Early and Late Complications of Orbital Fractures
Craig R. Dufresne, Paul N . Manson, and Nicholas T. lliff
0 RBITAL fractures involve not only the
orbital skeleton, but also the globe, perior-
bital soft tissues, eyelid, sinuses, and brain.
Complications arising from injuries range from
the mild and insignificant (of academic interest)
to the most severe and debilitating. With better
understanding of the injury and better radiologic
evaluation, the majority of these can be avoided,
anticipated, managed, or
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Orbital fracture complications may be classi-
fied according to their time of occurrence or pre-
sentation (Table 1). Those that occur or require
treatment within the first 24 hours of injury are
classified as “immediate;” those that require
treatment or occur within 2 weeks of injury may
be classified as “delayed;” and finally, those that
present after 2 weeks are classified as “late.”S0*76
The incidence and tabulation of complications
vary considerably within the literature. While
For personal use only.
evaluating severe midfacial fractures and subse-
quent orbital complication, Steidler et a177found
an incidence of 23.3 per cent in a patient popula-
tion of 240. Miller et alS8found an incidence of
16.6 per cent in 30 patients. Steidler et a1
subdivided their orbital complications into six
categories: blindness (33.9 per cent), diplopia
(32.1 per cent), blurred vision (5.4 per cent),
enophthalmos (12.5 per cent), telecanthus (3.6
per cent), and epiphora (1 2.5 per cent).77When
the categories of complications are broadened,
the overall incidence increase^.^*'^^
IMMEDIATE COMPLICATIONS
Loss of Vision
Ocular injuries are not uncommon in orbital
fractures. The overall incidence from the litera-
From the Departments of Plastic Surgery. Neurosurgery,
and Ophthalmology, Baltimore, Maryland: and the Depart-
ment of Plastic Surgery, The Maryland Institute of Emer-
gency Medical Systems. Baltimore. Maryland.
Reprinted with Modifcations from Clinics in Plastic
Surgery, Volume 15. Number 2, April 1988, p p 239-253.
0 1989 by W.B.Saunders Company.
Address reprint requests to Craig R . Dufresne, MD. The
Centerfor Plastic Surgery, P.C., Suite 1155.5454 Wisconsin
Avenue, Chevy Chase, MD 20815
0 1989 by W.B.Saunders Company.
0882-0538/89/0403-0004$5.00/0
176 Seminars in Ophthalmology, Vol4, No 3 (September), 1989: pp 176-190
ture ranges from 7 to 40 per cent.5*3’932,34s39*42*55
Most commonly, these are corneal abrasions,
hyphema, and retinal (Berlin’s) edema, which
usually resolve without any significant effect on
vision. The most devastating complication, loss of
v i ~ i o n , ~is~ usually
”~ the result of optic nerve
injury, ophthalmic artery vascular injury, or
severe direct injury to the globe.2~6~32~s5~s7~58
Dur-
ing the initial evaluation, if the loss of vision is
secondary to injury or contusion to the optic
nerve or to an optic canal fracture, it is important
to determine the timing of the onset of blindness
relative to the time of the injury. It has been
found that vision loss secondary to intracanalicu-
lar injury occurring at the time of trauma is
related to severe shearing or by contusive/
avulsive forces, and decompression of the nerve is
not effective.6 Vision that is lost in the post-
traumatic period may be improved by decompres-
sion of the nerve in the optic canal to relieve
compression from edema or hematoma.
Loss of vision may also result from disruption
of or bleeding from branches of the ophthalmic
artery or other periorbital vessels. Blindness is
due to devascularization through the loss of the
ophthalmic artery or compression of nutrient
vessels of the optic nerve by retrobulbar he-
matoma. The latter often presents as a loss of
vision with proptosis and increased intraorbital
p r e ~ s u r e .Under
~ . ~ ~ these circumstances, evacua-
tion of the hematoma with decompression of the
orbit should be performed.
Globe injuries at the time of orbital fractures
are common and quite varied. They include
corneal or scleral lacerations, rupture or avulsion
of the globe, angle recession (acute glaucoma),
vitreous detachment, retinal detachment, or iri-
dodialysis. It is essential to confirm visual acuity
and take any steps necessary to preserve vision
prior to and during manipulation of fracture
fragments for functional or aesthetic goal^.^,'^.^'^^^
The superior orbital fissure syndrome is a
specific constellation of findings resulting from
an extension of an orbital fracture into the
superior orbital fissure. Cranial nerves 111, IV, V,
or VI are involved, thus giving rise to ophthal-
moplegia and upper lid ptosis. Proptosis results
from hematoma and congestion in the superior
 COMPLICATIONS OF ORBITAL FRACTURES
Table 1. Complications of Orbital Fractures
I. Immediate complications
A. Loss of vision
1. Optic nerve injury
2. Ophthalmic vascular injury
3. Ocular globe injury
B. lntraorbital cranial nerve injury
C. Pulsating exophthalmos
D. Orbital and periorbital bleeding, epistaxis
E. Orbital emphysema
F. Skeletal and structural derangement
G. Soft-tissue and muscle entrapment or derangement
II. Delayed complications
A. Naso-orbital skeletal disruption
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1. Canthal disruption/derangament
2. Lacrimal drainage problems
B. Orbital and periorbital skeletal and structural derange-
ment
1. Exorbitism secondary to lateral wall fractures
