Grand Rounds

Grand Rounds ConferenceLara Rosenwasser Newman, MDUniversity of LouisvilleDepartment of Ophthalmology and Visual SciencesSeptember 5, 2014SubjectiveCC: 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.

2HistoryPMHx:AsthmaPSHx:Tympanostomy tube placementPOHx:NoneMedications:Albuterol inhaler, Beclomethasone dipropionate (QVAR inhaler)

3IOP:19mmHg20mmHgEOM:

Pain on attempted upgaze OS; no diplopiaClinical Exam OD OSVA (n,sc/Allen): 20/3020/30

Pupils: 32 32

0000(-)rAPD0-4-304Clinical ExamPLE: External/LidsSmall superficial laceration on upper lid OS, mild ecchymosis/edemaConjunctiva/ScleraClear/white; no subconj hemeCorneaClear OUAnterior ChamberFormed OUIrisNormal OULensClear OUVitreousNormal OU

DFE deferred per neurosurgeryExternal Appearance

Bradycardia with heart rate in 40s-50s

Nausea, vomiting

Waxing & waning consciousness since accidentPhysical ExamEOMs

CT Face

Minimally depressed fracture of L orbital floorMinor opacification of L ethmoid air cells, trace fluid or possibly hemorrhage in the L maxillary sinus

Assessment6 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)

PlanAdmitted to ICU 2/2 bradycardiaOphthalmology:Patient taken to OR for fracture repair within ~6 hours of arrival to ED by oculoplasticsL orbital floor fracture repair w/suprafoil implantSuccessful repositioning of orbital tissues

Follow-upPost-operative day #1:20/30 OD, 20/70 OSImproving periorbital edema, mild chemosisDiplopiaInfraduction OS -1DFE WNLFollow-upAt 1 week:L face swollenNo diplopia, intermittent painTrouble reading, covered 1 eye due to blurrinessSinus arrhythmia following with pediatricianLower lid OS with decreased excursion20/20 OU, motility full OU

WEBOF: White-Eyed BlowOut FractureBenign extraocular appearance w/minimal eyelid signs BUT w/significant EOM restriction Usually vertical gaze restrictionKids often do not complain of binocular diplopia (just close one eye)

Cartilaginous/bendable bones in kids lead to:Increased risk for trapdoor fracturesIncreased risk for EOM incarcerationWEBOF PresentationKids may present w/severe oculocardiac reflex:Nausea or vomiting, dehydration from anorexiaBradycardia or syncopeMay be misdiagnosed as concussionFracture/entrapment can be missed on CT headAlways get dedicated CT face or orbitsImagingCT can show trapdoor fracture with rectus muscle incarceration or missing inferior rectus

Inf rectusmuscle bellyMissinginf rectusYano, 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), e3014. doi:10.1016/j.bjps.2007.12.041

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.16Orbital Blow-out FracturesSymptoms:Pain on attempted eye movementTenderness, lid edema, binocular diplopia, trauma hxSigns:Restricted EOMs, subcutaneous or conjunctival emphysema, point tenderness, enophthalmosHypesthesia in distribution of theinfraorbital nerve

Byrne, Karen M. Infraorbital Nerve Block. Emedicine: http://emedicine.medscape.com/article/82660-overview17Differential Diagnosis of Muscle Entrapment in Orbital FracturesOrbital edema and hemorrhage without blow-out fractureCan still cause EOM limitation, swelling, ecchymosisResolves over 7-10 days

Cranial nerve palsyEOM limitation but no restriction on forced ductionsRule out intracranial & skull base processes w/CTWEBOF TreatmentConsider broad-spectrum abx if hx of chronic sinusitis, diabetes, or immune compromise. Not mandatoryNot evidence-based (limited, anecdotal evidence)Oxymetazoline BID for 3 days, no nose blowingQ1-2h ice packs for 20 mins for 24-28 hrsConsider oral steroids if swelling extensive and limiting exam of motility and globe positionWEBOF TreatmentImmediate 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 strabismusAlso to alleviate oculocardiac reflex

Surgical Repair TechniqueSurgical approach: Subconjunctival incision +/- lateral cantholysisElevate periorbita from orbital floorRelease prolapsed tissue from fractureUsually place implant over fracture to prevent recurrent adhesions and tissue proplapse

http://emedicine.medscape.com/article/882205-overview

Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 405. doi:10.4103/2231-0746.110078

Orbital ImplantsAlloplastic:Porous polyethyleneSupramid (nylon foil)Gore-TexTeflonSilicone sheetTitanium meshAutogenous:Split cranial bone, iliac crest bone, or fascia

http://emedicine.medscape.com/article/882205-overview#a3

Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 405. doi:10.4103/2231-0746.110078

Timoney et al describe use of 0.4 mm SupramidNylon foil non-porous, relatively inert, alloplastic implant59 orbits in 57 patients (all pediatric)3 patients (5.3%) had entrapment with vasovagal responses and immediate intervention6 had immediate post-op diplopia; all improved2 post-op complications without permanent sequellaeNone had noticeable post-op enophthalmos Concluded Supramid implant safe and effectiveTimoney, 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), 2124. doi:10.1097/IOP.0000000000000051

http://www.ophthalmologyweb.com/Oculoplastic-and-Orbital-Procedures/5561-Supramid-Sheet-Implants/

ReferencesBalaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 405. doi:10.4103/2231-0746.110078Foulds, J. S., Laverick, S., & MacEwen, C. J. (2013). White-eyed blowout fracture in children. Emergency Medicine Journal: EMJ, 30(10), 836. doi:10.1136/emermed-2012-201741Gerstenblith, 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), 23. doi:10.1093/jscr/rjt054Orbital Trauma. In: Basic and Clinical Science Course (BCSC) Section 7: Orbit, Eyelids, and Lacrimal System. San Francisco, CA: American Academy of Ophthalmology; 2014: 100-104.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), 2124. doi:10.1097/IOP.0000000000000051Verret, Daniel JDucic, Y. (2013). Implants, Soft Tissue, High-Density Porous Polyethylene (Medpor). Medscape Reference. Retrieved from http://emedicine.medscape.com/article/882205-overview#a3Yano, 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), e3014. doi:10.1016/j.bjps.2007.12.041