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  • Enophthalmos is a common sign of

    2018-11-12

    Enophthalmos is a common sign of orbital fracture. Enophthalmos ≥2 mm is aesthetically unacceptable and requires surgical correction. The severity of enophthalmos and treatment outcome following surgery are related to the number, location, and size of orbital wall fractures. Raskin et al reported that zolmitriptan immediate enophthalmos is commonly associated with orbital medial wall fracture of more than two-thirds involvement in combination with floor fracture. Hawes and Dortzbach recommended using tomography to estimate the fracture size and concluded that large orbital floor fractures (≥15 fracture volume units or one-half of the orbital floor) are likely to be associated with significant enophthalmos following surgery. The fracture volume unit was determined by multiplying the fracture width (cm), fracture length (cm), and fracture depth (cm) of prolapsed orbital tissue. Pearl has reported that fracture of the posterior orbital floor produced more volumetric loss behind the axis of the globe than anterior floor fractures did, resulting in significant enophthalmos. Most orbital fractures are not confined to only one specific area but may involve various parts of the orbital floor simultaneously. Consequently, the specific location of the most symptomatic orbital floor is difficult to determine, particularly in unconscious, traumatized patients. These undiagnosed fractures require surgical intervention at a later date in almost 50% of cases. The present study revealed that an increased number of orbital wall fractures are proportionate to an increased incidence of enophthalmos. Orbital fractures, such as Type III orbital fractures, were associated with the highest incidence of enophthalmos of 85.2% compared with single-wall (39.4%) and two-wall (74%) fractures. Despite the severity of orbital injury and the high incidence of enophthalmos, the incidence of residual enophthalmos following surgery in patients with Type III orbital fractures was low (16.4%). Conversely, for Type II orbital wall fractures, the incidence of residual enophthalmos following surgery was higher (27.4%), probably because when an extreme force trauma to the face is suspected, the acute intervention approach varies. Clinicians are more vigilant concerning the diagnosis of complex orbital fractures and employ an aggressive treatment approach. Therefore, overcorrection with implants during surgery for patients with Type III orbital fractures routinely occurs. By contrast, treating minor deformities of patients with Type I orbital fractures is relatively easy. However, the appropriate corrective volume for patients who sustain Type II orbital fractures is difficult to determine. Overcorrection during surgery may frequently result in postoperative exophthalmos in these cases, whereas minor orbital fractures are often managed inadequately, because small orbital wall fractures are often missed or not apparent during initial radiological investigations. These undiagnosed orbital wall fractures may remain untreated, resulting in unfavorable postoperative consequences. In general, residual enophthalmos is often a result of the failure to perform adequate surgical correction because of severe soft-tissue edema or an undetected neighboring orbital fracture segment, particularly in complex orbital fractures. In addition, conditions caused by unpredictable cicatricial contracture and fat atrophy of the intraorbital content following surgery may contribute to the unfavorable postoperative recovery outcomes. Hence, patients who are at risk of developing enophthalmos must be followed for at least 6 months for detecting changes to enable prompt secondary surgery at a later stage. Many authors agree that early repair of orbital fractures before the onset of edema or after its resolution offers the ideal opportunity to facilitate exposure for appropriate surgical reduction and fixation. Rarely, the immediate surgery for orbital fractures is indicated in “trapdoor fracture” when significant enophthalmos occurs in association with orbital soft-tissue entrapment, resulting in oculocardiac reflex and diplopia. For most orbital floor fractures, a 2-week window of observation was suggested in the absence of urgent surgical indications for orbital floor repair. Nevertheless, a prolonged period of observation before surgical intervention may yield suboptimal outcomes. Hawes and Dortzbach reported that delays in the timing of orbital floor reconstruction beyond 2 months yielded inferior results compared with early surgery. Dulley and Fells observed that 72% of patients who had surgery 6 months after initial trauma had enophthalmos, whereas the percentage was 20% in patients who had surgery within 2 weeks of trauma.