Orbital Trauma Research Articles

Radiologic assessment of maxillofacial, mandibular, and skull base trauma

Cranio-maxillofacial injuries affect a significant proportion of trauma patients either in isolation or concurring with other serious injuries. Contrary to maxillofacial injuries that result from a direct impact, central skull base and lateral skull base (petrous bone) fractures usually are caused by a lateral or sagittal directed force to the skull and therefore are indirect fractures. The traditional strong role of conventional images in patients with isolated trauma to the viscerocranium is decreasing. Spiral multislice CT is progressively replacing the panoramic radiograph, Waters view, and axial films for maxillofacial trauma, and is increasingly being performed in addition to conventional films to detail and classify trauma to the mandible as well. Imaging thus contributes to accurately categorizing mandibular fractures based on location, into alveolar, mandibular proper, and condylar fractures-the last are subdivided into intracapsular and extracapsular fractures. In the midface, CT facilitates attribution of trauma to the categories central, lateral, or combined centrolateral fractures. The last frequently encompass orbital trauma as well. CT is the imaging technique of choice to display the multiplicity of fragments, the degree of dislocation and rotation, or skull base involvement. Transsphenoid skull base fractures are classified into transverse and oblique types; lateral base (temporal bone) trauma is subdivided into longitudinal and transverse fractures. Supplementary MR examinations are required when a cranial nerve palsy occurs in order to recognize neural compression. Early and late complications of trauma related to the orbit, anterior cranial fossa, or lateral skull base due to infection, brain concussion, or herniation require CT to visualize the osseous prerequisites of complications, and MR to define the adjacent brain and soft tissue involvement.

眼か上壁Ｂｌｏｗ‐ｉｎ Ｆｒａｃｔｕｒｅの整復例

Blow-in fracture is a rare injury resulting from orbital trauma. Fragments of the orbital bone may increase orbital pressure, causing direct or indirect damage to the globe. Here, we report a case of impure type blow-in fracture of the orbital roof. A 28-year-old male presented with diplopia and frontal paresthesia caused by trauma. Coronal CT scan showed fracture of the orbital roof. We reduced the fracture via a frontal approach and achieved fixation with autologous septonasal mucosa to maintain mucociliary function of the frontal sinus. At 12 months' follow-up, he remains free of ophthalmologic symptoms and there is no clinical evidence of frontal disease.

Penetrating orbitocranial gunshot injuries

Background The aim of this study was to analyze the effect of a surgical management protocol and other important clinical features on the prognosis of patients who had penetrating orbitocranial gunshot injuries. Methods Thirty-five patients (30 unilateral, 5 bilateral) who had penetrating orbitocranial gunshot injuries were analyzed. The wounds were mainly caused by shrapnel fragments or bullets. Craniotomy was the standard treatment in all patients. Investigated clinical features included Glasgow Coma Scale (GCS) score on admission, the mode and the extent of brain injury, and the presence of an intracranial retained foreign body. The prognostic importance of complications such as infection, intracranial hemorrhage, cerebrospinal fluid leak, and epileptic seizures was also investigated. The mechanism and the injury characteristics of the patients were evaluated by predicting the visual outcome of the victims according to a newer classification system as well as other variables pertinent to this specific clinical setting of severe eye trauma. Final visual acuities of the patients were also measured. Results The outcome of 35 penetrating orbitocranial gunshot injured patients was as follows: death in 3 patients, vegetative state in 1, severe disability in 2, moderate disability in 2, and good recovery in 27 cases. Localization and extent of the injury and GCS score on admission were the most important indicator for good neurological outcome. The predictors for good visual outcome were type B, grade 1, zone I, and relative afferent pupillary defect–negative injuries. The predictors for poor outcome were type A, grade 5, zone III, and relative afferent pupillary defect–positive injuries. Conclusion The prognosis of the injury depends on the course of the bullet or shrapnel fragment and the interdisciplinary care. An extensive preoperative evaluation of penetrating orbital trauma and a combined ophthalmic and neurosurgical approach are recommended to minimize the morbidity of the patients. However, complete removal of the foreign material in a deep or ventricular localization is not mandatory because careful debridement and tight closure of dura provides desired outcome. Evaluation of trauma mechanism and injury characteristics according to the Ocular Trauma Classification System seems to predict accurately the visual outcomes in this series.

