AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Insult to the facial skeleton is a devastating result of low-, medium-, or high-velocity trauma. Orbital floor fractures can occur as isolated injuries or in combination with extensive facial bony disruption. Floor fractures may occur in combination with zygomatic arch fractures, Le Fort type II or III midface fractures, and medial wall or orbital rim fractures.

Technological strides in radiologic modalities (see Images 1-3) and surgical technique have resulted in improved diagnostic and management capabilities. The goal of treatment is to maintain or restore the best possible physiologic function and aesthetic appearance to the area of injury. A conservative approach may be warranted in some instances, whereas more invasive and aggressive intervention may be necessary in other situations.

For excellent patient education resources, see eMedicine's patient education articles Facial Fracture and Black Eye.

History of the Procedure

According to Ng et al, orbital floor fractures first were described by MacKenzie in Paris in 1844. In 1957, Smith and Regan described inferior rectus entrapment with decreased ocular motility in the setting of an orbital floor fracture and used the term "blow-out fracture."

Over the past decade, rigid internal fixation has become the most frequently used technique in repair of floor fractures. According to Patel and Hoffmann, materials employed for fixation have ancestry reaching back to the introduction of stainless steel wires by Dr Buck in the 19th century.

Plating has gained widespread acceptance, eclipsing stainless steel wiring in the repair of facial fractures. Since orthopedic surgeons have been using plating for the repair of long bones, these plates have been refined, and microplating systems and biocompatible implants offer the surgeon excellent techniques for fracture stabilization and restoration of normal bony architecture.

Problem

Orbital floor fractures can result in an increased volume of the orbit, and this may result in enophthalmos. If more than 2 mm of enophthalmos exists, this can create a noticeable imbalance. The globe also can be infraplaced or hypo-ophthalmic compared to the contralateral side. Additionally, the inferior rectus muscle or orbital tissue can become entrapped within the fracture site. This tethering prohibits the upward movement of the globe, causing diplopia. Occasionally, significant orbital emphysema from the communication with the maxillary sinus as well as orbital hemorrhage can occur. The globe can be ruptured or suffer less severe forms of trauma, resulting in hyphema or retina edema.

Frequency

Orbital floor fractures alone or in conjunction with other facial skeletal fractures are the most commonly encountered midfacial fractures, second only to nasal fractures.

The frequency of orbital floor fractures depends on demographics and socioeconomic conditions. Obviously, trauma centers and urban facilities encounter a higher prevalence of this injury type.

Etiology

Pure orbital floor fractures, also referred to as isolated floor fractures, result from an impact injury to the globe and upper eyelid. The object is usually large enough not to perforate the globe and small enough not to result in fracture of the orbital rim.

Pathophysiology

Orbital floor fracture results from a sudden increase in intraorbital hydraulic pressure. A high-velocity object that impacts the globe and upper eyelid transmits kinetic energy to the periocular structures resulting in pressure with a downward and medial vector. This force usually targets the infraorbital groove, with most fractures occurring in the posterior medial region, which is the thinnest bony orbital area.

Another proposed mechanism, which is less favored, states that fracture occurs when an object large enough to strike the inferior orbital rim disperses kinetic energy, causing buckling of the orbital floor without displacement of orbital contents.

Although most pure orbital fractures affect the region medial to the infraorbital groove, any fracture type, size, or geometry is possible.

Clinical

Most patients present after facial trauma and may describe decreased visual acuity, blepharoptosis, binocular vertical or oblique diplopia (especially in upgaze), and ipsilateral hypesthesia, dysesthesia, or hyperalgesia in the distribution of the infraorbital nerve. In addition, patients may complain of epistaxis and eyelid swelling following nose blowing.

Periorbital ecchymosis and edema accompanied by pain are obvious external signs and symptoms, respectively. Enophthalmos may be discerned, but initially it can be obscured by surrounding tissue swelling. This swelling also may restrict extraocular muscle motility, giving the impression of entrapment within the floor defect. Proptosis may result from retrobulbar or peribulbar hemorrhage. Palpation of the orbit may reveal a bony step-off of the orbital rim and point tenderness.

Examination of the globe is essential and may be difficult secondary to soft tissue edema. A set of Desmarres retractors may be helpful in this setting. Pupillary dysfunction, if present, coupled with decreased visual acuity should alert to the possibility of a traumatic optic neuropathy. Ocular misalignment, hypotropia or hypertropia, and limitation of elevation in the affected eye that is not found to the same degree in the contralateral eye can be present. Forced duction tests aid in differentiating entrapment from neuromyogenic etiologies. The supratarsal crease may deepen along with narrowing of the palpebral fissure as a result of enophthalmos or fibrous tissue contraction. Although the palpebral fissure may in fact narrow, the geometric shape is preserved since dehiscence or disruption of the canthal tendons is uncommon.

