An orbital fracture occurs when one or more of the bones surrounding the eye socket (orbit) are broken. The orbit contains several thin bones that can fracture upon facial trauma, allowing bone fragments or soft tissues to be displaced into the orbit. Common types include blow-out fractures, where a bone fragment is driven into the orbit, and blow-in fractures, where a fragment is pushed in the opposite direction out of the orbit. Clinical features may include swelling, bruising, double vision from impaired eye movement, and changes in eye position. Imaging such as CT scan is used to evaluate the fracture. Treatment involves correcting any tissue or bone displacements through surgical approaches to the orbit. Complications can include issues with vision, eye movement,

1. Orbital Fracture

2. Anatomy of Orbit
⚫ Orbit – conical cavity
⚫Base – Anteriorly
⚫Apex – directed at Optic Foramen
⚫Orbital Volume – 30cc ; Globe – 7cc
⚫By Age 5 years orbital growth is 85% complete , Finalised
between 7 years of age
⚫Bones – 7 (Maxillary, Zygomatic, Frontal, Ethmoid, Larimal,
Palatine, and Sphenoid )
⚫Four Walls – roof, lateral, medial, floor
⚫Medial wall & floor – thin ;
⚫Lateral wall & Roof – Stronger.
⚫Floor weakened – due to – Infraorbtal Canal passing through it

3. ⚫Medial wall – Formed by – Lamina Papyracea of
Ethmoidal bone & Lacrimal bone
⚫Vital Contents – Eyeball (Non Compressible)
⚫6 EXTRAOCULAR MUSCLES –
⚫Originate from Common Tendinous fibrous ring
⚫Annulus of Zinn – Fibrous ring – Common origin of 4
Rectus Muscle
⚫OPTIC NERVE – direct extension of Gray Matter
⚫Very sensitie to Compression and once damaged fails to
regenerate
SUPERIOR ORBITAL FISSURE
⚫Transmits – 3rd , 4th & 6th Cranial Nerves
⚫Opthalmic Division of 5th Cranial Nerve

4. Cranial Nerves and its Supply
⚫Occulomotor (C.N.-III)- Supplies –
⚫Superior Rectus
⚫Medial Rectus
⚫Inferior Rectus
⚫Inferior Obliqus
⚫Abducent Nerve – Lateral Rectus (LR6 )
⚫Trochlear Nerve – Superior Obliqus (SO4)

5. ⚫Theoretically, the mechanical load of the orbital
floor is approximately 0.0005 N/mm2 (30 g orbital
content onto 600 mm2 of orbital floor area), as
indicated by several cadaver investigations.

6. CLASSIFICATION
⚫ORBITAL WALL FRACTURES –
1. Blow Out Fracture
2. Pure Blow Out Fracture
3. Impure Blow Out Fracture
4. Blow In Fracture
⚫ISOLATED ORBITAL WALL FRACTURE :
5. Roof
6. Floor
7. Medial wall
8. Lateral wall

7. ⚫ISOLATED FRACTURES OF THE ORBITAL RIM
1. SUPERIOR RIM
2. INFERIOR RIM
3. MEDIAL RIM
4. LATERAL RIM
⚫COMPLEX COMMINUTED FRACTURES :
⚫Nasoethmoidal and fronto-naso-orbital fractures

8. Anatomy of Bony Orbit

9. Orbital Fissures/Canals and Their
Contents

11. Pathophysiology of Orbital Fractures

12. ⚫In the event of Trauma
⚫Thick Rims protect the Eyeball
⚫Absorb shock by Fracturing themselves
⚫Orbital walls (especially Medial Wall & Floor) fracture
in an isolated way
⚫Gets displaces Inwards or Outwards
⚫Called as ‘Blow-In’ or ‘Blow-Out’ fractures

13. ⚫PURE Blow Out OR Blow In –
⚫Orbital Walls fracture in Isolation
⚫IMPURE Blow Out or Blow In Fracture –
⚫Walls + Rim

14. Blow Out Fracture

15. Blow Out Fracture
⚫Term coined by – Smith and Regan – 1957
⚫First described by MacKenzie in Paris in 1844
PATHOPHYSIOLOGY
⚫Buckling Theory –
⚫This theory states that if a force was to strike any part of
the orbital rim, it will cause walls to undergo a rippling
effect & the force striking the rim will transfer to the
weaker portion especially the floor & cause them to
distort & eventually fracture

