Int. J. Oral Maxillofac. Surg.

2015; 44: 433–440

http://dx.doi.org/10.1016/j.ijom.2014.12.003, available online at http://www.sciencedirect.com

Systematic Review
Trauma

Controversies in orbital L. Duboisa, S. A. Steenena,

P. J. J. Goorisa, M. P. Mouritsb,
A. G. Beckinga

reconstruction—II. Timing of
a
Department of Oral and Maxillofacial
Surgery, Academic Medical Centre of
Amsterdam, Academic Centre for Dentistry
Amsterdam, University of Amsterdam,

post-traumatic orbital Amsterdam, The Netherlands; bDepartment

of Ophthalmology, Orbital Unit, Academic
Medical Centre of Amsterdam, University of

reconstruction: A systematic
Amsterdam, Amsterdam, The Netherlands

review
L. Dubois, S. A. Steenen, P. J. J. Gooris, M. P. Mourits, A. G. Becking:
Controversies in orbital reconstruction—II. Timing of post-traumatic orbital
reconstruction: A systematic review. Int. J. Oral Maxillofac. Surg. 2015; 44: 433–
440. # 2014 International Association of Oral and Maxillofacial Surgeons. Published
by Elsevier Ltd. All rights reserved.

Abstract. The timing of orbital reconstruction is a determinative factor with respect to

the incidence of potential postoperative orbital complications. In orbital trauma
surgery, a general distinction is made between immediate (within hours), early
(within 2 weeks), and late surgical intervention. There is a strong consensus on the
indications for immediate repair, but clinicians face challenges in identifying
patients with minimal defects who may actually benefit from delayed surgical
treatment. Moreover, controversies exist regarding the risk of late surgery-related
orbital fibrosis, since traumatic ocular motility disorders sometimes recover
Keywords: Orbit; Trauma; Classification;
spontaneously and therefore do not necessarily require surgery. In this study, all
Orbital fractures; Blowout fractures;
currently available evidence on timing as an independent variable in orbital fracture Reconstruction; Timing.
reduction outcomes for paediatric and adult patients was systematically reviewed.
Current evidence supports guidelines for immediate repair but is insufficient to Accepted for publication 1 December 2014
support guidelines on the best timing for non-immediate orbital reconstruction. Available online 25 December 2014

Introduction
Clinical decision-making in the manage-
ment of patients with orbital fractures is
challenging, and various aspects of orbital
fracture management are still debated.
Controversies exist regarding the indica-
tions for surgery, the timing of surgery,
and the best reconstruction material. To
date, no uniformly accepted guidelines
have been developed for the maximal
interval between trauma and reconstruc-
tive surgery. However, in many other
fields of trauma surgery, an increasing
body of evidence is stressing the impor-
tance of the optimal timing of surgery.1
Early revision and repair of blowout
fractures has been considered the first-line
treatment for optimal surgical outcome.2
The major clinical outcome parameters in
patients with orbital fractures include
functional impairment (vision, extraocular
muscle motility disorders, and diplopia),
cosmetic disturbance (enophthalmos), and
infraorbital hypaesthesia. Ocular motility
disturbances due to orbital fractures are
often related to contused ocular muscles