Wilkins and Havins reported a 30% incidence of a ruptured globe in conjunction with orbital fractures, supporting the notion that a thorough and complete ophthalmic examination is needed.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The timing and requirements for surgical intervention in the repair of pure orbital floor fractures are areas of long-standing debate. Most literature supports a 2-week window for repair to prevent fibrosis and resulting tissue contracture and entrapment. The authors often wait several days to allow dissipation of edema and hemorrhage in order to better assess enophthalmos and extraocular muscle function. In the event of tense inferior rectus incarceration, more immediate action is taken. Of special note is the pediatric patient with an orbital floor fracture, described by Egbert et al, who has nausea, vomiting, and extraocular muscle dysfunction; patients in this population experienced rapid improvement of these signs and symptoms and less risk of residual extraocular muscle dysfunction with a repair undertaken within 7 days.

A pure orbital floor fracture involving more than 50% of the floor, with or without concomitant medial wall fracture and with orbital tissue prolapse, usually results in significant enophthalmos (>2 mm) and is an indication for timely repair. In addition, diplopia may result because of limitations in upgaze and downgaze. If this limitation is present within 30° of primary gaze with a positive forced-duction test and CT scan confirmation of a fracture, undertake an early repair because of the high probability of persistence. Trapdoor or anteroposterior fractures can have clinical findings that are out of proportion to findings on radiologic studies. This must be considered, since a careful review can reveal soft tissue entrapment that should be corrected to diminish the chance of persistent diplopia.

Although diplopia within 30° of primary gaze, extraocular muscle entrapment, and enophthalmos greater than 2 mm are discussed in the context of large floor fractures, each can be an indication for repair.

Infraorbital nerve dysfunction occurs and is often the only complaint following pure orbital floor fracture. This sensory disturbance traditionally has not been an indication for repair. Some authors have reported improvement of this neuropathy following repair and nerve decompression.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The adult orbital floor has contributions from the maxillary, zygomatic, and palatine bones. It is the shortest of all the walls; it does not reach the orbital apex, measures 35-40 mm, and terminates at the posterior edge of the maxillary sinus. The infraorbital groove, canal, and foramen are contiguous and tunnel through the maxilla, encasing the maxillary branch of the trigeminal nerve. The maxillary branch of cranial nerve V exits as the infraorbital nerve, providing sensory innervations to the floor, mid face, and posterior upper gingival in an ipsilateral fashion. The infraorbital artery, a tributary of the maxillary artery, and the infraorbital vein also are found within the infraorbital groove flanking the infraorbital nerve and exiting the infraorbital canal.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical correction is contraindicated in patients who are medically unstable and unable to tolerate anesthesia.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• If alcohol or illicit drug use is suggested, obtain and document serum levels.
• As with most surgical patients, appropriate preoperative laboratory tests (eg, complete blood count, metabolic panels, activated partial thromboplastin time) and an international normalized ratio level are necessary. Obtain a pregnancy test when clinically warranted.

Imaging Studies

• A chest radiograph may be an indicated study before surgery. Radiographs can be used for soft tissue but are limited by the lack of ability to detect differences in tissue density of less than 10%, making evaluation of soft tissue difficult at best.
• • Anteroposterior views of the orbit usually are obtained with varying angulation of the x-ray beam vector.
  • The most common views are the Caldwell and Waters projections. The Caldwell projection allows for visualization of the orbital floor and orbital zygomatic process above the dense petrous pyramids. A more extended view of the orbit is afforded by the Waters projection. This angle of x-ray trajectory places the petrous pyramids below the maxillary sinus, allowing evaluation of the orbital floor, prolapsed orbital contents, and air-fluid levels in the maxillary sinus. Ng et al found a poor correlation between soft tissue opacities below the inferior orbital rim and inferior rectus muscle entrapment with a Waters view.
  • Lateral views often are confusing because of overlapping anatomic structures and offer little in the assessment of floor fractures.
• CT scanning has supplanted radiographs in evaluation of midfacial trauma (see Images 1-3).
• • A gray-scale image is created based on various soft tissue linear coefficients that are assigned a particular shade of gray. Direct axial, coronal, or sagittal images can be obtained with proper positioning of the patient.
  • CT scanning without contrast provides views of high-density bone. Obtain both axial and direct coronal 1.5- to 2.0-mm cuts to properly evaluate the orbit and the floor.
  • If the patient cannot be manipulated into proper position for direct coronal images, coronal views also may be obtained indirectly by reformatting thin axial windows. However, if possible, direct coronal images are preferable. Coronal orbital views provide bony and soft tissue windows, allowing for excellent detail of orbital floor fractures, adjacent sinuses, and soft tissue entrapment.
• Magnetic resonance imaging (MRI) uses a magnetic field and the activity of hydrogen atoms within this field to produce magnificently detailed images of the orbit.
• • MRI enables multiplanar imaging and is excellent for evaluating soft tissue masses and optic nerve pathology.
• Even though MRI provides exquisite detail of the orbital region, CT scanning remains the imaging of choice for evaluation of orbital trauma secondary to its ability to discern detail of bony structures. Of note, intraocular ferromagnetic foreign bodies can add additional insult to the eye and surrounding structures secondary to the magnetic field of the MRI.

