Staged Repair of Complex Pan-Orbital Trauma: A Novel Surgical Approach

Traumatic injuries resulting in complex pan-orbital fractures, often accompanied by fractures of the skull base, calvarium, and midface, present a unique surgical challenge. These injuries are often difficult to address in a single operation due to the need for staged neurosurgical and orbital reconstruction. Neurosurgical repair of the dura and orbital roof fractures may need to be performed before addressing fractures of the medial orbital wall and orbital floor. Pushing orbital contents back into the orbit from below is especially difficult with swelling from a CSF leak, and the risk of damaging a newly repaired orbital roof and dura. Waiting for the orbital roof and dural repair to heal is an option, but delayed repair of the other orbital walls is difficult once there is scarring and fibrosis of the orbital contents to sinus mucosa. In ballistic injuries with near-total destruction of the orbit, reconstruction is further complicated by the loss of natural anatomical landmarks. We present a novel staged operative repair of complex pan-orbital trauma due to a gunshot wound. This patient suffered multiple fractures of the orbit, including right orbital roof and medial orbital wall fractures, and left orbital roof, floor, and medial orbital wall fractures. The patient also had bifrontal herniation, CSF leak, and suffered a left globe obliteration rendering that eye unsalvageable.