Treatment of Zygomatic Arch and Lateral Orbit Fractures

Initial Assessment

The American Academy of Ophthalmology recommends a detailed sensorimotor examination to assess versions, ductions, saccades, pursuit, and alignment in multiple gaze positions 1
Vital signs must be monitored for bradycardia or heart block, which may indicate muscle entrapment causing oculocardiac reflex - a potentially life-threatening condition requiring urgent intervention 1
Forced duction and forced generation testing help distinguish restriction from paresis of extraocular muscles 1

Patients with CT evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex require immediate surgical repair 1
"White-eyed blow-out fracture" with muscle entrapment and oculocardiac reflex (particularly in children) requires immediate surgical repair 1
Globe subluxation into the maxillary sinus requires immediate surgical repair 1

Symptomatic diplopia with positive forced ductions or entrapment on CT with minimal improvement requires early surgical repair 1
Large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia require early surgical repair 1
Early enophthalmos or hypoglobus causing facial asymmetry requires early surgical repair 1

Restrictive strabismus and unresolved enophthalmos that persist after initial observation may require delayed repair 1

Minimal diplopia (not affecting primary or downgaze) may be managed with observation 1
Good ocular motility without significant enophthalmos or hypoglobus may be managed with observation 1

All life-threatening and vision-threatening conditions must be treated before addressing the strabismus 1
Serious ocular injury occurs in up to 24% of blowout fractures 1
Even with proper repair, strabismus and diplopia can persist in up to 37% of patients postoperatively 1
A short burst of oral steroids can hasten recovery and help identify strabismus that will persist despite resolution of orbital edema/hematoma 1
In cases without muscle entrapment, waiting 4-6 months after orbital trauma is advised as strabismus may resolve spontaneously 3

Occlusion, filters, Fresnel prisms, and prism glasses may provide temporary or permanent relief of diplopia in less severe cases 3