Orbital floor fracture: brief overview
- Definition: fracture of the orbit at its weakest point, the floor bone
- Causes: Typically a fist blow or being hit by a hard ball
- Symptoms: Swelling and bruising around the eye, double vision, disturbance of sensation in the face, limited mobility of the eye, sunken eyeball, further visual disturbances, pain
- Treatment: Depending on the extent and symptoms, conservative therapy, e.g. with painkillers, the fracture heals by itself; in severe cases surgery of the orbital floor fracture
- Prognosis: Under the right therapy the prognosis is usually good
What is an orbital floor fracture?
Orbital floor fracture is a break in the floor of the bony eye socket (orbit). It is caused by massive force applied to the eye or orbital frame. It often occurs together with a zygomatic or midface fracture. It is the most common form of orbital fracture, but other parts of the orbital wall may also be involved. If there is a sole orbital floor fracture, it is also called a blow-out fracture.
Orbital Floor Fracture: Symptoms
When an orbital floor fracture occurs, affected individuals typically have a swollen eyelid with severe bruising. Medical professionals also call this bruising around the eye a monocular hematoma. Often, the swelling pinches the eye muscles, limiting their movement. If the lower straight muscle is pinched, double vision occurs when looking upward. However, this may go unnoticed at first due to the limited movement. If the lower eye nerve (infraorbital nerve) is pinched or injured, which runs in the orbital floor, sensation in the cheek and upper lip may be disturbed.
If the eye or other nerves such as the optic nerve are injured, patients with an orbital floor fracture also suffer from visual disturbances. It becomes dangerous if blood also accumulates behind the eyeball. Affected persons can go blind in a short time due to this so-called retrobulbar hematoma.
In the case of a severe injury, the bone components can shift and collapse into the underlying maxillary sinus. In the worst case, the eye and soft tissues sink into the maxillary sinus. A kind of step is often visible at the edge of the eye socket.
In children, the symptoms of an orbital floor fracture manifest themselves differently than in adults. Swelling and bleeding are usually less pronounced. However, the growing bones are stronger and can “snap” again in children. This usually involves tissue and muscle entrapment. The fracture gap is often palpable.
Doctors also refer to this form of orbital floor fracture as a “white eyed blow-out fracture.” Affected individuals can no longer move their eyes properly because of the trapped muscles. As a result, an unusual amount of white eye skin is visible.
In addition, the injury to the eye socket can trigger the so-called oculocardial reflex. For example, the pressure on the eyeball or the trapped muscles causes breathing to slow down, blood pressure to drop, and nausea and vomiting to occur (due to irritation of the autonomic nervous system).
Orbital floor fracture: causes and risk factors
The impact of force can also cause the ethmoid cells to rupture. These are cavities in the skull that belong to the paranasal sinuses. They are located between the nose and the eye socket. If they rupture, air enters the eye socket or the surrounding skin (e.g. eyelid). Doctors refer to these air pockets as orbital and eyelid emphysema. When palpating the skin, affected persons may feel a crackling under the skin.
If such an injury is suspected, avoid blowing your nose for the next few days. Otherwise, further air and thus germs could be forced into the orbit.
Orbital floor fracture: examinations and diagnosis
In the case of an orbital floor fracture, the ophthalmologist and the otolaryngologist are the responsible specialists. To make the diagnosis, the doctor will ask you about exactly how the accident happened and your medical history. Possible questions might include:
- Was there direct force to the eye?
- What is the exact course of the accident?
- Do you see any double vision?
- Has there been any change in the feeling in the skin of your face?
- Do you feel any pain?
To determine the exact location of the orbital floor fracture, imaging, i.e. radiological examination, is necessary. Depending on the suspicion, the doctor performs classic X-ray examinations. Often, the doctor also arranges for a more accurate computed tomography (CT) or digital volume tomography (three-dimensional image) – especially before surgery may be necessary. In the case of an orbital floor fracture, the doctor will see a “hanging drop” on images of the sinuses if bone chips and orbital contents have fallen into the maxillary sinus.
Orbital floor fracture: treatment
Mild orbital floor fracture in which the eye muscles are not pinched does not require surgery. The bleeding will resolve itself over time, and the limited eye movement will subside. The irritated conjunctiva can be cared for with eye ointment.
On the other hand, if eye muscles are pinched, visual disturbances occur, the eyeball is sunken, or an oculocardial reflex is observed, doctors operate quickly to prevent permanent damage.
Orbital floor fracture: surgery
If the eye has sunk due to slipped fatty tissue, doctors surgically straighten the orbital floor from the maxillary sinus. For example, they attach the patient’s own bone or a special foil, which is resorbed by the body after about six months, to the orbital floor. In the case of pronounced comminuted fractures, the surgeons use mechanically stable titanium implants, for example.
Doctors also operate on orbital floor fractures when an eye muscle is pinched or the facial skin feels numb. They perform the surgery as soon as possible to avoid long-term damage. Only in the case of slight sensory disturbances, which already weaken in the first few days, do doctors wait until the swelling of the eyelid has subsided. Cortisone, which is administered via the vein, supports the reduction of swelling. Nevertheless, the doctors aim to operate within a week.
In severe cases of orbital injury, doctors can now make implants tailored to the patient. These orbital implants then completely replace the destroyed eye socket.
The extent of surgical intervention also depends in principle on other injuries to the facial skull.
Orbital floor fracture: course of disease and prognosis
With low-grade fractures or early surgery, the prognosis of orbital floor fracture is usually good. Occasionally, patients have double vision for a longer period of time. In this case, vision training is required. If the orbital floor fracture causes muscle or fatty tissue to become trapped in the fracture gap, the eye may sink into the orbit (enophthalmos) – especially if surgery is not performed – and may not be able to move properly for a long time due to the resulting scars.
