Orbital Trauma Management

ORBITALTRAUMA
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Introduction :
Anatomical region of clinical and surgical interest
“Cross roads” , signposts - complex
injuries needs additional expertise
Often underestimated and undertreated
Interesting & difficult areas in facial trauma


Orbit :
 Bony vault houses eyeball
 Quadrangular based pyramid
 Average volume - 30cc,globe - 7cc (1/4)
 Growth completed by 83% by 5yrs
 Seven bones form orbit


Orbital injuries :
 Alone or associated with others
 Low impact force - floor,NOE
 High impact force - roof,supraorbital rim
 Complicated by their proximity


Principles of ATLS :
 Airway
 Breathing
 Circulation
 Disability management & drainage
 Exposure & examine

Examination :
 Inspect ocular damage
 Lacerations - eyelid,lacrimal,cornea
 Oedema & circumorbital ecchymosis
 Subconjunctival - “Flame shaped”
 Bright red ecchymosis - Oxygen diffusion


Cont :
 Posterior limit defined

- conjunctival

 Posterior limit ill-defined - orbital wall #
 Medial wall - ecchymosis over sclera
 Fundus inspected with opthalmoscope
 Pupillary and occular levels on both
sides

Scoring system - BADACT :
 Blow out
 Acuity
 Diplopia
 Amnesia
 Comminuted Trauma

Pupils :
 Effort made to record size
 Reaction to illumination
 Swollen lids difficult to perform
 Fixed dilated pupils - occulomotor


Light reflex :


Surgical anatomy : Lateral wall
 By zygoma & greater wing sphenoid
 Inclined 45* - orbital apex,90*- each other
 FZ suture - line of relative weakness
 Orbital tubercle - 1cm below FZ suture


Medial wall :
 By very thin plate of ethmoid
 Anterior & posterior ethmoidal foramen
 Weakened by nasolacrimal apparatus
 Splaying apart
1. Walls
- Traumatic hypertelorism
2. Ligament - Traumatic telecanthus


Roof :
 Reinforced by greater wing of sphenoid
 Mainly of frontal bone - anterior cranial fossa
 Rim thick becomes thin posterior from edge
 Elderly - roof resorbed in selected areas
 Dura confluent with peri orbita - careful dissection


Floor :
 Orbital portion of maxilla & zygoma
 Posteriorly by small piece of palatine bone
 Triangular -“Guitar plectrum”
 Inferior orbital groove - 2.5cm from rim
 Inferior orbital canal - 5mm below rim
 Thin 0.5mm, weakest portion medial to groove

Cont :
 Not horizontal slopes upwards & medially 45*
ascends posteriorly at 30*
 Weakened by presence of groove
 Blow-out fracture occur medial to it
 Sagging of contents into maxillary sinus


Orbital rims :
 Supero lateral & inferior - thicker
 Part posterior to it and medial - thinner
 Floor & medial - common site #
 Inward displacement - increased intraocular pressure herniation
 Paranasal & ethmoidal sinuses - air bags
 Globe perforation - uncommon

Inferior orbital rim :
 Unable to withstand force
 Depression - origin of inferior oblique
 # often leads to diplopia
 Greatest diameter lies within and not at
periphery
 Direction of instrument changed - periosteal
elevation

Soft tissues : Eyelids
 Skin is thin - very lax areolar tissue
 Careless dissection -“Button-holing”
 Rich arterial & venous supply
 Trauma - circum orbital ecchymosis,”black eye”
 Delayed onset - # roof or anterior cranial fossa


Nerve injury :
 Anastomosis between sensory & motor
 Opening principally by levator
 Innervation - occulomotor - ptosis
 Closing principally by orbicularis oris
 Innervater by facial - lower eyelid drooping


Orbicularis oculi :
 3 parts
 Orbital ,palpebral , lacrimal
 Lateral eyebrow incision - parallel to palpebral
 In line of hair follicles,long axis of eyebrow
 Crows feet wrinkles - skin right angle to fibres
 FZ suture 1cm above outer canthus

