Eye and Periorbital Trauma
The role of the emergency physician in the evaluation of patients with eye and periorbital trauma is to determine that visual acuity, extraocular muscle function, the corneal surface, and the fundus are normal. Limitation of extraocular movements or diplopia, for which all patients deserve careful evaluation, is an important finding and suggests the need for urgent ophthalmologic consultation. In addition, the importance of fluorescein staining of the cornea followed by examination under ultraviolet light cannot be overemphasized and must be routinely performed in all patients with ocular symptoms. The evaluation of patients with periorbital trauma should begin as soon as possible because local swelling, if marked, may interfere with ocular assessment.
Radiologic assessment should be considered in all patients with significant periorbital trauma because signs of ophthalmologic injury need not be present in patients with important fractures. The need for urgent consultation in patients with posttraumatic limitation of extraocular movement or diplopia is also important to emphasize because surgical intervention may be necessary.
BLUNT INJURIES TO THE EYE AND ORBIT
Blunt injuries to the eye and orbit may result in periorbital contusion (“black eye”), orbital or ethmoid fractures, corneal abrasions and/or foreign bodies, traumatic iritis, hyphema, dislocation of the lens, or actual rupture of the globe.
Periorbital Contusion
Trauma to the periorbital structures may result in local blood vessel disruption and rapidly evolving, often extensive, swelling and ecchymosis; this reflects the relative distensibility of the periorbital soft tissues.
Patients should be advised to avoid aspirin, to apply cold to the area (never a chemical ice pack, which may leak), and to expect swelling and ecchymosis to persist for several days to weeks.
Elevating the head of the bed or using several pillows may somewhat impede gravity-induced nocturnal swelling.
In patients with periorbital contusion, the eye itself must be carefully examined to exclude more significant injury.
CT assessment of the orbit in patients with significant periorbital trauma is recommended (when available) because the classic signs of orbital fracture are frequently absent.
Orbital Floor Fracture
Orbital floor or “blow-out” fractures typically occur as a result of blunt trauma to the globe; these fractures may or may not be associated with injury to the eye itself and usually result from fist, ball, or other generally nonpenetrating contact.
Sudden increases in intraorbital pressure result in a blow-out fracture, that is, a fracture producing inferior displacement of the relatively weak orbital floor. Contents of the inferior orbit, particularly the inferior oblique and inferior rectus muscles, may herniate through the fracture site and, with evolving edema, may become entrapped and ischemic.
Diagnosis
Diagnosis is frequently difficult, particularly when delay occurs between injury and presentation; in these patients, local swelling may be marked.
A history of blunt trauma to the eye may be elicited; periorbital edema and ecchymosis, enophthalmos (backward displacement of the eye), infraorbital nerve anesthesia (upper lip gingiva), and subconjunctival hemorrhage may be present.
If inferior oblique or inferior rectus muscle entrapment exists, then limitation of upward eye movement may be noted.
Diplopia associated with muscle entrapment may be elicited historically or may be demonstrated by the physician.
Enophthalmos is a very specific sign of orbital floor fracture, but it may be masked by local swelling and hemorrhage.
Computed tomography (CT) assessment of the orbit (if available) should be routinely obtained when a diagnosis of orbital floor fracture is suspected.
If CT is not available, facial x-rays including the Waters projection can be helpful in confirming the diagnosis.
Radiologic findings in orbital floor fracture include clouding of the ipsilateral maxillary sinus (secondary to local hemorrhage or extrusion of orbital soft tissues into the sinus), fragmentation or disruption of the inferior orbital floor, often with depression of bony fragments into the sinus, and intraorbital free air.
Treatment
Patients with fractures of the orbital floor associated with diplopia or impaired extraocular muscle function require urgent ophthalmologic consultation.
Operative intervention may be required.
Prophylactic antibiotics are controversial in orbital fractures.
If used, they should cover sinus flora.
Patients should be instructed to refrain from blowing the nose for 10 to 14 days, because this maneuver may introduce the contents of the sinus into the orbit through the fracture site.
Ethmoid Fracture
Crepitus in association with trauma to the periorbital structures suggests an ethmoid fracture, which should be documented radiologically.
Treatment is the same as for orbital floor fractures.
Traumatic Iritis
Blunt trauma to the eye, if significant, is often associated with some degree of iritis. Patients report deep eye pain and photophobia, perilimbal conjunctival injection is noted (ciliary flush), the pupil is constricted, and “flare” is noted by slit-lamp examination representing inflammatory cells and exudate in the anterior chamber. Immediate ophthalmologic consultation is appropriate.
Treatment includes topical steroids and cycloplegics.
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