Orbital Floor Fracture

Orbital Floor Fracture
SYMPTOMS Diplopia, Ocular pain, Lid tenderness, Decrease in vision
SIGNS Ecchymosis, Swelling of the periorbital area, EOM restriction especially in upgaze, Oculocardiac reflex, Decreased sensation along cranial nerve V2, Enophthalmos, Orbital emphysema, Crepitus
WORK-UP Pupils | EOMs | Full eye exam with dilation | Cranial nerve testing | Exophthalmometry
TREATMENT Oral Prednisone for 5-7 days to help with swelling
Oral Antibiotic for 7-10 days to help decrease risk of infection
Educate patient on not blowing nose and avoiding forceful Valsalva-like maneuver
Refer to ER ASAP for CT of the orbit
Refer to oculoplastic specialist/ER for evaluation and surgical treatment under the following conditions: 1. Presence of the oculocardiac reflex (LIFE-THREATENING) 2. Retrobulbar hematoma with progressive vision loss 3. Enophthalmos of more than 2mm at the initial encounter 4. Presence of optic neuropathy 5. Presence of multi-bone fracture 6. A child with an orbital floor fracture
FOLLOW-UP Monitor weekly for the first month. Diplopia should improve or resolve on its own within 2-3 weeks. If diplopia is persistent with no improvement after 2-3 weeks, if there is almost no movement of the eye in upgaze, or if there is cosmetically unacceptable enophthalmos, refer patient to oculoplastic specialist for possible treatment (surgical treatment is usually withheld for the first 2 weeks)
ETIOLOGY Hydraulic theory: Increase in IOP from trauma leads to blow out of the orbital floor which is the point of greatest weakness
Buckling theory: Trauma leads to cracking of the orbital floor due to transmission of a pressure wave
DIFFERENTIAL DX Cranial nerve III palsy, Cranial nerve IV palsy, Cranial nerve IV palsy, Orbital congestion
NOTES A white-eyed blowout fracture is typically found in children and is associated with a white/quiet eye with vertical restriction of eye movement due to a small fracture. Must rule out the oculocardiac reflex in these patients