The orbit, commonly known as the eye socket, is a bony cavity in the skull that houses and protects the eyeball, eye muscles, nerves, and blood vessels. An orbital fracture is a break in one or more of the seven bones that form this protective structure. These injuries typically result from blunt force trauma, such as a sports injury, a fall, or a car accident.
A fracture can involve the thicker outer edges, known as the orbital rim, or the thinner bones of the floor and inner walls, often resulting in a “blowout fracture.” Any injury causing an orbital fracture requires immediate medical evaluation. Prompt attention is necessary to prevent complications that could affect vision and the long-term function of the eye.
Recognizing the Signs of an Orbital Fracture
The immediate aftermath of an orbital fracture is often marked by significant pain and observable physical changes. Swelling and bruising are nearly universal signs, sometimes described as “raccoon eyes.” This discoloration results from bleeding beneath the skin and indicates underlying trauma.
Patients frequently experience double vision (diplopia), which occurs when the eyes cannot move together. A fracture in the orbital floor or medial wall may pinch or trap an extraocular muscle, such as the inferior rectus muscle. When eye muscles are restricted, the patient may be unable to look in a specific direction, particularly upward or downward.
Numbness or a tingling sensation in the cheek, upper lip, and side of the nose on the injured side is also common. This altered sensation is caused by damage or compression to the infraorbital nerve, which runs along the floor of the orbit. If the eye appears sunken back into the socket (enophthalmos), it suggests the fracture has enlarged the orbital volume.
In severe cases, air from the adjacent sinuses may enter the soft tissues around the eye, causing a crackling sensation when touched, known as subcutaneous emphysema. Any of these symptoms, especially double vision or restricted eye movement, require an immediate visit to an emergency department.
Emergency Assessment and Diagnosis
Upon arrival at a medical facility, the initial focus is to ensure the patient’s overall stability and rule out life-threatening injuries. Once stable, a thorough eye examination by an ophthalmologist or facial trauma specialist is necessary. This evaluation starts with measuring visual acuity to establish a baseline for the patient’s vision.
The physical examination includes checking for restricted eye movement and assessing the degree of double vision in all directions of gaze. The physician will look for signs of direct injury to the eyeball, such as a globe rupture, which requires immediate surgical intervention. They will also check for pupillary response and signs of increased pressure within the orbit.
The definitive diagnostic tool for an orbital fracture is a Computed Tomography (CT) scan of the face and orbits. The CT scan provides cross-sectional images that clearly show the location and extent of the fracture, including the precise bones involved. This imaging is necessary to differentiate between a thicker orbital rim fracture and a blowout fracture of the orbital floor or medial wall.
The scan also helps identify if soft tissue, such as fat or an eye muscle, has become trapped within the fracture site. This trapped tissue is a significant finding because it restricts eye movement and is a strong indicator for surgical repair. The CT results guide the treatment plan, determining whether observation or surgery is the appropriate next step.
Treatment Pathways
The management of an orbital fracture depends on the size of the fracture, muscle entrapment, and symptom severity. For many small, non-displaced fractures without muscle entrapment or significant visual symptoms, treatment involves observation and non-surgical management. This conservative approach includes pain control, instructions to avoid blowing the nose to prevent air from entering the orbit, and oral antibiotics to prevent infection from the adjacent sinuses.
Surgical intervention is reserved for specific conditions causing functional or cosmetic problems unlikely to resolve naturally. A primary indication for surgery is the entrapment of an extraocular muscle, which manifests as persistent double vision or significant restriction of eye movement. This entrapment can cause a reflex that slows the heart rate and causes nausea, necessitating urgent release of the trapped tissue.
Surgery may also be considered if the fracture is large, typically involving more than half of the orbital floor, or if the eye is noticeably sunken (enophthalmos) or displaced. The goal of surgery is to restore the original anatomy and reconstruct the integrity of the bony walls. This procedure involves lifting and repositioning any prolapsed soft tissue, then covering the defect with an implant or bone graft material.
The timing of surgery depends on the patient’s initial swelling and symptoms. While severe muscle entrapment requires immediate attention, most other repairs are typically delayed for one to two weeks. This delay allows swelling to decrease, improving surgical access and allowing the surgeon to better assess the true severity of symptoms.
Post-Treatment Recovery and Potential Complications
Following treatment, recovery can span several weeks to a few months. Patients who undergo surgery must follow post-operative instructions, including avoiding forceful nose blowing and restricting activity. Regular follow-up appointments monitor bone healing and track the resolution of symptoms like double vision and numbness.
Even after successful treatment, certain long-term complications may persist. The most common residual issue is chronic double vision, which may not completely resolve if the injured muscle or nerve suffered permanent damage or if the surgical repair was imperfect. Specialized prism glasses or further minor eye muscle surgery may be required to correct remaining double vision.
Another potential complication is enophthalmos, where the eye remains sunken because the orbital volume was not fully restored or due to orbital fat atrophy. Although primarily a cosmetic issue, it may necessitate a secondary surgery to place additional volume-restoring implants. Furthermore, numbness from infraorbital nerve damage may persist indefinitely, resulting in chronic altered sensation in the cheek.
There is also a risk of infection, especially in fractures that communicate with the sinuses, and a small risk of implant-related complications following surgical repair. Patients should maintain open communication with their care team, seeking immediate attention for any signs of worsening vision, increasing pain, or new symptoms of infection such as fever or pus.