GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY

SEMINAR ON
ORBITAL ANATOMY &
ORBITAL FRACTURES
Presented By:
Dr. Sambhav K Vora
I MDS

CONTENTS
1. Orbital anatomy
2. Orbital trauma
a. Aim & objective
b. Classification
c. Pathophysiology
d. Clinical presentation
e. Ophthalmic evaluation
f. Imaging
g. Specialized investigation
h. anagement
i. Postoperative ophthalmic e!amination
j. Complication
". Conclusion
l. #eferences
Orbital anatomy:
Orbit is a bony cavity shaped like a pyramid with its apex at optic foramen.
Orbit growth is 85% completed at 5 yrs and growth is finalized between 7yrs to puberty.
even bones contribute to the formation of the orbit !
"axillary# $ygomatic# %rontal# &acrimal# 'thmoidal# phenoidal# (alatine.
Importance of orbit) to protect vital structures present within the orbital cavity# because globe is
surrounded by fat *medial wall *floor of the orbit are thin #so forces transmitted to the globe allows
fracture of the orbit without significant globe in+ury *this accounts for the higher incidence of the
fracture of the orbit as compared to open globe in+uries.
,elation)

uperiorly ! -nterior cranial fossa and frontal lobe.
.nferiorly ! "axillary sinus.
"edially ! /asal cavity#'thmoid sinus.
&aterally ! 0emporal fossa.
(osteriorly ! "iddle cranial fossa * temporal lobes of brain.
1oundaries )
,oof !it is formed by Orbital part of frontal bone and lesser wing of sphenoid 2(osteriorly3.
"edial wall !
'xtending in front from anterior lacrimal crest#running backwards across lacrimal bone
and then to paper thin orbital part of 2lamina papyracea3 and finally to bony of sphenoid.
1etween anterior and posterior lacrimal crest is the fossa for lacrimal sac# which leads
down into nasolacrimal canal.
-t +unction of roof and medial wall# lie anterior and posterior ethmoidal foramina.
4istance from anterior lacrimal crest to anterior ethmoidal foramen is 56 mm#from
anterior ethmoidal foramen to posterior ethmoidal foramen is75 mm#from posterior
ethmoidal foramen to optic foramen is 8 mm.so total distance from anterior lacrimal crest
to optic foramen is 65mm.
&ateral displacement of frontal process of maxilla# to which medial palpebral ligaments
are attached# produces a condition called traumatic telecanthus.
0,-9"-0.: 0'&':-/0;9) .t is bilateral displacement of medial palpebral ligaments by
outward movement of their bony attachments or avulsion.
.ntercanthal distance has to be known for checking telecanthus)
<aardenburg states 27=573>??mm to ?6mm in males
?5 mm to ??mm in females.
%reihofer 27=8@3> 58mm to ?8mm in males2avg ?7.73
?@.8 .n females.
-verage interpupillary distance is 55 mm.

&ateral wall ! 25cm long3
0his wall separates orbit from temporalis muscle.
%ormed by zygomatic bone and greater wing of sphenoid.
(osteriorly there is a gap called superior orbital fissure between lateral wall and roof
which lies in middle cranial fossa.
.nferior
orbital
fissure !
between
lateral
wall and
floor
which
lies in
pterygopalatine and infra temporal fossa.
:ontents of uperior orbital fissure)
lacrimal nerve#
frontal nerve#
trochlear nerve#
superior ophthalmic vein#
.nferior ophthalmic vein.
ophthalmic artery#
nasociliary #
abducent #
occulomotor
0he last ? contents are found within the muscle cone
-ny trauma which causes direct compression or compression hematoma on the contents
of superior orbital fissure produces a condition called superior orbital fissure syndrome
or full blown syndrome.
Features of full blown syndrome:
Loss of sensation over forehead-because of involvement of supratrochlear &supra
orbital nerve.
Edema of periorbital region-involvement of ophthalmic vein
Proptosis-because of intraconal &extraconal hemorrhage
Dilation of pupil-because of blocking of parasympathetic supply via occulomotor
nerve
Ptosis-occulomotor nerve
Opthalmoplegia-involvement of occulomotor trochlear &abducent nerve
Loss of corneal reflex-involvement of nasociliary branch.
Loss of direct light reflex-occulomotor nerve

:ontents of inferior orbital fissure
maxillary nerve#
%loor ! it is formed by orbital surface of maxilla# laterally by zygomatic bone *posteriorly by
orbital process of palatine bone.
.nfra orbital foramen lies about 7 cm below the middle of the infra orbital margin.
hape) triangular with rounded corners# being narrower posteriorly *merging medially with
orbital plate of ethmoid.floor slopes upwards *medially at 65degrees.
