Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Evaluation and Management of Acute Orbital Trauma Orbital injury following blunt facial trauma is not uncommon. In the largest series to date, Holt reported that 67% of those patients receiving formal ophthalmologic evaluation sustained eye injuries. Of these, 21% received serious or blinding injuries. The vast majority of the serious or blinding injuries occurred after mid facial or frontal trauma. The most common temporary injuries were subconjunctival hemorrhage and extraocular motility disturbance. The most common serious injuries were cranial nerve palsies, muscle entrapment, hyphema, and retinal hemorrhage. The successful management of orbital trauma is dependent upon proper initial evaluation. Penetrating trauma suggests the possibility of an open globe. Any manipulation of the eye risks additional injury or irreparable damage. A complete physical exam should be performed to rule out concomitant injuries including facial fractures and C-spine injuries. Documentation of visual acuity is important not only initially, but also to pick up deterioration on serial exams as may occur with optic nerve compression. The direct and consensual response of the pupil exam is important for documenting an afferent pupillary defect (APD) or Marcus-Gunn pupil. The swinging flashlight test displays the anomaly in which the consensual response is present, but the direct response is paradoxical ( the injured eye dilates with light ). An APD suggests optic nerve injury. Extraocular movement exam can reveal entrapment or cranial nerve palsy. The forced duction test is the definitive test for muscle entrapment and should be performed prior to any orbital fracture repair. Lastly, ophthalmoscopy is important for examination of the retina and the lens. An understanding of the anatomy of the eyelid is important in managing orbital trauma. If the protective function of the eyelid is compromised, serious ophthalmologic injury can result. The eyelid is formed by skin, subcutaneous tissue, orbicularis oculi (pretarsal, preseptal, preorbital), tarsal plate, levator aponeurosis, septum, and conjunctiva. The levator palpebrae is the main lid elevator and inserts into the anterior mid-tarsus and skin of the supratarsal crease. It is innervated by CN III. Mueller's muscle is the sympathetically controlled elevator which provides 2 mm of elevation. It is inserted into the inferior surface of the levator. The capsulopalpebral fascia is the lower lid analog of the levator, and the inferior tarsal muscle is the analog of Mueller's muscle. Horizontal lacerations of the eyelid require exploration if a foreign body is suspected. If ptosis is present, injury to the levator aponeurosis or Mueller's muscle may be suspected. If so, the cut ends can be sutured to the superior tarsal border using 6-0 absorbable suture. The eyelid should be closed in layers. Vertical lacerations involving the lid margin are more complex. A 6-0 silk suture is first placed at the gray line and is used for traction. Anterior and posterior lid margin sutures are then placed. The posterior and gray line sutures are left long, tied underneath the anterior margin suture, and taped to the cheek. The skin is closed with interrupted 6-0 silk. The tarsal plate must be repaired using 6-0 absorbable suture to prevent lid notching. Tearing injuries of the lid may involve the lacrimal canaliculi or nasolacrimal sac. The lacerated ends of the canaliculi or sac should be identified with a probe. The upper and lower lid puncta are intubated using a fine silicone tube stent across the laceration. The free ends are then tied in the nose. The laceration is then repaired using a 6-0 or 7-0 absorbable suture. The stent must remain in place for 4-6 weeks. Medial canthal injuries are frequently associated with eyelid avulsion injuries and NOE fractures. The Hallmark is post-traumatic telecanthus. This is characterized by medial blunting, decreased height of the palpebral fissure, and widening of the intercanthal distance. Mathog has classified these injuries into type I (simple laceration or avulsion), type II (comminution of ipsilateral orbital wall), type III (comminution of both medial orbital walls). Type I injuries require only simple repair. Type II injuries involve securing the tendon to the contralateral orbital wall. In type III injuries the tendons are secured transnasally to each other. Blindness following blunt facial trauma is a rare but devastating injury caused by optic nerve compression. In 1982, Anderson reported on 7 cases of monocular blindness following frontal head trauma treating with megadose steroids or optic nerve decompression. 3 of 6 had good response to steroids, while 1/4 had minor return of function after decompression. The Japanese literature reports success rates as high as 80% for optic nerve decompression. At Baylor, Miller and Woodson, recommended the following protocol:
