Can an orbital fracture be a medical emergency?

From the Guidelines

An eye socket fracture can indeed be a medical emergency that requires immediate attention, particularly if there is evidence of an entrapped muscle or periorbital tissue associated with a nonresolving oculocardiac reflex, as indicated by the 2020 study published in Ophthalmology 1. When considering the urgency of an eye socket fracture, it's crucial to evaluate the presence of specific symptoms and conditions that may necessitate immediate surgical repair. These include:

• CT evidence of an entrapped muscle or periorbital tissue associated with a nonresolving oculocardiac reflex
• "White-eyed blow-out fracture", a form of trap-door fracture with muscle entrapment and oculocardiac reflex
• Globe subluxation into the maxillary sinus According to the study, immediate repair is indicated for these conditions, highlighting the potential for serious complications if left untreated 1. In addition to these emergency situations, other conditions may require repair within a shorter timeframe, such as:
• Symptomatic diplopia with positive forced ductions or entrapment on CT and minimal improvement over time
• Significant fat or periorbital tissue entrapment
• Large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia
• Early enophthalmos or hypoglobus causing facial asymmetry These conditions should be addressed within about 2 weeks, as recommended by the 2020 study 1. It's essential to seek emergency care if symptoms such as severe pain, double vision, restricted eye movement, numbness around the eye or cheek, sunken appearance of the eye, or visible deformity following facial trauma are present. While waiting for medical care, applying ice to reduce swelling, avoiding blowing your nose, and taking acetaminophen for pain rather than NSAIDs may help mitigate potential complications.

From the Research

Emergency Classification of Eye Socket Fractures

• An eye socket fracture can be considered an emergency in certain situations, such as:
  • Globe rupture 2
  • Concern for entrapment 2
  • Orbital roof fractures 2
  • Retrobulbar hematoma 2
• These conditions may require immediate ophthalmic intervention, which was performed in 18.7% of patients in one study 2

Assessment and Triage of Orbital Fractures

• A structured approach to history and examination is crucial in assessing patients with ocular trauma, including orbital fractures 3
• The South Texas Orbital Fracture Protocol (STOP) can be used to properly assess and triage orbital fractures in the emergency department, reducing unnecessary consultations and improving healthcare efficiency 2
• Accurate history-taking and astute observation are paramount for timely treatment or referral that may prevent blindness 3

Management of Orbital Fractures

• Surgical intervention is required emergently in cases of tissue entrapment, and less urgently in cases of persistent diplopia, enophthalmos greater than 2 mm, and/or fractures involving greater than 50% of the orbital floor 4
• Understanding the anatomy of the orbit, clinical evaluation, indications for surgery, surgical approaches, complications, and postoperative care is essential in providing appropriate treatment for patients with orbital fractures 5