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

2. N.A. What constrains a retinal detachment? 1. A. Ciliary body 2. B. Hyaloid vessels 3. C. Ora Serrata 4. D. Zonular ligaments 5. E. Orbital septum

3. N.A. The following is not an indication for surgical correction of orbital Fx 1. A. Double vision 2. B. Enophthalmos 3. C. Greater than 50% floor involvement 4. D. Exophthalmos 5. E. None of the above

4. 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

5. 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

6. Which eye is abnormal? 1. A. Right 2. B. Left

8. Ocular Blood Locations: Anterior chamber: anterior hyphema Posterior chamber: posterior hyphema Vitreous: vitreous hemorrhage Choroidal detachment Retinal detachment

9. 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

11. Traumatic Cataract

14. Open Globes are Acutely Repaired Due to Risk of Endophthalmitis: Blindness

15. Foreign Bodies: Acute Rx

16. What kind of detachment?

18. Ocular Membranes Retinal detachment –NAT! Choroidal detachment Subhyaloid detachment Puncture

19. Detachment(s)

24. Vitreous Chamber Classic rupture Ocular hypotony Hemorrhage Puncture Late effect: Phthisis Bulbi

26. Why left eye?

29. Early Ocular Intervention Open globe Foreign bodies Corneal abrasions Hyphema Globe lacerations Detachments –Scleral buckling / vitrectomy Suck vitreous, treat retina, reinflate oil/gas/saline

30. Surgery for Hyphema Uncontrolled elevated IOP Corneal blood staining (opacification) Large hyphemas of long duration Sickle cell Active bleeding Paracentesis, AC washout, hyphectomy, trabeculectomy

31. 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

32. Phthisis Bulbi A small shrunken calcified globe usually secondary to trauma or inflammation c/o Bidyut Pramanik

33. Endophthalmitis

35. 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

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

37. 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

38. Retrobulbar Hematoma -Danger is that acute intraorbital pressure may result in retinal artery occlusion, optic nerve ischemia -Lateral canthotomy decompression

39. sheath

41. Conal: Muscle Avulsion

42. Orbital Trauma Vascular Carotid-cavernous fistula Pseudoaneurysm Varicosities

44. Carotid Cavernous Fistula May result in EOM enlargement due to venous engorgement All EOMs involved Superior Ophthalmic Vein is dilated Usually unilateral

47. 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

48. 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

49. 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

50. 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

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

52. Orbital Fracture

57. Extraconal Hematoma

58. Conclusions A common indication in ED practice Ocular, non-ocular findings often equally important Some fractures should be treated acutely Long term sequelae