Orbital Floor Fracture

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Medical History

  • Details of the accident, amnesia (traumatic brain injury requires 24-hour surveillance), nosebleeds, double vision
  • Occupation (e.g., trumpet player, diver)
  • Systemic therapy: anticoagulation, allergies


  • Inspection (haematoma, swelling, laceration)
  • Pupil reaction
    • Immediate action required if relative afferent pupillary defect (RAPD) is present
    • Rule out optic nerve compression by bone fragments or bleeding
  • Visual acuity
  • Ishihara test / red desaturation
  • Signs of blunt eye trauma slit lamp examination and fundoscopy, intraocular pressure, optic disc
  • Eye movement (duction test: differential diagnosis of incarcerated muscle / muscle oedema), double vision, hypoglobus, ptosis
  • Palpation (emphysema with crepitus, bone fracture), sensory deficits? (infraorbital sensitivity), nasal bone fracture?, check jaw closure (Le Fort fracture? Zygomatic bone? Teeth?)
  • Confrontational visual field testing
    • Goldman or Octopus for suspected visual field defect
  • Hertel exophthalmometer (for Exo-/Enophthalmus)
  • Photodocumentation (crucial for potential police investigations after fights/assaults/insurance claims), including motility if possible
  • Children: white fracture (greenstick fracture without clear radiological signs of a fracture)
  • Oculocardiac reflex: nausea/bradycardia upon upward gaze = indirect sign of muscle incarceration


  • No nose blowing for 2 weeks, avoid Valsalva manoeuvre (trumpet players, wind instrument musicians, and divers may experience issues for up to 3 months depending on the fracture)
  • Tetanus protection for open wounds
  • Antibiotic prophylaxis, especially in cases of non-compliance with Valsalva / nose blowing restrictions and signs of infection
  • Options for antibiotics:
    • Augmentin 625 mg 3x/day orally or intravenously
    • Ciprofloxacin 500 mg 2x/day orally (400 mg intravenously 2x/day)
    • Cefazolin 1 g twice daily intravenously
  • Decongestant measures (cooling, consider Mefenamic Acid 500 mg 3x/day orally)
  • Special pain medication generally not necessary, seek other causes if pain is severe, check Tinel’s sign (incarcerated infraorbital nerve?)
  • Imaging: fine-cut CT scan of the orbit (3mm) and paranasal sinuses axially and coronally within 24 hours
    • Look for fluid levels in the sinus or air around the eye on all CT scans as an indirect sign of fracture
  • In cases of suspected optic neuropathy, RAPD –> immediate CT for possible optic nerve decompression within 3-6 hours
    • Discuss high-dose steroid treatment for 3 days

Indications for Surgery

  • Urgent surgery required for:
    • Optic nerve compression
    • Unstable fractures
    • Intraorbital foreign body
    • Oculocardiac reflex, especially in children
      • In children, decision regarding surgery within 2-3 days
      • Vomiting, bradycardia when testing eye motility indicates incarceration (oculocardiac reflex), even without radiological evidence: greenstick fracture!
  • Within 2 weeks:
    • Persistent double vision due to muscle incarceration (positive duction test), usually in small fractures
    • Enophthalmus (>2mm) / hypoglobus, usually in large fractures
    • Sensory disturbances: primary infraorbital sensory deficit not a reason for surgery, decompression only if area is painful
    • Large orbital floor defect (>50% of orbital floor): risk of later enophthalmus
  • Observation:
    • Minimal double vision (clinical improvement in first weeks)
    • Subjectively non-disturbing enophthalmus and hypoglobus (can be treated later)
    • Good motility, without signs of incarcerated muscle in CT


  • EyeWiki Orbital Floor Fractures
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)