%loor is very thin# about @.5cm thick *is further weakened by infra orbital grooves
*canals.meadial to this line only most blow out fracture occurs.
O,1.0-& ,.")
&ateral rim> formed by frontal process of zygomatic bone *zygomatic process of frontal bone.
-pproximately @.75 cm above the rim# lacrimal gland is located. (ilot hole should be commenced
7.5 cm above the frontozygomatic suture *@.5 cm behind the rim# penetration should not be more
than @.75 cm
-bout 7 cm below the suture *? mm inside the rim .whitnalls tubercle is presentA transosseous
wiring should be avoided at this area.
uperior rim) more rounded# as it passes medially# where it overlies the outer limit of frontal sinus.
-ny in+ury to this area supra orbital * supratrochlear nerves *vessels will also be affected.
"edial rim) as medial palpebral ligament is attached to this part# displacement of bone in this
region causes displacement of canthal *suspensory ligaments.
.nferior rim) +ust within the rim# a small depression which marks origin of the inferior obliBue
muscle #only muscle not arising from back of the orbit.
,O/0-&C relationship of important structure to well define landmarks in the walls)
.nfra orbital foramen to midpoint of inferior orbital fissure>56 mm
%rontozygomatic suture to superior orbital fissure >?5mm
upra orbital notch to superior orbital fissure >6@ mm
upra orbital notch to superior aspect of optic canal>65mm
ubperiosteal dissection should not be extended more than 55mm posterior to inferior *lateral rim
and ?@ mm from superior rim *anterior lacrimal crest

'D'&.4)
-re movable folds covered externally by thin skin *internally by transparent mucous membrane
called palpebral con+unctiva which is reflected onto the eyeball# which continuous with bulbar
con+unctiva# which is thin# transparent *attached to anterior surface of eyeballs.
uperior *inferior eyelids are strengthened by superior *
inferior tarsi. 1etween the nose and medial angle of the
eye is "'4.-& (-&('1,-& &.E-"'/0# which
connects tarsi to medial margin of the orbit.orbicularis oris
originate * inserts into this. &-0',-& (-&('1,-&
&.E-"'/0 arises from tarsi *attaches to the marginal
tubercle of whitnallCs on zygomatic bone +ust below the
zygomaticofrontal suture# inside the orbital margin.
"edial canthus is separated by a small triangular space
called lacus lacrimalis# in the centre there is a small pink
elevation called caruncle.
Antimongoloid slant>separation of lateral palpebral ligament at frontozygomatic suture produces the
appearance called -ntimongoloid slant where in lateral canthi will be drooping downwards. &ateral
horn of levator tendon is also attached to this tubercle# so lowering of this structure along with
lowering of lateral attachment of suspensory ligament produces some degree of pseudoptosis.
"ongoloid slant) whenever there is fracture involving frontal process of the maxilla .medial canthal
ligament attached to this gets disturbed producing inferior displacement of bone resulting in
mongoloid slant .pseudoptosis is not seen here as medial horn of levator is poorly defined.
O,1.0-& %-:.-) 2periorbita3 it forms the periosteum of the bony orbit. 4ue to its loose
connection to bone .it can be easily stripped.posteriorly it is continuous with duramater *with sheath
of optic nerve. -nteriorly it is continuous with periosteum lining the bones around the orbital
margin. -t the upper * lower margins of the orbit .it send off flap like extension into the eyelids
called orbital septum. (eriosteum is very thin * easily perforated# when carrying out exploration of
orbital floor so that periorbital fat can readily escape.
1ulbar fascia) 2tenons capsule3 surrounds the eyeball *separates it from orbital fat. triangular
expansions from medial *lateral recti forms medial *lateral check ligaments# which are attached
respectively to lacrimal and zygomatic bones. leeve of inferior rectus is thickened on its underside
*blends with sleeve of inferior obliBue# as well as check ligaments to form 9('/O,D
&.E-"'/0 2hammock like support for the eye3.
O,1.0-& '(09") extends from periphery of the orbit to fuse with the attached margins of the
tarsal plate. .t arises from the thickened periosteum#then passes over the orbital rim to enter the orbit
is pierced by various tendons# nerves *vessels.
%ollowing nasoethmoidal fracture# surgical emphysema may result if patient has subseBuently blown
the nose as air gets collected in the preseptal space# anterior to tarsal plate.
(',.O,1.0-& %-0) %rictionless packing materials upon which muscles can rotate the eyeball
within the capsule of tenon.two principal compartments within the orbit are
:entralFintraconal>fusion of membrane with extra ocular muscle responsible for eye
movements.
