🔶 ORBITAL TRAUMA MANAGEMENT PROTOCOL 

A structured, clinically practical protocol for emergency, ophthalmology, and oculoplastic settings.

1. INITIAL ASSESSMENT & TRIAGE

A. Primary Survey (ATLS Principles)

Before focusing on the orbit, ensure:

  • Airway with cervical spine protection

  • Breathing

  • Circulation

  • Disability (neurological status)

  • Exposure (rule out multi-system trauma)

Red Flags requiring urgent stabilization:

  • Altered sensorium

  • Active bleeding

  • Airway compromise

  • Suspected head/neck injury

2. OCULAR EVALUATION (Secondary Survey)

A. Visual Function

  • Visual acuity (preferably with pinhole)

  • Relative Afferent Pupillary Defect (RAPD)

  • Color vision (Ishihara)

  • Confrontation visual fields

Red Flags:
âž¡ RAPD
âž¡ Sudden vision drop
âž¡ Diplopia with bradycardia (oculocardiac reflex)

B. External Examination

  • Periorbital edema, ecchymosis

  • Lacerations (check for canalicular/levator involvement)

  • Orbital emphysema

  • Globe displacement (proptosis/enophthalmos)

C. Globe Examination

  • Conjunctival chemosis

  • Corneal clarity

  • Anterior chamber depth/angle

  • Hyphema

  • Lens dislocation

  • Rule out open globe injury

    • Positive Seidel test

    • Peaked pupil

    • Prolapsed uveal tissue

If open globe suspected → No pressure on globe, shield eye, immediate surgery.

D. Ocular Motility

  • Limitation of gaze

  • Diplopia testing

  • Forced duction test (preferably intraoperative if swelling is present)

Entrapment indicators:

  • Pain with eye movement

  • Vomiting (oculocardiac reflex)

  • Severe motility limitation in vertical gaze

3. IMAGING PROTOCOL

A. Preferred Imaging: CT Orbit (1mm cuts)

  • Axial + coronal + sagittal

  • Bone algorithm

  • Soft tissue window

Assess:

  • Size and location of the fracture

  • Muscle/tissue entrapment

  • Retrobulbar hemorrhage

  • Optic canal fracture

  • Foreign body

  • Extraocular muscle shape (“rounding” → entrapment)

B. MRI Orbit (Selective Use)

Indications:

  • Suspicious soft tissue injury

  • Muscle/tendon rupture (e.g., inferior rectus avulsion)

  • Optic nerve injury (ON sheath hematoma)

4. CLASSIFICATION OF ORBITAL FRACTURES

1. Blow-out fracture

  • Floor

  • Medial wall

  • Combined

2. Orbito-Zygomatic Complex (ZMC) fracture

3. Naso-Orbito-Ethmoidal (NOE) fracture

4. Orbital Roof fracture

5. White-Eye Blowout Fracture (in children)

  • Minimal ecchymosis

  • Severe entrapment

6. Traumatic Optic Neuropathy (TON)

5. EMERGENCY MANAGEMENT INDICATIONS

A. Absolute Emergencies (Operate ASAP — within hours)

  • Orbital compartment syndrome (OCS):

    • ↓ Vision

    • RAPD

    • Proptosis

    • Tight eyelids

    • High IOP
      → Immediate lateral canthotomy + cantholysis

  • Open globe injury

  • Extraocular muscle entrapment (especially pediatric white-eye fracture)

  • Oculocardiac reflex (bradycardia, nausea, syncope)

B. Early Surgical Indications (Within 1–2 weeks)

  • Large floor/medial wall fracture (>50% surface)

  • Significant enophthalmos (>2 mm)

  • Persistent diplopia in primary gaze

  • Positive forced duction test

  • Non-resolving hypoglobus

  • Muscle impingement on CT

C. Delayed Indications (After 2–3 months)

  • Secondary enophthalmos

  • Poor cosmetic contour

  • Late-onset diplopia

  • Socket deformity

6. MEDICAL MANAGEMENT PROTOCOL

A. For all orbital fractures:

  • Ice packs for the first 48–72 hours

  • Head elevation

  • Analgesics (avoid NSAIDs if bleeding risk)

  • Short course of oral steroids (methylprednisolone 1 mg/kg/day × 5 days)

  • Avoid nose blowing × 2–3 weeks

  • Saline nasal decongestants

  • Antibiotics only if sinus involvement (amoxicillin/doxycycline)

B. OCS treatment (before imaging if vision threatened):

  • Lateral canthotomy + inferior cantholysis

  • IV mannitol (if globe safe)

  • IV methylprednisolone 1 g (optional)

C. Traumatic Optic Neuropathy (TON):

  • High-dose steroids (controversial)

  • Optic canal decompression ONLY if a compressive bone fragment is seen on CT

  • Close visual monitoring

7. SURGICAL MANAGEMENT

A. Surgical Approaches

  • Transconjunctival (preferred for floor)

  • Subciliary (less preferred due to scarring)

  • Transcaruncular (medial wall)

  • Endoscopic endonasal (medial wall/floor)

  • Combined approach (complex fractures)

B. Principles of Orbital Fracture Repair

  1. Identify fracture margins clearly

  2. Release entrapped soft tissues fully

  3. Restore orbital volume

  4. Implant placement

    • Titanium mesh

    • Porous polyethylene (Medpor)

    • Hybrid implants

    • 3D-printed patient-specific implants (PSI)

  5. Verify:

    • Smooth contour

    • No implant impingement

    • Good globe projection

C. Special Situations

1. White-Eye Blowout Fracture (Children)

  • Emergency surgery

  • Minimal external signs → high suspicion

2. NOE Fracture

  • Medial canthal tendon integrity

  • Telecanthus management

3. ZMC Fracture

  • Restore:

    • Zygomaticofrontal suture

    • Arch

    • Inferior orbital rim

    • Orbital floor

4. Roof Fracture

  • Neurosurgery involvement

  • CSF leak precautions

8. POSTOPERATIVE MANAGEMENT

A. Immediate Post-op

  • Cold compresses

  • Lubrication

  • Oral antibiotics (if indicated)

  • Steroids taper

  • Avoid heavy lifting and the Valsalva maneuver

B. Follow-up Protocol

  • Day 1: Vision, IOP, implant check

  • Week 1: Swelling, motility, wound

  • Week 4: Repeat CT if persistent diplopia

  • 3 months: Cosmetic + functional evaluation

9. COMPLICATIONS TO MONITOR

  • Persistent diplopia

  • Enophthalmos

  • Hypoglobus

  • Infraorbital nerve dysesthesia

  • Implant migration

  • Sinusitis

  • Optic neuropathy

  • Infection or extrusion

10. DOCUMENTATION checklist

  • Pre-op: Vision, RAPD, photos, CT report

  • Intra-op: Approach, implant used, muscle release

  • Post-op: Vision, motility, globe position, complications