Surgical treatment is indicated for orbital fractures that 1) prevent normal globe motility, 2) have caused a change in orbital volume and directly resulted in enophthalmos or hypoglobus (13), or 3) did not initially cause diplopia or altered globe position, but are expected to do so once swelling subsides.
Minor orbital fractures that do not fulfil the aforementioned criteria are usually treated conservatively. In all cases, patients should avoid blowing their nose for 2–3 weeks to avoid air collecting in the orbit or subcutaneously. This is important in fractures of the orbital roof involving the base of the skull to prevent intracranial air.
There is debate concerning the optimum time for surgical treatment of orbital fractures, but a recent meta-study showed that treatment within 2 weeks results in fewer sequelae (5). If there is uncertainty as to whether acute surgical treatment is indicated, it may nevertheless be wise to monitor the patient for 10–12 days following the time of injury. Reconstructive surgery is then indicated if diplopia or aesthetically disturbing enophthalmos develop (14).
In cases of extraocular muscle entrapment in children and adolescents, urgent surgery is recommended to prevent muscle necrosis resulting in permanent diplopia (14). If there are clinical signs of retrobulbar haematoma (increased pressure on palpation or measurement, reduced visual acuity or colour vision, impairment or loss of ocular motility, or considerable proptosis with a tight lower eyelid), decompression with lateral canthotomy and cantholysis is required (12). This is performed by a lateral incision between the eyelids and then release of the lower lateral canthal ligament. The eye can then sink forwards in the orbit, so reducing intraorbital pressure.
Surgical treatment of orbital fractures aims to reconstruct bony anatomy as well as release any entrapped periorbital tissue. By restoring the original orbital volume, the globe will be able to assume its correct position, resolving any diplopia.
A variety of different materials have been used to reconstruct orbital bone tissue, including autologous bone, cartilage and muscle, as well as various synthetic materials. The main materials used today are pure titanium plates, titanium combined with polyethylene, or resorbable polydioxanone plates (15). Patient-specific, 3D-printed reconstruction plates are appropriate for major or more complicated orbital fractures (16). These are made by mirroring the opposite orbit onto the fracture side and then manufacturing an anatomically correct implant. Alternatively, a 3D-printed model of the patient can be used to individualise the reconstruction plate. Other tools such as intraoperative CT and navigation also have a role in complex reconstructions (17, 18).
Access to the orbit is achieved via the transcutaneous or transconjunctival approach. The latter technique rarely causes visible scarring and is thus preferred for fractures of the floor and medial wall. Figure 4 shows the transconjunctival approach used for a titanium reconstruction plate which is fixed at the inferior orbital rim with screws. In major fractures of the medial wall, the incision can be extended to a transcaruncular incision. The same applies laterally by combining a transconjunctival approach with lateral canthotomy. Upper blepharoplasty incision in the upper eyelid skin fold is generally chosen for fractures of the orbital roof. Subciliary incision is often chosen for combined fractures of the orbital floor and inferior orbital rim, giving access for repositioning and osteosynthesis of the fracture in the inferior rim. Alternatively, the incision can be placed lower, such as via a subtarsal or infraorbital approach. However, the latter approach is only used if there is already a cut in the skin because cosmetic results are worse with this approach.
Fractures of the orbital roof cause less orbital volume change compared with fractures of the floor, but can cause restricted ocular motility, diplopia and entrapment of periorbital tissue. Communication of the fracture with the base of the skull may cause dural injury with resulting leakage of cerebrospinal fluid, which in certain cases may require craniotomy with duraplasty in addition to reconstruction of the orbital roof.