Trauma (Orbit)
Orbit and Zygoma Fracture Repair
Anatomy
Seven bones of the face form a pear-shaped box that surrounds and protects most of the eye. This box is called the orbit. An orbital fracture is a break in one or more of the bones that surround the eye. A computed tomography (“CT scan” or “CAT scan”) with axial (slices parallel to the floor) and coronal (slices parallel to the plane of the face) views is essential to fully evaluate any orbital fracture.The wall toward the nose is called the medial wall and it separates the orbit from the ethmoid sinus (air cavity). Large fractures of the medial wall, fractures with medial rectus muscle entrapment, or those causing diplopia or severe pain on gaze side-to-side usually require repair.The wall underneath the eye is called the orbital floor and it separates the orbit from the maxillary sinus (air cavity). In general, fractures that involve greater than 50% of the orbital floor area or greater than 30% of the floor in conjunction with large fractures of the medial wall are likely to cause the eye to sink backward or downward and will usually require repair. Other indications for repair include double vision (particularly on down or upgaze) or early evidence of the eye sinking backward. Repair of floor fractures may also result in more rapid improvement of facial numbness which may take up to 6-9 months to resolve. Less commonly, orbital floor exploration may worsen numbness along the cheek, side of the nose, and the upper lip.
The lateral (outside) wall of the orbit borders the temple region. Lateral wall fractures require tremendous force and are often associated with fractures of the zygoma (the cheek bone) and other mid-facial bones. Repair of lateral wall fractures is usually required to restore orbital anatomy and diminish the duration of tenderness often experienced while sleeping or leaning on the side of the face. Repair of zygoma fractures is indicated if there is pain on opening of the mouth, flattening of the cheek, or repair of other orbital fractures is also necessary. The front edge of the orbit is called the rim. Displaced fractures of the rim often cause significant changes in the orbital volume causing the eye to appear sunken into the face. Rim fractures are often repaired for comfort, volume preservation, and to avoid visible or palpable bumps in the bones around the eye.
Above and behind the orbit is the brain. It is uncommon for adults to break the roof of the orbit. These fractures occur more often in pediatric patients. Fractures of the roof are not usually repaired unless they are causing significant deformity or double vision. Repair of the orbital roof is difficult and requires a neurosurgical approach. Indications for urgent repair (as soon as can be arranged) include entrapment of an eye-moving muscle into a fracture site in children or young adults, a displaced orbital room fracture, or a bone fragment pushing on the eye (globe). Indications for possibly delaying repair up to 4-6 weeks include decreased vision from optic nerve injury, recent eye surgery, or significant injury to the eye (globe). In all other cases, the optimum time for repair is within 1-2 weeks after the injury once the swelling has improved. Repairs beyond this time are feasible in experienced hands, but are more difficult and carry greater risks of complications.
Orbit Surgery
95% of all orbital fractures can be repaired with a small skin incision in the outside corner of your eye along with a conjunctival incision on the inside of the eyelid. In some cases, no skin incision is required. Some lateral orbital rim fractures may require an incision near the eyebrow. Zygoma fractures may require a small incision in the scalp or an incision under the lip in the mouth to gain access for repair. Patients may spend the evening in the hospital and go home the morning following surgery. Repair of orbital floor and medial wall fractures usually requires placement of thin ‘plastic-like’ implants. Repair of rim and zygoma fractures typically requires the use of thin, Titanium screws and plates. Orbital implants are typically covered by the body’s own fibrous tissue and can remain in place for years. Rarely, implant complications such as bleeding, migration, exposure, or pain may require further surgery for implant removal. Implant complications may occur days, weeks, months, or even years after the original surgery. As with any surgery involving the eye, orbit, and surrounding structures, there are considerable risks. Severe complications are unusual but potentially serious. Infection, bleeding behind the eye, and partial or complete vision loss (blindness) are possible problems with orbit surgery.
