A patient presents 48 hours after blunt trauma to the orbit with enophthalmos, restricted upgaze, and diplopia on upgaze. CT scan shows a blow-out fracture of the orbital floor. On forced duction test, upgaze is restricted. The most appropriate timing for surgical repair is:

• A Immediate surgery within 24 hours regardless of degree of herniation
• B Surgery is only indicated if there is complete ophthalmoplegia
• C Surgical repair is never required in adults; prosthetic implants are preferred
• D Expectant management for 2 weeks to allow edema to resolve, then reassess; operate if diplopia and restriction persist or if enophthalmos >2 mm ✓

Explanation

Current guidelines recommend conservative management initially for most adult blow-out fractures: ice, nasal decongestants, and antibiotic prophylaxis. Most diplopia resolves as periorbital edema subsides. Indications for surgery include persistent diplopia with positive forced duction test (muscle entrapment) beyond 2 weeks, enophthalmos >2 mm causing cosmetic deformity, or large fracture (>50% of floor) with significant herniation. Immediate surgery within 24–48 hours is recommended in the 'white-eyed blowout fracture' (greenstick fracture in children) where inferior rectus is acutely entrapped without significant bruising — risk of ischemia.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.