Levator palpebrae superioris :
 From under surface of lesser wing
 Divides into 2 lamella
 Upper attached to tarsal plate & skin of eyelid
 Lower attached to upper margin of tarsal plate
 Mullers muscle - nonstriated,sympathetic
 Trauma - Ptosis,pseudo-enopthalmos,miosis

Orbital septum :
 Skeletal framework of eyelids
 Membraneous sheet attached to lacrimal crest
& orbital rims
 Thickened to form upper & lower tarsal plates
 Inferomedial aspect - incomplete - air escape to
preseptal space - periorbital swelling


Palpebral ligaments :
 By fibrous extensions of tarsal plates
 Lateral canthus - Y shaped
Superficial bundle - frontal process of zygoma
Deep bundle
- whitnalls tubercle
 Medial canthus - Y shaped
Anterior fibres - frontal process of maxilla
Posterior fibres - lacrimal fossa
 Maintain level & shape of orbiral fissure

Cont :
 Small muscle from inferior orbital rim to
posterior limb against lacrimal sac
 Enables lower eyelid movement - empty sac
 Transconjunctival incision - avoid damage
 Trauma - FZ suture - antimongoloid slant
 Medial aspect - traumatic telecanthus

Medial canthoplasty :


Tenons capsule :
 Applied like bursa to eyeball
 Thickened both sides - check ligaments
“Suspensory ligament of lockhood” - inferior bulbi
 Determinant of globe position - vertical
 Other determinants - intact walls, fat ,muscles


Periorbital fat :
 Cushion against which eye rotates
 Balance of fat with others - AP position of globe
 Many fibrous septa
 Blow out # - mechanical entrapement
 Interference with free rotation


Extraocular muscles :
 4 recti - “annulus of zinn” at back of orbit
 Superior oblique - lesser wing of sphenoid
 Inferior oblique - inferior orbital floor
 Medial & lateral recti - only horizontal movements
 Superior & inferior recti - complex combinations


Cont :


Optic nerve :
 Extension of brain - bathed with CSF
 Considerable mobility within orbit - escape trauma
 Dural sheath fused with canal - by Hotte
 Optic portion of optic - 3cm long
 Anterior 2/3 - central artery retina
posterior 1/3 - opthalmic artery


Blood vessels :
 Retina - central artery of retina
 Multiple posterior short ciliary branches encircle
optic nerve
 Enter choroid forming capillary plexus
 Congestion - secondary effect on retina
 Superior & inferior opthalmic vens - cavernous

Assessment :
 Opthalmic assessment
 Orthoptic test
 Plain radiographs
 Ultrasound
 Sinuscopy
 CT , MRI , Stereolithic models

Plain radiographs :
 OM view - 10 , 30
 Optic foramen - beam upwards & medially from PA
 Waters view - roof & floor
 Comparison of symmetry


Ultrasound :
 Occasionally used
 Orbital floor & medial wall
 Disruption of lens & inner surface of globe
 Opthalmic artery & vein investigated - contrast
 Retinal blood flow - fluoroscopic means


CT :
 Gold standard , investigation of choice
 Both soft tissues & orbital wall
 Volume assessment - biplanar CT - enopthalmos
 3-5mm sections in both planes - walls
 1.5mm axial cuts - optic canal #


Spiral 3D CT :
 More accurate
 Lacks definition - thin bones
 Stereolithic models very useful
 CT navigation device - reconstruction
 Amount & position of graft


MRI :
 Soft tissue injury & entrapment
 Radiolucent foreign body - wood
 Unresolving orbital emphysema
 Potential for displacement of metallic objects


Colour doppler :
 Provides 2D image
 Assessment of blood flow
 For post traumatic high flow cavernous fistula
 Angiography - confirmatory


Cover test :
 Diplopia & hypoglobus
 Occluding one eye followed by other
 Disappearance of peripheral image
 Affected eye & muscle involved


Hess or Lees chart :
 A dissociation test
 Reproducible pictorial record of ocular movements
of eye in all gaze
 Distinguish between entrapment & neurological
impairment
 Non injured eye will over react


Cont :
 Screen divided into squares
Inner field - 9 dots ( cardinal positions of gaze )
Outer field - 16 dots
 Chart plotted - showing limitation & overaction
 Patient 0.5m from screen , red & green glasses
 Examiner - red torch, patient - green torch
 Glasses reversed, also with normal eye

