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Ocular
Trauma
Blok 24Abraham Adiwidjaja Sutjiono
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BETT: Birmingham Eye Trauma Terminology
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Term - Definition and Explanation
Eyewall : Sclera and cornea
Although technically the eyewall has three coats posterior tothe limbus, for clinical and practical purposes, violation ofonly the most external structure is taken into consideration)
Closed globe injury : No full-thickness wound of eyewall Open globe injury: Full-thickness wound of the eyewall
Contusion: There is no (full-thickness) wound.
The injury is due to either direct energy delivery by the object
(e.g., choroidal rupture) or the changes in the shape of theglobe (e.g., angle recession)
Lamellar laceration: Partial-thickness wound of theeyewall
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Term - Definition and Explanation
Rupture: Full-thickness wound of the eyewall, caused by a bluntobject (Because the eye is filled with incompressible liquid, the impactresults in momentary increase in IOP.) The eyewall yields at itsweakest point (at the impact site or elsewhere; e.g., an old cataractwound dehisces even though the impact occurred elsewhere); theactual wound is produced by an inside-out mechanism
Laceration: Full-thickness wound of the eyewall, caused by a sharpobject. The wound occurs at the impact site by an outside-inmechanism
Penetrating injury: Entrance wound . If more than one wound is present, each must have
been caused by a different agent. Retained foreign object(s) Technically a penetrating injury, but grouped
separately because of different clinical implications
Perforating injury: Entrance and exit wounds. Both wounds caused bythe same agent
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OPEN GLOBE INJURY CLASSIFICATION
Type
A. Rupture B. Penetrating
C. IOFB
D. Perforating
E. Mixed
Grade (Visual acuity)
A. 20/40 B. 20/50 to 20/100
C. 19/100 to 5/200
D. 4/200 to light perception
E. NLP
Pupil
A. Positive, relative APD in injured eye
B. Negative, relative APD in injured eye
Zone
I. Cornea and limbus
II. Limbus to 5 mm posterior into sclera
III. Posterior to 5 mm from the limbus
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CLOSED GLOBE INJURY CLASSIFICATION
Type
A. Contusion B. Lamellar laceration
C. Superficial foreign body
D. Mixed
Grade (Visual acuity) A. 20/40
B. 20/50 to 20/100
C. 19/100 to 5/200 D. 4/200 to light perception
E. NLP
Pupil A. Positive, relative APD in injured eye
B. Negative, relative APD in injured eye
Zone (see Fig. 22) I. External (limited to bulbar conjunctiva, sclera, cornea)
II. Anterior segment (includes structures of the anterior segment and the pars plicata)
III. Posterior segment (all internal structures posterior to the posterior lens capsule)
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Eyelid Laceration
Symptoms
Periorbital pain, tearing.
Signs
Partial or full-thickness defect in the eyelid involving
the skin and subcutaneous tissues. Superficial
laceration/abrasion may mask a deep laceration or
injury to the lacrimal drainage system (e.g., puncta,canaliculi, common canaliculus, lacrimal sac).
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Eyelid Laceration contd
Work-Up
History: Determine mechanism of injury: bite, foreign body
potential, etc.
Complete ocular examination, including bilateral dilated
fundus evaluation. Make sure there is no injury to the globes
and optic nerves before attempting eyelid repair.
Determine the depth of the laceration (can look deceptively
superficial). Use toothed forceps or cotton-tipped applicators
to gently pull open one edge of the wound to determine
depth of penetration.
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Eyelid Laceration contd
Work-Up
CT scan of brain and orbits (axial and coronal views, 1- to 3-
mm sections) should be obtained when a foreign body,
ruptured globe, or severe blunt trauma is suspected. Loss of
consciousness necessitates CT scan of the brain. Depending
on the mechanism of injury, the cervical spine may need to
be cleared.
