Orbital Fracture (Enophthalmos, Sunken Eye)
What Is an Orbital Fracture?
The orbit is the bony socket that holds and protects your eyeball. Seven different bones come together to form this protective cup around your eye. These bones act like a shield, keeping your eye safe from everyday bumps and minor injuries.
The floor and inner wall of the orbit are made of very thin bone, which makes them more likely to break during an injury. When these delicate bones fracture, the tissues and muscles around your eye can shift out of place.
When an orbital bone breaks, it can create a hole or gap in the eye socket. The fat and muscles that normally support your eye may drop through this opening into the sinus space below. This shift causes your eye to sink backward into the socket, creating the sunken appearance we call enophthalmos.
The sunken look may appear right away or develop gradually over several days as swelling goes down. Sometimes the swelling actually hides the sunken appearance at first, and it becomes more noticeable as the injury heals.
We classify orbital fractures based on which bones break and how the injury happens. A blowout fracture occurs when the floor or inner wall breaks but the rim stays intact. This is the most common type we see, especially after direct blows to the eye.
- Orbital rim fractures involve the thick outer edge of the eye socket and are often part of a zygomaticomaxillary complex injury
- Nondisplaced fractures are simple cracks without bone movement
- Comminuted fractures occur when the bone breaks into multiple pieces
- Trapdoor fractures occur when a flexible bone segment springs back and traps muscle or soft tissue, more common in children
Signs You May Have an Orbital Fracture
Right after an injury to your eye or face, you may notice pain around the eye area. This pain often gets worse when you try to move your eyes or look in different directions. Many patients tell us that their eye socket feels tender to touch.
If you develop a bulging eye, severe pain, vision that suddenly worsens, a new dark pupil response compared with the other eye, or eyelids that feel rock hard, seek emergency care. These can be signs of dangerous pressure behind the eye.
You might also hear or feel a crunching sensation under the skin near your eye. This happens when air escapes from the sinus into the tissues around your eye, a condition we call subcutaneous emphysema. Do not blow your nose, since this can force more air into the orbit and worsen swelling.
Any vision changes after a face or eye injury need immediate evaluation by an ophthalmologist. You might experience blurred vision, reduced visual clarity, or even complete vision loss in the affected eye. These symptoms can signal damage to the eye itself or to the nerves that control vision.
We consider sudden vision loss a medical emergency that requires care within hours, not days. Even subtle changes in how clearly you see deserve prompt attention from an eye care provider. If there is sudden, severe vision loss, proptosis, or rapidly rising pain and pressure, call emergency services. Urgent pressure release around the eye may be needed to protect vision.
Double vision is one of the hallmark signs of an orbital fracture. This happens when the broken bones or displaced tissue trap the muscles that move your eye. When one eye cannot move properly to match the other, your brain receives two different images.
- You may see double when looking up or down
- Looking to one side might be difficult or impossible
- The double vision may worsen when you look in certain directions
- Your eye may appear stuck in one position
In children, a trapdoor fracture can cause an oculocardiac reflex. Nausea, vomiting, dizziness, or a slow heart rate with eye movement are warning signs of muscle entrapment that require urgent surgery.
Swelling and bruising around the eye typically develop quickly after an orbital fracture. The area around your eye may puff up dramatically, sometimes swelling so much that your eye closes completely. Bruising often appears as dark purple or black discoloration that spreads around the eye and down the cheek.
You may notice that one side of your face looks different from the other. Your cheek might appear flattened, or one eye may sit lower or further back than the other eye once swelling decreases.
Many people with orbital fractures experience numbness or tingling in specific areas of the face. This happens because a nerve that provides sensation to your cheek, upper lip, and teeth runs along the floor of the orbit. When this area fractures, the nerve can become bruised or damaged.
The numb feeling may affect your upper teeth on the injured side, making it feel like you just received dental anesthesia. This numbness can last for weeks or months, and sometimes it becomes permanent if the nerve suffered significant damage.
What Causes Orbital Fractures and Who Is at Risk
Orbital fractures usually result from blunt trauma to the eye or face. The force from the impact travels through the soft tissue and compresses the eyeball, which then pushes against the delicate orbital walls. When the pressure becomes too great, the thin bones crack or shatter.
- Direct blows to the eye from fists, balls, or other objects
- Impact from hard surfaces during falls
- Airbag deployment during car accidents
- Bicycle and motorcycle crashes
- Work-related accidents and industrial injuries
We see many orbital fractures in people who play contact sports or activities involving fast-moving objects. Basketball, baseball, and racquet sports account for a significant number of these injuries. Boxing and martial arts also carry a higher risk because of direct strikes to the face.
Athletes who do not wear proper protective eyewear face the greatest danger. Sports goggles and face shields designed for your specific activity can dramatically reduce your risk of serious eye injuries.
