Orbital Trauma Care
What is ‘orbit’?
The orbit is the facial area that is composed of the 7 facial bones – frontal, zygoma, maxilla, lacrimal, ethmoid, sphenoid and palatine.
The zygoma contains the lateral orbital rim while the frontal bone boasts of the superior orbital ridge and upper medial orbital ridge. The inferior and lower medial rims form the maxilla and the orbit’s floor is made of the upper border of the maxillary sinus. The ehtmoid bone consists of the medial wall and it forms a part of the posterior wall of the orbit. The 2 wings of the sphenoid bone form the rest of the posterior of the orbit while the palatine is the continuation of the lacrimal bone from the medial wall.
Injuries covered under orbital trauma and associated with orbital fractures are eye injuries. Corneal abrasion, lens dislocation, iris disruption, choroid tear, sclera tear, retinal detachment and globe rupture are associate injuries.
Orbital fractures and types
Orbital fractures is a traumatic injury to the orbital bones (in and around the eye socket), usually due to blunt force trauma to the eye, causing disruption of bone structure.
Orbital fractures can be anatomically classified thus
- In the internal side, they may occur in the internal orbital skeleton as in the isolated fractures of the orbital floor and medial wall and roof.
- On the rim, the isolated injury might be a inferior, lateral or superior fracture or it might be contiguous with the internal wall fracture
- The rest of the facial skeleton also comes under orbital and the common facial fracture patterns are zygomaticomaxillary (ZMC), naso-orbito-ethmoid (NOE), frontal-sinus, Le Fort II, and Le Fort III fracture
The classification and references of the orbital fracture areas can be used for communication purposes. Individual treatment methods will vary based on assessment and any of the orbital bones (ethmoid, frontal, palatine, maxilla) may be involved in trauma and the intensity and displacement of the fractures might also vary.
What should an orbital trauma surgeon focus on?
Usually, orbital trauma management aims to minimize and prevent early and late sequelae and complications. Vision loss and persistent diplopia, globe malpositioning are late problems that might occur as side effects of any sorts of trauma to the orbital bones.
They various types of orbital trauma
The pyramid or conical shaped chamber that is composed of a floor, roof, medial wall and lateral wall can be affected by a blunt injury devoid of any lacerations. Injuries of this kind might result in malpositioning or misalignment of the frontal bones or other orbital bones.
Whenever there is facial trauma, the orbit is the first affected area. To protect the eyeball from the full force of the hit, the thin walls give way and allow the eye ball to sink in and retract into the orbit, away from the force.
Orbital floor fractures
The medial orbital floor is the most commonly fractured wall of the orbit. The zygomatic bone is a bit separated from the maxillary and palatine bones by the orbital fissure that is a bundle of nerves and arteries. The floor fractures confuse this nerve structure and also affect the surrounding tissue.
The cosmetic angle of orbital fractures
Since the orbital bones are primarily facial bones and are touched only when there is any injury or trauma to the facial area, the post operative care might take on a cosmetic angle to ensure that the face itself is repaired as much as possible to its original state. Since orbital fractures might cause deformities, the functional and aesthetic aspects of this must be taken into account.
The Zygomatic arch is an important feature in the structure and appearance of the face, The zygoma and maxillary bones (part of the orbital floor and lateral orbital wall) are referred to as the malar complex.
Surgical treatment of Orbital trauma
Surgical treatment of orbital or maxillofacial fractures involve these steps
- Degloving the facial skeleton
- Anatomic reduction
- Replacing lost or comminuted bone
- Tissue resuspension
Proper preoperative and postoperative care is a must to avoid infection and to protect the cornea. Care must be taken to avoid orbital hemorrhage or optic nerve compression.
The posterior displacement of the eyeball within the orbit is called Enophthalmos. Most often, this is due to the changes in the volume of the orbit bone relative to its contents including the eyeball. Or loss of function of the orbitalis muscle. Enophthalmos can be congenital (primary) and congenital relative enophthalmos or ocular retrusion might occur in utero maldevelopment. Secondary enophthalmos might be due to an acquired change in the orbital fat and the eye.
The zygomaticomaxillary fracture, previously known as the tripod fracture or trimalar fracture is in the lateral orbital wall or the separation of the zygoma and maxilla, or the zygomatic arch and orbital floor. The tripod fracture is usually caused by a direct blow to the malar eminence of the cheek during an assault.
Dr. Debraj Shome is a practiced surgeon and has handled minor to severe orbital trauma cases with many instances of complete disfigurement being turned into cosmetically satisfying end results of almost normal looking faces. He combines unique techniques that treat the trauma as well as the appearance of the orbital area to give his patients their original face even in the cases of moderate orbital trauma.