Orbit - Randor Flashcards
(99 cards)
1
Q
who are orbital fractures the most common among?
A
young adults - adolescent males
2
Q
Most common etiology of orbital fractures?
A
blunt trauma
- MVA
- industrial accidents
- sports facial trauma
- assaults (domestic violence)
3
Q
7 bones of the orbit?
A
- sphenoid
- zygoma
- maxilla
- ethmoid bone (lamina papyrcea)
- palantine bone
- lacrimal bone
- frontal bone
4
Q
of the 7 bones of the orbit, what is the most commonly fractured?
A
the zygoma
5
Q
what is the most commonly fracture bone of the face?
A
nasal bone
6
Q
what bones make up the superior wall (roof) of the orbit?
A
frontal bone and sphenoid bone (lesser wing)
7
Q
what bones make up the inferior wall of the orbit?
A
maxilla, zygomatic bone, palantine bone
8
Q
what bones make up the medial wall of the orbit?
A
ethmoid bone, maxilla bone, lacrimal bone, sphenoid bone
9
Q
what is the thinnest wall, therefore easiest to fracture of the orbit?
A
medial wall
10
Q
what bones make up the lateral wall of the orbit?
A
zygomatic bone (frontal process), sphenoid bone (greater wing)
11
Q
what is the thickest wall, therefore hardest to fracture of the orbit?
A
lateral wall
12
Q
what do the medial and lateral cantonal ligaments do for the eye?
A
Maintain position of the eye, so eyelid isn’t higher or lower
13
Q
what are the 3 important sinuses and why must you assess them in an orbital fracture?
A
maxilla, ethmoid, frontal
-must assess in orbital fracture they can bleed easily (get blood in them)
14
Q
what happens when there is disruption of the medial and lateral cantonal ligaments?
A
disruption causes malpositioning of the eyelids
- entropion (inversion of the eyelid margin)
- ectropion (eversion of the eyelid margin)
15
Q
what nerve are the infraorbital and supraorbital nerves a part of?
A
the trigeminal nerve (CN V)
16
Q
what does the infraorbital nerve innervate?
A
lower eyelid, nose, and upper lip
17
Q
what does the supraorbital nerve innervate?
A
upper eyelid, forehead, scalp
18
Q
what causes vertical diplopia?
A
inferior rectus entrapment - can’t move eye upward
19
Q
what causes horizontal diplopia?
A
medial rectus entrapment - can’t move eye medially
20
Q
tell me about orbital roof fractures? are they rare or common? seen in who? potential for what?
A
rare, more common in children, potential for significant complications because of the brain
21
Q
orbital floor fracture
A
may have blow out fracture - floor collapses into the maxillary sinus
MOST COMMON TYPE
22
Q
what are blowout fractures
A
orbital floor fractures without fracture of the orbital rim with herniation of orbital contents
- the bone defect is filled with soft tissue and fat from the orbit
- alters support mechanism for extra ocular muscles
23
Q
what can become entrapped in blowout fractures?
A
EOM - entrapment of inferior rectus
24
Q
what is a pure blowout fracture?
A
aka “trapdoor”
- bone fragments involving central area of bone
- does NOT extend into rim
25
what is an impure blowout fracture?
fracture line extends into orbital rim
26
Blowout fracture types
Inferior floor, medial wall, lateral wall
27
what is a common finding in blowout fractures?
damage to infraorbital nerve
28
initial assessment of orbital fractures?
- hx - describe incident, mechanism of injury, symptoms
- inspect face and eye
- palpate for any step off deformity or crepitus and for sensation defect
29
orbital fracture symptoms
- facial pain
- ocular pain on movement
- neuropraxia (temporary loss of motor or sensory function nerve)
- diplopia
- color changes (loss of red indicates pressure on optic nerve)
- vitreous hemorrhage
- retinal detachment
- foreign body sensation
30
what are signs of retinal detachment?
flashers, veil or curtain
31
what are signs of vitreous floaters?
floaters, hazy vision, clouds, fog
32
what will you find upon inspection of an orbital fracture?
- periorbital edema and ecchymosis
- depression or defect of the orbit
- epistaxis
- CSF leakage
33
what will you find upon palpation of an orbital fracture?
- nerve neuropraxia
- emphysema (air or crepitus)
- pain
- step-off deformity
34
what do you assess on your initial assessment for orbital fracture?
- eye exam
- visual acuity
- pupil (if uneven means trauma to iris)
- cornea
- fundoscopic
- EOMS
- conjunctiva (slit lamp)
- lids
- color perception
35
orbital fracture eye exam findings?
