Keywords

FormalPara Learning Objectives

  • Knowledge about the anatomy, etiology, and pathophysiology of orbital fractures.

  • Recognition of a patient with an orbital fracture: the clinical presentation and symptoms.

  • The importance of the orthoptic evaluation and etiology of diplopia, ocular motility disturbance, and binocular single vision (BSV).

  • The role of CT imaging and the possibilities of advanced diagnostics in orbital fractures.

  • The controversies in clinical decision-making and management of orbital fractures.

  • The important aspects of a clinical protocol for orbital fractures.

Introduction

Orbital fractures can be challenging in many aspects. The comminution of the orbital walls can result in the herniation of both adipose and muscle tissue into the adjacent sinuses. This could also affect the periorbita and its function as a suspension system. Initially, the actual damage is difficult to assess due to swelling, contusion of muscles, and the possible presence of a hematoma. This soft tissue trauma may mask the underlying skeletal damage. The indication for orbital reconstruction can be assessed if the right diagnostics are deployed at the right time.

The treatment of orbital fractures varies considerably between specialities and countries. The scientific fundament for surgical indications is weak, as prospective studies based on a clinical protocol are scarcely available [1,2,3]. Diplopia is often an indication for orbital reconstruction without clearly defining the nature of the diplopia or motility disorder. Fracture size, another indication for surgery, is difficult to quantify and does not have a high correlation with persistent sequelae [4,5,6,7].

In many hospitals, the incidence of solitary orbital floor or medial wall fractures is relatively low, and experience of the individual surgeon is limited. The indication for surgery is partially based on expert opinion as clear guidelines are lacking. With the help of a good and clear clinical protocol, there will be more uniformity concerning the treatment. Since various anatomical and functional systems are affected after a fracture of the orbit, several disciplines (oral and maxillofacial (OMF) surgeon, ophthalmologist, orthoptist, and radiologist) are involved [8]. Each specialist is essential for their field of expertise, and this makes the management of orbital fractures a multidisciplinary matter.

Anatomy

The orbital cavity is composed of seven bones (frontal, lacrimal, ethmoid, zygomatic, maxillary, palatine, and sphenoid) that form a conical shape. The orbital floor and medial wall are relatively thin and are frequently the first to fracture. The orbital soft tissue is composed of the globe and adipose, connective, and muscle tissue. The globe receives support and protection from the adipose and connective tissue. The inferior, superior, medial, and lateral rectus muscles, together with the superior and inferior oblique muscles, move the globe [9, 10].

The connective tissue is a complex framework and can be seen as a suspension system that is important for functioning of the globe. The framework consists of septa, fascia sheets, and ligaments that contain smooth muscle cells. The ligaments support the orbit and hold the soft tissue in position [11]. An example of such a ligament is Lockwood’s ligament. This ligament can stabilise the globe in a vertical position and provide support to the inferior rectus and oblique muscles. Other structures such as the lacrimal system are also important but are usually not affected by an orbital fracture.

Etiology and Pathophysiology

The etiology of orbital fractures is determined by geographic and socioeconomic aspects [12]. The leading causes are interpersonal violence, traffic accidents, and sports. In the younger population, the fractures are mainly caused by interpersonal violence and sports. In the older age groups, they are primarily caused by traffic accidents and falls.

There are two biomechanical models that explain the occurrence of an orbital fracture: the hydraulic and the buckling theory [13, 14]. In the hydraulic theory, the force is directed to the soft tissue of the orbital cavity, increasing the infraorbital pressure. The increased pressure causes the weakest part of the orbital cavity to fracture. The soft tissue is actually pushed through the orbital floor or medial wall. In the buckling theory, the force is directed towards the bone. The strong infraorbital rim does not necessarily fracture, but it transfers the energy to the posterior thin orbital floor, resulting in a fracture. The cause of the fracture may be a combination of both biomechanical principles in most cases.

A distinction must be made between blow-out and trapdoor fractures.

