What is your diagnosis?
A 34-year-old woman presents with eyelid ecchymosis, double vision, and severe eye pain on upgaze.
The diagnosis is...
The image is consistent with a diagnosis of orbital fracture:
- The patient has an orbital floor, or "blowout," fracture, which is defined as a fracture of the orbital floor with an intact orbital rim.
- Fractures of the orbital floor are common. Approximately 10% of all facial fractures are isolated orbital wall fractures.
- Almost all patients have a history of recent trauma and may present with diplopia in upgaze or downgaze.
What is the role of the primary care or emergency medicine physician?
- For most cases, refer the patient to an ophthalmologist urgently.
- In cases with bradycardia or retrobulbar hemorrhage, refer to an ophthalmologist emergently.
What is the role of the ophthalmologist?
The role of the ophthalmologist includes the following:
- Perform a complete ophthalmologic examination, including visual acuity, pupillary response, extraocular motility, forced duction, intraocular pressure, slit-lamp biomicroscopy, and funduscopy.
- Rule out any associated globe trauma.
- Order a thin-cut orbital computed tomography scan (axial, coronal, and sagittal cuts) in cases where orbital floor fracture is suspected without clinical signs of entrapment.
- Assess whether urgent surgical intervention is indicated or the injury is likely to resolve without intervention.
What is the treatment?
Treatment of orbital fractures in adults is usually nonurgent. In terms of medical therapy, a 5- to 7-day course of corticosteroids may benefit patients.
Urgent surgical intervention is indicated in cases of severe entrapment. Most cases with less severe dysmotility resolve without intervention (one should wait at least 14 days to assess for signs of improvement before deciding to repair an isolated floor fracture). Surgery is also indicated when enophthalmos or diplopia interferes with the patient's daily activities.
Learn more: Ophthalmology resources for medical students