Browse the corpus

Extraocular muscle (EOM) management from ocular, orbital, and cranial trauma can be varied and complex. In the known ocular or orbital trauma setting, elucidating the mechanism, type, and severity of the injury helps triage critical components of the physical exam. This activity outlines the evaluation and management of extraocular muscles with globe and orbital trauma and highlights the role of interprofessional teams in improving care for patients with this condition. Objectives: Describe the pathophysiology of traumatic extraocular muscle injury. Outline the typical presentation, physical exam findings, and imaging findings associated with an extraocular muscle injury. Review the surgical considerations for extraocular muscles during globe and orbital trauma repair. Explain the importance of monitoring with continued follow-up exams by the interprofessional team for patients with extraocular muscle injury. Access free multiple choice questions on this topic.

Extraocular muscle (EOM) management from ocular, orbital, and cranial trauma can be varied and complex. In the known ocular or orbital trauma setting, elucidating the mechanism, type, and severity of the injury helps triage critical components of the physical exam. Recognition and treatment of life-threatening injuries following Advanced Trauma Life Support (ATLS) principles hold precedence over all others. These injuries are more commonly encountered when the body has sustained high-velocity forces, such as motor vehicle accidents or firearm assault. Addressing EOM management in trauma can be conceptualized in two ways: one where there is damage to the EOMs and one where there is not. Direct EOM involvement can range from mild: minimal displacement from adjacent soft tissue edema or hemorrhage; to moderate: contusion of the EOM itself; to severe: disinsertion, laceration, or incarceration of the EOM from the traumatic blow or by an orbital fracture. Indirectly, EOM motility may be impaired from cranial nerve palsy or supranuclear injury associated with head and neck trauma. Contrarily, the EOMs may not be damaged but may need to be iatrogenically detached from the globe to explore and repair open globe injuries. The presence or suspicion of an open globe injury and mechanical causes of strabismus or neurologic involvement guides the planning and timing of surgery. The goal of EOM management during acute ocular or orbital surgery is to limit the amount of fibrosis that could occur and result in strabismus.

Serious complications after globe and orbital surgery requiring immediate intervention include: Endophthalmitis Persistent open globe wound Sympathetic ophthalmia Orbital compartment syndrome Orbital cellulitis Orbital implant impingement on the optic nerve Orbital implant impingement on the rectus muscle eliciting an oculocardiac reflex Bradycardia is caused by the oculocardiac reflex Scleral perforation resulting in retinal breaks, tears, or detachments Complications also include: Anterior segment ischemia if multiple EOMs are transected, detached, and reattached Permanent mydriasis Infraorbital nerve hypoesthesia Upper or lower eyelid retraction Persistent diplopia Persistent diplopia can be a complication of: EOM adherence to mesh or porous implants EOM adherence/entrapment from inadequate orbital fracture reduction Fibrosis from scar tissue or orbital fat adherence Fibrosis from a damaged trochlea or superior oblique tendon resulting in an acquired Brown syndrome (though this typically resolves) Inadvertently resecting too much of the EOM Lost or "slipped" EOM EOM palsy from the initial trauma Contracture of the antagonist muscle

Traumatic globe and orbital surgery often involve an interprofessional team approach. Management of EOMs during globe and orbital trauma often begins with emergency room medical and nursing staff. If the patient has polytrauma, trauma surgeons are also involved in the initial assessment. The patient's medical status should be optimized before surgery. In polytrauma, life-saving interventions are prioritized. In the setting of combined ocular and orbital trauma, ophthalmologists are routinely consulted along with otolaryngologists and/or oral and maxillofacial surgeons. Ophthalmic sub-specialists, such as oculoplastic and orbital surgeons, often get involved in preoperative planning and surgery if a fracture needs repair. With few exceptions, nearly all globe and orbital trauma surgeries are performed under general anesthesia, so an anesthesiologist is also a part of the team. Prophylactic antibiotic medications are administered to prevent infection, and a pharmacist helps verify the appropriate dose and agent and ensures no drug-drug interactions. Intraoperative surgical technicians and nursing staff are vital to ensuring the appropriate equipment and medications are available. Post-operative nursing staff assists in reviewing aftercare instructions with the patient. Patients who undergo orbital surgery may require inpatient admission to monitor for retrobulbar hematoma. Post-operative management of globe and orbital injuries is under the ophthalmologist or orbital surgeon. If residual diplopia or strabismus develops, the patient can be referred to a strabismus surgeon, who can follow the patient over time to assess for stability in ocular alignment measurements. Social workers may be employed to help certain patients keep these appointments if access to healthcare is challenging. A successful outcome can only be accomplished with this interprofessional healthcare team approach. [Level 5]

Pre-operatively, early recognition or suspicion of open globe trauma and placement of a rigid shield is an easy step to perform if an ophthalmic exam is delayed. At the same time, the patient is being treated for other trauma. In addition, managing the patient's pain and nausea can prevent unnecessary movement and intraocular and intraorbital pressure. Intra-operatively, direct communication with the anesthesia provider on when an extraocular muscle will be manipulated can alert the anesthesia provider to medicate if an oculocardiac reflex is observed. Post-operative education on avoiding strenuous activity, heavy lifting, or bending during the early postoperative period is imperative, as well as other sinus precautions, including no nose blowing or drinking through a straw or suction (if there is an orbital fracture). These are typically iterated by the operating surgeons and post-operative nursing team. Post-globe repair management includes the installation of topical antibiotics and steroid eye drops. The steroid eye drop is continued until ocular inflammation is resolved and then tapered. Prolonged steroid tapers can result in elevated intraocular pressures. Often the elevation in intraocular pressure is transient and can be managed with eye drops. In cases with persistently elevated pressures or eyes refractory to conventional pressure-lowering drop therapy, the patient may need to be referred to a glaucoma specialist for surgical management. Often an oral antibiotic is continued for a week after surgery. The antibiotic used is generally a fourth-generation fluoroquinolone. The patient should be counseled on side effects such as prolonged ventricular depolarization (QTc prolongation) and muscle tendonitis. The appropriate dose, agent, and concomitant drug interactions are monitored by a pharmacist. The use of antibiotics after orbital surgery is variable. Clear communication and consolidation of the plan for antibiotics among the ophthalmologist and orbital surgeons (if part of a different department, such as otolaryngology or oral and maxillofacial surgery), nursing staff, patient, and primary trauma team can eliminate confusion.