1. Grand Rounds Conference
Lara Rosenwasser Newman, MD
University of Louisville
Department of Ophthalmology and Visual Sciences
September 5, 2014

2. Subjective CC: Evaluate globe OS
HPI: 6 yo African-American boy involved in a motor vehicle accident with waxing and waning consciousness. Pt complained of pain on eye movements, especially on upgaze. Denied diplopia.

3. History PMHx: PSHx: POHx: Medications: Asthma
Tympanostomy tube placement
POHx:
None
Medications:
Albuterol inhaler, Beclomethasone dipropionate (QVAR inhaler)

4. Clinical Exam OD OS VA (n,sc/Allen): 20/30 20/30 Pupils: 32 32
(-)rAPD
IOP: 19mmHg 20mmHg
EOM:
Pain on attempted upgaze OS; no diplopia -4 -3

5. Clinical Exam
PLE: External/Lids Small superficial laceration on upper lid OS, mild ecchymosis/edema Conjunctiva/Sclera Clear/white; no subconj heme Cornea Clear OU Anterior Chamber Formed OU Iris Normal OU Lens Clear OU Vitreous Normal OU DFE deferred per neurosurgery

6. External Appearance

7. Physical Exam Bradycardia with heart rate in 40s-50s Nausea, vomiting
Waxing & waning consciousness since accident

8. EOMs

9. CT Face Minimally depressed fracture of L orbital floor
Minor opacification of L ethmoid air cells, trace fluid or possibly hemorrhage in the L maxillary sinus

10. Assessment
6 yo AAM status post motor vehicle accident with orbital floor fracture OS, with clinical exam suggestive of entrapment of inferior rectus muscle (WEBOF: white-eyed orbital blow-out fracture)

11. Plan Admitted to ICU 2/2 bradycardia Ophthalmology:
Patient taken to OR for fracture repair within ~6 hours of arrival to ED by oculoplastics
L orbital floor fracture repair w/suprafoil implant
Successful repositioning of orbital tissues

12. Follow-up Post-operative day #1: DFE WNL 20/30 OD, 20/70 OS
Improving periorbital edema, mild chemosis
Diplopia
Infraduction OS -1
DFE WNL

13. Follow-up At 1 week: L face swollen No diplopia, intermittent pain
“Trouble reading, covered 1 eye due to blurriness”
Sinus arrhythmia – following with pediatrician
Lower lid OS with decreased excursion
20/20 OU, motility full OU

14. WEBOF: White-Eyed BlowOut Fracture
Benign extraocular appearance w/minimal eyelid signs BUT w/significant EOM restriction
Usually vertical gaze restriction
Kids often do not complain of binocular diplopia (just close one eye)
Cartilaginous/bendable bones in kids lead to:
Increased risk for “trapdoor” fractures
Increased risk for EOM incarceration

15. WEBOF Presentation Kids may present w/severe oculocardiac reflex:
Nausea or vomiting, dehydration from anorexia
Bradycardia or syncope
May be misdiagnosed as concussion
Fracture/entrapment can be missed on CT head
Always get dedicated CT face or orbits

16. Imaging
CT can show trapdoor fracture with rectus muscle incarceration or “missing” inferior rectus
Inf rectus
muscle belly
“Missing”
inf rectus
CT showing “missing rectus” on Left – no apparent fracture, inferior rectus absent. Muscle belly looks good on right side. Stuff below is orbital content incl rectus muscle herniating into maxillary sinus through invisible linear fracture.
Yano, H., Minagawa, T., Masuda, K., & Hirano, A. (2009). Urgent rescue of “missing rectus” in blowout fracture. Journal of Plastic, Reconstructive &
Aesthetic Surgery : JPRAS, 62(9), e301–4. doi: /j.bjps

17. Orbital Blow-out Fractures
Symptoms:
Pain on attempted eye movement
Tenderness, lid edema, binocular diplopia, trauma hx
Signs:
Restricted EOMs, subcutaneous or conjunctival emphysema, point tenderness, enophthalmos
Hypesthesia in distribution of the
infraorbital nerve
Byrne, Karen M. Infraorbital Nerve Block. Emedicine:

18. Differential Diagnosis of Muscle Entrapment in Orbital Fractures
Orbital edema and hemorrhage without blow-out fracture
Can still cause EOM limitation, swelling, ecchymosis
Resolves over 7-10 days
Cranial nerve palsy
EOM limitation but no restriction on forced ductions
Rule out intracranial & skull base processes w/CT

19. WEBOF Treatment
Consider broad-spectrum abx if hx of chronic sinusitis, diabetes, or immune compromise.
Not mandatory
Not evidence-based (limited, anecdotal evidence)
Oxymetazoline BID for 3 days, no nose blowing
Q1-2h ice packs for 20 mins for hrs
Consider oral steroids if swelling extensive and limiting exam of motility and globe position

20. WEBOF Treatment
Immediate repair (24-72 hrs) if evidence of muscle entrapment and non-resolving heart block, bradycardia, nausea, vomiting, or syncope
Release incarcerated muscle to decrease chance of ischemia and fibrosis causing permanent restrictive strabismus
Also to alleviate oculocardiac reflex

21. Surgical Repair Technique
Surgical approach:
Subconjunctival incision +/- lateral cantholysis
Elevate periorbita from orbital floor
Release prolapsed tissue from fracture
Usually place implant over fracture to prevent recurrent adhesions and tissue proplapse
Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi: /

22. Orbital Implants Alloplastic: Autogenous: Porous polyethylene
Supramid (nylon foil)
Gore-Tex
Teflon
Silicone sheet
Titanium mesh
Autogenous:
Split cranial bone, iliac crest bone, or fascia
Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi: /

23. Timoney et al describe use of 0.4 mm Supramid
Nylon foil – non-porous, relatively inert, alloplastic implant
59 orbits in 57 patients (all pediatric)
3 patients (5.3%) had entrapment with vasovagal responses and immediate intervention
6 had immediate post-op diplopia; all improved
2 post-op complications without permanent sequellae
None had noticeable post-op enophthalmos
Concluded Supramid implant safe and effective
Timoney, P. J., Krakauer, M., Wilkes, B. N., Lee, H. B. H., & Nunery, W. R. (2014). Nylon foil (supramid) orbital implants in pediatric orbital fracture repair.
Ophthalmic Plastic and Reconstructive Surgery, 30(3), 212–4. doi: /IOP

24. References
Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi: /
Foulds, J. S., Laverick, S., & MacEwen, C. J. (2013). “White-eyed” blowout fracture in children. Emergency Medicine Journal : EMJ, 30(10), 836. doi: /emermed
Gerstenblith, A. T., & Rabinowitz, M. P. (2012). The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia, PA: Lippincott Williams & Wilkins.
Hammond, D., Grew, N., & Khan, Z. (2013). The white-eyed blowout fracture in the child: beware of distractions. Journal of Surgical Case Reports, 2013(7), 2–3. doi: /jscr/rjt054
Orbital Trauma. In: Basic and Clinical Science Course (BCSC) Section 7: Orbit, Eyelids, and Lacrimal System. San Francisco, CA: American Academy of Ophthalmology; 2014:
Timoney, P. J., Krakauer, M., Wilkes, B. N., Lee, H. B. H., & Nunery, W. R. (2014). Nylon foil (supramid) orbital implants in pediatric orbital fracture repair. Ophthalmic Plastic and Reconstructive Surgery, 30(3), 212–4. doi: /IOP
Verret, Daniel JDucic, Y. (2013). Implants, Soft Tissue, High-Density Porous Polyethylene (Medpor). Medscape Reference. Retrieved from
Yano, H., Minagawa, T., Masuda, K., & Hirano, A. (2009). Urgent rescue of “missing rectus” in blowout fracture. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS, 62(9), e301–4. doi: /j.bjps