Question of the Week

A 24-year-old male playing at the World Cup is brought to the emergency department after blocking a shot from Christiano Ronaldo with his face. The patient never lost consciousness but reports feeling severe right eye pain and dizziness since the accident. His right eye appears swollen with 2.5mm of enophthalmos relative to the left eye. On fundoscopic examination, no retinal detachment is appreciated. Visual acuity is 20/40 OD. What is the next step in management?

Conservative management with ice pack and NSAIDs
Oral prednisone
Vasalva maneuver
Surgery within 14 days once swelling has subsided
Immediate surgical intervention

Answer

Correct answer: E

This patient most likely suffered an orbital floor/medial orbital wall fracture that usually is due to direct trauma aimed at the eye. The common symptoms found in the question are the unilateral eye pain, enophthalmos, and decreased visual acuity. The goals of treatment are to maintain function of the eye and keep its aesthetic appearance. Although this can be treated more conservatively, indications for immediate surgery include: pediatric patient with trapdoor fractures and vital sign instability, retrobulbar hematoma with progressive visual acuity loss, and enophthalmos of > 2 mm on initial evaluation. Due to the severity of the enophthalmos, immediate surgery is necessary to maintain function and appearance.

A) Conservative management can be used initially to relieve symptoms and for nondisplaced fractures.

B) Corticosteroids can be used to decrease the edema in these patients who do not require immediate surgical intervention, and will often be used prior to non-immediate surgery.

C) Blowing of the nose and the Valsalva maneuver can actually worsen this patient’s injury by worsening orbital emphysema.
D) Surgery must be performed within 14 days (often within 7) for these patients to prevent fibrosis which may lead to permanent enophthalmos and/or restricted motility.

Sources:

Koenen, L., & Waseem, M. (2023). Orbital floor fracture - StatPearls - NCBI bookshelf. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK534825/

Procacci, P. (2017, March). Modified technique for endoscopic endonasal reduction of medial orbital wall fracture using an absorbable packing. ResearchGate. https://www.researchgate.net/publication/236076522_Surgical_Management_of_Enophthalmos_in_Duane_Syndrome