M2 ANATOMY

A 42 year-old anatomy professor was seen in the Emergency Department following a contusion to an unprotected right eye by a squash ball during a competitive morning match at the Central Campus Recreation Building at the University of Michigan.  He sustained no alteration of mental status following the incident, but has significant pain in the orbit and periorbital region and right cheek.  His vital signs were stable with a heart rate of 84, a respiratory rate of 16, blood pressure of 134/82, temperature of 98.8 F, and a pulse oximetery of 99%.  His heart rate and rhythm were regular without murmurs, the lungs were clear anteriorly and posteriorly bilaterally, and general neurological examination was within normal.  His ENT examination demonstrated the following.  Visual acuity was 20/100 OD and 20/20 OS (OD is right eye; OS is left eye).  The pupils were equal and reactive bilaterally.  The extraocular muscles of the left eye were intact but the patient was unable to look up on the right and experienced diplopia with attempts to do so.  There was the presence of confluent bleeding covering the right half of the eye over the sclera and beneath the conjunctiva on the right side, and on ophthalmascopic examination there is a pool of blood in the anterior chamber of the right eye covering the iris and extending up to the inferior aspects (but not occluding the) the pupil.  There is pain to palpation of the bony infraorbital margin, yet hypoesthesia exists in the infraorbital region extending down towards the cheek.  In a darkened room a physician places a flashlight over the cheek and notes that light transilluminates the left maxillary sinus bot not the left.  On CT Scan the right side notes that orbital fat has prolapsed into the maxillary sinus and seems to be joined by a prolapse of the inferior rectus muscle.