Respiratory Epithelial Orbital Cyst: Report of a Case and Review of the Literature

Orbital cysts include the common epidermoid and dermoid cysts, cysts of conjunctival origin and cysts lined by respiratory‐type epithelium. Respiratory epithelial cysts are exceedingly rare and have been reported in common locations for dermoid cysts (superotemporal and superonasal anterior orbit) and in sites atypical for dermoid cysts. Most represent maxillary sinus mucoceles extending into the orbital floor. In some patients, a history of orbital trauma or previous sinus surgery has been implicated in the implantation of the respiratory epithelium in the orbit. Rarely, the respiratory epithelial cyst has been considered to be a choristoma. We report the case of a 72‐year‐old woman who presented with a cyst in the anterior superotemporal orbit. There was no history of recent or remote trauma. The clinical impression was of a dermoid cyst. Histopathologic examination revealed a cyst lined by non‐keratinizing squamous epithelium. A few goblet cells were present and focally, short strips of ciliated mucin secreting columnar cells were identified. The histopathologic findings were those of a respiratory epithelial cyst of the orbit. Given the rarity of this entity, valuable information can be gleaned from critical evaluation and reporting of new cases, in the context of existing data in the literature.

Diagnosis and treatment of retrobulbar haematomas following blunt orbital trauma: a description of eight cases

Retrobulbar haematoma following blunt orbital trauma is a rare, but potentially serious, complication, since it can evolve rapidly from visual impairment to permanent loss of vision. This sight-threatening situation most commonly arises from orbital bleeding accompanying undisplaced fractures of the orbital walls, an event that increases the pressure inside the orbit and results in vascular damage to the optic nerve. The clinical presentation includes pain, exophthalmos with proptosis, and internal ophthalmoplegia, with impairment or loss of the pupillary reflex. A thin-layer orbital CT scan is an essential diagnostic aid. Any delay between the onset of symptoms and treatment can have a significant effect on functional recovery. Therapy is based on orbital decompression, via different surgical approaches, with the intention of reducing the pressure on the nerve and vascular structures inside the orbit. This paper presents eight cases of retrobulbar haematoma and their follow-up, in detail.

Materialien in der rekonstruktiven Orbitachirurgie

Orbital traumas and tumour operations may cause defects the operative management of which sets high requirements on the surgeon. For covering defects, transplants or implants are available. There is a risk of inflammation due to the free contact of the implants to the cavity of the inner nose or the sinus. Today, implants made from titanium, porous polyethylene, PDS (poly-p-dioxanon) foils, and ceramic materials are preferred. Alternatively, autogenous transplants can be used. These are immunologically harmless but they are of only limited availability. Moreover, a second operation for taking the transplants with creation of a donor defect is necessary.

Reliabilit�t der sonographischen Diagnostik von Orbitabodenfrakturen und Frakturen des Infraorbitalrandes

The aim of the study was to evaluate the interobserver variation of the ultrasound diagnosis of orbital floor fractures and fractures of the infraorbital rim. A total of 25 patients with a clinical diagnosis of an orbital trauma were investigated prospectively by computed tomography (CT) and ultrasonography (US). Inter-observer variation was calculated using the lambda coefficient (lambda). The US images were reassessed by two inexperienced investigators. The lambda value for the US investigation of the orbital floor showed poor reliability comparing the US findings with the results of the re-investigators. The comparison between the two re-investigators showed a good reliability for the US evaluation of the orbital floor. The lambda for the US investigation of the infraorbital margin showed a good reliability comparing the US findings with the results of the both re-investigators. The comparison of the two re-investigators showed a good reliability as well. Ultrasound is not yet an alternative method for the evaluation of orbital floor fractures and fractures of the infraorbital margin. To replace CT which is accepted as the current gold standard, further studies have to be done to reach a better diagnostic quality of the method and to achieve a better calibration of the investigations.

Update on orbital trauma

To evaluate the recent developments in the evaluation and treatment of orbital trauma from April 2003 to March 2004. The scope of orbital trauma included a MEDLINE search under the keywords of zygoma and orbital fracture, and traumatic optic neuropathy. Preoperative volume assessment with computed tomography of orbital fractures can help surgical planning of volume replacement. Ultrasonography can visualize anterior orbital fractures, including rim and zygoma trauma. Orbital trauma has a high incidence of concurrent ocular trauma. Fractures in the presence of the oculocardiac reflex, persistence nausea/vomiting, or entrapped soft tissue require urgent repair. Endoscopic-assisted repair of orbital fractures offers an alternative approach to orbital fracture repair. Advances in ultrasonography and computed tomography allow better visualization of orbital fractures for better preoperative evaluation and intraoperative repair. Progress in endoscopic techniques offers alternatives in orbital fracture repair. New materials allow for options in orbital reconstruction. Unfortunately, few advances in the management of traumatic optic neuropathy were found in this review.