(eripheralFextraconal>presents between muscles *periorbita.
1oth of the above spaces contain fat
&-:,."-& -((-,-09) production *removal of tears. it consists of lacrimal
gland#lacrimal canaliculi#lacrimal sac#nasolacrimal duct.
&acrimal gland>it is a serous gland with large orbital *small palpebral part. orbital part lies in
the lateral part of the roof of the orbit supported by aponeurotic tendon of levator palpebrae
superioris.closure of the eyelids begins at the lateral side of the upper lid *moves medially so
tears spread across the eye. -t the medial end# low elevation at lid margin called lacrimal
papilla surrounded by lacrimal punctum which opens into lacrimal canaliculus which convey
tears to lacrimal sac. -nd from there to nasolacrimal duct# which is 5 cm long# slopes
downwards# backwards *laterally *opens into anterior part of the inferior meatus 5 cm
behind the nostril.
"9:&' O% 0;' O,1.0)
'xtra ocular muscle)
Goluntary >7.rectus) superior
.nferior
"edial
&ateral
5. ObliBue) superior
.nferior.
?. &evator palpebrae superioiris
.nvoluntary>superior tarsal muscle
.nferior tarsal muscle
Origin &insertion)
%our recti muscle arises from a common tendinous ring *inserted into the sclera.
uperior obliBue arises from body of sphenoid *inserted into the sclera.
.nferior obliBue muscle arises from the orbital surface of the maxilla
&evator palpebrae superioiris arises from the orbital surface of the lesser wing of the
sphenoid.
Nerve supply) all the muscles of orbit are supplied by occulomotor nerve except superior
obliBue *lateral rectus.
uperior obliBue is supplied by trochlear nerve.
&ateral rectus is supplied by abducent nerve.
Movements of the eyes:
uperior rectus) moves eye in upward direction# medial direction*intortion.
.nferior rectus) moves eyes in downward direction# medial direction * extortion.
uperior obliBue) moves eye in downward direction# lateral direction*intortion.
.nferior obliBue) moves eyes in upward * lateral direction*extortion.
"edial rectus) moves eyes in medial direction.
&ateral rectus) moves eyes in lateral direction.

Orbital trauma
AIM
7. 0o manage trauma or any in+ury to the orbital region by accurate diagnosis *appropriate
surgical approach.
5. to correct diplopia *enopthalmos.
O!"#$I%"
7. 0o eliminate cosmetic# functional *ophthalmic complications
5. 0o establish appropriate treatment modality for the achievement keeping complications in mind.
#&A''IFI#A$ION OF O(I$A& F(A#$)("'
O(I$A& *A&& F(A#$)("'
7. 1low out fractures
a. pure blow out fracture
b. impure blow out fracture.
5. 1low .n fracture.
.O&-0'4 O,1.0-& ,." %,-:09,')
a. superior
b. inferior
c. lateral
d. medial.
.O&-0'4 O,1.0-& <-&& %,-:09,')
a. roof
b. floor
c. medial
d. lateral.
O,1.0-& %,-:09,' <.0; %O9,
-11,'G.-0.O/
77
a. %our letters defining the localization)
%) frontal# /) nasal# ") maxilla# $) zygomatic bone.
b. 0wo acronyms describing fragment shift)
./) blow in# O90) blow out.
c. %our numbers defining ocular movement impairment)
7. uperior# 5. .nternal# ?. .nferior# 6. 'xternal extrinsic muscular deficit.
d. 0wo acronyms defining eye position)
'H) exopthalmos# '/O) enopthalmos.
('4.-0,.: :&-.%.:-0.O/ O% O,1.0-& %,-:09,'
75
0ype 7) pure orbital fracture 26@.7%3
0ype 5) craniofacial fracture 2?5%3
0ype ?) common fracture pattern 255.=%3
(-0;O(;D.O&OED
"echanism of fracture is still unclear. "any theories have been put forward to explain the
mechanism)
)#+&IN, $-"O(.
5
0his theory states that if a force was to strike any part of the orbital rim #it
will cause walls to undergo a rippling effect *the force striking the rim will transfer to the weaker
portion especially the floor *cause them to distort *eventually fracture.
-./(A)&I# $-"O(. 2(feiffer in 7=6?3) ;e said that it is evident that the force of the blow
received by the eyeball was transmitted by it to the walls of the orbit with fracture of the delicate
portions. 0herefore direct in+ury to the globe forcing it into the orbit was necessary.
%laws regarding these theories)
7. /ot isolating the striking force to specific areas of face.
5. 9sing dried fixed cadavers with lowered intra ocular pressure.
?. ome specimens having no orbital content.
