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Clinical Medicine > Orbit - Randor > Flashcards

Orbit - Randor Flashcards

1
Q

who are orbital fractures the most common among?

A

young adults - adolescent males

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2
Q

Most common etiology of orbital fractures?

A

blunt trauma

  • MVA
  • industrial accidents
  • sports facial trauma
  • assaults (domestic violence)
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3
Q

7 bones of the orbit?

A
  • sphenoid
  • zygoma
  • maxilla
  • ethmoid bone (lamina papyrcea)
  • palantine bone
  • lacrimal bone
  • frontal bone
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4
Q

of the 7 bones of the orbit, what is the most commonly fractured?

A

the zygoma

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5
Q

what is the most commonly fracture bone of the face?

A

nasal bone

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6
Q

what bones make up the superior wall (roof) of the orbit?

A

frontal bone and sphenoid bone (lesser wing)

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7
Q

what bones make up the inferior wall of the orbit?

A

maxilla, zygomatic bone, palantine bone

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8
Q

what bones make up the medial wall of the orbit?

A

ethmoid bone, maxilla bone, lacrimal bone, sphenoid bone

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9
Q

what is the thinnest wall, therefore easiest to fracture of the orbit?

A

medial wall

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10
Q

what bones make up the lateral wall of the orbit?

A

zygomatic bone (frontal process), sphenoid bone (greater wing)

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11
Q

what is the thickest wall, therefore hardest to fracture of the orbit?

A

lateral wall

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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

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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)

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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)
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15
Q

what nerve are the infraorbital and supraorbital nerves a part of?

A

the trigeminal nerve (CN V)

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16
Q

what does the infraorbital nerve innervate?

A

lower eyelid, nose, and upper lip

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17
Q

what does the supraorbital nerve innervate?

A

upper eyelid, forehead, scalp

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18
Q

what causes vertical diplopia?

A

inferior rectus entrapment - can’t move eye upward

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19
Q

what causes horizontal diplopia?

A

medial rectus entrapment - can’t move eye medially

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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

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21
Q

orbital floor fracture

A

may have blow out fracture - floor collapses into the maxillary sinus
MOST COMMON TYPE

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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
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23
Q

what can become entrapped in blowout fractures?

A

EOM - entrapment of inferior rectus

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24
Q

what is a pure blowout fracture?

A

aka “trapdoor”

  • bone fragments involving central area of bone
  • does NOT extend into rim
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25
Q

what is an impure blowout fracture?

A

fracture line extends into orbital rim

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26
Q

Blowout fracture types

A

Inferior floor, medial wall, lateral wall

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27
Q

what is a common finding in blowout fractures?

A

damage to infraorbital nerve

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28
Q

initial assessment of orbital fractures?

A
  • hx - describe incident, mechanism of injury, symptoms
  • inspect face and eye
  • palpate for any step off deformity or crepitus and for sensation defect
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29
Q

orbital fracture symptoms

A
  • 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
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30
Q

what are signs of retinal detachment?

A

flashers, veil or curtain

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31
Q

what are signs of vitreous floaters?

A

floaters, hazy vision, clouds, fog

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32
Q

what will you find upon inspection of an orbital fracture?

A
  • periorbital edema and ecchymosis
  • depression or defect of the orbit
  • epistaxis
  • CSF leakage
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33
Q

what will you find upon palpation of an orbital fracture?

A
  • nerve neuropraxia
  • emphysema (air or crepitus)
  • pain
  • step-off deformity
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34
Q

what do you assess on your initial assessment for orbital fracture?

A
  • eye exam
  • visual acuity
  • pupil (if uneven means trauma to iris)
  • cornea
  • fundoscopic
  • EOMS
  • conjunctiva (slit lamp)
  • lids
  • color perception
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35
Q

orbital fracture eye exam findings?

A
  • 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
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36
Q

what is the GOLD STANDARD for diagnosing orbital fractures?

A

CT w/out contrast

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37
Q

what is the axial view of CT best for visualizing for orbital fractures?

A

frontal fractures, NOE fractures, zygomatic arch, vertical orbital walls

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38
Q

what is the coronal view of CT best for visualizing for orbital fractures?

