Orbital Trauma

Grant S Lipman MD Wilderness Medicine Fellow Clinical Instructor, Division of Emergency Medicine Stanford University School of Medicine

Case Presentation

12 hrs s/p blepharoplasty c/c: bleeding eyelid. Ill only see a plastic surgeon. PE- venous blood from incision VSS, eye grossly normal VA 20/20 bilaterally , PERL Plastics: What kind of insurance does he have? Cash? Ill be down. 3- 4 hours later- repeat PE: VSS, right eye dilates to light.

Orbital Architecture

Approach to eye examination

ULTIMATE GOAL Systematic Exam VA vital signs EOM/Sensation Slit lamp exam Fundus Referral

Corneal Abrasions Presentation

Symptoms Signs

Corneal Abrasions

VA test Remove contacts Slit-lamp exam

Corneal Abrasions

Corneal Abrasions

Corneal Abrasions - Management

To patch or not to patch, that is the question. Flynn et al: J. Family Practice. 1998. Le Sage N et al:Ann of EM. 2001. Contact lens wearer Non-contact lens wearer Topical anesthetics Ophthalmology consult? Follow- up: 48 hrs

Subconjunctival Hemorrhages

Definition Symptoms Signs Complete exam Treatment

Iritis- Presentation

Definition Symptoms Photophobia Eye pain Signs Limbus injection Miosis Mydriasis VA

Anterior Chamber Reaction

Hypopyon

Iritis Management

Complete Examination. Cycloplegic NSAIDS Sunglasses No antibiotics Topical steroids? Follow-Up

Hyphema- Presentation

Definition Symptoms Grading 0 RBCs I <1/3 II 1/3 1/2 III > 1/2 IV eight ball

Hyphema- Management

Ophthalmic consult Pupillary play/Eye Patch Reverse Trendelenburg Anesthesia /Anti-emetic IOP control > 30 mmHg (>24 mmHg in HbSS) Admission

HbSS Anti-coagulated > Grade I Decreasing VA ED evaluation > 1 day after initial injury. Re-bleed Post-traumatic glaucoma

Complications

Lens subluxation and dislocation

Definition Disposition Subluxed Dislocated Post-traumatic Cataract

Retinal Detachment /Vitreous Hemorrhage

Definition Symptoms

Photopsia Image distortion Painless Floaters Floaters with flashing light Defects in VA

Vitreous Hemorrhage

VA/Red reflex/RAPD Fundoscopy Ophthalmology consult Disposition

Retinal Detachment

RAPD/VA Fundoscopy Shafer Sign Ophthalmology consult Disposition

Retrobulbar Hemorrhage Presentation

Definition Symptoms Critical signs Proptosis Visual acuity Marcus-Gunn pupil Red desaturation

Retrobulbar HemorrhageManagement
TIME IS RETINA Progressive Lateral canthotomy CT scan of orbit Disposition

Blowout Fracture- Presentation

Definition Symptoms

Pain Double vision Numbness to cheek tenderness Restricted EOM Subcutaneous emphysema Globe displacement 32%

Critical signs

Globe trauma

Blowout Fracture - Etiology

Theories Waterhouse 1999 Buckling Hydraulic Fracture site

Inferior wall Medial wall Superior rim

CNS injury CSF leak Intracranial - bleed

Blowout Fracture- X-ray

Screening Teardrop sign

Blowout Fracture- CT
Clinical indications
Depressed eye Nerve anesthesia EOM entrapment Orbital roof

Coronal and axial cuts

Blowout fracture- Management

Consults Nasal Decongestants Antibiotics
Evidence?

Sneezing/Blowing Nose Disposition With entrapment Without entrapment Associated injuries

Ruptured Globe Presentation

Incidence
1.1-3.5%

Symptoms Predictive signs

1) VA showing light perception or worse. 2) Abnormal deep/shallow anterior chamber. 3) Opacity preventing view of fundus. 4) IOP of 5 or less.

Ruptured Globe - Management

Diagnosis Suspected STOP Examination Do NOT put pressure on globe RSI Br. J of Anesth 1999 Antibiotics Tetanus Antiemetic CT scan Prepare for surgery.

Take home points

Systematic approach to eye exam

Visual acuity = vital signs of the eye. Goal protect the globe Complete ocular examination

Corneal Abrasions: antibiotics, do not patch Subconjunctival hemorrhages painless Iritis cycloplegics and sunglasses Hyphema- Ophthalmology, patch, IOP. Lens subluxed vs. dislocated Posterior segment floaters/ flashing lights = Ophtho Retrobulbar hemorrhage loss of VA, pain, proptosis. time is retina Blowout fracture Waters view, CT for entrapment. Globe rupture Ophthalmology, patch.

Case Presentation

Patient to OR for a stat lateral canthotomy. S/p operation, VA is 200/45 in right eye. Retrobulbar hemorrhage is a 1 in 15,000 side effect of blepharoplasty.

REFERENCES

Cullom, R. Douglas J (ed) et al. The Willis Eye Manual, Office and Emergency Room Diagnosis and Treatment of Eye Disease. J. B. Lippincott and Co. 1994 pp. pp. 19-48. Effect Of Rocuronium Compared With Succinycholine On IOP During RSI. British Journal of Anesthesiology. 1999 May; 82 (5): 757-60. Ferrera, Peter C (ed) et al. Trauma Management, An Emergency Medicine Approach. Mosby Inc, 2001: 201-215. Flyn CA, D Amico F, Smith G. Should We Patch Corneal Abrasions? Meta Analysis. Journal of Family Practice. 1998; (47): 264-70. Le Sage N, Verrenult R, Rochette L. Efficacy of Eye Patching for Traumatic Corneal Abrasions: Controlled Clinical Trial. Annals of Emergency Medicine. 2001 Aug; 38 (2): 129-34. Roberts, James R, Hedges, Jerris R (ed). Clinical Procedures in Emergency Medicine. W.B. Saunders Co. 1998: 1116 Tintinalli, Judith E (ed) et al. Emergency Medicine, A Comprehensive Study Guide. McGraw Hill, 2000: 1501-1506. Waterhouse N, Lyne J et al. Investigation Into Mechanism Of Orbital Blowout Fractures. British Journal of Plastic Surgery. 1999 Dec; 52 (8): 607-12.