Extraocular Muscle Entrapment Research Articles

The Impact of Surgical Timing in Orbital Fracture Repair: A New Paradigm.

For decades, there has been an ongoing debate about the ideal timing of orbital fracture repair (OFR) in adults. We conducted a retrospective review of patients who underwent OFR at two centers (2015-2019). Excluded were patients <18 years old and those with follow-up <2 weeks. Our primary outcome was the incidence/persistence of postoperative enophthalmos/diplopia at least 2 weeks following OFR. The association between surgical timing and postoperative ocular complications was assessed in patients with extraocular muscle (EOM) entrapment, enophthalmos and/or diplopia, and different fracture sizes. Of n=253 patients, n=13 (5.1%) had preoperative EOM entrapment. Of these, patients who had OFR within 2 days of injury were less likely to develop postoperative diplopia compared with patients who had OFR within 8-14 days (n=1/8 [12.5%], n=3/3 [100%]; P=0.018). Patients who had OFR for near-total defects within 1 week of injury were significantly less likely to have postoperative enophthalmos (n=0 [0.0%]) compared with those who had surgery after 2 weeks (n=2 [33.3%] after 15 to 28 days, n=8 [34.8%] after 28 days from injury, P<0.001). Patients who had delayed OFR for large fractures smaller than near-total defects, preoperative persistent diplopia, or enophthalmos were not at significantly greater likelihood of postoperative ocular complications compared with those who had early OFR. We recommend OFR within 2 days of injury for EOM entrapment and 1 week for near-total defects. Surgical delay up to at least 4 weeks is possible in case of less severe fractures, preoperative persistent diplopia, or enophthalmos.

A case series of surgical outcomes for orbital blowout fracture with extraocular muscle entrapment.

Although early surgical intervention to avoid muscle degeneration in patients with blowout fractures (BOFs) and extraocular muscle entrapment is recommended, there is still no gold standard for the surgical timing of extraocular muscle release. This study aimed to present our 10-year experience with surgical outcomes in BOF patients with extraocular muscle entrapment to provide supporting data for determining the surgical timing for better outcomes. We conducted a retrospective study of patients with BOFs with extraocular muscle entrapment who underwent surgery at a tertiary hospital between December 2009 and October 2019. Their demographics, causes of injury and clinical features including limitation of extraocular movement (EOM) and diplopia were collected. Patients diagnosed with BOF with extraocular muscle entrapment accounted for 3.08% (21/681) of all cases of BOFs over a 10-year period. The patients comprised 20 males and 1 female, with a median age of 17.0 years (IQR, 13-25 years). All 21 patients had diplopia preoperatively, and 20 had EOM limitations. Nausea and vomiting were observed in 5 patients (23.8%). Surgery was performed within 48 hours after injury in 19 cases (within 24 hours in 13 cases), with a median of 17.0 hours (IQR, 11-27). The median operative time was 47.5 minutes (IQR, 31.2-73.7 minutes). The median follow-up period was 9.0 months (IQR, 7-12). At the last follow-up, 4 patients still had EOM limitations and 3 had residual diplopia; however, this did not interfere with their daily activities. Early diagnosis through facial computed tomography and physical examinations and early intervention showed successful surgical outcomes of BOF with extraocular muscle entrapment.

Orbital Trapdoor Fracture With Extraocular Muscle Entrapment in Adults: A Case Series.

To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment. We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision. We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed. Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility.

Clinical correlations of extraocular motility limitation pattern in orbital fracture cases: a retrospective cohort study in a level 1 trauma centre

ABSTRACT Purpose Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits. Methods This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval. Results 278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3–27.2) and 5.22 (95%CI: 1.9–13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161). Conclusions OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

Review of 451 Patients Presenting With Orbital Wall Fractures: A Retrospective Analysis.

