CLINICAL PEARLS AND PITFALLS
A blowout fracture is a displaced fracture of the bones of the orbit.
Hallmark physical findings include impaired extraocular movements,
pain with extraocular movements, or periorbital swelling or ecchymosis.
Palpation of the bony rim of the orbit may not exhibit severe point
tenderness even in the presence of fracture, depending on the bone(s)
involved.
Blowout fracture requires emergent evaluation by ophthalmology.
Smaller fractures can tether extraocular muscles, especially the inferior
rectus muscle, causing bradycardia.

Current Evidence
There are two proposed mechanisms for blowout fractures. The first is that force
is transmitted from the orbital rim to the medial wall or floor. The second is that
force applied to the globe is transmitted to the orbital walls. The medial wall is
the most common site of fractures. CT is the diagnostic modality of choice.
Indications for operative management include rectus muscle entrapment,
enophthalmos, central-gaze diplopia, restriction of extraocular movements, or
loss of orbital support.

Goals of Treatment
The primary goal of therapy in the ED is prompt recognition of blowout fractures
and any associated intraocular injuries, including entrapment and commonly
associated globe injuries. Approximately 20% of displaced orbital fractures are
associated with globe injury; therefore, emergent ophthalmology consultation is
indicated in all cases. Pain control is the primary goal of treatment of
nondisplaced orbital fractures.

Clinical Considerations
Clinical Recognition
Blowout fracture is suggested if any of the following are present: restriction of

eye movements following trauma, enophthalmos, infraorbital anesthesia,
diplopia, step-off deformity, or subcutaneous emphysema. The pathophysiology
and diagnosis of blowout fractures are discussed in Chapter 28 Eye: Strabismus .
Fractures to the inferior and/or medial orbital wall are the most common as
they are the thinnest bone. The lateral wall is the least commonly fractured. The


intraocular contents often sink back into the fracture, giving an enophthalmic
appearance. Conversely, proptosis can occur from orbital hemorrhage. Superior
wall fracture (roof fractures) may be associated with pulsating proptosis as a
result of communication between the orbit and intracranial cavity. Fractures of the
inferior wall may be associated with numbness of the ipsilateral malar region
caused by injury to the infraorbital nerve, which travels along the floor of the
orbit. Point tenderness and “step-off” signs during palpation of the bony rim of
the orbit is highly concerning for fracture, although in some orbital fractures
palpation may be remarkably normal.
The hallmark sign of orbital fracture is a restriction of extraocular movement.
Usually, the eye is unable to look away from the fracture site because of a
tethering of intraocular muscle or other orbital tissues in the fracture (see Fig.
28.6 ). Conversely, orbital hemorrhage at the fracture site can less commonly
displace the globe away from the fracture and make it difficult for the eye to look
in the direction of the fracture.
Entrapment may occur with orbital fractures, and can increase vagal tone,
triggering the oculocardiac reflex. This can result in bradycardia, heart block, and
in rare cases, hemodynamic instability.
Axial (proptosis) or coronal displacement of the globe is an ominous finding
because it may be a sign of orbital hemorrhage, which can cause compression of
the optic nerve, requiring emergency surgical intervention. Retrobulbar
hemorrhage, presenting with severe pain, vision loss, and proptosis, may also be
associated with orbital fractures. Enophthalmos is also a sign that should lead to

urgent radiologic evaluation and may require surgical intervention.
Triage Considerations
Children who have sustained severe blunt facial trauma and/or eye trauma should
be promptly evaluated. Soft tissue swelling may increase over time, making
evaluation more difficult. While the majority of orbital fractures are treated
conservatively, those with associated ocular or intracranial injury require
immediate intervention.
Management
Some controversy exists among ophthalmologists, otolaryngologists, and
craniofacial surgeons regarding the urgency for radiologic evaluation and surgical
intervention in the management of orbital wall fractures. If a decision is made to
proceed with radiologic imaging, CT scan of the orbit with both axial and coronal
views remains the standard. The brain should be included, particularly when an


orbital roof fracture is suspected. Plain radiographs have little role in the
management of orbital wall fractures as they lack sensitivity. The necessity and
timing of surgical intervention is controversial; however, most agree that
significant extraocular restriction or persistent vomiting necessitates surgical
intervention. Orbital hemorrhage can lead to orbital compartment syndrome.
Retrobulbar hemorrhage can cause central retinal artery hypertension or even
occlusion. Vision loss, severe pain, and proptosis suggest retrobulbar hemorrhage.
A high suspicion or established diagnosis of such symptomatic hemorrhages
necessitates emergent lateral canthotomy and cantholysis by a trained emergency
provider or surgeon ( Fig. 114.8 ).

EYELID LACERATIONS
CLINICAL PEARLS AND PITFALLS
The following findings require ophthalmology consultation: fullthickness laceration of the eyelid, ptosis, orbital fat prolapse, eyelid
margin involvement, injury in close proximity to the tear duct system,

tissue avulsion, and concurrent globe injury ( Table 114.3 ).

Current Evidence
Simple eyelid lacerations may be managed by emergency providers with standard
wound care techniques; however, it is standard of care to initiate prompt
ophthalmology consultation when deeper injuries are suspected.

Goals of Treatment
Similar to other lacerations, the primary goal is wound closure to achieve
hemostasis, cosmesis, and prevent infection. Emergency providers may repair
simple lacerations of the eyelid and surrounding area using standard wound
closure methods. However, those lacerations requiring further evaluation for
possible injury to the eye itself, tear ducts, or other key structures or those
requiring surgical expertise should be promptly recognized.

Clinical Considerations
Clinical Recognition
Although eyelid lacerations are usually easy to detect, the clinician must
remember that the underlying globe might also have been lacerated or injured.
Seemingly superficial lacerations of the eyelid may be associated with penetration
into the orbit or intracranial cavity, particularly when a pointed implement caused


the injury. Puncture wounds of the upper eyelid with a stick or a pencil can result
in perforation of the orbital roof and entry into the intracranial subfrontal space,
with surprisingly few signs or symptoms. Oblique lacerations that extend into the
medial canthal area (juncture of the upper and lower lids medially) may involve
the proximal portion of the nasolacrimal system ( Fig. 114.9 ). Sometimes, the
eyelid margin puncta, which drains tears into the system, is displaced laterally as
a result of the laceration ( Fig. 114.9 ).

Full-thickness eyelid lacerations, the presence of ptosis, orbital fat prolapse,
eyelid margin involvement, injury in close proximity to the tear duct system,
presence of tissue avulsion, and the presence of concurrent globe injury should
prompt ophthalmology consultation.