Decreased Ocular Motility After Facial Trauma

Michael A. Puente, Jr; Honey H. Herce, MD; Amit R. Bhatt, MD; Douglas P. Marx, MD; Kimberly G. Yen, MD


November 17, 2014

Clinical Presentation

An 8-year-old previously healthy boy was referred to the pediatric ophthalmology service after being kicked in the right periorbital region while jumping on a trampoline.

The child immediately experienced vertical diplopia that improved with closing his right eye. He was found by his primary care provider to have an upgaze deficit in the right eye. He had one episode of nausea and vomiting before arrival to the emergency department. He also reported pain with right eye elevation but denied blurry vision. His parents have not observed any change in mental status.

On ocular examination, the child had visual acuity of 20/20 in both eyes at near, with no visual field defects by confrontation. Primary gaze is shown in Figure 1. In comparison to primary gaze, he had a -4 supraduction deficit with upgaze (Figure 2) and -2 infraduction deficit with downgaze in the right eye. His left eye had normal ductions. Horizontal eye movements were normal for both eyes.

The intraocular pressure in the right eye was 13 mm Hg in primary gaze but increased to 23 mm Hg in upgaze. The intraocular pressure in the left eye was 12 mm Hg.

His pupils were normal, and examination of the adnexa and anterior and posterior segments was unremarkable bilaterally, with both eyes white and quiet.

Maxillofacial CT (Figure 3) showed a slightly displaced right orbital floor fracture.

Figure 1. Primary gaze.

Figure 2. Upgaze.

Figure 3. Maxillofacial CT.


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