Page 120 - Advanced concepts in orbital wall fractures

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Chapter 6
Tendon and ligamentous support might also be sufficient to keep the soft tissue in place3. In some studies the incidence of enophthalmos might have been higher due to differences in severity of the fractures6,15,22,32. Based on the findings of this study, there is no justification in indicating surgery based on CT imaging alone.
The multidisciplinary nature of the investigators in this study allowed the combination of available expertise from all three specialties in the development of the clinical protocol and during follow-up. This cooperation also presented challenges, mainly in terms of communication and logistics, which took effort and time. In retrospect, an aesthetic QoL questionnaire for enophthalmos could have added value to this research. This may be incorporated in future studies. The patients in this study were not randomised, because it was an observational study with a single clinical protocol. Future randomisation with different clinical protocols may very well increase the scientific strength in comparison with this study. Further studies may also need larger numbers and more centres, with concomitant logistics and cooperation. The drop-out of 17 % was substantial, but not surprising. Trauma patients treated in an acute setting are known for high losses to follow-up58. Nonsurgical treatment, absence of symptoms, and intense and time-consuming orthoptic evaluation may decrease commitment to studies in general.
We hypothesise, that as long as the musculofibrous network of the globe is relatively undamaged, orbital fractures heal spontaneously without significant motility disturbance or enophthalmos. Whether or not this supportive framework is severely damaged, appears as a function of eye motility. Change of motility therefore is an important predictor of outcome of orbital fractures.
Based on these outcomes, our recommendations in orbital wall fractures are:
1. To postpone surgery for at least 2 weeks in absence of an acute indication or early enophthalmos. It may even be worth considering a wait of 3 months, since significant improvements can still be observed during this period.