Change Language German
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
Examination
- 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
Management
- 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
Sources
- 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)