:O/G',' *".0;) due to increase in the hydrostatic pressure induced by direct trauma to the
globe.
%9I./O *"-J./O) entrapment of periorbital tissue between fractured orbital segments.
&'/4./E) bone elasticity facilitates deformations of orbital framework which in turn causes
fracture of the orbital floor.
#&INI#A& 0("'"N$A$ION
according to LESTER
9
&his associates the following findings were found more frequently
(eriorbital ecchymosis 27@@%3
.nability to elevate globe 2=@%3
Gertical diplopia 2=@%3
.nfra orbital hypoesthesia 258%3
4epression of the globe 2?@%3
'nopthalmos 25.75%3
-long with this !

edema
ubcon+unctival hemorrhage
(tosis
(seudoptosis
.ntraocular pain
O0$-A&MI# "%A&)A$ION
7. Gisual acuity>it is tested independently for each eye using a snellen chart at a standard 5@ foot
distance or a near card 2standard type print at 76 inches3if a snellen s chart is not available. if
the patient wears corrective lenses #then should be worn during examination.
5. Ocular motility
?. Gisual fields>are tested for each eye #one at a time by confrontation. this involves directly
aligning the patient s* examiners faces 5 feet apart2both maintaining direct front
gaze3*asking the patient to detect movement at the extremes of the examinerCs own visual
field.
6. :olor examination
5. (upilary responses>(upilary size# shape *symmetry should be evaluated# as well as light
reactivity. -n irregular pupil often points towards the site of globe penetration or in+ury.
8. %undoscopic examination
IMA,IN,
73 tandard radiographs>foreign bodies can be detected on plain films# but localization is
difficult. .t is inadeBuate in evaluating internal orbital fractures *soft tissues.
53 :aldwellCs pro+ection 2superior# lateral# medial orbital rim and ethmoidal and frontal sinuses
are better viewed3
?3 <aterCs pro+ection>allows visualization of orbital roof *floor blow fractures.
63 &ateral pro+ections>may be used to study floor *posterolateral orbital wall
53 1asal *obliBue pro+ections may be used to evaluate the optic canal.
83 :0 scan
8
:0 allows excellent visualization of orbital soft tissues as well as the ability to
simultaneously assess the intra cranial cavity when evaluating orbital trauma. %ractures are
best evaluated when the imaging plane is perpendicular to the fracture line.
agittal plane are most important radiological view in diagnosis of orbital floor blow out
fracture 2view is however impractical and unnecessary3.
:oronal plane :0 scan provides successful diagnosis
tandard approach is ?mm axial and coronal scanning
:oronal section shows orbital floor and roof fracture
agittal section shows anterior and posterior fracture margins.
&imitations of :0> 7.coronal ct is uncomfortable *often impossible to perform.
5. edation is freBuently reBuired in pediatric patients.
? .cost of ct scanning is higher than the cost of standard radiographs.
6. ,adiolucent foreign bodies are often missed on ct scan.
73 ",.
&imited use in orbital trauma.
9seful for assessing soft tissue involving such as incarceration of extra ocular muscles or
orbital fat.
O&I1)" 'A,,I$A& %I"* A' AN A/!A#"N$ $O #O(ONA& #$
23
4For the evaluation
of orbital floor fracture5
&ocation and the size of the fracture in the anteroposterior dimension and volume displaced from the
orbit into the maxillary sinus and the evidence of the inferior rectus muscle entrapment were
improved in this techniBue.
'0"#IA&I6"/ IN%"'$I,A$ION
)&$(A'O)N/ /IA,NO'I' ! of the orbital wall fracture with a curved array transducer
5@
. .t has
not yet reached the diagnostic Buality of :0# but is a helpful diagnostic imaging tool in cases with
clear clinical symptoms.
%oreign bodies in the anterior orbit may be identified.
#/I 4#olor /oppler imaging5 ! recent ultrasound techniBue gives simultaneous two dimensional
imaging of structures and blood flow. 'valuates post traumatic high flow carotid cavernous fistula.
7. %orced duction test) a local analgesic solution is instilled into the con+unctival fornices
*tendon of the inferior rectus muscle is grasped by forceps through the con+unctiva *an atte
mpt made to rotate the eye upwards. -lternatively a suture may be passed through the tendon
for the same purpose but care should be taken to ensure the suture does not come in contact
with the cornea.
9se of succinylcho line provides sustained contraction
of the extra ocular muscles that interfere with the accurate interpretation of the forced duction
test up to 5@ mins.
5. "lectromyography ! it is done by ophthalmologist. .t helps in differential diagnosis of
combined in+uries such as incarceration of inferior rectus muscle in association with
weakness of superior rectus.
