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Margaret L Pfeiffer, Helen Merritt, Karina Richani, Margaret E. Phillips; Clinical and Radiographic Features of Extraocular Muscle Entrapment. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):563.
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This is a retrospective chart review to investigate the clinical and radiographic features of extraocular muscle entrapment in patients presenting to the emergency department with orbital wall fractures.
Patients who presented to the Memorial Hermann Hospital emergency department, diagnosed with an acute orbital wall fracture with extraocular muscle entrapment, and evaluated by ophthalmology from January 2013 through November 2014 were included. Clinical data were analyzed for the presence of symptoms and signs associated with entrapment: diplopia, pain with eye movements, nausea or vomiting, syncope, bradycardia, and restriction in extraocular movements. Radiographic data were obtained including interpretation of computed tomography (CT) by both ophthalmology and radiology.
Eight patients with an orbital wall fracture with extraocular muscle entrapment confirmed by forced ductions were identified. The median age was 22 (range: 9 to 72) years with 6 (75%) males and 4 (50%) white. Mechanisms of injury included 3 (37.5%) sports-related, 2 (25%) assault, 2 (25%) motor vehicle collision, and 1 (12.5%) fall. Diplopia and pain with eye movements were the most common symptoms in 7 (87.5%) patients followed by nausea or vomiting in 3 (37.5%). No patients had syncope. Two patients (25%) were bradycardic with a pulse of less than 60 beats per minute; an additional 2 had a pulse of 60. All had restricted extraocular motility. Radiology accurately identified entrapment on CT in 3 (37.5%) cases and interpreted an additional 3 (37.5%) as suspicious for entrapment. Ophthalmology accurately identified entrapment on CT in 5 (62.5%) cases and interpreted an additional 1 (12.5%) as suspicious. Overall, ophthalmology correctly diagnosed entrapment in 5 (62.5%) cases based on clinical and radiographic data. Three (37.5%) patients were found to have entrapment on follow-up examination. In those patients whose entrapment was not diagnosed, forced ductions were not performed on initial evaluation.
Diplopia and pain with eye movements were the most common symptoms of entrapment. Ophthalmology correctly identified more cases of entrapment on CT than radiology, but 3 cases were misdiagnosed by ophthalmology. We recommend high suspicion for entrapment when both diplopia and pain with eye movements are present and recommend performing forced ductions in all cases with definite or suspicious imaging and clinical findings.
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