Other Tests

• An ECG also may be indicated.

Diagnostic Procedures

• If the CT scan is equivocal when evaluating a patient with presumed entrapment, forced ductions can be performed. Directly assessing the ability or inability to further supraduct the eye while the patient is looking upward can yield important clinical confirmation of an entrapped muscle or tissue or of a paretic muscle.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical Therapy

Medical treatment is warranted for patients for whom surgery is not indicated. Such patients present without significant enophthalmos (2 mm or more), a lack of marked hypo-ophthalmus, absence of an entrapped muscle or tissue, a fracture less than 50% of the floor, or a lack of diplopia.

• The patient can be treated with oral antibiotics on an empiric basis due to the disruption of the integrity of the orbit in communication with the maxillary sinus.
• A short course of oral prednisone also may benefit the patient by reducing edema of the orbit and muscle. This also may allow for a more thorough assessment of the relative contribution to enophthalmos or entrapment from the fracture versus that from edema.
• Discourage nose blowing to avoid creating or worsening orbital emphysema. Nasal decongestants can be used if not contraindicated.

Surgical Therapy

The orbital floor can be accessed through a conjunctival approach, through cutaneous exposure, or through a transmaxillary approach. Access to this region allows for exploration and release of displaced or entrapped soft tissue, thereby correcting any extraocular motility disturbances. In addition, repair of the bony defect with removal or repositioning of bony fragments allows for restoration of the partition between the orbit and maxillary antrum, thereby preserving orbital volume and eliminating any impingement on soft tissue structures.

Transconjunctival approach

The transconjunctival approach can be combined with a lateral canthotomy for exposure of the orbital floor (see Image 4).

• Initiate this approach with a curvilinear incision approximately 3 mm below the tarsal plate parallel to lower lid punctum.
• Carry this surgical plane forward in a fashion posterior to the orbicularis oculi muscle and anterior to lower lid retractors and orbital septum.
• Placement of this dissection is paramount. If placed too low, orbital fat prolapse likely compromises visibility of the fracture, and if placed too high, postoperative architectural distortion may ensue.
• Moving in a vector anterior to the septum, approach the orbital rim and overshoot it for several millimeters. Incise the periosteum at the medial aspect of the anterior border of the inferior orbital rim and carry it laterally.
• Then elevate the periosteum with a hand-over-hand technique using sharp periosteal elevators, starting nasally and moving temporally until adequate exposure is obtained.
• Preserve an anterior flap to be sutured at the conclusion of the procedure and remain cognizant of the location of the infraorbital groove and foramen that enshroud the infraorbital neurovascular bundle.
• The advantages of this approach include the absence of visible scars and reduced risk of lower eyelid retraction.

Cutaneous approach

• The cutaneous approach commences with a skin-muscle flap elevation via an incision 2-3 mm below the lower lid margin. Carry this dissection anterior to the orbital septum until the orbital rim is exposed.
• Incise the periosteum and liberate it from its bony attachments as described in the transconjunctival approach. Of note is the downward sloping of the floor immediately posterior to the rim, which can result in breech of the septum during periosteal dissection.

Transantral approach

• A transantral approach allows access to the orbital floor via the maxillary sinus. This approach may be especially useful when repairing a floor fracture of the trap door variety.
• Achieve exposure of the incision site with upper labial retraction exposing the buccal-gingival sulcus.
• Create a horizontal incision just inferior to the buccal-gingival sulcus so that a wide mucosal band is present. This wide band allows for imbrication of the wound, avoiding oral-antral fistulization.
• Employ a periosteal elevator to strip the anterior maxillary wall of periosteum. The proximity of the infraorbital foramen should be kept in mind to minimize the risk of insult to the neurovascular bundle.
• Fashion a Caldwell-Luc antrostomy with an osteotome and mallet, followed by rongeurs to increase the diameter of the antrostomy, providing access to the orbital floor, medial wall, and ethmoid sinus complex.
• Strip the mucosa from the maxillary antrum and cauterize the remnants.
• Following repair of the fracture, attention to hemostasis is followed by closing the buccal-gingival mucosa with fast-absorbing suture material.
• This approach results in inferior orbital floor exposure and is not favored for floor fracture repair.

