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1-10: Traumatic Exophthalmos

Christopher L. Stark

Clinical Summary

Traumatic exophthalmos typically occurs from blunt orbital trauma causing an intraorbital hematoma that pushes the globe anteriorly. Patients present with periorbital edema, ecchymosis, a marked decrease in visual acuity, and an afferent pupillary defect in the involved eye. The exophthalmos, which may be obscured by periorbital edema, can be better appreciated from a superior view. Visual acuity may be affected by the direct trauma to the eye (retinal detachment, hyphema, globe rupture), compression of the retinal artery, or neuropraxia of the optic nerve.

FIGURE 1.48

Traumatic Exophthalmos. (A) Blunt trauma resulting in periorbital edema and ecchymosis, which obscures the exophthalmos in this patient. The exophthalmos is not obvious in the anteroposterior view and can therefore be initially unappreciated. (B) The same patient viewed in the coronal plane from over the forehead demonstrating right eye exophthalmos. (Photo contributor: Frank Birinyi, MD.)

An anterior view of the face shows swelling and redness surrounding the eye. A coronal view of the face from above the forehead shows the right eyeball protruding outward.
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An anterior view of the face shows swelling and redness surrounding the eye. A coronal view of the face from above the forehead shows the right eyeball protruding outward.
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Management and Disposition

Maxillofacial or orbital CT best delineates the presence and extent of a retrobulbar hematoma and associated facial or orbital fractures. Emergent ENT and ophthalmology consultation is indicated. Emergent lateral canthotomy and cantholysis to decompress the orbit can be sight saving.

FIGURE 1.49

Retrobulbar Hematoma. CT of the patient in Fig. 1.48 with right retrobulbar hematoma and traumatic exophthalmos. (Photo contributor: Frank Birinyi, MD.)

An axial cut of the C T of face shows the collection of blood behind the right eye causing the right eyeball to protrude outward.
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FIGURE 1.50

Traumatic Exophthalmos. Proptosis, hyphema, periorbital ecchymosis, and marked swelling in the patient with a retrobulbar hematoma from severe head and face trauma. Examination findings are more obvious than in Fig. 1.48. (Photo contributor: David Effron, MD.)

A close-up of the right eye shows bulging of the eyeball, a collection of blood in the conjunctiva, and swelling and redness around the eye.
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Pearls

  1. The retrobulbar hematoma and exophthalmos may not develop for hours after the injury.

  2. A subtle exophthalmos may be detected by looking down over the head of the patient and viewing the eye from the coronal plane.

  3. Elevated intraocular pressure, relative afferent pupillary defect, and diminished visual acuity in patients with traumatic exophthalmos should have an emergent lateral canthotomy and cantholysis.

FIGURE 1.51

Traumatic Exophthalmos. Exophthalmos with an initial intraocular pressure that was too high to read in this patient on anticoagulants suggests orbital compartment syndrome. Lateral canthotomy/cantholysis brought the pressure to normal. (Photo contributor: Pamela Loveland, MD.)

A close-up of the right eye shows the result of traumatic exophthalmos: bulging out of conjunctiva, collection of blood behind the cornea, and swelling and reddish discoloration around the eye.
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FIGURE 1.52

Traumatic Enucleation. Complete enucleation of the right eye after a mechanical fall and hitting their face on the corner of a table. Family came with the patient with the eye in a plastic bag. No other injury is seen on orbit CT scan. (Photo contributor: Kevin S. Barlotta, MD.)

Two illustrations show the results of traumatic enucleation. An entirely removed eyeball. An axial C T of the orbit shows the absence of eyeball in the right orbit with no other injury to the bones.
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