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Orbital trauma
From WikEM
Contents
Background
- Must assess:
- Visual acuity
- Anterior chamber
- Integrity of globe
- Pupil shape and reactivity
- Use paperclip or eyelid speculum to open swollen eyes
Clinical Features
- Anterior chamber is flat +/- abnormal pupil
- Ruptured globe is certain
- Stop the exam; place eye shield, consult ophtho
- Hyphema
- Evidence of significant trauma; consult ophtho
- Extra-ocular movements
- Restricted upgaze or lateral gaze suggests Orbital Fracture with entrapment
- Obtain CT face
- Restricted upgaze or lateral gaze suggests Orbital Fracture with entrapment
- Orbital Rim
- Feel for step-off
- Sensation
- Test along distribution of inf orbital nerve (below eye and ipsilateral side of nose)
- Photophobia
- If photophobia in affected and unaffected eye, suspect traumatic iritis
- Decreased visual acuity +/- proptosis
- Clinically suspect Orbital Hematoma, check IOP if open globe has been ruled out
Differential Diagnosis
Maxillofacial Trauma
- Le Fort fractures
- Skull fracture (peds)
- Auricular hematoma
- Nasal fracture
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Dental trauma
- Mandible fracture
Orbital trauma
Acute
- Ruptured Globe^
- Corneal Abrasion
- Ocular foreign body
- Conjunctival laceration
- Caustic Keratoconjunctivitis^^
- Subconjunctival hemorrhage
- Traumatic iritis
- Traumatic hyphema
- Retinal detachment
- Retrobulbar hemorrhage/hematoma
- Traumatic mydriasis
- Orbital fracture
- Frontal sinus fracture
- Naso-ethmoid fracture
- Inferior orbial wall fracture
- Medial orbital wall fracture
Subacute/Delayed
Evaluation
- Slit-lamp exam with fluorescein
- Check for:
- Abrasion
- Laceration
- Foreign body
- Hyphema
- Iritis
- Pupil may be constricted or dilated
- Lens dislocation
- Globe rupture
- +Seidel test
- Full-thickness laceration
- Check for:
- Consider non-contrast face/orbital CT
- Consider ocular ultrasound
- Can be done AFTER open globe has been ruled out
- Check for: retinal detachment, vitreous hemorrhage/detachment
Management
Disposition
- Ophtho in 48hr if vision and ocular anatomy are preserved
