Orbital Trauma

Injury to the bony orbit, globe, soft tissues and contents from blunt force (assault, falls, road traffic accidents, sports balls), penetrating objects, high velocity missiles, explosive blasts or surgery.

• Most orbital injuries are associated with injury to the globe, optic nerve and adnexa, and facial or intracranial injury (frontal skull fractures, intracranial haemorrhage).
• Patterns: orbital contusion, haematoma (subperiosteal, intraconal), emphysema (orbital air through sinus fractures), fractures (floor, medial wall, roof, lateral wall, orbital rim, zygomaticomaxillary complex), orbital apex injury, penetrating injury (wood, glass, metal, dog bite, pencil), intraorbital foreign body, injury to the lacrimal system (canalicular laceration), and traumatic optic neuropathy.
• Penetrating organic foreign bodies (wood) carry a high risk of infection and abscess.

• Periorbital swelling and ecchymosis, subconjunctival haemorrhage without a visible posterior limit, proptosis (haematoma) or enophthalmos (fracture), subcutaneous or orbital emphysema (crepitus), diplopia, restricted motility, infraorbital numbness, epistaxis.
• Globe injury signs: hyphaema, irregular pupil, lens subluxation, vitreous haemorrhage, retinal tear, open globe (distorted globe, prolapsed uvea, low pressure).
• Emergencies: retrobulbar haemorrhage with tense proptosis, reduced vision and relative afferent pupillary defect; traumatic optic neuropathy; open globe; trapdoor fracture in children with vomiting and bradycardia; intracranial injury.
• Canalicular laceration: medial lid laceration with epiphora.

• Systematic assessment (airway, breathing, circulation and cervical spine first), then ocular examination: visual acuity, pupils (relative afferent defect), motility, intraocular pressure (avoid if open globe suspected), slit lamp and dilated fundus examination, facial sensation, bony palpation of rim (step deformities), lacrimal probing.
• CT head, orbits and facial bones (thin axial slices with coronal and sagittal reconstructions) for fractures, foreign body, haematoma, air; MRI for wood foreign bodies and soft tissue; MRI is contraindicated if metallic foreign body is possible.
• Tetanus status; ultrasound with care for the globe; plain radiography for metallic foreign body when CT unavailable.
• Visual field and colour vision when optic neuropathy suspected.

• Treat emergencies first: retrobulbar haemorrhage needs lateral canthotomy and cantholysis immediately; open globe: shield (no pressure), tetanus, systemic antibiotics (moxifloxacin 400 mg orally daily or ceftriaxone 1 g IV daily plus vancomycin 1 g IV twice daily), antiemetics (ondansetron 4 mg), nil by mouth, surgical repair within 24 hours.
• Closed orbital injury: cold compresses for 48 hours, head elevation at 30 degrees, analgesia (paracetamol 1 g four times daily; avoid aspirin and NSAIDs if bleeding risk), avoid nose blowing for 2 to 3 weeks.
• Antibiotics: amoxicillin clavulanate 625 mg three times daily for 5 to 7 days for fractures into sinuses and for contaminated wounds; add tetanus prophylaxis (tetanus toxoid 0.5 mL IM, human tetanus immunoglobulin 250 IU IM for tetanus prone wounds with uncertain immunisation).
• Decongestant sprays (oxymetazoline 0.05 percent twice daily for 3 days).
• Orbital emphysema: observe; needle decompression of the orbit only for compartment syndrome.
• Foreign body: remove organic (wood) and large accessible foreign bodies surgically with antibiotic cover; inert, small, deep metallic fragments may be observed.
• Soft tissue repair: primary closure of eyelid and canalicular lacerations (monocanalicular or bicanalicular silicone intubation for 3 to 6 months).
• Fracture repair when there is persistent diplopia with entrapment, a large floor defect, progressive enophthalmos above 2 mm, or an associated displaced facial fracture, ideally within 7 to 14 days; traumatic optic neuropathy managed by observation, with decompression only in selected cases.
• Follow up for late complications: enophthalmos, diplopia, ptosis, epiphora, glaucoma, cataract and retinal detachment.