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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**Evidence of significant trauma; consult ophtho | **Evidence of significant trauma; consult ophtho | ||
*Extra-ocular movements | *Extra-ocular movements | ||
**Restricted upgaze or lateral gaze suggests [[ | **Restricted upgaze or lateral gaze suggests [[orbital fracture]] with entrapment | ||
***Obtain CT face | ***Obtain CT face | ||
*Orbital Rim | *Orbital Rim | ||
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**If photophobia in affected and unaffected eye, suspect traumatic iritis | **If photophobia in affected and unaffected eye, suspect traumatic iritis | ||
*[[vision loss|Decreased visual acuity]] +/- proptosis | *[[vision loss|Decreased visual acuity]] +/- proptosis | ||
**Clinically suspect [[ | **Clinically suspect [[orbital hematoma]], check [[intraocular pressure|IOP]] if open globe has been ruled out | ||
===Exam=== | |||
[[File:Teardrop pupil.jpg|thumb]] | |||
**Bird's eye view for exophthalmos with retrobulbar hematoma | **Bird's eye view for exophthalmos with retrobulbar hematoma | ||
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture) | **Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture) | ||
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**Teardrop sign ([[globe rupture]]), [[hyphema]], reactivity (swinging flashlight test) | **Teardrop sign ([[globe rupture]]), [[hyphema]], reactivity (swinging flashlight test) | ||
*[[intraocular pressure|Pressure]] (only if rule out globe rupture) | *[[intraocular pressure|Pressure]] (only if rule out globe rupture) | ||
**Check in patients with exophthalmos, afferent nerve defect or evidence of [[retrobulbar hematoma] | **Check in patients with exophthalmos, afferent nerve defect or evidence of [[retrobulbar hematoma] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Latest revision as of 20:00, 18 January 2023
Background
- 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
- Restricted upgaze or lateral gaze suggests orbital fracture with entrapment
- 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
- Clinically suspect orbital hematoma, check IOP if open globe has been ruled out
Exam
- 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
- Limitation on upward gaze occurs with fracture of inferior and medial orbital wall
- Pupil
- Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
- 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
- Caustic keratoconjunctivitis^^
- Conjunctival hemorrhage
- Conjunctival laceration
- Corneal abrasion, Corneal laceration
- Globe rupture^
- Iridodialysis
- Lens dislocation
- Ocular foreign body
- Orbital fracture
- Frontal sinus fracture
- Naso-ethmoid fracture
- Inferior orbial wall fracture
- Medial orbital wall fracture
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage/hematoma
- Subconjunctival hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
Subacute/Delayed
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Hemorrhagic chemosis
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Evaluation
- Slit-lamp exam with fluorescein
- Check for:
- Abrasion
- Laceration
- Ulceration
- Foreign body
- Hyphema
- Hypopion
- Iritis
- Lens dislocation
- Globe rupture
- Check for:
- Consider non-contrast face/orbital CT
- Consider ocular ultrasound (if no suspicion for globe rupture)
Management
- Based on specific injury
Disposition
- Depends on specific injury