Current Evidence and Emerging Paradigms in Orbital Fracture Management

Abstract

Orbital fractures are among the most common forms of craniofacial trauma and present significant diagnostic and therapeutic challenges because of the orbit’s complex anatomy and the potential for long-term functional and aesthetic sequelae. This review synthesizes current evidence regarding the evaluation, imaging, management, and complications of orbital fractures, with emphasis on evolving treatment paradigms and ongoing areas of controversy. A PubMed^® literature review was conducted using search terms related to orbital fracture anatomy, physical examination, imaging, conservative management, surgical intervention, antibiotics, and complications, with emphasis placed on contemporary studies. Clinical assessment remains central to management, particularly evaluation of visual acuity, globe position, ocular motility, diplopia, and infraorbital sensation, while high-resolution computed tomography continues to represent the diagnostic gold standard for characterization of fracture morphology, soft tissue herniation, and muscle entrapment. Current evidence increasingly supports selective rather than routine operative intervention, emphasizing functional deficits such as persistent diplopia, clinically significant enophthalmos, extraocular muscle entrapment, and vision-threatening complications over fracture size alone. Urgent repair remains indicated in cases of oculocardiac reflex, orbital compartment syndrome, or pediatric trapdoor fractures. Advances in transconjunctival approaches, image-guided navigation, biomaterials, and patient-specific implants have improved reconstructive precision and reduced postoperative morbidity, although controversy persists regarding operative timing, implant selection, and the routine use of prophylactic antibiotics for fractures communicating with the paranasal sinuses. Postoperative complications, including diplopia, infraorbital nerve dysfunction, retrobulbar hematoma, eyelid malposition, enophthalmos, and implant-related morbidity, continue to influence clinical outcomes despite advances in care. Overall, contemporary management increasingly favors an individualized, multidisciplinary, and evidence-based approach tailored to patient symptoms and functional outcomes, while future prospective studies with standardized outcome measures are needed to clarify unresolved management questions and establish more consistent treatment algorithms for orbital trauma.