
• area
• Broad spectrum
antibiotics Steroids
No nose blowing 50
 Indications for
•
Surgery
Retrobulbar haematoma
• Diplopia
• Enophthalmos >2 mm
• Substantial soft tissue herniation
into maxillary sinus
• Displaced fracture esp if palpable
step at rim

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 Contraindications to
•
surgery
Hyphema
• Retinal detachment
• Globe perforation
• Only seeing eye
• Medically unstable
patient

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 Surgical
Approaches
• Transconjunctival
approach
• Infraorbital
• Subciliary

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 Factors to consider for
•
surgery
Site
• Location
• Severity
• What needs to be
corrected

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 Incisions
•Existing lacerations

•LowerEyelid –
• 1)Subciliary
• 2) Subtarsal
•3) Infraorbital
approaches

•Transconjuctival
Approach – Lower Eyelid
 SAGITAL SECTION THROUGH ORBIT &
GLOBE
 C- Palpebral
Conjuntiva
 IO- Inferior Oblique
muscle
 IR- Inferior Rectus
Muscle
 OO- Orbicularis
Oculi
 OS – Orbital
Septum
 P-
Periosteum/Periorbita
 Orbicularis Oris
Muscle
 Upper
 Eyelid
Innervated by–Cranial
LevatorNerve VII
Palpebral Superioris – Cranial
Nerve III

 Orbicularis Oculi -
 Orbital and
 Palpebral Portions

Palpebral Portion is divided into

fibers -
 Pretarsal Portion - in front of
the tarsus.
 Preseptal Portion - in front of
septum
 Subciliary Incision

The incision is approximately 2 mm below the eyelashes

and can be extended laterally as necessary (top dashed line). It
is made throug skin only.
 Subcutaneous dissection
through the lid margin

Subcutaneous dissection of skin,

leaving pretarsal portion of orbicularis
muscle attached to tarsus. Dissection 4-
6mm inferiorly in this plane is adequate
Use of scissors to dissect through
orbicularis oculi muscle over lateral orbital
rim to identify
periosteum.
Incision through the bridge of orbicularis
oculi muscle.
S
a
g
i
t
a
-Incision through periosteum along
anterior maxilla, 3 to 4 mm inferior
to infraorbital rim.
-Note the pretarsal muscle still
remaining on the inferior tarsus and
the orbital septum, which restricts
the orbital fat from entering the field.
- Subperiosteal dissection of anterior
maxilla and orbital floor. Note that the
periosteal elevator entering the orbit is
placed almost vertically as dissection
proceeds behind the rim.
-In the anterior region, the floor of the orbit
is at a lower level than the crest of the
rim, necessitating dissection inferiorly just
Sagital plane through orbit showing subperiosteal dissection of
the anterior maxilla and orbital floor.
 TRANSCONJUCTIVAL
APPROACH

•Fig.1 - Incision of the conjuctiva below the tarsal plate

•Fig 2 - Incision through periosteum. To facilitate this maneuver, a traction

suture is placed through the cut end of the conjunctiva to retract the tissue
and maintain the position of the corneal shield.
•Small retractors are placed so that the lower lid is retracted to the level of
the anterior surface of the infraorbital rim.
•The intervening tissue along the infraorbital rim is the periosteum. The
incision
•Sagital plane through the orbit and globe demonstrating
level and plane of incision. The conjunctiva and lower
lid retractors are incised with scissors.
SUBPERIOSTEAL DISSECTION OF THE ORBITAL FLOOR.
Note the traction suture placed through the cut end of the
conjunctiva, which assists in retracting the conjunctiva and
maintains the corneal shield in place.
 Orbital Floor Dissection
•Periorbital is elevated from the
underlying bone
•As dissection continues
posterolaterally, the inferior orbital
fissure are visualized

•The periorbital dissection along the

orbital floor proceeds posteriorly in a
twohanded technique using a
malleable ribbon retractor with a
wide rounded tip and a periosteal
elevator.

•In order to ensure a clean periosteal

dissection, the bony contours must
Surgical Exposure
 After periorbital
dissection is
performed, adequate
exposure, (proper
retraction) and
illumination of the
fractured area is
imperative.

 Malleable retractors,
spoons and special
orbital retractors
designed for the globe
•Transition between anterior mid
orbit , the orbital floor slopes
upwards giving rise to the –
posterior medial bulge & Slightly
convex bony platform
•Elevator passed transversely
along the inferior orbital fissure

•Infraorbital neurovascular bundle

can be visualized first shining
through the thin bony roof of its
canal

•Then it becomes directly visible in

the infraorbital groove
EXTENT OF DISSECTION
•Taking into account the extent of
fracture, the periorbital dissection
stops at the medial border of the
inferior orbital fissure leaving
the soft tissue invagination intact
•Laterally, the dissection is
continued to the posterior edge of
the floor to the orbital process
of the palatine bone. The suture
between the maxilla and the
palatine bone is indistinguishable
in the adult skull.
•Medially the periorbital
dissection (as shown in the
anatomic specimen) extends to
the zone over the internal orbital
buttress.
•In many cases a periorbital
dissection of the floor with
a tunnel medial to the
inferior orbital fissure will be
sufficient.
•For an EXTENDED ACCESS to
the posterior orbital floor, the
contents of the inferior orbital
fissure must be addressed and
transected to allow for this
additional access.

