BLOW

OUT
FRACTUR
E
Ocular Trauma
Closed Globe Injury Classification
Orbital Blow Out Fracture
• One of the most common orbital injuries
• History taking confirms a blow to the orbit with an object larger than
the opening of the orbit itself
• Caused by the fracture of the bone in inferomedial orbit
• The classical clinical triad include :
• Diplopia (caused by restrictive strabismus)
• Infraorbital numbness (caused by interruption of inferior orbital nerves)
• Periocular ecchymosis (can be absent in white-eyed blow out fracture)
• Other sign include emphysema and enophthalmos
anatomy
Things to take note of
• Vision loss could arise from orbital floor fracture, injury to optic nerve
or increased in IOP causing a compartment syndrome
• Orbital hemorrhage should be suspected in vision loss if associated
with proptosis and increased in IOP
• Entrapment (inferior ocular muscle trapped within fractured orbital
floor)  it is a clinical sign and CANNOT be diagnosed with ct scan
Examination
• Hertel Exophthalmometer
• Extraocular movement evaluation  might need forced duction test
• Visual Acuity  if loss VA was found it became true emergency
• Sensory examination in distribution of supra and infraorbital nerves
• Afferent Pupillary Defect
• Palpation of the orbital rims
• Auscultation for bruits
Imaging (CT Scan)
Orbital CT Scan provided the best images of relationship between the
bone and soft tissues
CT Scan Indication :
• Suspected orbital fractures
• Palpable bone step-off
• Restricted extraocular muscle movements
• Metallic orbital foreign bodies
Imaging (MRI)
Best at differentiating soft tissues and may be best for :
• Associated neurological damage
• Wooden foreign bodies (Ferrous foreign bodies are contraindicated)
Management
• Initially they can often be followed clinically
• If surgery is needed it is usually planned for 7-14 days after initial trauma
• Oral steroids (1 mg/kg per day for the first 7 days) decrease edema and
may help hasten the decision of whether surgery for diplopia is necessary.
Waiting allows time for :
• Spontaneous Improvement
• Resolution of swelling
• Precise surgical planning
Early repair of blowout fracture indications include
• Associated craniofacial trauma
• Marked enophthalmos and hypoglobus
• Complete disruption of orbital floor
Management
Surgical Indication
• Diplopia with limitation of upgaze and/or downgaze within 30° of the
primary position
• positive forced duction test
• radiologic confirmation of an orbital floor fracture
• Enophthalmos that exceeds 2 mm and is cosmetically unacceptable to the
patient.
• Large fractures involving at least half of the orbital floor, particularly when
associated with large medial wall fractures as determined by CT
Management
though many patients could take months to years to present because :
• Patient had life-threatening injuries at the time of initial trauma,
which took precedence over blow-out fracture repair
• Many craniofacial surgeons who repair fracture at the time of incident
do not explore orbit and repair blow out fracture
• During acute phase of injury orbits may simply be too edematous to
allow effective repair
• Delaying surgery more than 14 days often results in increased scarring
of the orbit make later correction of diplopia and/or enophthalmos
difficult
Surgical Approach
Inferior transconjunctival incision with or without lateral canthotomy
and inferior cantholysis
• Allows excellent exposure
• Conceal the incision
• Prevents postoperative lid retraction
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