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.
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
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 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 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. 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.