If laceration is nasal to either the upper or lower eyelid
punctum, even if not obviously through the canalicularsystem, perform punctal dilation and irrigation of the
canalicular system to exclude canalicular involvement
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Eyelid Laceration contd
Treatment
Consider tetanus prophylaxis
Give systemic antibiotics if contamination or foreign body is
suspected [e.g., dicloxacillin or cephalexin, 250 to 500 mg
p.o., q.i.d. (adults); 25 to 50 mg/kg/day divided into four
doses (children); for human or animal bites, consider
penicillin V (same dose as dicloxacillin)]. Continue for 5 to 7
days. For animal bites, if indicated, consider rabies
prophylaxis.
Assess eyelid laceration.
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Eyelid Laceration contd
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Eyelid Laceration contd
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Conjunctival Laceration
Symptoms:
Mild pain, red eye, foreign body sensation; usually, a
history of ocular trauma.
Signs
Fluorescein staining of the conjunctiva. The
conjunctiva may be torn and rolled up on itself.
Exposed white sclera may be noted. Conjunctivaland subconjunctival hemorrhages are often present.
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Conjunctival Laceration contd
Work-Up
History: Determine the nature of the trauma and whether a rupturedglobe or intraocular or intraorbital foreign body may be present.Evaluate mechanism for possible foreign body involvement, includingsize, shape, weight, and velocity of object.
Complete ocular examination, including careful exploration of thesclera (after topical anesthesia, e.g., proparacaine) in the region of theconjunctival laceration to rule out a scleral laceration or asubconjunctival foreign body. The entire area of sclera under theconjunctival laceration must be inspected. Since the conjunctiva ismobile, inspect a wide area of the sclera under the laceration. Use aproparacaine-soaked, sterile cotton-tipped applicator to manipulatethe conjunctiva. A Seidel test may be helpful. Dilated fundusexamination, especially evaluating the area underlying theconjunctival injury, must be carefully performed with indirectophthalmoscopy.
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Conjunctival Laceration contd
Work-Up
Consider a CT scan of the orbit (axial and coronal views, 1-
mm sections) to exclude an intraocular or intraorbital
foreign body. UBM may be helpful.
Exploration of the site in the operating room under
general anesthesia may be necessary when a ruptured
globe is suspected.
Children often do not give an accurate history of trauma.
They must be questioned and examined especially
carefully.
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Conjunctival Laceration contd
Treatment
Antibiotic ointment (e.g., erythromycin or bacitracin
t.i.d.) for 4 to 7 days. A pressure patch may be used
for the first 24 hours. Most lacerations will heal without surgical repair.
Some large lacerations (>1 to 1.5 cm) may be
sutured with 8-0 polyglactin 910 (e.g., Vicryl). When
suturing, take care not to bury folds of conjunctiva
or incorporate Tenon capsule into the wound. Avoid
suturing the plica semilunaris or caruncle to the
conjunctiva.
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Conjunctival Laceration contd
Conjunctival laceration vs subconjunctival
bleeding vs scleral foreign bodies vs scleral
rupture?
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Scleral foreign body. (A) The obvious finding is a small subconjunctival hemorrhage.
(B) With higher magnification and a slit illumination, the brassfragment from a .22 caliber bullet casing is seen to be transfixingthe sclera. In this case, 90% of the scleral foreign body was insidethe globe. The conjunctival laceration/hemorrhage did not overliethe scleral defect, a common situation in combined wounds of theconjunctiva and sclera.
(C) The removed foreign body.
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Corneal Laceration
Can be partial or full thickness corneal
laceration
Parital-Thickness Laceration
Signs
The anterior chamber is not entered and, therefore,
the cornea is not perforated.
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Corneal Laceration contd
Parital-Thickness Laceration
Work-Up Careful slit-lamp examination should be performed to exclude
ocular penetration. Carefully evaluate the conjunctiva, sclera, andcornea, checking for extension beyond the limbus in casesinvolving the corneal periphery. Evaluate the depth of the AC and
compare with the fellow eye. A shallow AC indicates an activelyleaking wound or a self-sealed leak. Deeper AC in the involved eyecan be an indication of a posterior rupture. Check iris fortransillumination defects (TIDs) and evaluate lens for a cataract ora foreign body tract (must have a high level of suspicion withprojectile objects). Presence of TIDs and lens abnormalities are an
indication of a ruptured globe. IOP should be measured only aftera ruptured globe is ruled out. Use applanation only if thelaceration site can be avoided. Otherwise, use a Tono-Pen to checkthe IOP.