2. Enophthalmossecondary to volume changes in the
orbit
3. Vertical dystopia secondary to maxillofacial de-
rangement
111. Late complications
A. Extraocular muscle imbalance
B. Enophthalmos
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C. Malpositioned orbital floor
D. Eyelid problems
E. Lacrimal drainage problems
F. Reconstruction failures
G. Pediatric fractures and growth disturbances
and retrobulbar orbit. A fixed, dilated pupil
results from parasympathetic blockade. The syn-
drome, first described by H i r ~ c h f e l d is
, ~ com-
~ support of packing; (4) Chronic infection and/or
pleted by sensory disturbances in the distribution
of the ophthalmic division of the trigeminal
nerve.69 Retrobulbar pain and neuralgia often
follow the Vth nerve injury. A gradual and
incomplete recovery without intervention is the
usual r e s u ~ t . ~ , ~ ~ , ~ ' , ~ ~ , ~ '
A partial superior orbital fissure syndrome is
also possible if the orbital fractures result in
partial loss of function of motor nerves 111, IV,
and VI. The superior or inferior division of the
oculomotor nerve may be injured, producing
ptosis, paralysis of superior gaze, mydriasis, and
an abducted, depressed posture of the globe.
Selective injury of the superior division on the
oculomotor nerve gives ptosis with loss of eye
movement in the field of action of the superior
rectus muscle. Isolated injury of the inferior
division of the oculomotor nerve causes mydriasis
and weakness of downward gaze in the field of
action of the inferior rectus muscle. There is also
177
weakness of upward and inward gaze and weak-
ness on a d d u c t i ~ n . ~ ' ~ ~ ~ * ~ ~ . ~ '
The orbital apex syndrome, first described by
K j ~ e in ~ contains the same elements as
r ~1945,
the superior orbital fissure syndrome plus optic
nerve involvement. This syndrome is character-
ized by blindness, ophthalmoplegia, mydriasis,
ptosis, and loss of sensation in the ophthalmic
division of the trigeminal The supe-
rior orbital fissure syndrome, orbital apex syn-
drome, and blindness may also result from the
treatment of the orbital and facial frac-
tUreS.6,8,42,48.51
One of the earliest approaches to the treatment
of orbital and facial fractures was by means of
the Caldwell-Luc antrostomy." This technique
allows the repositioning of the comminuted floor
from below via the maxillary antrum. The frag-
ments were often held in place by gauze packing
or an intra-antral balloon. This technique has the
advantages of leaving no external scar and does
not require insertion of any permanent alloplastic
material. However, it has several significant
disadvantages: (1) The "blind" elevation of the
orbital floor may produce excess pressure on
neurovascular structures or force bone spicules
into periocular soft tissues including the optic
nerve; (2) "Trapdoor"-type linear fractures may
go unrecognized; (3) Support for the globe ceases
in 10 to 24 days with the removal of the antral
oroantral fistula may develop; ( 5 ) Poor visualiza-
tion makes adequate reduction of the displaced
and herniated parts more difficult; (6) Intraor-
bital hemostasis is not readily obtained after
reduction; and (7) Sensory disturbances of the
infraorbital nerve are i n c r e a ~ e d . ' ~ ? ' ~ . ~ ~
The incidence in the literature for blindness
following the reduction of orbital and zygomatic
fractures varies from 0 to 8 per ~ e n t . ~ ~ , ~ ~ - ~ ~
Several factors associated with this complication
are (1) blind packing of the maxillary antrum,
(2) the use of an excessively large orbital floor
implant or graft that exerts pressure on the optic
nerve, (3) vigorous zygomatic or fracture manip-
ulation, (4) forceful retraction of orbital soft
tissue, ( 5 ) rough manipulation of the globe (reti-
nal detachment), and ( 6 ) retrobulbar hemor-
rhage.47*62 (7) Fractures may extend to the optic
canal with vigorous reduction maneuvers. (8)
The initial trauma to the globe may result in a
 178
retinal detachment, and excessive intraoperative
globe pressure may increase the severity of the
Cerebrospinal Fluid Leakage
The leakage of cerebrospinal fluid (CSF) into
the eyelid, orbital soft tissues, or nose is most
often seen following supraorbital, orbital roof,
glabellar, or naso-orbital fracturesg Spontane-
ous resolution of the leakage usually occurs. The
proper alignment of facial and naso-orbital frac-
tures will usually assist closure of the leak.49*S6.58 of dark red-blue ecchymosis in a sharply demar-
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In documented CSF leaks, there is significant
controversy in the literature concerning the use
of a n t i b i o t i ~ s . ’ ~It, ~has
~ , ~been
~ difficult to demon-
strate a benefit from antibiotics in the prevention
of meningitis; however, many surgeons utilize
perioperative antibiotics for orbital fracture
repair.38
Pulsating Exophthalmos
Pulsating exophthalmos results from the forma-
tion of arteriovenous fistulas in midfacial and
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skull base trauma or, more commonly, transmis-
sion of cerebral pulsation from the dura following
an orbital roof f r a ~ t u r e . During ~ ~ * ~nasal
~ ~ ~ the
initial examination, no evidence of a CSF leak is
evident; nor is a bruit heard.48vs1 After a short
time, the patients will describe hearing a “machin-
ery-like” noise.76 A bruit can often be auscul-
tated over the globe if an arteriovenous fistula
has occurred.72
