Jacqueline R. Carrasco

BASICS

DESCRIPTION

• Traumatic defect in the bony medial wall of the orbit

• Can extend from fractures of the maxilla, lacrimal bone, and ethmoid bones

• Indirect (blowout) fractures of the medial wall are not associated with fracture of the orbital rim

EPIDEMIOLOGY

Incidence and prevalence variable

RISK FACTORS

• Male gender

• Younger age (15–30 years)

• Participation in sports

• Substance abuse

GENERAL PREVENTION

Wear eye protection when engaging in sports involving objects that move at high velocity (baseball, softball, and hockey).

PATHOPHYSIOLOGY

• Blowout fractures of the medial wall are frequently extensions of orbital floor blowout fractures.

• Isolated medial wall blowout fractures can also occur.

ETIOLOGY

Trauma (see above)

COMMONLY ASSOCIATED CONDITIONS

• Globe rupture

• Hyphema/microhyphema

• Traumatic iritis

• Commotio retinae

• Choroidal rupture

• Traumatic optic neuropathy

DIAGNOSIS

HISTORY

• Inquire about the timing and specific circumstances of the trauma

• Classic history involves the orbital entrance being struck by an object larger than the diameter of the orbital opening (e.g., fist, dashboard, and ball).

• Nausea, vomiting, and bradycardia can indicate entrapment (more common in children and with associated floor fractures).

PHYSICAL EXAM

• Emphysema of the eyelids and orbit

• Eyelid ecchymosis

• Eyelid edema

• Diplopia

• Globe dystopia

DIAGNOSTIC TESTS & INTERPRETATION

Imaging

Computer tomographies (CT) of the orbits with coronal and axial views demonstrate a defect in the bony medial wall of the orbit with possible entrapment of soft tissue and/or extraocular muscle.

DIFFERENTIAL DIAGNOSIS

• Orbital hemorrhage and edema without a fracture: No fracture on CT

• Cranial nerve palsy: Normal forced-duction test

TREATMENT

MEDICATION

• Broad-spectrum oral antibiotics, especially if patient has a history of sinusitis, diabetes, or is immunocompromised: Cephalexin 250–500 mg PO q.i.d or erythromycin 250–500 mg PO q.i.d for 7 days

• Medrol dose pack if patient has extensive swelling

ADDITIONAL TREATMENT

General Measures

• No nose blowing

• Nasal decongestants

• Ice packs

Issues for Referral

• If not a surgical candidate, referral should be made to a general ophthalmologist to be seen within 7–10 days of the initial trauma.

• If a surgical candidate, referral should be made to an oculoplastic surgeon within 7–10 days of the initial trauma.

• Any patient with nausea, vomiting, or bradycardia secondary to entrapped extraocular muscle should be evaluated by an oculoplastic surgeon at the time of initial exam to evaluate the need for immediate repair.

Pediatric Considerations

A pediatric patient with an entrapped extraocular muscle should be evaluated by an oculoplastic surgeon at the time of initial exam to evaluate the need for immediate repair.

SURGERY/OTHER PROCEDURES

Indications:

• Fracture contiguous with a floor fracture involving a significant portion of the orbital floor on CT

• Enophthalmos >2 mm that is cosmetically unacceptable to the patient

• Diplopia

– Should take place within 2 weeks of initial trauma

– An eyelid or transconjunctival approach can allow for exploration of the orbital floor that can be continued up along the medial wall

– The medial orbital wall can also be approached through a transcaruncular approach

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Ophthalmologist

• Otolaryngologist/oral maxillofacial surgeon as needed

PATIENT EDUCATION

• www.nlm.nih.gov/medlineplus/eyeinjuries.html

PROGNOSIS

Depends on the extent of associated injuries

COMPLICATIONS

• Decreased vision

• Diplopia

• Enophthalmos

• Orbital cellulitis

ADDITIONAL READING

• Gilbard SM, Mafee MF, Lagouros PA, et al. Orbital blowout fractures: The prognostic significance of computed tomography. Ophthalmology 1985;92(11):1523–1528.

• Harris GJ, Garcia GH, Logani SC, et al. Correlation of preoperative computed tomography and postoperative ocular motility in orbital blowout fractures. Ophthal Plast Reconstr Surg. 2000;16(3):179–187.

• Jordan DR, Allen LH, White J, et al. Intervention within days for some orbital floor fractures: The white-eyed blowout. Ophthal Plast Reconstr Surg. 1998;14(6):379–390.

• Nolasco FP, Mathog RH. Medial orbital wall fractures: Classification and clinical profile. Otolaryngol Head Neck Surg 1995;112(4):49–56.

CODES

ICD9

• 802.8 Closed fracture of other facial bones

• 802.9 Open fracture of other facial bones

CLINICAL PEARLS

• Fractures of both the medial orbital wall and floor are associated with the highest rates of enophthalmos.

• Optimal time for repair is within 2 weeks of the initial trauma.

• Orbital CT scans are key for making the diagnosis and surgical planning.

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