Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following blunt ocular trauma with reported periorbital ecchymosis, edema, and subjective diplopia. Mechanism of injury involves [e.g., direct strike to globe]. Patient reports restricted extraocular movements, specifically on upward gaze, and infraorbital nerve paresthesia/hypesthesia. No reported vision loss, photopsia, or nausea.
Clinical Examination Findings
Physical exam reveals significant periorbital ecchymosis and edema. Ocular motility assessment demonstrates restricted vertical gaze (upgaze limitation). Infraorbital nerve distribution sensory deficit noted. Globe position assessment shows enophthalmos. Visual acuity is [e.g., 20/20] OU. Pupils are equal, round, and reactive to light (PERRL). No evidence of globe rupture or hyphema.
Treatment Protocol
Immediate management includes ice packs, head elevation, and avoidance of Valsalva maneuvers (no nose blowing). Prescribed prophylactic antibiotics and systemic steroids to reduce edema. Surgical intervention (orbital floor reconstruction) planned pending CT imaging confirmation of fracture size and entrapment of periorbital tissues.