Orbital and adnexal trauma

Abstract

Trauma to the canalicular system must be suspected in medial eyelid lacerations. When a laceration of the canaliculus is diagnosed, every attempt should be made to repair the canaliculus within the first 48 hours following the injury; epiphora may result from loss of the canaliculus, even if the opposite canaliculus remains intact, and late repairs are much less likely to result in a functioning tear outflow system. The surgeon should have an armamentarium of various techniques for canalicular repair. The pigtail probe, used with a delicate touch and immediately abandoned if smooth passage is not obtained, can be a very useful tool in these injuries. The main goals of orbital blowout fracture repair are prevention of late enophthalmos and ocular dystopia, and minimization of late restrictive motility defects. The availability of high-resolution orbital imaging studies has eliminated some of the uncertainty that used to characterize surgical decision making in isolated orbital blowout fractures. It is now possible to identify large fractures with significant expansion of orbital volume that will lead to enophthalmos and ocular dystopia; these patients are surgical candidates, and there is no advantage to delay. Patients with ocular motility disturbance and diplopia following orbital blowout fractures are significantly more complicated with regard to surgical decision making. There is no expert consensus and there are no good published data to provide absolute guidelines. The factors that militate in favor of surgical intervention include diplopia in the primary fields of gaze persisting beyond 1 to 2 weeks without improvement, positive forced duction testing, and evidence of soft tissue incarceration on orbital imaging studies. Fractures that involve the extended orbit, including the nasoorbitoethmoid region and the orbitozygomatic region, require surgical management when significant displacement of the bony fragments is diagnosed on orbital imaging studies. The availability of modern bone fixation systems and increasing use of wide subperiosteal exposure of all displaced fractures minimize the incidence of late orbital dystopia, telecanthus, asymmetry, and abnormal soft tissue scarring, which typically result from inadequately reduced orbital fractures. Ophthalmologists should be cognizant of the optimal methods for diagnosis and treatment of orbital fractures; those with orbital surgical training are particularly well prepared, based on their extensive knowledge of orbital anatomy and physiology, to serve as “captains” of the multidisciplinary team typically involved in the management of complicated midfacial fractures.