Other approaches

Tessier described vertical osteotomies of an intact orbital rim for exposure of the orbital floors. This myringotomy is essentially 2 vertical osteotomies on either side of the infraorbital foramen conjoined by a horizontal osteotomy. Two osteotomies of the orbital floor originating at the inferior rim and extending past the infraorbital groove origins are created, allowing for removal of this segment, which can be replaced at the conclusion of surgery.

Recent advances in endoscopic and surgical technique have allowed for repair of orbital floor fractures through minimal cutaneous incisions.

Adequate visualization of the fracture allows for thorough exploration and liberation of entrapped soft tissue from the defect. Once the fracture has been isolated, reconstruction of the orbital floor is paramount to restoring and maintaining orbital geometry and volume. Furthermore, reconstruction provides a partition between the orbit and maxillary antrum and provides support for the globe and intraorbital tissues.

Implants

A myriad of implants is available for reconstructive use. The ideal implant should be easy to insert and manipulate, inert, not prone to infection or extrusion, easily anchored to surrounding structures, and reasonably priced, and it should not rouse fibrous tissue formation. Most orbital floor defects can be repaired with synthetic implants composed of porous polyethylene, silicone, metallic rigid miniplates, Vicryl mesh, resorbable materials, or metallic mesh. Autogenous bone from the maxillary wall or the calvarium can be used, as can nasal septum or conchal cartilage. Each material has advantages and disadvantages that are not within the realm of this article. The surgeon should have a certain comfort level and familiarity with his or her choice of material.

Preoperative Details

• Before undertaking the repair, review and carefully document the patient's complete medical status and pertinent signs and symptoms pertaining to the injury.
• The procedure and the risks, benefits, and alternatives should be explained clearly and documented. The patient should be aware of the possibility of persistent, worsening, or new-onset diplopia, hypesthesia, and enophthalmos and of the risk of visual loss secondary to the procedure. Assess the patient's expectations to avoid a successful surgical outcome coupled with a poor outcome perceived by the patient.
• Clearly document visual acuity, degree of enophthalmos, pupillary and extraocular muscle function, and the amount of diplopia in all fields of gaze.
• A meticulous review of imaging with a neuroradiologist, if necessary, is essential for planning the surgical approach and identifying surrounding structures that may serve as anchoring sites for an implant.
• Secure the appropriate implant several days prior to surgery.

Intraoperative Details

• During surgical repair, periodically assess pupillary function. Assessing the pupil size prior to general anesthesia, after general anesthesia is induced, and after any periorbital injections containing epinephrine (prior to manipulating the globe) is worthwhile. Narcotics can cause pupillary constriction (miosis), and epinephrine can cause pupillary dilation (mydriasis). If not assessed before the orbital manipulation is undertaken, the cause of a dilated pupil can be obscured when the pupil is checked during surgery.
• Perform a thorough exploration of fracture for bony fragments and occult fractures involving the medial wall. Inspection of soft tissue for necrosis is also necessary once liberated from the fracture, and forced duction tests may be performed to confirm that the tissues have been released completely.
• Following floor restoration, assess the fit and stability of the implant. Take special care to be sure the implant is not protruding, which can result in an aesthetically poor result, patient discomfort, and soft tissue breakdown, which can invite infection.
• As for any surgical procedure, the surgeon should be made aware of the patient's overall status as monitored by the anesthesiologist. If extraocular muscle manipulation is forthcoming, inform the anesthesia staff, so that bradycardia secondary to the oculocardiac reflex can be identified and communicated. This phenomenon should abate with release of the extraocular muscles.

Postoperative Details

• Immediately following repair, elevate the patient's head to 30°.
• In addition, the authors prefer to gently place gauze soaked in iced saline over the closed eyelids.
• Assess visual acuity and pupillary function every 15 minutes for the first hour and every 30 minutes until discharge. Nose blowing, strenuous activity, and straining should be avoided in the immediate postoperative period.
• Instruct the patient to use cool compresses for 48 hours, to finish all prescribed oral antibiotics, and to use analgesics sparingly. Postoperative oral steroids may help reduce swelling.
• Any change in visual acuity or increase in pain should prompt the patient to contact the surgeon immediately.