Orbital and Periorbital Bleeding
Periorbital and naso-orbital soft-tissue injuries
and orbital fractures frequently result in disrup-
tion of vascular structures. A subconjunctival
hemorrhage is often associated with a break in
the orbital skeleton; the hemorrhage is the result
of dissection of blood within the orbital struc-
. ~ ~location of the blood sometimes is a
t u r e ~The
guide to the fracture site. Extensive bleeding
with no posterior limit suggests the possibility of
a skull fracture, although it also occurs with
simple fractures confined to the lower orbit.
Bleeding from a canaliculus is a sign of a tear or
laceration in the lacrimal collecting system, some-
times accompanying a naso-orbital fracture.
Bleeding from a conjunctival tear or laceration
may indicate that the deeper layers of the globe
may have been lacerated, and scleral penetration
DUFRESNE, MANSON, AND ILIFF
or globe rupture must be excluded.35 Severe
bleeding from the nose following an orbital
fracture could indicate an unusual situation in
which hemorrhage from the internal carotid
artery (cranial base fractures) into the sphenoid
sinus and nasopharynx has occurred. This is the
result of a comminuted cranial base fracture, and
blindness is often present in these s i t ~ a t i o n s . ~ ~ ~ ~ ~ , ~ ~
Patterns of orbital ecchymosis may sometimes
give clues to the underlying orbital damage. The
“owl eye” sign, or anterior Battle’s sign, consists
cated circle around the upper and/or lower lids
associated with extensive subconjunctival hemor-
rhages. The onset is rapid and suggests a break of
the anterior cranial vault with dissection of blood
into the orbit (Fig 1). The forward flow of the
blood is temporarily impeded by the insertion of
the orbital septum at the orbital rim, causing the
characteristic demar~ati0n.j~ This may be the
only sign of an anterior cranial base fracture.
When the anterior ethmoidal artery is dis-
rupted, a severe periorbital hematoma or marked
epistaxis may result. When the bleeding cannot
be controlled with conservative measures such as
~ ~packing
~ ~ ~ or~ cauterization,
~ a direct surgical
approach may be required for direct clamping or
ligation of the internal maxillary artery.63964
Periorbital bleeding usually originates from
the branches of the infraorbital artery or the
penetrating venous branches in the orbital floor.
Spontaneous cessation of bleeding usually occurs;
however, orbital decompression may be required
Fig 1. Periorbital hematoma following blunt trauma to
the head with an anterior skull bare fracture.
 COMPLICATIONS OF ORBITAL FRACTURES
if visual acuity is threatened by a large he-
matoma causing increased orbital pre~sure.~’
Ord found that significant visual disturbance
occurred with an incidence of 0.3 per cent follow-
ing repair of malar and orbital fractures63 and
suggests appropriate medical and surgical man-
agement for this problem, emphasizing the impor-
tance of early diagnosis.64
Subcutaneous Periorbital Emphysema
The presence of subcutaneous emphysema or
orbital emphysema is a common finding with
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orbital fractures, especially in the ethmoidal
region (Fig 2). Often, it is of little consequence
and disappears in a few days; however, complica-
tions can result from patients blowing their nose
after orbital fracture^.'^ Contaminated bone frag-
ments, nasopharyngeal drainage, and/or air may
also be forced into the cranial base, meninges,
and brain by virtue of skull fractures with their
associated dural and arachnoid disruptions.
Skeletal and Structural Derangement
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Skeletal and periorbital fractures should be
reduced as soon after the injury as possible to
provide the most satisfactory anatomic recon-
struction and yield the best aesthetic result.
Fractures and displacement of zygomaticomaxil-
Fig 2. A, Moderate periorbital emphysema after ”blowing” none, following a left orbital blowout fracture. 6 , Inferior
orbital contents entrapment following linear fracture of the floor.
179
lary segments may lead to flattening of the malar
eminence, dystopia of the globe, downward dis-
placement of the lateral canthus, diplopia, injury
to the cranial nerves, or entrapment of orbital
tissue in the fracture site76(Fig 3). Lower eyelid
retraction due to inferior traction on the orbital
septum by displaced inferior orbital rim bone
segments may also be seen in maxillary and
zygomatic fractures. Pain and displacement of
the globe when chewing has been described as
well as damage to the lacrimal gland and levator
muscle accompanying injuries of the superolat-
era1 orbital wall or orbital The lacrimal
gland often prolapses into the fracture site at the
zygomaticofrontal suture, and should be pro-
tected in zygomatic fracture reduction^.'^^^^
Orbital roof fractures represent approximately
5 per cent of all facial fractures. They may occur
as isolated fractures but more often are associ-
ated with fractures of the frontal or zygomatic
bone complex. Fractures of the superior orbital
rim and roof are usually the result of more force,
because these structures are thicker and stron-
ger. These fractures are often associated with
eyelid ecchymosis, forehead anesthesia, transient
diplopia, and limited upward gaze. Diplopia may
occur secondary to injury to the trochlea or
superior oblique muscle or tendon.29-49*50 These
 180 DUFRESNE. MANSON, AND ILlFF

