Download Phthisis Bulbi

Orbital Trauma
David M. Yousem, M.D., M.B.A.
Johns Hopkins Medical Institution
N.A. What constrains a retinal
detachment?
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2.
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4.
5.
A. Ciliary body
B. Hyaloid vessels
C. Ora Serrata
D. Zonular ligaments
E. Orbital septum
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N.A. The following is not an
indication for surgical correction of
orbital Fx
1. A. Double vision
2. B. Enophthalmos
3. C. Greater than 50%
floor involvement
4. D. Exophthalmos
5. E. None of the above
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Orbital Trauma
Goals and Objectives
• Describe injuries to globe (bulbar)
• List indications for acute globe
intervention
• Describe retrobulbar injuries including
fractures (intraconal/conal/extraconal)
• Discuss controversies re: fracture
intervention
Orbital Trauma : Background
• Trauma to eye = 3% of ED visits
• 4.5% of all orbital pathology is from
trauma
• 40% of monocular blindness in US is
from trauma
• Some findings require acute
treatment
Which eye is abnormal?
1. A. Right
2. B. Left
Ocular Blood Locations:
• Anterior chamber: anterior hyphema
• Posterior chamber: posterior
hyphema
• Vitreous: vitreous hemorrhage
• Choroidal detachment
• Retinal detachment
Anterior Chamber Trauma
• Rupture
– Pain, decreased vision, hyphema
– Flourescein slitlamp cobalt blue dilution
• Open injury
• Hyphema
– Delayed/acute glaucoma : laser iridotomy
• Traumatic cataract
• Lens Displacement / dislocation
Traumatic Cataract
Open Globes are Acutely Repaired
Due to Risk of Endophthalmitis: Blindness
Foreign Bodies: Acute Rx
What kind of detachment?
Ocular Membranes
• Retinal detachment
– NAT!
• Choroidal detachment
• Subhyaloid detachment
• Puncture
Detachment(s)
Vitreous Chamber
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Classic rupture
Ocular hypotony
Hemorrhage
Puncture
Late effect: Phthisis Bulbi
Why left eye?
Early Ocular Intervention
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Open globe
Foreign bodies
Corneal abrasions
Hyphema
Globe lacerations
Detachments
– Scleral buckling / vitrectomy
• Suck vitreous, treat retina, reinflate
oil/gas/saline
Surgery for Hyphema
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Uncontrolled elevated IOP
Corneal blood staining (opacification)
Large hyphemas of long duration
Sickle cell
Active bleeding
• Paracentesis, AC washout, hyphectomy,
trabeculectomy
Complications
• Phthisis bulbi
• Endophthalmitis in 10% of open globes
– Staph, Strep, Bacillus (rural, FB)
– Antibiotics mandatory; ? Pars plana
vitrectomy
– Vision loss in days
• Glaucoma: Drops then laser iridotomy
– Potential for optic nerve ischemia
• Staphyloma
Phthisis Bulbi
• A small shrunken
calcified globe
usually secondary
to trauma or
inflammation
c/o Bidyut Pramanik
Endophthalmitis
Staphyloma
• Acquired defects in the
sclera or cornea
• Posterior staphyloma is
associated with
increasing globe size
• Usually on the temporal
side of optic nerve
• Outward bulging with
uveoscleral thinning
• Anterior staphyloma is
seen with RA
c/o Bidyut Pramanik
Enucleation
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Blind painful eye
Endophthalmitis (esp open globe)
Phthisis bulbi
Severe traumatic rupture
Unsightly eye
Glaucoma
Non-ocular Orbital Trauma
• Intraconal / Conal
– Retrobulbar hematoma
– Optic nerve sheath hematoma
– Injury to nerve
– Injury to vessels
– Traumatic muscle edema/hematoma
– Muscular avulsion (Medial rectus)
– Vascular
Retrobulbar
Hematoma
-Danger is that
acute intraorbital
pressure may
result in retinal
artery occlusion,
optic nerve
ischemia
-Lateral
canthotomy
decompression
sheath
Conal: Muscle Avulsion
Orbital Trauma Vascular
• Carotid-cavernous fistula
• Pseudoaneurysm
• Varicosities
Carotid Cavernous Fistula
• May result in EOM enlargement due
to venous engorgement
• All EOMs involved
• Superior Ophthalmic Vein is dilated
• Usually unilateral
Extraconal: Orbital Fractures
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Orbital rim
Orbital floor
Medial orbital wall: lamina papyracea
Lateral orbital wall
Superior wall
– Globe injuries occur in 10-25% of patients
with orbital fractures
Indications for Surgery for
Orbital Fractures
• Enophthalmos > 2 mm (> 50% of floor)
• Hypoglobus (downward displaced globe)
• Diplopia
– Edema, heme, n. palsy, direct trauma
• Increase in orbital volume > 1 cc
– Correlates with enophthalmos
• Limited mobility (entrapment of EOM)
• Compressive optic neuropathy
Kontio R, Lindquist C. OMFC 2009: 21: 209-220
Indications for Surgery for
Orbital Fractures
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Fracture of > 50% of floor
Orbital tissue entrapment
Diplopia
Non-resolving oculocardiac reflex, also
known as Aschner reflex,
– Decrease in pulse rate associated with
traction applied to extraocular muscles
and/or compression of the eyeball
Chen CT et al. Cur Opinion Otol HNS 2010: 18: 311-6
Controversies in Surgery
• When to repair orbital fractures
– Rarely considered emergent
– ? Adhesions when delayed
– ? Benefit of decreased swelling
– Some say 14-21 days
• Unless optic neuropathy
– Oculocardiac reflex: vagus
– Children get operated earlier d/t increased
entrapment
– Early surgery for penetration
Kontio R, Lindquist C. OMFC 2009: 21: 209-220
Controversies in Surgery
• What to repair with
– Must be rigid to contain orbital contents
– Restore form and volume
– Contourable
• Autogenous grafts (iliac bone)
– ? Too rigid, difficult to place
• Alloplasts (non/resorbable)
– Many varieties
• Titanium mesh, Medpor
Kontio R, Lindquist C. OMFC 2009: 21: 209-220
Orbital Fracture
Extraconal Hematoma
Conclusions
• A common indication in ED practice
• Ocular, non-ocular findings often
equally important
• Some fractures should be treated
acutely
• Long term sequelae