Download Blow out fracture of the orbit

Blow out fracture of the orbit
(BOF)
Ayesha S Abdullah
14.09.2012
Learning objectives
1. Differentiate between preseptal and true
orbital cellulitis (OC) & explain why it is
considered to be an ocular emergency
2. Describe the causes, clinical presentation,
complications & line of management of
orbital cellulitis
3. Explain the mechanism of BOF of the orbit,
describe its clinical presentation,
complications & outline the management.
Review
Case #1
A one-year old baby presented to the OPD of the
department of Ophthalmology with the complaint
of a red swollen left lower lid for the last two
days. On examination the lid was red, warm &
mildly tender to touch. His vision was normal, the
eye had mild conjunctival redness, pupils were
normal and the ocular movements were also
normal. Watch the photograph….
Some questions
1.
2.
3.
4.
5.
What kind of orbital condition is this?
What structures are affected?
What more information should we ask for to?
What possible causes can you think of?
Is the condition confined to the lids or has it
involved the eyeball?
6. Why do you think so?
7. Would you like to have more information?
Some more information………
• The child had a history of insect bite on the
lid two days ago, the swelling increased
thereafter. The insect bite mark was visible
• There was no history of trauma or symptoms
suggestive of flu or URTI
• His temperature was normal
Some more questions
• What should be the management, keeping in
mind the nature of the problem?
• What could be the complications of such a
case?
• Is there any role of health education in this
case?
Don’t’ forget simple things can get
complicated
• Let us see an other case……..
Case #2
• A 12 year old child was brought to the OPD of the
department of ophthalmology with a history of red
swollen left upper lid for the last 5 days. He also had fever
for the last two days along with headache. On
examination the child had a grossly swollen lid. His visual
acuity was 6/18 OD & 6/6 OS. The lid was warm and
tender. The eye was moderately proptosed with
conjunctival chemosis. The pupil was slow to react to light
and the ocular movements were painful & limited. The
temperature was 1010 F & the child generally looked
unwell……..
Ocular signs
Some questions….
1. What kind of orbital condition is this?
2. What structures are affected?
3. What more information should we ask for to get an
idea about the cause of the problem?
4. Is the condition confined to the lids or has it
involved the eyeball?
5. Why do you think so?
6. What possible causes can you think of?
7. Would you like to have more information?
Some more information…….
• The child had a history of recurrent flu and
upper respiratory tract infections. He had
history of blocked nose and thick greenish
nasal discharge was noted on examination.
• The child was put on intravenous antibiotics
but didn’t get better
• A subsequent CT scan was done which
showed…….
The antibiotics were changed to intravenous ampicillin/sulbactam and after 5
days were changed to oral amoxicillin/clavulanic acid for a total of 14 days of
antibiotics.
Orbital abscess
Some more questions
• What should be the management, keeping
in mind the nature of the problem?
• What do you think can be done with the
abscess?
• Is there any role of health education in this
case?
Conclusion about the two cases
• What is the difference between the two cases?
• We consider the second case an ocular
emergency, why?
• How did the subperiosteal abscess form in the
second case?
• What other complications could happen in the
second case? Ocular/intracranial/orbital
• What could be included in the differential
diagnosis?....
Differential diagnosis of red swollen lids
1.
2.
3.
4.
Prespetal cellulitis
Orbital cellulitis
Contact dermatitis
Focal lesions like stye, chalazion ( especially if
infected)
5. Allergic reaction ( angioedema)
6. Tumours ( specifically Rhabdomyosarcoma in
children & malignant lid tumours, primary or
secondary in adults)
Management Preseptal cellulitis
1. Symptomatic; analgesics & NSAIDS
2. Specific:
3. For mild infection oral antibiotics with antihistamines in
case of dual pathology like in insect bite
4. Very severe infections may require intravenous
penicillins to avoid true orbital cellulitis
5. Lid abscesses should be drained
6. Third generation cephalosporins in penicillin allergy
7. In general practice it requires oral antibiotics and referral
to an ophthalmologist especially when more severe and
in children
Management Orbital Cellulitis
•
•
•
•
Admit
Requires care by an ophthalmologist
Symptomatic; antipyretic, NSAIDS
Specific ; hospitalization & antibiotic therapy
–
–
–
–
Braod spectrum antibiotic (I/V); Ceftazidime or cefotaxime
Ampicillin for H Influenzae infection
Cloxacillin for Staphylococcus aureus infection
Metronidazole 500mg tds, PO when anaerobic infection is suspected
especially in adults
– Vancomycin in case of allergy to the above mentioned
Management Orbital Cellulitis
• Surgical intervention in case of local abscess
or unresponsive cases
• Consultation with ENT specialist,
neurosurgeon & paediatrician if required
Let us summarize
• Preseptal orbital cellulitis & orbital cellulitis
are both infections.
