Page 135 - Advanced concepts in orbital wall fractures

General discussion and future perspectives
There is conflicting evidence on the correlation between volume increase or the size of the fracture and the occurrence of enophthalmos8,19,20. Early enophthalmos is an indication for surgery and is caused by an increase in orbital volume due to a large fracture, presumably in combination with severe damage to the connective tissue (fascia sheaths, ligaments, and periorbita). Other aspects, such as fibrosis, adhesions, and posttraumatic and iatrogenic fat atrophy, might contribute more to late enophthalmos21. No significant increase of more than 2 mm enophthalmos was observed in the nonsurgical group, despite the presence of several large (>2 cm2) fractures. Late enophthalmos did not develop in both the nonsurgical and surgical groups. The hypothesis is that in large fractures without late enophthalmos, the suspension system (described by professor L. Koornneef22), is still intact and can maintain the globe approximately in the position before the trauma. As a result, fat atrophy will neither have a substantial effect on the position. The study by Young et al. supports this hypothesis23. A decrease in fracture size and orbital herniation volume after nonsurgical treatment of orbital wall fractures is observed in that study. This demonstrates the outstanding regenerative capacity of the orbital soft tissues. Merely the size of the fracture (>50 % of the surface area or >2 cm2) is not a good indication for surgery and orbital reconstruction should not be performed in anticipation of possible late enophthalmos. Indications for surgery should be based on existing rather than expected problems.
A recent systematic review by Jazayeri et al., covering all available literature C7 on timing of surgery, illustrates that the available research is limited and of
very low quality24. Although they conclude that treatment within 2 weeks
results in better outcomes, there is no solid evidence to substantiate the
need for early surgery. The studies had a high degree of heterogeneity. The patient characteristics, the size of the fracture, the indications for orbital reconstruction, and the rationale behind late surgery were not well defined. It is feasible that in the studies that carried out an early intervention, there was no clear indication for surgery. The favourable results are attributed to the early intervention, while these patients may have been able to cure spontaneously with a nonsurgical treatment. Patients who underwent late surgery, have already demonstrated that
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