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Original article  47

Influence of time on the management of complications

of orbital floor fracture
Ayman Abd El-Ghafar

Department of Ophthalmology, Ophthalmic Purpose

Center, Faculty of Medicine, Mansoura
University, Mansoura, Egypt
Correspondence to Ayman Abd El-Ghafar, MD,
Department of Ophthalmology, Ophthalmology
Center, Faculty of Medicine, Mansoura
University, Mansoura 35516, Egypt
Tel: +20 502 216 440; fax: 2202207
e-mail: aiman_eg_123@yahoo.com
Received 11 November 2014
Accepted 29 April 2015
Journal of Egyptian Ophthalmological Society
2015, 108:47–51
The aim of this work is to evaluate the influence of time elapsed between the occurrence of
orbital floor fracture and management on improvement of complications.
Patients and methods
This is a prospective comparative interventional study that including 17 patients with pure orbital
floor fracture (without involvement of the orbital rim) who presented to Mansoura Ophthalmic
Center from January 2012 to September 2012; they presented with diplopia with or without
enophthalmos. For all cases, computed tomography-coronal cuts were performed. For all
cases, repair of the orbital floor fracture was performed using a titanium mesh. For cases
that had persistent diplopia after repair because of restrictive myopathy, adjustable inferior
rectus recession was performed. Those who did not achieve correction after recession were
corrected by prisms. Cases were followed for 6 months after surgery.
Results
This study included 17 cases with pure orbital floor fracture. They were divided into two groups
according to the time of presentation after trauma: group A included seven (41.2%) patients
who were operated within 3 weeks of trauma and group B included 10 (58.8%) patients who
were operated after 3 weeks up to 6 months of trauma. In group A, all cases presented with
diplopia in up gaze; however, one (14.3%) case presented with enophthalmos more than 2 mm.
In group B, all cases presented with diplopia in up gaze and three (30%) of them presented
with enophthalmos more than 2 mm. In group A, diplopia and enophthalmos were completely
resolved after surgical repair of orbital floor fracture; however, in group B, diplopia improved
only in two (20%) cases, but cases of enophthalmos were completely resolved. Among the
remaining eight (80%) patients with persistent diplopia who underwent adjustable inferior
rectus recession, seven (70%) patients improved and only one (10%) patient had persistent
diplopia that was corrected with prisms.
Conclusion
Early repair of orbital floor fracture (within 3 weeks) leads to complete improvement in diplopia;
however, late repair in most of the cases needs inferior rectus recession and sometimes prism
correction. However, enophthalmos is not affected by the time of repair.

Keywords:
diplopia, enophthalmos, influence of time on floor fracture, orbital floor fracture, proptosis