Car accidents remain one of the leading causes of orbital fractures that we treat. During a collision, your face may strike the steering wheel, dashboard, or window with tremendous force. Even with airbags, the impact can be strong enough to fracture the orbital bones.
Motorcyclists and bicyclists face particularly high risk because they have less protection during accidents. Wearing a helmet with a face shield offers important protection, though it cannot prevent all facial injuries.
Falls cause orbital fractures across all age groups, from children on playgrounds to older adults experiencing balance problems. The risk increases if you fall from a height or land on a hard surface like concrete or tile.
- Older adults with conditions that affect balance and bone strength
- People who work at heights or on ladders
- Anyone with a history of previous facial fractures
- Individuals involved in physical altercations or assaults
How We Diagnose an Orbital Fracture
We begin by carefully examining the area around your eye and testing how well you can see. The ophthalmologist will look at the position of your eyeball in the socket and measure whether one eye sits differently than the other. We also check your pupils to make sure they respond normally to light. We compare the pupils for a relative afferent pupillary defect and test color vision, which can signal optic nerve injury.
If a globe rupture is suspected, we avoid any pressure on the eye and protect it with a shield. Gentle palpation of the bone around your eye helps us identify areas of tenderness, irregularity, or movement that should not be there. We ask you not to blow your nose during this examination, as this can force air from your sinuses into the tissues around your eye.
Testing your eye movements helps us determine if muscles or nerves have become trapped or damaged. We ask you to follow our finger or a light in different directions while keeping your head still. This reveals whether your eyes move together smoothly or if one eye lags behind.
- Visual acuity testing with an eye chart
- Confrontation visual field testing
- Evaluation of how well your eyes work together as a team
- Measurement of the depth of each eye in the socket
- Forced duction testing when entrapment is suspected
A thin-slice CT scan of the orbits is the standard imaging test for orbital fractures. This imaging test creates detailed pictures of the bones and soft tissues around your eye. The scan shows us exactly which bones are broken, how large the fracture is, and whether any tissue has moved into the sinuses.
The CT scan usually takes just a few minutes and does not hurt. We typically arrange for this test urgently if we suspect an orbital fracture, often on the same day as your injury. MRI may be used for soft tissue assessment in select cases when no metallic foreign body is suspected.
Treating orbital fractures often requires a team approach. We may refer you to specialists who focus on facial bones and eye surgery. These experts might include oculoplastic surgeons, who specialize in the area around the eye, or oral and maxillofacial surgeons.
Your care team works together to create a treatment plan that addresses both your vision and your facial appearance. This collaboration ensures you receive comprehensive care for all aspects of your injury.
Treatment Options for Orbital Fractures
Not every orbital fracture requires surgery. Small fractures that do not trap eye muscles or cause significant problems with vision or eye position may heal well on their own. We may recommend careful observation if your eye moves normally, your vision is stable, and you have minimal enophthalmos.
During the observation period, we schedule regular follow-up visits to monitor your healing. We watch for signs that surgery might become necessary, such as persistent double vision or worsening of the sunken appearance. Mild cases are often observed for 7 to 14 days while swelling subsides, then reassessed.
Your clinician may recommend medications to manage symptoms. Antibiotics are not routinely needed for closed, isolated orbital fractures. They may be considered for open fractures, contaminated wounds, active sinus infection, implant placement, or if you have a weakened immune system.
- Decongestants for a short period to reduce sinus pressure
- Acetaminophen for pain control; avoid aspirin and NSAIDs in the first 24 to 48 hours unless your surgeon advises otherwise
- Short steroid course in select cases to reduce swelling, only if prescribed by your specialist
- Antibiotics only when specific risk factors are present
Surgery is recommended when problems are unlikely to improve on their own. Common indications include persistent double vision in primary or reading gaze after 1 to 2 weeks, radiographic muscle entrapment with positive forced ductions, enophthalmos of 2 mm or more, or a large floor defect greater than 50 percent or roughly more than 2 cm².
Entrapped muscle with nausea, vomiting, or bradycardia is an emergency, especially in children. Urgent release is recommended, often within 24 hours.
Before surgery, we provide detailed instructions about eating, drinking, and medications. The procedure typically involves making an incision near the eye to access the fractured bones. We carefully free any trapped tissue, remove small bone fragments, and place an implant to rebuild the orbital floor or wall if needed. Most repairs are done under general anesthesia using hidden incisions inside the eyelid or along the eyelid crease. Implants such as porous polyethylene or titanium mesh may be used to rebuild the orbital wall.