Interpretation :
 Position of central dot - deviation
 Smaller field - affected eye
Constriction - limitation, enlargement - overaction
 Larger field - unaffected eye
 Narrow field - restricted in opposite direction mechanical restriction


Others :


Diplopia :
 When non corresponding points stimulated in
two eyes by same object
 Minor degree - compensation - overaction of
synergistic muscle in unaffected eye
 Monocular - dislocated lens,macula lesion,retinal
detachment
 Binocular - following trauma

Binocular diplopia :
 False image projected in same direction which
ineffective muscle normally moves eye
 Horizontal diplopia - false image on right of true direction of lateral rectus
 Vertical diplopia - false image above true direction of superior rectus
 Identification - Cover test

Diplopia following trauma :
 Not due to paresis of prime mover
 Inability of antagonist to “pay out rope’
 Fibrosis between sheath & periosteum
 Inferior rectus entrapement - superior rectus
mechanically ineffective
 Axis of rotation shifted posteriorly

Cont :
 Elevation associated with posterior movement
of pole
 Deepening of supra tarsal crease
“RETRACTION SIGN”


Binocular fixation test :
 Demonstrate over which conjugate movement
possible
 Displays areas of binocular vision & diplopia
 Plotted on perimeter,white target used for fixation
 Patient follows target from centre to periphery
 Appreciated diplopia recorded

Interpretation:
 Field displaced away from direction of maximum
limitation
 Greater limitation - smaller field
 Narrow field - mechanical limitation


Soft tissue injuries - Eyelid :
 Most common is bruise
 Deep bruising - demarcation line, eye of panda
 Direct ocular injury - posterior limit seen
 Massive swelling of eyelid - sign of retrobulbar
 Laceration on medial side - lacrimal apparatus


Steps in eyelid closure :
 First

- suture to cut ends of tarsal plate

 Second - close posterior lamella of lid
 Third

- suture grey line to opposite side

 Fourth - suture 0rbicularis oculi within wound
 Fifth

- suture skin


Corneal injury :
 5 layered
 Epithelial damage - painful & irritable eye
 Stromal & endothelial damage - edema
 Diagnosis - light reflection & fluorescein stain
 Topical anaesthetic & cyclopentolate


Torsorrhaphy :
 To protect cornea
 For ectropion & paralytic drooping of lower eyelid
 Incise 6-8mm inter marginal tissues
 Incise base of bare area to open wounds
 Closure


Hyphema :
 Bleeding into anterior chamber
 Blood gravitates to lower segment
 Advised rest - major 2* haemorrhage
 Aqueous drainage obstruction - 2* glaucoma
 Steroid & acetazolamide


Iris :
 Iridiolysis - tear - D shaped pupil
 Common sequel following blunt trauma - hyphema
 Traumatic mydriasis - smooth muscle paralysis
 Angle recession occurs - gonioscopy , slit lamp
 Both reflexes absent


Lens :
 Subluxation - common sequel
 Principal clinical sign - wobbling of iris
 Dislocation into anterior chamber - emergency
 Changes in refraction
 Rupture of lens capsule - aqueous fluid entry traumatic catract, opacification

Retina :
 Retinal dialysis - peripheral retinal tear
 Vitreous fluid lifts retina - retinal detachment
 10% - immediate , 70% - 2yrs , 20% - > 2yrs
 Prevention by treating dialysis
 Treatment - photocoagulation,cryotherapy


Berlins edema :
 Traumatic retinal edema
 Whitening of eye
 Blurring of vision
 Opthalmoscopy - milk-white against red fundus
 Edema at macula - eclipse blindness


Classification :
 Associated zygomatic complex #
1. # stable after elevation
2. # unstable after elevation
 Isolated # of orbital rims
 Isolated # of orbital floor
 Complex comminuted #


# - clinical features :
 Circumorbital ecchymosis , subconjunctiva haemorrhage
 Proptosis - blood posterior to septum ,tenderness
 Surgical emphysema - crackling sensation,nasal
communication - attempt to blow nose
 Pneumogram in x-ray, through antral wall or roof
 Paraesthesia over infra orbital distribution - #
 Diplopia,telecanthus,ocular cant,epiphora,CSF leak

