Orbital Fracture: Signs, Diagnosis, and Treatment
Warning Signs After Facial Trauma
Double vision, especially when looking up or down, is one of the most telling signs of an orbital fracture. The AAO lists restricted upward gaze and cheek numbness as cardinal indicators. You may also notice that the affected eye appears sunken compared to the other side, a condition called enophthalmos.
Swelling and bruising around the eye develop within hours of the injury. Nosebleeds on the side of the fracture are common because the orbital floor borders the sinus cavity. Pain increases with eye movement and may worsen when you try to look upward.
If you suspect an orbital fracture, do not blow your nose. Blowing your nose can force air from the sinuses through the fracture and into the tissue around the eye, causing sudden swelling called orbital emphysema. This trapped air increases pressure and can worsen the injury.
Avoid sneezing through your nose if possible, and sneeze through your mouth instead. If you need to clear nasal discharge, wipe gently without creating pressure. Your doctor will tell you when it is safe to resume normal nose-blowing.
EyeWiki warns that 'white-eyed' blowout fractures in children are emergencies. Because children's bones are more flexible, the bone can snap back like a trapdoor and trap the eye muscle. A child with vomiting, restricted eye movement, and severe pain after facial trauma needs emergency evaluation even if bruising and swelling are minimal.
- Vomiting with eye pain and restricted gaze after trauma
- Inability to look up with the injured eye
- Minimal bruising that hides a serious fracture underneath
- Severe pain disproportionate to the visible injury
How Orbital Fractures Happen
A direct blow to the eye or cheekbone from a fist, ball, elbow, or fall can fracture the thin bones that form the floor and walls of the eye socket. The orbital floor is the thinnest wall and breaks most commonly. EyeWiki identifies blowout fractures of the orbital floor as the most frequent type.
Sports injuries, motor vehicle accidents, falls, and assaults are the leading causes. The force of impact transmits through the soft tissue of the eye and orbit, and the thinnest wall gives way to relieve the pressure.
A blowout fracture breaks the orbital floor or medial wall while leaving the bony rim intact. A rim fracture involves the thicker bone at the edge of the eye socket and usually results from higher-energy impacts. Complex fractures may involve multiple walls and extend into the surrounding facial bones.
The type and extent of the fracture determine whether surgery is needed and how urgently. Your doctor classifies the fracture based on CT imaging and clinical findings.
When bone fragments shift, they can trap the inferior rectus muscle or surrounding tissue in the fracture gap. This entrapment restricts upward eye movement and causes double vision in primary and inferior gaze. The AAO identifies muscle entrapment as one of the primary indications for surgical repair.
Entrapment in children can cut off blood supply to the trapped muscle, causing permanent damage within hours. This is why pediatric orbital fractures with restricted movement are treated as emergencies.
Diagnosis
EyeWiki states that CT with thin cuts in both axial and coronal planes is the imaging study of choice for orbital fractures. The scan shows the location, size, and displacement of the fracture, whether tissue is herniated into the sinus below, and whether muscle entrapment is present.
Plain X-rays can miss orbital fractures and are not sufficient for surgical planning. Your doctor orders the CT scan urgently when clinical signs suggest a fracture, especially in children with restricted eye movement.
Your eye doctor tests how well both eyes move in all directions. Restricted upward gaze on the injured side, especially with pain, suggests inferior rectus muscle involvement. Forced duction testing, where the doctor gently moves the eye with an instrument, can confirm whether the restriction is mechanical (entrapment) or neurological.
Your doctor measures the degree of double vision in different gaze positions and checks whether covering one eye eliminates it. This information helps determine whether surgery is needed.
Orbital fractures often occur alongside other injuries. Your doctor checks for globe rupture, hyphema (blood inside the front of the eye), retinal damage, and optic nerve injury. Cheek numbness from infraorbital nerve damage is common with floor fractures and usually improves over weeks to months.