Evaluation of ocular changes secondary to blowout fractures

There has been extensive debate over the standard of care of orbital fractures. Entrapment, diplopia, and hypoglobus, with or without enophthalmos, are the most common clinical indications for surgical intervention. Evaluation of these injuries is often limited in the early postinjury period because of edema. In assessing the severity of the injury, the clinician often uses parameters such as changes in visual acuity, patient-reported diplopia, gross changes in globe position, and an evaluation of the extraocular muscles. Many of these parameters are only grossly assessed and therefore are not specifically documented and tracked. The decision to proceed with surgical intervention may be based only on these gross clinical findings. The purpose of this article is to present a reliable and repeatable method for evaluating the degree of diplopia and the globe position of the orbital trauma patient by describing the use of the double Maddox rod test (Wilson Ophthalmic, Mustang, OK) and Hertel exophthalmometer (Wilson Ophthalmic). These methods can provide sequential documentation of the progression of the injury and help better define the need for surgical intervention and to follow the postoperative course.

Carotid-cavernous fistula in a child after minimal orbital trauma

We present a case of a direct carotid-cavernous fistula in a seven-year-old child with an unclear history of relatively mild orbital trauma. The child was initially diagnosed with a cranial nerve VI palsy, then admitted with a presumed diagnosis of orbital cellulitis. Further examination, including formal angiography, revealed a direct carotid-cavernous fistula with significant cortical venous drainage requiring prompt intervention. Treatment of the fistula by coil occlusion was successful. This case illustrates the importance of recognizing and understanding the pathophysiology and treatment of this rare but potentially fatal entity. CASE REPORT A seven-year-old boy presented to the emergency department with an edemetous, ecchymotic right eye and a right cranial nerve VI palsy one week after sustaining reportedly blunt trauma to his right medial orbit from colliding into a fence post. The diagnosis of “possible orbital fracture” was made. Noncontrast computed tomography of the head and orbits was ordered. He was given oral and topical antibiotics and instructed to return to the eye clinic in two days. On follow-up examination by an ophthalmology resident, the patient reported a different history, stating that he had been “poked” in the eye by a fence wire. His uncorrected visual acuity was 20/50 in his right eye and 20/40 in his left. Pupillary examination was normal. Intraocular pressure in his right eye was 26 mm Hg. His right eye was proptotic though nonpulsatile. Hertel measurements were not documented. A right esotropia and hypotropia, lateral gaze restriction, chemosis, and conjunctival hyperemia with torturous vessels were noted (Figure 1).

