Page 20 - Advanced concepts in orbital wall fractures

18
Chapter 1
This may make surgeons more inclined to operate, instead of ensuing a nonsurgical approach. A nonsurgical approach for most orbital wall fractures has been propagated in the past, based on the regenerative capacity of the body3.
The indications and timing of surgery are the main topics in the ongoing debate on the management of orbital wall fractures. Generally, small asymptomatic fractures do not need surgery and larger fractures with early enophthalmos do acquire an orbital reconstruction. The indications for immediate surgery are also obvious: vision-threatening trauma, retrobulbar haematoma, significant globe displacement, and a trapdoor phenomenon with muscle entrapment (‘white-eye’ orbital wall fracture and restrictive strabismus). Permanent damage to the orbital soft tissue will probably occur without intervention in these cases. The main controversy arises when confronted with large orbital wall fractures without early enophthalmos. In daily clinical practice, surgery is indicated based solely on the size (>2 cm2 or >50 %) of the fracture measured on a CT scan or in case of severe diplopia and limited motility within several days after trauma29,30. The size of the fracture does not necessarily correlate to late enophthalmos and severe diplopia could still resolve without intervention. There is no consensus concerning the ideal timing of an orbital reconstruction. The assumption is that early surgery (<2 weeks) has a better outcome and causes less iatrogenic damage31. As a consequence, there might be overtreatment of patients with early surgery that might have recovered spontaneously over time. There is also evidence of a good outcome after late orbital reconstruction32. The management of orbital wall fractures and clinical protocols should be regularly updated based on the latest scientific evidence.