Seidel test. If the Seidel test is positive, a full-thickness lacerationis present.
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Corneal Laceration contd
Parital-Thickness Laceration
Treatment
A cycloplegic (e.g., scopolamine 0.25%) and an antibiotic
[e.g., frequent polymyxin B/ bacitracin ointment (e.g.,Polysporin) or fluoroquinolone drops, depending on thenature of the wound].
When a moderate to deep corneal laceration isaccompanied by wound gape, it is often best to suture
the wound closed in the operating room to avoidexcessive scarring and corneal irregularity, especially inthe visual axis.
Tetanus toxoid for dirty wounds
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Corneal Laceration contd
Follow-Up Reevaluate daily until the epithelium heals.
Full-Thickness Laceration See Ruptured Globe and Penetrating Ocular Injury.
Note that small, self-sealing, or slow-leakinglacerations may be treated with aqueous
suppressants, bandage soft contact lenses,fluoroquinolone drops q.i.d. Alternatively, apressure patch and twice-daily antibiotics may beused. Avoid topical steroids.
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Corneal Laceration
Full-thickness corneal laceration
with positive Seidel test
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Chemical Injuries
Acids vs alkalis
Alkalies readily penetrate into the eye,
damaging the corneal stroma and endothelium
as well as other anterior segment structures(e.g., iris, lens, ciliary body). Most acids tend to
remain confined to the ocular surface.
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Chemical Injuries contd
Work-up: elimination of residual alkali or acid from the eye;
institution of topical and systemic medical therapy tominimize adverse sequelae.
Treatment:
Irrigate copiously IMMEDIATELY :
No therapeutic differences have been identified betweennormal saline, normal saline with bicarbonate, lactatedRingers, balanced salt solution (BSS), and BSS-plus.
Try to use other neutral fluids
As it is impossible to overirrigate a chemically injured eye,
irrigation for 15 to 30 minutes is recommended.
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Chemical Injuries contd
An eyelid speculum and topical anesthetic (e.g.,proparacaine) can be placed prior to irrigation. Upper andlower fornices must be everted and irrigated
NEVER use acidic solutions to neutralize alkalis or vice versaas acid-base reactions themselves can generate harmful
substrates Check the pH a few minutes after irrigation
Debridement
Medical therapy Topical corticosteroids
Topical antibiotics
Glaucoma medications
Cycloplegics
Sodium ascorbat
Artificial tears
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Chemical Injuries contd
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Corneal and Conjunctival Foreign Bodies
Symptoms
Foreign body sensation, tearing, history of trauma.
Signs
Critical. Conjunctival or corneal foreign body with or
without rust ring.
Other. Conjunctival injection, eyelid edema, mild AC
reaction, and SPK. A small infiltrate may surround acorneal foreign body; it is usually sterile. Vertically
oriented linear corneal abrasions or SPK may
indicate a foreign body under the upper eyelid.
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Corneal and Conjunctival Foreign Bodies Contd
Work-Up
History: Determine the mechanism of injury [e.g.,
metal striking metal, power tools or weed-whackers
may suggest an intraocular foreign body (IOFB)].Attempt to determine the size, weight, velocity,
force, and shape of the object. Safety goggles?
Document visual acuity before any procedure is
performed. One or two drops of topical anesthetic
may be necessary to control blepharospasm and
pain.
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Corneal and Conjunctival Foreign Bodies Contd
Work-Up Slit-lamp examination: Locate and assess the depth of
the foreign body. Rule out self-sealing lacerations.Examine closely for iris tears and transillumination
defects, lens opacities, AC shallowing, andasymmetrically low IOP in the involved eye.
If there is no evidence of perforation, evert the eyelidsand inspect the fornices for additional foreign bodies.