0901-5027/040433 + 08 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
434 Dubois et al.
and post-traumatic oedema. In the 1970s,
it was observed that contused ocular mus-
cles usually recover spontaneously within
1 or 2 weeks, thus a conservative approach
was suggested in order to avoid surgery-
related complications.3 The introduction
of computed tomography (CT) provided
increasingly accurate information on the
extent of the fractures and the presence of
herniated tissue, and resulted in CT-based
treatment protocols in the 1980s and
1990s. The focus of the debate on optimal
timing has since then shifted from the
indications for early intervention towards
the question of which patients are eligible
for delayed repair. In general, a distinction
needs to be made between immediate
(within hours), early (within 2 weeks),
and delayed late orbital reconstruction.
There is consensus on the indications for
immediate surgery. An emergency situa-
tion in orbital trauma exists if a retrobulbar
haematoma develops with apical compres-
sion of the globe or the optic nerve in
combination with impaired vision. These
conditions are an indication for immediate
surgery within 6 h after presentation.4,5,6
Another indication for urgent surgical in-
tervention is muscle incarceration and pos-
sible ischaemia in the paediatric patient.
New light was shed on the timing issue
by Jordan et al.7 in 1998, who found that
although children under the age of 16 years
presenting with diplopia and vertical gaze
restriction (‘white-eyed blowout fractures’)
might show little or no radiological evi-
dence of muscle entrapment, this patient
category is vulnerable to the development
of eye motility disorders that are highly
resistant to surgery. Parbhu et al.8 found
that CT evidence for soft tissue entrapment
in children is easily missed or underesti-
mated by radiologists because of the
trapdoor mechanism. Minor muscle entrap-
ment in children may rapidly result in
muscle fibrosis followed by persistent dip-
lopia, and requires intervention within 2–4
days. In addition, the oculocardiac reflex,
due to orbital wall fractures and vagal
stimulation in children, causes serious bra-
dycardia with potential life-threatening
complications.6,9,10,11
Indications for early intervention within
2 weeks have also been reported in the
literature, and include enophthalmos larg-
er than 2 mm with significant hypoglobus
or diplopia.12 Large displaced fracture
defects generally require surgery within
2 weeks, since the development of
enophthalmos is anticipated. Enophthal-
mos may be obvious at the time of presen-
tation, but may be masked by oedema or
haematoma. However, if surgery is
delayed until enophthalmos is apparent,
fibrosis may develop between orbital soft
tissues, the sinus mucosa, and bone frag-
ments. To prevent fibrosis of the injured
orbital tissue, early repair within 2 weeks
has been proposed for patients who
have clinically unimproved diplopia with
radiological evidence of orbital tissue
compression.13 Delaying the operation
further may increase the complexity of
the reconstruction14 and introduce the risk
of additional complications, such as sinus-
itis, dacryocystitis, late ptosis, and func-
tional deficits (e.g. enophthalmos,
hypoglobus, and diplopia).12
Delayed reconstructions are commonly
indicated in patients who have developed
aesthetically disturbing enophthalmos or
persistent diplopia 2 weeks after trauma.
In these patients, the indication for surgical
intervention may be uncertain in the early
stages after trauma. This uncertainty
applies specifically to small orbital defects,
e.g. in patients with orbital fractures who
have good ocular motility and only slight
displacement of the orbital content. In a
retrospective study, Dal Canto and Linberg
14 found similar complication rates be-
tween orbital floor and/or medial wall frac-
ture repairs conducted within 14 days and
those performed 15–29 days after trauma.
However, the majority of studies10,11,15–18
support early reconstruction because of the
better postoperative results and a decreased
incidence of diplopia and enophthalmos.
These outcomes are thought to result from
reduced scarring of soft tissue.10,11,15–18
The initial contusion, shearing, and lacera-
tion cannot be prevented; however, early
reversal of an ongoing tissue crush or
severe stretch might limit late fibrosis, es-
pecially in cases of fractures with dispro-
portionate soft tissue displacement.11
If an orbital wall defect needs recon-
struction, several decisions need to be
made on the timing of surgery. The aim
of the present study was to systematically
review all the available controlled clinical
trials on post-traumatic orbital reconstruc-
tion with a focus on the timing, or delay of
surgery.
Methods
A systematic literature search in PubMed
(updated 14 September 2013; all indexed
years) with multiple search terms was per-
formed, combining the subjects ‘orbital
fracture’, ‘timing’, and ‘delay’. The search
excluded case series with 10 or fewer sub-
jects, and the language was restricted to
English, German, and Dutch. All prospec-
tive and retrospective human clinical stud-
ies reporting comparative data regarding
the interval between the injury and the
reconstructive orbital surgery and also the
outcome of the orbital fracture treatment
met our entry criteria; these studies could
include either adults or children. During
the primary review process (performed in
accordance with the PRISMA criteria,
(preferred reporting items for systematic
reviews and meta-analyses) for systematic
reviews19), two authors (SS and LD)
assessed the relevance of the retrieved arti-
cles based on the abstracts. In a secondary
review, full articles were retrieved and
relevant articles were included. Any dis-
agreements were resolved through discus-
sions with a third person (PG). Fig. 1 shows
a flow diagram of the inclusion process.
The PubMed search terms (all indexed
years) were as follows: ((((‘‘Orbital Frac-
tures’’[Mesh] OR orbital fracture*[tiab]
OR orbit fracture*[tiab] OR orbital trau-
ma*[tiab] OR orbit trauma*[tiab] OR or-
bital injur*[tiab] OR orbit injur*[tiab] OR