Follow-up

Follow-up examinations should assess and document visual acuity, pupillary and extraocular muscle function, neuralgia, and the amount of enophthalmos and diplopia.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

As with any surgical procedure, bleeding, infection, and the need for additional surgery are risks. The possible loss of vision is the most ominous complication associated with floor repair.

Residual or new-onset diplopia, neuralgia, and extraocular muscle dysfunction are potential complications. The patient should understand these risks completely, and no promises are to be made concerning resolution of any presurgical neuralgia.

Implant extrusion and residual enophthalmos are postoperative sequelae requiring additional surgical intervention.

Although the surgery may be a complete success in the eyes of the surgeon, the patient may view the outcome as unsatisfactory. To minimize this, the surgeon and patient should be in mutual agreement regarding the realistic outcome of the repair.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Successful repair of orbital blowout fractures may be complicated by persistent problems. Neuralgia in the distribution of the infraorbital nerve may worsen after surgery. Improvement of this problem, if any, may take 6 months or more.

More troubling is persistent diplopia. If isolated to extreme positions of gaze, it may go unnoticed or may not be bothersome to the patient. However, if the diplopia affects functional positions of gaze, corrective prisms can be tried. Ultimately, eye muscle surgery may be required to address this problem with repositioning of the extraocular muscles to allow for orthophoric fixation of images.

Enophthalmos can worsen over time. Despite adequately repairing the fracture, atrophy of the orbital fat can occur, resulting in further enophthalmos.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The timing and indications for reconstruction of orbital floor fractures remain controversial.

Early repair (within the first 2 wk) often is indicated when criteria discussed within this article are met. However, these are at best broad guidelines and not absolute criteria for management. Patients who demonstrate significant improvement without signs of entrapment can be treated conservatively. Delayed repair is also an option in select patients. Even after an orbit is repaired, further surgery may be needed for persistent diplopia. Each case must be addressed individually and discussed with the patient to maximize the potential for restoration of the orbital structures, visual function, and cosmetic appearance.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Facial trauma, orbital floor fractures (blowout). Coronal CT scan (soft tissue window) showing right orbital floor fracture, vertical elongation of right orbit, reduction in size of right maxillary sinus, and soft tissue swelling of the right maxillary sinus mucosa.
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Media type:  CT

Media file 2:  Facial trauma, orbital floor fractures (blowout). Coronal CT scan showing orbital floor fracture posterior to the globe. A fracture of the lateral maxillary sinus wall also is present.
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Media type:  CT

Media file 3:  Facial trauma, orbital floor fractures (blowout). Coronal CT scan showing posterior extension of floor fracture.
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Media type:  CT

Media file 4:  Facial trauma, orbital floor fractures (blowout). Operative photo of fracture repair via transconjunctival approach.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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• Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg. Jun 1999;103(7):1839-49. [Medline].
• Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital floor fracture : direct extraocular muscle involvement. Ophthalmology. Oct 2000;107(10):1875-9. [Medline].
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• Lee C, Jacobovicz J, Mueller RV. Endoscopic repair of a complex midfacial fracture. J Craniofac Surg. May 1997;8(3):170-5. [Medline].
• Metzger MC, Schon R, Weyer N. Anatomical 3-dimensional Pre-bent Titanium Implant for Orbital Floor Fractures. Ophthalmology. Jul 25 2006;[Medline].
• Ng P, Chu C, Young N, Soo M. Imaging of orbital floor fractures. Australas Radiol. Aug 1996;40(3):264-8. [Medline].
• Patel BC, Hoffmann J. Management of complex orbital fractures. Facial Plast Surg. 1998;14(1):83-104. [Medline].
• Rowe-Jones JM, Adam EJ, Moore-Gillon V. Subtle diagnostic markers of orbital floor blow-out fracture on coronal CT scan. J Laryngol Otol. Feb 1993;107(2):161-2. [Medline].
• Smith B, Regan WF Jr. Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture. Am J Ophthalmol. Dec 1957;44(6):733-9. [Medline].
• Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg. Mar 1973;1(1):3-8. [Medline].
• Wilkins RB, Havins WE. Current treatment of blow-out fractures. Ophthalmology. May 1982;89(5):464-6. [Medline].
• Yab K, Tajima S, Ohba S. Displacements of eyeball in orbital blowout fractures. Plast Reconstr Surg. Nov 1997;100(6):1409-17. [Medline].

Article Last Updated: Dec 18, 2006