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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 :

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.

Orbital Architecture:

Orbital Architecture

Approach to eye examination:

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

Corneal Abrasions – Presentation:

Corneal Abrasions – Presentation Symptoms Signs

Corneal Abrasions:

Corneal Abrasions VA test Remove contacts Slit-lamp exam

Corneal Abrasions:

Corneal Abrasions

Corneal Abrasions:

Corneal Abrasions

Corneal Abrasions - Management:

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:

Subconjunctival Hemorrhages Definition Symptoms Signs Complete exam Treatment

Iritis- Presentation:

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

Anterior Chamber Reaction:

Anterior Chamber Reaction

Hypopyon:

Hypopyon

Iritis – Management:

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

Hyphema- Presentation:

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

Hyphema- Management:

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

Lens subluxation and dislocation:

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

Retinal Detachment /Vitreous Hemorrhage:

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

Vitreous Hemorrhage:

Vitreous Hemorrhage VA/Red reflex/RAPD Fundoscopy Ophthalmology consult Disposition

Retinal Detachment:

Retinal Detachment RAPD/VA Fundoscopy Shafer Sign Ophthalmology consult Disposition

Retrobulbar Hemorrhage - Presentation:

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

Retrobulbar Hemorrhage- Management:

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

Blowout Fracture- Presentation:

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

Blowout Fracture - Etiology:

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:

Blowout Fracture- X-ray Screening Teardrop sign

Blowout Fracture- CT:

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

Blowout fracture- Management:

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

Ruptured Globe – Presentation:

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:

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:

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:

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:

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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