orbital wall fracture*[tiab] OR orbital wall
injur*[tiab] OR orbital wall trauma*[tiab]
OR orbital floor fracture*[tiab] OR orbital
floor injur*[tiab] OR orbital floor trau-
ma*[tiab] OR blow-out fracture*[tiab]
OR blowout fracture*[tiab] OR supraor-
bital fracture*[tiab] OR trapdoor frac-
ture*[tiab] OR malar fracture*[tiab] OR
tripod fracture*[tiab] OR orbitozygomatic
fracture*[tiab] OR orbito-zygomatic frac-
ture*[tiab] OR zygomatico-orbital frac-
ture*[tiab] OR tripartite fracture*[tiab]
OR (le fort[tiab] AND fracture*[tiab])
OR (lefort[tiab] AND fracture*[tiab])))
AND (‘‘Time’’[Mesh] OR time[tiab]
OR timing[tiab] OR delay*[tiab] OR
moment[tiab] OR wait*[tiab] OR early[-
tiab] OR late[tiab] OR week*[tiab] OR
day[tiab] OR days[tiab])) NOT (case
reports[pt] NOT (cases[tiab] OR series[-
tiab] OR group[tiab] OR patients[tiab] OR
review[tiab] OR retrospective[tiab])))
AND (English[la] OR Dutch[la] OR Ger-
man[la]).
Results
In the systematic search, a total of 17
studies including 1579 patients with orbit-
al injuries were identified (Tables 1–3).
Prospective studies
Several prospective studies on orbital frac-
ture surgery specified the timing of the
reconstruction. The timeframe reported typ-
ically ranged from immediate repair
to repair within 1 month after the inju-
ry,20,21,22,23,24,25 with the exception of one
study in which the maximum interval ran-
ged up to 3 months after trauma.26 Nonethe-
less, only two of these studies analysed the
 Controversies in orbital reconstruction—II. Timing of post-traumatic orbital reconstruction
Initial PubMed search
792 Hits (all indexed years)
After primary review (reading
abstracts)
23 Articles
After secondary review (reading full-text
articles)
2 Prospective studies
1 RCT
1 Cohort study
15 Retrospective studies
9 Adult population studies
4 Paediatric population studies
2 Studies involving all ages
Fig. 1. Flow diagram of the present review performed in accordance with the PRISMA criteria.
actual effect of timing as a variable in the
clinical outcome measures (Table 1).20,21
One randomized controlled trial by
Bayat et al.20 compared the effects of nasal
septal cartilage (n = 11) with conchal car-
tilage (n = 11) for orbital blowout fracture
reconstruction, and found that timing the
reconstruction to <4 weeks after the injury
had a significant positive effect on postop-
erative enophthalmos. However in this
study, the timing of the operation was not
randomized over the groups, and it was not
specified why the subjects were treated ear-
lier or to which groups they were allocated.
In addition, a cohort study by Kontio
et al.21 followed 24 subjects with orbital
floor fractures (of whom 13 had associated
facial fractures) for a mean 234 days
(range 146–406 days), and found no cor-
relation between the timing of the opera-
tion (mean 7 days, range 0–26 days) and
the outcome of postoperative diplopia.
Collectively, the results suggest that the
prospective studies have not provided
Excluded after primary
review: 769 articles
722 Off-topic
27 Animal studies
20 Cadaver studies
Excluded after secondary
review: 6 articles
Did not analyse the timing of
repair as a variable in the
surgical outcome
evidence on whether to perform early,
delayed, or late orbital reconstruction.
Retrospective studies
There are numerous retrospective studies
in the literature providing descriptive data
on the timing of orbital reconstruction.
However, only 15 studies were found that
reported comparative analyses on the ef-
fect of surgical timing on various clinical
outcome measures (Tables 2 and 3). Nine
of these studies included only adult
patients,14,27–34 four studies only paediat-
ric patients,7,35–37 and two included both
adults and children.38,39
With regard to adult orbital fractures,
four studies found a statistically signifi-
cant positive effect of the earlier timing of
surgery on clinical outcome measures
(enophthalmos and ocular motility),27,31,
33,34
whereas five studies were inconclu-
sive (Table 2).14,28–30,32
435
With regard to paediatric orbital frac-
tures, one study with paediatric patients
found a statistically significant correlation
between surgery performed within 3
weeks and diplopia at long-term follow-
up,36 while five studies were inconclusive
(Table 3).7,35,37–39
In summary, two retrospective studies
found some advantageous effects for
surgery performed at <2 weeks for
adults, although six studies found no
significant differences, and one of six
studies in paediatric patients provided
evidence for a correlation between ear-
lier repair and the occurrence of diplopia
and extraocular motility disorders.
Discussion
This review identified two prospective and
15 retrospective trials concerning the
effects of surgical timing on post-traumatic
orbital reconstruction outcomes. Although
most authors agree on the indications for
immediate intervention, no randomized
controlled trials have evaluated the effects
of surgical timing as an independent vari-
able on clinical outcome measures. A
strong limitation to the majority of studies
is that the reasons for the different time
intervals between trauma and reconstruc-
tion chosen by the clinicians and institu-
tions are rarely specified. It has been
proposed that early surgical intervention
may improve the ultimate outcome, but
identifying patients at risk of late compli-
cations remains challenging.40 Although
there is strong consensus on the indications
for immediate repair, current available data
are insufficient to provide a solid base for
guidelines on optimal timing of orbital
fracture reduction.
Quantification and analysis of orbital
trauma is highly complex due to the het-
erogeneous nature of the injuries. First,
orbital volume is dependent on soft tissue
components, which tend to change over
time (e.g. post-traumatic oedema, incar-
ceration of peri-orbital tissue, late fibrosis,
and late atrophy). Second, the size and
location of the bony defect and volumetric
changes can be critical factors with regard
to the clinical outcome.41 Differences in
results between studies must thus be inter-
preted with caution.
