A Man With Double Vision After a Fight

C. Robert Bernardino, MD


October 31, 2012

In This Article


Treatment options include observation vs surgical repair. Timing and need for surgical repair are based on a few considerations, including presence or absence of entrapment, presence of diplopia, and enophthalmos.

Entrapment of a rectus muscle requires urgent surgical intervention. These injuries typically occur in children or young adults, in whom the orbital bones are flexible and can break and snap back, entrapping soft tissue. These patients will usually have significant nausea and vomiting and may be bradycardic due to the oculocardiac reflex. If urgent surgical intervention is not performed, an entrapped muscle can become permanently injured within 24 hours, leaving a patient with permanent double vision.

For a fracture without entrapment, it is often helpful to wait for resolution of the swelling before surgical intervention. Initial diplopia due to edema and contusion often resolves. Also, not all patients develop enophthalmos in the setting of a floor fracture. Surgical intervention can certainly repair an anatomic defect, but it has the risk of worsening symptoms, including double vision, orbital pain, hypaesthesia, or loss of vision.


This case demonstrated an orbital floor fracture without entrapment. Initially, the patient had no enophthalmos and minimal diplopia. However, as the swelling subsided after approximately 1 week, he developed 2 mm of enophthalmos and worsening diplopia. Surgical repair was performed via a transconjunctival approach, and the enophthalmos and diplopia resolved.

In cases of trauma, it is always important to rule out ocular emergencies such as a ruptured globe, orbital fracture with entrapment, and retrobulbar hemorrhage. After they have been ruled out, close observation is helpful for determining the need for surgical intervention.

Suggested Reading

Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109:1207-1213.

Harris GJ. Orbital blow-out fractures: surgical timing and technique. Eye (Lond). 2006;20:1207-1212.

Yano H, Nakano M, Anraku K, et al. A consecutive case review of orbital blowout fractures and recommendations for comprehensive management. Plast Reconstr Surg. 2009;124:602-611.