Eye Pain and Double Vision

Diagnosis 

Superior orbital wall fracture with retro-orbital hematoma. Limitation of upward gaze in the setting of trauma is most commonly associated with a fracture of the floor of the orbit, typically referred to as “blowout fracture.” Entrapment of the inferior rectus muscle within the orbital floor may lead to ophthalmoplegia and diplopia. In such cases, posterior displacement of the globe and prolapse of orbital contents into the maxillary sinus more commonly leads to enophthalmos (recession of the globe into the orbit), as opposed to proptosis.1

This patient had limitation of upward gaze, with proptosis and orbital dystopia with the right eye lower than the left (Figure 1). Here, limitation of upward gaze was due to a mass lesion (retro-orbital hematoma) impinging on the globe (Figure 2), rather than extraocular muscle dysfunction. Orbital roof fractures are rare,2 although they are more common in young children because of their high cranium-to-midface ratio.1, 2, 3, 4 Such fractures have a high association with intracranial injury, most commonly epidural hematoma, as was seen in our patient (Figure 3).