Current concepts on the management of orbital blow-out fractures

Surgical versus nonsurgical treatment of orbital blow-out fractures has been controversial in the past. In the 1950s it was advocated that all blow-out fractures be treated surgically based on the conception that extraocular muscles were blown out and trapped in the fracture hole, causing double vision and enophthalmos. Gradually, however, a shift to a more conservative approach occurred, probably because of the complications of surgery, the disappointing results in improvement of motility and enophthalmos, and the growing evidence of spontaneous improvement of double vision. This article analyzes the literature chronologically and blends this analysis with the results of a new anatomical approach to the human orbit. New theories on the mechanism of blow-out fractures are postulated. No longer is entrapment of muslces in a blow-out fracture held responsible for the severe motility problems; rather it is viewed as caused by a dysfunction of the entire motility apparatus in the fracture region. Consequently, conventional surgical treatment, repairing the orbital floor only, seems to have lost its theoretical foundation and a conservative approach is advocated until microsurgical techniques become more readily avaliable to treat the sequelae of blow-out fractures at their origin.