eye trauma and orbit disorders

Question 1

infection of eyelids and periocular tissues that is anterior to the orbital septum

generally benign and my be treated in outpatient setting

Answer 1

periorbital cellulitis

Question 2

infection of the orbital soft tissues posterior to the orbital septum

may be life and vision threatening

must be treated inpatient with IV antibiotics and occasionally surgical drainage

Answer 2

orbital cellulitis

Question 3

how to differentiate between periorbital and orbital cellulitis

Answer 3

contrast enhanced CT scan of the orbits and sinuses differentiate the two conditions and identifies complications

lab studies do NOT discriminate between the two conditions

Question 4

MC organisms of Preseptal (periorbital) cellulitis

Answer 4

staph aureus*
staph epidermidis
strep species
anaerobes

Question 4

outward experience of both periorbital and orbital cellulitis can be similar

Answer 4

excessive tearing, fever, erythema, warmth, tenderness to palpation of the lids and periorbital soft tissues

Question 5

usually associated with URI (esp paranasal sinusitis)

may also result from eyelid problems such as hordeolum, chalazion, insect bites, and trauma

primarily disease of childhood (most patients < 10 years of age)

Answer 5

preseptal (periorbital) cellulitis

Question 6

URI symptoms
low grade fever
redness and swelling of eyelid
excessive tearing (epiphora)

eye itself is NOT involved

visual acuity and pupillary reaction are maintained

full painless ocular motility is preserved

Answer 6

preseptal (periorbital) cellulitis

Question 7

preseptal (periorbital) cellulitis imaging for decreased ocular motility or other signs of orbital involvement ( or exam not reliable)

Answer 7

obtain CT scan

Question 8

preseptal (periorbital) cellulitis treatment for nontoxic adult patient and older child with mild preseptal cellulitis

Answer 8

oral antibiotics (amoxicillin/clavulanic acid or 1st gen cephalosporin)

hot packs

follow up in 24-48 hours

Question 9

occurs most frequently from spread of paranasal sinusitis (ethmoid sinus MC)

can also occur following trauma, intraorbital foreign body, spread of periorbital skin infection, seeding from bacteremia, and ocular surgery

Answer 9

postseptal (orbital) cellulitis

Question 9

preseptal (periorbital) cellulitis treatment for severe or when orbital cellulitis cannot be ruled out

Answer 9

ophthalmology consult and consider admission

Question 10

postseptal (orbital) cellulitis treatment

Answer 10

consult ophthalmology immediately

hospitalization and IV antibiotics

nafcillin PLUS one of the following:
metronidazole or clindamycin (to treat anaerobic infections)

Question 10

postseptal (orbital) cellulitis polymicrobial pathogens

Answer 10

staph aureus
strep pneumo
anaerobes

Question 11

symptoms:
gradual onset of upper respiratory symptoms (rhinitis, facial pressure, fever)

PE:
pain with eye movement
limitation of EOM
chemosis
proptosis

HA and fever in association with deficits of CN 3,4, 6 suggest cavernous sinus thrombosis

Answer 11

postseptal (orbital) cellulitis

Question 12

defined as full thickness disruption of sclera or cornea

vision threatening

Causes:
blunt trauma
penetrating trauma
increased intraocualr pressures can cause extrusion of ocular contents
can happen after ocular surgery such as cataract, LASIK, corneal transplant

gross deformity of the eye without obvious volume loss is clear evidence

MC in males

Answer 12

globe rupture

Question 14

globe rupture exam rules

Answer 14

1. if suspected, do not apply any pressure to the eye including avoiding eyelid retraction or tonometry
2. do not place medications such as tetracaine or fluorescein into the eye unless directed to by opthalmology

Question 15

markedly decreased visual acuity (not always- especially if small object causing rupture)

relative afferent pupillary defect

eccentric or teardrop pupil

increased or decreased anterior chamber depth

extrusion of vitreous

external prolapse of uvea (iris, ciliary body, or choroid) or other internal ocular structures

tenting of the cornea or sclera at the site of globe rupture

low intraocular pressure

positive seidel sign

Answer 15

globe rupture signs

Question 16

left pupil is the same size as the right under all conditions of illumination because the efferent pathways are intact, but both pupils are smaller when light is directed at the right eye than when it is directed at the left eye, because light is detected better by the right eye. alternate swinging of the light between the two eyes therefore produces dilation each time the light is directed to the left eye