Trapdoor fractures are relatively rare. A part of the orbital content is trapped between the fractured orbital wall in these fractures (Fig. 9.1). This can both be muscle (seldom) or orbital fat with its many septa. Trapdoor fractures occur when the orbital wall is resilient, as is usually the case in children. The pressure wave fractures the bone and the orbital soft tissue bulges into the adjacent sinus. After the pressure drops, the elastic bone bounces back trapping the soft tissue [15]. If an ocular muscle is trapped, there is an indication for immediate surgical intervention, and, in most cases, it is sufficient to free the entrapped tissue. In children, fibrosis and necrosis of the rectus muscles can occur quickly. Entrapment of periorbital tissue can also trigger an oculocardiac reflex in addition to pain.

Fig. 9.1
2 representations of the trapdoor fracture in the left eye. A is the lateral view diagram that highlights a fracture at the center of the orbital floor. B is a coronal view C T scan that highlights the extrusion of the orbital fat outside the anatomical bed of the orbital floor.

(a) Trapdoor fracture; (b) CT scan coronal view left orbital floor trapdoor fracture; (c) clinical example limited elevation right globe

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The majority of the orbital fractures are blow-out fractures (Fig. 9.2). The increased orbital pressure results in the shattering of one or more orbital walls. The loss of support from the vulnerable floor or medial wall increases orbital volume and can result in protrusion of orbital content into the adjacent sinuses. This can cause displacement of the globe (vertical = hypoglobus; horizontal = enophthalmos) and could result in a disturbed ocular motility. Traditionally, a distinction between pure and impure blow-out fractures has been made in the literature. An impure blow-out fracture is caused by concomitant injury of the surrounding bony structures, e.g., the zygomatic complex (ZMC), naso-orbital-ethmoid (NOE) complex or maxillary (Le Fort II/III) fractures. In these combined injuries, the incidence of enophthalmos and hypoglobus is higher through the involvement of an additional orbital wall (lateral wall in the case of ZMC fractures) or loss of anterior globe support due to dislocation of the infraorbital rim (Fig. 9.3). A sudden change in the vertical or horizontal position of the globe will result in diplopia in most cases. Although this is a logical consequence, the oculomotor function and degree of diplopia cannot always be directly correlated to the severity of the injury. This adds an extra dimension to the complexity in clinical decision-making, as the direct damage to the periorbital soft tissue caused by the trauma is difficult to assess directly after the trauma [16].

Fig. 9.2
3-part image. A is a lateral view diagram that highlights the complete breakage of the orbital floor. B is a coronal view C T scan of the skull that highlights the displacement of the orbital globe downwards due to the fracture. C is a photograph of a male patient with the head tilted backward.

(a) Blow-out fracture; (b) CT scan coronal view left orbital blow-out fracture; (c) clinical example enophthalmos left globe

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Fig. 9.3
2-part image. A is a lateral view diagram that highlights the displacement of the orbital globe downwards and a complete fracture of the orbital floor. B has a photograph, a lateral view of the 3-D structure of the skull, and 3 C T scans that highlight the hypoglobus.

(a) Hypoglobus; (b) clinical example and CT scan

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Clinical Presentation

Orbital fractures can be the result of relatively low-impact blunt trauma or a high-energy trauma (HET). Presentation and workup can be different in both categories of trauma patients. The first category will present itself at the general practitioner or the emergency department and the second category in the shock room. Patients brought in after a HET may be unconscious and intubated, making clinical examination more difficult. However, these patients routinely receive a whole-body CT scan, which helps to establish the diagnosis. In these severely injured patients, the risk of vision-threatening emergencies rises. These compromising injuries, e.g., a retrobulbar hematoma, globe perforations or oculocardiac reflex, will be discussed in Chap. 13.

