Orbital floor fractures (OFFs) occur frequently, mainly in the context of trauma from physical altercations or road traffic accidents [1]. The main demographic characteristic that presents with this type of injury is the involvement of young men [2]. Orbital floor fracture can either be direct or indirect, where direct involves the orbital rim while indirect are exclusive to the orbital floor. On inspection, periorbital edema and bruising may be observed. In those who have sustained direct fractures, palpation may reveal a tender 'step-off' area on the orbital rim.

OFFs usually present with a combination of visual disturbances and eye movement dysfunction that include diplopia, proptosis, displacement of the eyeball in the orbit, either posteriorly (enophthalmos) or inferiorly (hypoglobus), and muscle or nerve entrapment. Hypesthesia, dysesthesia, and hyperalgesia are all signs of nerve injury. Extraocular muscle entrapment is evidenced by restricted ocular movements and the presence of an oculocardiac reflex, characterized by bradycardia, syncope, and nausea [3].

Children frequently have an atypical presentation, often described as 'white-eyed' orbital floor fracture, due to the absence of significant ecchymosis and erythema. Radiological signs are often minimal, and orbital emphysema may be present [4] [5].

Furthermore, "trapdoor" fractures are mostly seen in children. These involve muscle (inferior rectus) entrapment, however, they present with little sign of bone displacement or serious injury [6]. They usually exhibit a disturbance in ocular movements. This is important for physicians to note, as delayed treatment leads to permanent neuromuscular complications.

• Plethora

  There is a plethora of literature on different reconstruction methods. Autogenous bone and cartilage grafts from various areas have been used in the reconstruction of the floor. [ncbi.nlm.nih.gov]

• Fracture

  RESULTS: There were 3 linear, 20 trapdoor-type and 7 blowout fractures. There was a tendency toward a higher incidence of linear fractures at younger ages and of blowout fractures in older patients. [ncbi.nlm.nih.gov]

• Diplopia

  PURPOSE: The purpose of our study was to investigate whether the occurrence of preoperative diplopia determines the incidence of postoperative diplopia after orbital floor repair. [ncbi.nlm.nih.gov]

• Enophthalmos

  Our patient had delayed enophthalmos in a manner similar to silent sinus syndrome or imploding antrum syndrome. [ncbi.nlm.nih.gov]

• Strabismus

  Despite the publication of multiple studies suggesting neuroimaging criteria for associated extraocular muscle entrapment, restrictive strabismus related to blowout fracture remains a clinical diagnosis. [aao.org]

  Ortube MC, Rosenbaum AL, Goldberg RA, Demer JL (2004) Orbital imaging demonstrates occult blow out fracture in complex strabismus. J AAPOS 8: 264-273. [omicsonline.org]

  Orbital Floor Fracture Orbital Floor Fracture Orbital Trauma, Emphysema Orbital wall fracture secondary to trauma Periorbital hematoma Phthisis Bulbi After Injury Retrobulbar Hemorrhage Secondary to Peribulbar Anesthesia Tumors, Neoplasma Retina Sclera Strabismus [atlasophthalmology.net]

  Treatment of double vision may require prisms in your glasses, further orbital surgery or eye muscle (strabismus) surgery. Patients with double vision will often have their care coordinated with a strabismus surgeons. Dr. [klapperplasticsurgery.com]

  Usually 6-9 months should elapse after surgery before assuming that no further recovery will be observed, and before strabismus surgery, if indicated, should be performed. [eyewiki.aao.org]

• Unilateral Proptosis

  Abstract Three patients developed unilateral proptosis 13, 16, and 20 years after repair of blow-out fracture with orbital floor Teflon implants. In one patient trauma preceded the onset of proptosis. [ncbi.nlm.nih.gov]

• Anisocoria

  Although the orbital fracture was repaired, anisocoria persisted 18 months after the initial trauma. [ncbi.nlm.nih.gov]

• Distractibility

  The white-eyed blowout fracture in the child: beware of distractions. J Surg Case Rep. 2013 Jul 12;2013(7) July 30, 2015 0 [dontforgetthebubbles.com]

• Epistaxis

  About the Author More Articles Hereditary Hemorrhagic Telangiectasia - May 25, 2016 Hereditary Hemorrhagic Telangiectasia: Septal Perforation and Nose Bleeds - May 23, 2016 Hereditary Hemorrhagic Telangiectasia: Epistaxis and Septal Perforation - May [ohniww.org]

  In addition, patients may complain of epistaxis and eyelid swelling following nose blowing. Periorbital ecchymosis and edema accompanied by pain are obvious external signs and symptoms, respectively. [emedicine.medscape.com]

  […] inferior rectus and sometimes the inferior oblique muscles Enophthalmos Usually following initial swelling and proptosis Patient reports feeling of pressure in orbit when attempting to blow nose Facial anesthesia due to entrapment of the infraorbital nerve Epistaxis [learningradiology.com]

