Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Grand Rounds Conference Lara Rosenwasser Newman, MD University of Louisville Department of Ophthalmology and Visual Sciences September 5, 2014."— Presentation transcript:

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 AsthmaPSHx: Tympanostomy tube placement Tympanostomy tube placementPOHx: None NoneMedications: Albuterol inhaler, Beclomethasone dipropionate (QVAR inhaler) Albuterol inhaler, Beclomethasone dipropionate (QVAR inhaler)

4 IOP:19mmHg20mmHg EOM: Pain on attempted upgaze OS; no diplopia Clinical Exam OD OS OD OS VA (n,sc/Allen): 20/3020/30 Pupils: 3  2 3  (-)rAPD

5 Clinical Exam PLE: External/LidsSmall superficial laceration on upper lid OS, mild ecchymosis/edema Conjunctiva/ScleraClear/white; no subconj heme CorneaClear OU Anterior ChamberFormed OU IrisNormal OU LensClear OU VitreousNormal OU DFE deferred per neurosurgery

6 External Appearance

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

8 EOMs

9 CT Face Minimally depressed fracture of L orbital floor Minimally depressed fracture of L orbital floor Minor opacification of L ethmoid air cells, trace fluid or possibly hemorrhage in the L maxillary sinus Minor opacification of L ethmoid air 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) 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 Admitted to ICU 2/2 bradycardia Ophthalmology: Ophthalmology: Patient taken to OR for fracture repair within ~6 hours of arrival to ED by oculoplastics Patient taken to OR for fracture repair within ~6 hours of arrival to ED by oculoplastics L orbital floor fracture repair w/suprafoil implant L orbital floor fracture repair w/suprafoil implant Successful repositioning of orbital tissues Successful repositioning of orbital tissues

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

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

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

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

16 Imaging CT can show trapdoor fracture with rectus muscle incarceration or “missing” inferior rectus CT can show trapdoor fracture with rectus muscle incarceration or “missing” inferior rectus Inf rectus muscle belly “Missing” inf 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: /j.bjps

17 Orbital Blow-out Fractures Symptoms: Symptoms: Pain on attempted eye movement Pain on attempted eye movement Tenderness, lid edema, binocular diplopia, trauma hx Tenderness, lid edema, binocular diplopia, trauma hx Signs: Signs: Restricted EOMs, subcutaneous or conjunctival emphysema, point tenderness, enophthalmos Restricted EOMs, subcutaneous or conjunctival emphysema, point tenderness, enophthalmos Hypesthesia in distribution of the Hypesthesia in distribution of the infraorbital nerve Byrne, Karen M. Infraorbital Nerve Block. Emedicine:

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

19 WEBOF Treatment Consider broad-spectrum abx if hx of chronic sinusitis, diabetes, or immune compromise. Consider broad-spectrum abx if hx of chronic sinusitis, diabetes, or immune compromise. Not mandatory Not mandatory Not evidence-based (limited, anecdotal evidence) Not evidence-based (limited, anecdotal evidence) Oxymetazoline BID for 3 days, no nose blowing Oxymetazoline BID for 3 days, no nose blowing Q1-2h ice packs for 20 mins for hrs Q1-2h ice packs for 20 mins for hrs Consider oral steroids if swelling extensive and limiting exam of motility and globe position 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 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 Release incarcerated muscle to decrease chance of ischemia and fibrosis causing permanent restrictive strabismus Also to alleviate oculocardiac reflex Also to alleviate oculocardiac reflex

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

22 Orbital Implants Alloplastic: Alloplastic: Porous polyethylene Porous polyethylene Supramid (nylon foil) Supramid (nylon foil) Gore-Tex Gore-Tex Teflon Teflon Silicone sheet Silicone sheet Titanium mesh Titanium mesh Autogenous: Autogenous: Split cranial bone, iliac crest bone, or fascia 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: /

23 Timoney et al describe use of 0.4 mm Supramid Timoney et al describe use of 0.4 mm Supramid Nylon foil – non-porous, relatively inert, alloplastic implant Nylon foil – non-porous, relatively inert, alloplastic implant 59 orbits in 57 patients (all pediatric) 59 orbits in 57 patients (all pediatric) 3 patients (5.3%) had entrapment with vasovagal responses and immediate intervention 3 patients (5.3%) had entrapment with vasovagal responses and immediate intervention 6 had immediate post-op diplopia; all improved 6 had immediate post-op diplopia; all improved 2 post-op complications without permanent sequellae 2 post-op complications without permanent sequellae None had noticeable post-op enophthalmos None had noticeable post-op enophthalmos Concluded Supramid implant safe and effective Concluded Supramid implant safe and effective 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: /IOP

24 References Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi: / Foulds, J. S., Laverick, S., & MacEwen, C. J. (2013). “White-eyed” blowout fracture in children. Emergency Medicine Journal: EMJ, 30(10), 836. doi: /emermed 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: /jscr/rjt Orbital Trauma. In: Basic and Clinical Science Course (BCSC) Section 7: Orbit, Eyelids, and Lacrimal System. San Francisco, CA: American Academy of Ophthalmology; 2014: 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: /IOP Verret, Daniel JDucic, Y. (2013). Implants, Soft Tissue, High-Density Porous Polyethylene (Medpor). Medscape Reference. Retrieved from overview#a 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: /j.bjps


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

Similar presentations


Ads by Google