?. Orbitography ! it is a diagnostic techniBue based upon# in+ection of the radio opaBue
contrast medium along the floor of the orbit.
MANA,"M"N$
:onservative approach
Medical #are
7. teroids to decrease orbital edema
(rednisolone 8@ mgF kgFday on 7 st day# followed by 8@ mg next 56 hours# * then
followed by 6@ mg for next 5 days
;ydrocortisone >7 gm Fkg Fday# with a tapering dose.
5. -ntibiotics preoperatively incase of elderly patients and continued for 5 weeks post
operatively.
?. . .v fluids in the form of mannitol @.5 mg or 5@@ ml of 5@ % solution should be given to
reduce any hemorrhage or hematoma
6. . .v acetazolamide 5@@ mg can be given to reduce hemorrhage * also intra ocular pressure to
some extent.
5. -voiding nose blowing for several weeks to avoid orbital emphysema.
urgical approach
$iming of repair
7
Immediate repair
7. /on resolving oculocardiac reflex with entrapment.
2. Early enopthalmos measuring more than 3 mm.
3. hite eyed floor fracture! commonly seen in children.
(epair within 3 wee8s
7. ymptomatic diplopia with a positive forced duction test.
5. &arge orbital floor fracture that may cause enopthalmos.
?. 'vidence of soft tissue entrapment on :0.
6. (rogressive infraorbital hypoesthesia.
Observation
7. "inimal diplopia 2not in primary or down gaze3
5. Eood ocular motility
?. /o significant enopthalmos i.e. not more than 7 >5 mm.
'urgical #are
:riterion for surgical intervention
7. 0o release increased volume of the orbit.
5. 0o relieve any entrapment of the muscle
?. %or proper functioning of the eye.
-bsolute :ontraindications
7. :ritical condition of the patient.
5. ,upture of the globe
?. ingle eye functioning
'urgical intervention
'teps involved in surgical intervention:
i. -pproach to the fractured site
ii. election of graft material
iii. (lacement of graft material
iv. tabilization of graft material
v. ,epositioning of periosteum
vi. ,epositioning of the tissues
". -ccess to orbital floor is made through various approaches.
91:.&.-,D -((,O-:;
78


Once the skin is incised# the surgeon has three options. 0he first is to dissect between the skin and the muscle
until the orbital rim is reached# at which point another incision through muscle and periosteum is made to the
bone. 0he second option is to incise through muscle at the same level as the skin incision and dissect down
+ust anterior to the orbital septum to the orbital rim. 0he third option is a combination of these in which
subcutaneous dissection toward the rim proceeds for a few millimeters followed by incision through the
muscle at a lower level# producing a step>incision# then following the orbital septum to the rim.

0he first flap is technically difficult to elevate and accidental KbuttonholeK dehiscence can occur. - further
problem that may occasionally be seen is a slight darkening of the skin in this area after healing. (resumably#
the skin flap becomes avascular and essentially acts as a skin graft. -n increase in the incidence of ectropion
has also been noted by some investigators with this approach. 'ntropion and lash problems have occasionally
been experienced after this Kskin onlyK flap
0he second option# in which the dissection is made between muscle and orbital septum# is technically less
difficult. :are must be taken# however# because the thin orbital septum can be easily violated# causing
periorbital fat to herniate into the wound
0he third techniBue# in which a layered dissection is used# avoids the disadvantages of the
Others. 0he main advantage of the KsteppedK incision through skin and muscle is that the pretarsal
%ibers of the orbicularis occuli can be kept attached to the tarsal plate# presumably assisting in
maintaining the position of the eyelid and its contact with the globe postoperatively
%irst approach>
.ncisions are made 5mm below the edge of the eyelid and a mid tarsal incision is made between the
edge and the orbital rim. %irst protection of the globe has to be done with the help of temporary
tarsorraphy suture or scleral shell. 0here is a skin crease which is situated about 5 to ? mm away which
provides a convenient line to follow. 0his incision is made through skin only. 0he skin is then reflected
down# by blunt dissection# until it is free from the pretarsal part of the orbicularis occuli. 0he muscle
fibers are then spread to expose the periosteum of the lateral border initially. ub muscular dissection is
continued until septum orbitale is seen. "ost surgeons try not to incise the septum in that it causes
herniation of orbital fat through it. 0his can be difficult to manage. .t also will reduce the risk of vertical
lid shortening. %rom this the infraorbital rim can easily be identified. 0herefore periosteal incision and
elevation can take place. 'levation of the orbital contents to expose any floor defect can be
made
-dvantages
i. Luick and easy to do
ii. 'stimation of giving incision can easily be done in case of edema
iii. car inversion is greatly diminished.
