A 16-year-old boy is brought to the emergency department due to an eye injury. About an hour ago, he was playing paintball and was shot in the face by an opponent. The patient was not wearing eye protection. He felt immediate pain and had difficulty seeing. He has no chronic medical conditions. Temperature is 37.5 C (99.5 F). Examination shows periorbital edema and ecchymosis with proptosis of the left eye. Palpation over the left eyelid reveals rock-hard induration. Visual acuity is 20/100 in the left eye and 20/20 in the right. There is a relative afferent pupillary defect in the left eye. Which of the following is the best next step in management of this patient?

Question

A 16-year-old boy is brought to the emergency department due to an eye injury.  About an hour ago, he was playing paintball and was shot in the face by an opponent.  The patient was not wearing eye protection.  He felt immediate pain and had difficulty seeing.  He has no chronic medical conditions.  Temperature is 37.5 C (99.5 F).  Examination shows periorbital edema and ecchymosis with proptosis of the left eye.  Palpation over the left eyelid reveals rock-hard induration.  Visual acuity is 20/100 in the left eye and 20/20 in the right.  There is a relative afferent pupillary defect in the left eye.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5ef_0127_bc81_2791306dde8a_MD0003_00 This patient's eye findings are concerning for orbital compartment syndrome (OCS), a rare ophthalmologic emergency that can lead to permanent vision loss. OCS occurs when swelling and/or hemorrhage within the confined orbital space causes rapidly increased intraorbital pressure and subsequent ischemia of the optic nerve and globe. Eye trauma, as seen in this patient, is the most common precipitating event; however, underlying coagulopathy, orbital infection, and recent periocular surgery are also risk factors. OCS presents with acute eye pain and vision loss. Examination reveals a tight orbit characterized by a rock-hard eyelid, periorbital edema, proptosis, and resistance to retropulsion (ie, pushing on the eye). Optic nerve injury can cause a relative afferent pupillary defect, in which both pupils dilate in response to a swinging flashlight shining light from the normal to the affected eye; and eye movements may be impaired due to extraocular muscle compression. Diffuse subconjunctival hemorrhage and periorbital ecchymoses are also common, particularly with posttraumatic OCS. afferent pupillary defect To preserve vision, the first step in managing OCS is immediate surgical decompression of the orbit via lateral canthotomy with cantholysis. Temporizing measures to limit acute increases in intraorbital pressure include elevation of the head of the bed and pain control. Imaging (eg, CT scan or MRI of the orbit) should be delayed until after surgery. (Choice A) Cool compresses and nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are used to treat an isolated periorbital hematoma, which typically presents after trauma with pain and bruising around the eye. Decreased visual acuity, an afferent pupillary defect, and proptosis would not be seen. (Choice B) CT venography can be used to diagnose a cavernous sinus thrombosis, which most commonly occurs secondary to infection (eg, sinusitis, orbital cellulitis). Symptoms include headache and eye findings (eg, periorbital swelling, proptosis, vision loss, cranial nerve palsy). This patient's acute eye changes after trauma make OCS more likely. cavernous sinus (Choices C and E) Detailed ophthalmologic evaluation with dilated funduscopic examination and tonometry should not precede emergency surgery for OCS due to increased morbidity with delayed decompression. In addition, serial tonometry is not typically required for OCS because intraocular pressure should normalize after surgery. Educational objective: Orbital compartment syndrome causes eye pain and vision loss due to rapidly increased intraorbital pressure from trauma. Examination shows a tight orbit (eg, periorbital swelling, hard eyelid, proptosis) and an afferent pupillary defect. Management is immediate surgical decompression to prevent permanent vision loss. References: Orbital compartment syndrome: an update with review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/31806931)

A 16-Year-Old Boy Is Brought to the Emergency Department Due