eye trauma and orbit disorders Flashcards
infection of eyelids and periocular tissues that is anterior to the orbital septum
generally benign and my be treated in outpatient setting
periorbital cellulitis
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
orbital cellulitis
how to differentiate between periorbital and orbital cellulitis
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
MC organisms of Preseptal (periorbital) cellulitis
staph aureus*
staph epidermidis
strep species
anaerobes
outward experience of both periorbital and orbital cellulitis can be similar
excessive tearing, fever, erythema, warmth, tenderness to palpation of the lids and periorbital soft tissues
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)
preseptal (periorbital) cellulitis
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
preseptal (periorbital) cellulitis
preseptal (periorbital) cellulitis imaging for decreased ocular motility or other signs of orbital involvement ( or exam not reliable)
obtain CT scan
preseptal (periorbital) cellulitis treatment for nontoxic adult patient and older child with mild preseptal cellulitis
oral antibiotics (amoxicillin/clavulanic acid or 1st gen cephalosporin)
hot packs
follow up in 24-48 hours
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
postseptal (orbital) cellulitis
preseptal (periorbital) cellulitis treatment for severe or when orbital cellulitis cannot be ruled out
ophthalmology consult and consider admission
postseptal (orbital) cellulitis treatment
consult ophthalmology immediately
hospitalization and IV antibiotics
nafcillin PLUS one of the following:
metronidazole or clindamycin (to treat anaerobic infections)
postseptal (orbital) cellulitis polymicrobial pathogens
staph aureus
strep pneumo
anaerobes
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
postseptal (orbital) cellulitis
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
globe rupture
globe rupture exam rules
- if suspected, do not apply any pressure to the eye including avoiding eyelid retraction or tonometry
- do not place medications such as tetracaine or fluorescein into the eye unless directed to by opthalmology
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
globe rupture signs
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
example of left afferent pupillary defect
globe rupture diagnosis
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
globe rupture treatment
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
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
hyphema
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
hyphema signs and symptoms
what to use for microhyphema diagnosis
slit lamp exam only
hyphema diagnosis
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
hyphema treatment
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)
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
subconjunctival hemorrhage
rupture of blood vessels between the conjunctiva and sclera
ballooning out
bullous subconjunctival hemorrhage
bullous subconjunctival hemorrhage should raise concern for
injury to sclera
possible open globe
laceration to conjunctiva
needs CT
subconjunctival hemorrhage treatment
monitor
reassurance
usually resolves within 2 weeks
if recurrent, check for coagulopathy
often associated with:
intracranial injury
intraocular injury
bones involved:
frontal
zygomatic
maxillary
sphenoid
orbital fractures
MC location of a fracture of the orbital rim
orbital zygomatic fracture
medial rectus muscle may become trapped in fractures of the medial wall of the orbit
nasoethmoid fracture
fracture of the floor of the orbit- typically occur when a small round object (such as a baseball)* strikes the eye
orbital floor fracture (“blowout fracture”)
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
orbital fractures
orbital fractures, what to do if patient is stable
eye exam to rule out ocular trauma, ruptured globe, hyphema
can give clue that there may be an orbital hematoma
proptosis (eye is protruding out)
orbital hematoma assessment
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
orbital hematoma treatment
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
