Blow-out fracture repair and its timing have been controversial. Originally all x-ray proven fractures were repaired regardless of size or symptoms. Later a controversial report of a large series of cases indicated repair to be unnecessary. Today, x-ray proven fractures with enophthalmos justify surgery, but double vision alone is insufficient. Observation of improving diplopia for several days is suggested. Evaluation of x-rays, enophthalmos, diplopia with restriction, and facial anesthesia are recommended before surgery. Recognition of diagnostic signs and symptoms, as well as potential severe cosmetic and functional complications, have aided the approach to the decision for or against fracture repair.