HPI

• 31 year old male presents to the ED after assault from multiple assailants with fists
• Pt reports unknown drug use
• Pt c/o pain in the L side of his face around his eye only
• Eye is swollen shut and he has not been able to assess his vision
• Pt denies headache,  neck pain,  difficulty speaking or trismus, no pain in other parts of his body

Physical exam

 BP 153/73, HR 118, T 97.4, RR 18, SpO2 99% on room air

HEENT: +Periorbital edema, eye swollen shut. L zygomatic arch sunken/deformed. 2cm laceration to L eyebrow. No nasal septal hematoma. Normal maxilla, mandible, normal oropharynx, normal R side of face. When providers attempt to open eye to examine globe, patient recoils due to pain

Cardiac: tachycardic, normal S1/S2, no murmurs/rubs/gallops

Pulmonary: clear breath sounds bilaterally, no signs of trauma on chest or back

Abdomen: soft, nontender, no signs of trauma Extremities: normal distal pulses in all extremities, no signs of trauma

Neurologic: patient slurring speech, not oriented to time, has repetitive answers to some questions

Initial ED Management -

• Pt became more confused and agitated and uncooperative with exam and IV access
• Pt was intubated and sedated to facilitate care
• On eye exam after intubation, patient with significant chemosis, proptosis of L eye. Pupil minimally reactive, unable to assess EOM because of sedation

Differential Diagnosis 

• Orbital compartment syndrome from traumatic injury causing elevated IOP and proptosis
• Possible intracranial hemorrhage causing agitation in the setting of evidence of head trauma 
• Likely facial bone fractures

Further Management 

• Intraocular pressure was measured with tonopen: OS 43, OD 17
• Lateral canthotomy performed at the bedside to left eye, with repeat IOP 18
• Watch this quick video on how to perform this vision saving procedure here
• Labs/Imaging - CT head, C spine, facial bones, orbits: Acute, nondisplaced left inferior orbital wall fracture with findings suggestive of mild left retrobulbar hemorrhage. Mild hemorrhagic opacification left maxillary sinus. - No other signs of traumatic injury
• Pt admitted to trauma ICU for serial intraocular pressures and further management/monitoring 
• Seen by ophthalmology in the morning: IOP remained normal.
• Pt ultimately discharged home with outpatient ophtho follow-up

Teaching Pearls

• In patients with evidence of eye trauma: - a thorough exam includes IOP as long as there is no clinical evidence of globe rupture
• If there is proptosis and elevated IOP >20 (though usually closer to 40), this is consistent with orbital compartment syndrome and patient requires emergency lateral canthotomy   
• Do not delay lateral canthotomy for CT imaging
• In agitated/altered patients with evidence of head trauma, if unable to peform proper exam or obtain a necessary work-up, patients consider intubation/sedation so that they can be properly evaluated and treated