Orbital wall fracture reconstruction it-
self may produce dissatisfactory results,27
such as persistent diplopia or enophthal-
mos. For the development of evidence-
based treatment guidelines, it is necessary
to review and investigate all variables that
influence these outcomes.41 Some logisti-
cal factors such as patient delay, doctor’s
delay, and the availability of operating
436 Dubois et al.
Table 1. Overview of prospective studies on the timing of surgical orbital fracture repair, 2006–2010.
Study Fracture
[Ref.] Design type
Bayat Randomized Blowout
et al.20 controlled fractures
clinical trial
Kontio Cohort study Isolated floor
et al.21 (11) and floor
with associated
facial fracture
(13)
NS, not significant; SD, standard deviation; N/A, not available.
rooms may influence the timing of
surgery. Recent studies have shown that
technological advancements such as pre-
operative planning, rapid prototyping,
customized implants, and intraoperative
navigation may influence the predictabili-
ty of the orbital reconstruction.42–45 How-
ever, additional unwanted effects of new
technologies can include the need for extra
time and manpower for planning, prepar-
ing, and performing surgery. It has been
reported that the surgeon’s experience
may also be an important factor in the
outcome of complex reconstructions.46,47
After 1–2 weeks, most swelling has dis-
appeared, which allows a more cosmetic
assessment. Extra time may therefore
prove to be a co-variable positively influ-
encing the outcome of reconstruction.
A minimally displaced orbital fracture
is generally referred to as a ‘small frac-
ture’. However, a significant transient dis-
placement of bone fragments at the time of
injury may remain unnoticed after the
entrapped soft tissues have snapped back
into position. In these cases, motility rath-
er than volume is the primary concern, and
surgery is usually advised only if there is
clinically significant diplopia that does not
resolve within 2 weeks, when most of the
acute swelling has disappeared. Putterman
et al.3 were the first to evaluate this con-
servative approach. Some years later, the
Amsterdam-Korneef group found that
Number Interval from
Surgical of injury to surgery
technique patients (delay)
Nasal septal 22 <4 weeks: n = 8
cartilage (11) >4 weeks: n = 13
vs. conchal
cartilage (11)
Autogenous 24 7 Days
iliac cortical (range 0–26)
graft
diplopia in blowout fractures due to oede-
ma, haematoma, or oculomotor nerve pal-
sy (n = 17) recovered spontaneously
within 1 year after injury in all patients.48
Since it has been shown that entrapment is
easily missed or underestimated in CT
scans of younger patients (<16 years of
age) who present with diplopia and/or
motility disturbances after trauma, the
conservative approach applied to children
may lead to eye motility disorders highly
resistant to surgery.7,8 These patients are
likely to benefit from immediate or early
intervention.
Entrapment of peri-orbital tissue may
lead to early fibrosis followed by persis-
tent diplopia.8 Nowinski et al.36 have
shown an association between early recon-
struction and the prevention of fibrosis.
However, five other studies on paediatric
patients found no differences between
groups.7,35,37–39 Everhard-Halm et al.48
demonstrated a complex network of fi-
brous septa that functionally unite the
sheath of the inferior rectus muscle, the
fibro-fatty tissues, and the periosteum of
the orbital floor. In orbital fractures, mo-
tility may be limited by displacement of
this entire complex, or by entrapment of
any of its components. It is unclear which
tissue types (peri-orbital content such as
fat, septa, periosteum, or muscle) are re-
sponsible for late motility disorders, and it
should be specified whether the inferior
Follow-up Results
3–6 At baseline, differences
Months in the mean values of
the enophthalmos
between patients
treated within or after 4
weeks of injury were
non-significant (mean
(SD), 4.8 (0.89) vs. 5.1
(0.8) mm, respectively;
P = NS). However, the
mean correction of the
enophthalmos (and
residual enophthalmos)
was significantly
higher (and lower) at
each follow-up visit in
patients who were
treated within 4 weeks
of injury (P = N/A)
5–13 Timing of the operation
Months did not affect the
occurrence of diplopia
(P = N/A)
rectus muscle or the inferior oblique mus-
cle contributes most to motility limita-
tions.
Enophthalmos related to shredding of the
fat of the peri-orbit due to trauma or surgery
is difficult to predict. Overcorrection in
reconstructive surgery is sometimes recom-
mended, but it is unknown to what extent. A
core benefit of early intervention is the
reduction of fat atrophy. A recent consen-
sus is that early reconstruction results in
less enophthalmos because of minimal soft
tissue scarring.10,11,15–18 The initial haema-
toma with contusion, shearing, and lacera-
tion of the orbital content cannot be
prevented, but early reconstruction may
limit damage to the fatty tissue.11 This
theory states that late reconstruction leads
to novel haematoma formation and may
therefore subsequently cause even more
fatty tissue atrophy. However, supporting
evidence remains limited.
It should be noted that in rare cases,
surgery may also be delayed because of
contraindications such as the patient’s
general condition not allowing surgery,
an orbital fracture near the only seeing
eye, or severe ocular injury (e.g. retinal
detachment, ruptured globe, hyphema, or
traumatic optic nerve lesions).
Orbital reconstruction is challenging
because of the high level of unpredict-
ability. A perfect anatomical reconstruc-
tion does not guarantee a perfect
Table 2. Overview of retrospective studies on the timing of surgical orbital fracture repair in adults, 1983–2013.
Number Interval from injury to
Study [Ref.] Design Fracture type of patients surgery (delay) Follow-up Results
Hawes and Consecutive Orbital floor fractures 51 <2 Months (n = 43) >6 weeks ‘Early’ vs. ‘late’ repair
Dortzbach31 case series (either with diplopia or vs. >2 months (n = 8) Enophthalmos postoperative: 7% vs. 50%
enophthalmos) (P < 0.002)
Motility ‘satisfactorily’ corrected: 88% vs.
40% (P < 0.02)