Fig 3. A, Enophthalmos and

vertical dystopia following na-
soethmoid fracture and LeFort
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11-111 maxillary fractures. B, Fol-

lowing deep orbital reconstruc-
tion and advancement of the
orbit rim with the use of rib
grafts, refracture of the nasoet-
hmoid fracture, and left lateral
canthopexy.

fractures have been described to extend into the
optic canal more frequently than do other frac-
tures, and CSF rhinorrhea is more frequent.76
The presence of intracranial air is pathogno-
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may not be accompanied by diplopia if the
blowout fracture is large and no entrapment of
the extraocular muscles or orbital fat occurs. The
patient is able to realign the visual axes despite

monic of dural tears and arachnoid laceration. If the difference in globe l e ~ e l . ’ ~ - ~ ’

the fracture extends into the frontal sinus area, The most troublesome late complications of
definitive frontal sinus ablation by mucosal re- blowout fractures are diplopia and enophthal-
moval, obliteration, or “cranialization” mini- mos. Anterior inferior rectus entrapment can
mizes the possibility of late mucocele f~rmation.’~ cause limitation in downgaze as well as upgaze
The sequelae and complications of orbital roof by isolating the posterior portion of the muscle
fractures, therefore, are a mirror image of those
seen with orbital floor fractures. Both fractures
can result in eyelid malpositions, pulsating exoph-
thalmos, abnormal mobility of the globe, diplo-
pia, hypesthesia, and orbital i n f e ~ t i o n . ~ ~

