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Orbital Trauma David M. Yousem, M.D., M.B.A. Johns Hopkins Medical Institution N.A. What constrains a retinal detachment? 1. 2. 3. 4. 5. A. Ciliary body B. Hyaloid vessels C. Ora Serrata D. Zonular ligaments E. Orbital septum 0% 0% 0% 0% 0% 1 2 3 4 5 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 0% 0% 0% 0% 0% 1 2 3 4 5 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 • • • • • Classic rupture Ocular hypotony Hemorrhage Puncture Late effect: Phthisis Bulbi Why left eye? Early Ocular Intervention • • • • • • Open globe Foreign bodies Corneal abrasions Hyphema Globe lacerations Detachments – Scleral buckling / vitrectomy • Suck vitreous, treat retina, reinflate oil/gas/saline Surgery for Hyphema • • • • • 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 • • • • • • 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 • • • • • 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 • • • • 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