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Recurrent Spontaneous Globe Subluxation: A Case Report and Review of Manual Reduction Techniques
The Journal of Emergency Medicine, Vol. 44, No. 1, pp. e17–e20, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2011.06.129
Clinical Communications: Adults RECURRENT SPONTANEOUS GLOBE SUBLUXATION: A CASE REPORT AND REVIEW OF MANUAL REDUCTION TECHNIQUES Elizabeth W. Kelly, MD* and Michael T. Fitch, MD, PHD*† *Department of Emergency Medicine and †Neurosciences Program, Wake Forest University School of Medicine, Winston-Salem, North Carolina Reprint Address: Elizabeth W. Kelly, MD, Department of Emergency Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
, Abstract—Background: Spontaneous globe subluxation is an uncommon problem that develops acutely and can present with significant patient distress from ocular pain and vision loss. Objectives: To present an unusual case of recurrent spontaneous globe subluxation and describe several methods emergency physicians can use to reduce a subluxation. Case Report: We describe a patient with recurrent spontaneous globe subluxation who presented to the Emergency Department with acute ocular pain and vision loss. The subluxation was emergently reduced, resolving the pain and restoring normal vision. Various manual reduction techniques are discussed. Conclusion: There are a number of manual reduction techniques used for treating spontaneous globe subluxation. Ó 2013 Elsevier Inc.
When patients present with a globe subluxation, it can be a challenge for emergency physicians who have not previously treated this condition. When subluxation occurs, reduction of the globe can be easily accomplished if one is familiar with manual reduction techniques. We describe a case of recurrent spontaneous globe subluxation requiring emergent reduction. CASE REPORT A 60-year-old man with a history of non-insulindependent diabetes, hypertension, and chronic bilateral exophthalmos presented with a chief complaint that his ‘‘right eye popped out.’’ He reported that he had been laughing hard, and accidently brushed his right eyelid with his open hand, and subsequently experienced excruciating eye pain. A bystander called Emergency Medical Services due to the patient’s extreme pain and vision loss. The paramedics applied a piece of gauze soaked in normal saline to the right eye, and gave the patient intravenous morphine. Upon arrival in the Emergency Department (ED), the patient was in acute distress due to ocular pain and monocular vision loss. The patient had experienced four prior episodes of spontaneous ocular subluxation, all when he was much younger; the last being 23 years prior. Several years before the first episode of ocular subluxation, the patient was diagnosed with Graves disease, but no specific
, Keywords—globe subluxation; spontaneous globe subluxation; eye emergency; manual reduction techniques
INTRODUCTION Ocular subluxation occurs when the equator of the globe protrudes anterior to the eyelid aperture, and often the eyelids slip beyond the globe equator (1). Patients with an acute globe subluxation develop extreme proptosis, and are unable to close their eyelids due to spasm of the orbicularis oculi, which limits extraocular movements and makes globe reduction difficult (1). Most patients with acute ocular subluxation present after a first episode, which can be a very frightening and painful experience (2).
RECEIVED: 29 August 2010; FINAL SUBMISSION RECEIVED: 28 April 2011; ACCEPTED: 5 June 2011 e17
e18
E. W. Kelly and M. T. Fitch
Figure 1. Photographs demonstrating an ocular subluxation. (A) Frontal view of subluxation. (B) Lateral view of subluxed globe. Figure 1 images were adapted and printed with permission from: Arch Ophthalmol 1999;117:138–9. Copyright 1999 American Medical Association. All rights reserved.