A retrospective review of the electronic medical records of patients presenting to the University Medical Center in Lubbock, Texas with orbital wall fractures. Clinical data such as associated ocular injuries and different management approaches are analyzed and discussed to help clarify the specific indications for, and timing of, a formal ophthalmologic examination. All patients who presented to the emergency department for an orbital fracture after suffering various types of traumas between 2008 and 2017 were included. The study reviewed 451 patients with orbital wall fractures with a wide variety of presentations as well as demographics. There were 411 cases of adults presenting with an average age of 34 years and 40 pediatric presentations with an average age of 14 years. The average age of the combined study population was 30 years. Only 16.9% of patients required surgical correction for their orbital fractures and assault accounted for nearly 50% of all the orbital fractures reviewed in this study. In this large retrospective review, no notable relationship was found between orbital wall fractured and ocular injury. Alarm symptoms for more visual threatening injuries such as retinal tears, detachments, open globe injury, and extraocular muscle entrapment are all reasonable indications to consult ophthalmology emergently. Most orbital fractures are not vision threatening, do not usually require surgical correction, and typically occur in the setting of assault.

P-66118405-104 - Isolated paediatric orbital fractures: A case series at a major trauma center.

<h3>Purpose</h3> Paediatric orbital fractures are rare. The existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis. <h3>Methods</h3> This was a retrospective study, conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to King's College Hospital, London between 2010-2020. <h3>Results</h3> 20 patients with pure orbital fractures presented to our Unit in this period. The average age of the patients was 11 years with a male preponderance. The predominant aetiology was road traffic accidents, but in surgical patients aged 13 to 16 this was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. 9 patients required surgical intervention due to diplopia caused by entrapment of extraocular muscles. 5 patients had nausea, vomiting or bradycardia associated with the occulocardiac reflex. Surgical intervention occurred within 24 - 48hours of the patient sustaining their injury in 6 cases. Resorbable sheet was used to reconstruct the orbit. Resolution of diplopia occurred in 7 patients within 6 months. Length of follow up ranged from 1 to 18 months. <h3>Conclusions</h3> Paediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.

Isolated paediatric orbital fractures: a case series and review of management at a major trauma centre in the UK.

PurposePaediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis.MethodsThis retrospective study was conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to a major trauma unit in London between 2010 and 2020.ResultsThirteen patients with isolated orbital fractures presented to our unit in this period. The average age was 13 years. Surprisingly the predominant aetiology was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. One medial wall fracture case was missed in the emergency department.Eight patients required surgical intervention due to diplopia caused by muscular entrapment of extraocular muscles; the final patient had a large defect resulting in enophthalmos requiring a large titanium plate. A transconjuctival approach was preferred for surgical access and resorbable sheet was used in the remaining cases. Five patients had nausea, vomiting or bradycardia associated with the oculocardiac reflex. Surgical intervention occurred within 24–48 h of injury in 6 cases. Resolution of diplopia occurred in 7 patients within 6 months.ConclusionPaediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.

English

Zygomaticomaxillary complex (ZMC) fractures are relatively common. Zygomatic complex fractures with functional or aesthetic impairments often require surgical intervention. Treatment of ZMC fractures consists of reduction and fixation of the dislocated bone fragments to their original location. The zygomaticomaxillary complex functions as a major buttress for the face and because of its prominent convex shape, is frequently involved in facial trauma.1 ZMC fractures are also called tripod, tetrapod, quadripod, malar or trimalar fractures. They account for approximately 15 % - 23.5 % of maxillofacial fractures.2,3 The aetiology of zygomatic complex fractures primarily includes road traffic accidents (RTA), violent assaults, falls and sports injuries. They are the second most common facial fracture after nasal bone fractures.3-6 ZMC fractures are more common in men than women, and most commonly occur in the third decade of life.7-10 The main clinical features of zygomatic complex fractures include diplopia, enophthalmos, subconjunctival ecchymosis, extraocular muscle entrapment, cosmetic deformity, malocclusion and neurosensory disturbances of the infra-orbital nerve.10 The gold standard radiological investigation for evaluation of ZMC fractures is computed tomography (CT) scan. Surgical intervention is effective in cases of displaced and comminuted fractures involving functional and aesthetic defects, whereas a nonsurgical approach is often used for non-displaced fractures.11 Various surgical approaches and treatment strategies have been proposed to obtain a successful treatment outcome. Based on review of literature, it has been observed that the open reduction with internal fixation using mini plates and screws is the most commonly preferred treatment for displaced and comminuted fractures.10-12 Here, we report a clinical case of right zygomaticomaxillary complex fracture and its management.

