• Description: A break in the inferior orbital wall, commonly from blunt trauma; may cause enophthalmos, diplopia, or infraorbital nerve hypoesthesia.

• Treatment: Urgent referral to oculoplastics or ENT for surgical repair if entrapment, muscle restriction, or enophthalmos >2 mm; otherwise observe with nasal precautions and oral antibiotics.

• Emergency?: Yes, if muscle entrapment or oculocardiac reflex symptoms (bradycardia, nausea).

• Helpful Testing: CT scan 

• Differential Diagnoses: Zygomatic fracture, orbital cellulitis, retrobulbar hemorrhage, traumatic optic neuropathy.

Notes:

• Pediatric floor fractures can result in a “trap door” phenomenon where the IR is trapped. The eye is typically quiet in these cases. Urgent surgery is indicated in pediatric cases with entrapment.

• Description: A retained foreign object within the orbit; may be metallic, organic, or inert; risk of infection or inflammation.

• Treatment: Referral for removal if organic, causing symptoms, or risk to ocular structures; broad-spectrum antibiotics; tetanus prophylaxis.

• Emergency?: Yes, especially if vision-threatening or infectious.

• Helpful Testing: CT scan

• Differential Diagnoses: Orbital cellulitis, orbital hemorrhage, orbital emphysema, orbital abscess.

Notes:

• FB penetration can also involve the optic nerve. Organic matter carries significant risk of infection and should be removed surgically. Long-standing iron foreign body can produce iron toxicity (siderosis) and retinopathy. Patients can be asymptomatic. Precise history is critical.

• Remember, a CT scan is preferred over an MRI due to the possibility of the foreign body being metallic!

• Description: Infection of eyelid anterior to the orbital septum, often due to skin trauma, insect bite, or spread from local infection.

• Treatment: Oral antibiotics (e.g., Augmentin or Keflex); warm compresses; monitor for orbital involvement.

• Emergency?: No, but requires prompt treatment to prevent progression.

• Helpful Testing: Check lymph nodes, assess optic nerve function or orbital involvement to rule out orbital cellulitis (check pupils, EOMs, color vision, red cap desaturation, OCT nerve)

• Differential Diagnoses: Orbital cellulitis, allergic dermatitis, hordeolum, chalazion.

Notes:

• Etiology: usually follows periorbital trauma or dermal infection. Suspect Staphylococcus aureus in traumatic cases and Haemophilus influenzae in children <5 years old.

• Tx for severe cases, septic patients, noncompliance patients, and <5 yo: Referral for systemic IV antibiotic: Cefuroxime 1g IV q8h or Ampicillin-sulbactam 1.5-3.0g IV q6h.

• It's extremely important to differentiate preseptal cellulitis from orbital cellulitis! If there are any signs of optic nerve compromise or orbital involvement (reduced VA, APD, EOM restriction/pain with eye movement, monocular color deficiency, (+) red cap desaturation, RNFL loss), suspect orbital cellulitis! 

• Description: Infection posterior to the orbital septum, often from sinusitis; presents with proptosis, ophthalmoplegia, and fever.

• Treatment: Hospital admission; IV antibiotics (vancomycin + ceftriaxone); surgery if abscess present.

• Emergency?: Yes, can progress to vision loss, cavernous sinus thrombosis, meningitis.

• Helpful Testing: CT scan, assess optic nerve function and orbital involvement (check pupils, EOMs, color vision, red cap desaturation, OCT nerve).

• Differential Diagnoses: Preseptal cellulitis, orbital abscess, rhabdomyosarcoma, thyroid eye disease.

Notes:

• Most common 2^ ethmoid sinusitis, and can also result from frontal, maxillary, or sphenoid infection. Streptococcus and staphylococcus are most common isolates. H. influenzae are common for children <5 yo. Phycomycetes are most common causes of fungal orbital infection and typically occur in immunocompromised patients, and can be fatal because of intracranial spread.

• Involvement of multiple cranial nerves suggests extension posteriorly to the orbital apex.

• Alternative treatment: Subperiosteal abscess requires urgent referral to an oculoplastic surgeon for close observation and possible surgical drainage. Otolaryngology consult is indicated to obtain tissue diagnosis for opacified sinuses if phycomycosis is suspected.

• Pts with DM or immunocompromised are at high risk for phycomycosis (mucormycosis). These patients require emergent debridement and biopsy, systemic IV antifungal (amphotericin B 0.25-1.0 mg/kg IV divided equally q6h), and management of underlying medical disorders.

• It's extremely important to differentiate preseptal cellulitis from orbital cellulitis! If there are any signs of optic nerve compromise or orbital involvement (reduced VA, APD, EOM restriction/pain with eye movement, monocular color deficiency, (+) red cap desaturation, RNFL loss), suspect orbital cellulitis! 

• Description: Clouding of the natural lens as proteins degrade with age leading to decrease vision, complaints of foggy vision, difficulty driving at night. 

• Treatment: Cataract surgery.

• Emergency?: No (unless causing pupillary block/angle closure).

• Helpful Testing: BAT, laser interferometry.

• Differential Diagnoses: Congenital cataracts.

Notes:

• Different types of cataracts; most common include nuclear sclerosis, cortical, posterior subcapsular.

• PSC cataracts typically cause the fastest symptomatic vision change. They are associated with long term steroid use, DM, RP. 

• Nuclear sclerosis commonly causes myopic shifts.

• Anterior subcapsular cataracts can cause hyperopic shifts. 

• Remember to talk about refractive correction options with patients you are referring for cataract surgery! Discuss options for vision correction such as monovision and multifocal IOLs if applicable.