Orbital fracture
Background
- Water's view is 83% sensitive at detecting these.
- 10-20% have ocular injury. binocular diploplia from direct muscle injury resolves in 82%, but diploplia from entrapment requires surgical repair.
- Malignant emphysema and/or retrobulbar hemmorhage are emergencies requiring a lateral canthotomy.
Diagnosis
- Eye
- Acuity, extraocular movements
- Blurry, double, or decreased vision?
- Pain with EOM?
- Pupil
- Reactivity, size, shape
- Globe
- Proptosis or enophthalmos?
- Increased intercanthal distance?
- Extrusion of intraocular contents?
- Orbit
- Crepitus from fracture into sinuses?
Orbital CT Indications
- Evidence of fracture on exam
- Decreased extraocular mobility
- Decreased visual acuity
- Severe pain
- Unable to perform adequate exam
DDX
- Orbital Hematoma
- Proptosis, diffuse pain
- Ruptured Globe
- Tear-shaped pupil
- Extrusion of intraocular content
- Orbital zygomatic fracture
- Most common
- Nasoethmoid fracture
- Damage to medial canthal ligament
- Damage to lacrimal duct
- Medial rectus entrapment
- Orbial Floor fracture
- Entrapment of inferior rectus
- Enophthalmos
- Damage to infraorbital nerve
- Retinal Detachment
- Hyphema
- Optic Nerve Shealth Hematoma
Treatment
- Azithromycin or augmentin
- Extraocular muscle entrapment
- May result in oculocardiac reflex -> vagal symptoms
- Consider release of entrapped muscle
- Decreased extraocular movement not due to entrapment
- Consider corticosteroids
- Surgical indications include greater tha 2mm enopthalmos and/or persistent diploplia.