Adult Orbital Fractures with Extraocular Muscle Entrapment

Orbital fractures with entrapment are well described in children but occur less frequently in adults. The true incidence, natural history, and ideal timing of surgical intervention of adult orbital fractures with entrapment are unknown. A single institution, retrospective chart review of 5 adult patients with orbital fractures with entrapment who underwent surgical intervention and had at least 1 follow up visit was performed. Ages ranged from 21 to 62 years old (mean = 37.6). Timing between initial presentation and surgery ranged from 14 to 62 hours (mean = 34.8). Intra-operatively, all patients had clinical entrapment of extraocular muscles and underwent surgical release followed by orbital implant reconstruction. Follow up ranged from 1 week to 1 year (mean = 16 weeks). Three of 5 patients had significant improvement of extraocular movements at their last follow up. Two patients had residual exotropia and difficulty with adduction; one was a unique case with medial rectus transection which has not been previously described. It is important that clinical suspicion for entrapment remains high in orbital fractures even in adult populations. Based on current literature, early surgical intervention is recommended for adult patients with entrapment even in the absence of oculocardiac reflex.

New Extraocular Muscle Entrapment after Facial Fracture Repair

Extraocular muscle entrapment is a well-recognized complication of orbital fracture, wherein the inferior rectus muscle becomes lodged within the fracture fragments at the time of the initial trauma. New onset entrapment cannot occur without new force applied to the orbit, displacing the fragments and the inferior rectus. Theoretically, in complex orbital fractures, manipulation of disjunct fragments may apply pressure to the orbital contents and induce new entrapment in an otherwise non-operative orbital floor fracture. Here we present the only described case of new extraocular muscle entrapment after open reduction and fixation of a supraorbital rim and frontal sinus fractures and emphasize the need for careful assessment after repair of such a fracture to ensure that new entrapment has not occurred.

Two Cases of Orbital Blowout Fractures with Extraocular Muscle Entrapment in Children

Orbital blowout fracture is a common result of facial trauma and with the expanded use of endoscopy in orbital blowout fracture surgery, otolaryngologists are participating more often blowout fracture surgery. Because orbital blowout fracture may result in sequelae such as diplopia and enophthalmos, proper diagnosis and timing of repair are crucial. Orbital blowout fracture with extraocular muscle entrapment is uncommon and almost exclusively seen in children. It needs emergent release of entrapped muscle to prevent permanent sequelae (e.g., diplopia). The authors experienced two cases of orbital blowout fracture with extraocular muscle entrapment and had good surgical results without any sequelae. We report these cases with a review of the literature.

Inferior Oblique Entrapment After Orbital Fracture With Transection and Repair.

Extraocular muscle (EOM) entrapment with resulting reduction in motility and diplopia is a known complication of orbital fractures. Less commonly, transection of the EOMs due to trauma, iatrogenic injury, or intentional myotomy may lead to persistent diplopia. The inferior oblique (IO) is often encountered during orbital surgery along the medial wall and floor, and may be disinserted to aid in visualization. The authors present a case of IO entrapment which occurred during zygomaticomaxillary fracture reduction. Intraoperatively, an IO transection was performed and the muscle was reattached within the orbit. Postoperatively, the patient did not develop diplopia or motility disruption. This technique may provide a useful solution to an unusual problem during orbital fracture repair.

Characterization of Facial Trauma Associated with Standing Electric Scooter Injuries

Abstract This case series describes 34 patients presenting with facial injuries after standing electric scooter use at two academic emergency departments, 6/2018-5/2019. The severity of injuries highlights this important emerging health risk and policy implications.

Oculocardiac Reflex: An Underrecognized But Important Association With Orbital Trap Door Fractures.