4isadvantages
i. ;ighest incidence of ectropion.
ii. Gertical lid shortening.
A&$"(NA$I%" $"#-NI1)": "9$"N/"/ &O*"( "."&I/ A00(OA#-
0he incision for the KextendedK subciliary approach is exactly as described for the standard
subciliary incision# but the incision must be extended laterally approximately 7 to 7#5 cm in a
natural crease . .f no natural skin crease extends laterally from the lateral palpebral
fissure# the extension can usually be made straight laterally# or slightly inferolaterally.
upraperiosteal dissection of the entire lateral orbital rim is performed with scissor
dissection to a point above the frontozygomatic suture . 0he orbicularis occuli
musculature and superficial portion of the lateral canthal tendon are retracted as the dissection proceeds
<ith retraction# an incision through the periosteum 5 to ? mm lateral to the lateral orbital
rim is made from the highest point obtained with supraperiosteal dissection . 0he
periosteal incision is connected to the one described from the standard approach to the orbital floor
and infraorbital rim . ubperiosteal dissection must strip all of the tissue from the
orbital floor and lateral orbital wall. 0his includes stripping the insertions of the deep portion of the
lateral canthal tendon# &ockwoodMs suspensory ligament# and the lateral check ligament# from the
orbital 2<hitnallMs3 tubercle of the zygoma. Eenerous subperiosteal dissection deep into the lateral
orbit allows retraction of these tissues to expose the frontozygomatic suture.

0,-/:O/I9/:0.G-& "'0;O4)
0he transcon+untival incision# also called the inferior fornix incision# is a popular approach for
exposure of the orbital floor and infraorbital rim. 0wo basic transcon+untival approaches# the
preseptal and retroseptal# have been described. 0hese approaches vary in the relationship of the
orbital septum to the path of dissection 2%ig. ?>73. 0he retroseptal approach is more direct than the
preseptal approach and easier to perform. 0he periorbital fat may be encountered during the
retroseptal approach# but this is of little concern and causes no ill effects. - lateral canthotomy is
freBuently used with transcon+unctival incisions for improved lateral exposure. 0he approach that
will be demonstrated here is the retroseptal transcon+unctival approach with a lateral canthotomy
0his approach involves no disruption of the outer surface of the eye lid. .n this method the lower lid is
pulled forward * held by traction suture which is inserted into the margin of the lower eyelid .a small
incision is made ? mm below the tarsal plate on the medial aspect .tissues are then separated on a plane
superficial to orbital septum but deep to orbicularis oculi muscle#using blunt dissection *a small guaze
swabs until the orbital rim is reached. 0he periosteum is then divided +ust above the infra orbital foramen
*elevated from the lateral to medial aspect until the rim is reached.
0o help increase the laxity of the lid a lateral canthotomy can be performed. 0his will allow the edge of
the tarsus to be seen. 0wo methods can then be used to achieve access to the floor. (reseptal or
retroseptal.
0he preseptal incision is where the incision is made at the edge of the tarsus.this will ensure that the
space can be created in front of the orbital septum to reach the orbital rim#
0he retroseptal incision involves incision 5mm below the tarsus#however dissection to get to orbital rim
is same.
-dvantages
i. 'xcellent asthetic results and Buick to do.
ii. /o skin muscle resection
iii. &ow incidence of ectropion
iv. car can rarely be seen
4isadvantages
i. &imitation of access
ii. "edial extent is limited
5. 0issues are then separated on a plane superficial to the orbital septum# but deep to orbicualris
oculi muscle using blunt dissection and small gauze swabs# until rim is reached. (eriosteum is
now divided +ust above the infraorbital foramen and elevated from lateral to medial side.
,etraction is maintained by means of malleable copper strip. 0his allows elevation of
periorbita along the floor and release of entrapped orbital contents.
?. -fter release of entrapped contents# repair is carried out by means of grafts
75.
-uto grafts ! are used for larger defects. 4ifferent types of auto grafts used are
:alvarial bone
.nner plate of ileum
=
eptal cartilages
-dvantages)
i. -voids risk of infected implants.
4isadvantages
i. -dditional operative time
ii. 4onor site morbidity
iii. Eraft absorption
-lloplastic materials
57
used are
'ialastic sheets
0orous poly ethylene
-dvantages of silastic sheets>
/ice capsule forms along the implant# decreases the chance of extrusion rate
.t has smooth surface so orbital tissue does not get attached to the implant
*therefore less chances of diplopia later on.
'ase of shaping# conforming and placement are comparable.
$itanium ! are used for larger defects
4isadvantages
.t has to be cut into proper shape to adapt it to the defect wall# so while
adapting that it creates sharp edges which need to be trimmed off or abraded s
.t has holes in it# so chances of orbital tissue getting incorporated is more #*
0herefore more chances of postoperative complications.