Soft-Tissue and Muscular Entrapment or

Derangement
Orbital fractures, particularly “blow-out” frac-
tures, result either from a “buckling” force to the
orbital rim or increased intraorbital pressure
secondary to a blow to the eye or rim from a
nonpenetrating object. The thin orbital floor
medial to the infraorbital nerve and inferior
aspect of the medial wall breaks first, followed by
a herniation of orbital tissue (Fig 4). Rupture of
the globe may accompany blowout fractures,
although it is less common.60
Inferior displacement of the globe into the
maxillary sinus occurs because of inferior dis-
Fig 4. Orbital floor fracture with inferior rectus muscle
placement of the orbital floor and the orbital entrapment (arrows): Soft-tissue orbital contents herniat-
contents. However, marked global hypotropia ing (incarcerated) through bone defect.
 COMPLICATIONS OF ORBITAL FRACTURES 181

from the globe. Posterior fractures are more

likely to cause more limitation of supraduction
than infraduction.
It is imperative that forced duction tests be
performed during the initial motility examina-
tion, and repeated at the termination of any
surgical procedure. Horizontal diplopia, second-
ary to entrapment of the medial rectus muscle,
may occur without retraction of the globe if the
muscle is entrapped posteriorly.35s76Horizontal
diplopia is much less common than vertical
diplopia. Entrapment of extraocular muscles is
uncommon in lateral orbital wall fracture^.^'-^^
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Enophthalmos results from orbital enlarge-

ment with herniation of orbital fat into the
maxillary and ethmoid sinuses. Posterior entrap-
Fig 5. Orbital emphysema and anophthalmos following
ment of the inferior rectus muscle has been severe NO€ fracture.
postulated to pull the globe backward, but proba-
bly does not produce e n o p h t h a l m o ~ . ~Or-
~ . ~ ~ . ~identified
~ at the initial examination and plans for
bital floor and orbital wall fractures create an repair instituted, because delayed medial canthal
increased orbital volume and set the stage for reconstruction is more difficult and the results
enophthalmos. Fibrosis, scarring, contracture, less satisfactory.2 During the repair, medial,
and fat atrophy occur late (weeks to months)
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superior, and posterior overcorrection of the

following orbital injuries and result in late enoph- canthal tendon insertion is required in order to
thalmos. Diplopia and enophthalmos may not prevent postoperative malposition of the medial
necessarily occur together. portion of the eyelid.
DELAYED COMPLICATIONS
Nasal-Orbital Skeletal Disruption
With the high number of high-speed motor
vehicle accidents, midfacial fractures and dis-
placed nasal-orbital-ethmoidal (NOE) fractures
are rather common (Fig 5 ) . Frequently, in the
NOE fracture, the nasal bones are telescoped
into the ethmoidal sinuses, producing an outward
displacement of the medial orbital walls. The
medial orbital rim, medial canthus, and canthal
tendon insertion are displaced laterally, resulting
in an increased intercanthal distance and a round-
ing of contour of the medial canthal
(Figs 6 and 7).
Owing to the severe skeletal derangement,
there is often severe injury to the lacrimal excre-
tory system. Epiphora may be present as a result
of damage to the lacrimal pump mechanism,
canaliculi, lacrimal sac, and lacrimal duct.
Delayed complications in patients with NOE
fractures occur from damage to the trochlea,
entrapment of orbital tissue or extraocular mus-
cles, and these may not be noted on the initial Fig 6. Acute left telecanthus following a hemi-NOE
examination. Medial canthal disruptions must be fracture.
 182 DUFRESNE, MANSON, AND ILIFF

Injuries to the canaliculus are best repaired

ear1y24*28*76with microscopic anastomosis over
fine silicone tubing. However, if repair of canali-
culi cannot be performed within several days,
secondary canicular repair or conjunctival dacry-
ocystorhinostomy (Jones tube) can be done at a
later date.76

