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Basics ⬇

Author(s): Jennifer J.Mitchell, MD, FAAFP, CAQSM and Kelly T.Mitchell, MD

Description

  • Fracture of the osseous walls of the orbit
  • Orbital anatomy:
    • Bony orbit is a conical structure:
      • Base faces anterolaterally.
      • Apex originates posteromedially.
      • Seven bones: frontal, maxilla, zygoma, ethmoid, lacrimal, palatine, sphenoid
    • Orbital roof:
      • Forms floor of frontal sinus
    • Orbital floor:
      • Forms roof of maxillary sinus
      • Most commonly fractured area of orbit
    • Medial wall:
      • Forms walls of ethmoid sinus, sphenoid sinus, and nasal cavity
      • Second most frequently fractured area of orbit
    • Lateral wall:
      • Not bordered by a sinus
      • Thickest and strongest of the orbital walls (1)
  • Types of orbital fractures:
    • Orbital rim: caused by direct blow to bony orbit
    • Orbital wall: caused by blunt trauma to globe:
      • Blowout fracture: most common; fracture fragment is directed away from the bony orbit.
      • Blow-in fracture: trauma typically directed against frontal bone or maxilla; fracture fragment(s) is displaced toward the orbital space, decreasing the orbital volume (2).
  • Trapdoor orbital fracture
  • Pure orbital floor fracture, typically in pediatric patient
  • Bony fragment displaces into maxillary sinus.
  • Extraocular muscle(s) can become entrapped (inferior oblique or inferior rectus, most commonly).
  • Usually, restriction of upward gaze occurs.
  • Also called white-eyed blowout fracture due to minimal outward signs of trauma
  • Significant oculocardiac reflex can occur (3,4).

Epidemiology

  • ~1/3 of orbital blowout fractures are sustained during sport. Other causes include motor vehicle accidents, assaults, and falls.
  • Eye injury is the second leading cause of visual impairment after cataract.
  • 40% of monocular blindness is due to eye trauma.
  • 57% of eye injuries were sustained by individuals <30 yr of age.
  • Males sustain around 80% of eye injuries.
  • 13% of serious eye injuries are related to sports and recreation.
  • Estimated 1,400 of every 100,000 U.S. citizens will sustain an eye injury in their lives (5).

Incidence

Trauma to the eye represents ~3% of all emergency department (ED) visits in the United States.

Prevalence

  • Around 2.5 million new eye injuries occur annually.
  • Eye trauma is the cause of 40,000 to 60,000 new cases of blindness each year.
  • Annually, ~11,000 eye injuries sustained by children are caused by toys or home playground equipment (5).

Etiology and Pathophysiology

  • Blowout fractures:
    • Occur along medial wall and/or orbital floor
    • Orbital rims are intact.
  • Two proposed theories (3):
    • Hydraulic theory:
      • Blunt object of larger than diameter of the orbital entrance strikes the eye.
      • Compresses globe, resulting in sudden increase in intraorbital hydraulic pressure
      • Globe does not rupture.
      • Increased intraocular pressure dissipates via soft tissues to weakest portions of orbit: posteromedial orbital floor, lamina papyracea of ethmoid bone, or medial orbital wall.
    • Buckling theory:
      • Fractures occur as a result of direct trauma to the inferior orbital rim.
      • Causes buckling of the orbital floor
      • Thinnest area fractures

Risk-Factors

  • Most common causes of orbital fracture:
    • Sporting events/falls/assaults
  • Sports most commonly associated with orbital fracture in the United States:

General Prevention

  • Use of eye protection for any sport where an object or another participant may impact the globe
  • Monocular athlete should always wear polycarbonate eye protection in American Society for Testing and Materials (ASTM)-approved frames (1).

Commonly Associated Conditions

  • Ocular injury is associated with blowout fracture 14–40% of the time.
  • Potential associated injuries:
    • Mild ocular injuries:
    • Vision-threatening injuries:
    • Injuries to ocular adnexa:
      • Eyelid contusion ± ecchymosis
      • Eyelid laceration ± margin involvement
      • Canthal injury, laceration, or avulsion
      • Traumatic ptosis
    • Intracranial injuries:
      • Pneumocephalus
      • Cerebral injury
      • Cerebrospinal fluid leak
    • Delayed complications:
      • Enophthalmos
      • Hypoglobus

Diagnosis ⬆ ⬇

History

  • Timing
  • Mechanism:
  • Location
  • Protective eyewear in use
  • Visual symptoms:
    • Change in vision
    • Diplopia
    • Discharge
    • Flashing lights
    • Floaters
    • Pain
    • Photophobia
  • Prior ocular history:
    • Contact lens use
    • Previous visual impairment/visual correction
    • Prior trauma
    • Surgical history
  • Tetanus status

