Figure 1

Figure 2

This 24 year-old man complained of diplopia. He was involved in a fight two weeks earlier.

a. What do the pictures show and what is the diagnosis?

Figure 1 shows left enophthalmos and figure 2 shows failure of the left to elevate on upgaze.

The history and the physical signs indicate a left blow-out fracture.

b. What other physical signs may be present?

Two other common physical signs are:

• hypoanaesthesia of the left infraorbital area due to compression of the infraorbital nerve
• orbital emphysema due to communication between the orbit and the maxillary sinus.

c. What are the indications for surgery in this condition?

The indications for surgery for blow-out fracture include:

• diplopia with motility problem
• significant enophthalmos which is usually taken to be more than 3mm
• large fracture
• entrapment of orbital content with globe retraction

This patient had a large orbital fracture with muscle entrapment. The fracture site was explored surgically via the floor of the orbit. The trapped tissue was freed and a silastic plate placed over the fracture site to prevent further entrapment.