Orbital Trauma

David M. Yousem, M.D., M.B.A.Johns Hopkins Medical Institution

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N.A. What constrains a retinal detachment?

1. A. Ciliary body2. B. Hyaloid vessels3. C. Ora Serrata4. D. Zonular ligaments5. E. Orbital septum

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N.A. The following is not an indication for surgical correction of

orbital Fx

1. A. Double vision2. B. Enophthalmos3. C. Greater than 50%

floor involvement4. D. Exophthalmos5. E. None of the above

• Describe injuries to globe (bulbar)• List indications for acute globe

intervention• Describe retrobulbar injuries including

fractures (intraconal/conal/extraconal)• Discuss controversies re: fracture

intervention

Orbital Trauma Goals and Objectives

Orbital Trauma : Background

• Trauma to eye = 3% of ED visits• 4.5% of all orbital pathology is from

trauma• 40% of monocular blindness in US is

from trauma• Some findings require acute

treatment

Which eye is abnormal?

1. A. Right2. B. Left

Ocular Blood Locations:

• Anterior chamber: anterior hyphema• Posterior chamber: posterior

hyphema• Vitreous: vitreous hemorrhage• Choroidal detachment• Retinal detachment

Anterior Chamber Trauma

• Rupture– Pain, decreased vision, hyphema– Flourescein slitlamp cobalt blue dilution

• Open injury• Hyphema

– Delayed/acute glaucoma : laser iridotomy• Traumatic cataract• Lens Displacement / dislocation

Traumatic Cataract

Open Globes are Acutely Repaired

Due to Risk of Endophthalmitis: Blindness

Foreign Bodies: Acute Rx

What kind of detachment?

Ocular Membranes

• Retinal detachment– NAT!

• Choroidal detachment• Subhyaloid detachment• Puncture

Detachment(s)

Vitreous Chamber

• Classic rupture• Ocular hypotony• Hemorrhage• Puncture• Late effect: Phthisis Bulbi

Why left eye?

Early Ocular Intervention• Open globe• Foreign bodies• Corneal abrasions• Hyphema• Globe lacerations• Detachments

– Scleral buckling / vitrectomy• Suck vitreous, treat retina, reinflate

oil/gas/saline

Surgery for Hyphema

• Uncontrolled elevated IOP• Corneal blood staining (opacification)• Large hyphemas of long duration • Sickle cell• Active bleeding

• Paracentesis, AC washout, hyphectomy, trabeculectomy

Complications

• Phthisis bulbi• Endophthalmitis in 10% of open globes

– Staph, Strep, Bacillus (rural, FB)– Antibiotics mandatory; ? Pars plana

vitrectomy– Vision loss in days

• Glaucoma: Drops then laser iridotomy– Potential for optic nerve ischemia

• Staphyloma

Phthisis Bulbi• A small shrunken

calcified globe usually secondary to trauma or inflammation

c/o Bidyut Pramanik

Endophthalmitis

Staphyloma• Acquired defects in the

sclera or cornea• Posterior staphyloma is

associated with increasing globe size

• Usually on the temporal side of optic nerve

• Outward bulging with uveoscleral thinning

• Anterior staphyloma is seen with RA

c/o Bidyut Pramanik

Enucleation

• Blind painful eye• Endophthalmitis (esp open globe)• Phthisis bulbi• Severe traumatic rupture• Unsightly eye• Glaucoma

Non-ocular Orbital Trauma

• Intraconal / Conal– Retrobulbar hematoma– Optic nerve sheath hematoma– Injury to nerve– Injury to vessels– Traumatic muscle edema/hematoma– Muscular avulsion (Medial rectus)– Vascular

Retrobulbar

Hematoma-Danger is that acute intraorbital pressure may result in retinal artery occlusion, optic nerve ischemia

-Lateral canthotomy decompression

sheath

Conal: Muscle Avulsion

Orbital Trauma Vascular

• Carotid-cavernous fistula• Pseudoaneurysm• Varicosities

Carotid Cavernous Fistula

• May result in EOM enlargement due to venous engorgement

• All EOMs involved• Superior Ophthalmic Vein is dilated• Usually unilateral

Extraconal: Orbital Fractures

• Orbital rim• Orbital floor• Medial orbital wall: lamina papyracea• Lateral orbital wall• Superior wall

– Globe injuries occur in 10-25% of patients with orbital fractures

Indications for Surgery for Orbital Fractures

• Enophthalmos > 2 mm (> 50% of floor)• Hypoglobus (downward displaced globe)• Diplopia

– Edema, heme, n. palsy, direct trauma• Increase in orbital volume > 1 cc

– Correlates with enophthalmos• Limited mobility (entrapment of EOM)• Compressive optic neuropathy

Kontio R, Lindquist C. OMFC 2009: 21: 209-220

Indications for Surgery for Orbital Fractures

• Fracture of > 50% of floor• Orbital tissue entrapment• Diplopia• Non-resolving oculocardiac reflex, also

known as Aschner reflex, – Decrease in pulse rate associated with

traction applied to extraocular muscles and/or compression of the eyeball

Chen CT et al. Cur Opinion Otol HNS 2010: 18: 311-6

Controversies in Surgery• When to repair orbital fractures

– Rarely considered emergent– ? Adhesions when delayed– ? Benefit of decreased swelling– Some say 14-21 days

• Unless optic neuropathy– Oculocardiac reflex: vagus– Children get operated earlier d/t increased

entrapment– Early surgery for penetration

Kontio R, Lindquist C. OMFC 2009: 21: 209-220

Controversies in Surgery

• What to repair with– Must be rigid to contain orbital contents– Restore form and volume– Contourable

• Autogenous grafts (iliac bone)– ? Too rigid, difficult to place

• Alloplasts (non/resorbable)– Many varieties

• Titanium mesh, MedporKontio R, Lindquist C. OMFC 2009: 21: 209-220

Orbital Fracture

Extraconal Hematoma

Conclusions

• A common indication in ED practice• Ocular, non-ocular findings often

equally important• Some fractures should be treated

acutely• Long term sequelae