Diagnosing an orbital fracture without imaging can be challenging, as the clinical presentation varies considerably. However, a numb upper lip is highly suspicious for a trauma of the ipsilateral inferior orbital nerve as a consequence of an orbital floor fracture. In addition to the diplopia, motility disturbance, enophthalmos, and hypoglobus, as mentioned earlier, other clinical symptoms are disturbed vision, pain, hyposphagma, periorbital swelling, hematoma, ecchymosis, and infraorbital nerve paresthesia. During inspection and palpation, an asymmetrical osseous projection may be caused by a zygomatic or Le Fort II/III fracture. The pupil reflex should be tested with a penlight exam together with a global assessment of vision, eye motility, and diplopia. Attention should also be paid to signs of retrobulbar hematoma such as proptosis, tense tissue, and severe pain [17]. Enophthalmos can be objectified by clinical examination in bird or submental view or with the help of Hertel exophthalmometer (Fig. 9.4) [18]. Swelling and potential concomitant facial fractures complicate the quantification of enophthalmos. The globe is less visible with swelling of the eyelids and the surrounding tissue. This creates an optical illusion that gives the appearance of an enophthalmos. A Naugle exophthalmometer is an alternative for the Hertel exophthalmometer in case of concomitant injuries.

Fig. 9.4
A photograph illustrates the measurement of the axial position of the eyes using the exophthalmometer.

Hertel exophthalmometer in use

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A multidisciplinary approach is vital in the good clinical management of orbital wall fractures. In general, the OMF surgeon is involved in all patients with facial injuries. During office hours, referral to an orthoptist is recommended to quantify the amount of diplopia and motility disturbance. If required, an ophthalmologist should be consulted for a more extensive assessment of the globe (vision, globe pressure, etc.). Outside office hours, it is advisable to have the ophthalmologist assess the trauma and send the patient to the orthoptist the next working day.

Orthoptic Examination

The orthoptic examination is perhaps the most essential guide in clinical decision-making in orbital fractures. Diplopia and motility disturbance are objectively measured and analysed. Using a motility perimeter, the ductions and the field of binocular single vision (BSV) can be measured (Fig. 9.5) [19]. Average maximum ductions are 40° elevation, 60° depression, and 50° abduction and adduction. With a Hess screen test, it is also possible to measure the deviation and the amount of overaction and underaction of the extraocular muscles. The measurements performed at the first presentation serve as a baseline and possible improvement may be assessed over time. If the values improve significantly in the first 2 weeks after the trauma, the restrictions were probably due to swelling or contusion. If the restrictions persist, an orbital reconstruction may be necessary. A poor BSV at first presentation correlates with persistent sequelae and incomplete recovery. This will be discussed in more detail later in the clinical protocol The orthoptic examination is perhaps the most essential guide in clinical decision-making in orbital fractures. Diplopia and motility disturbance are objectively measured and analysed. Using a motility perimeter, the ductions and the field of binocular single vision (BSV) can be measured (Fig. 9.5) [19]. Average maximum ductions are 40° elevation, 60° depression, and 50° abduction and adduction. With a Hess screen test, it is also possible to measure the deviation and the amount of overaction and underaction of the extraocular muscles. The measurements performed at the first presentation serve as a baseline and possible improvement may be assessed over time. If the values improve significantly in the first 2 weeks after the trauma, the restrictions were probably due to swelling or contusion. If the restrictions persist, an orbital reconstruction may be necessary. A poor BSV at first presentation correlates with persistent sequelae and incomplete recovery. This will be discussed in more detail later in the clinical protocol subsection. The orthoptic examination requires a certain degree of mobility and cooperation that is not always present in trauma patients. Detailed information about the orthoptic examination can be found in Chap. 6.

Fig. 9.5
A photograph on the left depicts the set-up for the binocular exam. The diagram at the right highlights the binocular single vision field test as per the eye movements.

