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Orbital Trauma

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. “I’ll only see a plastic surgeon.” PE- venous blood from incision

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Orbital Trauma

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

  2. Case Presentation • 12 hrs s/p blepharoplasty – c/c: bleeding eyelid. • “I’ll 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? I’ll be down.” • 3- 4 hours later- repeat PE: • VSS, right eye dilates to light.

  3. Orbital Architecture

  4. Approach to eye examination • ULTIMATE GOAL • Systematic Exam • VA – vital signs • EOM/Sensation • Slit lamp exam • Fundus • Referral

  5. Corneal Abrasions – Presentation • Symptoms • Signs

  6. CornealAbrasions • VA test • Remove contacts • Slit-lamp exam

  7. Corneal Abrasions

  8. Corneal Abrasions

  9. 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  

  10. Subconjunctival Hemorrhages • Definition • Symptoms • Signs • Complete exam • Treatment

  11. Iritis- Presentation • Definition • Symptoms • Photophobia • Eye pain • Signs • Limbus injection • Miosis • Mydriasis • VA

  12. Anterior Chamber Reaction

  13. Hypopyon

  14. Iritis – Management • Complete Examination. • Cycloplegic • NSAIDS • Sunglasses • No antibiotics • Topical steroids? • Follow-Up

  15. Hyphema- Presentation • Definition • Symptoms • Grading • 0 RBC’s • I <1/3 • II 1/3 – 1/2 • III > 1/2 • IV eight ball

  16. 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. • Complications • Re-bleed • Post-traumatic glaucoma

  17. Lens subluxation and dislocation • Definition • Disposition • Subluxed • Dislocated • Post-traumatic Cataract

  18. Retinal Detachment /Vitreous Hemorrhage • Definition • Symptoms • Photopsia • Image distortion • Painless • Floaters • Floaters with flashing light • Defects in VA

  19. Vitreous Hemorrhage • VA/Red reflex/RAPD • Fundoscopy • Ophthalmology consult • Disposition

  20. Retinal Detachment • RAPD/VA • Fundoscopy • Shafer Sign • Ophthalmology consult • Disposition

  21. Retrobulbar Hemorrhage - Presentation • Definition • Symptoms • Critical signs • Proptosis • Visual acuity • Marcus-Gunn pupil • Red desaturation

  22. Retrobulbar Hemorrhage-Management • “TIME IS RETINA” • Progressive • Lateral canthotomy • CT scan of orbit • Disposition

  23. Blowout Fracture- Presentation • Definition • Symptoms • Pain • Double vision • Numbness to cheek • tenderness • Critical signs • Restricted EOM • Subcutaneous emphysema • Globe displacement • Globe trauma • 32%

  24. Blowout Fracture - Etiology • Theories Waterhouse 1999 • Buckling • Hydraulic • Fracture site • Inferior wall • Medial wall • Superior rim • CNS injury • CSF leak • Intracranial - bleed

  25. Blowout Fracture- X-ray • Screening • Teardrop sign

  26. Blowout Fracture- CT • Clinical indications • Depressed eye • Nerve anesthesia • EOM entrapment • Orbital roof • Coronal and axial cuts

  27. Blowout fracture- Management • Consults • Nasal Decongestants • Antibiotics • Evidence? • Sneezing/Blowing Nose • Disposition • With entrapment • Without entrapment • Associated injuries

  28. 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.

  29. 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.

  30. 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.

  31. 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.

  32. 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.

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