Trauma | Ophthalmology
Orbital Blowout Fracture
Background
- Definition
- Orbital Blowout Fracture
- Fracture of the orbital floor, medial wall, lateral wall, or roof due to direct trauma to the face with preservation of the orbital rim
- Enophthalmos
- Posterior displacement of the globe within the orbit
- Oculocardiac reflex
- Significant bradycardia, syncope, and vomiting due to entrapment of extraocular muscles
- Synopsis
- Common fractures in mid-facial trauma
- Severity varies
- Minor disruption of one orbital wall
- Major orbital disruption
- Anatomical considerations
- Fracture limited to internal orbital skeleton
- Orbital floor
- Orbital medial wall
- Orbital roof
- Examples
- Blow-out fractures
- Blow-in fractures
- Orbital rim fractures
- May be isolated injuries
- May be seen with internal orbital skeleton fractures
- Associated with other fractures
- Naso-orbital-ethmoid (NOE) fractures
- Frontal sinus fractures
- Le Fort II and III fractures
- Orbital apex fractures
- Associated with neurovascular damage
- Traumatic optic neuropathy
- Patient presentation can range from asymptomatic to severe symptoms requiring specific evaluation for blowout fractures
- Most patients will be managed conservatively or with delayed surgical repair.
Pathophysiology
- Mechanism
- Pressure in orbit increases due to trauma
- Floor of orbit bursts into maxillary sinus
- Lateral wall bursts into ethmoid sinus
- Inferior rectus muscle may entrap in bony floor
- Patient unable to look up
- Three main hypothesis of isolated orbital blowout fractures
- Buckling Theory: direct blow to the thicker orbital rim that is not strong enough to break the rim; however, with enough force to break the thinner orbital wall
- Hydraulic Theory: increased intraocular pressure due to displacement of the globe but no direct contact with the orbital wall
- Globe-to-wall: displacement of the globe with direct contact to the orbital wall
- Any part of the orbital wall can be fractured
- Floor and medial wall: most common
- Roof: can be associated with intracranial injury and CSF leak
- Lateral wall: least common and least likely to require operative repair
- Can be associated with globe injury, orbital rim fractures, nasoethmoid fractures, LeFort type fractures
- Etiology/Risk Factors
- Direct blunt facial trauma
- MVC
- Sports injuries
- Industrial accidents
- Altercations
- Fractures
- Blow-out fracture (most common)
- Orbital rim fracture
- Direct trauma to orbital rim
- Orbital roof fracture
- Associate with intracranial injury
- Dural tears
- CSF leakage
- Pneumocephalus
- Epidemiology
- Increasing incidence with age
- Most common in young adult and adolescent males
- Medial orbital wall fractures are most common site
- Morbidity depends on co-existing injuries
- Severity can vary depending on associated injuries
- Entrapment of extra-ocular muscles
- Inferior rectus
- Inferior oblique
- Infraorbital nerve injury
- Ocular injuries (20-40%)
- Blindness occurs 1 in 1500 cases with pure orbital blowout fracture
- Corneal abrasion
- Subconjunctival hemorrhage
- Hyphema
- Ruptured globe
- Lens dislocation
- Retinal detachment
- Retrobulbar hemorrhage
Diagnostics
- History/Symptoms
- History of trauma to face/orbit
- MVC
- Sports injury
- Altercation
- Pain with ocular eye movements
- Most commonly pain with vertical eye movement
- Restricted eye movements
- Lateral and/or upward gaze
- Bony tenderness periorbital and midface
- Periocular ecchymosis and swelling
- Double vision in the primary or upward gaze
- Orbital crepitus suggestive of subcutaneous or conjunctival emphysema
- Sunken Eye
- Significant if enophthalmos > 2 mm
- Decreased sensation over the cheek, upper lip, and lateral portions of the nose
- Physical Exam/Signs
- Periorbital swelling, ecchymosis
- Very tender infraorbital rim, periorbital area
- May have enophthalmos
- EOM exam
- +/- diplopia on upward gaze
- Complete eye exam
- 20-40% have ocular injuries
- Visual Acuity
- Intraocular pressure
- Ocular eye movements
- Pupil exam
- Visual fields
- Slit lamp
- Ocular and retinal exam
- External eye exam
- May have cheek anesthesia
- From infraorbital nerve injury
- May have step-off deformity
- Assess for bloody drainage from ipsilateral nares
- CSF rhinorrhea
- 25% with type II & III
- CSF glucose > 50 mg/dL [2.8 mmol/L]
- 3 rings seen when fluid is put on bed linen
- Beta-2 transferrin test
- Definitive evaluation
- Collect 1 mL of fluid in red-top tube
- Beta-2 transferrin found in
- CSF
- Vitreous humor of eye
- Perilymph of ear
- Labs/Tests
- CBC +Diff, CMP
- Coagulation profile
- Pregnancy test
- Imaging
- CT of orbits and mid-face without contrast is considered the Gold Standard
- If CT not readily available obtain plain radiographs with the following views:
- Submentovertex
- Occipitomental 30°
- Posteroanterior face
- Findings include
- Orbital emphysema
- Bony fragments displaced into the maxillary sinus
- Air-fluid levels in maxillary sinus
- Prolapsing orbital contents into the sinus
- Plain radiograph
- Helps suspect an orbital floor fracture in the presence of the following
- Subcutaneous emphysema
- Soft-tissue teardrop along the roof the maxillary sinus
- Air-fluid level in the maxillary sinus
- Other Tests/Criteria
- If intraocular eye pressure > 40 mmHg immediate canthotomy or cantholysis is indicated
