The Impact of Surgical Timing in Orbital Fracture Repair: A New Paradigm

Purpose: For decades, there has been an ongoing debate about the ideal timing of orbital fracture repair (OFR) in adults. Methods: We conducted a retrospective review of patients who underwent OFR at two centers (2015-2019). Excluded were patients <18 years old and those with follow-up <2 weeks. Our primary outcome was the incidence/persistence of postoperative enophthalmos/diplopia at least 2 weeks following OFR. The association between surgical timing and postoperative ocular complications was assessed in patients with extraocular muscle (EOM) entrapment, enophthalmos and/or diplopia, and different fracture sizes. Results: Of n= 253 patients, n= 13 (5.1%) had preoperative EOM entrapment. Of these, patients who had OFR within 2 days of injury were less likely to develop postoperative diplopia compared with patients who had OFR within 8-14 days ( n= 1/8 [12.5%], n= 3/3 [100%]; P=0.018). Patients who had OFR for near-total defects within 1 week of injury were significantly less likely to have postoperative enophthalmos ( n= 0 [0.0%]) compared with those who had surgery after 2 weeks ( n= 2 [33.3%] after 15 to 28 days, n= 8 [34.8%] after 28 days from injury, P <0.001). Patients who had delayed OFR for large fractures smaller than near-total defects, preoperative persistent diplopia, or enophthalmos were not at significantly greater likelihood of postoperative ocular complications compared with those who had early OFR. Conclusion: We recommend OFR within 2 days of injury for EOM entrapment and 1 week for near-total defects. Surgical delay up to at least 4 weeks is possible in case of less severe fractures, preoperative persistent diplopia, or enophthalmos.