- Vision testing in both eyes to detect any decrease in visual acuity
- Pupil testing to check for optic nerve damage
- Examination of the retina for tears or hemorrhage
- Measurement of any difference in eye position between the two sides
Treatment
Small orbital fractures without muscle entrapment or significant enophthalmos may heal without surgery. Your doctor will prescribe antibiotics to prevent sinus infection from reaching the orbit, recommend cold compresses for swelling, and advise you to avoid blowing your nose for several weeks.
Follow-up visits at one to two weeks monitor healing and check for late-developing double vision or sunken eye appearance. Some patients develop delayed enophthalmos as swelling resolves and may need surgery later.
The AAO identifies four main indications for orbital fracture surgery: enophthalmos greater than two millimeters, persistent double vision in primary or downward gaze, confirmed muscle entrapment, and fractures involving more than half of the orbital floor. Surgery typically occurs within two weeks of injury unless muscle entrapment in a child requires emergency repair within hours.
The surgeon accesses the fracture through an incision inside the lower eyelid or just below the lash line, frees any trapped tissue, and places an implant to reconstruct the orbital floor. Implant materials include titanium mesh and porous polyethylene. Most patients go home the same day.
Swelling and bruising peak two to three days after surgery and then gradually resolve over two to three weeks. Your surgeon will instruct you to sleep with your head elevated, avoid blowing your nose, and skip strenuous activity for several weeks. Ice packs applied gently over the cheek reduce swelling.
Double vision often improves over weeks to months as swelling resolves and the eye muscles regain normal function. Some patients need prism glasses or further treatment if double vision persists after healing is complete.
Long-Term Outlook
Most patients see significant improvement in swelling and bruising within two weeks. Double vision may take several weeks to several months to resolve fully, depending on the severity of the fracture and whether muscle entrapment was present. Cheek numbness from infraorbital nerve injury improves gradually over months but may be permanent in some cases.
Your eye doctor will monitor your eye alignment, vision, and the appearance of the orbit at follow-up visits. Additional surgery is rarely needed but may be considered if significant double vision or enophthalmos persists.
Wear polycarbonate sport goggles or a face shield during contact sports, racquet sports, and any activity with a risk of facial impact. Polycarbonate lenses resist shattering and absorb impact energy. Standard eyeglasses do not provide adequate orbital protection during sports.
If you have had a previous orbital fracture, discuss activity restrictions with your doctor. The repaired area may be more or less vulnerable depending on the implant material and healing quality.
Contact your doctor immediately if you develop new or worsening double vision, sudden vision loss, increasing pain, fever, or progressive swelling after initial improvement. These symptoms may indicate a complication such as infection, implant displacement, or a missed injury that needs attention.
Any new nosebleed after the healing period warrants a call to your doctor, as it may indicate a problem at the fracture site. Keep all scheduled follow-up appointments so your doctor can catch complications early.
Orbital Fracture Questions
Most double vision from orbital fractures improves as swelling resolves and muscles regain their range of motion. Small fractures without entrapment often produce double vision that clears within a few weeks. More severe injuries may take months, and some patients need prism glasses or surgery if double vision persists.
Your doctor will typically recommend avoiding nose-blowing for at least two to four weeks after an orbital fracture. Blowing your nose forces air through the fracture and into the tissue around the eye, which can cause dangerous swelling. Follow your surgeon's specific instructions, as the timeline varies by fracture severity.
Yes. Many small fractures without muscle entrapment, significant double vision, or sunken eye appearance heal well without surgery. Your doctor monitors your recovery at follow-up visits to confirm that no late complications develop that would require surgical intervention.
When surgery is needed, it typically occurs within one to two weeks to allow initial swelling to decrease while preventing scar tissue from forming. Children with muscle entrapment may need surgery within 24 to 48 hours because trapped muscle can lose blood supply and sustain permanent damage rapidly.
Surgeons typically access the orbital floor through an incision hidden inside the lower eyelid or along the natural crease just below the lash line. These incisions heal well and produce minimal or no visible scarring in most patients.
Get Care After Facial Trauma
If you have double vision, cheek numbness, or a sunken appearance of one eye after facial trauma, seek urgent evaluation from your eye doctor or emergency room. Early diagnosis guides timely treatment and protects your vision.