- Children may develop white-eye syndrome if eye has little to no edema or ecchymosis however there is restriction of vertical eye movement
- Differential Diagnosis
- Orbital Edema and hemorrhage
- Laceration of extraocular muscle
- Rule out any possible comorbid conditions
- Retinal detachment
- Lens dislocation
- Globe rupture
- Retrobulbar hemorrhage/hematoma
- Traumatic optic neuropathy
- Optic nerve sheath hematoma
- Hyphema
- Intracranial hemorrhage
- Abducens nerve palsy
- Traumatic diplopia
- Traumatic diplopia
- Compressive optic neuropathy
- Oculomotor nerve palsy
- Trochlear nerve palsy
Treatment
- Initial/Prep/Goals
- ATLS/ABCs as indicated
- Ice to reduce swelling
- 15-20 minutes every 1-2 hrs for first 48 hrs after injury
- Consider antibiotics
- Blowout fractures are essentially open fractures into sinus
- Patient should avoid:
- Medical/Pharmaceutical
- Antibiotics for 7-10 days
- Steroids
- Per facial trauma recommendations; may reduce edema
- Avoid if associated with traumatic brain injury
- Prednisone: 1 mg/kg/day
- Decongestants for max 3 days
- Topical ophthalmic ointments to keep eye moist
- Consider tetanus immunization
- Surgical/Procedural
- Definitive treatment is surgical
- Indications for surgery
- Cosmetic deformity
- Acute enophthalmos or hypoglobus
- Nerve incarceration
- Limitation of gaze due to extraocular or periorbital tissue entrapment
- Relative indications
- High-risk fracture for enophthalmos
- Involves over 1/2 of the orbital floor or lateral orbital wall
- Surgery should be undertaken within 14 days to prevent fibrosis
- Most surgeons wait 24-72 hours to allow the edema to subside before undertaking surgery
- Children w/ orbital fracture and oculomotor dysfunction
- Have a more favorable outcome if the repair is done w/in the first 7 days
- Contraindications to surgery
- Hyphema
- Retinal tears
- Globe perforation
- Medical instability
- Complications
- Persistent enophthalmos
- Persistent diplopia
- Can be accompanied with other significant facial trauma
- Surgical complications
- Entropion
- Ectropion
- Diplopia
- Infraorbital paresthesia
- Enophthalmos
- Blindness
- Prevention
- Use of face guard or eye protection when participating in activities with high probability of facial trauma
Disposition
- Admission criteria
- Significant eye injury
- Other significant injuries
- Consults
- Maxillofacial surgery
- Ophthalmology
- Discharge/Follow-up instructions
- May discharge if:
- No significant eye injury
- Facial trauma consulted and clear follow-up
- Return if:
- Visual changes
- Fever, worse pain
- Sudden orbital emphysema
- After blowing nose, sneeze, etc
- D/c stable pt w/o extraocular muscle abnormality with ENT f/u
- 1-2 weeks with ophthalmology to be evaluated for persistent diplopia and enophthalmos
- Otherwise as per ENT/ophthalmology
- Patient education
- Do not blow nose or Valsalva to decrease risk of subcutaneous or conjunctival emphysema
- Sneeze with their mouth open
- Keep head of bed elevated
- Discuss warning signs of
- Retinal detachment: flashes of light with floaters, vision loss, shadows in peripheral vision
- Orbital cellulitis: painful swelling, pain with eye movements, fever, erythema
- Most diplopia at initial presentation will resolve by 2 weeks
References
- Yano H, Nakano M, Anraku K, et al. A consecutive case review of orbital blowout fractures and recommendations for comprehensive management. Plast Reconstr Surg. Aug 2009;124(2):602-611
- Bagheri N, Wajda BN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7 ed. Philadelphia, PA: Wolters Kluwer, 2017
- Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. Nov 17, 2015;9:2127-2137
- Steinegger K, De Haller R, Courvoisier D, Scolozzi P. Orthoptic Sequelae Following Conservative Management of Pure Blowout Orbital Fractures: Anecdotal or Clinically Relevant? J Craniofac Surg. Jul 2015;26(5):e433-437
- Brady SM, McMann MA, Mazzoli RA, Bushley DM, Ainbinder DJ, Carroll RB. The diagnosis and management of orbital blowout fractures: update 2001. Am J Emerg Med. 2001 Mar;19(2):147-54
- Chung SY, Langer PD. Pediatric orbital blowout fractures. Curr Opin Ophthalmol. Sep 2017;28(5):470-476
- Tintinalli JE, Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education. 2015
- Miller AF, Elman DM, Aronson PL, Kimia AA, Neuman MI. Epidemiology and Predictors of Orbital Fractures in Children. Pediatr Emerg Care. Jan 2018;34(1):21-24
- Delpachitra SN, Rahmel BB. Orbital fractures in the emergency department: a review of early assessment and management. Emerg Med J. Oct 2016;33(10):727-731
- Tintinalli, JE; Emergency Medicine A Comprehensive Study Guide 6th Edition;pp.1587-1588
- Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC. The Trauma Manual (Second Edition), 2002;pp.178
- Cepela MA, George CE: Orbital trauma. Curr Opin Ophthalmol. Oct 1997;8(5):64-69
- Cantrill SV. Face. In: Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed.,2002;pp.319-329
- Ellis E 3rd, Scott K. Assessment of patients with facial fractures. Emerg Med Clin North Am. Aug 2000;18(3):411-448, vi
- Dutton JJ. Management of blow-out fractures of the orbital floor. Surv Ophthalmol. Jan-Feb 1991;35(4):279-280
- Orbital Floor Fracture. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK534825/. [Accessed May 2022]
Contributor(s)
- Ming, Gerald, MD
- Buckalew, Elizabeth, DO
- Arnold, Dylan, DO
- Singh, Ajaydeep, MD
Updated/Reviewed: May 2022