Controversies in orbital reconstruction—II. Timing of post-traumatic orbital reconstruction

Verhoeff et al.30 Chart review Orbital trauma with 28 <2 Weeks vs. >2 weeks >6 months Higher complete recovery rate in earlier
subsequent motility <2 Months vs. >2 months repair (73% <2 weeks vs. 40% <2 months
disorders needing repair vs. 25% >6 months); P = N/A
Harris et al.33 Cohort study Orbital floor fracture with 30 Mean 16/24 days 4–10 weeks Higher than median ocular motility outcome
or without medial wall Range 1–2920 days postop. in patients treated < 1 week; P = N/A
extension, and diplopia
Matteini et al.28 Chart review Pure orbital fractures 108 <2 h, 2–24 h, 1–3 Days, 2–6 months ‘Strong relation’ between timing of surgery
3–7 days, 7–12 days (mean 4 months) and the variables ‘functional impairment or
muscle entrapment’ and ‘serious conditions
of compression or ischaemia’; P = N/A
Dal Canto and Chart review Orbital fractures (floor 58 <14 Days (n = 36) vs. >3 weeks No significant difference between ocular
Lindberg14 and/or medial wall) 15–29 days (n = 22) motility (preop. and postop.), self-reported
diplopia, and strabismus between ‘early’
and ‘delayed’ groups. Time to resolution or
stability of diplopia postop. independent of
the time to surgery
Simon et al.32 Consecutive Orbital floor fracture with 50 <2 Weeks vs. >2 weeks No apparent difference between early and
case series entrapment or late repair. Repair <2 weeks was associated
enophthalmos with less improvement in enophthalmos vs.
>2 weeks (delta 0.2  1.1 vs.
1.3  1.9 mm, P = 0.02)
Shin et al.29 Chart review Orbital fractures with 233 <14 Days vs. 15–30 days >6 months No significant difference in degree of preop.
diplopia or motility and postop. diplopia, motility restriction,
restriction and enophthalmos between the two groups
Brucoli et al.27 Chart review Blowout fractures without 51 <2 Weeks vs. >2 weeks 6–81 months Timing of surgery at <2 weeks vs. >2
orbital rim involvement (mean 39 months) weeks was significantly associated with a
positive influence on diplopia at long-term
follow-up (P < 0.05), on postop.
enophthalmos (P < 0.05), and on
infraorbital hypaesthesia (P < 0.05)
Shin et al.34 Chart review Pure blowout fractures 952 <3 Days, 4–7 days, 8–14 There was no significant difference in the
days, 15–30 days, >1 month improvement of diplopia according to
timing of surgery (P < 0.05, McNemar test),
but timing of surgery (operated after 1 week)
was significantly related to postoperative
extraocular movement limitation and
enophthalmos (P > 0.05, McNemar test)
N/A, not available.

