History
Because orbital fractures are the result of trauma, primary survey and attention to ABCs take priority. Focus questions on patency of the airway, control of the cervical spine, breathing difficulties, and symptoms of shock or neurologic impairment, such as loss of consciousness.
Once you have addressed life-threatening issues, obtain a thorough (AMPLE) history:
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Allergies
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Medications
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Past medical history
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Last meal
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Events leading to injury
Ask the patient questions about the injury such as these:
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Do you have epistaxis or clear fluid running from the nares or ears?
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Did you lose consciousness? If so, for how long?
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Have you had any visual problems, such as double or blurred vision?
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Have you had any hearing problems, such as decreased acuity or tinnitus?
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Do you have crooked teeth or a poor bite? Can you bite down without pain?
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Do you have areas of numbness or tingling on your face?
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(For women) Was this injury caused by a partner? Do you feel threatened by anyone?
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(For children) Was this injury caused by someone you know? Are you afraid of anyone because they have hurt you?
Ask the patient questions specific to the eye:
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(To assess for diplopia indicating possible entrapment or lens dislocation) Do you ever see 2 images of 1 object, especially when you look to the right or the left or upward?
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(To assess for possible entrapment or periorbital edema) Do you have pain with eye motion?
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(To assess for iritis/photophobia) Do you sometimes have redness of the eye, eye pain, sensitivity to light, blurred vision, or dark floating spots in your field of vision?
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(To assess for retinal detachment) Have you experienced flashes of light?
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(To assess for hyphema, retinal detachment, or vitreous hemorrhage) Do you have blurred vision?
Physical
Perform a complete exam of the face. [Asterisks (*) designate portions of the exam that are involved specifically with orbital fracture or associated eye injuries.] [7, 11, 17]
Inspect the face for asymmetry while looking down from the head of the bed. From this position, it is easiest to see enophthalmos (sunken eye) or proptosis (protruding eye).*
Examine lids for lacerations. If present, consider the possibility of globe penetration.*
Palpate bony structures of the supraorbital ridge and frontal bone for step-off fractures.*
Examine ocular movements, especially in upward and lateral gaze, and test for diplopia.*
Check visual acuity.*
Check the cornea, using fluorescein if needed, for abrasion (uptake of dye) or lacerations (streaming of fluid in dye).*
Check pupils for roundness and reactivity, both direct and consensual.*
Examine the anterior chamber for the presence of blood (flaring on slit-lamp exam) or hyphema (blood layering in the inferior aspect of the anterior chamber).*
Examine the limbus for signs of laceration (teardrop sign) or deformity.*
Perform a funduscopic exam to check for blood in the posterior chamber, and examine the retina for signs of detachment.*
Inspect the nares for telecanthus (widening of the nasal bridge), then palpate for tenderness and crepitus.
Inspect the nasal septum for clear rhinorrhea, indicating cerebrospinal fluid (CSF) leak, and for septal hematoma.
Check facial stability by grasping the teeth and hard palate and gently pushing horizontally then vertically, feeling for movement or instability of the midface.
Test the teeth for stability and inspect for bleeding at the gum line—a sign of fracture through the alveolar bone.
Check the teeth for malocclusion and step-off.
Palpate the mandible along its symphysis, body, angle, and coronoid process (anterior to ear canal) to check for tenderness, swelling, and step-off.
Evaluate supraorbital, infraorbital,* inferior alveolar, and mental nerve distributions for anesthesia.
Palpate the zygoma along its arch, as well as its articulations with frontal bone, temporal bone, and maxillae.
Perform a slit-lamp examination of the eye to exclude eye injury.*
Complications
Complications include the following:
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Corneal abrasion
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Lens dislocation
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Iris disruption
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Choroid tear
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Scleral tear
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Ciliary body tear or bruise
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Retinal detachment and tear
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Hyphema
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Ocular muscle entrapment
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Globe rupture
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Left orbital floor fracture. This patient presented with little motility disturbance; however, because of the large defect in the orbital floor, late enophthalmos was predicted. Surgical repair was undertaken. Note the pneumo-orbitum.
