What's the Diagnosis? By Dr. Loran Hatch

A 75 yo M presents to the ED after a mechanical fall w/ L facial pain and swelling. He fell forward, hitting his face on the ground. He denies LOC and is not on anticoagulation. On exam, there is noted L eyelid swelling. PERRLA, and EOM and vision are intact. A CT of the facial bones is done and shown below. What's the diagnosis? (scroll down for answer)




Answer: Orbital Floor Fracture

  • Medial aspect of the orbital floor is one of thinnest portions of orbit (along w/ medial wall/lamina papyracea of ethmoid bone)
  • Evaluate visual acuity, pupils and EOM
    • Entrapment of inferior oblique and rectus muscles --> restricted upward gaze and diplopia
  • Possible signs/symptoms:
    • Decreased sensation in infraorbital nerve distribution
    • Enophthalmos- globe displaced posteriorly
    • Afferent pupillary defect
    • Oculocardiac reflex: pressure on globe or entrapment causes bradycardia or nausea/vomiting
  • Requires immediate (within 48 hours) vs. delayed (within 2 weeks) surgical repair
    • Indications for immediate repair: enophthalmos > 2cm, defect > 2cm, symptomatic entrapment, unresolving oculocardiac reflex



Gart MS. Gosain AK. Evidence-based Medicine: Orbital Floor Fractures. Plast Reconstr Surg. 2014 Dec; 134(6):1345-55.