Surgery or Symptom-Based Management? Resolving the 50-Year Debate on Orbital Blowout Fractures

Background: The indications for reconstructing asymptomatic orbital blowout fractures remain controversial. We aimed to evaluate whether these fractures can be managed using a symptom-based protocol, disregarding radiological criteria. Methods: In this single-center prospective follow-up study, we included adult patients with unilateral, isolated, and dislocated blowout fractures. The recommendation for surgical treatment was based exclusively on clinical symptoms and findings: obvious diplopia, restricted eye movements, or >2 mm of globe malposition (GMP). We assessed clinical outcomes and patient satisfaction over a 9-month follow-up. The reduction in surgical interventions was compared to historical data. Results: A total of 206 consecutive patients were included. Of these, 35 (57% male, mean age 38 years) underwent early reconstruction, while 171 (53% male, mean age 55 years) were managed non-surgically. At 9 months, >2 mm of GMP was observed in 11% of the follow-up group and in 7.1% of the early reconstruction group. All patients who developed >2 mm GMP during follow-up declined reconstructive surgery. Compared to the surgical group, the follow-up group had lower rates of obvious diplopia (0% vs. 14%), any diplopia (13% vs. 63%), restricted eye movements (0% vs. 7%), and paresthesia (19% vs. 39%). Satisfaction with diplopia (97% vs. 64%) was also higher. Implementation of the new protocol reduced the reconstruction rate from 41.6% to 17.0%. Conclusions: Development of subjectively disturbing late GMP in asymptomatic orbital blowout fractures is rare. Ocular function tends to recover spontaneously. A symptom-based approach is a safe and effective way to treat orbital blowout fracture patients.