After surgery, you will have some swelling and bruising that gradually improves over several weeks. Most patients go home the same day, though some may stay overnight for observation. We provide specific instructions about head elevation, ice application, and activity restrictions. Your surgeon will review risks that include persistent diplopia, residual enophthalmos, numbness of the cheek or teeth, implant infection or exposure, and lower eyelid malposition.
Healing from an orbital fracture takes time and patience. The bone itself typically heals within six to eight weeks, but complete recovery of eye movement and appearance may take several months. Swelling continues to decrease during this period, and your final appearance becomes clearer.
Some patients experience lasting effects such as mild double vision in extreme gaze positions or slight differences in eye position. We discuss these possibilities before treatment so you know what to expect. In some cases, atrophy of the orbital fat can lead to delayed enophthalmos. A small number of patients may need a secondary procedure to fine-tune eye position or double vision.
Caring for Yourself After an Orbital Fracture
Protecting your eye during the healing period is essential for good recovery. We recommend avoiding any activities that could result in another blow to your face. Contact sports, heavy lifting, and straining should be avoided for several weeks while your bones heal.
- Do not blow your nose for 4 to 6 weeks, and sneeze with your mouth open
- Avoid bending over or putting your head below your heart
- Sleep with your head elevated on two or three pillows
- Wear protective eyewear once you return to physical activities
- Avoid CPAP or other positive pressure devices until your surgeon clears you
- Use a stool softener to avoid straining
- Avoid driving until your double vision has resolved or is corrected with prisms
Applying ice packs to the area around your eye helps reduce swelling and discomfort during the first few days. We recommend using ice for 20 minutes at a time, several times per day. Always wrap ice in a clean cloth rather than applying it directly to your skin. Do not press directly on the eye when icing.
Use acetaminophen as recommended. Avoid aspirin and NSAIDs in the first 24 to 48 hours unless your surgeon advises otherwise. Do not smoke, since it can impair bone healing. Keeping your head elevated even while resting reduces swelling and speeds your recovery.
Certain symptoms after an orbital fracture require emergency attention. Contact us immediately or go to the emergency room if you experience sudden vision loss, severe eye pain that worsens rapidly, or new double vision that was not present before.
- Fever or signs of infection around your eye
- Increasing redness or discharge from your eye
- Sudden increase in swelling after it had been improving
- Difficulty moving your eye in any direction
- A bulging eye, severe pain, or sudden loss of vision
- Nausea, vomiting, dizziness, or a slow heart rate when trying to move the eye
These can be signs of dangerous pressure in the orbit or muscle entrapment and need emergency care.
Regular follow-up appointments help us track your healing and address any concerns early. We typically schedule your first follow-up visit within one to two weeks after your injury or surgery. Additional visits occur over the next several months as needed.
During these visits, we measure your eye position, test your vision and eye movements, and assess how well the bones are healing. Your eye surgeon will guide you through recovery and help manage any persistent symptoms.
Frequently Asked Questions
It depends on the size and location of your fracture. Mild cases may look better as swelling resolves. Larger defects usually do not correct on their own because the orbital volume has increased, and scar tissue does not reliably restore the normal volume. Surgery is often needed to restore eye position.
While most orbital fractures heal without lasting vision problems, permanent vision loss can occur in severe cases. Direct injury to the optic nerve or retina at the time of trauma poses the greatest risk. Prompt evaluation and treatment minimize the chances of permanent damage, which is why we stress the importance of immediate care after eye injuries.
The bones themselves typically knit together within six to eight weeks, similar to fractures elsewhere in your body. However, full recovery of appearance and function often takes three to six months. Swelling takes time to fully resolve, and your eye muscles need time to regain their strength and coordination after being affected by the injury.
Avoid air travel until your surgeon clears you, typically at least two weeks and longer if there is orbital emphysema. Scuba diving should be avoided for at least six to eight weeks and until you are medically cleared, since pressure changes can harm a healing orbit.
Children do have some advantages in healing from orbital fractures because their bones remodel more actively than adult bones. However, they also face unique risks, especially trapdoor fractures where muscle becomes severely trapped. Young patients may not communicate their symptoms clearly, so we monitor them closely and often recommend earlier surgical intervention when eye movement is restricted.
Temporary options include occlusion or a Fresnel prism. Some patients benefit from prism glasses once alignment is stable. If double vision persists after healing, strabismus surgery may be considered.
Getting Help for Orbital Fracture (Enophthalmos, Sunken Eye)
If you have experienced an injury to your eye or face and notice any of the symptoms we have discussed, seek medical attention right away. An ophthalmologist can evaluate your injury, order the necessary imaging studies, and either provide treatment or coordinate your care with surgical specialists. Early diagnosis and appropriate treatment offer the best chance for full recovery of both your vision and your appearance. If symptoms are severe or your vision is rapidly changing, call emergency services.