Double-everting the upper eyelid with a Desmarreseyelid retractor may be necessary. Carefully inspect aconjunctival laceration to rule out a scleral laceration orperforation. Measure the dimensions of any infiltrateand the degree of any AC reaction.
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Corneal and Conjunctival Foreign Bodies Contd
Work-Up
Dilate the eye and examine the posterior segment
for a possible IOFB
Consider a B-scan ultrasonography (UBM), acomputed tomography (CT) scan of the orbit (axial
and coronal views, 1-mm sections), or
ultrasonographic biomicroscopy (UBM) to exclude
an intraocular or intraorbital foreign body. Avoid
magnetic resonance imaging (MRI) if there is a
history of possible metallic foreign body.
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Corneal and Conjunctival Foreign Bodies Contd
Innert vs non-innert FB
Principle: take it out in fashioned ways..
Corneal metallic foreign body with rust ring
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Corneal and Conjunctival Foreign Bodies Contd
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Corneal foreign body - Treatment
Apply topical anesthetic (e.g., proparacaine). Remove thecorneal foreign body with a foreign body spud or fine forceps
at a slit lamp. Multiple superficial foreign bodies may be more
easily removed by irrigation.
Remove the rust ring as completely as possible on the firstattempt. It is sometimes safer to leave a deep, central rust
ring to allow time for the rust to migrate to the corneal
surface, at which point it can be removed more easily.
Measure the size of the resultant corneal epithelial defect.
Treat as for corneal abrasion
Alert the patient to return as soon as possible if there is any
worsening of symptoms.
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Conjunctival foreign body - Treatment
Remove foreign body under topical anesthesia. Multiple or loose foreign bodies can often be removed
with saline irrigation.
A foreign body can be removed with a cotton-tipped
applicator soaked in topical anesthetic or with fine forceps. For deeply embedded foreign
bodies, consider pretreatment with a cotton-tippedapplicator soaked in phenylephrine 2.5% to reduceconjunctival bleeding.
Small, relatively inaccessible, buried subconjunctivalforeign bodies may sometimes be left in the eye withoutharm unless they are infectious or proinflammatory.Occasionally, they will surface with time, at which pointthey may be removed more easily.
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Conjunctival foreign body - Treatment
Sweep the conjunctival fornices with a glass rod
or cotton-tipped applicator soaked with a
topical anesthetic to catch any remaining
pieces. A topical antibiotic (e.g., bacitracin ointment
b.i.d.; trimethoprim/polymyxin B or
fluoroquinolone drops q.i.d.) may be used. Artificial tears (e.g., Refresh q.i.d. for 2 days)
may be given for irritation.
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Follow-up
Corneal foreign body: Follow up as with corneal
abrasion. If residual rust ring remains,
reevaluate in 24 hours.
Conjunctival foreign body: Follow up as needed,or in 1 week if residual foreign bodies were left
in the conjunctiva.
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Hyphema
Blood in the AC commonly accumulates in case
of (closed as well as open) globe trauma.
Consequences include IOP elevation, corneal
blood staining, the formation ofanterior/posterior synechiae, cataract, and a
wide variety of indirectly related pathologic
changes.
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Hyphema
Symptoms
Pain, blurred vision, history of blunt trauma.
Signs
Blood or clot or both in the AC, usually visible
without a slit lamp. A total (100%) hyphema may be
black or red. When black, it is called an 8-ball or
black ball hyphema; when red, the circulatingblood cells may settle with time to become less than
a 100% hyphema.
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Hyphema contd
Work-Up History: Mechanism (including force, velocity, type,
and direction) of injury? Protective eyewear? Timeof injury? Time of visual loss? Usually the visualcompromise occurs at the time of injury; decreasingvision over time suggests a rebleed or continuedbleed. Use of medications with anticoagulantproperties [aspirin, NSAIDs, warfarin (e.g.,
Coumadin), or clopidogrel (e.g., Plavix)]? Personal orfamily history of sickle cell disease/trait? Symptomsof coagulopathy (e.g., bloody nose-blowing,bleeding gums with tooth brushing, easy bruising)?