(a) Motility perimeter; (b) binocular single vision (BSV) score chart

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Imaging

In case of an orbital fracture, it is advisable to perform a CT scan (orbital series or complete skull if more facial injuries are suspected 1-millimetre (mm) slices). The size and location of the orbital floor fracture can be best examined in coronal and sagittal view and the medial wall in axial view. Possible entrapment or impingement of soft tissue, a retrobulbar hematoma, emphysema, or stretching of the optic nerve can be observed in soft tissue setting (Fig. 9.6). Based on a CT scan, advanced diagnostics can be performed, a surgical plan can be created, and the scan, can be used during computer-assisted surgery. For these reasons, it is crucial to think ahead about using the proper scan protocol. A Cone Beam CT (CBCT) scan is less appropriate when assessing an orbital fracture. Nevertheless, an intraoperative CBCT scan is ideal for evaluating the orbital implant location in real-time. The clinical decision-making for orbital wall fractures is conducted based on clinical characteristics, both subjective and objective measurements, and CT imaging. In addition to conventional diagnostics, it is also possible to use advanced diagnostics based on a CT scan.

Fig. 9.6
4 C T scans of the skull reveal the orbital fracture. A, B, and D are the coronal views, and C is the axial view.

Soft tissue setting of CT scan with (a) swelling; (b) hematoma formation of the extra ocular muscles; (c) emphysema axial view; (d) emphysema coronal view

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Advanced Diagnostics

Advanced diagnostics can be used to support clinical decision-making. The aim of advanced diagnostics is to extract as much information as possible from the DICOM data and add information if necessary. The CT scan may be viewed as a virtual representation of the patient, subdivided into voxels (three-dimensional pixels). Each voxel has a particular grayscale value corresponding to the X-ray absorption within the voxel’s volume. Image viewers allow assessment of the image data in the multiplanar view (two-dimensional axial, coronal, and sagittal slices). Visual comparison between affected and unaffected orbit is feasible, but more sophisticated analysis options only become available if specialised software that allows image manipulation is used (e.g., iPlan Cranial (Brainlab AG, Munich, Germany)).

The workhorse for advanced diagnostics is the segmentation: partitioning the image data in voxels that belong to the same anatomical structure [20]. The easiest segmentation method is thresholding. The user chooses a cut-off HU value; voxels above the threshold are included in the selection, and voxels below are excluded. The selection of bony structures within the image data is an example of thresholding. The orbital walls are more difficult to annotate in the image data: the thin bony structures are frequently not completely included in thresholding operations. More sophisticated segmentation approaches are required to fill the gap. Atlas-based segmentation is an example of a segmentation method that can provide an accurate segmentation of the orbit and orbital contents [21,22,23]. Since segmentation occupies a central position in advanced diagnostics (and subsequent virtual surgical planning), continuous research on even more effective segmentation strategies with minimal user input is performed. Artificial intelligence (AI) is a promising technique that meets these desires and may become available soon.

The segmentation itself is a clarification of the image data, but it does not add new information. The information in the patient model can be expanded by creating a 3D model from the voxel selection; these models can subsequently be manipulated. In unilateral orbital fractures, the unaffected orbit’s segmented model may be mirrored (Fig. 9.7) and overlaid on the affected orbit in the multiplanar views. The mirrored model now provides a blueprint for the pretraumatised anatomy of the affected side [21, 24,25,26]. Comparison between affected and unaffected orbit is much more straightforward than side-to-side visualisation and not affected by angulation of the slice (Fig. 9.8). A more thorough insight into the fracture’s location and extent is obtained. A separate segmentation of the orbital contents could quantify the increase of intraorbital volume due to the trauma. Attaching segmentations of surrounding structures to the orbital segmentation model is another manipulation possibility (Fig. 9.9). In the example of a zygomatic complex fracture, the combined model of the orbit, and zygoma provides additional information on displacement of the zygoma (Fig. 9.10). This additional information could affect surgical indication and treatment of the orbit.

Fig. 9.7
3 3-D model structures of the skull. The leftmost model does not highlight any part of the skull, the center model highlights the left eye, and the rightmost highlights both eyes with some color.

Segmentation and mirroring of the orbit

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Fig. 9.8
3 C T scan of the pre-traumatized skull. The leftmost is an axial view, the center is a coronal view, and the rightmost is a sagittal view scan. These scans highlight the position of the orbital globe and orbital walls.

