Presentation on theme: "Orbital Trauma Grant S Lipman MD Wilderness Medicine Fellow Clinical Instructor, Division of Emergency Medicine Stanford University School of Medicine."— Presentation transcript:
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 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.
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 - Management To patch or not to patch, that is the question. Flynn et al: J. Family Practice Le Sage N et al:Ann of EM Contact lens wearer Non-contact lens wearer Topical anesthetics Ophthalmology consult? Follow- up: 48 hrs
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 % 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 pp. pp Effect Of Rocuronium Compared With Succinycholine On IOP During RSI. British Journal of Anesthesiology May; 82 (5): Ferrera, Peter C (ed) et al. Trauma Management, An Emergency Medicine Approach. Mosby Inc, 2001: Flyn CA, D Amico F, Smith G. Should We Patch Corneal Abrasions? Meta Analysis. Journal of Family Practice. 1998; (47): Le Sage N, Verrenult R, Rochette L. Efficacy of Eye Patching for Traumatic Corneal Abrasions: Controlled Clinical Trial. Annals of Emergency Medicine Aug; 38 (2): 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: Waterhouse N, Lyne J et al. Investigation Into Mechanism Of Orbital Blowout Fractures. British Journal of Plastic Surgery Dec; 52 (8):