  The most common symptoms are bruising, tenderness and swelling around the eye; redness of the eye; double vision, or diplopia (seeing two images at the same time); numbness of the cheek, nose or teeth; and nose bleeds (epistaxis) [See figure 1]. [aapos.org]

  […] such as a blow from a fist or a small ball striking the eye/orbit at high speed. symptoms — pain (especially on vertical movement), local tenderness, diplopia (especially on vertical gaze), eyelid swelling and crepitus after nose blowing Examination: epistaxis [lifeinthefastlane.com]

• Facial Pain

  Keywords Accidental Falls — Emphysema/etiology — Face — Facial Pain/etiology — Female — Follow-Up Studies — Humans — Mediastinal Emphysema/etiology — Middle Aged — Neck/pathology — Orbital Fractures/complications/surgery — Reconstructive Surgical Procedures [archive-ouverte.unige.ch]

  For example, nerve diseases like trigeminal neuralgia or Bell's palsy sometimes cause facial pain, spasms and trouble with eye or facial movement. Birth defects can also affect the face. [icdlist.com]

• Hyperalgesia

  Hypesthesia, dysesthesia, and hyperalgesia are all signs of nerve injury. Extraocular muscle entrapment is evidenced by restricted ocular movements and the presence of an oculocardiac reflex, characterized by bradycardia, syncope, and nausea. [symptoma.com]

  Presentation After facial trauma, patients may describe decreased visual acuity, blepharoptosis, binocular vertical or oblique diplopia (especially in upgaze), and ipsilateral hypesthesia, dysesthesia, or hyperalgesia in the distribution of the infraorbital [emedicine.medscape.com]

• Hyperactivity

  The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits [ncbi.nlm.nih.gov]

As OFFs are sustained via trauma, the initial workup should involve a primary survey and detailed physical examination. Subsequent examination of the globe is important, as patients may have sustained injuries to its structures which can be sight threatening and may need to be addressed urgently. The latter include retinal detachment, corneal abrasion, and neuropathy [7]. Patients may also have acute closed angle glaucoma, vitreous hemorrhage, and globe rupture. Patients may complain of loss of color vision and a deterioration in visual acuity. Presentations lacking visual symptoms do not rule out the possibility of globe injuries [8]. Elements that should be evaluated are the location and extent of damage, the presence of hemorrhage, globe injury, and soft tissue entrapment [9].

The principal imaging technique used is computed tomography (CT). This is a precise imaging modality in the assessment of the integrity of skeletal structures of the orbit. Furthermore, the use of CT scanning is useful in predicting the outcome of injury [10]. Entrapment of muscle can be evaluated by forced ocular supraduction or infraduction. However, this is only done if CT assessment does not yield clear results.

X-rays are no longer routinely requested, having been largely replaced by CT. The former may detect fat prolapse through what is known as the "tear drop" sign, in addition to the fluid collection in the maxillary sinus and orbital emphysema. Magnetic resonance imaging (MRI) has the advantage of being able to show multiple planes and is best in visualizing soft tissue injuries.

• Atelectasis

  This clinical entity has later been described after trauma in which damage to the ostiomeatal complex leads to atelectasis of the maxillary sinus. [ncbi.nlm.nih.gov]

1. Yilmaz M, Vayvada H, Aydin E, Menderes A, Atabey A. Repair of fractures of the orbital floor with porous polyethylene implants. Br J Oral Maxillofac Surg. 2007;45(8):640–644.
2. Gomes PP, Passeri LA, Barbosa JR. A 5-year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg. 2006;64(1):63–67.
3. Simon GJ, Syed HM, McCann JD, Goldberg RA. Early versus late repair of orbital blowout fractures. Ophthalmic Surg Lasers Imaging. 2009;40(2):141–148.
4. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol. 2003;14(5):236-240.
5. Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital floor fracture: Direct extraocular muscle involvement. Ophthalmology. 2000;107(10):1875-1879.
6. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology. 2000;107(5):829–836.
7. Cook T. Ocular and periocular injuries from orbital fractures. J Am Coll Surg. 2002;195(6):831–834.
8. Mellema PA, Dewan MA, Lee MS, Smith SD, Harrison AR. Incidence of ocular injury in visually asymptomatic orbital fractures. Ophthal Plast Reconstr Surg. 2009;25(4):306–308.
9. Zilkha A. Computed tomography of blow-out fracture of the medial orbital wall. AJR Am J Roentgenol. 1981;137(5):963-965.
10. Bruneau S, De Haller R, Courvoisier DS, Scolozzi P. Can a Specific Computed Tomography-Based Assessment Predict the Ophthalmological Outcome in Pure Orbital Floor Blowout Fractures? J Craniofac Surg. 2016;27(8):2092-2097.