Periocular trauma encompasses injuries to the eyelids, orbit, and lacrimal system. Because the eyelids protect the globe and the orbit houses the optic nerve, even apparently minor periocular trauma can have significant visual consequences. The initial priority in any periocular trauma is to rule out globe injury before proceeding with eyelid or orbital repair. A ruptured globe requires urgent ophthalmologic evaluation; wound exploration should be deferred until the globe is assessed and protected.
For a detailed review of orbital anatomy — bones, walls, foramina, and contents — see our dedicated Anatomy Overview page.
Orbital Floor Fractures
Orbital floor fractures result from blunt trauma to the periorbital region. The orbital floor (the roof of the maxillary sinus) is one of the thinnest orbital walls and fractures most commonly, followed by the medial wall adjacent to the ethmoid sinus. The medial wall (lamina papyracea) is actually thinner, but it is buttressed by the ethmoid air-cell septa, so the relatively unsupported floor tends to give way first. When force is applied to the orbit, intraorbital pressure rises acutely, causing the weakest wall to fracture outward into the adjacent sinus — a decompression mechanism that may protect the globe from more serious injury.
Published Research in Oculoplastic Surgery
Brown MS. Concomitant Ocular Injuries with Orbital Fractures. Research highlights the importance of comprehensive ocular evaluation at the time of orbital fracture presentation, as globe injuries frequently occur alongside orbital fractures and may be missed on initial assessment.
Pure blowout fracture — fracture limited to the orbital walls without rim involvement; the rim remains intact. Most commonly involves the floor or medial wall. Fat and occasionally muscle herniate into the adjacent sinus.
Orbital rim fracture — fracture involves the orbital rim itself; often associated with zygomaticomaxillary complex (ZMC) fractures, frontal sinus fractures, or LeFort patterns.
Trapdoor fracture — a greenstick variant most common in children; the bone flexes and snaps back, trapping orbital contents within the fracture. Children may have minimal external signs yet present with severe restriction of upgaze, nausea, and bradycardia (“oculocardiac reflex”). This constitutes a surgical emergency — urgent repair within 24–48 hours is required to prevent ischemic contracture of the entrapped inferior rectus muscle.
Mechanism of Injury
Three classic theories explain how a blunt blow fractures the thin orbital floor:
Buckling theory: a blow to the rim transmits force that buckles the thin orbital floor.Globe-to-wall theory: the eye is driven back, transmitting pressure directly onto the floor.Retropulsion (hydraulic) theory: a sudden rise in orbital pressure blows out the floor.
Clinical Findings
Enophthalmos — posterior displacement of the globe from increased orbital volume; may be delayed 2–4 weeks as edema resolves
Hypoglobus — downward displacement of the globe with large floor fractures
Diplopia — from muscle entrapment, direct muscle injury, or periorbital edema restricting eye movement; most resolves spontaneously as swelling decreases
Infraorbital nerve hypoesthesia — numbness of the cheek, lower lid, and upper gum from injury to the infraorbital nerve as it traverses the orbital floor
Subcutaneous emphysema — air in periorbital tissues from sinus communication; patients should be instructed not to blow their nose, since forceful nose-blowing can rarely cause a sudden, vision-threatening rise in orbital pressure requiring emergency care
Periorbital ecchymosis and edema — bilateral periorbital bruising (“raccoon eyes”) with orbital rim fractures may suggest a skull base fracture
Imaging
CT of the orbits in coronal and axial planes with bone and soft-tissue windows is the study of choice. The coronal view best demonstrates floor and medial wall fractures and muscle entrapment. CT findings guide surgical planning: fracture size and location, degree of fat or muscle herniation, and presence of bone fragments within the sinus.
Surgical Indications and Timing
Not all orbital fractures require surgery. Repair is indicated for:
Symptomatic diplopia persisting beyond 2 weeks without improvement, particularly with a positive forced duction test confirming mechanical entrapment
Clinically significant enophthalmos (>2 mm) or hypoglobus causing functional or cosmetic concern
Large floor fracture (> 50% of the orbital floor) predicting late enophthalmos, even without current symptoms
Trapdoor fracture with muscle entrapment — urgent repair within 24–48 hours
For non-emergency fractures, most surgeons prefer to wait 10–14 days to allow edema to resolve before repair. The orbital floor is typically accessed through a transconjunctival incision (hidden inside the eyelid, leaving no visible skin scar). Herniated contents are reduced and the fracture is covered with a reconstruction plate — porous polyethylene, titanium mesh, or resorbable material depending on defect size.
Lacrimal Trauma
Medial eyelid laceration involving the canaliculusSilicone stent intubation — maintains canalicular lumen during healing
Canalicular lacerations result from trauma to the medial eyelid — commonly from dog bites, fingernail injuries, or blunt trauma that avulses the medial canthal region. The lower canaliculus is traditionally considered to carry the majority of tear drainage, and lower-canalicular lacerations are more common; however, modern studies show both canaliculi contribute substantially to drainage, so repair is recommended for any canalicular laceration, upper or lower. Any laceration medial to the punctum should be evaluated for canalicular involvement by slit-lamp exam or probing under magnification.
