Treatment of Orbital Wall Fractures

Initial Assessment and Life-Threatening Conditions

The American Academy of Ophthalmology recommends treating life-threatening and vision-threatening conditions first, as serious ocular injury occurs in 24% of blowout fractures and complete vision loss occurs in 5.5% of one eye and 0.8% of both eyes in facial fracture patients 1, 2
Monitor vital signs carefully for bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness, which indicate an entrapped muscle causing oculocardiac reflex, requiring urgent medical and surgical intervention 1, 2
Obtain CT imaging rather than MRI if any concern exists about ferrous-metallic foreign body, as CT provides sufficient information about fracture presence and entrapment 1, 2

Proceed to immediate surgical repair for CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1
Schedule surgical repair within 2 weeks for symptomatic diplopia with positive forced ductions or CT evidence of entrapment, significant fat or periorbital tissue entrapment, large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia 1, 3
Consider delayed repair for restrictive strabismus that persists beyond 4-6 months, and unresolved enophthalmos after observation period 1, 3
Observe without surgery for minimal diplopia, good ocular motility without significant enophthalmos or hypoglobus 1, 3

Wait 4-6 months after orbital trauma before considering strabismus surgery, as many cases resolve spontaneously, unless substantial fat and orbital pulley entrapment is present 1, 3, 4
A short burst of oral steroids can hasten recovery and reveal persistent strabismus that will remain after orbital edema/hematoma resolution 1, 3
Conservative treatments during the observation period include occlusion for diplopia management, Fresnel prisms for temporary relief, prism glasses for temporary or permanent diplopia relief, and botulinum toxin injection in select cases 3, 4

Even with proper surgical repair, diplopia persists in 37% of patients postoperatively, so set realistic expectations with patients 1, 3
Perform forced duction and forced generation testing to distinguish restriction from paresis, critical for surgical planning 1, 2
Fat entrapment can be nearly as challenging as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection around the involved muscle 3, 4
For patients requiring delayed strabismus surgery after fracture repair, wait until alignment is stable and use adjustable sutures when possible, as complete elimination of diplopia may not be achievable due to multifactorial etiology 3, 4