Approaches to the Orbit

Author Credentials 

Jared M. Theler, MD
Chief Facial Plastics and Reconstructive Surgery
Department of Otolaryngology
Tripler Army Medical Center
​1 Jarrett White Road
Tripler AMC, Hawaii 96859-5000
Jared.m.theler.mil@mail.mil

Module Summary

Approaches to the orbit are wide in their variety, abilities and potential complications. With the advent of the endoscopic approach; many previously favored approaches are becoming less common. However; traditional transconjunctival and transcaruncular approaches are the gold standard for large and/or complex fracture patterns. The supraorbital region can also be addressed often via transbleph approaches with favorable cosmetic outcomes.

Module Learning Objectives 
  1. Understand the basic anatomy of orbit and how it relates to orbital trauma and reconstruction.
  2. Recognize how the orbital rims and their corresponding fractures affect the width and projection of the face based on the “buttressing” concept.
  3. Recognize how to approach the orbit via the Tranantral Endoscopic, Transnasal Endoscopic, Subcilliary, Transconjunctival, Retroseptal, Supratarsal and Tran/Retrocarunchular Approaches.

Anatomy

Learning Objectives 
  1. Describe the bony anatomy of the orbit and recognize the significance of the 3 dimensional orbito-sphenoid suture line in assuring proper alignment of ZMC fractures of the orbit.
  2. Understand the relationship of the medial canthal ligament and the lacrimal system.
  3. Recognize how the arcus marginalis, ligaments and septum of the orbit hold the orbital contents in place.
References 
  1. PMID: 27105794. Sand JP, Zhu BZ, Desai SC: Surgical Anatomy of the Eyelids. Facial Plast Surg Clin North Am. 2016 May;24(2):89-95.
  2. Sam P. Most, Steven Ross Mobley, Wayne F. Larrabee Jr: Anatomy of the Eyelids. Facial Plastic Surgery Clinics. 2005 Nov;13(4):487-492.

Pathogenesis

Learning Objectives 
  1. Understand the basic concept of the crumple zone and sinus’s within the face.
  2. Describe the hydraulic principle and how it relates to orbital floor fractures.
References 
  1. PMID: 10658130 Waterhouse N1, Lyne J, Urdang M, Garey L: An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg. 1999 Dec;52(8):607-12.

Incidence

Learning Objectives 

Forces needed for orbital fractures.

References 
  1. PMID: 28278314 Patel S, Andrecovich C, Silverman M, Zhang L, Shkoukani M: Biomechanic Factors Associated With Orbital Floor Fractures. JAMA Facial Plast Surg. 2017 Mar 9.

Genetics

Learning Objectives 

Be able to assess normal extraoccular movements, diplopia, entrapment, trapdoor blowout fracture, hyper/hypoglobus, ex/enopthalmos and normal lid positions.

References 
  1. PMID: 10371897 Patel BC, Hoffmann J: Management of complex orbital fractures. Facial Plast Surg. 1998;14(1):83-104.

Imaging

Learning Objectives 

Be able determine the need for fracture repair based on imaging findings.

References 
  1. PMID: 24756375 Betts AM, O'Brien WT, Davies BW, Youssef OH: A systematic approach to CT evaluation of orbital trauma. Emerg Radiol. 2014 Oct;21(5):511-31.
  2. PMID: 28005760 Bruneau S, De Haller R, Courvoisier DS, Scolozzi P: Can a Specific Computed Tomography-Based Assessment Predict the Ophthalmological Outcome in Pure Orbital Floor Blowout Fractures? J Craniofac Surg. 2016 Nov;27(8):2092-2097.

Pathology

Learning Objectives 

Understand evidence for when to repair fractures.

References 
  1. Timothy D. Doerr: Evidence-Based Facial Fracture Management. Facial Plastic Surgery Clinics. 2015 Aug;23(4):335-345. 
  2. PMID: 26275096. Scawn RL1, Lim LH, Whipple KM, Dolmetsch A, Priel A, Korn B, Kikkawa DO: Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury. Ophthal Plast Reconstr Surg. 2016 Jul-Aug;32(4):296-301.
  3. PMID: 27165680 Damgaard OE, Larsen CG, Felding UA, Toft PB, von Buchwald C: Surgical Timing of the Orbital "Blowout" Fracture: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2016 Sep;155(3):387-90.

