Practice. 1998. Le Sage N et al:Ann of EM. 2001. Contact

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.
• Ill 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? Ill 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
CornealAbrasions

• VA test
• Remove contacts
• Slit-lamp exam

7
Corneal Abrasions
8
Corneal Abrasions
9
Corneal Abrasions - Management

• To patch or not to patch, that is the question.
• Flynn et al J. Family Practice. 1998.
• Le Sage N et alAnn of EM. 2001.
• 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 RBCs
• I lt1/3
• II 1/3 1/2
• III gt 1/2
• IV eight ball

16
Hyphema- Management

• Ophthalmic consult
• Pupillary play/Eye Patch
• Reverse Trendelenburg
• Anesthesia /Anti-emetic
• IOP control gt 30 mmHg (gt24 mmHg in HbSS)
• Admission
• HbSS
• Anti-coagulated
• gt Grade I
• Decreasing VA
• ED evaluation gt 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
• 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.

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
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  and Treatment of Eye Disease. J. B. Lippincott
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• 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.