Visual DX- “My Eye Popped Out”

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A 44-year-old male with hypertension presents via EMS with this ocular complaint after having sneezed. What’s your assessment?

by Lauren Westafer, DO and Nicholas Daniel, DO

A 44-year-old male with hypertension presented via EMS with the complaint “my eye popped out!” The patient reported right eye swelling and pain immediately after sneezing.

He denied trauma or change in his visual acuity, but admitted to a prior history of cocaine abuse. Physical exam revealed periorbital subcutaneous emphysema and intact accommodation and extraocular movements. His pupils were equal and reactive to light. Visual acuity was measured at 20/70 OD, 20/40 OS. Intraocular pressures were measured at 23 mmHg and 20 mmHg in the right eye and left eye, respectively.

Non-contrasted CT scan of the orbits showed massive subcutaneous emphysema without foreign body, violation of the globe, or optic nerve edema. A possible subtle bony defect was found in the right medial orbital wall (right).

The patient’s orbital emphysema started to mildly improve while in the ED. His case was discussed with an ophthalmologist and the patient was discharged to follow up in the eye clinic.

Orbital Emphysema

Orbital emphysema is an uncommon condition occurring when air is forced into subcutaneous tissue around the orbit. Patients with this condition commonly have a history of sinusitis, facial trauma or surgery. The thin lamina papyracea is the most common site of the bony defect allowing passage of air from paranasal sinuses to the subcutaneous tissues.1 Most case reports of orbital emphysema describe preceding trauma or instrumentation, while sneezing is a known precipitant.2,3,4

Orbital emphysema is usually benign and spontaneously resolves as the air is absorbed. However there may be complications including orbital compartment syndrome and resultant loss of vision.5

Examination should focus on signs of orbital compartment syndrome and resultant optic nerve ischemia, such as decreased visual acuity, afferent pupillary defect, disc edema, and increased intraocular pressure. If there is suspicion for orbital compartment syndrome, emergent decompression is necessary and is typically performed by lateral canthotomy and cantholysis. Some large orbital bony defects may require surgical repair, particularly in patients with diplopia and evidence of entrapped muscle or periorbital tissue, large fractures, and enophthalmos that does not resolve.6

Lauren Westafer, DO is Emergency Medicine Chief Resident at Baystate Medical Center in Springfield, MA. Nicholas Daniel, DO is an emergency medicine attending physician and wilderness medicine faculty at Baystate Medical Center in Springfield, MA.

References available online at epmonthly.com

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