Austin McCormick

                                                  Consultant Ophthalmic and Oculoplastic Surgeon MBChB, FRCOphth

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Tel: 01517098442                             Fax: 01517097509                                Email:                               Address:  86 Rodney Street  L1 9AR UK

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Orbital Fractures

Click here to see before and after photographs                                                                 Orbital-fracture-photographs.html

What is an orbital fracture?

  1. The orbit is the bony eye socket that contains the eyeball, eye muscles and lacrimal gland. There are also nerves, arteries, veins and orbital fat.

  2. An orbital fracture may occur after blunt trauma to the eye, eyelids or area around the eyelids.

  3. Any of the 4 walls of the orbit may fracture but commonly it is the floor and medial(nasal) wall that are fractured.

  4. The mechanism of fracture is displacement of the eyeball back into the socket, which causes a rapid rise in orbital pressure causing the thin orbital bones to out-fracture or “blow out”. For this reason these fractures are also known as “blow out fractures”.

  5. Orbital tissue, particularly eye muscle and fat may become trapped in between the fractured bone edges causing limitation of eye movement and double vision.

  6. If a fracture is large, orbital tissue may sink into it, dragging the whole eye with it. This may cause the eye to move back into the socket creating a sunken appearance (enophthalmos).

Medial orbital wall fracture.

Small orbital floor fracture causing

entrapment of the inferior rectus muscle

Inferior rectus muscle

Thin bone of medial orbital wall

Orbital floor

Infraorbital nerve in the orbital floor

Infraorbital nerve exiting to supply the cheek

What are the symptoms and signs of an orbital fracture?

  1. The white of the eye is usually red due to dilated blood vessels. The exception to this is in children where the bone is immature and may “green stick” fracture. This white eye blow out fracture with limitation of eye movement and sometimes pain and nausea on eye movement is an emergency.

  2. Double vision, meaning seeing two images instead of one.

  3. Pain, which may be worse on eye movements, particularly in the direction of double vision.

  4. The eyeball may protrude from the eye socket (proptosis) if there has been bleeding in the eye socket.

  5. The eyeball may sink back into the socket (enophthalmos) if the fracture is large.

  6. Vision may deteriorate due to haemorrhage pressing on the nerve of vision. This is an emergency and requires urgent treatment.

  7. The upper cheek, side of nose and upper teeth on the side of the fracture may be numb. This is because a sensory nerve runs inside the bone in the floor of the orbit and may be damaged by the fracture.

How is an orbital fracture treated?

  1. You must not blow your nose for 6 weeks as this may force air under the skin and lead to infection.

  2. You should take oral antibiotics for 1 week.

  3. Your eye movements will be assessed by an orthoptist in the eye department.

  4. Not all fractures require surgery. Many will not cause long term problems if left to heal.

  5. Double vision looking straight ahead is an indication for surgery.

  6. A significant amount of enophthalmos (sunken eye) is another indication for surgery.

  7. A very large fracture without symptoms but which, in the opinion of an experienced surgeon, is very likely to cause symptoms in the future, is an indication for surgery.

  8. The incision used depends on the site of the fracture. Fractures in the lower orbit may be approached from the inside of the lower eyelid, sometimes with a small 7-10mm skin incision at the outer corner of the eyelids.

  9. Fractures of the medial (nasal) wall of the orbit may be approached from behind the lower eyelid or by a small incision between the eyelids in the corner of the eye near to the nose.

  10. The fracture is repaired by removing the tissue that is trapped in it and then covering the fracture with a plate of man made material called MEDPOR.

  11. MEDPOR implants can be moulded to fit the orbital walls or, if the fracture is large, it may be fixed to the rim of the orbit with screws.

  12. The procedure will require an overnight stay.

  13. This operation is carried out under general anaesthetic, which means you are completely asleep with a breathing tube inserted.

What are the risks and possible complications of surgery?

  1. All surgery caries a risk of bleeding and infection, both are fortunately uncommon in this operation.

  2. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics.

  3. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding.

  4. A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department where Mr. McCormick or an on call Ophthalmologist will attend to you.

  5. Any orbital surgery carries a very small risk of permanent loss of vision. This could be due to damage to the nerve of vision during the procedure or bleeding after the operation.

  6. Any orbital surgery carries with it a risk of double vision. In most cases, if this occurs, it is temporary but rarely it is permanent. Permanent double vision may be corrected with surgery or prisms in spectacles.

  7. Whenever the skin is incised a scar may form. Every attempt is made by Mr. McCormick to minimise and hide scars but sometimes they can be visible. 

  8. You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.

What will happen before surgery?

  1. Before the operation you will be seen in the clinic by Mr. McCormick.

  2. He will ask you about the orbital problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you).

  3. He will examine your eyes.

  4. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia.

  5. You will be asked to read and sign a consent form after having the opportunity to ask any questions.

  6. You will need to have a CT scan of the orbits. This will be booked by Mr. McCormick if it has not already been carried out as part of your trauma assessment.

  7. You will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise when you need to starve before the operation. 

What should I do about my medication?

  1. Mr. McCormick will want to know all the medication that you take and about any allergies you have.

  2. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery.

  3. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual.

  4. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.

What should I expect after surgery?

  1. Usually a pad will be placed on the eye, which will remain until the following day when you can remove it.

  2. In some cases your eye will be examined at regular intervals after surgery to make sure there are no signs of post-operative bleeding.

  3. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls.

  4. After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks.

  5. It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve.

  6. Usually the skin sutures used are dissolvable and will be left to fall out by themselves.

  7. The time when you can return to normal activities varies from person to person. For some it is 1 week, others 2 weeks.

Postoperative Instructions

  1. If an eye pad is placed it should remain until the next morning when you may remove it

  2. For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls.

  3. Chloramphenicol ointment to the eye and wound, three times a day for 2 weeks

  4. Oral antibiotic for 5 days

  5. No nose blowing for 6 weeks

  6. No hot drinks for 48 hours

  7. Sleep propped up at 45 degrees for 48 hours

  8. Follow up appointment 1 week later.

Both scans are CT showing fractures. This photograph of the bony orbit shows how thin the bone of the medial wall and floor is. That is why blow out fractures commonly occur here. The infraorbital nerve travels within the bone of the orbital floor (dotted white line). The nerve exits below the orbital rim to enter the cheek (solid white arrow). A fracture may damage this nerve and cause numbness of the lower eyelid, cheek, upper lip and upper teeth.