Orbital trauma: Difference between revisions

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==Background==
==Background==
*Must assess:
[[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]]
*Must [[Eye exam|assess]]:
**Visual acuity
**Visual acuity
**Anterior chamber
**Anterior chamber
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==Clinical Features==
==Clinical Features==
#Anterior chamber is flat +/- abnormal pupil
*Anterior chamber is flat +/- abnormal pupil
##Ruptured globe is certain
**[[Ruptured globe]] is certain
##Stop the exam; place eye shield, consult ophtho
**Stop the exam; place eye shield, consult ophtho
#Hyphema
*[[Hyphema]]
##Evidence of significant trauma; consult ophtho
**Evidence of significant trauma; consult ophtho
#Extra-ocular movements
*Extra-ocular movements
##Restricted upgaze or lateral gaze suggests [[Orbital Fracture]] w/ entrapment
**Restricted upgaze or lateral gaze suggests [[orbital fracture]] with entrapment
###Obtain CT face
***Obtain CT face
#Orbital Rim
*Orbital Rim
##Feel for step-off
**Feel for step-off
#Sensation
*Sensation
##Test along distribution of inf orbital nerve (below eye and ipsilateral side of nose)
**Test along distribution of inf orbital nerve (below eye and ipsilateral side of nose)
#Photophobia
*Photophobia
## If photophobia in affected and unaffected eye, suspect traumatic iritis
**If photophobia in affected and unaffected eye, suspect traumatic iritis
#Decreased visual acuity +/- proptosis
*[[vision loss|Decreased visual acuity]] +/- proptosis
##Clinically suspect [[Orbital Hematoma]], check IOP if open globe has been ruled out
**Clinically suspect [[orbital hematoma]], check [[intraocular pressure|IOP]] if open globe has been ruled out


==Diagnosis==
===Exam===
#Slit-lamp exam w/ fluorescein
[[File:Teardrop pupil.jpg|thumb]]
##Check for:
**Bird's eye view for exophthalmos with retrobulbar hematoma
###Abrasion
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
###Laceration
*[[vision loss|Acuity]]
###Foreign body
*[[Diplopia]]
###Hyphema
**Binocular diplopia suggests entrapment of extraocular muscles
###Iritis
**Monocular diplopia suggests [[lens dislocation]]
####Pupil may be constricted or dilated
*Extraocular motion
###Lens dislocation
**Limitation on upward gaze occurs with [[orbital fractures|fracture of inferior and medial orbital wall]]
###Globe rupture
*Pupil
####+Seidel test
**Teardrop sign ([[globe rupture]]), [[hyphema]], reactivity (swinging flashlight test)
####Full-thickness laceration
*[[intraocular pressure|Pressure]] (only if rule out globe rupture)
#Ocular US
**Check in patients with exophthalmos, afferent nerve defect or evidence of [[retrobulbar hematoma]
##Can be done AFTER open globe has been ruled out
 
##Check for: retinal detachment, vitreous hemoarrhage/detachment
==Differential Diagnosis==
{{Eye trauma}}
{{Maxillofacial trauma DDX}}
{{Unilateral red eye DDX}}
 
==Evaluation==
*[[Slit-lamp]] exam with fluorescein
**Check for:
***[[corneal abrasion|Abrasion]]
***Laceration
***[[corneal ulcer|Ulceration]]
***[[ocular foreign body|Foreign body]]
***Hyphema
***Hypopion
***[[Iritis]]
***[[Lens dislocation]]
***[[Globe rupture]]
*Consider non-contrast face/orbital CT
*Consider [[ocular ultrasound]] (if no suspicion for globe rupture)
 
==Management==
*Based on specific injury


==Disposition==
==Disposition==
#Ophtho in 48hr if vision and ocular anatomy are preserved
*Depends on specific injury
 
==External Links==
*[http://webeye.ophth.uiowa.edu/eyeforum/tutorials/trauma.htm EyeRounds Ocular Trauma]
*[http://www.emdocs.net/em-cases-blunt-ocular-trauma/ emDocs Ocular Trauma]


==See Also==
==See Also==
*[[Orbital Fracture]]
*[[Maxillofacial trauma]]
*[[Traumatic Hyphema]]
*[[Retrobulbar Hematoma]]


==References==
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 20:00, 18 January 2023

Background

Eye anatomy.
  • Must assess:
    • Visual acuity
    • Anterior chamber
    • Integrity of globe
    • Pupil shape and reactivity
  • Use paperclip or eyelid speculum to open swollen eyes

Clinical Features

  • Anterior chamber is flat +/- abnormal pupil
    • Ruptured globe is certain
    • Stop the exam; place eye shield, consult ophtho
  • Hyphema
    • Evidence of significant trauma; consult ophtho
  • Extra-ocular movements
    • Restricted upgaze or lateral gaze suggests orbital fracture with entrapment
      • Obtain CT face
  • Orbital Rim
    • Feel for step-off
  • Sensation
    • Test along distribution of inf orbital nerve (below eye and ipsilateral side of nose)
  • Photophobia
    • If photophobia in affected and unaffected eye, suspect traumatic iritis
  • Decreased visual acuity +/- proptosis

Exam

Teardrop pupil.jpg
    • Bird's eye view for exophthalmos with retrobulbar hematoma
    • Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
  • Acuity
  • Diplopia
    • Binocular diplopia suggests entrapment of extraocular muscles
    • Monocular diplopia suggests lens dislocation
  • Extraocular motion
  • Pupil
  • Pressure (only if rule out globe rupture)
    • Check in patients with exophthalmos, afferent nerve defect or evidence of [[retrobulbar hematoma]

Differential Diagnosis

Orbital trauma

Acute

Subacute/Delayed

Maxillofacial Trauma

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Evaluation

Management

  • Based on specific injury

Disposition

  • Depends on specific injury

External Links

See Also

References

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