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Grand Rounds Conference

Grand Rounds Conference. Lara Rosenwasser Newman, MD University of Louisville Department of Ophthalmology and Visual Sciences September 5, 2014. Subjective. CC: Evaluate globe OS

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Grand Rounds Conference

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  1. Grand Rounds Conference Lara Rosenwasser Newman, MD University of Louisville Department of Ophthalmology and Visual Sciences September 5, 2014

  2. Subjective CC: Evaluate globe OS HPI: 6 yo African-American boy involved in a motor vehicle accident with waxing and waning consciousness. Pt complained of pain on eye movements, especially on upgaze. Denied diplopia.

  3. History PMHx: • Asthma PSHx: • Tympanostomy tube placement POHx: • None Medications: • Albuterol inhaler, Beclomethasonedipropionate (QVAR inhaler)

  4. Clinical Exam -4 0 0 0 0 0 0 -3 OD OS VA (n,sc/Allen): 20/30 20/30 Pupils: 3232 (-)rAPD • IOP: 19mmHg20mmHg • EOM: • Pain on attempted upgaze OS; no diplopia

  5. Clinical Exam PLE: External/Lids Small superficial laceration on upper lid OS, mild ecchymosis/edema Conjunctiva/Sclera Clear/white; no subconjheme Cornea Clear OU Anterior Chamber Formed OU Iris Normal OU Lens Clear OU VitreousNormal OU DFE deferred per neurosurgery

  6. External Appearance

  7. Physical Exam Bradycardia with heart rate in 40s-50s Nausea, vomiting Waxing & waning consciousness since accident

  8. EOMs

  9. CT Face Minimally depressed fracture of L orbital floor Minor opacification of L ethmoidair cells, trace fluid or possibly hemorrhage in the L maxillary sinus

  10. Assessment • 6 yo AAM status post motor vehicle accident with orbital floor fracture OS, with clinical exam suggestive of entrapment of inferior rectus muscle (WEBOF: white-eyed orbital blow-out fracture)

  11. Plan • Admitted to ICU 2/2 bradycardia • Ophthalmology: • Patient taken to OR for fracture repair within ~6 hours of arrival to ED by oculoplastics • L orbital floor fracture repair w/suprafoil implant • Successful repositioning of orbital tissues

  12. Follow-up • Post-operative day #1: • 20/30 OD, 20/70 OS • Improving periorbital edema, mild chemosis • Diplopia • Infraduction OS -1 • DFE WNL

  13. Follow-up • At 1 week: • L face swollen • No diplopia, intermittent pain • “Trouble reading, covered 1 eye due to blurriness” • Sinus arrhythmia – following with pediatrician • Lower lid OS with decreased excursion • 20/20 OU, motility full OU

  14. WEBOF: White-Eyed BlowOut Fracture • Benign extraocular appearance w/minimal eyelid signs BUT w/significant EOM restriction • Usually vertical gaze restriction • Kids often do not complain of binocular diplopia (just close one eye) • Cartilaginous/bendable bones in kids lead to: • Increased risk for “trapdoor” fractures • Increased risk for EOM incarceration

  15. WEBOF Presentation • Kids may present w/severe oculocardiac reflex: • Nausea or vomiting, dehydration from anorexia • Bradycardia or syncope • May be misdiagnosed as concussion • Fracture/entrapment can be missed on CT head • Always get dedicated CT face or orbits

  16. Imaging Inf rectus muscle belly “Missing” inf rectus CT can show trapdoor fracture with rectus muscle incarceration or “missing” inferior rectus Yano, H., Minagawa, T., Masuda, K., & Hirano, A. (2009). Urgent rescue of “missing rectus” in blowout fracture. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS, 62(9), e301–4. doi:10.1016/j.bjps.2007.12.041

  17. Orbital Blow-out Fractures • Symptoms: • Pain on attempted eye movement • Tenderness, lid edema, binocular diplopia, trauma hx • Signs: • Restricted EOMs, subcutaneous or conjunctival emphysema, point tenderness, enophthalmos • Hypesthesiain distribution of the infraorbital nerve Byrne, Karen M. Infraorbital Nerve Block. Emedicine: http://emedicine.medscape.com/article/82660-overview