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Hyphema contd
Work-Up Ocular examination, first ruling out a ruptured globe
Evaluate for other traumatic injuries. Document theextent (e.g., measure the hyphema height) and location
of any clot and blood. Measure the IOP. Perform adilated retinal evaluation without scleral depression.Consider a gentle UBM if the view of the fundus is poor.Avoid gonioscopy unless intractable increased IOPdevelops. If gonioscopy is necessary, gently use a Zeiss 4mirror lens. Consider UBM to evaluate the anteriorsegment if the view is poor and lens capsule rupture,IOFB, or other anterior segment abnormalities aresuspected.
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Hyphema contd
Work-Up
Consider a CT scan of the orbits and brain (axial and
coronal views, with 1- to 3-mm sections through the
orbits) when indicated (e.g., suspected orbitalfracture or IOFB, loss of consciousness).
Black and Mediterranean patients should be
screened for sickle cell trait or disease (order
Sickledex screen; if necessary, may checkhemoglobin electrophoresis).
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Hyphema contd
Treatment Confine either to bed rest with bathroom privileges or
to limited activity. Elevate head of bed to allow blood tosettle.
Place a shield (metal or clear plastic) over the involvedeye at all times. Do not patch because this preventsrecognition of sudden visual loss in the event of arebleed.
Atropine 1% solution b.i.d. to t.i.d. or scopolamine
0.25% b.i.d. to t.i.d. No aspirin-containing products or NSAIDs.
Mild analgesics only (e.g., acetaminophen). Avoidsedatives.
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Hyphema contd
Treatment
Use topical steroids (e.g., prednisolone acetate 1%
four to eight times per day) if any suggestion of iritis
(e.g., photophobia, deep ache, ciliary flush),evidence of lens capsule rupture, any protein (e.g.,
fibrin), or definitive white blood cells in anterior
chamber. Reduce the frequency of steroids as soon
as signs and symptoms resolve to reduce thelikelihood of steroid-induced glaucoma.
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Hyphema contd
Treatment For increased IOP:
Start with a beta-blocker (e.g., timolol or levobunolol 0.5%b.i.d.).
If IOP still high, add topical alphaagonist (e.g., apraclonidine0.5%, or brimonidine 0.2% t.i.d.) or topical carbonic anhydraseinhibitor (e.g., dorzolamide 2%, or brinzolamide 1% t.i.d.).Avoid prostaglandin analogs and miotics (may increaseinflammation). In children under 5, topical alphaagonists are
contraindicated. If topical therapy fails, add acetazolamide (500 mg p.o., q12h
for adults, 20 mg/kg/day divided three times per day forchildren) or mannitol [1 to 2 g/kg intravenously (i.v.) over 45minutes q24h]. If mannitol is necessary to control the IOP,
surgical evacuation may be imminent.
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Hyphema contd
Treatment If hospitalized, use antiemetics p.r.n. for severe nausea or
vomiting [e.g., prochlorperazine 10 mg intramuscularly (i.m.)q8h or 25 mg q12h p.r.n.; 48 hours, despite maximal medical therapy (toprevent optic atrophy).
IOP >25 mm Hg with total hyphema for >5 days (to prevent cornealstromal blood staining).
IOP 24 mm Hg for >24 hours (or any transient increase in IOP >30 mmHg) in sickle trait/disease patients.
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Hyphema contd
Follow-Up The patient should be seen daily for 3 days after initial
trauma to check visual acuity, IOP, and for a slit-lampexamination. Look for new bleeding, increased IOP,corneal blood staining, and other intraocular injuries asthe blood clears (e.g., iridodialysis; subluxated,disclocated, or cataractous lens). Hemolysis, which mayappear as bright red fluid, should be distinguished froma rebleed, which forms a new, bright red clot. If the IOPis increased, treat as described earlier.
The patient should be instructed to return immediatelyif a sudden increase in pain or decrease in vision isnoted (which may be symptoms of a rebleed orsecondary glaucoma).
