CLINICAL PEARLS AND PITFALLS A blowout fracture is a displaced fracture of the bones of the orbit Hallmark physical findings include impaired extraocular movements, pain with extraocular movements, or periorbital swelling or ecchymosis Palpation of the bony rim of the orbit may not exhibit severe point tenderness even in the presence of fracture, depending on the bone(s) involved Blowout fracture requires emergent evaluation by ophthalmology Smaller fractures can tether extraocular muscles, especially the inferior rectus muscle, causing bradycardia Current Evidence There are two proposed mechanisms for blowout fractures The first is that force is transmitted from the orbital rim to the medial wall or floor The second is that force applied to the globe is transmitted to the orbital walls The medial wall is the most common site of fractures CT is the diagnostic modality of choice Indications for operative management include rectus muscle entrapment, enophthalmos, central-gaze diplopia, restriction of extraocular movements, or loss of orbital support Goals of Treatment The primary goal of therapy in the ED is prompt recognition of blowout fractures and any associated intraocular injuries, including entrapment and commonly associated globe injuries Approximately 20% of displaced orbital fractures are associated with globe injury; therefore, emergent ophthalmology consultation is indicated in all cases Pain control is the primary goal of treatment of nondisplaced orbital fractures Clinical Considerations Clinical Recognition Blowout fracture is suggested if any of the following are present: restriction of eye movements following trauma, enophthalmos, infraorbital anesthesia, diplopia, step-off deformity, or subcutaneous emphysema The pathophysiology and diagnosis of blowout fractures are discussed in Chapter 28 Eye: Strabismus Fractures to the inferior and/or medial orbital wall are the most common as they are the thinnest bone The lateral wall is the least commonly fractured The intraocular contents often sink back into the fracture, giving an enophthalmic appearance Conversely, proptosis can occur from orbital hemorrhage Superior wall fracture (roof fractures) may be associated with pulsating proptosis as a result of communication between the orbit and intracranial cavity Fractures of the inferior wall may be associated with numbness of the ipsilateral malar region caused by injury to the infraorbital nerve, which travels along the floor of the orbit Point tenderness and “step-off” signs during palpation of the bony rim of the orbit is highly concerning for fracture, although in some orbital fractures palpation may be remarkably normal The hallmark sign of orbital fracture is a restriction of extraocular movement Usually, the eye is unable to look away from the fracture site because of a tethering of intraocular muscle or other orbital tissues in the fracture (see Fig 28.6 ) Conversely, orbital hemorrhage at the fracture site can less commonly displace the globe away from the fracture and make it difficult for the eye to look in the direction of the fracture Entrapment may occur with orbital fractures, and can increase vagal tone, triggering the oculocardiac reflex This can result in bradycardia, heart block, and in rare cases, hemodynamic instability Axial (proptosis) or coronal displacement of the globe is an ominous finding because it may be a sign of orbital hemorrhage, which can cause compression of the optic nerve, requiring emergency surgical intervention Retrobulbar hemorrhage, presenting with severe pain, vision loss, and proptosis, may also be associated with orbital fractures Enophthalmos is also a sign that should lead to urgent radiologic evaluation and may require surgical intervention Triage Considerations Children who have sustained severe blunt facial trauma and/or eye trauma should be promptly evaluated Soft tissue swelling may increase over time, making evaluation more difficult While the majority of orbital fractures are treated conservatively, those with associated ocular or intracranial injury require immediate intervention Management Some controversy exists among ophthalmologists, otolaryngologists, and craniofacial surgeons regarding the urgency for radiologic evaluation and surgical intervention in the management of orbital wall fractures If a decision is made to proceed with radiologic imaging, CT scan of the orbit with both axial and coronal views remains the standard The brain should be included, particularly when an orbital roof fracture is suspected Plain radiographs have little role in the management of orbital wall fractures as they lack sensitivity The necessity and timing of surgical intervention is controversial; however, most agree that significant extraocular restriction or persistent vomiting necessitates surgical intervention Orbital hemorrhage can lead to orbital compartment syndrome Retrobulbar hemorrhage can cause central retinal artery hypertension or even occlusion Vision loss, severe pain, and proptosis suggest retrobulbar hemorrhage A high suspicion or established diagnosis of such symptomatic hemorrhages necessitates emergent lateral canthotomy and cantholysis by a trained emergency provider or surgeon ( Fig 114.8 ) EYELID LACERATIONS CLINICAL PEARLS AND PITFALLS The following findings require ophthalmology consultation: fullthickness laceration of the eyelid, ptosis, orbital fat prolapse, eyelid margin involvement, injury in close proximity to the tear duct system, tissue avulsion, and concurrent globe injury ( Table 114.3 ) Current Evidence Simple eyelid lacerations may be managed by emergency providers with standard wound care techniques; however, it is standard of care to initiate prompt ophthalmology consultation when deeper injuries are suspected Goals of Treatment Similar to other lacerations, the primary goal is wound closure to achieve hemostasis, cosmesis, and prevent infection Emergency providers may repair simple lacerations of the eyelid and surrounding area using standard wound closure methods However, those lacerations requiring further evaluation for possible injury to the eye itself, tear ducts, or other key structures or those requiring surgical expertise should be promptly recognized Clinical Considerations Clinical Recognition Although eyelid lacerations are usually easy to detect, the clinician must remember that the underlying globe might also have been lacerated or injured Seemingly superficial lacerations of the eyelid may be associated with penetration into the orbit or intracranial cavity, particularly when a pointed implement caused the injury Puncture wounds of the upper eyelid with a stick or a pencil can result in perforation of the orbital roof and entry into the intracranial subfrontal space, with surprisingly few signs or symptoms Oblique lacerations that extend into the medial canthal area (juncture of the upper and lower lids medially) may involve the proximal portion of the nasolacrimal system ( Fig 114.9 ) Sometimes, the eyelid margin puncta, which drains tears into the system, is displaced laterally as a result of the laceration ( Fig 114.9 ) Full-thickness eyelid lacerations, the presence of ptosis, orbital fat prolapse, eyelid margin involvement, injury in close proximity to the tear duct system, presence of tissue avulsion, and the presence of concurrent globe injury should prompt ophthalmology consultation ... may be a sign of orbital hemorrhage, which can cause compression of the optic nerve, requiring emergency surgical intervention Retrobulbar hemorrhage, presenting with severe pain, vision loss,... such symptomatic hemorrhages necessitates emergent lateral canthotomy and cantholysis by a trained emergency provider or surgeon ( Fig 114.8 ) EYELID LACERATIONS CLINICAL PEARLS AND PITFALLS The... concurrent globe injury ( Table 114.3 ) Current Evidence Simple eyelid lacerations may be managed by emergency providers with standard wound care techniques; however, it is standard of care to initiate