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Orbital Trauma Grant S Lipman MD Wilderness Medicine Fellow

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Presentation on theme: "Orbital Trauma Grant S Lipman MD Wilderness Medicine Fellow"— Presentation transcript:

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. Afferent Pupillary Defect Defect of the visual pathway – involving either the retina, optic nerve, or retinal artery. Affected pupil dilates instead of contracts when a light is shone directly. pupil is malfunctioning, so moving light away from uninjured eye css reactive dilation, more powerful than impaired constriction…bad.

3 Orbital Architecture Present the anatomy of the eye, from anterior to posterior. Structures. What can happen to these structures in blunt trauma How they present in the ED How to Dx the pathology Visualize the orbit – and from outside to inside. Anterior segment- Corneal Abrasions; Anterior chamber findings; Iritis; Hyphema; Lens dilocations/subluxations; Vitreous Hemorrhages; Retinal Detachments; Retrobulbar Hemorrhages; Blowout fractures; and finally, Globe rupture.

4 Approach to eye examination
ULTIMATE GOAL Systematic Exam VA – vital signs EOM/Sensation Slit lamp exam Fundus Referral Ultimate Goal- Diagnose and protect a ruptured globe – why? Stop the extrusion of globe contents. Systematic Examination- from anterior to posterior -Visualize Eye Early…after blunt trauma, increasing edema will make visualization of the globe increasingly difficult. -Vital Sign of the eye. of the optic nerve,initial VA will allow treatment course. -A flat anterior chamber, hyphema, blind eye, or obvious extravasation of orbital contents – suspect a ruptured globe. Put a shield over eye- stat Optho consult -restricted upward gaze suggests a blowout fracture and entrapment with damage EO muscles. W/ fluorescein - examines cornea, conjunctiva, sclera, lens, and anterior chamber and iris. Visualize the fundus? - if no injuries found. Ophtho w/in 48 hours. Beginning at the anterior portion of globe, corneal abrasions.

5 Corneal Abrasions – Presentation
Symptoms Signs - Corneal Epithelium …5-6 cells thick. Healing is done by leading edge of epithelium and usually takes hours Sx:FB sensation, blurred vision, pain, photophobia, halo around lights Sx- Conjunctival injection, decreased VA.

6 Corneal Abrasions VA test Remove contacts Slit-lamp exam
-lid should be everted, fornix inspected under magnification. For residual particles….may use topical anesthetic intially for pt comfort (to help with VA testing). flourescein will permanently stain soft contact lenses. -1-2 drops of anesthetic ( proparacaine / tetracaine ), then put drop of anesthetic on tip of fluroscein paper, and touch to inside lower lid, have pt blink to spread dye. fluorescein adhere to abrasion ….especially under cobalt blue light. -Size, shape, location (mm, round, linear, 4’oclock)…penetrate ant. Chamber? Slit lamp findings…

7 Corneal Abrasions Ice rink sign…FB under eyelid

8 Corneal Abrasions Seidel test… leaking aqueos humor, dx globe rupture.
Under white light, fluorosc is diluted by the aqueous and appears as a green (dilute) stream w/in the dark – orange (concent) dye. Under the blue light, the leak is a swirling stream of green w/in a background of green.) Stop exam.

9 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   -Flynn et al wrote meta-analysis in (J of family practice) 7 studies healing rates of non- p .87 vs patched .90 (summary ratios w/ CI of 95%). Pain 6 studies. 4 – no difference. 2 – decr. Pain with non- p….no difference in either complications. -Le Sage N et al n= 163 in single blind prospective trial. Both arms given Abx wand w/o Patch. F/u by EM dr w/ SL. Healing (Day 1, 2, 3) – P: 51%, 78%, 92% ; UnP: 60%, 83% 88% Discomfort dec.(Visual analog scale) – P: 4.8, 4.1, 5.5cm; UnP: 3.3, 5.1, 6.1cm. Non-C: E-mycin ointm or Ciloxin drops (Cipro drops) – 2-3 /dy until eye no longer red. C- Tobramycin drops. No patch (inc. risk of pseudomonas infxn). Resume contacts after “eye is normal”. …stay away from neomycin containing (cs allergic conjunctivitis) -Anesthesia- abrasions may wursen, and further injury may insensate eye. Also lead to corneal toxicity – resulting in blindness. -Ophtho consult: abrasion > 2mm, penetrates ant chamber, or 2nd visit following an earlier abrasion (worsening) - if minor, f/u only if pain or visual sx’s persist for > 2 days Behind the cornea is the conjunctiva

