A 40-Year-Old with Swelling After a Direct Blow to the Eye

Differential Diagnosis

• Orbital floor fracture
• Soft tissue edema secondary to trauma
• Traumatic diplopia

Diagnosis

This patient had a right orbital floor fracture. Findings include partial opacification of the right maxillary sinus, an irregularity on the inferior orbital rim and a subtle discontinuity on the orbital floor. The most common mechanism is a direct blow to the central orbit from a fist or ball. 

Findings/What to Look for

• Orbital fractures can involve any wall of the orbit (medial, lateral, superior or inferior), the orbital rim, or both
• The inferior wall is the most common fractured
• Clinical findings can include:
  • Enophthalmos (sunken eyes)
  • Diplopia (double vision due to extraocular muscle entrapment)
  • Orbital emphysema, especially when the fracture is into an adjacent sinus
  • Malar region numbness (due to injury to the infraorbital nerve)
  • Hypoglobus (affected eye is lower than unaffected eye)

Pearls for Urgent Care Management

• Cold packs should be applied to reduce swelling
• Referral for ophthalmologic or surgical evaluation is needed
• Surgery may be indicated if there is nerve incarceration, acute enophthalmos or hypoglobus, and limitation of gaze

Acknowledgement: Images and case provided by Experity Teleradiology (www.experityhealth.com/teleradiology).