Open Reduction and Internal Fixation of Orbital Blowout Fracture

Description:

An orbital blowout fracture refers to a fracture of the orbital floor, which may result in herniation or entrapment of orbital contents, such as fat or extraocular muscles, into the maxillary sinus. During repair of these fractures, the orbit is accessed via a subciliary (lower eyelid) or transconjunctival approach. Any herniated contents are returned to the orbit and the orbital floor is overlaid with an implant.

Indications for Surgery:

Orbital blowout fractures with clinical or radiologic evidence of enophthalmos (recession of the eyeball into the orbit) or extraocular muscle entrapment.

Contraindications to Surgery:

  • Medical comorbidities that would preclude surgical or anesthesia risk

Pre-Operative Evaluation:

  • Visual acuity, visual field, and forced duction testing should be performed and the results documented prior to surgery.
  • A maxillofacial computed tomography (CT) scan should be obtained in order to visualize the orbital floor fracture and any other associated fractures of the mid-face.
  • Surgery is generally delayed until 5-7 days post-injury to allow for resolution of edema.

Anesthesia:

General endotracheal

Surgical Technique (Subciliary):

  1. The patient is placed supine on the operating table and general anesthesia is induced via endotracheal intubation.
  2. A corneal shield is placed to protect the globe from injury.
  3. A subciliary incision is marked in an existing skin crease 2-3 mm inferior to the palpebral margin and carried laterally.
  4. The incision site is injected with 1% lidocaine with 1:100,000 epinephrine.
  5. The lateral portion of the marked incision is sharply incised down to the orbicularis oculi muscle. The tissue is spread until the lateral orbital rim is reached.
  6. The remainder of the subciliary incision is then made and dissection is carried inferiorly to the infraorbital rim in a plane just superficial to the periosteum. The orbicularis oculi is divided.
  7. A traction suture is placed through the orbicularis fibers attached to the lower lid and retracted superiorly.
  8. The periosteum is incised along the inferior aspect of the infraorbital rim and elevated while the globe is retracted to expose the orbital floor and associated fractures.
  9. Any herniated orbital contents are delivered out of the maxillary sinus.
  10. The anterior-posterior and medial-lateral dimensions of the orbital floor are measured. An implant is trimmed to size and placed over the fractures. The implant may be free if stable on 3 points, or may be fixed anteriorly. Forced duction testing may be repeated to ensure that the implant is not causing entrapment.
  11. The periosteum is closed, followed by the skin. No muscle or subcutaneous closure is performed to avoid post-operative ectropion.
  12. The corneal shield is removed and care of the patient is returned to the anesthesiologist for extubation and recovery.

Surgical Technique (Transconjunctival with lateral canthotomy):

  1. The patient is placed supine on the operating table and general anesthesia is induced via endotracheal intubation.
  2. The incision site is injected with 1% lidocaine with 1:100,000 epinephrine.
  3. A lateral canthotomy is made with a #15 blade at the lateral canthus and parallel to the Frankfort plane.
  4. Iris scissors are used to perform inferior cantholysis (release of the lateral canthus tendon).
  5. The lower lid is retracted and the tarsus is identified.
  6. Starting laterally, a transconjunctival incision is made parallel and 2-3 mm inferior to the tarsus.
  7. Two 6-0 silk sutures are placed in each of the upper and lower conjunctival flaps. The inferior flap is retracted over the cornea for protection.
  8. A pre-septal dissection is performed to the orbital rim using iris scissors.
  9. The periosteum is incised along the infraorbital rim with a #15 blade. It is elevated, while the globe is retracted with an insulated malleable retractor, to expose the orbital floor and associated fractures.
  10. Any herniated orbital contents are delivered out of the maxillary sinus.
  11. The anterior-posterior and medial-lateral dimensions of the orbital floor are measured. An implant is trimmed to size and placed over the fractures. The implant may be free if stable on 3 points, or may be fixed anteriorly. Forced duction testing may be repeated to ensure that the implant is not causing entrapment.
  12. The conjunctiva is closed with running fast-gut suture, followed by repair of the canthus. The skin is closed with fast-gut suture.
  13. Care of the patient is returned to the anesthesiologist for extubation and recovery.

Post-Operative Care:

  • Open reduction and internal fixation of an orbital blowout fracture may be performed on an outpatient basis.
  • The postoperative examination should document visual acuity and extraocular movements.
  • The patient is discharged with erythromycin ophthalmic ointment to be applied to the subciliary incision.

Complications:

  • Ectropion
  • Residual entrapment
  • Orbital hematoma
  • Wound infection
  • Implant migration





« Nasal AbnormalitiesOpen Reduction and Internal Fixation of Mandibular Fracture »