Orbital and Periorbital Skeletal and Structural

Derangement
Exophthalmos is occasionally seen with iso-
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lated lateral orbital wall fractures, which de-

creases the orbital volume owing to the inward
displacement of the lateral orbital wall (Fig 8).
Fig 7. Medial canthus attached to NOE fracture seg-
This is most marked when soft-tissue compres-
ments. sion occurs posterior to the axis of the globe.
Careful evaluation of CT scans determines that
this is secondary to bone displacement and not to
retrobulbar hemorrhage, which may result in an
expanding hematoma and possible blindne~s.~'.~~
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Fig 8. A, Mild right proptosis following depressed

lateral orbital fracture. 8, Depressed lateral orbital wall
fracture resulting in a decreased orbital volume.
 COMPLICATIONS OF ORBITAL FRACTURES
Enophthalmos may be secondary to cicatricial
contracture and fibrosis of the retrobulbar soft
tissue and ligaments to displaced bone structures.
Furthermore, enophthalmos may also be second-
ary to fat atrophy or extraocular muscle fibro-
sis.4 I ,50.52
Persistent vertical dystopia occurs in dislo-
cated maxillofacial fractures when inadequate
fixation has been carried out, when the midfacial
bone fragments devoid of their blood supply have
resorbed or when postoperative rotation owing to
loosened fixation has
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LATE COMPLICATIONS
Extraocular Muscle Imbalance
Numerous ocular motility problems can result
from orbital fractures. Corrective eye muscle
surgery or prism lenses are indicated once the
pattern of imbalance is stabilized and a constant
deviation is noted. This may take several months
following the initial injury. Muscles may become
paretic or fibrotic following ischemia or crushing
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injuries (Fig 9). Often, strabismus surgery on
Fig 9. A, Young patient with a right blowout fracture with
incarceration and devascularizationof the inferior rectus mus-
cle. 8, Forced duction test carried out intraoperatively to
demonstrate free movement of the globe and release of all
entrapped elements. C, Lack of mobility secondary to late
fibrosis of the inferior rectus muscle or upward gaze.
183
these muscles is postponed for 6 to 12 months,
during which time patches or prisms are utilized
to manage diplopia. On occasion, a ptotic eyelid
will hide dipl~pia.’~,~’,’~
The objective in patients with extraocular
muscle dysfunction is to obtain fusion in all
positions, but especially with primary position
and inferior gaze. Frequently, transient postoper-
ative diplopia follows surgical treatment for a
blowout or more complex orbital fracture.35
The incidence of persistent diplopia following
orbital fracture ranges from 2 to 50 per cent in
the literature. Diplopia in the primary field of
gaze is much more significant and debilitating
than in the extremes of gaze. Diplopia secondary
to neuromuscular contusion may take 6 months
to resolve or stabilize; therefore, corrective mus-
cle surgery should not be contemplated until this
time.37,52,80Diplopia may also be secondary to an
inadequate release of the originally incarcerated
soft tissues, reincarceration, or fibrous adhesions
to a bone graft or the implanted alloplastic
material.52*71
 184 DUFRESNE. MANSON, AND ILIFF

Enophthalmos
Enophthalmos is one of the more difficult and
frustrating problems to treat as a late complica-
tion of orbital fractures. The frequent presence of
a functioning eye without double vision compli-
cates this problem. The literature quotes inci-
dences from 15 to 22 per cent of persistent
enophthalmos. Progressive enophthalmos may
develop despite adequate reduction of the frac-
ture and is presumably secondary to fat atrophy
and fibrotic contracture.
Surgical correction is frustrating with fibrosis
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and extraocular muscle contraction often prevent-

