A wide range of orbital trauma can occur concomitant with orbital fractures. The ocular Sequelae of mid-facial fractures are usually considered to be edema and ecchymosis of the soft tissues, subconjunctival hemorrhage, diplopia, iritis, retinal edema, ptosis, enophthalmos, ocular muscle paresis, mechanical restriction of ocular movement and nasolacrimal disturbances. More severe injuries such as optic nerve trauma and retinal detachments have also been reported. Reported rates of intraocular injury range from 1% to nearly 70%.
The relationship, if any, between the purity of orbital fractures and their secondary ocular problems has not been elucidated to date.
- Intraocular injuries occur in a wide pattern when orbital bones are fractured. While many studies have reminded the community of the importance of the ophthalmic examination in patients who sustain orbital fractures, to date, there have been only a handful of studies which focus on the incidence of intraocular injuries in patients with fractures.
- Of these, there is no agreement as to the incidence of injury. It is likely that the specialty of the physician conducting the research may account for the inconsistencies. In contrast, since our hospital protocol requires that all orbital fractures receive an ophthalmic examination, we believe that our results are unbiased; the true incidence of intraocular injury is approximately 17%.
Evaluation – Full Ophthalmic Exam Plus
- Diplopia field: limit on up or downgaze: r/o IR entrapment vs hemorrhage/edema alone: CT
- Hypo-ophthalmos (globe ptosis)
- Orbit/lid emphysema 2nd to sinus wall fracture
- IOP straight and upgaze (may inc w/IR entrapment)
- Infraorbital anesthesia in floor fracture
- Forced generation, forced duction
- Lid measurements (PF and MRD1)
The rates of injury were also compared between pure orbital floor fractures (only floor) and impure (floor and rim). Of patients who sustained a pure orbital floor fracture, intraocular injuries occurred in 5.6%, compared with only 2% that sustained an impure fracture. Intraocular injuries are more common in patients who sustained PURE orbital fractures than in patients with rim involvement (IMPURE).
Results from an inability of both eyes to move equally
See pre-operative and post-operative photos below illustrating down gaze limitation of the right eye.
- Most fractures do not require surgery.
- Early surgery for marked muscle restriction confirmed on CT, forced duction testing.
- Should observe 1-2 weeks, oral steroids (prednisone 1 mg/kg/day with taper) to decrease swelling and fibrosis.
- Antibiotics and nasal decongestants, we advice patients not to blow nose to decrease orbital emphysema.
Medial Orbital Fracture
- if indirect (blowout) extension of floor fracture, no surgery needed unless medial rectus (MR) entrapped.
- lid/orbit emphysema common.
- Direct naso-orbital fracture more serious, depressed nasal bridge; compl inlc cerebral/ocular damage, ant ethmoid art. damage with severe epistaxis, CSF rhinorrhea, traumatic telecanthus, needs miniplate stabilization.
- Tripod fracture often has 4 zygoma breaks at lateral & inferior orb rim, zygoma arch, lateral wall of maxillary sinus.
- Can involve orbital floor.
- If displaced, can have cosmetic deformity, trismus (2o to impingement on coronoid process of mandible).
Orbital Apex Fracture
- Often w/traumatic optic neuropathy (needs spinal cord dose IV steroids, maybe decompression w/in 5 days, see neuro-op), other fractures.
- Look for CSF rhinorrhea, cartoid-cavernous (CC) fistula.
Orbital Roof Fracture
- May have intracranial lesions, CSF rhinorrhea, pneumocephalus.
- Neurosurgery consult.
- If severe can cause Central Retinal Artery Occlusion, etc if loculated ball valve type wound.
- Usually smaller medial wall injuries.
- Air usually located in area of wound.
- Air decompression.
- CT for localization.
- Retrobulbar needle into air pocket.
- Fill syringe with saline, take out plunger, watch for bubbles to appear.
- Look on CT for intracranial air: needs neurosurgery consult.