Blowout fractures of the floor of the orbit can serve as a "trap door" for extraocular muscles. Presentation of inferior orbital muscle entrapment classically involves an upward gaze restriction. Diplopia and exophthalmos can also be present. Rarely, orbital fractures can result in an oculocardiac reflex, which is a triad of bradycardia, syncope, and nausea. The purpose of this study was to describe a patient who had orbital floor fracture with symptoms highly suggestive for oculocardiac reflex after a traumatic injury. Although entrapment of extraocular muscles does require early intervention to prevent ischemia and tissue necrosis, the presence of oculocardiac reflex warrants emergent evaluation and management by an ophthalmologist due to the risk of developing arrhythmias. Frequently, there may be none or very subtle clinical findings present, and abnormal motility may be the only apparent clinical sign, which can be difficult to assess in very young and uncooperative children; therefore, a high index of suspicion must be maintained for early identification and management as well as a reduction of complications.

Management of pediatric orbital wall fractures

ABSTRACTBackgraound: The purpose of this study was to review the clinical features of pediatric orbital wall fracture.Methods: The MEDLINE literature database was searched for English language articles containing the following keywords: “pediatric orbital wall fracture,” “pediatric orbital blow-out fracture,” “pediatric orbital trapdoor fracture,” “orbital floor fractures in children,” “orbital blow-out fractures in children,” and “orbital trapdoor fractures in children.” The authors critically evaluated the unique aspects of orbital wall fractures in children with regard to epidemiology, clinical presentation, surgical management, and outcomes.Results: Orbital wall fractures in children are less common compared with in adults. The pattern of orbital fracture changes as children age because of the ongoing evolution in pediatric facial skeletal anatomy. Although the management of pediatric orbital fractures continues to progress, a thorough clinical assessment with computed tomography scan imaging remains essential. Urgent surgical intervention is indicated in cases of entrapment or severe hypoglobus. Entrapment with oculocardiac reflex is common in white-eyed blow-out or trapdoor fractures. Otherwise, pediatric fractures can be treated conservatively with surveillance. A variety of autogenous and allogenic materials may be used to repair the fractured orbit.Conclusion: Adult treatment algorithms are often not ideal for the management of orbital fractures in children in major part due to differences in the maturing status of the craniofacial structures. A multidisciplinary approach that utilizes imaging studies, an awareness of occult extraocular muscle entrapment, and an emphasis on the findings on physical examination should be employed to diagnose and treat pediatric orbital floor fractures. These injuries can be grouped into two categories based on the status of inferior extraocular muscles, as follows: (1) entrapped or “trapdoor” floor fractures and (2) nonentrapped orbital floor fractures. The former requires earlier intervention.

Orbital fractures in children: clinical features and management outcomes

To report the clinical characteristics and management outcomes of orbital fractures in children. The medical records of pediatric patients (<18years of age) who presented with orbital fractures over a 15-year period (January 2001-December 2015) were reviewed retrospectively. The cause of injury, imaging findings, clinical features, management, and outcomes were noted. A total of 52 patients (39 males) were included. Mean age at presentation was 10.9years (range, 2-18). Road traffic accidents (18/52 [35%]) were the most common cause, with the orbital floor (42/52 [81%]) being the most common fracture site. The most common complaint was double vision (52%). Thirty-eight patients underwent surgical intervention, and extraocular muscle entrapment (56%) was the most common indication for surgery. Early surgical intervention within 15days of injury resulted in complete resolution of diplopia. In our study cohort, orbital floor fracture was most common. The trapdoor type of fracture was seen in almost half of the patients, with diplopia being the most common presenting complaint. Early surgical intervention was associated with complete resolution of ocular motility limitation and diplopia.s.

Comparison of clinicoradiological findings between patients with recovering diplopia and those with residual diplopia after surgery for pure orbital blowout fracture