•The transsection is prepared with

a dissection along the inferior
portion of the lateral orbital wall in
order to create a second tunnel
alongside the vertical softtissue
•The intervening soft tissue
invagination is transected in a
stepwise fashion using
bipolar electrocautery and sharp
dissection across the fissure above
the level of
Müller’s vestigial muscle, stripping
the periorbita along the lateral
edge of the
inferior orbital fissure.

•This illustration demonstrates the

stripping of the periorbital layer
from the inferior lateral orbital wall
immediately adjacent to the inferior
orbital fissure with a sharp
elevator proceeding posteriorly.
Limit of Dissection
 Inferiorly – Upto 28-30mm.
 Laterally – Superior Orbital Fissure
 Superiorly – Orbital roof dissection is stopped at
periorbital surrounding Recurrent Meningeal
Artery – passing through bony canal within the
Sphenofrontal suture line
 Medially – Posterior extent – Posterior Ethmoidal
vessels , running in the Fronto-Ethmoidal
Suture line Anterior to Optic foramen.
•The subperiosteal dissection is
continued using a periosteal or
freer elevator in a
lateromedial direction and lifted up
and retracted by and by with the
ribbon
retractor until the entrance of the
apex is reached.
 Orbital
Implants
• Use of implants based on degree
of comminution and size of
fracture
• Various implant material used
– Autogenous bone and cartilage
– Alloplastic material
• Teflon
• Marlex
• PDS

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Reconstruction Material
 Pre-formed Orbital Implant

ADVANTAGES :
•Radiopacity
•Smooth Surface
•Minimal or no countouring necessary
DISADVANTAGE :
•Cost
 Bone Graft

Disadvantages :
•Additional Donor site needed
•Possible contour and dimensional changes due to
remodeling
•Difficult to shape according to patients anatomy
 Porous Polyethylene Sheet
(PPE)

Disadvantages :
•Not Radiopaque (Not visble on Post Operative
Radiographs
•Lack of Rigidity when very thin wafer of PPE is used.
When a more thick rigid wafer is used there is a risk
of causing dystopia
 POLYETHYLENE AND
 TITANIUM
By combining titaniumMESH
mesh
with porous polyethylene –
 Material becomes
radioopaque
 More rigid than porous
PPE.
 ADVANTAGE :
 Stability
 Contouring
 Adequate in large three wall
fractures
 Radiopacity
 No Donor Site Needed
 RESORBABLE MATERIALS
 Thermoplastic and Non
Thermoplastic Materials
 ADVANTAGES :
 Availability Handling/
 Contourability (only for
thermoplastics)
 Smooth surface and smooth
edges
 Disadvantages:
-No radiopacity
-Degradation of material with
possible contour loss Sterile
infection / inflammatory response
-Difficult to shape according to
patients anatomy (only for non-
thermoplastics)
-Less drainage from the orbit
than
COMPLICATIONS
 EARLY COMPLICATIONS :

 1. Hemorrhagic or orbital hematoma – treated by

-lateral cathotomy immediately, lateral canthal
Tendonlysis ,

Lateral canthotomy – indicated when –

- Decreased visual acuity
- Introcular pressure more than 40mmHg
- Proptosis
- Opthalmoplegia
Retrobulbar hemorrhage
- Rare, rapidly progressive
life threatening emergency
that results in accumulation
of blood in the retrobulbar
space
- Increased IOP 
stretching of the optic
nerve & blockage of ocular
perfusion

- Proptosis , marked
subconjuctival ecchymosis
& edema ,
 Symptoms seen are – pain , decreasing visual acuity,
diplopia
 Treatment includes
 iv mannitol – (used to treat raised intracranial
pressure)
 Acteazolamide – carbonic anhydrase inhibitor ;
diuresis in PCT of kidney – excretion of NA, K, Cl –
lowering BP, IOP
 Megadose Steroid Therapy – 100mg Dexa as an i.v.
bolus with 40mg 6 hourly in severe unresponsive
cases ( Anderson et al 1982)

3. Blindness
OCULOCARDIAC REFLEX/ TRIGEMINOCARDIAC/
TRIGEMINOVAGAL REFLEX –
- The oculocardiac reflex pathway begins with the
- afferent fibres of the long & short ciliary nerves that
travel with
- the opthalmic division of the trigeminal nerve to
- the gasserion ganglion via
- the sensory nucleus of the trigeminal nerve.
- In the floor of the 4th ventricle short internuncial
fibres in the reticular formation connect them with the
efferent pathway from the motor nucleus of the
vagus nerve to the depressor nerve ending in the
mucle tissue of the heart.
 CLINICAL FEATURES –
- Bradycardia
- Faintness
- Further stimulation can lead to cardiac
dysrhythmias
- Atrioventricular blocks
- Asystole

- Bradycardia has been attributed to Trigeminal

derived vagal reflex
LATE COMPLICATIONS
 Altered vision
 Diplopia
 Ectropion – lower eyelid turns outward
 Epiphora – overflow of tears onto the face –
insufficient tear film drainage from eyed in that
tears will drain down the face rather than through
nasolacrimal system
 Enopthalmous
References
 ROWE & WILLIAM’S Maxillofacial Injuries
 FONSECA -
 Peterson’s
 Textbook of Oral & Maxillofacial Surgery – R.M.
Borle