Eye emergencies – quiz

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Cite this article as:
Singh, B. Eye emergencies – quiz, Don't Forget the Bubbles, 2016. Available at:
http://doi.org/10.31440/DFTB.10452

Anatomy

Label all the parts of the following diagram:

anatomy1

Source – https://quizlet.com/87549518/visual-anatomy-physiology-ch-7-facial-and-cranial-bones-flash-cards/

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A – parietal

B – frontal

C – nasal

D – temporal

E – sphenoid

F – ethmoid

G – lacrimal

H – zygomatic

I – maxilla

J – mandible

K – vomer

Label all the parts of the following diagram:

Source -

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1 – foramen magnum

2 – occipital condyles

3 – zygomatic arch

4 – temporal bone

5 – temporal bone

6 – vomer

7 – palatine bone

8 – maxilla


History and examination:

Trauma directly to the globe is associated with what pattern of orbital injury?

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Orbital pressure results in a buckling effect, resulting often in a small fracture of the orbital floor, minimal herniation, sparing of the medial wall and roof.

True or false: Trauma to the lower orbital rim is commonly associated with minor orbital injury?

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False: Trauma to the lower orbital rim result in larger fractures that can involve orbital roof, medial wall, orbital   floor, resulting in herniation of orbital contents into maxilla.

Eye lid laceration may be a sign of which serious cranio-orbital injury/ies?

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High force injury, penetrating cranio-orbital injury.

How do you test for a relative afferent pupil defect? What is a positive test?

Other then pain, list 5 clinical features you may find with in patients with a suspected orbital injury:

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  • Periorbital ecchymosis
  • Ptosis
  • Hypertelorism (increased distance between orbits)
  • Enophthalmos/exophthalmos
  • Oronasal bleeding
  • Facial asymmetry
  • Loss of sensation
  • Restriction of ocular motility with diplopia

Radiology

First off, let’s have a quick reminder of facial bone x-ray interpretation.

Now for the questions…Spot the abnormality in the following x-rays:

Question 1

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Patient A: blowout fracture of orbital floor, teardrop sign

Question 2

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Patient B: orbital emphysema (eyebrow sign) on the right side and fluid in the maxillary antrum on the left side.

Question 3

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Patient C: Tripod fracture: widening of zygomatico-frontal suture, orbital floor fracture, zygomatic arch fracture (best seen on OM 30 degree)

Question 4

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Patient D: Left zygomatic arch fracture

Case histories (from eyerounds.org)

Case 1

This 14 year old adolescent was involved in a fight. He was punched in the face. There was loss of consciousness temporarily. There are no other red flag features for head injury.

case1

 

Describe the examination findings in the picture

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Right side: Restriction of upward gaze, subcutaneous haemorrhage, periorbital bruising, laceration superior to the right eyelid.

What specific injuries might you expect this patient to have?

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Inferior rectus entrapment from a blowout fracture.

What investigations might you require?

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Trauma assessment, visual acuity, CT head & facial bones.

Describe your management plan.

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Antibiotics, avoid blowing your nose, NBM, urgent referral to max-fax/opthalmology for repair and release.

N.B. Patients with stable orbital blowout fractures should be informed on discharge, to avoid blowing their nose and sneeze with an open mouth.

Case 2

This 10 year old boy injured himself while using his father’s nail gun. The gun misfired twice. He is complaining of headache and a sore eye.

case2

Describe the examination findings above.

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Foreign body penetrating the cornea into the globe

What are your management priorities?

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Analgesia, antibiotics, urgent ophthalmology, leave the foreign object.

How, if needed, will you transfer this patient?

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Ambulance blue light – this is a threat to sight.

What imaging, if any, does this patient need?

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This is a high velocity injury with possible cranio-orbital involvement. The patient needs a CT head/facial bones to query whether there is a deeper injury from the other nail.

Case 3

This is a 15 year old male who has had an accident near his house after an altercation. He has a crowbar jammed into the right eye. He has normal visual acuity and complains of pain. CT demonstrates orbital roof fracture.

case3

Describe your management plan.

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General trauma approach, analgesia, antibiotics, check visual acuity, check cornea, maxfax referral +/- ophthalmology review

In the department, he becomes persistently bradycardic rate 30, and feels nauseous with this. How would you approach managing this?

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APLS approach: consider atropine/glycopyrolate and anti-emetics. Bradycardia is likely due to oculo-cardiac reflex. This would be an indication for urgent surgical management.

Lateral canthotomy

LITFL already has a great summary of of a case for this topics, which we have replicated below:

A 12 year-old martial artist presents with loss of vision in his right eye after being on the wrong end of a spinning back fist.

Examination of the right eye reveals:

  • He is unable to detect light when the eyelids are passively opened.
  • There is a relative afferent pupillary defect affecting the right eye.
  • Extraocular movements are markedly reduced.
  • Tonometry reveals an intraocular pressure of 45 mmHg.

eye-litfl

What is shown and what is the likely diagnosis?