A

orbital roots, orbital floors, ptyergoid plates

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39
Q

additional dx for orbital fractures?

A
  • forced ductions test (done by specialist)
  • fluorescein stain
  • hertel exophtalmometer (measures displacement of the fracture)
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40
Q

complications with orbital fractures

A
  • blindness
  • long term diplopia
  • infection (e.g., sinus infection)
  • EOM entrapment
  • orbital dystopia/cosmetic issues (enopthalmus, hypoglobus)
  • neuropraxia
  • intracranial bleed (superior orbit)
41
Q

what can cause blindness in orbital fractures?

A
  • ruptured glove
  • hyphema
  • retinal detachment
  • optic nerve sheath hematoma
  • retrobulbar hematoma
  • glaucoma
42
Q

initial management of orbital fractures

A
  • 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
Q

what should you avoid in management of orbital fractures?

A

Aspirin (bleed risk) & nose blowing (air will get stuck under soft tissue -> emphysema)

44
Q

if there is visual impairment after an orbital fracture, what must be done?

A

patient must follow-up with ophthalmologist immediately

45
Q

what will happen if aqueous flow is interrupted by blood?

A

increased IOP -> blindness

46
Q

hyphema

A

blood in anterior chamber

-bleeding from tears on the vessels of the ciliary body or iris

47
Q

what can hyphen lead to?

A

blindness b/c blood is thick and will block exit -> increasing IOP

48
Q

epidemiology of hyphemas?

A
  • white males
  • 70% in children
  • 10-20 y/o
49
Q

causes of hyphemas?

A
  • blunt and penetrating traumas

- sponteanous

50
Q

blunt traumas causing hyphemas include what?

A

children -> sports

adults -> assault (40%), MVA (airbag deployment)

51
Q

what do penetrating traumas causing hyphemas include?

A

globe rupture

52
Q

spontaneous hyphemas (common or not common? occur in who?)

A
  • less common

- occur in its with underlying conditions (hemophilia, anticoagulant therapy)

53
Q

differential dx for hyphemas

A
  • corneal abrasion
  • retinal detachment
  • globe rupture
  • glaucoma
54
Q

symptoms of hyphema

A
  • decreased visual acuity
  • photophobia
  • pain
55
Q

physical exam findings for hyphema

A
  • blood in anterior chamber
  • decreased visual acuity
  • photophobia
  • anisocoria (uneven pupils)
  • elevated IOP
56
Q

hyphema dx

A
  • ophthalmoscope

- slit lamp

57
Q

treatment for hyphema

A
  • 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
Q

what can you use to paralyze pupil for hyphema (cycloplegia)?

A

cyclopentolate or homatropine

59
Q

follow-up of hyphema

A

refer to ophthalmologist and monitor IOP daily

60
Q

when is a hyphema emergent?

A

If:

  • open globe
  • orbital compartment syndrome
  • large hyphemas (grade 3 or 4)
  • hyphemas associated w/dyscrasia (bleeding disorder)
61
Q

complications of hyphemas

A
  • intractable glaucoma
  • secondary hemorrhage
  • posterior synechiae
  • peripheral synechiae
  • optic atrophy
62
Q

what can intractable glaucoma (complication of hyphema) lead to?

A

permanent vision loss and blindness

63
Q

what are posterior synechiae and peripheral synechiae

A

posterior synechiae - iris adheres to lens -> vision issues

peripheral synechiae - iris adheres to cornea -> vision issues

64
Q

what is the cornea innervated by?

A

trigeminal nerve (Reason why so much pain)

65
Q

what layer of the cornea is the most common to have a corneal abrasion?

A

epithelium

66
Q

what is the presenting history for a corneal foreign body?

A

windy weather, working with power tools, gardening

67
Q

corneal foreign body symptoms

A
  • pain
  • foreign body sensation
  • photophobia
  • tears
  • red eye
  • blurred vision
68
Q

exam findings for corneal foreign body

A
  • 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
Q

what does the Seidel test, test for in corneal foreign body/

A

tests for corneal perforation

-if perforated globe is ruptured and have outflow from anterior chamber

70
Q

diff dx for corneal foreign body

A

keratitis, intraocular foreign body, corneal abrasion

71
Q

what is the #1 treatment for corneal foreign body?

