Page 134 - Advanced concepts in orbital wall fractures

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Chapter 7
In certain situations, preoperative planning and intraoperative CBCT imaging are the technological tools required for predictable orbital reconstruction. The preoperative plan can be used for the initial positioning of the implant and intraoperative imaging can serve as direct feedback. The position can be checked after the superimposition of the images and, if required, adjusted immediately. This approach has previously been investigated for zygomatic fractures, with or without an orbital floor fracture, with promising results17. Obtaining the best position of the implant in these types of fractures is often more complicated, compared to isolated orbital wall fractures, and might therefore benefit more from this workflow.
Optimisation of the treatment protocol
The principal dilemmas in the management of orbital wall fractures are indications and timing of orbital reconstruction. Based on the clinical protocol discussed in chapter 6, an attempt was made to gain more knowledge on this subject by evaluating the results of the protocol at the end of follow-up.
Improvement of diplopia and eye motility in the first weeks after the trauma is likely to be the result of recovery after contusion, oedema, and haematoma. There is an indication for surgery if there is a limited improvement, which is presumably attributable to partial entrapment of a rectus muscle or surrounding connective tissue that needs to be explored. It is difficult to predict in the early stage how the soft tissue will recuperate. Other suspected obstacles to long-term recovery are adhesions, fibrosis, and altered anatomy of the suspension system due to disruption after trauma. Bianchi et al. state that vertical incomitance, a form of strabismus related to the acquired paralytic and mechanical- restrictive factors, could predict persistent diplopia18. According to our study, both diplopia and ductions improve significantly in the first 2 weeks, with additional substantial improvement up to 3 months. The patient- reported outcomes reveal that only a few patients experience minor limitations in the daily routine at the end of follow-up. This endorses the use of a nonsurgical approach, which also prevents iatrogenic damage.