Isolated posterior orbital floor fractures, diplopia and oculocardiac reflexes: a 10-year review

Isolated fractures of the posterior orbital floor are rarely encountered in facial trauma, but warrant appropriate management to afford optimum recovery from debilitating diplopia and symptoms of activation of the oculocardiac reflex. We reviewed all records of patients with isolated fractures of the orbital floor between 1997 and 2007. Seven of 58 fractures operated on during this time involved the posterior orbit alone (all male, age range: 10-23). These seven patients presented with serious diplopia in the primary gaze, intense orbital pain, and a range of signs and symptoms of activation of the oculocardiac reflex. Early operations were done in all cases (usually within 24h), which immediately relieved pain and the effects of the oculocardiac reflex. Postoperatively diplopia resolved substantially in upgaze but was worse in downgaze, and took between 2 and 6 months to resolve to normal functional ranges, which were confirmed by a Hess chart. This review suggests that this fracture pattern is not restricted to children as is often reported, and operation should be within 24-48h of injury to optimise outcome. Diplopia will improve postoperatively, but will persist over months, and patients should be well informed of this. Interestingly none of our patients' injuries were the result of assault, even though this accounted for nearly 75% of all facial fractures treated in our department. Five of the seven patients were adults, and the mechanism of fracture pointed to being crushed by injuries of low velocity and high force.