Case Study

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This Case Study follows the treatment of a patient who presented at the Accident and Emergency Department, Lincoln County Hospital with a painful swollen right eye. The department was very busy, and with no doctors available for some time I decided (with the patient’s agreement) to see him as a Nurse Practitioner. I followed the guidelines laid down in the terms of reference for examination of eyes and it was clear from an early stage that the patient would need referral to the casualty doctor.

Presenting Complaint	Painful, swollen right eye.
History of Presenting Complaint	31 year old male, playing rugby 4 hours ago. Patient was hit in the right eye by another player’s elbow. Unable to continue playing due to pain and blurred vision. Initial first aid involved the application of icepacks, Paracetamol 1gram taken orally and eye bathed with Optrex. Patient does not wear glasses/contact lenses.
Past Medical History	No serious illnesses. No past eye problems. No surgery to the eyes.
Drug History	No allergies. Not taking medications at present.
Social History	Lives with girlfriend, 1year old son.
On Examination	Visual acuity right eye = 6/6. Left eye = 6/6. Both pupils equally reacting to light. Right eye virtually closed, slight blurring of vision. Upper lid everted nothing abnormal detected. Conjunctiva injected. Cornea stained with fluoroscein nothing abnormal detected. Tenderness and moderate swelling around the orbital rim. No obvious step deformity.

The casualty doctor then completed the examination with the following findings:

Sensory changes around the rim.

Eye movements checked - nothing abnormal detected.

Impression

? Fractured facial bones.

The history, signs and symptoms the patient presented with comprised of blunt trauma, tenderness and soft tissue swelling around the orbital rim, blurring of vision, pain and a strange sensation on nose blowing. They all combined to suggest fractured facial bones.

Plan

The patient was sent for facial x-rays

While waiting for the x-rays the patient was advised not to blow his nose, as this can cause exophthalmus.

Diagnosis

Fracture involving orbital floor.

Patient was reassured and antibiotic cover was given. Augmentin 375mg three times a day for five days was prescribed and the patient was referred to the facial maxillary surgeon on call.

Common causes/aetiology.

Blunt trauma to the face and periorbital area can result in a variety of ocular and orbital injuries. If a large object (for example a. football) hits the eye most of the impact is usually taken by the orbital margin. Alternately, if a smaller object such as a squash ball hits the area then the eye itself may take most of the impact. As force is applied to the orbital opening or orbital rim, fracture of the orbital floor, walls or roof may occur. The most common type of fracture in this setting is the blowout fracture, in which the medial wall or orbital floor fractures outward, allowing orbital fat to herniate into the ethmoid or maxillary sinuses respectively.

Presentations.

Assess the eye by first examining the area around the eyes. The eyelid and rim need careful inspection before the eye itself. The patient may present with bruising, emphysema of the eyelid tissues, infraorbital anaesthesia, or double vision. The bony orbits are palpated bimanually and bilaterally to detect asymmetry steps off, tenderness and soft tissue emphysema.

The eyes are examined for subconjunctival haemorrhage, hyphaema and pupillary reaction, and the patient’s visual acuity is recorded. The history and examination findings may allow a firm conclusion on diagnosis and management.

Common differential diagnoses.

In a patient with a history of blunt trauma to this region, it would either be bruising/soft tissue injury or bony injury. The infra orbital anaesthesia may be due to either severance of the nerve or its compression by surrounding soft tissue swelling.

Treatment.

X-rays a routine facial series should be obtained when a facial fracture is suspected. The suspected fracture should be viewed in at least two planes, preferably three. More recently panoramic zonography has been developed for superior visualisation of orbital fractures. Panoramic zonography offers convenience as the patient is examined in the recumbent position with minimal repositioning and radiation exposure.

All patients with orbital fractures should be cautioned against nose blowing in the early post injury period. Unless this precaution is followed the elevation of intranasal air pressure on blowing the nose may result in pressurised air entering the orbit causing a sudden and frequently frightening exophthalmus.

Prognosis.

It has been the fashion to repair orbital fractures, but more conservative management has shown that function in most cases is recovered spontaneously. If the patient has step deformity present they will need referral to facial maxillary surgeons because extensive disruption to the orbit leaves a very poor cosmetic appearance when left untreated. Since many fractures do not restrict eye movement or cause significant disfigurement, they do not demand surgical intervention. Generally urgent care is not indicated unless there is a sudden deterioration in vision or onset of proptosis or pain, suggesting a retrobulbar haemorrhage. If this occurs it requires immediate consultation with the ophthalmic doctor as it is an ophthalmic emergency.

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		Last updated 1 Jan 98