Preventing Vision Loss After Orbital Fracture Surgery: A 25-Year Analysis of Medical Litigation and Evidence-Based Safety Strategies

Objectives: To identify preventable factors contributing to vision-threatening complications after orbital fracture surgery through systematic analysis of medical litigation cases, and to develop evidence-based safety strategies for global implementation. Methods: All civil court rulings related to orbital fracture surgery complications in South Korea from 2000 to 2025 were analyzed using judicial databases. Cases were evaluated for legal outcomes (breach of care, informed consent violations), clinical factors (complication type, timing, interventions), and system failures. On the basis of findings, a comprehensive prevention framework was developed. Results: Six litigation cases involving permanent vision loss were analyzed. Three distinct mechanisms emerged: secondary ischemic injury from postoperative retrobulbar hematoma (50% of cases), direct intraoperative nerve injury in the context of chronic fracture repair (17%), and cases where causation could not be determined due to absent preoperative documentation (33%). Key failures included delayed recognition of postoperative warning signs (hematoma cases) and the absence of preoperative visual documentation. Conclusions: This analysis reveals that vision loss after orbital fracture surgery results from distinct pathways requiring different prevention strategies. Although secondary injury from hematoma demands robust postoperative monitoring and emergency response protocols, direct intraoperative injury in complex or chronic cases underscores the necessity of meticulous surgical technique, comprehensive preoperative assessment, and detailed informed consent. Prevention of unknown etiology cases requires mandatory baseline visual documentation.