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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 (see examples of CT Scans) 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 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. Rarely, 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 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 indicated.
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 palpable bumps in the bones around the eye.
Above and behind the orbit is the brain. It is very uncommon for adults to break the back or roof of the orbit. Repair of the orbital roof is difficult and requires a neurosurgical approach. Fractures of the roof are not usually repaired unless they are causing significant deformity or double vision. A neurosurgical consultation is required.
Indications for urgent repair (as soon as possible) 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. Indications for delaying repair up to 4-6 weeks include decreased vision from optic nerve injury, recent eye surgery, or significant injury to the eye. In all other cases, the optimum time for repair is 1-2 weeks after the injury once the swelling has improved. Repairs beyond this time are certainly feasible in experienced hands, but are more difficult and carry greater risks.
If you have an orbital fracture, DO NOT BLOW YOUR NOSE for at least 3 weeks. Blowing your nose may cause air to become trapped behind the eye, possibly damaging your vision. After your injury or and for 3 weeks following your surgery, avoid any activity that will turn your face red such as heavy lifting, bending over, or running. Over exertion after surgery may lead to bleeding behind the eye, vision loss, worsening of double vision, or increased swelling with and a greater risk for an abnormal eyelid position or loosening of your stitches. To speed the resolution of swelling after the injury or surgery, apply ice packs as much as possible for 2-3 days. Warm compresses may be applied on day 4 and beyond to help improve bruising.
If surgery is recommended to repair your orbital and/or facial fractures, and you elect to proceed with repair, you should be aware of the following:
95% of all orbital fractures can be repaired with a skin incision that is less than ¼ of an inch in the outside corner of your eye. 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. Most patients spend the evening in the hospital and go home the morning following surgery. A postoperative visit in Dr. Klapper's office is usually arranged 1-2 days 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. As with any surgery involving the eye and surrounding structures, there are considerable risks. These risks are rare but potentially serious. Infection, bleeding behind the eye, and partial or complete vision loss are possible.
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 patient 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.
For you to make appropriate decisions regarding your situation and options for management, it is imperative that you fully understand the risks and alternatives available to you. We encourage you to discuss your condition with Dr. Klapper and our staff.
Stephen R. Klapper, M.D., F.A.C.S. is a board certified Ophthalmologist and has completed extensive fellowship training in Ophthalmic Plastic and Reconstructive Surgery. In addition to his clinical practice Dr. Klapper has published numerous scientific articles in peer reviewed journals and presented several papers at regional, national, and international meetings on topics related to the field of eyelid and facial plastic surgery. Dr. Klapper's practice is limited to adult and pediatric cosmetic and reconstructive eyelid and facial surgery, tear duct surgery, orbital disease, thyroid eye disease and the anophthalmic patient. Dr. Klapper also has extensive experience performing facial Botox® injections and Restylane® lip and facial fold injections.
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Contact our office to discuss your eyelid problem with Dr. Klapper or a member of his staff. (317) 818-1000
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