A

REMOVAL OF THE FOREIGN BODY

-if deep call ophthalmologist

72
Q

Medical management of corneal foreign body?

A
  • Topical erythromycin or ciprofloxacin (for contact lens wearers)
  • topical cycloplegis
  • avoid contacts until healed
  • tetanus
  • follow-up with specialist
73
Q

how often does pt with corneal foreign body follow up with a specialist/

A

every 2 days until healed

74
Q

corneal abrasion definition

A

any defect on the corneal surface

75
Q

corneal abrasion causes?

A
  • eye trauma
  • retained foreign body
  • improper contact lens use
  • spontaneous
76
Q

what identifies the etiology of a corneal abrasion?

A

history taking

77
Q

if pt has traumatic corneal abrasion what will the history be?

A

history of direct trauma to the globe

78
Q

symptoms of corneal abrasion?

A

same as corneal foreign body

-pain, foreign body sensation, photophobia, tearing, red eye, blurred vision

79
Q

differential dx for corneal abrasion?

A
  • acute globe rupture
  • retained foreign body
  • infectious keratitis
  • corneal ulcer
  • acute angle glaucoma
80
Q

dx for corneal abrasion?

A

fluorescein stain with woods or slit lamp

81
Q

what is the mainstay of txt for corneal abrasion?

A

Topical erythromycin ointment or ciprofloxacin drops for contact lens wearers

82
Q

what do you give for mild-moderate pain control for corneal abrasion?

A

NSAIDs (Motrin) PO or topical (diclofenac/ketorolac)

83
Q

what do you give for severe pain (large abrasion) control for corneal abrasion?

A

oral opioids for 48 hours

also cycloplegics but inhibit healing

84
Q

who does NOT need a follow-up for corneal abrasion?

A 
small abrasions (heal in 24-48 hrs)
-but return if have eye drainage, decreased vision, sx persist >48 hours
85
Q

who needs a follow-up with an ophthalmologist for corneal abrasion?

A
  • large abrasion
  • contact lens wearers
  • abrasions in young children
  • rust ring
  • abrasions with vision changes
86
Q

keratitis

A

inflammation of cornea

-develops into corneal ulcer

87
Q

what is the #1 infectious cause of corneal ulcer?

A

viral (HSV/Zoster)

88
Q

bacterial causes of corneal ulcers

A

-pseudomonas (CONTACT LENS)
-moraxella (DM, alcoholics and immunosuppressed)
-strep
-staph
MRSA

89
Q

risk factors for corneal ulcers

A
  • contact lens
  • previous eye surgery
  • eye injury
  • hx of HSV
  • immunocompromised or autoimmune state (diabetes, RA)
  • use of topical or systemic steroids
90
Q

symptoms of corneal ulcers

A
  • lid and ocular swelling
  • injected conjunctive
  • injected eyelid
  • miotic pupil
  • discharge: clear or mucopurulent
91
Q

what are non-infectious causes of corneal ulcers?

A
  • 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
Q

Findings of corneal ulcers

A
  • punctate or diffuse branching of dendritic lesions (HSV/Zoster)
  • corneal ulceration
  • hypopyon
  • anterior cell/flare
93
Q

if pseudomonas is the cause of the corneal ulcer, what will you see on findings?

A

grey/yellow infiltrate

94
Q

dx of corneal ulcer

A
  • slit lamp and fluorescein stain

- culture and gram stain or PCR

95
Q

what type of treatment does corneal ulcer require?

A

aggressive txt

96
Q

what is the initial treatment for corneal ulcer?

A

abx, unless dendritic pattern then acyclovir

97
Q

abx for corneal ulcer

A

fluoroquinolone (b/c don’t know if it’s pseudomonas or not)

98
Q

txt for viral corneal ulcer

A

topical acyclovir

99
Q

corneal ulcer complications

A
  • corneal scarring
  • corneal perforations
  • anterior/posterior synechiae
  • glaucoma
  • cataracts
  • blindness

Clinical Medicine (11 decks)

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