Eye Pain and Double Vision
Article Outline
A 7-year-old presented to the emergency department (ED) with complaints of right eye pain and double vision. The patient had been involved in a sledding accident 1 week before, in which he crashed into a fence. There was no loss of consciousness. On examination in the ED, the right eye was proptotic and dystopic (Figure 1), although with normal visual acuity and no deficits during visual field testing. The pupils were equal, round, and reactive to light, without evidence of an afferent pupillary defect. Dilated funduscopic examination was normal. Extraocular mobility demonstrated limitation of upward gaze and adduction of the right eye. Computed tomographic imaging of the head including facial cuts was performed (Figure 2, Figure 3).
Figure 1.
Patient with proptosis and orbital dystopia, with the right eye lower than the left. There is also limitation of upward gaze.
Figure 2.
Coronal computed tomographic image.
Figure 3.
Sagittal computed tomographic image. Used with permission of Mark I. Neuman, MD, MPH, the Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA.
Diagnosis
Superior orbital wall fracture with retro-orbital hematoma. Limitation of upward gaze in the setting of trauma is most commonly associated with a fracture of the floor of the orbit, typically referred to as “blowout fracture.” Entrapment of the inferior rectus muscle within the orbital floor may lead to ophthalmoplegia and diplopia. In such cases, posterior displacement of the globe and prolapse of orbital contents into the maxillary sinus more commonly leads to enophthalmos (recession of the globe into the orbit), as opposed to proptosis.1
This patient had limitation of upward gaze, with proptosis and orbital dystopia with the right eye lower than the left (Figure 1). Here, limitation of upward gaze was due to a mass lesion (retro-orbital hematoma) impinging on the globe (Figure 2), rather than extraocular muscle dysfunction. Orbital roof fractures are rare,2 although they are more common in young children because of their high cranium-to-midface ratio.1, 2, 3, 4 Such fractures have a high association with intracranial injury, most commonly epidural hematoma, as was seen in our patient (Figure 3).
References
- . Facial trauma. In: Fleisher GLS, Henretig R editor. Textbook of Pediatric Emergency Medicine. 5th ed.. Philadelphia, PA: Lippincott Williams & Wilkins; 2005;p. 1475–1484
- Orbital subperiosteal hematoma associated with subfrontal extradural hematoma. J Trauma. 2007;62:523–525
- Orbital fractures in children. Arch Otolaryngol Head Neck Surg. 1995;121:1375–1379
- Intracranial neurological injuries associated with orbital fracture. Pediatr Neurosurg. 1997;26:261–268
For the diagnosis and teaching points, see page 481.
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PII: S0196-0644(07)01955-5
doi:10.1016/j.annemergmed.2007.12.030
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