- lid lacerations
- periocular ecchymosis
- exophthalmos/proptosis (have increased IOP)
- retrobulbar hematoma
- enopthalmos (1 eye is lower)
- hypoglobus (sim to exophthalmos)
- subconjunctival hemorrhage
- hyphema
- traumatic mydriasis
- cantal ligament disruptions
- ephipora
- corneal abrasion
- ruptured globe
- vitrous hemorhage
- retinal detachment/tears
- EOM entrapment
36
what is the GOLD STANDARD for diagnosing orbital fractures?
CT w/out contrast
37
what is the axial view of CT best for visualizing for orbital fractures?
frontal fractures, NOE fractures, zygomatic arch, vertical orbital walls
38
what is the coronal view of CT best for visualizing for orbital fractures?
orbital roots, orbital floors, ptyergoid plates
39
additional dx for orbital fractures?
- forced ductions test (done by specialist)
- fluorescein stain
- hertel exophtalmometer (measures displacement of the fracture)
40
complications with orbital fractures
- blindness
- long term diplopia
- infection (e.g., sinus infection)
- EOM entrapment
- orbital dystopia/cosmetic issues (enopthalmus, hypoglobus)
- neuropraxia
- intracranial bleed (superior orbit)
41
what can cause blindness in orbital fractures?
- ruptured glove
- hyphema
- retinal detachment
- optic nerve sheath hematoma
- retrobulbar hematoma
- glaucoma
42
initial management of orbital fractures
- ice for 48 hrs
- elevation of HOB
- nasal decongestants
- broad spectrum abx if sinus involved
- +/- steroids for orbital edema with diplopia
- follow up with ophthalmologist
43
what should you avoid in management of orbital fractures?
Aspirin (bleed risk) & nose blowing (air will get stuck under soft tissue -> emphysema)
44
if there is visual impairment after an orbital fracture, what must be done?
patient must follow-up with ophthalmologist immediately
45
what will happen if aqueous flow is interrupted by blood?
increased IOP -> blindness
46
hyphema
blood in anterior chamber
| -bleeding from tears on the vessels of the ciliary body or iris
47
what can hyphen lead to?
blindness b/c blood is thick and will block exit -> increasing IOP
48
epidemiology of hyphemas?
- white males
- 70% in children
- 10-20 y/o
49
causes of hyphemas?
- blunt and penetrating traumas
| - sponteanous
50
blunt traumas causing hyphemas include what?
children -> sports
| adults -> assault (40%), MVA (airbag deployment)
51
what do penetrating traumas causing hyphemas include?
globe rupture
52
spontaneous hyphemas (common or not common? occur in who?)
- less common
| - occur in its with underlying conditions (hemophilia, anticoagulant therapy)
53
differential dx for hyphemas
- corneal abrasion
- retinal detachment
- globe rupture
- glaucoma
54
symptoms of hyphema
- decreased visual acuity
- photophobia
- pain
55
physical exam findings for hyphema
- blood in anterior chamber
- decreased visual acuity
- photophobia
- anisocoria (uneven pupils)
- elevated IOP
56
hyphema dx
- ophthalmoscope
| - slit lamp
57
treatment for hyphema
- shield over eye
- elevate HOB 30 degrees
- bed rest/dim lighting/limited activity
- tylenol for pain
- antiemetics for N/V
- 5% require surgical clot evacuation
- cycloplegia
58
what can you use to paralyze pupil for hyphema (cycloplegia)?
cyclopentolate or homatropine
59
follow-up of hyphema
refer to ophthalmologist and monitor IOP daily
60
when is a hyphema emergent?
If:
- open globe
- orbital compartment syndrome
- large hyphemas (grade 3 or 4)
- hyphemas associated w/dyscrasia (bleeding disorder)
61
complications of hyphemas
- intractable glaucoma
- secondary hemorrhage
- posterior synechiae
- peripheral synechiae
- optic atrophy
62
what can intractable glaucoma (complication of hyphema) lead to?
permanent vision loss and blindness
63
what are posterior synechiae and peripheral synechiae
posterior synechiae - iris adheres to lens -> vision issues
peripheral synechiae - iris adheres to cornea -> vision issues
64
what is the cornea innervated by?
trigeminal nerve (Reason why so much pain)
65
what layer of the cornea is the most common to have a corneal abrasion?
epithelium
66
what is the presenting history for a corneal foreign body?