Answer 16

example of left afferent pupillary defect

Question 17

globe rupture diagnosis

Answer 17

usually clinical

IMMEDIATE ophthalmology consult

CT orbits non contrast
- if suspect metal FB do and X-ray or CT (do not do an MRI)

highly recommend not to do an ultrasound

Question 18

globe rupture treatment

Answer 18

emergent consult
- don’t put anything in eye
- avoid anything that will raise IOP (lid retraction, tonometry)

bandage eye and cover with shield that rests on face, not the eye

head of bed elevated to 30-45 degrees

do not remove foreign bodies

patient should remain still and avoid moving the eye
- antiemetics
- pain control
- sedation
- avoid ketamine

IV antibiotics (vancomycin plus ceftazidimide)

may require surgery so make the patient NPO

Question 18

blood or blood clots in the anterior chamber

common complication of blunt or penetrating injury to the eye

can be spontaneous (rare) – associated with sickle cell disease

predisposing conditions: sickle cell disease, bleeding disorders, blood thinners

Answer 18

hyphema

Question 19

physical exam: may need to use slit lamp

decreased visual acuity

eye pain with pupillary constriction to bright light

damage to adjacent structure or abnormal IOP

Answer 19

hyphema signs and symptoms

Question 20

what to use for microhyphema diagnosis

Answer 20

slit lamp exam only

Question 21

hyphema diagnosis

Answer 21

clinical diagnosis: slit lamp consider CT if suspected open globe consider US (once open globe has been ruled out) look for lens damage, intraocular foreign bodies, retinal detachment, hemorrhage

Question 22

hyphema treatment

Answer 22

preventing rebreed and intraocular hypertension elevate patients head to 30-45 degrees to promote settling of suspended RBC inferiorly (prevents occlusion of trabecular meshwork) consult ophthalmologist - antifibrinolytic agents - corticosteroids (systemic and topical)

Question 23

rupture of blood vessels between the conjunctiva and sclera most common caused by trauma (blunt trauma, intrathoracic pressure --> sneezing, coughing, vomiting, hard bowel movement, contact lenses spontaneous causes: hypertension, diabetes, coagulopathy painless

Answer 23

subconjunctival hemorrhage

Question 23

rupture of blood vessels between the conjunctiva and sclera ballooning out

Answer 23

bullous subconjunctival hemorrhage

Question 24

bullous subconjunctival hemorrhage should raise concern for

Answer 24

injury to sclera possible open globe laceration to conjunctiva needs CT

Question 25

subconjunctival hemorrhage treatment

Answer 25

monitor reassurance usually resolves within 2 weeks if recurrent, check for coagulopathy

Question 25

often associated with: intracranial injury intraocular injury bones involved: frontal zygomatic maxillary sphenoid

Answer 25

orbital fractures

Question 26

MC location of a fracture of the orbital rim

Answer 26

orbital zygomatic fracture

Question 27

medial rectus muscle may become trapped in fractures of the medial wall of the orbit

Answer 27

nasoethmoid fracture

Question 28

fracture of the floor of the orbit- typically occur when a small round object (such as a baseball)* strikes the eye

Answer 28

orbital floor fracture ("blowout fracture")

Question 29

bony tenderness and swelling periocular ecchymosis (raccoon eyes) diplopia (worse with EOM) decreased sensation in the distribution of infraorbital nerve (V2) orbital emphysema (crepitus) check acuity ASAP because continued swelling may make that more difficult

Answer 29

orbital fractures

Question 30

orbital fractures, what to do if patient is stable

Answer 30

eye exam to rule out ocular trauma, ruptured globe, hyphema

Question 31

can give clue that there may be an orbital hematoma

Answer 31

proptosis (eye is protruding out)

Question 32

orbital hematoma assessment

Answer 32

CT scan CT should be performed for a patient with orbital trauma and any of the following findings - evidence of a fracture of physical exam - limitation of extraocular movement - decreased visual acuity - severe pain - inadequate examination (usually because of soft tissue swelling) particularly in patients with altered mental status

Question 33

orbital hematoma treatment

Answer 33

address any life-threatening conditions consult ophthalmology or plastic surgery (sometimes needs surgery if there is nerve entrapment) prophylactic oral antibiotics to cover sinus pathogens for patients with orbital fracture into sinus - cephalexin patients with limitation of EOM receive oral corticosteroids to decrease swelling