Mirrored orbit visualised in multiplanar views

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Fig. 9.9
3 3-D models of the skull of the patient. In the first 2 models, the left eye pocket is highlighted, and in the third model, both eye pockets are highlighted.

Combining the segmented models of the orbit and surrounding bony structures before mirroring

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Fig. 9.10
3 C T scans of the skull. The leftmost is the axial view, the center is the coronal view, and the rightmost is the sagittal view. The scans highlight the irregular orbital floor bone under the left eye.

Mirrored orbit + bone model in multiplanar views

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The most considerable benefits of advanced diagnostics are improved visualisation of the problem and enhanced analysis methods for objective quantification. With advanced diagnostics, the surgeon can be sure that the treatment decision is supported by all the information present in the image data. If surgery is indicated, advanced diagnostics are the precursors of virtual surgical planning in the computer-assisted surgery workflow. Much information gathered in the advanced diagnostics can be reused in the virtual surgical planning process. The mirrored orbit provides the target anatomy, which is helpful in positioning a virtual implant. Surface models of the orbit, orbital contents, and bony anatomy surrounding the orbit serve as the input for the design of a patient-specific implant. In contrast, the mirrored model of the zygomatic bone already acts as the planning for repositioning of the zygomatic bone. A detailed description of the virtual surgical planning process is provided in Chap. 10.

Clinical Decision-Making

Several specialities are involved in the treatment of orbital fractures, including OMF surgery, ophthalmology and, less so, plastic surgery and ear, nose, and throat surgery. In recent decades, there has been a clear trend in the management of orbital fractures, alternating between conservative and surgical treatment preferences. The development of new treatment modalities and types of implants has led to an increase in surgical treatment in the past [27, 28]. Nevertheless, the body’s regenerative capacity seems to be significant in orbital fractures, so that surgery is often not required [6].

One of the main topics in the ongoing debate on the management of orbital fractures is the indication for surgery. Most surgeons are apt to repair and reconstruct traumatic injuries of the bony orbit. Evidently, there are some clear and immediate indications for surgery, such as vision-threatening emergencies, significant globe displacement (globe in maxillary sinus), pediatric trapdoor fractures, trapdoor fractures with clear muscle entrapment, or a persistent oculocardiac reflex. Permanent damage to the orbital soft tissue will probably occur without early intervention in these cases. Other indications for orbital reconstruction are all relative [29]. For most clinicians, it is clear that small asymptomatic orbital wall fractures do not need surgery and larger fractures with early enophthalmos do require an orbital reconstruction. In either case, the lack or presence of clinical symptoms (diplopia or enophthalmos) determine the indication for surgery. True controversy arises in large orbital wall defects without early enophthalmos. Some clinicians will perform surgery to anticipate on expected enophthalmos, although it is uncertain if this will occur. It is the other way around with regard to diplopia, which can resolve spontaneously after the swelling disappears. As there are no clear predictors for enophthalmos or cut-off points for the recovery of diplopia, this discussion will continue. For most surgeons, there is an indication for surgery if the defect size is large (>2 cm2 or >50% of surface measured on a CT scan) or if diplopia is severe or persistent [3, 30]. Interestingly, the size of the fracture does not necessarily correlate to late enophthalmos and the persistence of diplopia (Fig. 9.11). The literature also demonstrates that it is difficult to measure or estimate the defect size, so it seems illogical to base the indication for surgery on the CT scan. Treatment choices can be made more effectively based on clinical symptoms that are present at the time, not what is expected based on the size of the fracture.

Fig. 9.11
3-part image. A consists of 3 C T scans that highlight the eye sinking in the eye socket. B and C are photographs of the patient's head tilted backward, highlighting the bruise around the eye in early enophthalmos and the recovered eye, respectively.

