![]() Slit-lamp examination is used to diagnose co-morbidities of ocular trauma including corneal abrasion, hyphema, traumatic iritis, iridodialysis, iris sphincter tears, lens dislocation, cataract, vitreous hemorrhage, or a ruptured globe. It is extremely important to ask about diplopia and perform careful assessment of extraocular motility and forced ductions (if necessary) to detect orbital tissue entrapment or extraocular muscle paralysis. Hertel exophthalmometry is used to quantify the presence of exophthalmos or enophthalmos. Intraocular pressure can raise or lower suspicion for a retrobulbar hemorrhage causing an orbital compartment syndrome. If there is a relative afferent pupillary defect, this may indicate a traumatic optic neuropathy. Visual acuity and pupils should be checked. Associated signs may include eyelid ecchymosis, subcutaneous emphysema, ptosis, pupillary dilation, and epistaxis (5).Įxam and workup should be modified to detect the common sequelae mentioned above. Signs and symptoms of orbital floor fractures include orbital pain, enophthalmos, hypesthesia in the V2 distribution (due to damage to the infraorbital nerve) and vertical diplopia. In adults and children, the medial and inferior orbital walls are the most vulnerable to fracture (2-4) due to their thin bone structure. Orbital blowout fractures are caused by hydraulic mechanisms transmitting force through orbital soft tissue into the orbital walls, direct buckling mechanisms as the result of deformation of the bony orbital rim, or a combination of the two (1). Motility deficits completely resolved one month after the surgical repair. There are mild residual upgaze and downgaze deficits but marked improvement compared with preoperative motility. Figure 3: External photographs of extraocular eye movements one week after surgical repair. At the one month follow-up visit, the patient was noted to have 20/15 visual acuity, no diplopia, full extraocular movements and no enophthalmos. At the one week follow-up visit, the patient was noted to have 6 prism diopters of left hypertropia, mild diplopia in all gaze directions and mild deficits in up and down gaze of the left eye (see figure 3). A 0.4mm Supramid implant was used to cover the floor defect and secured with titanium screws along the inferior orbital rim. The entrapped orbital tissues were released. A transconjunctival approach was used to expose the inferior orbital wall fracture and entrapment of the inferior rectus was confirmed. Forced ductions showed marked limitation to elevation of the left eye. He was taken to the operating room for surgical repair within 8 hours of presentation. Figure 2b shows a more posterior aspect of the orbital floor fracture with the inferior rectus muscle body completely herniated within the maxillary sinus (arrow)īased on history, clinical exam and CT imaging, the patient was diagnosed with a left orbital floor fracture with entrapment. Figure 2a shows an anterior portion of the orbital floor fracture that involves inferior rectus entrapment (arrow). ![]() Maxillofacial computed tomography (CT): (see figure 2) Figure 1: External video of extraocular eye movements demonstrating marked supraduction deficit OS.įigure 2: Maxillofacial computed tomography (CT): left inferior orbital floor fracture with entrapment of intraorbital fat and left inferior rectus muscle. Restriction on forced supraduction OS compared with OD Patient became nauseated during the ocular motility testing. OD: full motility, OS: Significantly reduced supraduction and pain when looking up (see figure 1). Ocular motility: Left hypotropia in primary gaze. Slit lamp exam (OS): few scattered, small sub-conjunctival hemorrhages OS, otherwise normal OU Hertel Exophthalmometry: Base 104 mm right eye (OD): 19 mm, left eye (OS) 16 mmĮxternal Exam: minimal periorbital edema, no ecchymosis Intraocular pressure (IOP): OD: 20 mmHg, OS: 19 mmHg OCULAR EXAMINATIONīest Corrected Visual Acuity (BCVA): Right eye (OD): 20/20, Left eye (OS): 20/20 Subsequently, he experienced significant pain when attempting to look up and had associated nausea and vomiting. He immediately noted double vision with both eyes open. History of Present Illness: The patient was a 17-year-old male who was involved in a physical altercation that resulted in a closed fist blow to the left side of his face. ![]() Chief Complaint: Diplopia, pain with eye movement, nausea and vomiting ![]()
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