The better surgical timing and approach for orbital fracture: a systematic review and meta-analysis

A large number of empirical studies on the surgical timing and approach of orbital fracture have been published, but which surgical timing and approach is better is still a dispute. We use a systematic review and meta-analysis to solve this problem.

We performed a systematic search in the databases of PubMed, Cochrane Clinical Trials Database, Embase, and Web of Science for relevant literature. The search terms included those concerning or describing orbital fracture, timing, and approach, which are based on population, intervention, control, outcome, and study (PICOS) framework. The statistical software packages RevMan 5.4 and Stata 14.0 were used for data analysis. We sought to evaluate postoperative complications, and results were expressed as odds ratio (OR) with 95% confidence interval (CI). Forest plots, sensitivity analysis, funnel plots, Egger's test, and risk bias analysis were also performed on the included articles by using the Newcastle-Ottawa scale (NOS).

A total of 7 trials involving 1,283 patients compared the surgical timing of ≤14 days versus >14 days, and another 14 trials involving 1,768 patients compared the surgical strategy of transconjunctival approach (TCA) with that of subciliary approach (SCA) for orbital fracture. The quality of all articles was higher than 7 points, which means all articles were at low risk of bias. Surgery conducted within 14 days significantly reduced the incidence of diplopia (OR: 0.53, 95% CI: 0.34 to 0.83, P=0.005) and enophthalmos (OR: 0.32, 95% CI: 0.12 to 0.83, P=0.02); TCA had a significantly lower incidence of ectropion (OR: 0.20, 95% CI: 0.10 to 0.38, P<0.00001), scleral show (OR: 0.22, 95% CI: 0.12 to 0.38, P<0.00001), and visible scar (OR: 0.15, 95% CI: 0.03 to 0.65, P=0.33) compared to SCA, but had a significantly higher incidence of entropion (OR: 5.41, 95% CI: 1.83 to 15.96, P=0.002). There was no significant publication bias among our included studies.

The operation in ≤14 days is better than that in >14 days. However, regarding the choice of surgical approach, TCA and SCA have their advantages and disadvantages, the exploration of which requires further research.