Clinical Practice and Cases in Emergency Medicine

Case Presentation: A 16-year-old girl presented to the emergency department after being struck in the right eye by another player’s elbow during a basketball game. She had only minimal periorbital swelling but developed persistent nausea, repeated vomiting, and diplopia with upward gaze. Visual acuity, visual fields, and pupillary light reflexes were normal. Extraocular movement testing showed mild limitation of upward gaze of the right eye, and upward gaze reproducibly provoked diplopia, marked nausea, and vomiting. Computed tomography (CT) showed no intracranial hemorrhage, and orbital CT was initially interpreted as showing no obvious orbital floor fracture or extraocular muscle entrapment. Given the discrepancy between the mild external appearance and the severe ocular symptoms, white-eyed blowout fracture with trapdoor-type entrapment and an oculocardiac reflex was suspected. She underwent emergent surgery, after which her vomiting, diplopia, and ocular motility disturbance improved immediately.

Discussion: White-eyed blowout fracture is a trapdoor-type orbital floor injury seen mainly in children and adolescents and may present with minimal external signs and subtle or negative-appearing CT findings.1-3 Gaze-evoked nausea or vomiting, diplopia, and relative bradycardia are important bedside clues to extraocular muscle entrapment with an oculocardiac reflex.1-3 This case highlights that white-eyed blowout fracture may be detected by careful bedside examination even when CT does not clearly show an orbital floor fracture. Emergency physicians should recognize this entity as a clinically important, easily missed diagnosis in pediatric orbital trauma.