Perioperative Care
Orbital and facial fracture surgery is performed under general anesthesia. Patients may have the option to stay overnight in the surgical facility (ambulatory surgery center or outpatient hospital) as a 23 hour observation. This is generally considered outpatient surgery. The overnight stay may be recommended to receive intravenous antibiotics, orticosteroids, pain medication, and nausea medication. Once at home, patients will require assistance during the initial 2-4 days (sometimes more). Oral antibiotics, prednisone, and pain medications are prescribed for one week. Ice packs and rest is recommended during the first week. Patients are asked to avoid nose blowing, heavy lifting, or strenuous activity during the first three to four weeks after surgery. Absorbable sutures are frequently used and do not require removal. Detailed postoperative instructions will be given to you immediately following your surgery. You will need to see Dr. Klapper in his office 1-3 days after surgery and often again at 7-14 days. Additional postoperative visits are adjusted on an individual basis.
Expectations and Potential Risks of Surgery
Double Vision
Some patients who undergo orbital fracture repair already have some double vision. Patients with double vision before surgery may find that there symptoms do not immediately improve or are worse after surgery. Release of an injured muscle may lead to increased swelling and diminished muscle contractility. Unless scar tissue develops (fibrosis within the injured muscle) or the nerve to the muscle was injured at the time of the trauma, then most patients experience resolution of their double vision within 2-4 months after surgery. Rarely, patients may require eye muscle surgery if their double vision does not improve after 4-6 months of observation. In some patients the double vision improves with surgery and in other individuals the double vision is worse after surgery. Treatment of double vision may require prisms in your glasses, further orbital surgery or eye muscle (strabismus) surgery. Patients with double vision will often have their care coordinated with a strabismus surgeons. Dr. Klapper works with several excellent strabismologists in central Indiana.
Numbness of the Lips and Gums
The sensory nerve, contained within the floor of the orbit, is responsible for feeling in the upper lip and gum as well as the cheek. Numbness of these areas frequently occurs with orbital floor fractures. This is not a visible finding, but it can be somewhat of a nuisance. This numbness (infraorbital nerve hypesthesia) frequently resolves over 4-6 months. Orbital surgery may or may not accelerate recovery of infraorbital nerve sensory funtion.
Severe Bruising and Swelling
This operation takes place in an area that is very vascular with a large number of blood vessels. Frequently, patients will already have substantial swelling and bruising (bleeding in the tissues) associated with their original injury. Patients taking anti-coagulant medications ("blood thinners") may need to coordinate, when possible, cessation of these medications with their prescribing physician (primary care physician or cardiologist). Unfortunately, surgery in the trauma setting may not permit optimization of a patient's medical condition prior to surgical intervention. Swelling of the conjunctiva (mucosal covering of the outside of eye) may result in a 'blistered or bubbled' appearance of the eye. This typically resolves with frequent ocular lubrication (eye drops and lubricating ointment) over several weeks. Excessive bleeding and swelling, if severe, could conceivably result in vision loss.
Loss of Vision
Anytime surgery is performed around the eye, especially in the orbit behind the eye, there is a risk of partial or severe vision loss (blindness). Even in the best of surgical hands, bleeding, injury to a critical blood vessel or nerve may cause unexpected vision loss. Additionally, spontaneous orbital bleeding (hemorrhage) can occur days, months, or even years after surgery.
Need for Additional Eyelid Surgery
Trauma is a common cause of eyelid malposition. Eyelid scarring may result in a droopy eyelid (ptosis) or, more commonly, eyelid retraction. Scarring within an eyelid following surgery may also cause eyelid retraction, ectropion (outward turned eyelid), or lagophthalmos (incomplete eyelid closure). Patient with orbital injuries may also require reconstructive eyelid procedures either at the time of orbital surgery or as secondary procedures.
Summary
Orbital Fracture repair is a frequent but potentially complex surgical procedure. It is essential that patients review all of the information provided by Dr. Klapper and his staff regarding orbital surgery and anticipated preoperative and postoperative care. It is important that patients understand the indications for surgical repair of orbit and mid-face fractures, including double vision, pain on eye movement, periorbital deformity, and large fractures. While orbital fracture repair is often a successful operation, there are substantial risks associated with orbital surgery including continued double vision, vision loss, implant complications, and the need for further surgeries. To help you make appropriate decisions regarding your particular situation and options for management, We encourage you to discuss your condition with Dr. Klapper and have all of your questions and concerns addressed prior to surgical intervention.