10 Subconjunctival Hemorrhages
Definition Symptoms Signs Complete exam Treatment Def-Conj – thin, moist, clear covering of sclera (white part of eye). Heavily vascularized with fragile vessels may easily burst – causing bleeding b/w conjunc and sclera. Sx- painless. ( if Pain - may be indicative of more severe process manifestation… Sx-appears flat, no break in conjunctival membrane, painless, Limtied to conjunctiva- does not impinge on iris. (Entire 360 conj, bilateral eyes). Usually clears w/in 14 days…artificial tears , f/u if further H’s or no resolution

11 Iritis- Presentation Definition Symptoms Photophobia Eye pain Signs
Limbus injection Miosis Mydriasis VA Inflammation to anterior segment. (cornea, conjunctiva, sclera, ant chamber, iris, and lens). Sx –pain, tearing, blurred vision, h/o ocular trauma preceding 2-3 days. VA usually mildly decreased- severe Photophobia- ciliary muscle spasm And consensual photophobia. Due to ciliary muscle contraction- may be pain on accommodation, hurts to read. Bulbar conjunctiva is injected , esp limbus, globe is tender.. Traumatic miosis (pupil is smaller and sluggish than uninjured eye)…after several hours pupil may dilate traumatic mydriasis. .. Disruption of the circular iris sphincter…..pupil may appear scalloped ( months - indefinitely).

12 Anterior Chamber Reaction
The anterior chamber reaction 2% - 18% of trauma. Slit lamp – cells and flare in ant chamber. Tall and narrow bright beam of white light at oblique angle to ant. Chamber. Suspended white cells sparkle as they float into path of light. Tall thin white slit lamp beam at a 90o angle.css suspended protein to flare. “ head lights in a fog”

13 Hypopyon If the anterior chamber rxn large enough for the white cells to layer out – a hypopyon (pus in anterior chamber) forms. Severe Iritis

14 Iritis – Management Complete Examination. Cycloplegic NSAIDS
Sunglasses No antibiotics Topical steroids? Follow-Up DDX: - Corneal Abrasion ; Traumatic microhyphema; Traumatic Retinal Detachment…seen on fundus exam. Mngt- Pain d/t ciliary spasm…cycloplegic-   Cyclogyl – last 24 hrs after discontinuation...not Scopolamine (1 week)….Atropine, 2 wk effects. …. NSAIDS for 3 days. Sunglasses. No Abx, inspite of white cells, an inflammation, NOT infection. severe rxns- Optef (Hydrocortisone) Pred Forte (Prednisolone) – 1-2 days, w/ f/u by Ophtho. Ophthalmic consult within 24 hours Should clear over 1 week. The anterior chamber…

15 Hyphema- Presentation
Definition Symptoms Grading 0 RBC’s I <1/3 II 1/3 – 1/2 III > 1/2 IV eight ball Layering and/or clot of blood in the anterior chamber due to a ruptured iris root vessel. SX: Pain, blurred vision, h/o trauma. VA is variably effected 1) traumatic hyphema bleeding is usually due a ruptured iris root vessel. 2) In spontaneous hyphema, often associated with Sickle cell disease. Amount of bleeding into ant chamber grossly quantified: microscopic (suspended RBC’s – ant rxn); 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 - Assoct’d inj: ruptured globe….protect the globe- patch/ stat consult. -   constriction / dilation of iris to changing light conditions - stretch on iris vessel …usual source of bleeding….stretch may promote further bleeding. (should not compromise outflow angle and outflow tract in normal individuals). - -   rest quietly in ED, raise head of bed ( promotes settling of suspended RBC’s inferiorly) Cover EYE – protect the globe. - No NSAIDs, give anti-emetic… control IOP. > 30mmHg,Timolol – 1 drop… dilation of Canal of Schlemm, increase outflow. Give Diamox 500 mg PO/IV… (HbSS) - CAI’s lower aqueous pH and RBC’s will sickle, less flexible, clog outflow and raise IOP. mannitol 1-2 g/kg IV/45 min if no result. Re-bleeding - can occur 3-5 days later in 30%, usually worse than initial bleeding PT Glc – bleeding plugs the drainage channel with exudates – raises IOP Dispo- usually < grade I followed as o/pt. Optho’s decision. … RELIABLE… Bed rest as much as possible with head elevated for 4-5 days…no strenuous activities…seen on a daily basis,…no NSAIDs, cyclopegic, shield the eye (no patch)… return if increased pain or decreased vision