J Egypt Ophthalmol Soc 108:47–51

© 2015 The Egyptian Ophthalmological Society
2090-0686

adopt a more conservative approach to the

Introduction
Blowout fractures are repaired on the basis of the
clinical symptoms and signs of the patients, although
reconstruction may not completely resolve the cosmetic
and functional problems. Recognized sequelae of orbital
blowout fractures include enophthalmos, diplopia
from extraocular muscle dysfunction, infraorbital
nerve anesthesia, disfiguring facial contour, and
tearing because of the obstruction of the nasolacrimal
duct [1–3].
Pure orbital floor fractures (no inferior orbital
rim involvement) have several indications for
surgical intervention: diplopia secondary to soft
tissue entrapment within the orbital floor defect,
enophthalmos greater than 2 mm, or a clinically
significant fracture [4]. Some oculoplastic surgeons
2090-0686 © 2015 The Egyptian Ophthalmological Society
management of pure orbital floor fractures, but will
intervene immediately if patients have entrapment and
a nonresolving oculocardiac reflex, a trap-door fracture,
early enophthalmos, or hypoglobus [1].
Entrapment of extraocular soft tissues (muscle, fat, and
connective tissue) within the orbital floor defect can
cause diplopia, restricted, and/or painful vertical gaze,
which can persist without intervention [5].
Enophthalmos is a condition where the globe recedes
posteriorly and inferiorly as extraocular support
systems of the globe become disrupted and displaced
bone fragments alter the boundaries of the orbital
cavity. Signs may not be present initially because of soft
tissue swelling and bruising, which is why surgeons
will operate to prevent enophthalmos if the size of the
DOI: 10.4103/2090-0686.161389
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48  Journal of Egyptian Ophthalmological Society
defect is greater than or equal to 50% of the orbital
floor or greater than 2 cm2 [5]. The high-resolution
computed tomography scan can be used with a forced
duction test to assess for indications to intervene.
Surgical intervention, when indicated, should be
prompt because subsequent scarring decreases the
efficacy of future intervention [6].
Early repair (<2 months) yielded better results than
late repair (>2 months) in terms of both enophthalmos
and extraocular muscle dysfunction, and early repair
of large fractures, preferably within two weeks after
injury, is recommended [6].
Surgical repair of blowout fractures within two weeks
of trauma decreases the incidence of residual diplopia
and enophthalmos [7].
Patients and methods
This is a prospective comparative interventional
study that included 17 patients with pure orbital
floor fracture (the orbital rim was not involved) who
attended Mansoura Ophthalmic Center from January
2012 to September 2012; they presented with diplopia
with or without enophthalmos at different periods after
trauma ranging from 10 days to 6 months (Fig.  1a).
For all cases, a full ophthalmological examination was
performed including history of the cause of trauma, date
of trauma, epistaxis, diplopia, loss of sensation on the
cheek, fainting with eye movement, and any previous
surgical interference. Visual acuity testing using
Landolt’s broken rings, examination of the anterior
segment using the slit lamp, and posterior segment
using indirect ophthalmoscopy were performed to
exclude any effect of trauma on the globe.
Examination of ocular motility was performed in all
directions of the gaze to detect limitations of ocular
motility that affect the up and down gaze in orbital
floor fracture due to entrapment of the inferior rectus
muscle or soft tissue around.
Detection of enophthalmos or proptosis in comparison
with the other side using Hertl’s exophthalmometer
and determination of the degree of enophthalmos.
The sensation on the infraorbital area was tested to
detect infraorbital anesthesia because of injury of
the infraorbital nerve. As all cases presented with
diplopia, a forced duction test was performed to detect
any restriction in the inferior rectus muscle. Topical
anesthesia was used (benoxinate 0.4%), a speculum
was applied, two nontoothed forceps were applied at
the limbus at 3 and 9 o’clock, gentle forward traction
was applied to the globe, then the globe was mobilized
upward and downward, and any limitation was noted.
Computed tomography was performed for all cases
and we ordered thin coronal cuts (2–3 mm) slices that
would detect any defect in the orbital floor (Fig. 1b).
Also, axial cuts were used to detect associated medial
wall fracture. In all cases, there was entrapment of
the inferior rectus or surrounding tissues through the
defect in the orbital floor and four of them presented
with enophthalmos more than 2 mm.
Operative techniques
After obtaining written consent and ethical approval,
all cases were operated under general anesthesia.
A subciliary incision was used in all cases for wider
exposure, the periosteum was opened 2 mm below
the inferior orbital rim and elevated posteriorly with
a periosteal elevator, and all prolapsed tissues were
elevated from the fracture site until the entire defect in
the orbital floor became obvious (Fig. 1c).
We used titanium mesh of 0.6 mm thickness to cover
the defect and we tailored the mesh to cover the defect
all around and to ensure that no residual tissue was
present under the mesh. Then, the mesh was fixed
to the orbital floor through two holes in the anterior
portion of the mesh using two self-drilling titanium
screws 4 mm in length. Now, the mesh covered the
entire defect and the prolapsed tissues were above the
mesh (Fig. 1d).
During dissection and after application of the mesh,
the pupil was examined for any dilatation, which
means compression of the optic nerve that would
require immediate release of that compression. Then,
Figure 1
(a) Right eye shows limitation in up gaze and enophthalmos in a
patient with right orbital floor fracture. (b) Computed tomography both
orbits (coronal cut) shows right orbital floor fracture with entrapment of
inferior rectus and surrounding tissues. (c) Intraoperative exposure of
the fracture in the orbital floor. (d) Repair of the fracture using titanium
mesh after repositioning of the prolapsed contents.
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Orbital floor fracture Abd El-Ghafar  49