Surgical approaches and complications

Orbital fractures may affect any and all of the four walls of the orbit formed by the three main bones comprising the orbital rim, frontal zygomatic, and maxillary as well as the interior walls from rim to orbital apex. Interior wall access to the zygomatic, maxillary, frontal, sphenoid, ethmoid, and lacrimal bones approaching the orbital apex must be thorough in selected cases in order to gain three-dimensional reduction and fixation of fractures as well as reconstruction of orbital wall defects not recoverable via reduction methods. In addition, reduction of soft tissue components and preventive positioning to overcome cicatrix formation are hallmarks of good technique. The medial and lateral canthus, septum orbitale, lids, orbital muscles, globe, retrobulbar tissues, and fat need to be managed in order to obtain favorable position, blood supply. and functional movement, Full surgical access by means that ensure retention of all soft tissue function and aesthetics is necessary to offer the best clinical outcome.Traditional methods of surgical access including infraorbital, brow, open sky, and Lynch incisions are now rarely the best means of accessing the orbit. Subciliary incision, transconjunctival incisions, medial canalicular incisions, transcaruncular incisions, superior blepharoplasty, lateral canthotomy, vestibular, endoscopic sinus, and coronal approaches are rapidly improving the level of surgical exposure, surgical repair and thus the esthetic functional outcomes of the orbital trauma patient. A review of these techniques and clinical experiences permit a better understanding of their utility and the mix of techniques that may be applied to a given clinical situation.Complications of the surgical approach to the orbit include seventh nerve paresis, hematoma, infection, entropion, ectropion, blindness, diplopia, enophthalmos, exophthalmos, ptosis, telecanthus, and contour deficit, pain, and scarring among others. The prevention and management of these will be discussed.ReferencesWestfall CT, Shore JW, Nunery WR, et al: Operative complication of the transconjunctival inferior fornix approach Ophthalmology 98:1525, 1991Graham SM, Thomas RD, Carter KD, et al: The transcaruncular approach to the medial orbital wall. Laryngoscope 112:986, 2002Konito R: Treatment of orbital fractures: The case for reconstruction with autogenous bone. J Oral Maxillofac Surg 62:863, 2004 Orbital fractures may affect any and all of the four walls of the orbit formed by the three main bones comprising the orbital rim, frontal zygomatic, and maxillary as well as the interior walls from rim to orbital apex. Interior wall access to the zygomatic, maxillary, frontal, sphenoid, ethmoid, and lacrimal bones approaching the orbital apex must be thorough in selected cases in order to gain three-dimensional reduction and fixation of fractures as well as reconstruction of orbital wall defects not recoverable via reduction methods. In addition, reduction of soft tissue components and preventive positioning to overcome cicatrix formation are hallmarks of good technique. The medial and lateral canthus, septum orbitale, lids, orbital muscles, globe, retrobulbar tissues, and fat need to be managed in order to obtain favorable position, blood supply. and functional movement, Full surgical access by means that ensure retention of all soft tissue function and aesthetics is necessary to offer the best clinical outcome. Traditional methods of surgical access including infraorbital, brow, open sky, and Lynch incisions are now rarely the best means of accessing the orbit. Subciliary incision, transconjunctival incisions, medial canalicular incisions, transcaruncular incisions, superior blepharoplasty, lateral canthotomy, vestibular, endoscopic sinus, and coronal approaches are rapidly improving the level of surgical exposure, surgical repair and thus the esthetic functional outcomes of the orbital trauma patient. A review of these techniques and clinical experiences permit a better understanding of their utility and the mix of techniques that may be applied to a given clinical situation. Complications of the surgical approach to the orbit include seventh nerve paresis, hematoma, infection, entropion, ectropion, blindness, diplopia, enophthalmos, exophthalmos, ptosis, telecanthus, and contour deficit, pain, and scarring among others. The prevention and management of these will be discussed. References Westfall CT, Shore JW, Nunery WR, et al: Operative complication of the transconjunctival inferior fornix approach Ophthalmology 98:1525, 1991 Graham SM, Thomas RD, Carter KD, et al: The transcaruncular approach to the medial orbital wall. Laryngoscope 112:986, 2002 Konito R: Treatment of orbital fractures: The case for reconstruction with autogenous bone. J Oral Maxillofac Surg 62:863, 2004

Late correction of complications of orbital trauma

Koornneef L: Current concepts on the management of orbital blowout fractures. Ann Plast Surg 9:185, 1982 Bartkowski SB, Krzystkowa KM: Blow-out fracture of the orbit. Diagnostic and therapeutic considerations and results in 90 patients treated. J Oral Maxillofac Surg 10:155, 1982 Putterman AM, Stevens T, Uris TMG: Non-surgical management of blow-out fractures of the orbital floor. Am J Ophthmal 76:232, 1974

Surgical correction in traumatic orbital fracture and eyelid ptosis using Medpor implant and frontalis suspension

目的 评价高密度聚乙烯(Medpor)作为填充物同期行额肌瓣悬吊术在治疗晚期眶壁骨折伴外伤性上睑下垂中的作用.方法对眼眶壁骨折伴上睑下垂进行整复,术中使用Medpor人工材料充填修复眶壁缺损,以矫治眼球内陷和移位;同期行额肌瓣与上睑提肌远端吻合治疗外伤性上睑下垂.结果 1998年1月～2002年12月施行此手术7例,随访3～24月(平均9.8月),显示整形后的眼眶眼睑外形良好,无感染、排异;其中7例原眼球内陷、下移均获得改善,7例睑裂宽度与健眼对称,3例复视消失,4例复视明显的改善.结论 Medpor是一种良好的眼眶骨缺损填充替代骨移植的人工材料,同期行额肌瓣与上睑提肌远端吻合治疗复杂眼眶骨折伴上睑下垂疗效确切。