• It is more common in children
• The route of infection could be from the
nearby infectious focus like infected sinuses,
skin wound or spread of infection via blood
• The most common cause especially in children
is ethmoidal sinusitis
• Both preseptal and orbital cellulitis may have:
– Fever
– Eyelid edema
– Pain
– Red eye
– Child is ill-appearing
• Orbital cellulitis signifies spread of
inflammation to the posterior orbital contents
that is the eyeball, extraocular muscles:
helpful signs to distinguish it are:– Proptosis
– Decreased visual acuity ( may be normal in the
beginning)
– Red eye with conjunctival chemosis of moderate to
intense congestion
– Painful limited eye movements
– Afferent pupillary defect
Why is OC an emergency
• Prior to the availability of antibiotics, patients with orbital
cellulitis had a mortality rate of 17%, and 20% of survivors
were blind in the affected eye. However, with prompt
diagnosis and appropriate use of antibiotics, this rate has
been reduced significantly
• blindness can still occur in up to 11% of cases. Orbital cellulitis
due to methicillin-resistant Staphylococcus aureus can lead to
blindness despite antibiotic treatment.
• The infection can spread to the meninges and brain & may
cause death
• That is why it is an emergency
Ocular & orbital complications of OC
• Corneal scarring from exposure
Extraocular muscle palsies
Optic nerve damage
• Central retinal artery and central retinal
vein occlusion
• Orbital abscess
• Visual loss and blindness
Extraocular complications of OC
•
•
•
•
Brain abscess
Meningitis
Cavernous sinus thrombosis
Osteomyelitis of skull and orbit bones
Cavernous sinus thrombosis
Brain abscess
Lets us see this case
• A 45 year old umpire of cricket while standing
at the wickets got hit by a close throw on his
left eye a day earlier. He suddenly felt
excruciating pain in and around the eye. As he
opened his eyes he noticed double vision
especially as he looked up. On examination he
had a black eye (bruised) with limited upward
movement of the left eye.
•
•
•
•
What happened?
Why was he having diplopia?
Why did it get worse while looking up?
What investigations would you like to do for
confirming your diagnosis?
• What complications can you expect in such a
case?
• How could it be managed?
What happened?
What investigation would you like to do to confirm
the diagnosis?
For confirmation of fracture
• CT scan / X ray orbit
For confirmation of muscle entrapment
• CT scan & forced duction test, differential
intraocular pressure assessment ( primary
position and up-gaze)
What complications can you expect in such a case?
• EOM problems
• Visual loss : Hyphaema, RD, Damage to the angle of
the anterior chamber— glaucoma, Vitreous
haemorrhage, Orbital hematoma,Damage to the
optic nerve
• Cosmetic , small eye, asymmetry in face
• Secondary infection from the sinuses- orbital cellulitis
& spread of the infected contents of the sinuses to
the vital tissues like the eyeball & the brain
How could it be managed?
Is it an emergency?
Should we admit?
• Symptomatic/ conservative: NSAID for relief of
pain & reduction of inflammation ( discourage
blowing of the nose to prevent forcing of the
infected sinus contents into the orbit), antibiotics
• If the diplopia persist beyond 2 weeks/
enophthamos is significant then surgical repair of
the fracture with release of entrapped muscles
may be required
Summary
Blowout fracture is not a common disorder
but is common in sports & violence related
trauma, it can mostly be managed
conservatively but in case of a large fracture
or persistent ocular movement problems &
enophthalmos requires surgical repair.
References
• Orbit, eyelids & lacrimal system. American Academy
of Ophthalmology; 1997-98
• Jack J Kanski. Clinical ophthalmology a systematic
approach. 5th ed;2003:557-89
• Parsons’ diseases of the eye. Diseases of the adnexadiseases of the orbit. 19th ed. 2004; 505-524
• Newell F W. The orbit. In Ophthalmology principles &
concepts.7th ed; 1992:259-69
WEB RESOURCES
• http://www.emedicine.com/oph/topic758.ht
m.
• http://www.emedicine.com/oph/orbit/exopht
halmos
• http://www.ccmcresidents.com/wpcontent/uploads/2011/08/242.full_.pdf