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.

• Surgical Procedure

  The technique of endoscopic, endonasal transantral surgery is described, together with a retrospective analysis of 17 patients who had undergone this surgical procedure in the Department of Otorhinolaryngology, University of Regensburg, between July 2013 [ncbi.nlm.nih.gov]

  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]

  Chamber Brain and Optical Pathway Choroid Congenital Syndromes, Malformations and Abnomalities Conjunctiva Cornea Glaucomas, Ocular Hypertension Hypertensive Retinopathy Iris and Ciliary Body Lacrimal System Lens Lids Neuro-Ophthalmology Optic Nerve Orbit Surgical [atlasophthalmology.net]

  Finally, the combination of careful preoperative evaluation and planning, as well as specific intraoperative investigations when mydriasis is encountered, can be immensely valuable in assuaging surgeons’ anxiety during this surgical procedure. [austinpublishinggroup.com]

• Inflammation

  Causes of late proptosis include peri-implant inflammation, capsular hemorrhage, gelatin film cyst, implant infection, sino-orbital fistula, intraorbital sinus mucocele, and carotid-cavernous fistula. [ncbi.nlm.nih.gov]

  […] or fist) or a collision injury (such as that caused by the impact of an automotive air bag or secondary to contact with an object following a fall). 5 Common clinical findings include: photophobia; lacrimation associated with the post-traumatic uveal inflammation [reviewofoptometry.com]

  Antibiotics are normally prescribed with complex fractures and a short course of steroids may be used to reduce inflammation. [patient.info]

• Fracture

  Indirect fractures of the orbital floor are not associated with fracture of the inferior orbital rim. [aao.org]

  Impure blow out fracture of orbital floor. Indian J Ophthalmol 1984;32:31-3 Blow out fracture is defined as fracture of the floor of orbit without involving the orbital rim. [ijo.in]

  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]

  […] wall Inferior blowout fracture Inferior blowout fractures are the most common. [radiopaedia.org]

  References Ng P, Chu C, Young N, Soo M (1996) Imaging of orbital floor fractures. AustralasRadiol 40: 264-268. Smith B, Regan WfJr (1957) Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture. [omicsonline.org]

• Diplopia

  Diplopia with limitation of upgaze, downgaze, or both. [aao.org]

  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]

  The commonest indication for surgical intervention is cosmetically unacceptable enophthalmos and a distressing diplopia [11]. [ijo.in]

  Ocular movements were full with no diplopia and lid position was normal. [omicsonline.org]

• Enophthalmos

  If significant enophthalmos is present within the first 2 weeks in association with a large orbital floor fracture, even greater enophthalmos can be anticipated in the future. [aao.org]

  This is a report of impure blow out fracture with the classical clinical manifestations such as enophthalmos, limitation of elevation, infra orbital manifestations such as enophthalmos, limitation of elevation, infra orbital anaesthesia and additional [ijo.in]

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

  This allows for assessment for noticeable enophthalmos, diplopia, or extraocular muscle impairment once the swelling has subsided 7,8. [radiopaedia.org]

• Lacrimation

  This case demonstrates that orbital floor implants should not be placed too anteriorly or too medially in the anatomic region of the lacrimal sac and that they should be fixed to prevent implant migration. [ncbi.nlm.nih.gov]

  Stevens scissors are used to expose the periosteum of the posterior lacrimal crest. A malleable retractor is then placed and the periosteum is elevated from the medial orbital wall with the Freer periosteal elevator. [webeye.ophth.uiowa.edu]

  Bony Orbit• Seven bones form the bony orbit – Maxilla – Zygoma – Lacrimal – Ethmoid – Palantine – Sphenoid – Frontal 6 6. 7 7. [slideshare.net]

  Seven facial bones make up the bony orbit: the frontal, maxilla, zygoma, ethmoid, lacrimal, greater and lesser wings of the sphenoid, and palatine bones. [e-acfs.org]

• 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]

  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]

  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]

  However, strabismus surgery (eye muscle surgery) is sometimes necessary for persistent double vision. Occasionally, persistent double vision can be treated with non-surgical methods (prism glasses or botulinum toxin injections). Updated 03/2017 [aapos.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]

• Epistaxis

  […] 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]

  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]

• 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]

• Confusion

  […] headache that gets worse or does not go away Repeated vomiting or nausea Convulsions or seizures An inability to wake up Dilated (enlarged) pupil in one or both eyes Slurred speech Weakness or numbness in the arms or legs Loss of coordination Increased confusion [icdlist.com]

  In this case it is characterised by bradycardia, nausea, and near-syncope – symptoms which could easily be confused with those of a rapidly expanding intra-cranial haemorrhage. [dontforgetthebubbles.com]

  To determine if the athlete has any signs and symptoms of concussion check for the following: • Dizziness • Headache • Confusion • Nausea • Ringing in the ears • Inability to answer simple questions If any of the above symptoms are present, assume that [sportsmd.com]

  “That canal is lined with periosteum, and as we go in to repair a broken floor, it’s easy to confuse tissue that you want to tug out, with the nerve that you definitely do not want to tug out. [aao.org]

  […] clinical examination (diplopia, enophthalmos, visual acuity, impaired ocular movements) and imaging studies (computed tomography) to evaluate muscle or nerve entrapment. 3 Concomitant evaluation of symptoms, signs, and radiographs reduces ambiguity and confusion [journals.lww.com]