17 Lens subluxation and dislocation
Definition Disposition Subluxed Dislocated Post-traumatic Cataract Def: Subluxation – > 25% zonular fibers disrupted; lens decentered but remains in pupillary aperture. -Dislocation – complete disruption of fibers; lens displaced out of aperture. SX: Decreased vision, diploplia (dbl vision persists when covering one eye) Note uniL/BilLat and direction of displaced lens. Work-Up: Systemic evaluation- Family Hx (homocystinuria / Marfans), Trauma , Systemic Illness (Syphilis). RPR, EKG. --Dispo- If subluxed and asymptomatic – may send home with Optho follow up, otherwise admission for lens relocation and/or surgery. Complication can occur d/t rupture and disturbance of capsule/ lens where vitreous fluid contact lens fibers…lens opacity.

18 Retinal Detachment /Vitreous Hemorrhage
Definition Symptoms Photopsia Image distortion Painless Floaters Floaters with flashing light Defects in VA Vitreous Body – 4/5 globe, 99% H2O, clear, avascular. 24mL av. VH – disruption of retinal vessels.  Tractional RD- Separation of inner layer or retina from Retinal Pigment Epithelium without break PHOTOPSIA- flashing lights, d/t separation of post retina that mechanically stimulates the retinal tissue, release of phosphenes – light Floating specks / bugs -ominous…blood cells floating in visual axis. pathognomonic for VH. Few hours – cobwebs – blood forming clots in vitreous If new onset floaters with flashing lights- retinal tear until proven otherwise Defects in VA – late finding. .

19 Vitreous Hemorrhage VA/Red reflex/RAPD Fundoscopy
Ophthalmology consult Disposition Afferent Pupillary Defect Defect of the visual pathway – involving either the retina, optic nerve, or retinal artery. Affected pupil dilates instead of contracts when a light is shone directly. pupil is malfunctioning, so moving light away from uninjured eye css dilation, more powerful than impaired constriction…bad. red fundus – red reflex may be absent, funduscopy – red, unable to visualize fundus blood may appear to obscure parts of vessels of fundus… Unable to visualize fundus – cannot r/ o retinal detachment – admit/ ocular US

20 Retinal Detachment RAPD/VA Fundoscopy Shafer Sign
Ophthalmology consult Disposition Elevation of retina, gray with dark blood vessels/folds in retina. Shafer Sx – in vitreous - floating pigment or “tobacco dust” . Pathognomonic for reitnal tear in 70% css w/ no previous eye disease or surgery. Dispo –if don’t threaten Macula- may be d/c with f/u in 1- 2 weeks.

21 Retrobulbar Hemorrhage - Presentation
Definition Symptoms Critical signs Proptosis Visual acuity Marcus-Gunn pupil Red desaturation Disruption and hemorrhage of the posterior arterial supply – incr. Pressure w/in rigid orbit css. Increasing IOP. Develops within 24 hours s/p trauma. Sx- Pain, decreasing VA Signs – Proptosis , dystopia (malposition of eye) , diffuse conjunctival hamorrhage – posterior, eyelid echymosis, chemosis, proptosis. Marcus-Gunn Pupil RAPD red desaturation (Take a bright red object. Ask the patient to view the object with each eye, keeping the other covered, compare the two images. With optic nerve damage, the object appears gray or washed out) - decreasing VA = Compression of the Central retinal artery/ optic nerve. retina is ischemic

22 Retrobulbar Hemorrhage- Management
“TIME IS RETINA” Progressive Lateral canthotomy CT scan of orbit Disposition Mngt- immediate Ophtho consult Slowly develops- elevate head, ice pack, acetazolamide (500mg IV), mannitol (20%) 1-2g/kg IV /45 minutes Timolol 0.5% q30 min Avoid NSAIDS Reasses VA APD q30minutes Rapidly- lateral canthotomy / cantholysis….allows further proptosis of eye…relieves compression. Anesthetize lateral canthal area with Lido + Epi….place hemostat horizontally on lat canthus tissue extending over orbital rim and clamp for 1 minute…release clamp and cut compressed tissuefor 1 cm into canthus with sterile scissors….separate the skin and conjunctival tissue, exposing inf arm of lateral canthus tendon …. Cut the tendon with vertical incision scissors….hemostasis usually achieved with pressure. CT scan of orbit delayed until after treatment, where vision is threatened. Admit to Optho.