0o overcome this problem titanium sheets covered by thin sheets of porous
polyethylene on both sides are recently used.
'mooth nylon foils 2suprafoil3 orbital implants
7?

!hese are recently used materials for reconstruction of orbital floor
.
(econstruction with resorbable mesh plate
2:
-dvantages)
i. "aintenance of orbital contents against herniation forces during initial healing phase
4isadvantages)
i. -nterior displacement of mesh causing ectropion and enopthalmos and reBuiring
reoperation.
6. 0o secure this graft) > soft stainless steel wire or fine braided stainless steel suture wires are
passed through graft.
0itanium mesh also useful to support large bony grafts.
-lternatively microplate or miniplate can also be used.
5. -fter securing the graft# irrigation of the wound is done. Orbital periosteum and its free
margin sutured to the cut edge below the inferior orbital rim with interrupted ?>@ chromic
catgut. /ext level to be closed is muscular layer# only 5>? sutures are given. kin edges are
accurately apposed with slight evertion of the margins using 5>@ gauge silk suture or similar
size synthetic material.
"N/O'#O0I# O(I$A& F&OO( ("0AI(
:
'ndoscopic repair of the orbital blow out fractures could become predictable and efficient treatment
alternative to traditional methods.
0he purpose was to provide anatomical description of orbital floor via endoscopic approach.
@

degree and ?@ degree rigid endoscope was used by a :aldwell luc approach.
"axillary osteum # orbital floor and lateral ethmoid air cells were visualized including fracture
pattern and force transmission pathways.
-nd orbitomaxillary sinus bony thickening was identified and described for the first time.
#ombination of transcon;unctival and endoscopic transnasal approach
2

-dvantages
i. (osterior edge of the fracture and herniated tissue before reduction can be seen.
ii. &ess invasive
iii. 4ual manipulation by two surgeons is also possible in reduction and reconstruction of orbital
floor.
7@ degrees straight endoscopy is introduced through an enlarged ostium as for functional sinus
surgery allowed clear site of the roof of the antrum. 0hrough transcon+uctival approach reduction and
reconstruction was assisted from antrum.
0he large orbital defects were reconstructed with silicon sheets# thin iliac bone grafts or nasal septal
cartilage.
(ost operative infection was not observed.
$ranscaruncular approach for reconstruction of medial orbital fracture
2<
"edial orbital fracture can cause horizontal diplopia and enopthalmos.
.ncision is made in the caruncle and extended into the con+unctiva superior and inferior into the
fornices for 7@>75mm.0he tissue is bluntly dissected in an anteroposterior direction. 0he periosteum
was incised dorsally of the posterior lacrimal crest and after elevation of the periosteum# the
fractured orbital wall was visible.
0ransplant upto a height of 5cm could be inserted for reconstruction using resorbable poly dioxanone
plate.
:ortical bone was used for reconstruction of late enopthalmos
car formation was absent
:> -," 0,-/:O/I9/:0.G-& -((,O-:;
?
/ew approach using a : shaped extended transcon+uctival approsch os possible to have one field of
vision to see the frontozygomatic suture# the lateral orbital wall# inferior orbital rim# lateral maxillary
buttress and zygomatic arch.
-dvantages over other approaches
i. &ess operation time
ii. (ost surgical scars are lesser.
O0$-A&MI# "9MINA$ION
a. (re operative
b. .ntra operative
c. (ost operative
(,'O(',-0.G' 'G-&9-0.O/
i. (alpation and observation > 'yelid# canthus# eye movements
ii. chirmerCs test>this test is done to check the dryness of the eye.
- standardized strip of sterile filter paper are placed over the margins of the lower eyelid# by
measuring the length of wetting of filter paper tear production can be assessed. Galues below
5 mm after 5 min period are highly susceptible of keratocon+unctivitis sicca. * values from @
to 5 mm strongly confirm dry eye state.
iii. %undoscopic examination>this is done by ophthalmoscope or fundoscope.it is used in
determining health of retina *vitreous humour .it is also indicated for raised intra ocular
pressure.
0here are 5 types of ophthalmoscopes>direct *indirect.
4irect>it is the instrument of the size of a small flash light with several lenses that can
magnify up to 75 times. 0his is routinely used for examination.
.ndirect>it has a light attached to a headbandA in addition to small handheld lens. it has a
wider view of the inside of the eye.
iv. (atency of the lacrimal system can be demonstrated by passage of dye from con+unctival cul
de sac into the nasal cavity.
v. :0 scans and ",.
