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Severe trauma to the area around the eye can damage the bony walls that surround the eyeball. These injuries can range from small cracks to larger fractures with minor bone displacement, or even extensive comminuted fractures where an entire wall collapses.
Orbital fractures usually occur as a result of strong blows to the face, such as those sustained during physical assaults, sports accidents involving impact with a ball or equipment, falls, car or motorcycle accidents, or occasionally gunshot injuries.
When a strong impact hits the area around the eye, the high energy is transmitted to the orbital walls, causing them to fracture.
Any of the orbital bones can fracture due to trauma; however, the most common fracture site is the orbital floor. These fractures can occur alone or together with fractures of the medial wall, which consists of very thin bone. In some cases, isolated medial wall fractures can also be seen.
Orbital floor fractures often occur as “blow-out” fractures, where the bone is displaced downward into the maxillary sinus below. The most common causes are a strong punch to the eye area or a high-impact strike with a ball roughly the size of a tennis or baseball that fits perfectly into the orbital rim.
The bones of the orbital roof and lateral wall are thicker and relatively stronger, so fractures in these areas are less frequent compared to those of the floor and medial wall. Such fractures are more commonly seen in traffic accidents, falls from height, or gunshot injuries.
Fractures of the anterior edge of the orbit are called orbital rim fractures. These fractures require a significant amount of force and therefore are often accompanied by other facial bone fractures.
Another type of fracture more commonly seen in children is the trapdoor fracture. These typically occur in the orbital floor, and occasionally in the medial wall. Because children’s bones are highly elastic, the broken bone can snap back into place within milliseconds, trapping soft tissue, nerves, or muscles between the broken edges. This tissue entrapment requires urgent surgical intervention. Though rare, similar cases can also occur in adults.
The symptoms of an orbital fracture vary depending on the severity, location, and the structures involved. In some cases, there may be no noticeable symptoms, but common signs and symptoms include:
In trapdoor fractures, symptoms are often minimal — bleeding or swelling around the eye is rare. The main sign is usually the inability of the eye to move upward and/or downward, accompanied by nausea or vomiting during attempted eye movement.
This occurs due to the entrapment of muscle or nerve tissue within the fractured orbital floor, and it requires urgent medical intervention.
To diagnose an orbital fracture, your ophthalmologist will first take a detailed medical history, then perform a thorough examination of your eyes and surrounding tissues. This includes assessing visual function, eye movement limitations, and any abnormalities in the pupil’s reaction.
If the patient has suffered a head injury and has lost consciousness, life-threatening conditions take priority. Once the patient is stabilized, the integrity of the eyeball must be carefully evaluated to rule out any globe rupture. Only after these steps is the fracture itself assessed.
A comprehensive eye examination is essential to check for possible damage to the retina (the light-sensitive layer inside the eye) and the optic nerve. The position of the eyeball, any misalignment or sinking (enophthalmos),and the function of the muscles responsible for opening and closing the eye will be measured and analyzed.
If clinical findings and symptoms suggest an orbital fracture, imaging is required—typically an X-ray or, more commonly, an orbital CT scan (computed tomography) for more detailed visualization.
Contrary to common belief and the routine practice in some medical fields, most orbital fractures do not require surgery. The human body is an excellent healer. If the fracture is small, does not cause significant volume change, vision problems, eye movement restriction, or noticeable sinking of the eye, the surrounding connective tissue and bone will usually heal on their own.
In such cases, careful observation and timely intervention only when necessary is the best medical approach. During this recovery period, the physician may prescribe antibiotics, anti-inflammatory medications, pain relievers, decongestants, and recommend cold compresses. Patients should avoid strenuous activities and refrain from blowing their nose to prevent complications.
Every orbital fracture must be thoroughly evaluated through detailed examination and appropriate imaging. Any functional deficits or changes in orbital shape or volume should be documented. The assessment should include visual acuity, ocular motility, eye position, alignment, the degree of inward or outward displacement of the eyeball, and the pupil’s reaction to light.
In most cases, orbital CT scanning is the most useful diagnostic tool. By combining clinical and imaging findings, the ophthalmologist can determine:
Determining whether an orbital fracture requires surgical repair—and if so, when to perform it—is a critical decision-making process.
In cases of trapdoor fractures, where muscle or nerve entrapment is detected, or when the optic nerve is at risk, urgent surgical intervention is required and should not be delayed.
