A Systematic Review Comparing Endoscopic and Open Approaches in Orbital Fracture Surgery

Orbital floor fractures are a common form of facial bone injury and typically present with diplopia, infraorbital nerve paresthesia, and enophthalmos. Open surgical approaches offer wide exposure but are potentially associated with visible scarring and eyelid malposition. Despite growing use of minimally invasive methods, comparative data on functional outcomes remain limited. This systematic review evaluated postoperative results (enophthalmos and diplopia) of open versus endoscopic orbital floor fracture repair. In accordance with PRISMA guidelines, a comprehensive search of PubMed/MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Library (2000-2025) was performed. This review included clinical trials and observational studies (cohort and case-control) in adults with surgically indicated orbital floor fractures comparing open external repair versus endoscopic repair. The search identified 266 records. Seven studies met inclusion criteria, encompassing 538 patients (open: n = 340; endoscopic: n = 198). Five were non-randomized studies, whereas 2 were randomized controlled trials (RCTs). Postoperative diplopia was reported across all included studies and occurred less frequently after endoscopic repair relative to open approaches (odds ratio = 0.31; 95% confidence interval (CI): 0.15-0.61; p = 0.0008). Postoperative enophthalmos, evaluated in 6 studies, was also less frequent after endoscopic repair (odds ratio = 0.32; 95% CI: 0.13-0.79; p = 0.01). Meta-analysis for extraocular muscle (EOM) limitation, paresthesia, and change in enophthalmos severity was not feasible due to limited data. Endoscopic orbital floor fracture repair demonstrated lower postoperative incidence of diplopia and enophthalmos compared with open approaches, with statistically significant pooled effects and low to moderate heterogeneity. Clinicians may consider endoscopic techniques in appropriate candidates, recognizing that evidence for secondary outcomes was limited by sparse and heterogeneous reporting.