therapy had been prescribed. After the first two episodes of ocular subluxation, the patient had eye surgery that consisted of recession of the conjunctiva and Muller’s muscle, a procedure intended to prevent further episodes of subluxation. The patient’s vital signs were: temperature 36.4 C, (97.6 F), pulse 98 beats/min, blood pressure 135/ 111 mm Hg, respiratory rate 18 breaths/min, oxygen saturation 100% on room air. He reported severe ocular pain. The patient complained of complete vision loss in the right eye. The ophthalmologic examination revealed mild exophthalmos of the left eye, and marked proptosis of the right eye with globe subluxation (see Figure 1 for representative photos of globe subluxation; a photo before the procedure in this patient was unable to be obtained due to the clinical urgency of reducing the globe). The patient could not close his upper and lower right eyelids. The patient’s neurologic, cardiovascular, pulmonary, abdominal, and musculoskeletal examinations were normal. The patient was given intravenous hydromorphone hydrochloride for pain. An Ophthalmology consult was requested, and the emergency physician manually reduced the patient’s subluxed right globe before the consultant’s arrival. The subluxed globe was reduced by applying gentle manual traction to the upper and lower lids, and maneuvering the eyelids back around the apex of the subluxed globe without applying any direct ocular pressure (see Figure 2 for the reduction technique used in this case). After reduction, the patient had immediate relief of pain and return of normal vision (see Figure 3 for photographs of the globe after reduction). Ophthalmology evaluated the patient after the reduction and obtained a maxillofacial computed tomography (CT) scan with contrast. This revealed bilateral proptosis, right greater than left (Figure 4). The patient was asymptomatic with a normal ocular examination, and was discharged home with a scheduled follow-up visit with Ophthalmology.
DISCUSSION Subluxation of the globe is characterized by the anterior displacement of the globe beyond the orbital rim. This is a very rare condition, and may be caused by eyelid manipulation or trauma, and has been described previously in patients who wear contact lenses and frequently manipulate their eyelids during lens insertion. Etiologies also include exophthalmos associated with hyperthyroidism and orbital tumors. The case described here is unique in that the patient had a history of recurrent subluxation, which is unusual even in patients with a history of chronic exophthalmos. On the first four occasions that this patient had spontaneous ocular subluxation, the patient’s eye either reduced spontaneously or he was able to manipulate the globe back into place himself. On this occasion, he couldn’t reduce the subluxation himself and had to come to the ED for reduction.
Figure 2. Photograph of the manual reduction technique utilized to reduce a recurrent spontaneous globe subluxation of the right eye. Gentle traction is applied to the upper and lower eyelids to allow them to slide back behind the apex of the subluxed globe. No direct pressure is applied to the globe during this reduction.
Recurrent Globe Subluxation
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Figure 3. Photograph of the patient’s right eye after emergent manual reduction of the globe subluxation by the emergency physician. (A) Frontal view of the right eye after reduction. (B) Lateral view of the right eye after reduction, demonstrating the patient’s baseline proptosis.
The keys to a successful reduction include relaxation of the patient and of the orbicularis muscles (3). Use of anxiolytics and analgesics is therefore recommended, and a topical ocular anesthetic such as 0.5% proparacaine can be used if direct manipulation of the globe is required (3). One simple reduction technique is to instruct the patient to maintain a downward gaze and, while pinching and pulling the upper eyelid upward, the index finger of the other hand touches the superior scleral surface and pushes the globe downward and backward at the same time (4). This motion allows the upper eyelid to arch over the equator. Next, the examiner should continue to firmly pinch and pull the upper eyelid skin forward and then instruct the patient to look upward (see Figure 5 for an illustration of this technique) (4). This movement usually correctly repositions the globe. Another reduction option is to perform a similar procedure but with the help of a lid speculum, Desmarres
Figure 4. Computed tomography scan of the patient after globe subluxation was reduced, demonstrating bilateral proptosis, right greater than left.
retractor, or tissue forceps (2). If these items are not readily available, a large paperclip, bent at a right angle, also can be used as a lid retractor (3,4). The long arm of the paperclip is bent slightly, and the sharp end of the wire is bent slightly upward to avoid contact with the globe (4). Topical anesthetic should be applied to the globe, and the long arm of the paperclip is then shoehorned between the upper lid and the globe and gentle upward traction can be applied to facilitate passage of the lid over the globe (4). After successful globe reduction, the patient should have immediate relief of pain and return of vision and extraocular movements, although delays in functional recovery have been reported of up to 1 week (1,3). There is no consensus about whether a CT scan of the orbits is emergently necessary after reduction. Patients who experience this painful event should be counseled to avoid triggers such as aggressive lid manipulation in contact lens wearers. Weight loss may help avoid the condition as this decreases the amount of retro-bulbar fat in obese patients (5,6). Lid-lengthening procedures may be necessary to prevent recurrence in some patients. Other patients may require lateral tarsorrhaphy, which involves suturing together a small segment of the upper and lower lids at the lateral canthus (1,3). This procedure has been shown to help reduce cases of recurrent subluxation (1).