23 Blowout Fracture- Presentation
Definition Symptoms Pain Double vision Numbness to cheek tenderness Critical signs Restricted EOM Subcutaneous emphysema Globe displacement Globe trauma 32% Def- Fx in one of the orbit bones, with possible orbital contents including Eomm pushed through into break into sinus. Sx- H/O trauma, Pain, esp on vertical movm’t, local tenderness, binocular diploplia (dbl vision disappears when one eye is covered), eyelid swelling after nose blowing. Numbness of ipsilateral cheek/upper lip (infraorbital n. distribution), step-off along orbital rim. Signs: restricted eye movm’t (espc up/lat gaze), enophthalmos, peri-orbital ecchym/peri-orbital edema. peri-orbital subC emphysema, inferior globe displacement (ocular trauma in 32% of blowout fx). globe trauma: abrasion, traumatic iritis, hyphema, lens disloc/subluxt’n, retinal tear/ detachment.

24 Blowout Fracture - Etiology
Theories Waterhouse 1999 Buckling Hydraulic Fracture site Inferior wall Medial wall Superior rim CNS injury CSF leak Intracranial - bleed 2 theories- Buckling Theory – t-mission force from orbital rim to floor Hydraulic Theory- force t-mitted to floor via direct blow to orbir (Westfall and Shore – 47 cadavers w/ both mech – unable to differentiate). Most frequent sites of fx: Infer wall: Maxillary sinus (inf rectus intrapment) ; Medial wall: Ethmoid sinus (lamina papyracea) – may be asscot’d w/ epistaxis, rarely medial rectus damaged ( lateral diploplia) and nasolcarimal system damage.  -Superior orbital rim fx – heavy bone structure –rarely damaged, assoct’d w/ CNS injury, ductal tear with CSF leak, frontal sinus fx, intracranial bleed, intracranial FB. (rare sup. rectus/oblique mm)

25 Blowout Fracture- X-ray
Screening Teardrop sign Screen for fx. Waters view. …may see a cloudy maxillary sinus on side of fx from blood and fluid. Positive “teardrop sign” (obital contents /fat herniated into max sinus).

26 Blowout Fracture- CT Clinical indications Coronal and axial cuts
Depressed eye Nerve anesthesia EOM entrapment Orbital roof Coronal and axial cuts Study of choice – coronal and axial CT scan… an orbital roof fx considered. If you clinically suspect Fx will need Sx, get a CT Eye is depressed in orbit Nerve anesthesia EOM entrapment

27 Blowout fracture- Management
Consults Nasal Decongestants Antibiotics Evidence? Sneezing/Blowing Nose Disposition With entrapment Without entrapment Associated injuries Neuro consult – d/t severity of assoc’t injuries. Afrin days -   No evidence, but treat for sinusitis (augmentin, Erythromycin)…10 days. -     Don’t hold nose when sneeze, do not want to further extrude orbit from socket. -     Ice packs hours -      Muscle entrapment-does NOT require immediate Sx….Contact an: OMF, ENT, plastics (3-10 days). - ALL blow/o fx: Optho f/u w/in 48 hrs – r/o unidentified retinal tears or detachments. - Admitted: Intraocular hemorrhage, globe rupture, severe facial deformity, traumatic glaucoma, violation cranial vault.

28 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 in % trauma cases.conjunctiva is often intact. Sx….pain, decreased vision h/o trauma. Signs …severe conjunctival hemorrhage – may be 360 dgrs. Deep/shallow ant chamber…hyphema… hemorrhagic chemosis, irregular pupil (teardrop pupil – point towards area of globe rupture), extravasion of contents. - Any one of 4 sx’s has 100% sensitivity and 98.5% specificity for predicting rupture. 1.      Abn deep or shallow ant chamber 2.      IOP of 5 or less 3.      Media opacity preventing clear view of fundus 4.      VA showing light perception or worse.

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. - Shield the eye as soon as rupture suspected…eye shield, cup, secure with tape. NPO Do not remove or manipulate penetrating object - Stat Ophtho consult RSI – don’t squeeze the grape… raise IOP –Sedating –ketamine Paralyzing- succinylcholine. Effect of rocuronium compared w/ Succ on IOP during RSI. IOP- IOP impulse tonometer (15 v 15), sedation – pro/fent ROC mmHg ; Succ – 21.6 mmHg Prophylaxis with Abx…(Bacillus, Staph epidermitus/aureus, Strep, gram negatives)…. 4th gen Cephalosprin + Gentamycin Antiemetics – vomiting will raise IOP and extrude intraocular contents CT scan to exclude intraocular FB’s and confirm dx Prepare pt for surgery. admit

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 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):

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