Question of the Week

A 17-year-old male presents to the ED with blunt trauma to the left orbit after a physical altercation. He noticed diplopia immediately after impact. He now feels pain with upward gaze, nausea, and vomiting. On exam, there is minimal periorbital edema and restriction of supraduction in the left eye. Visual acuity, intraocular pressure, and pupillary reflexes are normal. On slit lamp, there are a few small sub-conjunctival hemorrhages in the left eye. CT imaging reveals an orbital floor fracture with entrapment, as shown in the figure.

Which of the following is the most appropriate next step in management?

A. Observation and repeat imaging in 1 week

B. High-dose corticosteroids

C. Urgent surgical repair

D. Broad-spectrum antibiotics

E. Patch the affected eye

Answer

The correct answer is C.

This presentation is classic for an orbital floor fracture with entrapment, otherwise known as a white-eyed blowout fracture. This can occur in young patients with minimal external signs despite significant internal injury. Prompt surgical intervention, within hours to days, is indicated to release entrapped muscle, prevent ischemic injury, and prevent persistent motility deficits. Observation (choice A) is not appropriate, given the greater risk of tissue damage as the muscle remains entrapped longer. Corticosteroids (choice B) and antibiotics (choice D) do not address the mechanical entrapment. Patching the eye (choice E) may help any residual diplopia after treatment, but it is not an appropriate initial management.

Source: Rixen J, Call C, Carter KD. White-eyed blowout fracture. EyeRounds.org. January 11, 2012; Available from: https://eyerounds.org/cases/145-white-eyed-blowout-fracture.htm