PurposeDiplopia is a common symptom of blowout fracture (BOF), and can persist after proper surgical management. We compared clinicoradiological findings between patients with recovering diplopia and those with residual diplopia after surgery for orbital BOF. Materials and methodsWe retrospectively evaluated the CT images of 170 patients with orbital BOF and preoperative diplopia. We reviewed the following factors: sex, age, mechanism of injury, presence of diplopia before surgery, presence of enophthalmos before surgery, presence of an ocular motility abnormality before surgery, time interval between the trauma and surgery, fracture type, fracture size, volume of herniated orbital soft tissue, ratio of the volume of herniated orbital soft tissue to fracture size, number of points of contact between the extraocular muscle (EOM) and bony edge, EOM swelling, EOM swelling ratio, EOM displacement, EOM circling, EOM tenting, and EOM entrapment.The associations between the presence of diplopia 6 months after surgical repair and various clinicoradiological findings were analyzed using Wilcoxon rank-sum tests, Student's t-tests, Fisher's exact tests for univariable analysis, and logistic regression analysis for multivariable analysis. A Kaplan–Meier curve and log-rank test were used to identify the recovery status from diplopia. ResultsThe following findings were significantly different between patients with recovering diplopia and those with residual diplopia on univariable analysis (p < 0.05 for each): patient age, EOM entrapment, EOM circling, and EOM tenting. Multivariable analyses showed that patients who were older or those who had EOM circling or tenting on CT images had a greater probability of residual diplopia after surgery [p-values: 0.006, 0.013, and <0.001, respectively; odds ratio (95% confidence interval): 1.035 (1.010–1.061), 14.809 (1.775–123.556), and 4.851 (2.069–11.375), respectively]. The recovery rate for diplopia was significantly different between patients with EOM tenting and those without (p = 0.02). Additionally, young patients (0–12 years) showed a shorter recovery time from diplopia compared with older patients (>24 years) (p < 0.05). ConclusionPatients with residual diplopia after surgical management have different clinicoradiological findings compared with patients with recovering diplopia. Patients who are older, or those who have circling or tenting of the EOM on CT scans, are more likely to have residual diplopia.

Diplopia and the DVLA – Our responsibility

Introduction: Diplopia or double vision can occur with maxillo-facial trauma injuries including: ocular or orbital oedema, haemorrhage, displacement, damage to or entrapment of extra-ocular muscles or damage to cranial nerves III, IV and VI. Diplopia can also be residual post treatment. Testing for diplopia is part of a routine maxillo-facial assessment. Diplopia affects an individual's ability to drive safely. The Driver Vehicle Licence Authority (DVLA) states that patients with diplopia must inform the DVLA and must not drive. The General Medical Council (GMC) advises doctors they have a duty to inform the DVLA if they believe a patient has failed to comply.

Surgical Treatment of Orbital Blowout Fractures: Complications and Postoperative Care Patterns.

Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on an outpatient basis postoperatively (p = 0.04). For orbital blowout fractures, the number of immediate postoperative complications at our institution is low. In addition, North American trends in postoperative management of orbital blowout fractures may suggest that selected patients can be managed on an outpatient basis, which would have a positive effect on conservation of diminishing healthcare resources.

Safety of Outpatient Isolated Orbital Floor Fracture Repair.

Orbital fractures are common, accounting for nearly 40% of all facial fractures. Open repair is required to restore preinjury orbital volume and relieve any extra-ocular muscle entrapment. Monitoring for postoperative intraorbital hemorrhage, and its consequent potential for visual impairment, has triggered most surgeons to observe their patients in the hospital overnight postoperatively. The real risk of postoperative hemorrhage in this patient group, however, is uncertain and the need to contain healthcare costs clear. The objective of this study was thus to determine the incidence of emergent postoperative complications in patients undergoing orbital fracture repair to determine the feasibility of performing this operation on an outpatient basis. Patients who sustained isolated orbital fractures and underwent open repair at this level-1 trauma center between January 2002 and January 2012 using International Classification of Disease-9 and Current Procedural Terminology 2012 coding were identified. Demographic data and postoperative complications were identified by reviewing the electronic medical record. Furthermore, critical analysis of available published evidence was performed. Ninety-three patients who satisfied the inclusion criteria were selected. There were no patients of an intraorbital hematoma or other immediate postoperative complications that required operative intervention. Average hospital length of stay was 0.85 days. Repair of orbital fractures on an outpatient basis appears to be safe. The theoretical risk of a complicating intraorbital hematoma seems to be between 0 and 3.2%. This can be minimized through: the use of open surgical access site and perforated floor replacement materials, careful early monitoring, education of patients, and admission of those at potentially elevated risk.