Figure 5. Illustration of a technique for manually reducing an ocular subluxation. (A) The patient maintains a downward gaze while the clinician pinches and pulls the upper eyelid upward and uses the index finger of the other hand to provide gentle pressure downward and backward on the globe. (B) The examiner continues to firmly pinch and pull the upper eyelid skin forward while the patient looks upward to complete the reduction procedure.
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E. W. Kelly and M. T. Fitch
CONCLUSION
REFERENCES
Spontaneous globe subluxation is an alarming event that causes severe pain and anxiety, and the physician must act quickly to manage this condition when visual acuity is impaired. Patients who have an uncomplicated reduction with return of normal vision and extraocular eye movements can be scheduled to follow-up closely with an ophthalmologist. Laboratory testing and imaging may be appropriate to detect underlying medical conditions such as hyperthyroidism or an orbital tumor as indicated.
1. Love JN, Bertram-Love NE. Luxation of the globe. Am J Emerg Med 1993;11:61–3. 2. Kunesh JC, Katz SE. Spontaneous globe luxation associated with contact lens placement. CLAO J 2002;28:2–4. 3. Zeller J, Murray SB, Fisher J. Spontaneous globe subluxation in a patient with hyperemesis gravidarum: a case report and review of the literature. J Emerg Med 2007;32:285–7. 4. Tse DT. A simple maneuver to reposit a subluxed globe. Arch Ophthalmol 2000;118:410–1. 5. Offenbach B. Dislocation (luxation) of the eyeball. N Engl J Med 1954;251:338–9. 6. Carlson RE, Scheribel KW, Hering PJ, Wolin L. Exophthalmos, global luxation, rapid weight gain: differential diagnosis. Ann Ophthalmol 1982;14:724–9.
doi:10.1016/j.jemermed.2011.06.129
Clinical Communications: Adults RECURRENT SPONTANEOUS GLOBE SUBLUXATION: A CASE REPORT AND REVIEW OF MANUAL REDUCTION TECHNIQUES Elizabeth W. Kelly, MD* and Michael T. Fitch, MD, PHD*† *Department of Emergency Medicine and †Neurosciences Program, Wake Forest University School of Medicine, Winston-Salem, North Carolina Reprint Address: Elizabeth W. Kelly, MD, Department of Emergency Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
, Abstract—Background: Spontaneous globe subluxation is an uncommon problem that develops acutely and can present with significant patient distress from ocular pain and vision loss. Objectives: To present an unusual case of recurrent spontaneous globe subluxation and describe several methods emergency physicians can use to reduce a subluxation. Case Report: We describe a patient with recurrent spontaneous globe subluxation who presented to the Emergency Department with acute ocular pain and vision loss. The subluxation was emergently reduced, resolving the pain and restoring normal vision. Various manual reduction techniques are discussed. Conclusion: There are a number of manual reduction techniques used for treating spontaneous globe subluxation. Ó 2013 Elsevier Inc.