16. Pathophysiology of blow out fracture
of the orbit
⚫ Hydraulic Theory (Pfeiffer in 1943) – he said that it is
evident that the force of the blow received by the eyeball was
transmitted by it to the walls of the orbit with fracture of the
delicate portions.
- Therefore direct injury to the globe forcing it into the orbit was
necessary.
⚫ Medial Wall & Floor –Thin & Fragile

17. Clinical Features
⚫ Circumorbital Edema -
⚫ Subconjunctival Bleeding – due to fracture subperiosteal bleeding 
escapes in subconjunctival plane.
⚫ Enopthalmous  Increase in size of Orbit  Eyeball sinks
⚫ Periorbital Fat Herniates through fractured walls
⚫ ‘Hanging-drop’ Appearance
⚫ Unilateral Epistaxis – bleeding into antrum
⚫ Numbness in area of distribution of Infraorbital Nerve
⚫ Diplopia or Vertical gage – Inferior Rectus or Inferior Obliqus gets
entrapped in fracture  inability of eyeball to move in vertical direction.

18. Enopthalmus following Blow-Out
Fracture
⚫Retracting action of
extraocular muscles –
Enopthalmus.
⚫Diplopia – Entrapment
of Inferior Rectus &
Inferior Obliqus

19. Pathophysiology
⚫ Raised Intraorbital Pressure (due to
Hematoma/Displaced fractured segments)
⚫Compression of contents of Sup. Orbital Fissure
⚫Paresis of Nerve
⚫Neurological deficit in their distribution

20. ⚫Occulomotor supplies – SR , MR, IR , IO
⚫Abducent – LR
⚫Trochlear – SO
⚫Due to paresis of these nerves  all these
extraocular muscles undergo paralysis  eyeball
fails to move  ‘External Opthalmoplegia’
⚫As affected eye does not move  whereas
contralateral normal eyeball moves  focal axis
gets disturbed  two images - Diplopia

21. Clinical Manifestations
⚫External Opthalmoplegia – Eyeball fails to move
⚫Diplopia – Two images of one object
⚫Internal Opthalmoplegia – Fixed Dilated pupils
(parasympathetic – III cranial nerve – Occulomotor )
⚫Ptosis of Upper Eyelid – upper eyelid drops down
like a curtain – parasympathetic supply.
⚫Orbital Apex Syndrome – If Optic Nerve
Involvement is present.

22. BLOW IN FRACTURE
⚫Fragmented bones of the orbital floor are
displaced into the orbit.
⚫Proptosis – Exopthalmous
⚫More commonly seen in fractures of – orbital roof

23. CLINICAL EXAMINATION
⚫Initial Opthalmological evaluation –
1. Periorbital Examination
2. visual acuity – SNELLEN CHART
3. ocular motility – FORCED DUCTION TEST
4. Pupillary responses ,- pupillary size, shape&
symmetry, light reactivity,
5. Visual fields – HESS CHART
6. Fundoscopic examination
- TONOMETRY – to assess Intraocular pressure
(Normal 10-20mmHg)
7. Hertel Exopthalmometer – measure exopthalmous

24. Forced Duction Test
⚫ Prior to the performance of a
forced duction test, a cotton-
tipped applicator is soaked with
topical anesthetic drops and held
against the limbus for a few
minutes.
⚫ Fine-toothed forceps are then
used to grasp the conjunctiva
and Tenon’s capsule just
posterior to the limbus.
⚫ The patient is then asked to look
in the direction of restriction of
movement of the eye .

