Grand Rounds Conference
Lara Rosenwasser Newman, MD
University of Louisville
Department of Ophthalmology and Visual Sciences
September 5, 2014
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.
History
PMHx:

Asthma
PSHx:

Tympanostomy tube placement
POHx:

None
Medications:

Albuterol inhaler, Beclomethasone dipropionate
(QVAR inhaler)
Clinical Exam
OD
VA (n,sc/Allen): 20/30
OS
20/30
Pupils:
32
IOP:
EOM:
32
(-)rAPD
19mmHg
20mmHg
0
-4
0
0
0
0
0
-3
Pain on attempted upgaze OS; no diplopia
Clinical Exam
PLE:
External/Lids
Conjunctiva/Sclera
Cornea
Anterior Chamber
Iris
Lens
Vitreous
Small superficial laceration
on upper lid OS, mild ecchymosis/edema
Clear/white; no subconj heme
Clear OU
Formed OU
Normal OU
Clear OU
Normal OU
DFE deferred per neurosurgery
External Appearance
Physical Exam

Bradycardia with heart rate in 40s-50s

Nausea, vomiting

Waxing & waning consciousness since accident
EOMs
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
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)
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

Follow-up

Post-operative day #1:
20/30 OD, 20/70 OS
 Improving periorbital edema, mild chemosis
 Diplopia
 Infraduction OS -1


DFE WNL
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

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

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
Imaging

CT can show trapdoor fracture with rectus
muscle incarceration or “missing” inferior rectus
Inf rectus
muscle belly
“Missing”
inf rectus
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:10.1016/j.bjps.2007.12.041
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: http://emedicine.medscape.com/article/82660-overview
Differential Diagnosis of Muscle
Entrapment in Orbital Fractures

Orbital edema and hemorrhage without blowout 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

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 24-28 hrs
Consider oral steroids if swelling extensive and
limiting exam of motility and globe position
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
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

http://emedicine.medscape.com/article/882205-overview
Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial Surgery, 3(1), 40–5. doi:10.4103/2231-0746.110078
Orbital Implants

Alloplastic:
Porous polyethylene
 Supramid (nylon foil)
 Gore-Tex
 Teflon
 Silicone sheet
 Titanium mesh


Autogenous:

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), 40–5. doi:10.4103/2231-0746.110078

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:10.1097/IOP.0000000000000051
http://www.ophthalmologyweb.com/Oculoplastic-and-Orbital-Procedures/5561-Supramid-Sheet-Implants/
References
1.
2.
3.
4.
5.
6.
7.
8.
Balaji, S. M. (2013). Residual diplopia in treated orbital bone fractures. Annals of Maxillofacial
Surgery, 3(1), 40–5. doi:10.4103/2231-0746.110078
Foulds, 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-2012-201741
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:10.1093/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: 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), 212–4. doi:10.1097/IOP.0000000000000051
Verret, Daniel JDucic, Y. (2013). Implants, Soft Tissue, High-Density Porous Polyethylene
(Medpor). Medscape Reference. Retrieved from http://emedicine.medscape.com/article/882205overview#a3
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:10.1016/j.bjps.2007.12.041