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Hyphema contd
Follow-Up If a significant rebleed or an intractable IOP increase
occurs, the patient should be hospitalized.
After the initial close follow-up period, the patient may
be maintained on a long-acting cycloplegic (e.g.,atropine 1% solution q.d. to b.i.d., scopolamine 0.25%q.d. to b.i.d.), depending on the severity of thecondition. Topical steroids may be tapered as the blood,
fibrin, and white blood cells resolve. Glasses or eye shield during the day and eye shield at
night. As with any patient, protective eyewear(polycarbonate or Trivex lenses) should be worn anytime significant potential for an eye injury exists.
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Hyphema contd
Follow-Up
The patient must refrain from strenuous physical
activities (including bearing down or Valsalva
maneuvers) for 1 week after the initial injury orrebleed. Normal activities may be resumed 1 week
from the date of injury or rebleed. This period
should be extended if blood remains in the anterior
chamber.
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Orbital Blow-Out Fracture
Symptoms
Pain on attempted eye movement (orbital floor
fracture: pain on vertical eye movement; medial
wall fracture: pain on ab-/adduction), localtenderness, eyelid edema, binocular diplopia,
crepitus after nose-blowing, recent history of
trauma. Tearing may be a symptom of nasolacrimal
duct fracture seen with medial buttress or Leforte IIfractures, but this is typically a late complaint. Acute
tearing is usually due to ocular surface irritation
(e.g., conjunctival chemosis, corneal abrasion, iritis).
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Orbital Blow-Out Fracture contd
Signs Critical. Restricted eye movement (especially in upward
or lateral gaze or both), subcutaneous or conjunctivalemphysema, hypesthesia in the distribution of theinfraorbital nerve (i.e., ipsilateral cheek and upper lip),point tenderness, enophthalmos (may initially bemasked by orbital edema).
Other. Nosebleed, eyelid edema, and ecchymosis.Superior rim and orbital roof fractures may show
hypesthesia in the distribution of the supratrochlear orsupraorbital nerve (ipsilateral forehead) and ptosis.Trismus, malar flattening, and a palpable step-offdeformity of the inferior orbital rim are characteristic oftripod (zygomatic complex) fractures. Optic neuropathymay be present.
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Orbital Fracture
Palpebral Edema Ophthalmoplegi
Enopthalmus
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Orbital Blow-Out Fracture contd
Differential Diagnosis
Orbital edema and hemorrhage without a blow-out
fracture: May have limitation of ocular movement,
periorbital swelling, and ecchymosis due to soft-tissue edema and hemorrhage, but these resolve
over 7 to 10 days.
Cranial nerve palsy: Limitation of ocular movement,
but no restriction on forced-duction testing. Willhave abnormal results on force generation testing.
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Orbital Blow-Out Fracture contd
Work-Up Complete ophthalmologic examination, including
measurement of extraocular movements and globedisplacement. Compare the sensation of the affectedcheek with that on the contralateral side; palpate theeyelids for crepitus (subcutaneous emphysema); palpatethe orbital rim for step-offs; evaluate the globe carefullyfor a rupture, hyphema or microhyphema, traumaticiritis, and retinal or choroidal damage. Measure IOP.Check pupils and color vision to rule out a traumaticoptic neuropathy If eyelid and periocular edema limitthe view, special techniques may be necessary (e.g., useof Desmarres retractors, lateral cantholysis,examination under general anesthesia).
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Orbital Blow-Out Fracture contd
Work-Up
Forced-duction testing is performed if restriction of
eye movement persists beyond one week.
CT orbit scans (axial and coronal views, 3-mmsections, without contrast) are obtained in all cases
of suspected orbital fractures. Bone windows are
especially helpful in evaluation of fractures. If there
is any history of loss of consciousness, brain imagingis required.
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Orbital Blow-Out Fracture contd
Treatment
Broad-spectrum oral antibiotics [e.g., cephalexin
(Keflex) 250 to 500 mg p.o., q.i.d.; or erythromycin
250 to 500 mg p.o., q.i.d.] for 7 days. The use ofprophylactic antibiotics in orbital fracture is
controversial. Antibiotics are recommended if the
patient has a history of sinusitis, diabetes, or is
otherwise immunocompromised. In all otherpatients, the decision about antibiotic use is left up
to the treating physician.