the periosteum was closed with polyglactin 5/0 sutures In group A, diplopia and enophthalmos were
and the skin was closed with black silk 5/0 sutures. completely resolved after surgical repair of the orbital
floor fracture (Fig. 2a and b).
Postoperative systemic antibiotics and analgesic were
used for one week and silk sutures were removed after In group B, diplopia improved only in two (20%)
5 days. Cases were followed for improvement in diplopia, cases and eight (80%) cases did not improve
limitation of ocular motility, and enophthalmos. because of restrictive myopathy of inferior rectus
muscle; however, three cases of enophthalmos were
Patients who did not show improvement in diplopia
because of restrictive myopathy were re-evaluated completely resolved. Among the remaining eight
by the forced duction test and those with restriction patients with persistent diplopia who underwent
were reoperated within 3 weeks by performing adjustable inferior rectus recession, seven (70%)
adjustable suture inferior rectus recession. Surgery was patients improved and only one (10%) patient had
performed under general anesthesia after application persistent diplopia that was corrected with prisms
of a speculum; a fornix-based conjunctival flap was (Table 2).
performed and exposure of the inferior rectus as
posterior as the vortex was performed. Double-armed Table 1 Sex, age, cause, presentation, and time of presentation
polyglactin 5/0 sutures were applied at the insertion of the two groups
of the muscle then, the insertion of the muscle was N (%) Significance test
severed, the muscle was over-recessed, and the suture Early diagnosis Late diagnosis
(7) (group A) (10) (group B)
was applied to the insertion site and tied in a bow-tie
Sex
manner. The next day, the movement was evaluated Male 6 (85.7) 6 (60) FET, P = 0.34
and the adjustable suture was adjusted accordingly Female 1 (14.3) 4 (40)
and the conjunctiva was closed with polyglactin Age
5/0 sutures. Postoperative topical combined steroid Minimum– 18–35 20–37 t = 1.4, P = 0.2
antibiotic combination was used and the patients maximum
were followed up for 6 months. Mean ± SD 25 ± 5.9 29.5 ± 6.9
Cause
Car accident 6 (85.7) 9 (90) FET, P = 1.0
Fall from 1 (14.3) 1 (10)
height
Results Presentation
This is a prospective comparative interventional study Diplopia 7 (100) 10 (100) FET, P = 0.6
that included 17 patient with pure orbital floor fracture Enophthalmos 1 (14.3) 3 (30)
(data were analyzed using SPSS, version 16; SPSS Time of 1–3 weeks 4–24 weeks
Inc., Chicago, Illinois, USA); seven (41.2%) of these presentation 2.25 ± 0.96 17.6 ± 6.3
after trauma
patients (group A) were diagnosed within the first
3 weeks (1–3 weeks, with a mean of 2.25 ± 0.96 weeks) FET, Fisher’s exact test.

after trauma and six (85.7%) of these patients were

men and one (14.3%) was a woman. They ranged in Figure 2
age from 18 to 35 years (mean 25 ± 5.9 years), and
the cause of trauma was a motor car accident in six
(85.7%) cases and fall from height in one (14.3%) case.
All cases presented with diplopia in up gaze; however,
one (14.3%) case presented with enophthalmos more
than 2 mm (Table 1).