• Paresthesia

  Treatment of traumatic infra orbital nerve paresthesia. Natl J Maxillofac Surg 2012; 3 (02) 218-219 13 Hu KS, Kwak HH, Song WC., et al. Branching patterns of the infraorbital nerve and topography within the infraorbital space. [thieme-connect.com]

  Ultimately, a diagnosis of entrapment is made clinically and not by radiographic findings. 5 Infraorbital paresthesia is caused by damage to the infraorbital nerve. [mdmag.com]

  Complications included ectropion, enophthalmos, paresthesia, anterior ischemic optic neuropathy, up-gaze diplopia, and postoperative mydriasis as listed in Table 2. [journals.lww.com]

• Dizziness

  This may manifest as dizziness, nausea, hypotension and even syncope and has been reported in orbital wall fractures with entrapment of extraocular muscles [ 10 ]. [omicsonline.org]

  To determine if the athlete has any signs and symptoms of concussion check for the following: • Dizziness • Headache • Confusion • Nausea • Ringing in the ears • Inability to answer simple questions If any of the above symptoms are present, assume that [sportsmd.com]

• Tingling

  Symptoms of a fracture are Intense pain Deformity - the limb looks out of place Swelling, bruising, or tenderness around the injury Numbness and tingling Problems moving a limb You need to get medical care right away for any fracture. [icdlist.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.

We describe the treatment of each case individually; in most cases, the implant was removed. All 12 patients had a satisfactory outcome after treatment. CONCLUSIONS: Proptosis presenting 2 months or more after orbital floor fracture is rare. [ncbi.nlm.nih.gov]

Treatment and complications of orbito-zygomatico fractures. Int J Odontostomat 2012; 6 (03) 255-262 2 Jungell P, Lindqvist C. Paraesthesia of the infraorbital nerve following fracture of the zygomatic complex. [thieme-connect.com]

Discussion : There are several options for treatment of an orbital wall fracture. [ohniww.org]

[…] continuation of the internal orbital buttress, supporting the orbital contents from posterior intraorbital soft tissue herniation volume ≥1.5 cm 3 a linear relationship between the volume of intraorbital contents and depth of enophthalmos 7 Treatment and prognosis [radiopaedia.org]

Prognosis Good prognosis is suggested by: Union of bones. Lack of any deformity. Full range of mandibular movement. [patient.info]

What’s the likely prognosis? Discussion External examination of our patient showed evidence of substantial bruising. Additional testing included a study of ocular motility to confirm the full range of motion. [reviewofoptometry.com]

Prognosis Most patients who suffer an isolated orbital floor fracture—even those requiring surgical repair—have good outcomes. [eyewiki.aao.org]

The authors report, discuss, and propose an etiology of an abnormal pupil in a child with an orbital floor fracture before surgical repair. A case report is described. [ncbi.nlm.nih.gov]

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]

Forced duction testing can differentiate entrapment versus neuromyogenic etiologies of muscle underaction. The supratarsal crease may deepen, along with narrowing of the palpebral fissure stemming from enophthalmos or fibrous tissue contraction. [emedicine.medscape.com]

The etiology for the facial trauma is commonly a motor vehicle accident or an interpersonal altercation. [ispub.com]

Epidemiology Frequency Orbital floor fractures alone or in conjunction with other facial skeletal fractures are the most commonly encountered midfacial fractures, second only to nasal fractures. [emedicine.medscape.com]

Eye Injury Registry is a federation of state eye injury registries that maintains a standardized database, with the goal of better understanding the epidemiology and outcomes of ocular trauma. [aao.org]

Epidemiology Maxillofacial fractures can have various causes, including traffic accidents, falls, assaults and sports injuries. [ 2, 3 ] The incidence and causes of maxillofacial trauma and facial fractures vary widely in different regions of the world [patient.info]

More recently, there has been success with endoscopic, or minimally invasive, approaches. [16] Epidemiology [ edit ] Orbital fractures, in general, are more prevalent in men than women. [en.wikipedia.org]

Epidemiology and management of orbital fractures. Curr Opin Ophthalmol. 2004;15(5):416–421. 2. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12-year study of 391 patients. J Craniofacial Surg. 2009;20(4):1218–1223. 3. [dovepress.com]

Pathophysiology Orbital floor fractures are secondary to a sudden increase in intraorbital hydraulic pressure. A high-velocity object that impacts the globe and upper eyelid transmits kinetic energy to the periocular structures. [emedicine.medscape.com]

ANATOMY AND PATHOPHYSIOLOGY Of the bony orbit, the thin portion is defined posterolaterally by sphenomaxillary fissure but without any distinct border medially. [e-acfs.org]

Pathophysiology Two theories predominate to explain the occurrence of orbital “blowout” fractures. In the “hydraulic” theory, the eyeball itself is struck directly from an object such as a fist or a baseball. [eyewiki.aao.org]

Pathophysiology Many hypotheses have been proposed regarding the pathogenesis of the “blowout” fracture. [dovepress.com]

Repair of orbital floor fractures often involves the reduction of the herniated orbital contents and implantation of a sturdy, inelastic material to prevent the orbital contents from prolapsing into 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.