2.  16 yo male presents to ED
c/o pain and blurry vision
to right eye after being hit
in the face by a thrown
baseball.
 AFVSS
 Gen: WDWN, A&Ox4
 HEENT: PERRL, R-sided
enopthalmos, orbital
ecchymosis and
subconjunctival
hemorrhage. Right eye has
limited motion with
upward gaze. Nml bilat
visual acuity.
 Neuro: GCS-15. Nml motor
function and sensation x 4

4. 1. Right orbital floor fx
2. Herniated inferior rectus and
periorbital fat
3. Air/fluid level in Max sinus
Waters’ view with teardrop
sign

5.  CT Max/face for all suspected orbital wall injuries
 Orbital floor fractures require:
 Abx (amox/clav) for sinus pathogens
 Decongestants – Afrin 2 sprays, each nostril, BID
 NO NOSE BLOWING!
 Optho consult (30% will have globe injury)
 Face consult (ENT, OMFS, Plastics) – repair usually within 2
weeks (after swelling subsides), but children is earlier.
 Conservative tx for pt’s w/o globe or entrapment injuries
 Analgesics and Ice
 Optho f/u in 3 days

6.  With suspected “Blowout” fractures, careful
examination of globe is warranted, including visual
acuity, EOMs, and slit-lamp.
 Key exam findings include enopthalmos, orbital rim
defects, infraorbital anesthesia, diplopia on upward
gaze.
 Hirschberg reflex (asymmetric corneal light reflex)
may be appreciated. Compare the pupillary level on
the affected side with the unaffected side, since it may
be lower from prolapse of the orbital contents into the
maxillary sinus.

7. Mechanism of blowout
Positive Hirschberg’s sign: Hypotropia
(affected pupil lower than non-affected)

8.  Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The




Atlas of Emergency Medicine, 3rd ed:
http://www.accessmedicine.com
Marx: Rosen’s Emergency Medicine, 7th ed. Ch 69:
Opthomology
Strange GR, Ahrens WR, Schafermeyer RW, Wiebe RA:
Pediatric Emergency Medicine, 3rd ed:
http://www.accessemergencymedicine.com
Tintinalli’s Emergency Medicine: A Comprehensive
Study Guide, 7th ed. Chapter 256: Trauma to the Face
http://wikipedia.org/wiki/Hirschberg_test