PANCE Blueprint EENT (7%)

Traumatic disorders (PEARLS)

The NCCPA™ PANCE EENT Content Blueprint => disorders of the eye => traumatic disorders

Blowout fracture (ReelDx)
ReelDx Virtual Rounds (Blowout fracture)
Patient will present as → a 13-year-old who was hit in the right eye by a baseball. The area is ecchymotic and swollen. He complains of pain, rated 6 out of 10. On physical exam, the patient has eyelid swelling, decreased visual acuity, enophthalmos (sunken eye), and anesthesia/paresthesia in the gums and upper lips.

History of blunt trauma, muscle entrapment, eyelid swelling, gaze restriction, double vision, decreased visual acuity, enophthalmos (sunken eye)

  • Pain with EOM, epistaxis, erythema/ecchymosis, “raccoon eyes”
  • Anesthesia/paresthesia in the gums, upper lips, and cheek indicate damage to the infraorbital nerve

DX: diagnosed with CT scan

TX: Prompt ophthalmic referral ⇒ treatment with surgery

  • Antibiotics to prevent infection
Corneal abrasion (ReelDx)
ReelDx Virtual Rounds (Corneal abrasion)
Patient will present as → a 10-year-old boy who was hit in the right eye with a piece of bark that was thrown on the playground. He developed a sudden onset of eye pain, photophobia, tearing, and blurring of vision. He claims there is “something stuck in my eye.” On physical examination, there is a significant conjunctival injection.

Sudden onset of eye pain, photophobia, tearing, foreign body sensation, blurring of vision, and/or conjunctival injection

DX: fluorescein staining - increased absorption in the devoid area

TX: Antibiotic eye ointment, no patching

Globe Rupture
Patient will present as → a 15-year-old male with no significant PMHx is brought to the emergency department by his coach after being struck in the right eye by a baseball. The patient reports pain in the right eye with complete loss of vision. On physical examination, you note scleral buckling, and the visual acuity testing reveals light perception only.

Globe rupture occurs when the integrity of the outer membranes of the eye is disrupted by blunt or penetrating trauma

  • Any full-thickness injury to the cornea, sclera, or both is considered an open globe injury
  • The vitreous and/or aqueous humour drain through the site of the rupture, causing the eye to deflate (sunken appearance)
  • Immediate ophthalmology consultation

DX: CT scan: non-contrast 1 to 2 mm cuts axial and coronal through the orbits

TX: Avoid any examination procedure that might apply pressure to the eyeball, such as eyelid retraction or intraocular pressure measurement by tonometry

  • Requires referral to ER or emergent ophthalmologist
  • Do not remove any protruding foreign bodies
  • Begin IV antibiotics with Vancomycin PLUS either ceftazidime or fluoroquinolone
  • Avoid placing any medication (eg, tetracaine) or diagnostic eye drops (e.g., fluorescein) into the eye
  • A Fox eye shield or other rigid devices (bottom of a polystyrene foam cup) should be placed over the affected eye
  • Surgical repair should be expedited

Hyphema (ReelDx)
ReelDx Virtual Rounds (Hyphema )
Patient will present as → a 14-year-old who sustained blunt trauma to his right eye after being struck by a baseball. He complains of blurry vision. On physical exam, you note unequal pupils, injected conjunctiva/sclera, and blood in the anterior chamber of the right eye.

Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris) and may cover the iris

  • The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye
  • Usually from blunt/penetrating trauma ⇒ ensure no other type of injury (skull fracture, orbital fracture)

DX: orbital CT if indicated + ophthalmology consult

TX: usually, blood is reabsorbed over days/weeks

  • Elevate head at night at 30 degrees, acetaminophen for pain, patch/shield
  • May use beta-adrenergic blockers or carbonic anhydrase inhibitors
  • Surgery if high pressure/persistent bleeding
  • NSAIDs contraindicated (may increase bleeding)
Retinopathy (Lecture) (Prev Lesson)
(Next Lesson) Blowout fracture (orbital floor fracture) (ReelDx)
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