Surgical Therapies

Learning Objectives 
  1. Understand advantages and disadvantages of the following approaches to the orbit:
    1. Orbital Floor
      1. Lower Lid
        1. Transconjunctival
          1. Fornix /Retroseptal approach
          2. Preseptal Approach
        2. Subcilliary
        3. Subtarsal
      2. Endoscopic/Trans-antral
    2. Medial Wall Fractures
      1. Transcaruncular/Retrocaruncular
      2. Endoscopic/Trans-nasal
    3. Orbital Roof Fractures and Orbitofrontal
      1. Superior Lid Crease Incision
      2. Coronal
      3. Lateral Brow
    4. Canthotomy/Cantholysis
References 
  1. ISBN-13: 978-0781754996 Surgical Approaches to the Facial Skeleton, Second Edition. Edward Ellis III DDS MS, Michael F. Zide DDS.
  2. PMID: 25397709 Ellis E 3rd: Surgical approaches to the orbit in primary and secondary reconstruction. Facial Plast Surg. 2014 Oct;30(5):537-44.
  3. Michael R. Markiewicz, R. Bryan Bell: Traditional and Contemporary Surgical Approaches to the Orbit. Oral and Maxillofacial Surgery Clinics. 2012 Nov;24(4):573-607. 
  4. PMID: 1961638 Westfall CT, Shore JW, Nunery WR, Hawes MJ, Yaremchuk MJ: Operative complications of the transconjunctival inferior fornix approach. Ophthalmology. 1991 Oct;98(10):1525-8.
  5. PMID: 19467402 Ducic Y, Verret DJ: Endoscopic transantral repair of orbital floor fractures. Otolaryngol Head Neck Surg. 2009 Jun;140(6):849-54
  6. John S. Rhee, Chien-Tzung Chen: Endoscopic Approach to Medial Orbital Wall Fractures. Facial Plastic Surgery Clinics. 2006 Feb;14(1);17-23.
  7. D. Gregory Farwell, E. Bradley Strong: Endoscopic Repair of Orbital Floor Fractures. Facial Plastic Surgery Clinics. 2006 Feb;14(1);11-16.
  8. PMID: 25954840 Kempton SJ, Cho DC, Thimmappa B, Martin MC: Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study. Ann Plast Surg. 2016 Mar;76(3):295-300.
  9. PMID: 18025357 Goldberg RA, Mancini R, Demer JL: The transcaruncular approach: surgical anatomy and technique. Arch Facial Plast Surg. 2007 Nov-Dec;9(6):443-7.

Case Studies

  1. A 22 year old female presents with a large right sided orbital floor fracture involving 60% of the orbital floor in addition to a medial wall fracture with 2mm of medial displacement of the wall. She is 1 week from her injury initially triaged at an outside hospital and presents to your clinic for further evaluation. She says her “eye looks smaller” on the injured side, but her double vision seems to be getting better slowly. She has 2 mm of current enophthalmos and would like to know what options she has for treatment. She does not want to have any scars if possible and is very image conscious. What would you consider for her for treatment? What surgical approaches would you consider and why?
    • Consideration: Given she is within the 2 week window for repair and she already is presenting with 2mm of aesthetically notable enophthalmos; repair is indicated. Her enophthalmos is likely to progress in the coming weeks as further fat atrophy and swelling resolve. Given her desire for no visible incision you could consider a transconjunctival approach for the orbital floor. Given the medial wall fracture a trancaruncular vs. endoscopic medial wall approach could also be considered. Given the large floor fracture and multiple walls involved an endoscopic floor and medial wall approach combined would likely be challenging but could still be considered.
  2. A 52 year old male with a right orbital rim and floor fracture after a fall from height presents with 3 mm enophthalmos. He has lost vision in his left eye from a prior trauma and only has sight in his right eye. What intervention would you like to offer the patient? Given his only seeing eye would you consider one approach over another?
    • Considerations: Given loss of vision in his non-injured eye; any intervention recommended should be conservative and as safe as possible. Even with the 3 mm of enophthalmos you could consider repair of the rim only and leave the floor unrepaired as diplopia is not of concern. If the patient has aesthetic consider and would like to proceed with floor repair you could consider a retroseptal approach with canthotomy and cantholysis (if for no other reason would provide wider access for ease of placement in addition to rapid decompression if orbital compartment syndrome was to develop with simple removal of the canthoplasty suture).

Complications

Learning Objectives 
  1. Recognize retro bulbar hematomas and know how to treat them emergently.
  2. Understand the incidence and cause of pre/post-operative diplopia and when to intervene.
  3. Recognize postoperative entropion, extropion, lacrimal system dysfunction.
  4. Understand the pitfalls of improper implant placement that can cause:
    1. Optic nerve compression
    2. Exophthalmos
    3. Hyperglobus
References 
  1. Regina E. Rodman, Robert M. Kellman: Controversies in the Management of the Trauma Patient. Facial Plastic Surgery Clinics, Vol. 24, Issue 3, p299–308.
  2. PMID: 24874836 Harris. GJ: Avoiding complications in the repair of orbital floor fractures. JAMA Facial Plast Surg. 2014 Jul-Aug;16(4):290-5.
  3. PMID: 27162565 Kesselring AG, Promes P, Strabbing EM, van der Wal KG, Koudstaal MJ. Lower Eyelid Malposition Following Orbital Fracture Surgery: A Retrospective Analysis Based on 198 Surgeries. Craniomaxillofac Trauma Reconstr. 2016 Jun;9(2):109-12.
  4. PMID: 27899021 Ramphul A, Hoffman G: Does Preoperative Diplopia Determine the Incidence of Postoperative Diplopia After Repair of Orbital Floor Fracture? An Institutional Review. J Oral Maxillofac Surg. 2017 Mar;75(3):565-575.
  5. PMID: 20466466 Ethunandan M1, Evans BT: Linear trapdoor or "white-eye" blowout fracture of the orbit: not restricted to children. Br J Oral Maxillofac Surg. 2011 Mar;49(2):142-7.

Review

Review Questions 
  1. What are the different indications for repair of orbital fractures?
  2. What are the different approaches to the orbit for surgical repair of the floor, rim and medial wall?
  3. What are the strengths and weaknesses of endoscopic vs. open approaches?
Resources 

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Academy U: Resident Manual of Trauma to the Face, Head and Neck