ing adequate correction. Dissection is extraorri-
narily difficult due to disruption of tissue planes,
scarring and fibrosis. Repositioning of the globe
by reduction of orbital volume with implant
material is often needed.
It is important to determine if anterior displace-
ment of the globe is still possible by performing
the “forward traction test” before formulating a
Fig 10. Enophthalmos and vertical dystopia following
treatment plan. Should fibrosis and extraocular
breakage of frontozygomatic wire, allowing rotation of
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movement contraction prevent forward motion of
the globe, orbital implants may not bring about
the desired correction. Autogenous materials and
grafts are readily incorporated by the surround-
ing tissue, but have an unpredictable degree of
absorption.~4~~7,~9,23,~3
Synthetic or alloplastic materials are readily
available; however, they have the potential disad-
vantages of possible rejection, intermittent bouts
of orbital cellulitis, sinus infection, fistulas, and
extrusion in some patient^.^,'^,"
It is believed to result from many possible
interrelated factors: (1) severe scarring of the
extraocular muscles, (2) fat atrophy, (3) contrac-
ture of the intraorbital structures, (4) increased
orbital volume, or (5) a combination of these
fa~tors.~~,~~,’~
Malpositioned Orbital Floor
Fragments of the maxilla or zygoma that are
poorly aligned can lead to a displacement of the
orbital floor. Sequelae of this skeletal derange-
ment include ptosis of the globe, displacement of
the lateral canthus, infraorbital nerve contusion
producing hypesthesia or neuralgia, and lower lid
retraction (Fig 10). Depressed fractures of the
orbital rim are usually repaired by refracturing
the zygoma or maxilla, rewiring the fragments
maxillary-zygomaticcomplex. The original injury was exten-
sive comminuted midface fractures that were recon-
structed with primary bone grafting and Timesh orbital
floor and orbital wall reconstruction.
into position, and placing bone grafts or alloplas-
tic materials to build up the orbital floor and
rim.76 A depressed lateral canthus following
malunited zygomatic fracture may be corrected
by a selective elevation by lateral canthoplasty or
canthopexy. Care must be taken in performing
secondary orbital osteotomies because new frac-
ture lines may be created that may extend to the
optic canal, producing b l i n d n e ~ s . ~ ~ . ~ ’ . ~ ~ ’ ~ ~
Ptosis of the globe in the absence of significant
extraocular muscle injury or entrapment may or
may not cause diplopia depending on the pa-
tient’s fusion capabilities. In general, the eleva-
tion of the globe or correction of the globe
position should precede strabismus ~urgery.’~
Hypesthesia or anesthesia of the infraorbital
nerve is a common problem following orbital
floor fractures. In the majority of patients, suffi-
cient regeneration of the nerve occurs. Infraor-
bital neuralgia, a rare condition, is much more
annoying than anesthesia. In this situation, even
sectioning of the nerve for relief of symptoms is
not e f f e c t i ~ e . ~ ~ . ~ ’ . ~ ~
 COMPLICATIONS OF ORBITAL FRACTURES
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For personal use only.
Fig 11. Soft-tissue scarring and contrscture around the
right orbit following infection and extrusion of an alloplastic
mslsr and inferior orbital rim implant.
Eyelid Problems
Ectropion, or vertical lid shortening, occurs in
1 to 10 per cent of orbital fractures. This may
result from an exaggerated reduction of the
fracture; however, it is frequently caused by an
adhesion of the orbital septum or scarring within
the orbicularis of the skin. Improvement usually
occurs spontaneously. The lower eyelid demon-
strates a vertical shortening caused by tethering
of the eyelid by cicatricial tissue connecting from
the orbital rim by way of the orbital septum
(Figs 11 and 12). Release and excision of scar
tissue, the use of bone grafts to build up the
orbital rim and autogenous cartilage, or scleral
grafts are useful in improving this eyelid
Persistent edema of the lower eyelid is most
likely caused by a disruption in the lymphatic
channels at the lateral aspect of the lower eyelid.
The eyelid edema can follow surgical incisions at
the midtarsal or rim level when they are not
extended too far laterally.76
Marked epicanthal folds following nasal or-
bital fractures are usually corrected at the time
185
of transnasal wiring of the medial canthal ten-
dons. Dissection of scar tissue from the skin and
subcutaneous tissue internally is req~ired.”.’~
Ptosis of the upper eyelid should be corrected
late, after all orbital edema, settling of grafts,
and softening of scar tissue has occurred. Contin-
ued postinjury improvement influences the final
position of the upper eyelid margin76(Fig 13).
Lacrimal Drainage Problems
A wide range of complications, ranging from
an everted punctum to a lacrimal mucocele, may
occur following nasoethmoidal fractures. Injury
to the branch of the facial nerve innervating the
medial aspect of the orbicularis muscle may
result in dysfunction of the lacrimal pump mech-
anism. In addition, eversion of the punctum and
epiphora may occur.13976
Severed or scarred canaliculi discovered months
after the initial injury respond poorly to surgery.
A conjunctival dacryocystorhinostomy with inser-
tion of a Jones (Pyrex glass) tube may be
required. Chronic dacryocystitis with mucocele
formation should be treated with a dacryocys-
torhinostomy. If a large mucocele of the lacrimal
sac is present, it may occlude the common
canaliculus and present the false impression of an
associated canalicular obstruction. In general, it
is unwise to perform reconstructive surgery on
the eyelids or orbits in the presence of a lacrimal
mucocele or infected lacrimal sac.6913976
Reconstructive Failures
Alloplastic material is commonly used to pro-
vide structural support and has done well despite
the free communication between the orbit and
maxillary sinus. The most commonly used allo-
plastic materials are Teflon, Supramid, and Silas-
tic. Recently, Marlex mesh, Gelfilm, and Med-
pore have proven satisfactory in the repair of
extensive, as well as minor, defects. Occasionally,
problems develop from the use of synthetic im-
plants from several months to several years
following surgical reconstruction. These compli-
cations include extrusion or malposition, chronic
sinus infection, fistula formation, or local tissue
reaction (Fig 14). Maxillary sinusitis is believed
to complicate about 4 per cent of orbital frac-
tures. In this antibiotic era, the maxillary sinus
does not need to be drained or irrigated if
 186
Semin Ophthalmol Downloaded from informahealthcare.com by University of Alberta on 10/15/14
appropriate antibiotics are used. Persistent sinusi-
tis is usually the result of a foreign body or
necrotic bone fragments, which usually require a
Caldwell-Luc approach for drainage and debride-
ment. In most cases, the cause is obstruction of
For personal use only.
the duct leading to the nose, which is treated by
nasal antrostomy (Fig 15). The incidence of
Fig 13. Fibrosis and paresis of levator mechanism
following severe frontal bone and supraorbital rim frac-
tures.
DUFRESNE, MANSON, AND ILIFF
Fig 12. A, Submentovertex
view demonstrating the extent
of enophthalmos and displace-
ment of inferior orbital rim and
anterior maxilla. 6, Soft-tissue
derangement following an un-
treated orbital-zygomatic frac-
ture.
infection following orbital fractures is between 3
and 4 per cent, and the frequency of implant
extrusion is well below 3 per cent. The possibility
of extrusion is prevented by securing the implant
to the inferior orbital rim with wire or screw,
perforating the implant to allow fibrous ingrowth
or cutting a small tongue to place the implant
under an intact portion of orbital floor to prevent
forward m i g r a t i ~ n . ' ~ . ~ ~ ' ~ ~
The implants should be free of contamination
from lint, powder, or other foreign material.
Placement of the implants should be between the
periosteum and bone. The implants should be
thin, and there should be no space between the
implant and the intact floor of the orbit. In severe
injuries, caution should be exercised in the exact
placement of the implant, because an implant
placed too far posteriorly may injure the optic
nerve. Inadvertent placement below the infraor-
bital neuromuscular bundle may result in mas-
sive orbital hemorrhage if the vessel is avulsed.
Retrobulbar hemorrhage has been associated
with loss of vision.76
The use of autogenous graft material, such as
cartilage, fascia lata, iliac bone, antral wall bone
grafts, calvarial bone grafts, split rib grafts, and
mandibular cortex have been described. Advo-
cates of autogenous material point out that there
is no incidence of late infection or extrusion, even
when the antral mucosa has been perforated.
Autogenous bone may also be used to rebuild the
rim in impure blowout fracture^.",'^,^^
On rare occasions, mucocele formation can
lead to distortion of the orbital structures or to
 COMPLICATIONS OF ORBITAL FRACTURES 187
Semin Ophthalmol Downloaded from informahealthcare.com by University of Alberta on 10/15/14