Primary repair with silicone stent intubation is performed within 24–48 hours when possible. The stent maintains the canalicular lumen while healing occurs and is removed at 3–6 months. When both canaliculi are severed or the lacrimal sac is disrupted, dacryocystorhinostomy (DCR) may be required to restore drainage. See the Lacrimal System page for detailed information on repair technique and anatomy.
Eyelid Lacerations
Complex eyelid lacerationLayered eyelid repair
Eyelid lacerations are classified by depth (partial vs. full-thickness), involvement of the lid margin, and canalicular involvement. Eyelid tissue has excellent vascularity — even tissue that appears devitalized should be preserved whenever possible.
Evaluation
Globe injury must be excluded first — do not probe wounds or apply pressure until globe assessment is complete
Lid margin involvement — any laceration through or near the gray line requires careful layered repair to prevent notching, trichiasis, or entropion
Medial lacerations — any laceration medial to the punctum should be assumed to involve the canaliculus until proven otherwise
Fat visible in wound — indicates penetration through the orbital septum; orbital fat prolapse signals potential posterior injury
Ptosis at presentation — may indicate levator aponeurosis injury requiring repair at the time of laceration closure
Repair Principles
Copious irrigation and debridement of debris; antibiotic prophylaxis for contaminated wounds, and tetanus prophylaxis updated as indicated
Full-thickness lid lacerations are repaired in layers: tarsal plate (posterior lamella) first, then skin and orbicularis (anterior lamella); the lid margin requires precise alignment of the gray line, mucocutaneous junction, and lash line to prevent notching or misdirected lashes
Tissue avulsion — even small bridges of attached tissue should be preserved; significant tissue loss may require staged reconstruction with advancement flaps or grafts
Dog bites cause significant crush and avulsion injury; antibiotic prophylaxis covering Pasteurella multocida and Capnocytophaga is essential; primary repair is often possible owing to excellent eyelid vascularity, though heavily contaminated or delayed-presentation wounds may require delayed or staged closure
Frequently Asked Questions
What is an orbital blowout fracture?
An orbital blowout fracture occurs when blunt trauma to the eye or face forces orbital contents through the thin bones of the orbital floor or medial wall, sometimes trapping the inferior rectus muscle and causing double vision (diplopia) and enophthalmos (sunken eye appearance). Surgical repair involves releasing trapped tissue and placing an implant to reconstruct the fractured wall.
How are eyelid lacerations repaired?
Eyelid lacerations require careful layered repair to restore both function and appearance. Oculoplastic surgeons assess the depth of injury (skin only vs. full-thickness), involvement of the eyelid margin, canalicular injury, or tarsal plate damage. The eyelid margin must be precisely realigned to prevent notching and abnormal lash direction.
When does an orbital fracture need surgery?
Not all orbital fractures require surgery. Indications include: persistent diplopia with confirmed muscle entrapment on imaging, significant enophthalmos (>2 mm), large fractures (>50% of the orbital floor) with risk of progressive enophthalmos, and the 'white-eyed blowout fracture' in children (immediate surgery to release trapped muscle and prevent ischemia).
What should I do immediately after an eye or eyelid injury?
First, avoid touching or applying pressure to the injured area. Gently rinse the eye with clean water if there's a foreign object, and apply a cold compress if safe to do so. Seek immediate medical attention, especially if you experience vision changes, severe pain, bleeding that won't stop, or obvious tissue damage. Early evaluation by an oculoplastic surgeon can prevent complications and improve healing outcomes.
What happens during a consultation for eyelid or orbital trauma?
Dr. Caster will perform a detailed examination, which may include checking your vision, eye movements, eyelid function, and imaging studies like CT scans to assess the full extent of injury. They'll discuss your specific injury, review treatment options, and explain what to expect during and after surgery. This consultation helps create a personalized treatment plan tailored to your injury and goals for healing.
What are the potential complications of untreated orbital fractures or severe eyelid injuries?
Untreated trauma can lead to chronic problems such as double vision from muscle entrapment, eyelid drooping, dry eye, vision loss, and facial deformity. Infections, bleeding, and scarring can develop if injuries aren't properly repaired. Prompt surgical intervention by a specialist significantly reduces the risk of these long-term complications and improves functional and cosmetic outcomes.
How long does recovery typically take after trauma surgery?
Initial healing usually occurs within 1-2 weeks, but complete recovery can take several months depending on the severity of injury. You may experience swelling, bruising, and mild discomfort during the first few weeks, which can be managed with prescribed medications and cold compresses. Dr. Caster will provide specific activity restrictions and follow-up schedules to ensure proper healing and monitor for any complications.