When patients present with a globe subluxation, it can be a challenge for emergency physicians who have not previously treated this condition. When subluxation occurs, reduction of the globe can be easily accomplished if one is familiar with manual reduction techniques. We describe a case of recurrent spontaneous globe subluxation requiring emergent reduction. CASE REPORT A 60-year-old man with a history of non-insulindependent diabetes, hypertension, and chronic bilateral exophthalmos presented with a chief complaint that his ‘‘right eye popped out.’’ He reported that he had been laughing hard, and accidently brushed his right eyelid with his open hand, and subsequently experienced excruciating eye pain. A bystander called Emergency Medical Services due to the patient’s extreme pain and vision loss. The paramedics applied a piece of gauze soaked in normal saline to the right eye, and gave the patient intravenous morphine. Upon arrival in the Emergency Department (ED), the patient was in acute distress due to ocular pain and monocular vision loss. The patient had experienced four prior episodes of spontaneous ocular subluxation, all when he was much younger; the last being 23 years prior. Several years before the first episode of ocular subluxation, the patient was diagnosed with Graves disease, but no specific
, Keywords—globe subluxation; spontaneous globe subluxation; eye emergency; manual reduction techniques
INTRODUCTION Ocular subluxation occurs when the equator of the globe protrudes anterior to the eyelid aperture, and often the eyelids slip beyond the globe equator (1). Patients with an acute globe subluxation develop extreme proptosis, and are unable to close their eyelids due to spasm of the orbicularis oculi, which limits extraocular movements and makes globe reduction difficult (1). Most patients with acute ocular subluxation present after a first episode, which can be a very frightening and painful experience (2).
RECEIVED: 29 August 2010; FINAL SUBMISSION RECEIVED: 28 April 2011; ACCEPTED: 5 June 2011 e17
e18
E. W. Kelly and M. T. Fitch
Figure 1. Photographs demonstrating an ocular subluxation. (A) Frontal view of subluxation. (B) Lateral view of subluxed globe. Figure 1 images were adapted and printed with permission from: Arch Ophthalmol 1999;117:138–9. Copyright 1999 American Medical Association. All rights reserved.
therapy had been prescribed. After the first two episodes of ocular subluxation, the patient had eye surgery that consisted of recession of the conjunctiva and Muller’s muscle, a procedure intended to prevent further episodes of subluxation. The patient’s vital signs were: temperature 36.4 C, (97.6 F), pulse 98 beats/min, blood pressure 135/ 111 mm Hg, respiratory rate 18 breaths/min, oxygen saturation 100% on room air. He reported severe ocular pain. The patient complained of complete vision loss in the right eye. The ophthalmologic examination revealed mild exophthalmos of the left eye, and marked proptosis of the right eye with globe subluxation (see Figure 1 for representative photos of globe subluxation; a photo before the procedure in this patient was unable to be obtained due to the clinical urgency of reducing the globe). The patient could not close his upper and lower right eyelids. The patient’s neurologic, cardiovascular, pulmonary, abdominal, and musculoskeletal examinations were normal. The patient was given intravenous hydromorphone hydrochloride for pain. An Ophthalmology consult was requested, and the emergency physician manually reduced the patient’s subluxed right globe before the consultant’s arrival. The subluxed globe was reduced by applying gentle manual traction to the upper and lower lids, and maneuvering the eyelids back around the apex of the subluxed globe without applying any direct ocular pressure (see Figure 2 for the reduction technique used in this case). After reduction, the patient had immediate relief of pain and return of normal vision (see Figure 3 for photographs of the globe after reduction). Ophthalmology evaluated the patient after the reduction and obtained a maxillofacial computed tomography (CT) scan with contrast. This revealed bilateral proptosis, right greater than left (Figure 4). The patient was asymptomatic with a normal ocular examination, and was discharged home with a scheduled follow-up visit with Ophthalmology.
DISCUSSION Subluxation of the globe is characterized by the anterior displacement of the globe beyond the orbital rim. This is a very rare condition, and may be caused by eyelid manipulation or trauma, and has been described previously in patients who wear contact lenses and frequently manipulate their eyelids during lens insertion. Etiologies also include exophthalmos associated with hyperthyroidism and orbital tumors. The case described here is unique in that the patient had a history of recurrent subluxation, which is unusual even in patients with a history of chronic exophthalmos. On the first four occasions that this patient had spontaneous ocular subluxation, the patient’s eye either reduced spontaneously or he was able to manipulate the globe back into place himself. On this occasion, he couldn’t reduce the subluxation himself and had to come to the ED for reduction.
Figure 2. Photograph of the manual reduction technique utilized to reduce a recurrent spontaneous globe subluxation of the right eye. Gentle traction is applied to the upper and lower eyelids to allow them to slide back behind the apex of the subluxed globe. No direct pressure is applied to the globe during this reduction.
