Randon Hall, MD
NBA Sixers - Why Joel Embiid’s Orbital Fracture is So Risky?
Philadelphia 76ers C Joel Embiid sustained a fracture to his left eye orbit on March 28th. He underwent surgery to repair his orbit and now the debate is on when he should return to play. What complicates matters is that he is arguably the best player on a 76ers team that hasn’t made the playoffs in a long time. To understand how risky his injury and subsequent return to play actually is, you have to start with the basics. Keep in mind on this post, I am definitely not an eye surgeon, so I will do my best to break it down.
What is an Orbital Fracture?
Firstly, the orbit of the eye is basically the bones that surround the eye creating a cavity to protect the eye. The orbit is commonly referred to as the eye socket and is created by the connection between several facial bones. The eye socket contains the eye, eye muscles, fat pad and the optic nerve among many other important structures. There are multiple theories on how an orbit fracture occurs. It likely occurs due to a combination of the things, including increased eye pressure, the eye being pressed into the surrounding bones as well as the blunt force to the face being transmitted through the bones. However it occurs, the result is that one or more of the walls of the eye socket is broken or completely busted out.
CT Scan of Fractured Orbit
When to Consider Surgery?
Surgical intervention appears to be a fluid and possibly controversial topic within the literature. One surgeon reports, that it primarily depends on if the patient has any issue with facial appearance or with function of the eye mechanism. For example, a fracture can occur which causes one of the eye muscles to get trapped within it and prevent the proper movement of the eye. This is referred to entrapment and can be a cause of persistent double vision, which is an indication for surgery. Other surgeons report that the severity of the fracture does play a role in the indication for surgery. The most common modality to assess the fracture is a CT scan of the orbits. However, it was not clearly reported if Embiid had any significant asymmetry of the eye as well as persistent double vision or any other visual dysfunction. One topic discussed in the literature is the timing of treatment of the fracture. Several sources recommended waiting 7-14 days to allow the swelling to improve as well as reassess the symmetry of the face and function of the eye. I believe Joel Embiid's surgery took place approximately 3 - 4 days after the injury. When surgery is chosen, usually some type of implant, such as titanium mesh, is used to recreate or solidify the portion of the orbit that has been fractured.
Why Joel Embiid’s Orbit Fracture is So Risky?
Let's take a moment and remind ourselves that we are talking about a man's eye. There is no functional eye reconstruction or replacement like there is for an ACL or a knee. So merely because we are talking about an eye the stakes are higher. For starters, the optic nerve exits the eye socket out of the back of the eye and connects directly to the brain. After surgery, you have an implant within the orbit of the eye and if that becomes dislodged it could impinge on the eye muscles or optic nerve causing double vision or vision loss respectively. Secondly, there is fat within the eye that is meant to cushion and properly position the eye within the socket. An additional trauma after surgery could disrupt the fat pad and cause malpositioning and asymmetry of the eye. Last but not least is a dramatic increase in intraocular pressure (pressure within the eye). An additional trauma could result in elevated pressure in the eye and cause hemorrhage or reduced blood flow to the optic nerve causing blindness.