Dexamethasone Steroid Protocol ( from Anderson et al):
Case Presentation The patient is a 43-year-old black man with a history of alcohol and substance abuse. He reported being struck in the face with a pipe during an altercation shortly before admission. Physical examination revealed a depressed left maxilla, with a small stepoff at the left infraorbital rim, and trismus. He denied visual change or diplopia. His visual acuity, extraocular movements, and pupil examination were normal and intact. A CT exam revealed a left zygomatico-maxillary complex fracture and left subcondylar fracture. The patient was placed into maxillomandibular fixation. His left orbit and ZMC were explored through a transconjunctival approach. ORIF of the lateral orbital rim was performed using a 5-hole microplate. The patient's postoperative coarse was complicated by chemosis with secondary decreased extraocular motility. He was evaluated by the ophthalmologic service and treated conservatively. The edema resolved 3 weeks postoperatively with full return of extraocular movements. At 6 weeks, the patient was well healed and was taken out of maxillomandibular fixation with good results. Bibliography Anderson RL, Panje WR, Gross CE. Optic nerve blindness following blunt forehead trauma. Ophthalmology 1982;89:445-455. Appling WD, Patrinely JR, Salzer TA. Transconjunctival approach vs. subciliary skin-muscle flap approach for orbital fracture repair. Arch Otolaryngol Head Neck Surg 1993;119:1000-1007. Bähr W, Bagambisa FB, Schlegel G, Schilli W. Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: a retrospective study. Plast Reconstr Surg 1992;90:585-591. Beyer CK, Fabian RL, Smith B. Naso-orbital fractures, complications, and treatment. Ophthalmology 1982;89:456-463. Brent BD, May DR. Orbital apex syndrome after penetrating orbital trauma. Ann Ophthalmology 1990;22:267-268. Coogan P, Debehnke D. Occult penetrating orbital trauma. Am J Emerg Med 1993;11:396-399. Crumley RL, Leibsohn J, Krause CJ, Burton TC. Fractures of the orbital floor. Laryngoscope 1977;87:934-947. Fujino T, Makino K. Entrapment mechanism and ocular injury in orbital blowout fracture. Plast Reconstr Surg 1980;65:571-574. Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of 727 cases. Otolaryngol Head Neck Surg 1983;91:276-279. Holt GR, Holt JE. Lacerations of the lacrimal apparatus, parotid duct, and facial nerve: case report. J Trauma 1976;16:414-419. Holt GR, Holt JE. Management of orbital trauma and foreign bodies. Otolaryngol Clin North Am 1988;21:35-52. Holt JE, Holt GR. Nasolacrimal evaluation and surgery. Otolaryngol Clin North Am 1988;21:119-134. Holt JE, Holt GR. Ocular injuries in craniofacial trauma. Facial Plast Surg 1988;5:237-242. Holt JE, Holt GR, Blodgett JM. Ocular injuries sustained during blunt facial trauma. Ophthalmology 1983;90:14-18. Holt JE, Holt GR, Van Kirk M. Use of temporalis fascia in eyelid reconstruction. Arch Otolaryngol 1985;111:165-167. Knox BE, Gates GA, Berry SM. Optic nerve decompression via the lateral facial approach. Laryngoscope 1990;100:458-462. Koornneef L. Current concepts on the management of orbital blow-out fractures. Ann Plast Surg 1982;9:185-200. Lipkin AF, Woodson GE, Miller RH. Visual loss due to orbital fracture: the role of early reduction. Arch Otolaryngol Head Neck Surg 1987;113:81-83. Manson PN, Iliff NT. Orbital fractures. Facial Plast Surg 1988;5:243-259. Manson PN, Ruas E, Iliff N, Yaremchuk M. Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr Surg 1987;79:120-126. Mathog RH. Posttraumatic telecanthus. Facial Plast Surg 1988;5:261-267. McCord CD, Moses JL. Exposure of the inferior orbit with fornix incision and lateral canthotomy. Ophthalmic Surg 1979;10:53-63. Meyers A. Recent advances in the management of orbital trauma: reconstruction and complications. Arch Otolaryngol Head Neck Surg 1991;117:593. Osguthorpe JD, Sofferman RA. Optic nerve decompression. Otolaryngol Clin North Am 1988;21:155-169. Waite PD, Carr DD. The transconjunctival approach for treating orbital trauma. J Oral Maxillofac Surg 1991;49:499-504. Weisman RA. Surgical anatomy of the orbit. Otolaryngol Clin North Am 1988;21:1-12. Weymuller EA Jr. Blindness and Lefort III fractures. Ann Otol Rhinol Laryngol 1984;93:2-5. Young WC, Holt GR, Holt JE. Eyelid trauma. Ear Nose Throat J 1980;59:59-72. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
|