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The right eye appears proptosed with a dilated pupil, extensive subconjunctival haemorrhage and bloody chemosis, as well evidence of periorbital swelling and haematoma.

The likely underlying diagnosis is:

Retrobulbar haemorrhage due to trauma, resulting in acute orbital compartment syndrome.

Haemorrhage into the potential space within the rigid orbit and around the eye transmits pressure onto the optic nerve. Acute orbital compartment syndrome occurs when this results in a compressive optic neuropathy.

The main differentials are:

  • ruptured globe – proptosis and raised intraocular pressure are not consistent with this
  • orbital blowout fracture – raised intraocular pressure, RAPD and decreased visual acuity are not seen in this condition unless there is coexistent retrobulbar haemorrhage.

What are the clinical features of this condition on history?

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History:

  • Symptoms – pain, decreased vision, inability to open the eyelids due to severe swelling.
  • Cause – history of trauma or surgery to the eye or orbit, or retrobulbar injection.
  • Risk factors for spontaneous hemorrhage – bleeding disorder, anticoagulants and anti-platelet drugs, pregnancy.

What are the clinical features of this condition on examination?

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Examination

  • Visual acuity and visual fields – decreased with dyschromatopsia (signs of optic neuropathy)
  • External exam – Proptosis with resistance to retropulsion, diffuse subconjunctival haemorrhage, tight eyelids (rock hard) with echymosis and chemosis.
  • Extraocular eye movements – limited extraocular motility
  • Pupils – RAPD.
  • Tonometry – increased intraocular pressure (IOP)
  • Fund0scopy – papilloedema from compressive optic neuropathy may be present, retinal artery or vein occlusion.

What investigation should be performed and what are the typical findings?

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Retrobulbar haemorrhage with acute orbital compartment syndrome is primarily a clinical diagnosis.

CT orbit (axial and coronal views) can confirm the diagnosis – but if vision is threatened treat first!

Usual findings on CT:

  • diffuse, increased reticular pattern of the intraconal orbital fat rather than a discrete hematoma.
  • teardrop or tenting sign is ominous – it occurs when the optic nerve is at maximum stretch and distorts the back of the globe into a teardrop shape.

What is the treatment of this condition?

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Admit to hospital and treat with aggressive decompression.

Therapy depends on whether there is compressive optic neuropathy or severely raised IOP:

  • Evidence of optic neuropathy or severely raised IOP (>40 mmHg) – lateral canthotomy and cantholysis should be performed immediately (ideally by an ophthalmologist); use procedural sedation in the ED if it does not cause a delay.
  • No evidence of optic neuropathy but IOP is raised (e.g. >30 mmHg) – treat with agents used to lower IOP (e.g. topical timolol, acetazolamide, mannitol; see acute glaucoma).
McInnes and Howes suggest the DIP-A CONE-G mnemonic for remembering the indications and contra-indications for this procedure:
  • Primary indications:
    – Decreased visual acuity
    – Intraocular pressure >40 mm Hg
    – Proptosis
  • Secondary indications:
    – Afferent pupillary defect
    – Cherry red macula
    – Ophthalmoplegia
    – Nerve head pallor
    – Eye pain
  • Contraindications:
    – Globe rupture

How is a lateral canthotomy/cantholysis performed?

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The main steps in emergency canthotomy/cantholysis are:

  • Use local anaesthetic but warn the patient that they may feel pain
  • Perform the canthotomy:
    • Place the scissors across the lateral canthus and incise the canthus full thickness
  • Perform cantholysis:
    • Grasp the lateral lower eyelid with toothed forceps
    • Pull the lower eyelid anteriorly
    • Point the scissors toward the patient’s nose, place the blades either side of the lateral canthal tendon, and cut.

Cantholysis is done more by feel than by visual identification of landmarks – the lower eyelid will come completely away from the globe once the tendon has been completely severed.

The procedure is described more fully here by McInnes and Howes.

Videos showing a lateral canthotomy and cantholysis being performed:

Video 1

Video 2

References

  • Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
  • Johnson D, Schweitzer K, Sharma S. Ophthaproblem: Can you identify this condition? Retrobulbar hemorrhage. Can Fam Physician. 2009 Jun;55(6):605, 607. PMID: 19509203; PMCID: PMC2694083.
  • Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com]
  • McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002 Jan;4(1):49-52. PMID: 17637149. [fulltext]
  • NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide, 2007. [link to free pdf]
  • Pramanik, S. Assessment and Management of Ocular trauma. EyeRounds.org [fulltext]
  • Perry M. Acute proptosis in trauma: retrobulbar hemorrhage or orbital compartment syndrome — does it really matter? J Oral Maxillofac Surg. 2008 Sep;66(9):1913-20. PMID: 18718400.
  • Delpachitra SN, Rahmel BB, Orbital fractures in the emergency department: a review of early assessment and management, Emerg Med J 2016 33: 727-731

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Baljinder Singh is an emergency medicine registrar with an interest in education & simulation.

Author: Baljinder Singh Baljinder Singh is an emergency medicine registrar with an interest in education & simulation.

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