Emphysema :


Access to orbital # :
 Lateral & medial eyebrow
 Crows feet , existing laceration
 Subciliary or blepheroplasty
 Infraorbital , medial canthal
 Transconjunctival, bicoronal
 Transnasal , antral , buccal sulcus

Orbital rim & wall # :
 Inferior orbital rim - most common
 Supra orbital margin - highest resistance to impact
 Isolated # - kinetic energy absorbed over small area
 Early ages - lack of frontal sinus - anterior cranial fossa #
 Medial - NOE complex #
 Lateral - zygomatic complex #

Treatment :
 Supra orbital margin - no treatment
 Closed reduction - digital manipulation , bone hooks
 Open reduction FZ suture - lateral eyebrow
Base of frontal process of zygoma - Subciliary,lateral part
 Trans osseous wires, bone plates,K wire,external pins


Orbital floor # :
 Most common - thinnest - 0.27mm
 Hydraulic force - sudden application of pressure
 2 types - Direct , Indirect
 Inclination of walls - medial & downward direction of force


Indirect :
 Classical blow-out # by Converse & Smith - 1957
 Object of greater diameter than rim - blow out #
 # of bony floor anterior to inferior orbital fissure
 Blunt trauma to globe - increased intra orbital pressure
 Herniation of orbital fat , inferior rectus & oblique - antrum
 Rim intact , also called as “impure #”

Direct :
 # of orbital floor through extension of force
 Trauma to rim
 # of rim - also called as “pure #”
 Herniation may or may not be present


Blow-out – C/F :
 Diplopia
 Enophthalmos , supratarsal fold deepening
 Narrowing of palpebral fissure
 Paresthesia, alteration of occular level
 Restricted movement of eye - full vertical


Investigations :
 OM view - “hanging-drop” appearance , antral opacity
 Coronal view - floor & medial wall
 Saggital view - kind of implant
 MRI - soft tissue incarceration
 Sinuscopy - herniation of fat , floor defect


Traction test :
 Forced duction test
 Performed bilaterally in conscious patient
 Tendon of inferior rectus grasped - LA
 Rotate eye upwards
 Restriction - muscle entrapment, fibrous adhesions
 No restriction - does not exclude floor defect

Others :
 Electromyography - Bjork - Diagnosis of combined lesion
inferior rectus incarceration & superior rectus weakness

 Orbitography - radio opaque contrast medium - Milauskas Communication between orbit & antrum


Blow-in # :
 Dingmann & Natvig - 1964
 Elevation of fragments of floor or roof , intact rim
 Upward herniation of floor
 Compression of air within antrum
 Linear shock wave with negative pressure from rebound
of orbital contents
 Rarely demands surgical correction

Surgical intervention :
 Defect <1cm,>5mm, positive clinical & x-ray ,duction test
 Defect >1cm
 Emert et al - diplopia with positive duction - delay 2wks
 Putterman et al - all blow out # waited for 4-6 months
 Most clinicians - waiting period 2 wks
 Diplopia & enopthalmos - surgical intervention
“Sooner the better”

Access – Blow-out :
 Antral approach
 Trans conjunctival
 Infra orbital
1. Subciliary
2.Subpalpebral
 Pre existing scar


Antral approach :
 Cald well luc, inspect floor - fibroptic source
 Trap- door #, fragments attached to periosteum - support
 Antral pack - material of choice
 Exert controlled force upon specific area of antral roof
 3-6m of gauze soaked in whitehead varnish, aural forceps
 Build up in layers ,avoid force in postero superior corner

Cont :
 Inspect ocular level - avoid overpacking
 Pack - free of infection - iodoform
 Pack removal - 3wks
 Antral balloon - 30ml Foley catheter - Jackson et al (1965)
 Through intranasal antrostomy - No 16 -18 catheter
 Disadvantage - no selective pressure
 Removal - after 14www.indiandentalacademy.com
days