Orbital imaging demonstrates occult blow out fracture in complex strabismus

Background While strabismologists are familiar with diagnostic evaluation of suspected blow out fractures, unsuspected blow out fractures may further complicate difficult cases of strabismus not clinically supposed to be related to orbital trauma. Methods According to a prospective protocol, we studied five adults presenting with diplopia, and one with convergence-related asthenopia. No patient recalled or had any clinical suspicion of orbital fracture at initial evaluation. Surface coil magnetic resonance imaging of the orbits was performed at 312 μm resolution, slice thickness 2 mm. Quasicoronal images in central gaze were supplemented with eccentric gaze positions, and sagittal and axial images as indicated. Results Five patients had incomitant hypertropia, and one had abducens paralysis. Magnetic resonance imaging disclosed previously unsuspected blow out fractures in all six patients. Three patients had medial wall fracture, one bilaterally. Two patients had inferior wall fractures, and one inferomedial. Although only one patient had an extraocular muscle displaced into a sinus, all had evidence of orbital connective tissue distortion in the region of the rectus extraocular muscle pulleys influencing muscle paths. These effects altered the presentations of more familiar pathologies such as superior oblique palsy. After learning of the MRI findings, most patients then recalled orbital trauma from as early as childhood. Conclusion Unsuspected blow out fractures occur and may confound the usual findings in complex strabismus. High-resolution orbital imaging can detect blow out fractures and clarify the pathophysiology, enabling appropriate surgical management.

Use of pupil size and reaction to detect orbital trauma during and after surgery

Use of pupil size and reaction to detect orbital trauma during and after surgery

A single reformatted oblique sagittal view as an adjunct to coronal computed tomography for the evaluation of orbital floor fractures

Purpose We sought to determine whether it is beneficial to routinely include a single reformatted oblique sagittal view as an adjunct to coronal computed tomography (CT) for the evaluation and treatment of orbital floor fractures, when imaging is obtained on patients with orbital trauma. Materials and methods A retrospective analysis of 12 midface CT scans was performed. All of the patients included in the study had been determined by a staff radiologist to have radiographic evidence of orbital fractures. Five surgeons who treat orbital floor fractures, but do not routinely order oblique sagittal views, were asked to evaluate the selected CT scans without being given a clinical history. The surgeons were allowed to evaluate the reformatted coronal CT and were asked to rate their ability to determine the location and the size of the fracture in a medial-lateral dimension and an anterior-posterior dimension, volume of orbital contents herniated into the maxillary sinus, and radiographic evidence of inferior rectus entrapment. The surgeons were then allowed to evaluate a single reformatted oblique sagittal view through each orbit. They were asked the same questions and these 2 additional questions, “Do you think the oblique view gave you additional information, and would it change your treatment plan?” Results Confidence in determining the size and location of the fracture in a medial-lateral dimension was not improved with the addition of the reformatted oblique sagittal view; however, location and size of the fracture in an anterior-posterior dimension and volume displaced from the orbit into the maxillary sinus and evidence of inferior rectus entrapment were improved with the addition to the oblique sagittal view. Seventy-eight percent of responders said that the oblique sagittal view provided additional information, and 18% of the responders said that the additional information changed the treatment plan. Conclusion Routinely obtaining a single reformatted oblique sagittal view as an adjunct to coronal CT provides additional valuable information to the surgeon in treating orbital floor fractures. Reformatted views do not subject patients to additional radiation and the time to obtain these views is minimal.

Effectiveness of ultrasonography in determining medial and lateral orbital wall fractures with a curved-array scanner

Purpose The purpose of the study was to evaluate the diagnostic value of ultrasonography to determine medial and lateral orbital wall fractures. Materials and methods Sixty-two patients with the clinical diagnosis of an orbital trauma underwent coronal computed tomography (CCT) and ultrasonographic investigation (US). Inclusion criteria were clinically suspected orbital injuries defined by reduced bulbus motility, diplopia, or additional traumatic injuries of the orbit or the globe. US and CCT were used as imaging diagnostic methods. Results Ultrasonography showed a sensitivity of 56%, a specificity of 95%, and an accuracy of 88% at the medial orbital rim. Regarding the lateral orbital rim, ultrasonography showed a sensitivity of 92%, a specificity of 88%, and an accuracy of 90% using CCT as a reference method. Conclusion Ultrasonography with a curved-array scanner seems to be a valuable method in the detection of lateral orbital wall fractures. Further studies have to be done to improve sensitivity in the interpretation of medial orbital wall fractures.