  18. Differential Diagnosis of Muscle Entrapment in Orbital Fractures • Orbital edema and hemorrhage without blow-out fracture • Can still cause EOM limitation, swelling, ecchymosis • Resolves over 7-10 days • Cranial nerve palsy • EOM limitation but no restriction on forced ductions • Rule out intracranial & skull base processes w/CT

  19. WEBOF Treatment • Consider broad-spectrum abx if hx of chronic sinusitis, diabetes, or immune compromise. • Not mandatory • Not evidence-based (limited, anecdotal evidence) • Oxymetazoline BID for 3 days, no nose blowing • Q1-2h ice packs for 20 mins for 24-28 hrs • Consider oral steroids if swelling extensive and limiting exam of motility and globe position

  20. WEBOF Treatment • Immediate repair (24-72 hrs) if evidence of muscle entrapment and non-resolving heart block, bradycardia, nausea, vomiting, or syncope • Release incarcerated muscle to decrease chance of ischemia and fibrosis causing permanent restrictive strabismus • Also to alleviate oculocardiac reflex

  21. Surgical Repair Technique • Surgical approach: • Subconjunctival incision+/- lateral cantholysis • Elevate periorbita from orbital floor • Release prolapsed tissue from fracture • Usually place implant over fracture to prevent recurrent adhesions and tissue proplapse http://emedicine.medscape.com/article/882205-overview Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi:10.4103/2231-0746.110078

  22. Orbital Implants http://emedicine.medscape.com/article/882205-overview#a3 • Alloplastic: • Porous polyethylene • Supramid (nylon foil) • Gore-Tex • Teflon • Silicone sheet • Titanium mesh • Autogenous: • Split cranial bone, iliac crest bone, or fascia Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi:10.4103/2231-0746.110078

  23. Timoney, P. J., Krakauer, M., Wilkes, B. N., Lee, H. B. H., & Nunery, W. R. (2014). Nylon foil (supramid) orbital implants in pediatric orbital fracture repair. Ophthalmic Plastic and Reconstructive Surgery, 30(3), 212–4. doi:10.1097/IOP.0000000000000051 • Timoney et al describe use of 0.4 mm Supramid • Nylon foil – non-porous, relatively inert, alloplastic implant • 59 orbits in 57 patients (all pediatric) • 3 patients (5.3%) had entrapment with vasovagal responses and immediate intervention • 6 had immediate post-op diplopia; all improved • 2 post-op complications without permanent sequellae • None had noticeable post-op enophthalmos • Concluded Supramid implant safe and effective http://www.ophthalmologyweb.com/Oculoplastic-and-Orbital-Procedures/5561-Supramid-Sheet-Implants/

  24. References • Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi:10.4103/2231-0746.110078 • Foulds, J. S., Laverick, S., & MacEwen, C. J. (2013). “White-eyed” blowout fracture in children. Emergency Medicine Journal : EMJ, 30(10), 836. doi:10.1136/emermed-2012-201741 • Gerstenblith, A. T., & Rabinowitz, M. P. (2012). The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia, PA: Lippincott Williams & Wilkins. • Hammond, D., Grew, N., & Khan, Z. (2013). The white-eyed blowout fracture in the child: beware of distractions. Journal of Surgical Case Reports, 2013(7), 2–3. doi:10.1093/jscr/rjt054 • Orbital Trauma. In: Basic and Clinical Science Course (BCSC) Section 7: Orbit, Eyelids, and Lacrimal System. San Francisco, CA: American Academy of Ophthalmology; 2014: 100-104. • Timoney, P. J., Krakauer, M., Wilkes, B. N., Lee, H. B. H., & Nunery, W. R. (2014). Nylon foil (supramid) orbital implants in pediatric orbital fracture repair. Ophthalmic Plastic and Reconstructive Surgery, 30(3), 212–4. doi:10.1097/IOP.0000000000000051 • Verret, Daniel JDucic, Y. (2013). Implants, Soft Tissue, High-Density Porous Polyethylene (Medpor). Medscape Reference. Retrieved from http://emedicine.medscape.com/article/882205-overview#a3 • Yano, H., Minagawa, T., Masuda, K., & Hirano, A. (2009). Urgent rescue of “missing rectus” in blowout fracture. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS, 62(9), e301–4. doi:10.1016/j.bjps.2007.12.041

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