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This 36-year-old man suffered blunt trauma to the area of the right eye two months earlier.  He complains of dizziness and diplopia in all fields although on cover testing he demonstrates only a small exotropia with an “A” pattern.  His visual acuity is OD 20/20 and OS 20/20 unaided.  Refraction is plano OU.  The right pupil reacts sluggishly to light.  The media are clear and the fundus is normal in each eye.  There is a slight limitation of abduction in the right eye.  The right eye has a reading 4.0 mm less compared to the left using the exophthalmometer.

1.	The most likely diagnosis is:
	a -- blow out fracture of the right orbit  This is a typical history and clinical picture for a blow out fracture of the orbit.
2.	This patient would also be likely to demonstrate:
	c -- decreased sensitivity to touch along the skin of the upper right cheek Because the infraorbital nerve is commonly disrupted, patients with blow out fracture usually have decreased sensitivity in the skin served by this sensory nerve.
3.	The most important next step in evaluating this patient would be:
	b -- imaging of the orbits Imaging of the orbits is the most important next step in the work up of a patient with this clinical picture.  The orbital CT’s of this patient show a large blow out fracture of the medial wall of the right orbit.  This will require surgical treatment.