A severe blow to the face can fracture any of several bones that form the orbit (the bony cavity that contains the eyeball, muscles, nerves, and blood vessels, as well as the structures that produce and drain tears). Fractures of the floor of the orbit (blowout fractures) are common, but fractures of other parts of the orbit also occur. Occasionally, the eyeball itself also is damaged.
Sometimes the eye is struck in such a way that the force of the blow is received by the eyeball and not blocked by the strong bones around the eye (as when struck by a small object such as a golf ball). In this case, the pressure on the eyeball is transmitted to the walls of the orbit. This pressure can fracture the most fragile part of the orbit, which is typically the part underneath the eyeball (orbital floor). This type of injury is known as a blowout fracture. Fractures can also occur to the sides (walls) and roof of the orbit. Sometimes part of the eye or the muscles attached to it are forced through the fractured bone and become trapped.
Blowout fractures sometimes cause double vision, a sunken eyeball, an eyeball that is stuck looking downward, a decreased sensitivity to touch and pain around the cheek and upper lip (caused by injury to the nerves below the orbit), or an accumulation of air in the tissues under the skin (subcutaneous emphysema). Double vision can occur if one of the muscles that move the eye is trapped in the fracture. The trapped muscle prevents the eye from aiming itself at the object the other eye is looking at. Subcutaneous emphysema occurs if a fracture of the orbital floor allows air from the nose or sinuses to enter the tissues around the eye, particularly when people blow their nose.
Fractures are painful, and the area swells because blood and fluid accumulate. The accumulated blood usually causes the swollen area to appear blue or purple (a black eye). Sometimes the nose bleeds.
Vision may be impaired if the eyelids are swollen shut, or on rare occasions if the eyeball is damaged or if blood from torn blood vessels accumulates behind the eyeball (retrobulbar hematoma) and puts pressure on the nerve leading to the brain (optic nerve).
Diagnosis and Treatment
Diagnosis is suspected based on the symptoms and results of a physical examination. A doctor who suspects an orbital fracture does computed tomography (CT), which shows any fractures, collections of blood, and displaced or trapped tissue.
People who have an orbital fracture should avoid blowing their nose, which may cause swelling if the air they blow out collects under the skin around the eye. Using a nasal spray that constricts blood vessels (topical vasoconstrictor) for 2 to 3 days may help minimize nosebleeds. Applying ice as for other fractures and injuries can help decrease pain and swelling. Keeping the head elevated above the level of the heart may also help prevent further swelling. Analgesics can help control pain. Surgical repair of the facial bones is usually necessary if a blowout fracture traps muscles or soft tissues of the orbit and causes double vision or nerve injury or makes the eyeball sunken and if symptoms do not go away in 2 weeks. After ensuring that the fracture has not damaged a vital structure, the surgeon restores the bones to their proper position, sometimes using implants, a thin plastic sheet, or a bone graft to connect the broken parts and assist healing.
Last full review/revision January 2013 by Kathryn Colby, MD, PhD