windy weather, working with power tools, gardening
67
corneal foreign body symptoms
- pain
- foreign body sensation
- photophobia
- tears
- red eye
- blurred vision
68
exam findings for corneal foreign body
- normal/decr vision
- conjunctival injection (1-2 hrs after)
- ciliary injection
- VISIBLE FOREIGN BODY
- rust ring
- epithelial defects with stain
- anterior chamber with hazy spots
- excessive tears
- corneal edema
69
what does the Seidel test, test for in corneal foreign body/
tests for corneal perforation
| -if perforated globe is ruptured and have outflow from anterior chamber
70
diff dx for corneal foreign body
keratitis, intraocular foreign body, corneal abrasion
71
what is the #1 treatment for corneal foreign body?
REMOVAL OF THE FOREIGN BODY
| -if deep call ophthalmologist
72
Medical management of corneal foreign body?
- Topical erythromycin or ciprofloxacin (for contact lens wearers)
- topical cycloplegis
- avoid contacts until healed
- tetanus
- follow-up with specialist
73
how often does pt with corneal foreign body follow up with a specialist/
every 2 days until healed
74
corneal abrasion definition
any defect on the corneal surface
75
corneal abrasion causes?
- eye trauma
- retained foreign body
- improper contact lens use
- spontaneous
76
what identifies the etiology of a corneal abrasion?
history taking
77
if pt has traumatic corneal abrasion what will the history be?
history of direct trauma to the globe
78
symptoms of corneal abrasion?
same as corneal foreign body
| -pain, foreign body sensation, photophobia, tearing, red eye, blurred vision
79
differential dx for corneal abrasion?
- acute globe rupture
- retained foreign body
- infectious keratitis
- corneal ulcer
- acute angle glaucoma
80
dx for corneal abrasion?
fluorescein stain with woods or slit lamp
81
what is the mainstay of txt for corneal abrasion?
Topical erythromycin ointment or ciprofloxacin drops for contact lens wearers
82
what do you give for mild-moderate pain control for corneal abrasion?
NSAIDs (Motrin) PO or topical (diclofenac/ketorolac)
83
what do you give for severe pain (large abrasion) control for corneal abrasion?
oral opioids for 48 hours
also cycloplegics but inhibit healing
84
who does NOT need a follow-up for corneal abrasion?
```
small abrasions (heal in 24-48 hrs)
-but return if have eye drainage, decreased vision, sx persist >48 hours
```
85
who needs a follow-up with an ophthalmologist for corneal abrasion?
- large abrasion
- contact lens wearers
- abrasions in young children
- rust ring
- abrasions with vision changes
86
keratitis
inflammation of cornea
| -develops into corneal ulcer
87
what is the #1 infectious cause of corneal ulcer?
viral (HSV/Zoster)
88
bacterial causes of corneal ulcers
-pseudomonas (CONTACT LENS)
-moraxella (DM, alcoholics and immunosuppressed)
-strep
-staph
MRSA
89
risk factors for corneal ulcers
- contact lens
- previous eye surgery
- eye injury
- hx of HSV
- immunocompromised or autoimmune state (diabetes, RA)
- use of topical or systemic steroids
90
symptoms of corneal ulcers
- lid and ocular swelling
- injected conjunctive
- injected eyelid
- miotic pupil
- discharge: clear or mucopurulent
91
what are non-infectious causes of corneal ulcers?
- exposure keratitis (exophthalmos, Bell's palsy with lid lag)
- severe allergic disease
- severe dry eye
- inflammatory/autoimmune (RA, Sjrogren's, SLE)
- vit A deficiency
92
Findings of corneal ulcers
- punctate or diffuse branching of dendritic lesions (HSV/Zoster)
- corneal ulceration
- hypopyon
- anterior cell/flare
93
if pseudomonas is the cause of the corneal ulcer, what will you see on findings?
grey/yellow infiltrate
94
dx of corneal ulcer
- slit lamp and fluorescein stain
| - culture and gram stain or PCR
95
what type of treatment does corneal ulcer require?
aggressive txt
96
what is the initial treatment for corneal ulcer?
abx, unless dendritic pattern then acyclovir
97
abx for corneal ulcer
fluoroquinolone (b/c don't know if it's pseudomonas or not)
98
txt for viral corneal ulcer
topical acyclovir
99
corneal ulcer complications
- corneal scarring
- corneal perforations
- anterior/posterior synechiae
- glaucoma
- cataracts
- blindness
