Diplopia as an alarm sign in orbital traumatism

Orbital fractures represent between 10% and 25% of all facial fractures. This pathology is more frequently observed in traffic accidents, being characteristic its greater complexity given the appearance of concomitant injuries at the organic level, zygomatic fractures as well as multiple fractures of the orbital wall [1].  The most frequent clinical signs observed in adults in orbital fractures are periorbital ecchymosis and subconjunctival hemorrhage, although symptoms related to proptosis, feeling of orbital or eyelid pressure, a "crackling" sound with the eyelid pressure or eye movement, numbness of the cheek, nasal wing or ipsilateral forehead, diplopia, pain or nausea in a particular direction of the gaze, and an unexplained desire to keep the eye closed after a trauma [2]. Hereby, we summarize a brief review of orbital fractures a purpose of a case of patient affected by diplopia after facial trauma.

An 85-year-old man with a history of hypertension, type 2 diabetes mellitus, dyslipidemia, chronic hearing loss, and benign prostatic hyperplasia was admitted in our health center due to falling from his own height in a casual way after stumbling over a curb, suffering a left hemifacial traumatism with slight bleeding from the left nostril. He denied loss of consciousness after the event. Two hours after the concussion, the patient started progressive diplopia and left periorbital pain, which was why he consulted.

On physical examination, there was an abrasion at the level of the left zygomatic region as well as a left palpebral hematoma with crepitus associated. At the neurological level, any disturbs were observed at cranial nerves excepting the third pair, where a possible involvement of the inferior rectus was observed due to a limitation in adduction and left ocular descent.

Given these alterations and the suspicion of a possible periorbital fracture, it was referred to the hospital to complete the radiological study. In this center, a computerized axial tomography (CT) of the face was performed, showing a fracture of the floor of the left orbit (left maxilla), with the displacement of a bone fragment to the ipsilateral maxillary sinus, which also had liquid content in relation to the trauma. In addition, signs of entrapment of the left inferior rectus muscle with pre- and postseptal emphysema and edema of the left palpebral soft tissue were observed (Figure 1).

 Given these findings, the case was discussed with the maxillofacial surgery department indicating the initiation of antibiotic therapy (Amoxicillin/Clavulanic), non-steroidal anti-inflammatory drugs, and corticosteroid therapy as conservative management. At present, after three months of the event, alternate diplopia persists, which is why ambulatory control is followed.

Between 11% and 15% of orbital fractures represent an ophthalmological emergency, which is frequently related to a decrease in visual acuity or other visual disturbs. Nevertheless, it should be noted that this is not pathognomonic given that close to 100% of orbital trauma (with or without associated fracture) is associated with alterations in visual acuity [5]. Another frequent symptomatology observed in orbital fractures is periorbital ecchymosis and subconjunctival hemorrhage, although it can also present with proptosis, sensation of orbital or eyelid pressure, a "crackling" sound with pressure of the eyelid or eye movement, numbness of the cheek, nasal wing or ipsilateral forehead, diplopia, pain or nausea in a particular direction of the gaze, and an inexplicable desire to keep one eye closed after a trauma. Diplopia is usually related to fractures of the floor of the orbit and trapping of the inferior rectus [2], although there are series of cases (up to 80%) that observe that this visual alteration does not imply entrapment of an extraocular muscle, but rather which may be a consequence of orbital edema. This may be due to transient paralysis of the inferior rectus secondary to trauma as a consequence of local edema and contusion [6]. Apart from diplopia, restriction in ocular motility, nausea, vomiting, and bradycardia secondary to the oculocardiac reflex may give the suspicion of entrapment of the inferior rectus [7].

The standardized diagnostic method for the diagnosis of orbital fractures is CT, which adds more prognostic and diagnostic information since they are usually observed in polytraumatized patients. Nevertheless, some authors suggest that in cases of suspected fracture secondary to low energy mechanisms, ultrasound and cone beam CT may be equally useful, especially in fractures of the orbital floor [8]. Attending to the treatment, conservative management may be performed, requiring surgery within two weeks if persistent diplopia is found, enophthalmos >2 mm, malposition of the eyeball, orbital floor fracture >50%, or associated fractures which requires surgery [7].

In conclusion, orbital fractures are a frequent entity within facial fractures. They are usually produced by high energy mechanisms, although sometimes not, causing little disturbs in the physical examination and thus reducing the diagnostic suspicion. Due to that, an adequate neuro-ophthalmological exploration is especially relevant to rule out serious injuries, including the entrapment of oculomotor muscles such as the lower rectus.

1. Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60:398-403.
2.   Roth FS, Koshy JC, Goldberg JS, Soparkar CN. Pearls of orbital trauma management. Semin Plast Surg 2010;24:398-410.
3.  Phan LT, Jordan Piluek W, McCulley TJ. Orbital trapdoor fractures. Saudi J Ophthalmol 2012;26:277-82
4.  Felding UNA. Blowout fractures - clinic, imaging and applied anatomy of the orbit. Dan Med J 2018;65. pii:B5459.
5.    Mellema PA, Dewan MA, Lee MS, Smith SD, Harrison AR. Incidence of ocular injury in visually asymptomatic orbital fractures. Ophthal Plast Reconstr Surg 2009;25:306-8.
6.   Back CPN, McLean NR, Anderson PJ, David DJ. The conservative management of facial fractures: indications and outcomes. J Plast Reconstr Aesthet Surg 2007;60:146-51.
7.  Grob S, Yonkers M, Tao J. Orbital fracture repair. Semin Plast Surg 2017;31:31-39.
8. Johari M, Ghavimi MA, Mahmoudian H, Javadrashid R, Mirakhor Samani S, Fouladi DF. A comparable study of the diagnostic performance of orbital ultrasonography and CBCT in patients with suspected orbital floor fractures. Dentomaxillofac Radiol 2016;45:20150311.