437
 438
Table 3. Overview of retrospective studies on the timing of surgical orbital fracture repair in children, 1998–2011.
Number Interval from injury
Study [Refs.] Design Fracture type Age, years of patients to surgery (delay) Follow-up Results

Dubois et al.
Jordan et al.7 Chart review Post-traumatic 4–18 20 Range 48 h–40 days 4 Weeks to 1 year In patients who had surgery
enophthalmos or <48 h: n = 5 within 4 days (n = 5), symptoms
diplopia with >48 h to <4 days: n = 1 resolved between 3 and 6 weeks
motility disorder; >14 to <40 days: n = 14 postop
‘white-eyed blowout’ Patients who had surgery at 2–3
weeks tended to show slower
symptom resolution (over
months); 3 patients had
permanent restriction (P = N/A)
Gerbino et al.35 Chart review Trapdoor fractures 6–16 24 Range <24 h–192 h Average 36 months A correlation was found between
<24 h: n = 12 (‘urgent’) timing (<24 h vs. >24 to <96 h
>24 to <96 h: n = 8 (‘early’) vs. >96 h) with regard to residual
>96 h: n = 4 (‘delayed’) diplopia (8.3% vs. 37.5% vs.
100%) at follow-up (P = N/A)
Wang et al.37 Chart review Blowout fracture 5–18 41 0–2 Days: n = 4 (‘immediate’) Mean 6.5 months Higher mean changes in
(Mean 12.7) 3–14 Days: n = 18 (‘early’) (range 0.3–59) supraduction limitation when
15–30 Days: n = 11 (‘delayed’) operated after 3–14 days vs. <2
>30 Days: n = 8 (‘late’) days (P = 0.47). Surgery at <1
month: 60% complete resolution
of preop. motility restriction and
51.6% complete resolution of
diplopia at follow-up, vs. 0%
improvement of diplopia and
motility when operated at >1
month (P = N/A)
Ethunandan Case series Blowout fracture 4–53 10 Range 0–41 days Mean 5.1 months No diplopia at follow-up in
and Evans39 with painful gaze (Mean 19.6) (mean 12.3 days) (range 1–12) patients who had surgery within 7
restriction days. One patient treated at 20
days had troublesome diplopia
that required extraocular muscle
surgery. None of the other
patients, including one treated 41
days after injury, had any relevant
residual diplopia (P = N/A)
Amrith et al.38 Consecutive Blowout fracture 7–76 63 (13 <1 Week, >1 week >6 Months (53%) Children had earlier surgery than
case series (Median 27) Children) <6 Months (47%) adults (P < 0.001) and tended to
have better motility outcomes
than adults (however, P = 0.684).
Surgery at <1 week showed a
trend towards better motility
outcomes (P = 0.231)
Nowinski et al.36 Chart review Complex orbital 5–15 14 <3 Week: n = 11 (‘early’) 4.7 Years Correlation between surgery at
fractures in (Mean 9.4) >3 Week: n = 3 (‘postponed’) (range 1.2–13.1) >3 weeks and diplopia at long-
combination with term follow-up (P = 0.04,
traumatic brain injury Fisher’s exact test)
N/A, not available.
 Controversies in orbital reconstruction—II. Timing of post-traumatic orbital reconstruction 439

