Page 103 - Advanced concepts in orbital wall fractures

Introduction
The management of blow-out fractures remains open to discussion after decades of predominantly retrospective research1-8. Some authors suggest that a defect size of >2 cm2 or >50 % of the surface measured on the computed tomography (CT) scan is considered an indication for surgery5,8-10. Unfortunately, the defect size is easily overestimated, which may potentially lead to overtreatment11. Moreover, measuring defect size based on CT scans is not the most effective way to predict enophthalmos12,13. Some authors argue that the herniated volume, the orbital volume ratio, or the location of the fracture, with or without involvement of the posterior ledge and inferomedial strut, are better predictors of enophthalmos14-16.
Diplopia and limited motility of the globe are also indications for surgery.
In most studies this is merely a subjective observation measured shortly
after trauma and not an objective, accurate, and standardised consecutive measurement performed by an orthoptist17-19. Some groups stress the
importance of quantitative evaluation of ocular motility20,21. Moreover,
further improvement of globe motility can occur weeks or even months C after trauma22. 6
The ideal timing for orbital reconstruction is not well established. Some studies show that a delay in treatment does not interfere with outcome, while other studies propose a more aggressive approach23-26. Unless there are immediate indications, such as a trapdoor phenomenon with muscle entrapment or significant globe displacement, surgery is usually delayed until initial swelling has resolved. Early surgery (<2 weeks) is sometimes proposed to prevent late enophthalmos or persistent diplopia. Several studies show that enophthalmos does not necessarily develop in all cases6,22. The rationale behind early surgery is that the fracture is more accessible, and less iatrogenic damage is caused due to absence of fibrosis and fewer adhesions in the soft orbital tissues27,28. However, there is insufficient proof that postponing surgery has adverse effects on outcome24,29-31.
Clinical perspective
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