What is the next step in managing a patient with an orbital injury and air visualized on X-ray?

Management of Orbital Injury with Air Visualized on X-ray

The next step in managing this patient should be an orbital CT scan to evaluate for potential orbital fracture, soft tissue injury, and possible intracranial extension.1

Rationale for Orbital CT

The presence of orbital air on X-ray is highly concerning in the setting of trauma and requires immediate further evaluation. CT is the gold standard for orbital trauma assessment for several reasons:

• CT is considered the most useful imaging modality for evaluating orbital trauma and is the most accurate method for detecting fractures1
• CT provides critical information about soft tissue injuries including:
  • Globe integrity
  • Extraocular muscle status (entrapment, edema)
  • Presence of hemorrhage
  • Foreign bodies
  • Potential intracranial extension1

Clinical Significance of Orbital Air

The visualization of air in the orbit on X-ray strongly suggests:

1. A communication between the orbit and adjacent air-filled structures (sinuses)
2. Possible orbital floor or medial wall fracture (blow-out fracture)
3. Risk for serious complications including:
   • Muscle entrapment
   • Orbital compartment syndrome
   • Potential intracranial injury2

Assessment Algorithm

1. Immediate Orbital CT without contrast

   • Thin-section axial imaging with multiplanar reconstructions1, 3
   • Evaluate for:
     • Fracture patterns (especially orbital floor/medial wall)
     • Soft tissue injuries
     • Muscle entrapment
     • Orbital emphysema extent
     • Globe integrity
     • Optic nerve status

2. Urgent ophthalmology consultation if CT reveals:

   • Muscle entrapment
   • Large orbital floor fractures
   • Significant enophthalmos or hypoglobus
   • Evidence of globe injury1

3. Neurosurgical consultation if:

   • Pneumocephalus is present
   • Orbital roof fracture with intracranial extension
   • Evidence of optic nerve compression2

Management Based on CT Findings

Immediate Surgical Repair Indicated For:

• Entrapped muscle or periorbital tissue with oculocardiac reflex (bradycardia, nausea, vomiting)
• Globe subluxation
• Evidence of optic nerve compression1

Early Repair (Within 2 Weeks) For:

• Symptomatic diplopia with positive forced ductions
• Entrapment on CT with minimal improvement
• Large floor fractures with hypoglobus
• Progressive infraorbital hypoesthesia
• Early enophthalmos causing facial asymmetry1

Observation Appropriate For:

• Minimal diplopia not affecting primary or downgaze
• Good ocular motility
• No significant enophthalmos or hypoglobus1

Important Clinical Considerations

• Do not perform MRI if there is any suspicion of a metallic foreign body1
• Monitor for oculocardiac reflex (bradycardia, nausea, vomiting) which may indicate muscle entrapment requiring urgent intervention1
• Evaluate visual acuity and extraocular movements as these are the two most critical ophthalmologic functions to assess4
• Consider short course of oral steroids to reduce orbital edema and help reveal underlying strabismus that may persist1

Pitfalls to Avoid

1. Relying solely on X-ray findings - Plain radiographs are insufficient for proper evaluation of orbital trauma1
2. Delaying CT imaging - Early detection of entrapment is crucial to prevent ischemic muscle injury
3. Missing subtle fractures - Use systematic approach (e.g., "BALPINE" method: bones, anterior chamber, lens, posterior globe, intraconal orbit, neurovascular structures, extraocular muscles)5
4. Overlooking intracranial extension - Air in the orbit may communicate with intracranial spaces2
5. Premature surgical intervention - Unless there are urgent indications, allowing 1-2 weeks for edema resolution may be appropriate before definitive repair1

This 28-year-old male with orbital air visualized on X-ray after trauma requires prompt orbital CT to guide appropriate management and prevent potential vision-threatening complications.