Trans conjunctival :
 Bourguet - 1928 - cosmetic procedure
 Traction suture - eyelids, fixation suture - fornix
 Incision between conjunctiva & tarsal plate
 Incise palpebral portion of oculi superficial to septum
 Small incision 3mm below tarsal plate


Cont :
 Conjunctiva & septum freed from orbicularis oculi
 Dissection upto rim

 Incise periosteum 5mm below,rim - periorbital fat herniation
 Sub periosteal dissection - retraction with copper strip
 Dissection upto inferior orbital fissure
 Excellent access - floor . Inferior orbital rim


Invisible scar , restricted access

Subciliary - stepped incision :
 Blephroplasty type of incision
 Excellent access - floor,medial & lateral wall
 Parallel & 2-3mm below margin of lower eyelid only skin
 Undermining of skin,do not incise muscle fibres
 Palpate rim - incise muscle fibres
 5mm below rim - incise periosteum

Inferior marginotomy:
 WOLFE - 1982
 Access to herniated fat at posterior limit of floor

 Rim intact , elective osteotomy - 1.5cm each side of foramen
 From rim to level of infraorbital nerve
 Vertical cuts joined horizontally,convergent cuts along floor
 Segment mobilised - excellent access to affected area
 Wired back in position

Reconstruction :
 To seal off antral cavity
 Physiologically acceptable smooth surface - adhesions
 Restore dimension & contour of orbit
 Indirect support for globe
“Key area” - posterior part of medial wall
1.Main support for anterior projection of globe
2.Paper thin structure - damaged in orbital injuries
3.Technically difficult to repair

Key points :
 Medial canthal ligament left undisturbed
 2 steps - Orbital frame ,Internal orbit
 Orbital frame - reduce zygoma ,arch,lateral orbital wall - key
 Internal orbit - key area - platform for further grafts

 Globe protrude 2mm - compensate for volume loss - swelling
 End of reconstruction - forced duction test

Autografts :
 Large defects - key, defects > 1-1.5cm
 Kaye - antral wall
 Rowe - iliac crest
 Hotte - mastoid , contralateral side
 Bell & Weisenbaugh - nasal septal cartilage
“Calvarial graft” - graft of choice

Cont :
 Graft greater in size , edges bevelled
 Stable medial & lateral margins - hole - rim to 3mm inner
 Posterior margin - adequately supported
 Cortical surface - facing globe
 Compare pupillary levels on both sides


Cont :
 Infra orbital nerve free - graft above - adhesions
 Children >11yrs - 8,9,10 rib cartilage
 Release of internal stresses - graft curl - floor contour
 Graft resorption - 25%
 Less risk of extrusion & infection


Pre–op :


Calvarial bone graft :


Homograft :
 Defect less than 1cm
 Lyodura since 1970
 Absorbed & replaced with fibrous tissue - indistinguishable
 Inert , non allergic , sterile
 Subperiosteal location
 Pre sterilized packs - rehydrated with saline

Allelograft :
 Encapsulated by fibrous tissue - not replaced
 Function - seal off communication until encapsulation
 Polyglactin & tricalcium phosphate,polydiaxone - resorption
 Teflon (tetrafluoro ethylene ), silicone
 Dacron reinfoced silastic - better retention
 Extent - 3mm behind rim to tnferior orbital fissure
 Passive , no pressure

MEDPOR channel implant :


Reconstruction of orbital floor fracture with polyglactin
910/polydioxanon 2005 May;63(5):646-50.retrospective study.
patch (ethisorb): a
J Oral Maxillofac Surg.
Buchel P, Rahal A, Seto I, Iizuka T.
Department of Cranio-Maxillofacial, Skull Base, Facial Plastic and Reconstructive Surgery,
Inselspital University of Berne, Switzerland.