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Orbital Blow-Out Fracture contd
Treatment Instruct patient not to blow his or her nose.
Nasal decongestants [e.g., pseudoephedrine (Afrin)
nasal spray b.i.d.] for 3 days. Use is limited to 3 days tominimize the chance of rebound nasal congestion.
Apply ice packs to the orbit for the first 24 to 48 hours.
Consider oral steroids (e.g., Medrol dose pack) if
extensive swelling limits examination of ocular motilityand globe position. If corticosteroids are used, systemic
antibiotics should also be considered.
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Orbital Blow-Out Fracture contd
Treatment Neurosurgical consultation is recommended for all
fractures involving the orbital roof, frontal sinus, orcribriform plate and for all fractures associated with
intracranial hemorrhage. Otolaryngology or oralmaxillofacial surgery consultation is recommendedfor frontal sinus, midfacial, and mandibularfractures.
Surgical repair: Immediate repair (within 24 to 72 hours)
Repair in 1 to 2 weeks
Delayed Repair
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Ruptured Globe and Penetrating Ocular Injury
Symptoms Pain, decreased vision, loss of fluid from eye. History of
trauma, fall, or sharp object entering globe.
Signs
Critical. Full-thickness scleral or corneal laceration,severe subconjunctival hemorrhage (especially involving360 degrees of bulbar conjunctiva, often bullous), adeep or shallow AC compared to the fellow eye, peaked
or irregular pupil, iris TIDs, lens material in the AC,foreign body tract in the lens, or limitation ofextraocular motility (greatest in direction of rupture).Intraocular contents may be outside of the globe.
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Ruptured Globe and Penetrating Ocular Injury
Signs
Other. Low IOP (although it may be normal or
increased), iridodialysis, cyclodialysis, hyphema (i.e.,
clotted blood in AC), periorbital ecchymosis,vitreous hemorrhage, dislocated or subluxed lens,
and traumatic optic neuropathy. Commotio retinae,
choroidal rupture, and retinal breaks may be seen
but are often obscured by vitreous hemorrhage.
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Ruptured Globe and Penetrating Ocular Injury
Work-Up/Treatment
Once the diagnosis of a ruptured globe is made,
further examination should be deferred until the
time of surgical repair in the operating room. This isto avoid placing any pressure on the globe and
risking extrusion of the intraocular contents.
Diagnosis should be made by penlight, or if possible,
by slit-lamp examination (with very gentlemanipulation). Once the diagnosis is made, then the
following measures should be taken:
Protect the eye with a shield at all times.
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Ruptured Globe and Penetrating Ocular Injury
Work-Up/Treatment Obtain CT scan of the brain and orbits (axial and coronal
views, 1-mm sections) to rule out IOFB in most cases.
Gentle UBM may be needed to localize posterior rupture
site(s) or to rule out intraocular foreign bodies not visibleon CT scan (nonmetallic, wood, etc.). However, UBMshould not be done in patients with an obvious anteriorrupture for the risk of extrusion of intraocular contents. Atrained ophthalmologist should evaluate the patient
before UBM or other manipulation is performed on aruptured globe suspect.
Admit patient to the hospital with no food or drink (NPO).
Place patient on bed rest with bathroom privileges. Avoid
bending over and Valsalva maneuvers.
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Ruptured Globe and Penetrating Ocular Injury
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Ruptured Globe and Penetrating Ocular Injury
Work-Up/Treatment Systemic antibiotics should be administered within 6 hours of injury.
For adults, give cefazolin 1 g i.v. q8h or vancomycin 1 g i.v. q12h. Alsogive ciprofloxacin 400 mg p.o./i.v. b.i.d. (fourth-generationfluoroquinolones, such as gatifloxacin 400 mg q.d. or moxifloxacin
400 mg q.d. may have better vitreous penetration). For children