(a) Large comminuted fracture without (b) early enophthalmos and (c) no late enophthalmos or persistent diplopia 6 months after nonsurgical treatment

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The aforementioned considerations are even more complex with diplopia, as there is a great variability in the extent and cause of diplopia and motility restrictions. These are not only caused by entrapment of the inferior rectus muscle or surrounding soft tissue, but also by muscle edema, hemorrhage, and motor nerve palsy. These are conditions that cannot be treated with an orbital reconstruction. In time, some of these deficits may resolve spontaneously. Edema will resolve within several days to weeks, but hemorrhage, fibrosis, and motor nerve palsy can take up to 12 months to recover. The dilemma in clinical decision-making occurs when enophthalmos is minimal or absent, motility has improved, but significant diplopia persists. Diplopia is too complex and multifactorial to rely on subjective observations shortly after trauma. For that reason, multiple studies stress the importance of quantitative evaluation of ocular motility and diplopia [6, 7]. Quantification by a Hess screen test or interpretation of ductions and the field assessment of binocular single vision (BSV) can be extremely helpful in decision-making. Using these measurements, the improvement of ocular motility and diplopia can be objectified over weeks or even months after trauma. In severe diplopia (BSV <60), orbital reconstruction has a significant effect on the outcome [7].

The effect of surgery on the amount of diplopia appears to be limited in mild diplopia (BSV 60–80). In limited diplopia (BSV >80), orbital reconstruction may even worsen the clinical outcome. This stresses the relevance of standard orthoptic evaluation in the workup and decision-making process.

Another critical factor in the decision-making process is the potential adverse effect of delay if the watchful waiting strategy is used. On the one hand, there will be no overtreatment as the diplopia can recover spontaneously over time. On the other hand, there is an assumption that early surgery (<2 weeks) has a better outcome and causes less iatrogenic damage. Nonetheless, there is no solid evidence that delayed surgery has a worse outcome than early intervention [2]. Taking the time for evaluation is, for that reason, recommended in all relative indications.

Clinical Protocol

The clinical protocol presented and suggested here was developed at the Amsterdam UMC [6]. The protocol was part of the Advanced Concept on Orbital Reconstruction (ACOR) research program and had an extensive scientific fundament [27]. The protocol gives the clinician tools for clinical decision-making and contains a flow chart in which nonsurgical and surgical patients are monitored. At each visit, the decision can be made to opt for surgical intervention based on various indications (Table 9.1).

Table 9.1 Indications for orbital reconstruction
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The emphasis of this protocol is on nonsurgical treatment. The decision for surgery is primarily based on clinical observations and orthoptic measurements and not solely on the size or location of the fracture. The initial clinical presentation can vary widely. Patients with a large fracture may have relatively few symptoms, while a small fracture may cause severe diplopia. As mentioned before, this often does not predict the extent to which the diplopia and restricted ocular motility will recover spontaneously. Frequently, considerable improvement can be observed within 2 weeks of trauma.

First Presentation

The clinical examination should focus on the various symptoms that may indicate an orbital fracture. Objective and standardised measurements are needed to assess the patient properly. If there is a high suspicion of an orbital fracture, a CT scan should be ordered to confirm the diagnosis and determine the severity.

As mentioned before, immediate intervention is necessary in vision-threatening situations. In a trapdoor fracture with oculocardiac reflex or significant globe dislocation (Fig. 9.12), urgent intervention (<24 h) is also required to prevent permanent damage. An orthoptic examination is highly recommended if there is no acute indication for intervention and diplopia or limited motility is present. If the clinical and orthoptic examination show that there is no early enophthalmos (>2 mm) or an absolute elevation (<15°) or abduction limitation (<25°), nonsurgical treatment with a check-up after 10–14 days can be considered. If early enophthalmos or severe ocular motility restrictions are present, there is an indication for orbital reconstruction within 2 weeks. The expectation is that there is entrapment of the muscles and the connective tissue around the muscles, which will not recover without release.

Fig. 9.12
4-part image. A. A photo displays an orbital globe pushed outward from the eye socket. B. A sagittal view C T scan of the skull displays the dislocation of the orbital globe. C. A photo of the abnormal left eye alignment. D. A sagittal view C T scan marks the location of the orbital globe backward.