Physical Exam

  • Signs and symptoms include (3)[A]:
    • Decreased vision.
    • Diplopia.
    • Enophthalmos.
    • Exophthalmos.
    • Hypoesthesia in V2 distribution:
      • Infraorbital, cheek, lateral nose, upper lip
    • Intraorbital emphysema.
    • Nosebleed.
    • Periorbital ecchymosis.
    • Step-off abnormality of bony structures.
  • Systematic physical examination includes the following (3)[A],(4)[C]:
    • Neurologic survey first
    • If neurologically intact, then initial visual acuity (VA) to evaluate for emergent visual changes
    • Avoid placing pressure on globe; risk of vitreous herniation if globe is ruptured
    • VA before manipulation of eye
    • Near vision (near-reading card or other readily available reading material)
    • Far vision (Snellen chart)
    • Patient should use his or her corrective lenses (not contacts).
    • Patient unable to see well enough to read:
      • Display number of fingers
      • Detection of hand motion
      • Light perception
    • Pupil exam:
      • Size, shape, symmetry
      • Reaction to light
    • Swinging flashlight test: Afferent pupillary defect is present if the pupil of the affected eye dilates when exposed to the light source.
    • Examine head, scalp, face, and periorbital tissues.
    • Lacerations: location, depth, length
    • Lid edema
    • Foreign body
    • Sensory deficit
    • Bony tenderness to palpation around orbital rim
    • Orbital rim fracture
    • Step-offs: blowout fracture
    • Exophthalmos
    • Enophthalmos
    • External eye structures:
      • Conjunctiva:
        • Blood (subconjunctival hemorrhage)
        • Chemosis (swelling)
        • Foreign bodies
      • Cornea:
        • Fluorescein stain/cobalt blue light
        • Irregularities (abrasion, laceration, ulceration)
        • Foreign bodies
    • Extraocular motility: Generally, decreased motility may be due to edema.
    • Impaired upward gaze: orbital floor fracture
    • Impaired downward gaze: inferior rectus or oblique muscle entrapment
    • Intraocular pressure: Use Tono-Pen; do not use Schiötz tonometer or manual pressure.
    • Funduscopic exam:
      • Defer if vision is near normal and ophthalmology will perform indirect exam less urgently.
      • If vision with significant abnormality, defer as ophthalmology evaluation is imminent.
      • Red reflex presence or absence
      • Decreased intensity can imply vitreous hemorrhage or large retinal detachment.
      • Central retinal artery pulsations
    • Slit-lamp exam:
      • If available: anterior chamber, cornea, iris, lens, or defer to ophthalmology
      • If not available, use penlight to look for:
        • Hyphema.
        • Obvious laceration.
        • Shrunken-appearing globe.

Diagnostic Tests & Interpretation

  • Plain-film radiographs:
    • Rarely used for diagnosis in orbital trauma
    • High false-negative rate: 50%
    • Nondiagnostic rate: 30%
  • If plain films ordered:
    • Waters view best displays inferior orbital rims, nasoethmoid bones, and maxillary sinuses.
    • Teardrop sign represents orbital contents herniated into maxillary sinuses.
    • Air–fluid levels/opacifications of sinuses that may indicate fracture
    • Orbital emphysema: medial wall blowout fracture
  • Computed tomography (CT) scan, standard imaging modality (4)[C]:
    • Thin-sliced helical CT with coronal reconstructions:
      • Improved image quality
      • Reduced radiation to lens
    • If helical CT scan not available (4)[C]:
      • CT scan with slices of 3 mm or less
      • Axial plane and coronal plane
      • Only way to assess orbital floor and roof
      • Sagittal reconstruction helpful
    • Sensitivity 79–96%
    • May help distinguish between orbital edema and entrapment of extraocular muscles
    • Findings may predict future enophthalmos or diplopia: may play a role in prompting surgery.
  • Ultrasound:
    • Contraindicated if high suspicion of globe rupture
  • Magnetic resonance imaging (MRI):
    • Limited usefulness in acute stages of ocular trauma
    • Do not perform if metallic intraocular foreign body may be present.
    • Helpful if suspicion of optic nerve injury
    • May identify organic foreign body

Treatment ⬆ ⬇

Not emergent unless:

  • Visual impairment
  • Globe injury
  • Immediate referral to ophthalmology for open globe injury, facial fracture, symptomatic orbital emphysema, orbital compartment syndrome, retrobulbar hemorrhage, child with trapdoor fracture, optic neuropathy, and to rule out other ophthalmologic injuries
  • Prehospital:
    • Airway, breathing, and circulation (ABCs) first priorities
    • Cervical spine immobilization and neurologic evaluation
    • Control active bleeding with direct pressure.
    • No direct pressure to orbit if open globe is possible or suspected.
    • Cover with a protective shield, and refer to ophthalmologist immediately.

