ORBITAL FRACTURES

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ORBITAL FRACTURES

• Brig Amer Yaqub
• FCPS, FRCSEd

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ANATOMY OF ORBIT
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ROOF OF THE ORBIT

• Roof is formed by two bones
• 1) Lesser wing of Sphenoid
• 2) Orbital plate of the Frontal
• It is located subjacent to the anterior cranial
  fossa and frontal sinus
• A defect in orbital roof may cause pulsatile
  proptosis

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LATERAL WALL OF THE ORBIT

• Lateral wall is formed by two bones
• 1) Greater wing of Sphenoid
• 2) Zygomatic
• Anterior half of the globe is vulnerable to
  lateral trauma since it protrudes beyond the
  lateral orbital margin

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FLOOR OF THE ORBIT

• Floor is formed by three bones
• 1) Zygomatic
• 2) Maxillary
• 3) Palatine
• The posteromedial portion of the Maxillary bone
  is relatively weak
• May be involved in a blowout fracture

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MEDIAL WALL OF THE ORBIT

• It is formed by four bones
• 1) Maxillary 3) Ethmoid
• 2) Lacrimal 4) Sphenoid
• Orbital cellulitis is therefore frequently
  secondary to Ethmoidal sinusitis

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OPTIC CANAL

• Optic canal lies in the lesser wing of sphenoid
• It is situated close to the apex of the orbit
• It connects the middle cranial fossa with the
  orbital cavity
• It is 4-10 mm long
• It transmits,
• 1) Optic nerve
• 2) Ophthalmic artery

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SUPERIOR ORBITAL FISSURE

• It is a slit between the greater and lesser wing
  of sphenoid bone
• Structures which passes through are,
• Superior portion contains
• Lacrimal nerve
• Frontal nerve
• Trochlear nerve
• Superior ophthalmic vein
• Inferior portion contains
• Superior Inferior division of Oculomotor nerve
• Abducent nerve
• Nasociliary nerve
• Sympathetic fibers

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INFERIOR ORBITAL FISSURE

• The lateral wall and the floor of the orbit are
  separated posteriorly with the inferior orbital
  fissure.
• Which transmites.
• Maxillary nerve its Zygomatic branch
• Ascending branches from the Sphenopalatine
  ganglion
• Inferior ophthalmic vein

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ORBITAL FRACTURES
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BLOW-OUT ORBITAL FLOOR FRACTURE

• A 'pure' blow-out fracture of the orbit does not
  involve the orbital rim
• Whereas an 'impure' fracture involves the orbital
  rim and adjacent facial bones
• It is caused by a sudden increase in the orbital
  pressure by a striking object which is greater
  than 5 cm in diameter
• Fracture most frequently involves the floor of
  the orbit
• Occasionally, the medial orbital wall may also be
  fractured.

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• Periocular signs
• Ecchymosis
• Oedema
• Subcutaneous emphysema.
• Infraorbital nerve anaesthesia
• Involving the lower lid
• Cheek
• Side of nose
• Upper lip
• Upper teeth and gums

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• Diplopia
• Enophthalmos
• Manifest after a few days, as the initial oedema
  resolves
• Ocular damage
• Hyphaema
• Angle recession
• Retinal dialysis

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• CT Scan
• Extent of the fracture
• Prolapsed orbital fat
• Extraocular muscles
• Haematoma

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• Hess test
• Useful in assessing and monitoring the
  progression of diplopia

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INITIAL TREATMENT

• Antibiotics
• Steroids
• No nose blowing

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SURGICAL TREATMENT

• Surgery recommended for symptomatic fractures
• Diplopia
• Muscle entrapment
• Enophthalmos
• Extensive fracture (gt50 of floor)
• Ideally surgery should be done within two weeks

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GOALS OF SURGERY

• Restore normal extraocular muscle movements
• Replace orbital contents into the orbit
• Restore normal orbit volume

