Senior Report 7.9

Case Presentation by Dr. Adam Bartsoff, MD

CHIEF COMPLAINT: “My eye fell out”

HISTORY OF PRESENT ILLNESS: This is a 25 year old African American female who presents to the emergency department stating that her right eye “fell out.” The patient states that she woke up in the early morning with a sensation that there was something in her right eye. When she attempted to wipe her eye she noticed that it was displaced slightly anterior and inferior and required to be “popped back in” with the palm of her hand. The event was non painful. The patient had some minor visual changes that she describes as blurry vision initially secondary to a glossy eye and eye watering which has since resolved. She denies any history of regular visual disturbances or eye pain. This has happened to the patient once before when she was 19. Also when the patient sneezes she always feels as though her eye is going to fall out. She has never seen an ophthalmologist regarding this. She denies any history of remote trauma to the right eye, pain with EOM, bleeding from the right eye or chronic headache.

REVIEW OF SYSTEMS:
HEENT:  Positive for: brief blurry vision, brief watery right eye
Negative for: eye trauma, eye pain, bleeding eye, double vision, recent sinus infection
NEURO:  Negative for regular headache, gait disturbances
CARDIOVASCULAR:  Negative for tachycardia, palpitations
ENDOCRINE:  Negative for heat or cold intolerance

PMH: borderline hypertension. Not up to date on tetanus immunization.
SURG HX: None
MEDICATIONS: None
ALLERGIES: Motrin
SOCIAL HISTORY: Occasional alcohol use socially. Denies tobacco or drug use.

 

EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
VITALS: TEMP: 37.9 c. HR: 85 bpm. RR: 12. BP: 120/80 mmHg. SpO2: 100% RA.
GENERAL: Sitting in chair in no acute distress.
HEENT: PERRLA, EOMI. No nystagmus. Slight right eye proptosis, no left eye proptosis. No hyphema. No eye discharge or bleeding. No lid lag. No Papilledema. Mild right eye conjunctival erythema. Fluorescein stain of the right eye reveals small corneal abrasion at the 7:00 o’clock position. Negative Seidel’s Sign. Slit lamp examination of the right eye reveals: No foreign body, No cell and flare, quiet anterior chamber, No corneal ulceration.

Visual Acuity: 20/30 bilaterally.

MSK: No pain to palpation of the orbit. No gross deformity of the facial bones.

NEURO: Non ataxic gait. No pronator drift. Negative Romberg. No dysdiadochokinesia. Symmetrical face. Tongue protrudes midline. Equal shoulder shrug. Strength in the upper and lower extremities equal and symmetrical rated 5/5. Sensation intact and symmetrical to light touch across the face and the upper and lower extremities.

 

QUESTIONS:
More than one answer may be correct.

1.   After a complete eye exam as documented above, what is your next step?
a) Discharge the patient with close follow up with ophthalmology .
b) Patch the right eye until follow up to prevent spontaneous globe luxation.
c) Tdap, erythromycin, ophthalmic ointment, lacri-lube, close ophthalmology follow up, discharge.
d) Consult ophthalmology.

2. When should you consult ophthalmology?
a) Always
b) With bilateral globe luxation
c) With significant visual acuity differences
d) If you cannot reduce the subluxed globe

3.  What are risk factors for spontaneous globe subluxation?
a) Trauma
b) Graves Disease
c) Eye lid manipulation
d) Space occupying lesion
e) Hyperopia

4.  The majority of globe subluxation cases are:
a) Spontaneous
b) Traumatic
c) Voluntary
d) Secondary to space occupying lesion

 

Answers:

1.C
2.
C,D
3. 
A,B,C,D
4.
A

Discussion: Globe Subluxation

BartsoffHistory:
The first case of spontaneous globe subluxation was reported in 1907. Fewer than 50 cases have been reported.

Presentation:
Globe subluxation can vary in presentation from asymptomatic to blindness. The most common cause of globe subluxation is spontaneous subluxation which usually occurs secondary to lid manipulation.

Mechanism:
Spontaneous globe subluxation is a rare orbital complication when the equator of the globe protrudes past the retracted lid. The mechanism of spontaneous globe subluxation is simple. Manipulation of the eye lid causes pressure to increases behind the globe. When the globe advances the cornea becomes dry. This induces the blink reflex and causes contraction of the orbicularis oculi. This limits extraocular movements and prevents globe reduction. Patients who attempt to reduce the spontaneous subluxed globe may cause a corneal abrasion. Other causes of spontaneous globe subluxation include extremes of gaze and valsalva maneuvers. Case reports exist of individuals experiencing globe subluxation when attempting to insert contact lenses because this requires lid retraction and an upward gaze.

Risk Factors:
There are many common risk factors for globe subluxation. The most common risk factor is exophthalmia. Individuals with exophthalmia usually have space occupying retrobulbar lesions, shallow orbits or both. Graves disease is the most common cause of a retrobulbar space occupying lesion secondary to inflammatory cell infiltration of extraocular muscles. The volume of the intraorbital contents increase but the orbital space remains limited. This causes the globe to protrude and the lids to retract. Pathologic processes such as cerebral granulomas, orbital tumors or arteriovenous malformations can also cause proptosis. Congenital processes such as abnormally enlarged globes or brachycephaly are also potential causes for spontaneous globe subluxation.. Myopia has also been shown to be an independent risk factor for spontaneous globe subluxation

Early Reduction is Key:
Early reduction is most important with globe subluxation and is key to preventing visual loss because globe subluxation produces traction on the optic nerve and vasculature. Before reduction a brief , full eye examination should be performed and visual acuity documented. Topical ocular anesthetic agents such as 0.5% proparacaine should also be used before manipulation of the globe.

A facial nerve block can be used to relax the of orbicularis oculi muscle and has been described in the literature. Rarely conscious sedation as required but may be necessary in mentally handicapped individuals or children.

Reduction of the Subluxed Globe:
Tse DT. A Simple Maneuver to Reposit a Subluxed Globe. Arch Ophthalmol. 2000;118(3):410-411.

While the patient is maintaining a constant downward gaze posture, the upper eyelid skin is pulled upward with the fingers of one hand and the globe is simultaneously depressed with the index finger of the other hand. The importance of contacting only the scleral surface is emphasized to the patient. This maneuver permits the retracted upper eyelid to ascend the posterior scleral surface and to arch over the equator. Ask the patient then to look upward and the superior rectus action will rotate the globe under the distracted upper eyelid. This maneuver usually will reposition the globe behind the eyelids.

Bartsoff 2j

Follow up:
A patient with a subluxed global which is been reduced can safely follow up with ophthalmology in 24 hours if they have not acute visual changes associated with the subluxation. Prior to discharge, patients should be educated in the potential triggers for recurrent subluxation. They should be referred to their primary care doctor to investigate for underlying predisposing conditions such as thyroid disease or other infiltrative conditions of the orbit. The patient should also be instructed on proper repositioning techniques such as the one described. Rarely surgical interventions are indicated.

 

References:

Talke. Globe Subluxation: Review and Management; 2007
Kelly EWFitch MT.

Recurrent spontaneous globe subluxation: a case report and review of manual reduction techniques; J Emerg Med. 2013 Jan;44(1):e17-20.

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