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CASE PRESENTATION on medial wall fracture of orbit
- 1. CASE PRESENTATION PRESENTER: DR.R BHAVANA FIRST YEAR POSTGRADUATE DEPARTMENT OF OPHTHALMOLOGY GOVERNMENT MEDICAL COLLEGE, SRIKAKULAM
- 2. PATIENT PROFILE • 45Year old, Male • Resident of Srikakulam • Court employee by profession
- 3. CHEIF COMPLAINTS • Painover RE since 2 days • Swelling over RE since 2 days
- 4. HISTORY OF PRESENTINGILLNESS Patient was apparently alright 2 days back when he presented with pain and swelling over right eye following trauma to right eye with a blunt iron rod ,which was • Sudden at onset • gradually progressive in nature • Associated with heaviness, watering in right eyes and gaze evoked pain in right eye. • Associated with redness, diplopia on right gaze.
- 5. • History ofloss of concious for 5 mins • Not associated with photophobia, coloured halos, discharge. History of epistaxis present
- 6. NEGATIVE HISTORY • Noh/o nasal block, recurrent sinusitis, frequent respiratory tract infection, epistaxis • No h/o headache, projectile vomiting, seizures. • No h/o postural variation, visible pulsations or change in colour of overlying skin • No h/o fever, sweating, loss of appetite, arthralgia and weight loss. • No h/o other swelling in the body • No h/o radiation therapy or chemotherapy in the past
- 7. PAST HISTORY • Nopast history of ocular trauma or ocular surgery. • No history of hypertension, diabetes mellitus, tuberculosis, and Cerebrovascular disease,coronary artery disease,Epilepsy,drug allergy,antiretroviral therapy, • No history of any other systemic diseases.
- 8. PERSONAL HISTORY • Mixeddiet • Normal sleep • Regular bowel and bladder habit. • Alcoholic occasionally, Non-smoker • No h/o allergy or atopy
- 9. FAMILY HISTORY • Noh/o similar ocular complaints in the family.
- 10. GENERAL PHYSICAL EXAMINATION •Conscious,well oriented to time, place and person •Moderately built, well nourished •NO pallor, icterus, cyanosis, clubbing or generalised lymphadenopathy •PR=74/min, Regular, hypervolemic, equal on both sides •BP: 150/90MMHG IN THE RIGHT ARM IN THE SITTING POSITION •RESPIRATORY RATE:12/MIN •spO2-99%in room air
- 11. SYSTEMIC EXAMINATION • CVS:S1S2 HEARD, NO MURMUR • RS: B/L AIR ENTRY, NORMAL VESICULAR BREATH SOUND+ • Temperature : afebrile • P/A: SOFT, NON TENDER, NO ORGANOMEGALY • No regional Lymph nodes enlargement (preauricular, submandibular) • Central and Peripheral Nervous System-Normal
- 12. LOCAL EXAMINATION PARAMETER HEAD POSTURENORMAL FACIAL SYMMETRY SYMMETRICAL on both sides FOREHEAD NORMAL
- 13. EXTRAOCULAR MOVEMENTS LEFT EYE RIGHTEYE -2 -2 -1 -2 -2 -2 -1 -2 +3 +3 +3 +3 +3 +3 +3 +3
- 14. RE LE HCRT 15degrees esotropia Central Inspection Axial proptosis Axial proptosis Nafziger’s Sign Negative (swollen eyelid visible beyond orbital rim) Negative Worm’s Eye View Anteroposterior displacement of eyeball Anteroposterior displacement of eyeball Eyebrows Normal Normal Eyelids BE RETRACTED BE UPPER AND LOWER LIDS FULLNESS NOTED BE RETRACTED BE UPPER AND LOWER LIDS FULLNESS NOTED Temporal Flare Present Present Lid Lag on Down Gaze Present Present Lagophthalmos Present Present Bell’s Phenomenon Good Good Variation with valsalva or bending forwards Absent Absent Pulsatile Proptosis No No Engorged or Corkscrew vessels over conjunctiva Absent Absent
- 15. OCULAR EXAMINATION PARAMETER RELE UCVA 6/12 6/18 BCVA 6/6 6/6 NEAR VISION +1.25DSPH N6 +1.25DSPH N6 EYELID EDEMA OF right upper , lower eyelid + NORMAL
- 16. CONJUNCTIVA RE LE CONGESTION+, CHEMOSIS+(grade III) QUIET CORNEA SIZE SHAPE/CURVATURE SENSATION TRANSPARENCY 11mm horizontal, 10mm vertical Normal INTACT in all quadrants CLEAR OCULAR EXAMINATION SCLERA NORMAL NORMAL
- 17. RE LE ANTERIOR CHAMBERVAN HERICK GRADE 4(PACD>CT—open angle) IRIS BROWN COLOUR, NORMAL PATTERN PUPIL Round,regular,reacting to light Round , regular, reactiing to light LENS CLEAR CLEAR FUNDUS: RED GLOW MEDIA OPTIC DISC CDR A:V PERIPHERY FR PRESENT CLEAR Normal size, shape, colour, margins well defined 0.3:1 2:3 WNL PRESENT PRESENT CLEAR Normal size, shape, colour, margins well defined 0.3:1 2:3 WNL PRESENT COLOUR VISION NORMAL, 17/17 plates correctly identified NORMAL, 17/17 plates correctly identified OCULAR EXAMINATION
- 18. RE LE Orbital MarginNo Bony Abnormality, On Palpation crepitus present, tenderness over medial orbital rim No Bony abnormality, No crepitations
- 19. PROVISIONAL DIAGNOSIS Sub-conjunctival emphysemaof Right eye with fracture medial wall of Orbit (Right eye).
- 20. DIFFERENTIAL DIAGNOSIS • Blow-outfracture (floor) • Zygomaticomaxillary complex fracture • Naso-orbito-ethmoidal fracture • Traumatic optic neuropathy • Orbital cellulitis / sinusitis extension
- 21. • Bscan orbit •RE - RCS intact & vitreous echofree • LE - RCS intact & vitreous echofree INVESTIGATIONS
- 22. CT ORBIT Impression(RE):Preseptal, post septalsurgical emphysema, proptosis of optic globe and disruption of lamina papyrace on right side. Herniation of orbital fat into ethmoidal air cells - Suggestive of post traumatic sequalae
- 23. TREATMENT • Cold compressestwice a day • Avoid nose blowing,straining ,coughing • Tab DICLOFENAC SODIUM 50mg BD PO for 5days • Tab CEFEXIME 200mg BD PO for 5days • Tab LEVOCETRIZINE 10mg HS for 3 days • REASURRANCE OF THE PATIENT • REGULAR FOLLOW UP
- 24.