Orbital Fractures Workup

Updated: Apr 14, 2022
  • Author: Neeraj N Mathur, MBBS, MS, DNB, MAMS, FAMS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Laboratory Studies

Laboratory studies are limited to those required for preoperative assessment in patients who require operative repair.


Imaging Studies

Computed tomography

CT scanning is considered the top choice in imaging studies for evaluating orbital trauma.

  • The study should be performed with nonenhanced axial and coronal 3-mm cuts; multiplanar reformation sections are then performed. The use of contrast material is generally not required.

  • Sections of 1-mm thickness may be useful to assess optic-canal fractures and traumatic optic neuropathy.

Three-dimensional reconstructed images of the orbit are useful adjuncts in planning the surgical repair of complex fractures.

When evaluating a patient with an orbital injury, the radiologist should do the following: [15]

  • Evaluate the bony orbit for fractures, note any herniations of orbital contents, and pay particular attention to the orbital apex.

  • Evaluate the anterior chamber.

  • Evaluate the position of the lens (the lens may be displaced, and may be either completely or partially dislocated).

  • Evaluate the posterior segment of the globe, look for bleeds or abnormal fluid collections, and evaluate for radiopaque or radiolucent foreign bodies.

  • Evaluate the ophthalmic veins and optic nerve complex, especially the orbital apex.

A study by Bruneau et al indicated that CT scan–based evaluation of pure orbital floor blowout fractures can be used to predict ophthalmologic outcomes, with, for example, the area ratio of the fractured orbital floor and the maximum height of periorbital tissue herniation being predictive for enophthalmos and diplopia, respectively. [16]

As previously mentioned, a study by Vicinanzo et al suggested that in cases of orbital floor fracture, clinical findings, rather than CT scan assessments, should be used to determine the need for surgery. The study, which involved 23 patients, showed only moderate agreement between neuroradiologists in their evaluation of the size of floor fractures, even though fracture size is considered to be an indication as to whether or not surgery should be performed. The magnitude of agreement between the neuroradiologists regarding anterior to posterior length of the fracture, as assessed using the intraclass correlation coefficient, was 0.66, while for transverse width, the magnitude of agreement was 0.44. [14]

A retrospective study by Pontell et al indicated that a CT scan finding of extraocular muscle herniation, extraocular muscle contour irregularity, or fat herniation does not effectively predict the presence of orbital entrapment in patients with orbital fracture. The positive predictive values of these features were found to be 7.9%, 4.8%, and 4.2%, respectively. The investigators state that physical examination should be the primary basis for diagnosing entrapment, with CT scanning serving only an adjunct function. [17]

Magnetic resonance imaging

See the list below:

  • The poor resolution of bone on magnetic resonance imaging (MRI) significantly limits its role in orbital trauma.

  • However, in cases of orbital-apex trauma and traumatic optic neuropathy, MRI may be useful for defining the anatomy of the apex and for depicting hemorrhage in the sheath of the optic nerve.

  • Before this is undertaken, one must make sure that no metallic foreign bodies are in the orbit.

Plain radiography

See the list below:

  • Prior to the use of CT scans, a facial radiographic series was used to assess facial fractures.

  • Waters, Caldwell, submental, anteroposterior (AP), and lateral views depict the facial skeleton.

  • Radiographic evidence of orbital fractures includes fragmentation and misalignment of bone contours, a fluid level in the maxillary sinus, air in the orbit, and prolapse of orbital soft tissue into the maxillary sinus.

  • Submental vertex images provide an excellent view of the zygomatic arch.


This study may be considered in patients with orbital apex fractures and in those patients with clinical features consistent with a carotid-cavernous fistula or carotid artery injury.


Other Tests

See the list below:

  • Assessment of field of binocular single vision

  • Forced duction test