Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma

We present the case of a 26-year-old man with significant periorbital trauma after blunt head trauma. Ultrasound techniques for evaluation of extraocular movements and pupillary light reflex are described as a proposed adjunct to physical examination and manual retraction of the eyelids. © 2010 Elsevier Inc. All rights reserved. 1. Background Examination of extraocular movements (EOMs) and pupillary light reflex in patients with severe periorbital edema can be challenging when eyelids cannot be retracted with ease. Conventional examination using manual eyelid retraction carries a risk of vitreous extrusion in cases of globe perforation, can be painful and difficult, and requires 2 providers. This clinical note describes ultrasonographic visualization as an alternate technique to assess both EOMs and pupillary light reflex. We describe the use of ocular ultrasound to assess for extraocular muscle entrapment and cranial nerves (CNs) III (oculomotor), IV (trochlear), and VI (abducens) function in the neurologically injured patient. Although this technique has been previously described for use by astronauts in the austere environment of outer space, it has not been well described in the emergency department (ED) setting (1). Several prior studies show the use of ocular ultrasound in the trauma patient for optic nerve sheath diameter as a proxy for elevated intracranial pressure, retinal detachment, vitreous hemorrhage, and retrobulbar hematomas (2-5). In trauma patients, early detection of muscular entrapment by ultrasound can allow the emergency physician to initiate urgent ophthalmologic consultation. In patients with intracranial injury at risk for neurologic decline and herniation, serial ultrasound examinations of the pupillary