Table 4. Criteria for orbital fractures.

Immediate Early Delayed
Time frame Within 24 h 1–14 Days >14 Days
Indications  Diplopia with CT evidence of an  Early enophthalmos/hypoglobus  Symptomatic diplopia without
entrapped muscle or peri-orbital causing facial asymmetry proven entrapment on CT
tissue associated with a  Symptomatic diplopia with positive examination, negative forced
non-resolving oculocardiac reflex: forced duction, evidence of an duction, and minimal clinical
bradycardia, heart block, nausea, entrapped muscle or peri-muscular improvement over time
vomiting, or syncope soft tissue on  Late-onset enophthalmos/hypoglobus
 ‘White-eyed blowout fracture’, CT examination
young patient (<18 years), history  Large floor fracture (<50% surface
of peri-ocular trauma, little displaced) causing latent enophthalmos
ecchymosis or oedema (white eye),
marked extraocular motility vertical
restriction, and CT examination
revealing an orbital floor fracture
with entrapped muscle or
peri-muscular soft tissue
Significant globe displacement with
vision threatening emergency
CT, computed tomography.

aesthetic and functional outcome, be-
cause soft tissue involvement poses dif-
ficulties in predicting the long-term
effect on function and aesthetics .41 Dif-
ferent aspects of timing are believed to
influence surgical outcome both posi-
tively and negatively. Based on this
systematic review, it is our opinion that
the Burnstine criteria must be critically
revisited (Table 4).
In conclusion, this systematic review
has analysed currently available data
and it is concluded that insufficient data
are available to provide a robust basis for
guidelines on the best timing of orbital
reconstruction. The evidence for early
post-traumatic orbital reconstruction is
limited to expert opinions and retrospec-
tive analyses. Several confounders, such
as local standards, available operating
room time, legal matters, and insurance,
may influence the clinician’s decision with
regard to the timing of reconstruction.
Prospective studies are required, and
should evaluate the extent of bony orbital
trauma, whether soft tissue entrapment is
present, the origin of the tissue involved,
and how much time has elapsed between
the trauma and diagnosis. Age has been
shown to play an important role in the
timing of surgical intervention. Adequate
follow-up to record potential postopera-
tive complications is essential. Future re-
search must strive to establish a
relationship between the extent of the
trauma, the time between trauma and in-
tervention, and age.
Funding
None.
Conflict of interest statement
None declared.
Ethical approval
Not required.
Patient consent
Not required.
Acknowledgement. We would like to thank
Ingeborg M. Nagel, clinical librarian, for
assistance in identifying appropriate
search terms.
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Corresponding author
Tel.: +31 20 5661364
fax: +31 20 5669032
E-mail: L.Dubois@amc.uva.nl