PURPOSE: We sought to evaluate the effectiveness and the complications related to
the use of Ethisorb (resorbable alloplastic material) in the reconstruction of orbital floor
fractures. PATIENTS AND METHODS: We retrospectively reviewed the charts of all
patients who underwent orbital floor fracture reconstruction with Ethisorb since 2001.
We only included patients with a minimum follow-up of 3 months. The following data
were recorded for every patient: age, gender, cause of trauma, time from trauma to
surgery, signs and symptoms, concomitant ocular injuries, radiographic analysis,
pertinent intraoperative findings (including the type of approach), follow-up time, and
postoperative complications. RESULTS: Eighty-seven patients were included in the
study. Twenty-one patients (24.1%) experienced postoperative complications. Of
these, only 3 patients (3.4%) had permanent complications directly related to the
Ethisorb membrane (diplopia, enophthalmos). Two of these patients required revision
surgery and are discussed in the article. CONCLUSIONS: The results of our study
demonstrate the effectiveness of Ethisorb in the repair of small-to-moderate
orbital floor fracture defects (up to a maximum size of 2 x 2 cm).

DOI : 10.2240/azojomo0106

Bioceramic Orbital Plate Implant
Jocelyn P. Reyes, Josefina R. Celorico, Lina C. dela Cuesta, James M. Filio, Leonilo G
Daan, Severino T. Bernardo and Jessica Marie Abano
Porous biphasic calcium phosphate bioceramic orbital plate implant consisting of about 77% βTCP and 23% HAp was developed as a low cost alternative to commercially available orbital
plate implant. The pore size of the material, which is 198 microns, contributed to the early
fibrovascular ingrowth into the pores of the plate implant. 12 orbits of 6 adult domestic cats
underwent orbital plate implantation. Results of biocompatibility tests show the excellent
potential of the developed bioceramic orbital plate implant for orbital floor fracture
reconstruction. It is biocompatible, allows vascularization, resistant to resorption, and has
proven to have physiological bone induction as well as bone conduction properties.
Conclusion
Bioceramics orbital plate implant was successfully developed using calcium phosphate dihydrate
and calcium carbonate as the starting materials. The processing conditions for the fabrication of
this material include the calcination of the starting materials at 800°C, the addition of clay as
binder and sintering at 1280°C for 3 hours. These contribute to the formation of a biphasic
calcium phosphate ceramic consisting of 77% beta-tricalcium phosphate and 23%
hydroxyapatite. The pore size of the material, which is 198 microns, promotes early
fibrovascular ingrowth into the pores of the plate implant. Moreover, post –operative
examinations showed that the developed orbital plate implants were biocompatible and did not
exhibit any kind of adverse effects to the surrounding tissues. Results of biocompatibility
tests on adult cats demonstrated the promising potential of the developed orbital plate
implant as an attractive and affordable option for orbital floor fracture reconstruction.

Complications :
 Retrobulbar haemorrhage
 Superior orbital fissure syndrome
 Orbital apex syndrome
 Carotico - cavernous fistula
 Enophthalmos


Decompression :
 Measurement - Hertel exophthalmometer
 Normal - 16-21mm beyond rim , > 21mm - diagnostic
 Remove any of walls
 Through caldwell-luc - ethmoidectomy
 Remove lamina papyracea,ethmoidal arteries intact
 Remove roof of antrum , later incise periosteum , support

Retrobulbar haemorrhage :
 Less than 1% - mid face trauma
 Injury within intraconal space - short ciliary artery
 Compression of other arteries
 Changes in perfusion pressure gradient
 Venous congestion & edema around optic


Cont :
 Central retinal vessels - obstruction
 Infarction - end result
 Irreversible retinal cell damage - 15 – 20 min
 Pressure gradient
Normal
- 2kPa(15mmHg)
Retrobulbar haemorrhage - 13.3kPa(100mmHg)


Mechanisms – Hertley et al :
 Two mechanisms
 Direct pressure

- Increased volume of contents

 Forward pressure - upon iris - obstruction outflow
aqueous humor
 Through canal of schlemm


Clinical features :
 Pain, Decreasing visual acuity
 Diplopia , opthalmoplegia & severe ptosis
 Marked subconjunctival edema & haemorrhage
 Dilated pupils - loss of light reflex with intact
consensual reflex
 Ophthalmoscope - “Cherry red macular spots”
constricted retinal arterioles