Medication

  • Antibiotics may be prudent when fracture communicates with sinus.
  • Pain control to include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, and local anesthetics. Avoid aspirin.

Additional Therapies

  • Cold packs for at least 48 hr
  • Nasal decongestants
  • Elevate head of bed.
  • Avoid nose blowing; increased risk of orbital cellulitis
  • Avoid Valsalva maneuvers such as coughing.
  • Sneeze with mouth open.
  • Tetanus booster, if not current (3)[A]

Surgery/Other Procedures

  • Surgical goal (4)[C]:
    • Reconstruct the defect area of the fractured wall
    • Does not attempt to achieve bone healing
  • Strong surgical indications (3)[A]:
    • Diplopia, not improving
    • Enophthalmos >2 mm
    • Fracture >50% of floor
    • Increase in orbital volume >1 cm3
    • Lack of ocular motility
    • Significant hypoglobus
  • Lesser degrees of trauma indications controversial
  • Timing of surgery is controversial:
    • Rarely urgent, except when:
      • Oculocardiac reflex present (bradycardia, nausea/vomiting)
      • Ocular motility lesions in children
      • Muscle entrapment in trapdoor fracture:
        • In pediatrics, early surgery (within 24 to 48 hr) appears to be associated with better outcomes (4)[C].
      • Penetrating craniocerebral injuries
      • Concern for optic nerve compression
    • Appropriate timing important for achieving good results:
      • Delay allows for:
        • Orbital swelling resolution.
        • Assisting in ensuring accurate diagnosis.
        • Strengthening indications for surgery.
  • No consensus on best material for repair
  • If not emergent indications, conservative management may be considered with close follow-up because spontaneous improvement is possible and may be an emerging paradigm (6)[B].

Ongoing Care ⬆ ⬇

Return to play:

  • Based on significance of ocular injury and associated findings
  • Fracture only:
    • Noncontact sport: 2 wk
    • Contact sport: 4 to 6 wk
  • Surgery for fracture:
    • Return will vary.
    • Depends on specific repair required
  • Return to activities with proper eye protection

Patient Education

Return sooner than planned follow-up for:

  • Intense eye pain.
  • Change in vision.
  • Proptosis.
  • Tense globe.

Additional Reading ⬆ ⬇

  • American Society for Testing and Materials: http://www.astm.org/Standards/F803.htm

  • Kontio R, Lindqvist C. Management of orbital fractures. Oral Maxillofac Surg Clin North Am. 2009;21(2):209–220.
  • Petrigliano FA, Williams RJ III. Orbital fractures in sport: a review. Sports Med. 2003;33(4):317–322.

References ⬆ ⬇

  1. Micieli JA, Easterbrook M. Eye and orbital injuries in sports. Clin Sports Med. 2017;36(2):299–314.
  2. Uzelac A, Gean A. Orbital and facial fractures. Neuroimaging Clin N Am. 2014;24(3):407–424.
  3. Gart MS, Gosain AK. Evidence-based medicine: orbital floor fractures. Plast Reconstr Surg. 2014;134(6):1345–1355.
  4. Chung SY, Langer PD. Pediatric orbital blowout fractures. Curr Opin Ophthalmol. 2017;28(5):470–476.
  5. May DR, Kuhn FP, Morris RE, et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol. 2000;238(2):153–157.
  6. Young SM, Kim YD, Kim SW, et al. Conservatively treated orbital blowout fractures: spontaneous radiologic improvement. Ophthalmology. 2018;125(6):938–944.

Clinical Pearls ⬆

  • Significant changes in VA or vision loss: possible optic nerve compromise:
    • Ophthalmic emergency
    • Immediate ophthalmology consultation
  • Significant other exam abnormality: immediate ophthalmology consultation
  • All other abnormalities: ophthalmology consultation within 48 hr
  • To diagnose orbital fracture, helical CT scan with coronal reconstructions or CT scan with 3-mm or smaller slices in both axial and coronal planes to assess orbit floor and roof is essential
  • Most orbital fractures will resolve without significant visual sequelae or need for surgical intervention.