For large fractures, or when imaging shows significant displacement of the eye or surrounding structures, or when there is severe double vision (diplopia),surgery is often unavoidable. Double vision in the primary gaze or downward gaze can seriously affect daily life and is therefore an important factor in the surgical decision.
In small fractures, where the orbital volume has not significantly changed and no visual problems are present, surgery is rarely necessary.
In non-emergency cases, although there is no universal agreement on the ideal timing, the best time for surgery is typically within 1–2 weeks after the injury—once swelling and bleeding have subsided and the tissues are in a more stable condition. In the first few days, swelling may mask an underlying deformity, giving the impression that the eye position is normal. However, as swelling resolves, enophthalmos (eye sinking) may become apparent. For this reason, close monitoring during this early phase and timely surgical intervention, if sinking is observed, are crucial.
Orbital fracture surgery requires individualized planning and is usually performed under general anesthesia, with stable blood flow and blood pressure. The surgeon’s experience plays a vital role in achieving successful results.
Before surgery, the location and extent of the fracture must be thoroughly evaluated through clinical examination and imaging to create a detailed surgical plan.
The transconjunctival approach, which reaches the orbital rim through the inner surface of the lower eyelid without making any skin incisions, is generally the preferred technique. This method allows direct access to the fracture without cutting the eyelid tissues, preventing visible scars and minimizing the risk of postoperative eyelid complications.
Once the orbital rim is reached, the periosteum (the membrane covering the bone) is lifted, and dissection proceeds beneath it to expose the bare bone. When the fracture line is identified, any displaced orbital tissues are carefully repositioned back into the orbit without the use of cutting instruments, avoiding further trauma.
To prevent the tissues from sagging or becoming trapped again, a barrier implant is placed between the bone and soft tissues at the fracture site. In cases of large orbital floor defects, the implant must extend to the back of the orbit and rest on a stable support to prevent postoperative enophthalmos.
There are many types of implants made from various synthetic materials or autologous tissues (taken from the patient’s own body). The surgeon selects the most appropriate implant based on their experience and the fracture type. Each implant has its own advantages and disadvantages, and patients should discuss the most suitable material and approach with their surgeon.
After orbital fracture surgery, patients are usually kept under observation in the hospital for about 24 hours. During this period, vision and pupillary light reflexes are checked frequently—every 2–3 hours initially, then at longer intervals throughout the day. Instead of tightly bandaging the eye, it is preferable to leave it uncovered and apply cold compresses to reduce swelling.
For about one week, antibiotic eye ointments or drops, oral antibiotics, and, if necessary, painkillers and anti-inflammatory medications may be prescribed. Patients should sleep with the head elevated at a 45-degree angle and avoid getting the surgical site wet for the first 3–4 days.
After discharge, it is important to avoid activities that increase intra-abdominal pressure, such as bending forward, lifting heavy objects, or straining, as well as any intense physical activity for 1–2 weeks. Swimming in the sea or pool, and airplane travel are typically restricted for 2–3 weeks.
In cases of medial wall or extensive orbital fractures, patients must be strictly reminded not to blow their nose, as this can cause air to enter the orbit and lead to complications. Most patients can return to school or work within about one week after surgery.
If double vision was present before surgery, it may resolve gradually within 2–3 days to 2–3 weeks after an uncomplicated operation. However, if there was bleeding into the muscles or nerve injury, recovery may take longer—and in severe trauma with permanent damage, double vision may persist.
If facial numbness or tingling is present, sensation may take 6–9 months to fully return.
Patients should immediately contact their surgeon if they experience persistent headache, nasal discharge, nausea, vomiting, or fever after surgery.
Worldwide, orbital fracture surgeries are most commonly performed by ophthalmologists specialized in oculoplastic and orbital surgery.
In complex fractures involving facial bones or brain tissue, surgery is often performed as a multidisciplinary team that may include maxillofacial, plastic, or neurosurgical specialists.
If access to an oculoplastic surgeon is not possible, ENT specialists, maxillofacial surgeons, or plastic surgeons with experience in orbital surgery may also perform these procedures. However, in such cases, it is essential for the patient to be evaluated by an ophthalmologist both before and after surgery to ensure the health and function of the eye.
Altuğ Çetinkaya, MD, FEBOOphthalmologist Turkey
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