Significant globe dislocations (a) clinical example; (b) CT scan sagittal view of clinical example; (c) clinical example; (d) CT scan sagittal view of clinical example

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Photographs taken at the time of initial presentation and subsequent visits can provide the practitioner and the patient with an insight into the recovery and the possible occurrence of cosmetic sequelae/complications, such as scarring or entropion after orbital reconstruction.

Immediately after the trauma, patients are advised to improve the ocular motility and train the ocular muscles by alternately closing one eye several times a day and looking as far as possible in all directions. In this way, the muscles do not slack and work on recovery, the pumping function of the muscles can reduce edema, and possibly fibrosis and adhesions are reduced.

Nonsurgical Follow-up After 2 Weeks

The second visit is meant to evaluate the improvement of motility disturbance and diplopia. If there is insufficient improvement (<8°) of the most limited affected duction or if severe diplopia (BSV < 60) is persistent, there is a strong indication for surgery. In these patients, an intervention is scheduled within 1 week. If it was not possible to perform an orthoptic examination in the first week after trauma, e.g., due to swelling or a noncooperative patient, the same values are used as described earlier (<15° elevation and <25° abduction).

After 2 weeks, it may be expected that most of the swelling has subsided. Conservative treatment can be continued if there is no clear enophthalmos (>2 mm). In these fractures, the periorbita has probably enough resistance to support the soft tissue content of the orbit sufficiently.

Nonsurgical Late Follow-up

If there is no clear indication for surgery, the next visit is scheduled 3 months after trauma and, if indicated, up to 12 months. Incidentally, late enophthalmos may occur, but this is usually within 3 months. If this is considered troublesome by the patient, it is an indication for a secondary reconstruction after the primary nonsurgical treatment failed. If there is persistent mild diplopia (BSV 60–80), surgical intervention can be considered. Diplopia, especially in downward gaze, can be highly disabling. The chance of full recovery is smaller if diplopia is severe (BSV < 60) at first presentation or has been present for a long time.

Follow-up After Orbital Reconstruction

After orbital reconstruction, additional visits are scheduled 1 and 3 weeks after surgery to assess the clinical recovery and, if necessary, manage potential complications after surgery. Due to swelling, ocular motility can still be restricted the first weeks after surgery. An orthoptic examination is scheduled 6 weeks after surgery for that reason. Further visits are similar to the nonsurgical case.

Tables 9.2 and 9.3 indicate which measurements are required for each visit. If the ductions have fully recovered at the 3-month check-up, further orthoptic examinations is performed only on indication. Likewise, the CT scan after 6 months is also only on indication. Often, patients without complaints will not come for a check-up after 3 months, but it is instructive to follow-up patients with complaints for a long time.

Table 9.2 Nonsurgical treatment follow-up
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Table 9.3 Surgical treatment follow-up
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To monitor the results of this protocol, we performed a two-center multidisciplinary prospective cohort study [6]. Fifty-eight patients completed the 3, 6, and/or 12 month follow-up. We assessed a full recovery without diplopia or enophthalmos (e.g., >2 mm) in 45 out of these 58 (78%) patients. The other 13 patients had limited diplopia, mainly in extreme upward gaze. Five of those 13 patients did not experience impairment of diplopia in daily life. No patients developed late enophthalmos.

We concluded that a high percentage of patients with orbital floor and/or medial wall fracture recovered spontaneously without lasting diplopia or disfiguring enophthalmos.

Conclusion

Despite the fact that nowadays, we treat orbital fractures in a multidisciplinary setting and know a lot about the anatomy and pathophysiology, it remains difficult to predict the outcome in part of the orbital fractures. By using the appropriate diagnostics at the first presentation, a proper assessment can be made whether there is an indication for surgery. Orthoptic measurements play a crucial role in this. After vision-threatening emergencies have been excluded, the advantages and disadvantages of surgery should be considered. In addition to enophthalmos, persistent diplopia is a sequala of orbital fractures. By performing subjective measurements and comparing them over time, an assessment can be made of the likelihood of full recovery or the necessity for surgery. The described protocol is a tool for future research and further implementation of clinical decision-making in the general clinic.