Radiographic Indications for Orbital Blowout Fracture Reconstruction: A Critical Review of 2 Decades of Literature

Background: Clinical criteria (eg, persistent diplopia, enophthalmos) are clear indications for surgery in orbital blowout fractures (OB-OFs). A variety of additional radiographic indications are often described (eg, fracture size, orbital volume changes, inferior rectus muscle [IRM] rounding and displacement) but their significance varies across studies. This systematic review aimed to evaluate the reliability of these radiographic criteria. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a PubMed search (2000–2024) was conducted to assess studies analyzing radiographic indications for surgery in OB-OFs. We included only studies where surgery was based exclusively on clinical grounds with radiographic correlation established retrospectively, or cohorts followed up conservatively until the development of symptoms. Identified studies were assessed for aim, design, methods, bias, radiographic criteria, surgery, and study outcomes. Results: Out of 683 articles, only 6 were eligible. Fracture size was found to be weakly predictive of symptoms or the need for surgery, with variable cutoff values (≥42%, >2.3 cm 2 , >3 cm 2 ). Orbital volume changes showed conflicting results. Herniated volume demonstrated contradictory outcomes with variable cutoff values (>0.531, 1.3–2.2, or >2.2 cm 3 ). IRM rounding was either weakly predictive or strongly associated with symptoms. IRM displacement, however, was found to be consistently predictive of symptomatic fractures. Conclusions: Clinical criteria remain the most reliable indications for OB-OF reconstruction. Caudal IRM displacement was consistently predictive of symptomatic fractures. Until a consensus is reached on a consistent methodology to calculate volume and fracture area, the reported cutoff values may be insufficient to guide treatment independently.