./0,-O(',-0.G' 'G-&9-0.O/
i. 'nopthalmos
ii. 0elecanthus
iii. (tosis
iv. 4uring dissection of medial orbital wall# optic nerve is at greater risk
(O0 O(',-0.G' :-,'
i. 'xamination of the function of the eye
ii. (atients with sighted eyes should be checked for visual acuity
iii. .f patient complains of loss of light perception then he should be returned immediately to the
operating room 2for either removal some of the bone graft or for decompression of optic
nerve3
#OM0&I#A$ION'
'arly complications
&ate complications
'-,&D :O"(&.:-0.O/ ! occurs at the time of or immediately after the surgery.
7.;emorrhagic or orbital hematoma>treated by lateral canthotomy immediately# lateral
canthal tendon lysis#iv acetazolamide 5@@mg #iv mannitol @.5 mg
5. ,etro bulbar hemorrhage>the following signs are seen..
(roptosis# marked subcon+unctival ecchymosis *edema# globe very hard on palpation#
dilating pupil# increased intraocular pressure on tonometry#
ymptoms seen are>pain# decreasing visual acuity# diplopia.
0reatment includes iv mannitol#25@@ ml of 5@%solution3#iv
acetazolamide5@@mg#*megadose steroids ?>6 mg Fkg as initial dose followed by 7>?
mgFkg 8 hourly for the following 56 hours reducing to 7 mgFkg over the next 5 days.
?. 1lindness
6. uperior orbital fissure syndrome
8. Oculo cardiac reflexF trigeminocardiacF trigeminovagal reflex !
0he oculo cardiac reflex pathway begins with the afferent fibres of the long * short ciliary
nerves that travel with the ophthalmic division of the trigeminal nerve to the gasserion
ganglion via the sensory nucleus of the trigeminal nerve. .n the floor of the 6
th
ventricle
short internuncial fibres in the reticular formation connect them with the efferent pathway
from the motor nucleus of the vagus nerve to the depressor nerve ending in the muscle
tissue of the heart.
:linical features> bradycardia# faintness# and further stimulation can lead to cardiac
dysrhythmias# ectopic beats# atrioventricular blocks * asystole.
1radycardia has been attributed to trigeminal derived vagal reflex.
8. :aratico cavernous fistula>if the in+ury of the orbit extends to cause a basal fracture
which tears the carotid artery within the cavernous sinus producing an arterio>venous
fistula. 0his characteristically results in a pulsating exophthalmoses worse on bending
down *diminished by occlusion of the ipsilateral carotid artery. 1ruit will be heard on
auscultation over the frontal region.
0reatment includes surgical closure of the fistula or its obliteration by embolisation.
&-0' :O"(&.:-0.O/
6
#ltered $ision
%iplopia
'ctropion and epiphora
'nopthalmos
("F"("N#"'
7. 1r.+ournalof plastic surgery A+an 5727357273?7 273?7 >66
5. 1uckling theory #+ craniofacial surgery sept 5@@5 vol 77
?. : arm of cranio facial surgery..5@@7#nov
6. :anadian +.of plastic surgery#septFoct 5@@7vol== 5#78?>7=5
5. :linical recommendations for repair of isolated orbital floor
fracture#".1urnstine.opthalmology5@@5 vol7@=#273#75@7>757@
8. 'ndoscopic orbital floor repair I. of craniofacial surgery.5@@8 +an
7. %onseca vol ? trauma
8. Iournal of laryngology *otology
=. &ester "c#blow out fractures of orbit Abr.+.plastic surgery#7=852783A777
7@. "aterials for reconstruction# "ichael burnstine#opthalmology5@@5
77. /ew classification and imaging of orbital fractures 2I :raniofacial urg /ov 5@@8# Gol.77# 8#
7@65>7@663
75. ObliBue agittal viewA+oms 5@@6 nov
7?. Ophthalmic plastic *reconstruction surgery.+ulyFaug 5@@8 56 263A588>57@
76. Ophthalmology# orbit vol 57 ? may 5@@8 767>757
75. (ediatric classification of orbital fracture# plastic reconstruction surgery#sept 5@@8#755
2?3#888>8=7
78. ,econstruction of floor with resorbablemesh plate I. of craniofacial
surgery#5@@7may782?3A5=8>8@5
77. ,owe and <illiams maxilla facial in+uries second edition vol 5
78. subcilairy approach#"I-%.A5@@6A8@ ?=5>?=6
7=. 0ranscaruncularapproach#i+oms#vol 5= issue 6 #586A587#may 5@@5
5@. 9ltra sound diagnosisA+oms 5@@8 +an
57. <endy.<.&ee# orbital floor implants )what to choose