ORBITAL BLOW-OUT FRACTURE:
Symptoms:
Pain (especially on attempted vertical eye movement), local tenderness, binocular double vision (the double vision disappears when one eye is covered), eyelid swelling and crepitus after nose blowing, recent history of trauma.
Critical Signs:
Restricted eye movement (especially in upward or lateral gaze or both), subcutaneous or conjunctival emphysema, hypesthesia in the distribution of the infraorbital nerve (ipsilateral cheek and upper lip), palpable step-off along the orbital rim, point tenderness, enophthalmos (may initially be masked by orbital edema).
Other Signs:
Nosebleed, eyelid edema and ecchymosis, and superior rim and orbital roof fractures may show hypesthesia in the distribution of the supratrochlear or supraorbital nerve (ipsilateral forehead), ptosis, point tenderness.
Differential Diagnosis:
Orbital edema and hemorrhage without a blow-out fracture (May have limitation of ocular movement, periorbital swelling, and ecchymosis, but these resolve over 7 to 10 days).Cranial-nerve palsy (Limitation of ocular movement, but no restriction on forced-duction testing).
Workup:
1.Complete ophthalmologic examination, including measurement of extraocular movements and globe displacement. Compare the sensation of the affected cheek with that on the contralateral side; palpate the eyelids for crepitus (subcutaneous emphysema); and evaluate the globe carefully for a rupture, hyphema or microhyphema, traumatic iritis, and retinal or choroidal damage. Intraocular pressure (IOP) should be measured.
2.Forced-duction testing is performed if restriction of eye movement persists beyond 1 week (see Appendix 5).
3.Computed tomography (CT) scan of the orbits and brain (axial and coronal views, 3-mm cuts) is obtained if the diagnosis is uncertain, if surgical repair is being considered, or if an orbital roof fracture is suspected (upward-moving trauma).
Treatment:
1.Nasal decongestants [e.g., pseudoephedrine (Afrin) nasal spray, b.i.d.] for 10 to 14 days.
2.Broad-spectrum oral antibiotics [e.g., cephalexin (Keflex) 250 to 500 mg, p.o., q.i.d., or erythromycin, 250 to 500 mg, p.o., q.i.d.] for 10 to 14 days.
3.Instruct the patient not to blow his or her nose.
4.Ice packs to the orbit for the first 24 to 48 hours.
5.Surgical repair at 7 to 14 days after trauma is undertaken if the patient has persistent diplopia when looking straight ahead or attempting to read, if he or she has cosmetically unacceptable enophthalmos, if a large fracture is present, or if the fracture is part of a complex trauma involving rim or zygomatic arch with displacement.
6.Neurosurgical consultation is recommended for most orbital roof fractures.
Note Some physicians use oral steroids initially to decrease the inflammatory reaction; generally, we do not. Some prefer immediate repair; we do not.
Follow-up:
Patients should be seen at 1 and 2 weeks after trauma and evaluated for persistent diplopia or enophthalmos after the acute orbital edema has subsided. The presence of these findings may indicate entrapment of the orbital contents or a large displaced fracture and the need for surgical repair. Patients should also be monitored for the development of associated ocular injuries (e.g, orbital cellulitis, angle-recession glaucoma, and retinal detachment). Gonioscopy of the anterior chamber (AC) angle and dilated retinal examination with scleral depression is performed 3 to 4 weeks after trauma. Warning symptoms of retinal detachment and orbital cellulitis are explained to the patient.
Symptoms:
Pain (especially on attempted vertical eye movement), local tenderness, binocular double vision (the double vision disappears when one eye is covered), eyelid swelling and crepitus after nose blowing, recent history of trauma.
Critical Signs:
Restricted eye movement (especially in upward or lateral gaze or both), subcutaneous or conjunctival emphysema, hypesthesia in the distribution of the infraorbital nerve (ipsilateral cheek and upper lip), palpable step-off along the orbital rim, point tenderness, enophthalmos (may initially be masked by orbital edema).
Other Signs:
Nosebleed, eyelid edema and ecchymosis, and superior rim and orbital roof fractures may show hypesthesia in the distribution of the supratrochlear or supraorbital nerve (ipsilateral forehead), ptosis, point tenderness.
Differential Diagnosis:
Orbital edema and hemorrhage without a blow-out fracture (May have limitation of ocular movement, periorbital swelling, and ecchymosis, but these resolve over 7 to 10 days).Cranial-nerve palsy (Limitation of ocular movement, but no restriction on forced-duction testing).
Workup:
1.Complete ophthalmologic examination, including measurement of extraocular movements and globe displacement. Compare the sensation of the affected cheek with that on the contralateral side; palpate the eyelids for crepitus (subcutaneous emphysema); and evaluate the globe carefully for a rupture, hyphema or microhyphema, traumatic iritis, and retinal or choroidal damage. Intraocular pressure (IOP) should be measured.
2.Forced-duction testing is performed if restriction of eye movement persists beyond 1 week (see Appendix 5).
3.Computed tomography (CT) scan of the orbits and brain (axial and coronal views, 3-mm cuts) is obtained if the diagnosis is uncertain, if surgical repair is being considered, or if an orbital roof fracture is suspected (upward-moving trauma).
Treatment:
1.Nasal decongestants [e.g., pseudoephedrine (Afrin) nasal spray, b.i.d.] for 10 to 14 days.
2.Broad-spectrum oral antibiotics [e.g., cephalexin (Keflex) 250 to 500 mg, p.o., q.i.d., or erythromycin, 250 to 500 mg, p.o., q.i.d.] for 10 to 14 days.
3.Instruct the patient not to blow his or her nose.
4.Ice packs to the orbit for the first 24 to 48 hours.
5.Surgical repair at 7 to 14 days after trauma is undertaken if the patient has persistent diplopia when looking straight ahead or attempting to read, if he or she has cosmetically unacceptable enophthalmos, if a large fracture is present, or if the fracture is part of a complex trauma involving rim or zygomatic arch with displacement.
6.Neurosurgical consultation is recommended for most orbital roof fractures.
Note Some physicians use oral steroids initially to decrease the inflammatory reaction; generally, we do not. Some prefer immediate repair; we do not.
Follow-up:
Patients should be seen at 1 and 2 weeks after trauma and evaluated for persistent diplopia or enophthalmos after the acute orbital edema has subsided. The presence of these findings may indicate entrapment of the orbital contents or a large displaced fracture and the need for surgical repair. Patients should also be monitored for the development of associated ocular injuries (e.g, orbital cellulitis, angle-recession glaucoma, and retinal detachment). Gonioscopy of the anterior chamber (AC) angle and dilated retinal examination with scleral depression is performed 3 to 4 weeks after trauma. Warning symptoms of retinal detachment and orbital cellulitis are explained to the patient.