Fig 14. A. Retraction of left lower eyelid with a chronic draining sinus tract and recurrent bouts of cellulitis secondary t o
Silastic orbital floor ivplant. 6. Removal of infected prosthesis used t o support the orbital contents after an orbital floor
fracture.
For personal use only.

Fig 16. A, Several months following a Supramid

orbital floor implant after a blowout fracture of the right
orbit, this patient developed a suppurative maxillary
sinusitis extending into the orbit. The extensive pus
accumulationand edema resulted in a severe proptosis. B
and C, CT scens of the orbit demonstrating the air-fluid
levels within the orbit and sinus. Approximately 10 cc of
purulent material was drained from the orbit itself.
 188
erosion of the thin bones of the inner orbital area.
Their presence is often unnoticed for years until
significant deformity occurs.so
Pediatric Fractures and Growth Disturbances
Orbital fractures in the growing child are
uncommon, owing to the resiliency of the bony
skeleton and the underdevelopment of the facial
sinuses. Nonetheless, enough energy distributed
to the orbital region may result in soft-tissue
injury and fractures. Orbital fractures may re-
sult in permanent growth disturbances, either by
Semin Ophthalmol Downloaded from informahealthcare.com by University of Alberta on 10/15/14
direct injury to the growth centers or by extensive
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