Specialist for Orbital Fracture
For an orbital fracture, you should consult an ophthalmologist with expertise in oculoplastics (orbital surgery), who will coordinate a multidisciplinary team that may include otolaryngology, maxillofacial surgery, or plastic surgery depending on the complexity and associated injuries. 1
Primary Specialist and Initial Evaluation
An ophthalmologist should perform the initial evaluation to rule out vision-threatening injuries including globe rupture, retrobulbar hematoma, traumatic optic neuropathy, and other serious ocular complications that occur in 24% of blowout fractures. 2, 1
Ophthalmology consultation changes ocular management in 27% of orbital fracture patients, particularly when eyelid lacerations, extraocular motion abnormalities, or pupillary defects are present. 3
The ophthalmologist must assess visual acuity, pupillary function, intraocular pressure, exophthalmometry, and perform forced duction testing to distinguish muscle restriction from paresis. 1, 2
When Orbital Surgery Specialists Are Required
An orbital specialist (oculoplastic surgeon) is specifically needed when orbital decompression surgery is being considered, particularly in cases with concurrent proptosis and significant strabismus. 1
Orbital surgeons manage the surgical repair of orbital fractures, with timing dependent on specific clinical findings detailed below. 1
Critical Red Flags Requiring Immediate Specialist Intervention
Monitor vital signs for bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness, as these indicate oculocardiac reflex from muscle entrapment—a potentially life-threatening condition requiring urgent medical and surgical treatment. 1, 4, 2
Immediate Repair Indications (Same Day):
- CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1, 4
- "White-eyed blowout fracture" (trap-door fracture with muscle entrapment seen in children) 1, 4
- Globe subluxation into the maxillary sinus 1, 2
Repair Within 1-2 Weeks:
- Symptomatic diplopia with positive forced ductions or CT evidence of entrapment with minimal improvement 1, 4
- Large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia 1, 4
- Early enophthalmos or hypoglobus causing facial asymmetry 1, 4
Observation Appropriate:
- Minimal diplopia (not in primary or downgaze) with good ocular motility, without significant enophthalmos or hypoglobus 1
- Wait 4-6 months after orbital trauma without muscle entrapment, as diplopia may resolve spontaneously if it hasn't persisted beyond 6 months. 4, 1
Multidisciplinary Team Coordination
A multidisciplinary approach combining ophthalmology, oculoplastics, otolaryngology, maxillofacial surgery, and neuro-ophthalmology is recommended for complex orbital trauma. 1
The ophthalmologist coordinates care and communicates with the orbital surgeon regarding surgical planning, particularly when strabismus surgery may worsen proptosis after recession of fibrotic muscles. 1
Imaging Requirements
CT orbit without contrast with fine cuts and multiplanar reconstructions is the study of choice, with 94.9% sensitivity for intraorbital foreign bodies and accurate detection of fractures and muscle entrapment. 2, 1
MRI provides more precise imaging of extraocular muscles and the pulley system but is contraindicated if metallic foreign body is suspected. 1, 2
Common Pitfalls
Diplopia alone does not always indicate muscle entrapment—soft tissue swelling, hematoma, or nerve paresis can also restrict ocular movement. 4, 5
Even without direct muscle entrapment, significant fat or periorbital tissue entrapment can result in permanent strabismus requiring surgical intervention. 4, 1
All life-threatening and vision-threatening conditions must be treated before addressing strabismus or diplopia, as 5.5% of facial fracture patients have complete vision loss in one eye. 2, 1
Diplopia occurs in 58-68% of blowout fractures, with strabismus surgery required in 7-24% of orbital floor fracture cases. 1, 5