Recurrent Globe Subluxation
e19
Figure 3. Photograph of the patient’s right eye after emergent manual reduction of the globe subluxation by the emergency physician. (A) Frontal view of the right eye after reduction. (B) Lateral view of the right eye after reduction, demonstrating the patient’s baseline proptosis.
The keys to a successful reduction include relaxation of the patient and of the orbicularis muscles (3). Use of anxiolytics and analgesics is therefore recommended, and a topical ocular anesthetic such as 0.5% proparacaine can be used if direct manipulation of the globe is required (3). One simple reduction technique is to instruct the patient to maintain a downward gaze and, while pinching and pulling the upper eyelid upward, the index finger of the other hand touches the superior scleral surface and pushes the globe downward and backward at the same time (4). This motion allows the upper eyelid to arch over the equator. Next, the examiner should continue to firmly pinch and pull the upper eyelid skin forward and then instruct the patient to look upward (see Figure 5 for an illustration of this technique) (4). This movement usually correctly repositions the globe. Another reduction option is to perform a similar procedure but with the help of a lid speculum, Desmarres
Figure 4. Computed tomography scan of the patient after globe subluxation was reduced, demonstrating bilateral proptosis, right greater than left.
retractor, or tissue forceps (2). If these items are not readily available, a large paperclip, bent at a right angle, also can be used as a lid retractor (3,4). The long arm of the paperclip is bent slightly, and the sharp end of the wire is bent slightly upward to avoid contact with the globe (4). Topical anesthetic should be applied to the globe, and the long arm of the paperclip is then shoehorned between the upper lid and the globe and gentle upward traction can be applied to facilitate passage of the lid over the globe (4). After successful globe reduction, the patient should have immediate relief of pain and return of vision and extraocular movements, although delays in functional recovery have been reported of up to 1 week (1,3). There is no consensus about whether a CT scan of the orbits is emergently necessary after reduction. Patients who experience this painful event should be counseled to avoid triggers such as aggressive lid manipulation in contact lens wearers. Weight loss may help avoid the condition as this decreases the amount of retro-bulbar fat in obese patients (5,6). Lid-lengthening procedures may be necessary to prevent recurrence in some patients. Other patients may require lateral tarsorrhaphy, which involves suturing together a small segment of the upper and lower lids at the lateral canthus (1,3). This procedure has been shown to help reduce cases of recurrent subluxation (1).
Figure 5. Illustration of a technique for manually reducing an ocular subluxation. (A) The patient maintains a downward gaze while the clinician pinches and pulls the upper eyelid upward and uses the index finger of the other hand to provide gentle pressure downward and backward on the globe. (B) The examiner continues to firmly pinch and pull the upper eyelid skin forward while the patient looks upward to complete the reduction procedure.
e20
E. W. Kelly and M. T. Fitch
CONCLUSION
REFERENCES
Spontaneous globe subluxation is an alarming event that causes severe pain and anxiety, and the physician must act quickly to manage this condition when visual acuity is impaired. Patients who have an uncomplicated reduction with return of normal vision and extraocular eye movements can be scheduled to follow-up closely with an ophthalmologist. Laboratory testing and imaging may be appropriate to detect underlying medical conditions such as hyperthyroidism or an orbital tumor as indicated.
1. Love JN, Bertram-Love NE. Luxation of the globe. Am J Emerg Med 1993;11:61–3. 2. Kunesh JC, Katz SE. Spontaneous globe luxation associated with contact lens placement. CLAO J 2002;28:2–4. 3. Zeller J, Murray SB, Fisher J. Spontaneous globe subluxation in a patient with hyperemesis gravidarum: a case report and review of the literature. J Emerg Med 2007;32:285–7. 4. Tse DT. A simple maneuver to reposit a subluxed globe. Arch Ophthalmol 2000;118:410–1. 5. Offenbach B. Dislocation (luxation) of the eyeball. N Engl J Med 1954;251:338–9. 6. Carlson RE, Scheribel KW, Hering PJ, Wolin L. Exophthalmos, global luxation, rapid weight gain: differential diagnosis. Ann Ophthalmol 1982;14:724–9.