Rosen & Barkin's 5-Minute Emergency Medicine Consult (616 page)

• Complete ophthalmologic exam
  
• Thorough neurologic exam to exclude cerebrovascular accident/transient ischemic attack
  

As needed to work up underlying diseases

Ocular US: ∼97% sensitive by trained EM physicians

• Intraocular pressure (IOP) measurement: IOP usually lower in the affected eye
  
• Dilating pupil with short-acting mydriatic carries very low risk of acute angle-closure glaucoma.
  

• Central retinal artery or vein occlusion
  
• Vitreous hemorrhage
  
• Migraine with or without aura
  
• Choroidal detachment
  
• Methanol poisoning
  
• Other retinal or CNS disease
  

TREATMENT

• Bed rest
  
• Consider transport to hospital with neurology and ophthalmology availability.
  

If suspected ERD, treat systemic disease.

• Bed rest:
  
  • Rest head on pillow with side of detachment down, side opposite of field defect
    
• Emergent ophthalmologic consultation
  

FOLLOW-UP

Need for surgical repair

• Any patient with retinal detachment seen by an ophthalmologist and deemed safe to go home
  
• Chronic retinal detachments are repaired over the same time course as it took to create them.
  
• ERD resolves with treatment of the underlying problem.
  

Detachments with macula involvement require repair within 1 day.

Per ophthalmologist

• Fundoscopy alone does not provide sufficient visualization to rule out detachment.
  
• Early recognition of retinal tears allows possible prophylactic:
  
  • 90% risk of retinal tear with “tobacco dust”
    
• Do not fail to recognize central retinal artery occlusion (CRAO):
  
  • Increased risk of stroke for patient with CRAO in setting of carotid disease or cardioembolic disease
    

• Gerstenblith AT, Rabinowitz MP.
  The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease.
  6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
  
• Kang HK, Luff AJ. Management of retinal detachment: A guide for non-ophthalmologists.
  BMJ
  . 2008;336:1235–1240.
  
• Pandya HK, Tewari A. “Retinal Detachment.” eMedicine. WebMD, updated Jan 29, 2013. Accessed Mar 26, 2013.
  
• Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment.
  J Emerg Med
  . 2011;40(1):53–57; Jul 21 2009; Epub ahead of print.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Visual Loss
  
• Vitreous Hemorrhage
  

CODES

• 361.00 Retinal detachment with retinal defect, unspecified
  
• 361.81 Traction detachment of retina
  
• 361.9 Unspecified retinal detachment
  

BASICS

• Also known as retrobulbar hematoma
  
• Rare complication of orbital trauma and facial surgery
  
• Collection of blood behind the globe causing increased retro-orbital pressure leading to tissue ischemia
  
• Vision loss can occur within 90 min if not diagnosed and treated with irreversible damage at 120 min
  
• A sight-saving procedure called lateral canthotomy is often needed to be performed in the emergency department
  
• A thorough exam is needed as many patients with ROH may be unconscious
  
• Frequent repeat exams are mandatory due to hematoma progression
  

• Incidence is difficult to estimate because ROH can be from multiple causes, both traumatic and iatrogenic.
  
  • 0.45–3% of blunt or penetrating trauma
    
  • 0.45–0.6% coexist with orbital wall fractures
    
  • 0.0052% of blepharoplasty
    
  • 0.3% of surgical facial fracture repair
    
  • 0.006% of endoscopic sinus surgery
    
• True incidence has been debated as only slightly more than half of diagnosed retro-orbital hemorrhage has been confirmed either with a preceding CT scan or with the presence of an evacuated hematoma.
  

• Trauma to the globe or orbital walls and the orbital plexus
  
• Rapid increasing pressure behind the orbit secondary to hematoma formation impedes venous outflow and arterial inflow to the retina and the optic nerve to cause orbital compartment syndrome
  
• There may also be a stretching to the optic nerve as the patient develops proptosis which contributes to the decrease in visual acuity
  

DIAGNOSIS

• Penetrating or blunt trauma to the orbit
  
• Recent facial/orbital surgery
  
• Eye pain
  
• Vision loss
  

• Decreased visual acuity
  
• Increased IOP
  
• Proptosis
  
• Diplopia
  
• Pain
  
• Decreased EOM
  
• Relative afferent papillary defect, preserved consensual reflex
  

• Obtain history of injury
  
• High degree of suspicion
  
• Thorough physical exam
  
• Evaluate for immediate surgical decompression
  
• STAT ophthalmology consult
  
• Imaging
  

None diagnostic or suggestive of this diagnosis

• CT scan is gold standard but do not delay sight-saving intervention pending imaging
  
• Ultrasound (bedside if available): Sensitivity/specificity not studied. “Guitar-pick” sign.
  

The patient may present after trauma to the face with any of the following:

• Decreased vision
  
• Blurry vision
  
• Eye pain
  
• Eye discharge
  
• Photophobia
  
• Eye pressure
  
• Nausea and vomiting
  

The patient may present after having the following procedures:

• Reduction of facial fracture
  
• Eyelid surgery
  
• Endoscopic sinus surgery
  
• Regional anesthesia via retrobulbar injection
  
• Dacryocystectomy
  

One must consider as their differential:

• Orbital fracture
  
• Retro-orbital edema
  
• Retro-orbital emphysema
  
• Blow-in fractures
  
• Orbital roof fractures with brain herniation
  
• Intracranial bleeds
  
• Other major trauma associated with injury