Orbital apex injury: trauma at the junction between the face and the cranium

Orbital apex injury is usually seen in multiply and severely injured patients who are subject to high-energy trauma. Orbital apex injury rarely occurs in isolation. By proximity, the face, the skull base, or their combination are the most likely regions to be injured in association with orbital apex trauma. The vast majority of these injuries occur as an extension of orbital, LeFort, naso-orbitoethmoid, panfacial, sphenoid, or temporal bone fractures of the skull. Complex osseous anatomic structures with intimately related multiple neurovascular organs make injuries to the orbital apex diagnostically and therapeutically challenging. Often other facial fractures extend into the orbital apex, or the orbital apex is damaged in conjunction with fractures of the skull base. Therefore abnormal imaging findings within the orbital apex may be indicators of traumatic injury to the entire junctional zone of face and cranium. In this article, we will giv ea n overview of normal CT anatomy, review clinical syndromes, which may indicate traumatic injury of the orbital apex and present an imaging strategy for evaluation of the orbital apex. # 2003 Published by Elsevier Ireland Ltd.

Ultrasound versus computed tomography in the imaging of orbital floor fractures

Purpose The aim of the study was to investigate whether orbital ultrasonography (US) with a curved-array transducer could be an alternative imaging method to computed tomography (CT) to detect orbital wall fractures and fractures of the infraorbital rim. Materials and Methods Fifty-eight patients with the clinical ophthalmologic or radiologic diagnosis of an orbital trauma were investigated prospectively by US and CT. The reference method was the intraoperative findings. Results CT evaluation of the infraorbital rim yielded a sensitivity of 79%, a specificity of 90%, and an accuracy of 94%. The positive predictive value (PPV) and the negative predictive value (NPV) of the infraorbital rim reached 69% and 83%, respectively. CT evaluation of the orbital floor showed a sensitivity of 96%, a specificity of 71%, and an accuracy of 96%. PPV and NPV resulted in 71% and 93%, respectively. US investigation of the infraorbital rim yielded a sensitivity of 77%, a specificity of 89%, and an accuracy of 97%, whereas PPV and NPV reached 65% and 83%, respectively. US investigation of the orbital floor reached a sensitivity of 94%, a specificity of 57%, and an accuracy of 96%, whereas PPV and NPV yielded 57% and 91%, respectively. No significant difference was found between US and CT in the investigation of the infraorbital rim ( P = .809) and the orbital floor ( P = .729). Conclusions US with a curved-array transducer appears to be a useful alternative method in the investigation of orbital floor fractures. Further studies have to be conducted to reduce the presence of false-negative results.

Diagnosis and Nonsurgical Management of Strabismus Secondary to Orbital Fracture

IntroductionWhen a large, blunt projectile strikes the eye with sufficient force, the acute rise in pressure within the orbit may result in fracture of the more fragile portions, as the pressure seeks release from the enclosed space. This type of injury may result in a variety of symptoms, including pain, numbness of the cheek, teeth and gums, sinus congestion, nausea, blurred and/or double vision.Mechanisms of StrabismusStrabismus secondary to orbital trauma may be due to peripheral cranial nerve palsy, incarceration of extraocular muscle or other orbital soft tissue within the fracture, edema or hemorrhage, or a combination. Actual entrapment of the muscle itself is uncommon, and is usually exclusive to posterior floor fracturesHistory and External ExamIn spite of the high prevalence of strabismus and diplopia, neither many be the chief ocular complaint of the trauma patient. In addition, not all patients with strabismus secondary to trauma present with a clear history of trauma. The injury may be quite old by the time the patient presents for examination, and the patient may not associate the symptoms with the old injuryClinical Diagnostic Testing: MotorAll patients with a history of orbital trauma should undergo sequential measurements of ocular alignment and motility in the diagnostic positions of gaze over the first 4 to 6 months. The strabismus that results from trauma is typically incomitant, variable, and complex, and may not readily indicate the mechanism of the disturbanceClinical Diagnostic Testing: SensoryDiagnostic testing for the trauma patient who presents with diplopia is straightforward. A red filter placed over the uninvolved eye will assist the patient in identifying the location of the double image and then neutralizing the diplopia with prisms. Not all trauma patients with strabismus present with complaints of diplopia. The patient who is obviously strabismic but has no diplopia should be evaluated for vision loss due to traumatic optic neuropathy or retinal detachment. The patient who is diplopic, but without obvious strabismus should be evaluated for monocular diplopia, media opacity, or retinal contusion.Nonsurgical Management of DiplopiaThe primary objective of nonsurgical treatment of strabismus with resulting diplopia is single binocular vision in primary and in down gaze.ConclusionStrabismus and diplopia are common sequelae of orbital trauma. In order to diagnose and manage these cases appropriately, the clinician must take a thorough history, complete a careful external exam, and perform sequential motility exams over a period of 4 to 6 months. These cases can be successfully managed with prisms, occlusion foils, or occlusion until such time as strabismus surgery may be indicated.