Orbital roof fractures as an indicator for concomitant ocular injury

  • Joseph SantamariaEmail author
  • Aditya Mehta
  • Donovan Reed
  • Halward Blegen
  • Bradley Bishop
  • Brett Davies



Orbital roof fractures are a significant cause of morbidity in trauma and are associated with a spectrum of orbital and ocular injuries. This study aims to characterize orbital roof fracture patterns and quantify the rate of acute intervention as compared with non-roof involving orbital wall fractures.


This study is a retrospective analysis of 340 orbital wall fractures diagnosed by CT imaging from August 2015 to October 2016. Orbital wall fractures were categorized as roof involving (N = 50) and non-roof involving (N = 290). Comparisons were made between these two groups to indicate a statistically significant difference in mechanism of injury, subjective symptoms, CT and exam findings, and final plan of care to include acute ophthalmologic intervention at the time of consultation.


Assault (40.7%) was the most common cause of non-roof-involving fractures while falls from height (20.0%) were associated with a higher rate of roof fractures. Roof-involving orbital wall fractures were associated with a higher prevalence of corneal abrasions (16.3%), lid lacerations (23.4%), and traumatic optic neuropathy (10.4%). A reliable subjective exam on initial ophthalmic consultation was not achieved in a larger proportion of roof fracture patients (30%). Despite this, the rate of acute intervention in this group (34%) was almost double, including lateral canthotomy and cantholysis.


Concomitant ocular injury is common in roof-involving orbital wall fractures, and may require more urgent ophthalmologic evaluation and acute intervention. As subjective patient data is often less readily available, a high index of suspicion and thorough investigation is warranted in caring for patients with roof-involving orbital wall fractures.


Eye injuries Orbital fractures Trauma centers Wounds and injuries 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the office of the Institutional Review Board (IRB), Department of Clinical Investigations at BAMC, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

The study was granted a waiver of informed consent by the IRB board at BAMC as it involved no more than minimal risk to the individuals and their privacy. The data is Health Insurance Portability and Accountability Act (HIPAA) compliant. Demographic and clinical data from the initial examination, surgical charts, and follow-up visits were recorded in a de-identified database.


The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of San Antonio Military Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Air Force, the Department of the Army, Department of Defense, the Uniformed Services University of the Health Sciences or any other agency of the U.S. Government.


  1. 1.
    Shere JL, Boole JR, Holtel MR et al (2004) An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers, 1980-2000. Otolaryngol Head Neck Surg 130(2):164–170CrossRefGoogle Scholar
  2. 2.
    Andrews BT, Jackson AS, Nazir N et al (2016) Orbit fractures: identifying patient factors indicating high risk for ocular and periocular injury. Laryngoscope. 126(Suppl 4):S5–S11CrossRefGoogle Scholar
  3. 3.
    Cook T (2002) Ocular and periocular injuries from orbital fractures. J Am Coll Surg 195(6):831–834CrossRefGoogle Scholar
  4. 4.
    Riaz N, Chatha AA, Warraich RA et al (2014) Ophthalmic injuries in orbito-zygomatic fractures. J Coll Physicians Surg Pak 24(9):649–652Google Scholar
  5. 5.
    Connon FV, Austin SJ, Nastri AL (2015) Orbital roof fractures: a clinically based classification and treatment algorithm. Craniomaxillofac Trauma Reconstr 8(3):198–2014Google Scholar
  6. 6.
    Shin JW, Lim JS, Yoo G et al (2013) An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg. 24(3):703CrossRefGoogle Scholar
  7. 7.
    Chi MJ, Ku M, Shin KH et al (2010) An analysis of 733 surgically treated blowout fractures. Ophthalmologica. 224(3):167–175CrossRefGoogle Scholar
  8. 8.
    Karabekir HS, Gocmen-Mas N, Emel E et al (2012) Ocular and periocular injuries associated with an isolated orbital fracture depending on a blunt cranial trauma: anatomical and surgical aspects. J Craniomaxillofac Surg 40(7):e189–e193CrossRefGoogle Scholar
  9. 9.
    Thurston TE, Jackson AS, Nazir N et al (2018) Risk assessment of isolated single-wall orbit fractures and eye injury. J Craniofac Surg. 29(4):943–945CrossRefGoogle Scholar
  10. 10.
    Kim YJ, Ahn S, Seo DW et al (2016) Patterns and injuries associated with orbital wall fractures in elderly patients who visited the emergency room: a retrospective case-control study. BMJ Open 6(9):e011110CrossRefGoogle Scholar
  11. 11.
    Fulcher P, Sullivan T (2003) Orbital roof fractures: management of ophthalmic complications. Ophthalmic Plast Reconstr Surg 19(5):359–363CrossRefGoogle Scholar
  12. 12.
    Chen X, Yao Y, Wang F et al (2017) A retrospective study of eyeball rupture in patients with or without orbital fracture. Medicine. 96(24):e7109CrossRefGoogle Scholar
  13. 13.
    Roh JH, Jung JW, Chi M (2009) A clinical analysis of bilateral orbital fracture. Craniofac Surg 25(2):388–392CrossRefGoogle Scholar
  14. 14.
    Mellema PA, Dewan MA, Lee MS et al (2009) Incidence of ocular injury in visually asymptomatic orbital fractures. Ophthal Plast Reconstr Surg 25(4):306–308CrossRefGoogle Scholar
  15. 15.
    Ko MJ, Morris CK, Kim JW et al (2013) Orbital fractures: national inpatient trends and complications. Ophthalmic Plast Reconstr Surg 29(4):298–303CrossRefGoogle Scholar
  16. 16.
    Stam LH, Wolvius EB, Schubert W (2014) Natural course of orbital roof fractures. Craniomaxillofac Trauma Reconstr 7(4):294–297CrossRefGoogle Scholar
  17. 17.
    Greenwald MJ, Boston D, Pensler JM et al (1989) Orbital roof fractures in children. Ophthalmology. 96(4):491–497CrossRefGoogle Scholar
  18. 18.
    Martello J, Vasconez H (1997) Supraorbital roof fractures: a formidable entity with which to contend. Ann Plast Surg 38(3):223–227CrossRefGoogle Scholar
  19. 19.
    Ha AY, Mangham W, Frommer SA et al (2017) Interdisciplinary management of minimally displaced orbital roof fractures: delayed pulsatile exophthalmos and orbital encephalocele. Craniomaxillofac Trauma Reconstr 10(1):11–15CrossRefGoogle Scholar
  20. 20.
    He Y, Zhang Y, An JG (2012) Correlation of types of orbital fracture and occurrence of enophthalmos. J Craniofac Surg 23(4):1050–1053CrossRefGoogle Scholar

Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply  2019

Authors and Affiliations

  1. 1.Department of OphthalmologySan Antonio Military Medical CenterSan AntonioUSA

Personalised recommendations