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TECHNIQUE OF SURGICAL REPAIR

• A transconjunctival or subciliary incision
• The periosteum is elevated from the floor of the
  orbit and orbital contents are removed from the
  antrum
• The defect in the floor is repaired using
  synthetic material such as Supramid, silicone or
  Teflon
• The periosteum is sutured

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COMPLICATIONS

• Diplopia (up to 75)
• Exophthalmos
• Hemorrhage
• Eyelid malposition
• Surgical trauma to
• Orbit
• Nerve
• Lacrimal apparatus

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Blow-out medial wall fracture

• Most medial wall orbital fractures are associated
  with floor fractures.

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SIGNS

• Periorbital haematoma

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• Defective ocular motility involving abduction
  and adduction.

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• CT will show the extent of damage

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TREATMENT

• Involves release of the entrapped tissue
• Repair of the bone defect

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ROOF FRACTURE

• Caused by trauma such as
• Falling on a sharp object
• Blow to the brow or forehead
• Most common in young children
• Complicated fractures caused by major trauma
  commonly affect adults

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Presentation

• Haematoma of the upper eyelid
• Periocular ecchymosis

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SIGNS

• Inferior or axial displacement of the globe.
• Large fractures may be associated with pulsation
  of the globe unassociated with a bruit
• Best detected on applanation tonometry.

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TREATMENT

• Small fractures may not require treatment
• Observe the patient for the possibility of a CSF
  leak which may lead to meningitis
• Sizeable bony defects with downwardly displaced
  fragments usually require reconstructive surgery

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LATERAL WALL FRACTURE

• Rare
• Because the lateral wall of the orbit is more
  solid than the other walls
• Fracture is usually associated with extensive
  facial damage

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Sympathetic Ophthalmitis
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Sympathetic ophthalmia

• lt0.5 of penetrating injury
• Severe bilateral granulomatous uveitis
• Anterior chamber inflammation, multiple yellow
  spots in peripheral fundus
• Injured eye is called
• exciting eye
• Fellow eye which also
• develops uveitis is
• called sympathizing eye

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Predisposing factors

• Penetrating wound ( less commonly intraocular
  surgery)
• Wounds in the ciliary region
• Wounds with incarceration of the iris, ciliary
  body or lens capsule
• More common in children than in adults

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Clinical Picture

• Exciting (injured) eye
• Persistent low grade plastic uveitis, which
  include ciliary congestion, lacrimation and
  tenderness
• Keratic precipitates (dangerous sign)
• Sympathizing (sound) eye
• Usually involved after 4-8 weeks of injury in the
  other eye
• Most of the cases occur within the first year
• Almost always, manifests as acute iridocyclitis
• Rarely it may manifest as neuroretinitis or
  choroiditis

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Complications

• Cataract
• Glaucoma
• Optic atrophy
• Exudative detachments
• Subretinal fibrosis

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Treatment

• Prophylaxis
• Early enucleation of the injured eye (best
  prophylaxis when there is no chance of saving
  useful vision)
• When there is hope of saving useful vision,
  following steps should be taken
• Meticulous repair of the wound using
  microsurgical technique should be carried out,
  taking great care that uveal tissue is not
  incarcerated in the wound
• Immediate treatment with topical as well as
  systemic steroids and antibiotics along with
  topical atropine should be started
• Late enucleation if uveitis not settled for 2 wks

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• Systemic immunosuppression
• Corticosteroids
• Mostly good prognosis gt6/18
• However, enucleate only if no visual potential

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SYMPATHETIC OPHTHALMIA
(BILATERAL granulomatous panuveitis after trauma)

• Onset 5 days to 66 years after penetrating
  trauma
• Onset 33 at 3 mo., lt50 after 1 year
• Removal of injured eye after onset does not help
• Cause antigen-antibody interaction
• Risk 0.015-1.9 (lowest after planned surgery)
• Treatment immunosuppressive therapy

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