Rosen & Barkin's 5-Minute Emergency Medicine Consult (107 page)

Caused by a projectile which strikes the globe. The force is transmitted through the noncompressible structures of the globe to the weakest structural point: the orbital floor resulting in a blow out fracture.

• Orbital roof fractures with associated CNS injuries more common in children
  
• Orbital floor fractures: Unlikely before 7 yr of age:
  
  • Orbital floor is not as weak a point in the orbit due to lack of pneumatization of the paranasal sinuses.
    
• Unfortunately fractures can occur in children and may result in unrecognized entrapment of the rectus muscle labeled the “white-eyed” fracture:
  
  • These children may present with marked nausea, vomiting, headache, and irritability suggestive of a head injury that commonly distracts from the true diagnosis.
    

DIAGNOSIS

• Periorbital tenderness, swelling, and ecchymosis
  
• Impaired ocular mobility or diplopia:
  
  • Restricted upward gaze owing to inferior rectus entrapment
    
  • Restricted ipsilateral lateral gaze with medial rectus entrapment
    
• Infraorbital hypoesthesia:
  
  • Caused by compression/contusion of infraorbital nerve
    
  • May extend to upper lip
    
• Enophthalmos:
  
  • Globe set back owing to orbital fat displaced through fracture
    
• Periorbital emphysema:
  
  • From the ethmoid or maxillary sinus
    
• Epistaxis
  
• Normal visual acuity:
  
  • If not, consider more extensive injuries
    
• No orbital rim step off
  

• Ocular injuries:
  
  • Ruptured globe:
    
    • Incidence up to 30% of blow-out fractures
      
    • Ophthalmologic emergency
      
  • Retrobulbar hemorrhage
    
  • Emphysematous optic nerve compression
    
• Cervical spine or intracranial injuries
  
• Commonly associated injuries:
  
  • Subconjunctival hemorrhage
    
  • Corneal abrasion/laceration
    
  • Hyphema
    
  • Traumatic mydriasis
    
  • Traumatic iridocyclitis (uveitis)
    
• Less common:
  
  • Iridodialysis
    
  • Retinal detachment
    
  • Vitreous hemorrhage
    
  • Optic nerve injury
    
• Associated fractures:
  
  • Nasal bones
    
  • Zygomatic arch fracture
    
  • Le Fort fracture
    
• Late complications:
  
  • Sinusitis
    
  • Orbital infection
    
  • Permanent restriction of extraocular movement
    
  • Enophthalmos
    

Struck in the eye with a projectile. Paintball, handball, racquetball, baseball, rock, or possibly fist. Larger-sized projectiles will likely be blocked by the orbital rim. Seen frequently after MVCs which are the most common cause of maxillofacial trauma.

• Thorough ophthalmologic exam:
  
  • Palpate bony structures of the orbit for evidence of step off.
    
  • Careful attention not to place pressure on the globe until ruptured globe excluded:
    
    • Desmarres lid retractors may be necessary to evaluate the eye with swollen lid.
      
• Document pupillary response
  
• Visual acuity (should not be affected):
  
  • Handheld visual acuity Rosenbaum card is most useful with injuries.
    
• Test extraocular movements for disconjugate gaze or diplopia.
  
• Test sensation in inferior orbital nerve distribution.
  
• Examine lid and adnexa:
  
  • Orbital emphysema may be present.
    
• Slit-lamp and fundoscopic exam to identify associated injuries.
  
• Full physical exam to identify associated injuries and neurologic impairment.
  

• Preoperative lab studies if indicated
  
• Pregnancy testing prior to radiography
  

• If CT unavailable or contraindicated, plain radiographs will provide important information:
  
  • Facial films
    
  • Orbits
    
  • Waters view and exaggerated Waters view:
    
    • Classic “teardrop sign” illustrates herniated mass of orbital contents in the ipsilateral maxillary sinus.
      
    • Opacification of or air–fluid level in the ipsilateral maxillary sinus (less specific)
      
    • Orbital floor bony fracture
      
    • Lucency in orbits consistent with orbital emphysema
      
• CT-preferred modality:
  
  • Defines involved anatomy
    
  • Obtain axial and coronal 1.5-mm cuts:
    
    • Reconstruction of coronals not preferred but acceptable if positioning impossible
      

Forced duction test:

• Distinguishes nerve dysfunction from entrapment
  
• Topical anesthesia applied to the conjunctiva on the opposite side, and the globe is pulled away from the expected point of entrapment; if the globe is not mobile, the test is positive—defining physical entrapment.
  

• Orbital CT: Study of choice:
  
  • Plain films less helpful
    
• Essential to identify entrapment early as long-term outcome will likely be affected if left undiagnosed:
  
  • Early surgical intervention for entrapment may significantly improve outcome.
    

• Cranial nerve palsy
  
• Orbital cellulitis
  
• Periorbital cellulitis
  
• Periorbital contusion/ecchymosis
  
• Retrobulbar hemorrhage
  
• Ruptured globe
  

TREATMENT

• Metal protective eye shield if possible globe injury
  
• Place in supine position.
  

Initial approach and immediate concerns:

• Assess for associated intracranial or cervical spine injuries.
  
• Rule out ruptured globe.
  
• Test visual acuity:
  
  • Decreased visual acuity suggestive of associated with more extensive injuries
    

• After globe rupture is excluded, apply cool compresses for the 1st 24–48 hr to decrease swelling to minimize or reverse herniation and avoid surgical intervention.
  
• Avoid Valsalva maneuvers and nose blowing to prevent compressive orbital emphysema.
  
• Prophylactic antibiotics to prevent infection
  
• Nasal decongestants if no contraindication
  
• Analgesics as needed
  
• Tetanus prophylaxis
  

• Antibiotics are recommended prophylactically to prevent sinusitis and orbital cellulitis:
  
  • Cephalexin 250 mg q6h for 10 days
    
• Systemic corticosteroids have been advocated to speed up the resorption of edema in order to more accurately assess any muscle entrapment and orbital damage:
  
  • Prednisone (60–80 mg/d) within 48 hr of the injury and continued for 5 days
    
• Nasal decongestants may be beneficial if not contraindicated:
  
  • Phenylephrine nasal spray: BID for 2–4 days
    

FOLLOW-UP

• Rarely indicated
  
• 85% resolve without surgical intervention.
  
• Consultation with facial trauma service in ED and consideration for admission if:
  
  • 50% of floor fractured
    
  • Diplopia or entrapment is identified
    
  • Particularly in children
    
  • Enophthalmos >2 mm or more
    

In most cases, observe for 10–14 days until swelling resolves, then follow up with facial trauma surgeon to determine need for surgical intervention.

Symptoms should improve over time:

• If at any point patient develops increased swelling, tenderness, redness, or pain around the eye, they should return to ED for re-evaluation.
  
• If any visual disturbance, visual loss, or increased eye pain return to ED for re-evaluation.
  

• Be hypervigilant in checking pupillary response and visual acuity:
  
  • Abnormal results may be the 1st sign of serious complications:
    
    • Globe rupture
      
    • Optic nerve injury possibly stemming from emphysematous or retrobulbar compression
      
• Careful evaluation for entrapment:
  
  • Essential for all, but particularly children, to exclude white-eyed fracture and its long-term complications
    
• The oculocardiac (Aschner) reflex may be associated with this injury. It manifests as a decrease in pulse rate associated with traction applied to extraocular muscles and/or compression of the eyeball:
  
  • May be seen more commonly in children
    
  • Treated by release of pressure and in some cases may require atropine
    

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