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Orbital Trauma Grant S Lipman MD Wilderness Medicine Fellow Clinical Instructor, Division of Emergency Medicine Stanford University School of Medicine.

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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:

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.

3 Orbital Architecture

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

5 Corneal Abrasions – Presentation Symptoms Signs

6 Corneal Abrasions VA test Remove contacts Slit-lamp exam

7 Corneal Abrasions


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

10 Subconjunctival Hemorrhages Definition Symptoms Signs Complete exam Treatment

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

12 Anterior Chamber Reaction

13 Hypopyon

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

15 Hyphema- Presentation Definition Symptoms Grading 0 RBC’s 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

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

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

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

20 Retinal Detachment RAPD/VA Fundoscopy Shafer Sign Ophthalmology consult Disposition

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

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

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

24 Blowout Fracture - Etiology Theories Waterhouse 1999 Buckling Hydraulic Fracture site Inferior wall Medial wall Superior rim CNS injury CSF leak Intracranial - bleed

25 Blowout Fracture- X-ray Screening Teardrop sign

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

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

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.

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.

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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