Case 2 - Indications for Surgery
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The next two slides are from a review article from the
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plastics people and facial reconstruction people with
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regard to the indications for acute
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surgery for orbital fractures.
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And you can see them listed here, enophthalmos, the
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eye being collapsed inward greater than 2 mm.
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So we're going to measure that.
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Hypoglobus, the eye pointing downward
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displaced globe. Diplopia, usually implying entrapment.
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Increased orbital volume by virtue of the level of the
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retrobulbar hematoma. Limited mobility and compressive
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optic neuropathy. Again, some of these are treated,
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the surgery is treating the fracture itself.
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Some of them are just treating the increased
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ocular pressure in the orbit, which can be
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treated with the lateral canthotomy.
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One of the issues is when do you
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repair these orbital fractures?
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And in most situations, it's rarely
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considered an emergent.
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You know the plastic surgeon has to come in that night or the
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oral or maxillofacial surgeon has to come in that night.
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These are usually treated next
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day for the emergent ones.
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And some of them, it's better to actually wait a couple
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of weeks. Why? Because of the edema.
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You don't want to be operating with all this
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surrounding hematoma and edema in the muscles
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so they actually wait. If you wait,
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you have run the risk of having some possibility of
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adhesions created or contrary to that would
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be the benefit of the decreased swelling.
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Again,
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operating when there's acute swelling is not as
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successful as when things have kind of calmed down
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a little bit. So some people would say, well,
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let's wait two to three weeks and we see this with
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some of the orbital fracture reconstructions, that
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it's two to three weeks later, sometimes acutely.
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Unless, of course,
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you have optic neuropathy in which case because
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the optic nerve is potentially in danger,
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they'll operate acutely.
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There is this oculocardiac reflex and
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it's mediated by the vagus nerve.
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And that is that when you push in on the globe and you
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have bradycardia, that is one of the clinical findings
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that suggest that the patient should be operated
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acutely because of potential cardiac problems
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associated with the ocular injury.
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Children tend to get operated earlier because
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they have a higher risk of entrapment and because
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of this risk of the inferior rectus and medial rectus
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muscle being entrapped in the fractures.
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And if you have a penetrating injury or an
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open globe, they're going to operate
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early and / or give antibiotics early.
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This is a patient who has had a reconstruction
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of the medial orbital wall and the orbital floor.
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He knows that there's no blood products
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and there's no edema
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on these bone windows, at least that we can see.
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This is because the fractures have been repaired
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a week or two after the actual injury, and that's not
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unusual if the only issue is the reconstruction
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of the fractures.
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When you look at these patients
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on the post op scan,
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you want to look for implant mal positioning on the
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postoperative CT or abnormal angulation or poking into
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an extraocular muscle as something that you would
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call the clinician about the surgeon band and say, "Hey,
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this medial band of the reconstruction is too far
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medially located and is abutting on the medial
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rectus muscle. In this case, this looks just fine.
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And this is nice
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orientation and positioning of the medial
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as well as the orbital floor implant.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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