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):