Medical treatment :
 Intraocular pressure reduction - dehydration
 Mannitol(200ml of 20%) - shrinks vitreous
 Acetazolamide(500mg) - inhibits carbonic
anhydrase - reduced aqueous production
 Hydrocortisone(100mg) - intraorbital edema , spasm
 Mega dose steroids - dexamethasone 3-4mg/kg 6 hourly - 24hrs,1mg/kg - 48hrs,continued 5 days

Surgical intervention :
 Explore intraconal space
 Post op - through intramuscular septum uniting inferior
& lateral rectus
 Open antrum - suction
 Lateral canthotomy - dividing intramuscular septum
 Direct access to intraconal spacee - by Moriarty (1982)
 Globe in extreme adduction - conjunctival flap raised divide lateral rectus insertion
 Point where fasciawww.indiandentalacademy.com
bulbi around tendon is reflected

Drainage – Extraconal space :
Septum incised at lateral aspect above or below
canthal ligaments
 Medial incision - damages
- inferior oblique
- trochlea
- nasolacrimal sac & duct


Decompression of optic
 Unless clear evidence of compression
 Perineural & interstitial edema - delayed blindness - benefit
from decompression
 Electrophysiological testing - assessment of vision
 Intra cranial approach - remove roof of canal
 Niho et al - combined transantral & frontal sinus approach
 Fukado - Transethmoidal approach

Adjunct :
 Spasmolytic agent - papaverine - cannula in
supraorbital artery
 Paracentesis of anterior chamber
 Incision parallel to iris anterior to canal of schlemm
 Using catract knife
 Iris return to normal position

Superior orbital fissure syndrome:
 Following impact from lateral aspect
 Gross periorbital edema , proptosis
 Subconjunctival haemorrhage
 Complex opthalmoplegia & ptosis - 3,4,6 nerves
“Loss of direct light & consensual reflex”


Cont :
 Specific sign - altered sensation - forehead to
vertex - frontal branch of trigeminal
 Dilated pupil - loss of corneal & accommodation
 Wait for resolution - 3-6 months
 Fixation of fracture with minimal manipulation
 Operative intervention - deferred 10 - 14 days


Orbital apex syndrome :
 Extension of superior orbital fissure syndrome
 Injury to optic nerve - hallmark
“Loss of consensual reflex in unaffected eye”
 Ischemic optic neuropathy - common reason
 Main area of impact - level of orbital roof
 Lateral orbitotomy - procedure of choice

Carotico-cavernous fistula :
 Orbital trauma extending to basal fracture
 Tears carotid artery within cavernous sinus
“Pulsating exophthalmos” , worse on bending
 Relieved by occlusion of ipsilateral carotid
“Bruit de debale” - associated murmur
 Opthalmoplegia,diplopia,dilated pupil,decreased acuity

Treatment :
 Diagnosis - arteriography
 Surgical closure - transcranial
 Embolization


Enopthalmos :
 Late consequence of orbital trauma
 Soft tissue manifestation of bony defect
 4 types
1.Simple enopthalmos

- related to abnormal bony position

2.With dystopia

- related to bone & soft tissue injury

3.Cicatrical enopthalmos - restriction in movement - scarring
4.Enopthalmos secondary to fat atrophy

Treatment :
 Correction of zygomatic position & orbital floor
 Augmentation of retrobulbar bulge
 Bone behind equator - push globe forward
 Grafting - floor,medial,lateral,behind equator
 Calvarial graft,iliac crest,rib,antral wall,auricular cartilage
“Calvarial” - less resorption (20%), difficult shaping
 Alloplastic - teflon, Homografts - lyodura & zenoderm

Hypoglobus :
 Linked to ball in foam
 Equator from lateral orbital plane to lacrimal crest
 Bone 1cm at inferior orbital rim or under equator
 Cantilevered from inferior orbital rim - deficient posteriorly
 Correct position of zygoma


Canalicular injuries :
 Penetrating injuries - between punctum & lacrimal sac
 Insert lacrimal probe - punctum into proximal severed part
 Cut end paler , dye through intact upper canaliculi
 Pigtail , through upper canaliculus
 Reconstruction - fine nylon plastic tubing
 6-0 silk suture in grey line, tube after 2 wks

THANK U

Orbital Trauma Management

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