25. Tonometer
Snellen chart

26. IMAGING
⚫CT Scan – Orbit
- To visualize the fractured segments
- CT Scan – also helps evaluate the Intraorbital
volume. By using a software to compare the
normal orbital volume to the affected
- MRI

27. Management

29. Indications for surgical
managment
⚫Unresolving soft tissue entrapment with disabling
diplopia
⚫Enopthalmous greater than 2mm
⚫CT scan evidence of a large fracture

30. Incisions
•Existing lacerations
•LowerEyelid –
• 1)Subciliary
• 2) Subtarsal
• 3) Infraorbital
approaches
•Transconjuctival
Approach – Lower Eyelid

31. Pre-formed Orbital Implant
ADVANTAGES :
•Radiopacity
•Smooth Surface
•Minimal or no countouring necessary
DISADVANTAGE :
•Cost

32. Bone Graft
Disadvantages :
•Additional Donor site needed
•Possible contour and dimensional changes due to
remodeling
•Difficult to shape according to patients anatomy

33. Porous Polyethylene Sheet
(PPE)
Disadvantages :
• Not Radiopaque (Not visble on Post Operative
Radiographs
•Lack of Rigidity when very thin wafer of PPE is used.
When a more thick rigid wafer is used there is a risk
of causing dystopia

34. POLYETHYLENE AND TITANIUM
MESH
⚫By combining titanium mesh
with porous polyethylene –
⚫Material becomes radioopaque
⚫More rigid than porous PPE.
⚫ADVANTAGE :
⚫Stability
⚫Contouring
⚫Adequate in large three wall
fractures
⚫Radiopacity
⚫No Donor Site Needed
⚫DISADVANTAGES : Less
Drainage from orbit than with

35. RESORBABLE MATERIALS
⚫ Thermoplastic and Non
Thermoplastic Materials
⚫ ADVANTAGES :
⚫ Availability Handling/
⚫ Contourability (only for
thermoplastics)
⚫ Smooth surface and smooth
edges
⚫ Disadvantages:
- No radiopacity
- Degradation of material with
possible contour loss Sterile
infection / inflammatory response
- Difficult to shape according to
patients anatomy (only for non-
thermoplastics)

36. COMPLICATIONS
⚫ EARLY COMPLICATIONS :
⚫ 1. Hemorrhagic or orbital hematoma – treated by
-lateral cathotomy immediately, lateral canthal
Tendonlysis ,
Lateral canthotomy – indicated when –
- Decreased visual acuity
- Introcular pressure more than 40mmHg
- Proptosis
- Opthalmoplegia

37. Retrobulbar hemorrhage
- Rare, rapidly progressive
life threatening emergency
that results in accumulation
of blood in the retrobulbar
space
- Increased IOP 
stretching of the optic
nerve & blockage of ocular
perfusion
- Proptosis , marked
subconjuctival ecchymosis
& edema ,

38. ⚫ Symptoms seen are – pain , decreasing visual acuity,
diplopia
⚫ Treatment includes
⚫ iv mannitol – (used to treat raised intracranial
pressure)
⚫ Acteazolamide – carbonic anhydrase inhibitor ;
diuresis in PCT of kidney – excretion of NA, K, Cl –
lowering BP, IOP
⚫ Megadose Steroid Therapy – 100mg Dexa as an i.v.
bolus with 40mg 6 hourly in severe unresponsive
cases ( Anderson et al 1982)
3. Blindness

39. ⚫OCULOCARDIAC REFLEX/ TRIGEMINOCARDIAC/
TRIGEMINOVAGAL REFLEX –
- The oculocardiac reflex pathway begins with the
- afferent fibres of the long & short ciliary nerves that
travel with
- the opthalmic division of the trigeminal nerve to
- the gasserion ganglion via
- the sensory nucleus of the trigeminal nerve.
- In the floor of the 4th ventricle short internuncial
fibres in the reticular formation connect them with the
efferent pathway from the motor nucleus of the
vagus nerve to the depressor nerve ending in the
mucle tissue of the heart.

40. ⚫CLINICAL FEATURES –
- Bradycardia
- Faintness
- Further stimulation can lead to cardiac
dysrhythmias
- Atrioventricular blocks
- Asystole
- Bradycardia has been attributed to Trigeminal
derived vagal reflex

41. LATE COMPLICATIONS
⚫Altered vision
⚫Diplopia
⚫Ectropion – lower eyelid turns outward
⚫ Epiphora – overflow of tears onto the face –
insufficient tear film drainage from eyed in that
tears will drain down the face rather than through
nasolacrimal system
⚫Enopthalmous

42. ⚫THANK YOU