A 15-year-old male presented to our emergency room 24 hours after he was playing basketball and was hit in his right eye by a fellow player's knee. Following the impact the patient said that his eye was sore, but he did not experience blurry or double vision. However, several hours after the game, the patient sneezed and felt like the skin around his eye "puffed out". Following this swelling, there was no deterioration or change in his vision; he chose to present to the emergency department as there had not been resolution of the swelling over a 24-hour period. On examination, the patient denied any visual disturbance. Visual acuity was 20/60 on the left and 20/80 on the right; the patient reported this was his baseline as he normally wore corrective lenses, but did not have them with him at the time of exam. He denied headache, nausea, vomiting, dizziness, nasal congestion or bloody discharge from his nose or eye. There was mild swelling of the right upper eyelid, but no crepitus or palpable bony step-off around the orbital rim. There was no proptosis and the remainder of his optical exam was normal including extraocular motion and pupillary reflex.
In light of the mechanism of injury and the abrupt onset of orbital swelling after the patient sneezed, there was a high suspicion for an orbital fracture with concomitant orbital emphysema. Computed tomography (CT) of the facial bones including the orbits was performed with contiguous axial imaging (Figure 1); coronal and sagittal reformatted images were generated (Figure 2, Figure 3). There was a right medial orbital wall (lamina papyracea) fracture, which was depressed by approximately 3 mm. A small amount of retro-orbital fat herniated into the adjacent right ethmoid air cells without entrapment of the medial rectus. There was gas between the right medial rectus and the medial orbital wall extending anteriorly into the periorbital soft tissues and superiorly into the supraorbital fat. While the patient's symptom of orbital swelling after sneezing suggest that orbital emphysema occurred after the sneeze, as no imaging was obtained prior to the patient's sneeze we are unable to formally exclude the possibility that there was orbital emphysema before the sneeze.
The patient was discharged from the emergency department in stable condition with a follow-up appointment with an ophthalmologist, a course of oral antibiotics, and instructions to use nasal decongestants and avoid blowing his nose. Surgical repair and decompression were not performed, and several weeks later the patient was doing well without sequela.
15-year-old male with occular trauma. Coronally reformatted CT shows fracture of the right medial orbital wall orbital (white arrow), herniation of orbital fat through the fracture (black arrow), and orbital emphysema (arrowheads). QuickTime movie of coronally reformatted CT in a separate window or tab (1.34 MB).