Ten (58.8%) cases (group B) presented after

3  weeks of trauma (4–24 weeks, with a mean of
17.6  ±  6.3  weeks); six (60%) of these patients were
men and four (40%) were women. They ranged in
age from 20 to 37 years (mean 29.5±6.9 years), and
the cause of trauma was a motor car accident in nine
(90%) cases and fall from height in one (10%) case. (a) Preoperative photo of a patient with left orbital floor fracture
All cases presented with diplopia in up gaze and three showing limitation in up gaze in the left eye. (b) Postoperative photo
(30%) of them presented with enophthalmos more of the same patient after repair of the fracture using a titanium mesh
within 3 weeks of trauma.
than 2 mm (Table 1).
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50  Journal of Egyptian Ophthalmological Society
Table 2 Outcome of the two groups
N (%) Significance test
Early diagnosis Late diagnosis
(7) (group A) (10) (group B)
Diplopia 7 (100) 2 (20) FET, P = 0.002
improvement
Enophthalmos 1 (100) 2 (66.7) FET, P = 1.0
improvementa
Inferior 0 8 (80) FET, P = 0.002
recession
Residual 0 1 (10) FET, P = 1.0
diplopia
FET, Fisher’s exact test; aAmong cases with enophthalmos.
Discussion
Isolated orbital wall fractures represent 5% of all
mid-facial fractures [8]. Folkestad and Westin [9], in
a series of 107 patients, found that in 55% of cases,
traumas resulted from domestic or street violence, 18%
from accidental falls, 13% from vehicle accidents, and
11% from accidents during sports activity. Men were
more prone to orbital floor fracture (62%) than women
(38%) [9].
Kamath et al. [10] reported that the most common
age group of orbital floor fracture was between 20
and 40 years. Among the causes of injury, 71.43% of
patients had been involved in road traffic accidents,
20% of patients had a history of falls, and 5.7% of
patients had sustained an injury with a blunt object.
In this study, we found that 85.7% of cases were
involved in motor car accidents in group A and 90%
in group B, which is more common than other studies;
however, 14.3% of patients in group A and 10% of
patients in group B had sustained injuries as a result
of fall from a height. Males were affected in 85.7% in
group A and 60% in group B; however, females were
affected in 14.3% in group A and 40% in group B and
this is in agreement with other studies in which men
were more prone to orbital floor fracture. The age of
the affected patients ranged from 18 to 35 years in
group A and from 20 to 37 years in group B, which is
in agreement with the Kamath et al.’s [10] study.
According to Lester et al. [11], limitation of ocular
motility and vertical diplopia occurred in 90% of cases
and enophthalmos in 5.75% of cases of orbital floor
fracture.
In our study, diplopia was present in 100% of cases;
however, enophthalmos occurred in 14.3% of cases in
group A and 30% in group B.
Hawes and Dortzbach [5], in a series of 51 patients
with orbital floor fractures who were studied
retrospectively to evaluate results in relation to time
of surgical repair and fracture size, had reported
that early repair (<2 months) yielded better results
than late repair (>2 months) in terms of both
enophthalmos and extraocular muscle dysfunction.
They recommended early repair of large fractures
preferably within two weeks after injury. Patients with
significant extraocular muscle dysfunction because of
tissue entrapment, irrespective of fracture size, should
undergo early repair, preferably within 2 weeks after
injury, if improvement does not occur spontaneously
by that time [5].
To prevent fat atrophy and scarring of the orbital fat to the
maxillary antrum, surgical repair should be performed
within 2 weeks. Orbital soft-tissue entrapment may
generate the oculocardiac reflex (bradycardia, heart
block, nausea, vomiting, and syncope), warranting an
immediate surgical intervention [1].
Matteini et al. [12] performed early surgery within
3 days in children with diplopia and within 7 days in
adults with diplopia.
Ceylan et al. [13] reported that there was no significant
difference in postoperative primary gaze diplopia when
comparing early versus delayed repair. Among seven
patients with persistent diplopia, three (7.6%) required
strabismus surgery to correct persistent diplopia,
although they had previously undergone orbital wall
reconstruction; however, in four (10.2%) patients,
strabismus surgery was performed without fracture
repair because of a history of trauma 28 months ago.
In this study, we found that, after early repair (within
3 weeks) of orbital floor fracture, diplopia had resolved
in all cases; however, in cases with delayed repair (after
3 weeks), only 20% of cases had improved and 80% did
not improve (statistically significant, P = 0.015). For
nonimproved cases, adjustable inferior rectus recession
enabled correction in seven (70%) cases and only one
(10%) case did not improve and was corrected by
prisms.
In contrast, there was no difference between early and
late repair in improvement in enophthalmos as all cases
had improved after repair of orbital floor fracture.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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