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ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 4  |  Page : 245-248

Orbital fracture due to camel bite - A case report


Department of Ophthalmology, S. M.S. Medical College and Hospital, Jaipur, India

Date of Web Publication24-Dec-2007

Correspondence Address:
B N Consul
Department of Ophthalmology, S. M.S. Medical College and Hospital, Jaipur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Consul B N, Sharma D P, Sharma R G. Orbital fracture due to camel bite - A case report. Indian J Ophthalmol 1968;16:245-8

How to cite this URL:
Consul B N, Sharma D P, Sharma R G. Orbital fracture due to camel bite - A case report. Indian J Ophthalmol [serial online] 1968 [cited 2020 Aug 9];16:245-8. Available from: http://www.ijo.in/text.asp?1968/16/4/245/37566

Fractures of the orbital floor can occur by two different mechanisms: (i) Backward displacement of the strong bone forming the orbital rim which results in fractures of thin bones. (ii) Increased internal orbital pressure caused by a blow of human list, a baseball, or a cricket ball (Con­verse and Smith, 1957) on the soft tissues of the orbit, producing frac­tures of the floor of the orbit without affecting the orbital rim, called 'blow out' fracture. Smith and Regan (1956) have reproduced this type of fracture experimentally on the cada­ver.

Comminuted fracture of orbital rim and floor is a more serious type and arises from a force similar in na­ture and direction but of much grea­ter magnitude. This fracture unlike the simple fracture of zygoma is us­ually attended with much greater immediate deformity and involves the orbital floor medially and poste­riorly. There is herniation of orbital contents into the antrum (Lang, 1899) and involvement of extra-ocular mus­cles. The globe loses its support and tends to occupy a lower position. The lateral canthus may show evidence of lowering. Pfeiffer (1911) reviewed 126 cases of the fractures of the orbit and found that enophthalmos was present in 53 of his cases.


  Treatment Top


The early recognition and repair of such fractures ensures maximum phy­sical and functional recovery. The treatment aims at freeing the orbital contents from the fracture site and restoring the integrity of the bony floor. Various materials that have boon used to provide support to the orbital floor include synthetic substances such as teflon and methyl methacrylate stents, silicon rubber and rubber baloons (Quereau, 1956; Anderson, 1963; Lipshutz, 1963; Pat­terson, 1962). Metal jack screw, tan­talum mesh (Anthony, 1957; Calla­han, 1953) and metal balls are the other materials used. The use of an­togenous, homogenous or processed bovine bone grafts (Converse and Smith, 1950; Anderson, 1965; Patter­son, 1967) provide most physiological substitutes and have given higher percentage of success in these cases. Autogenous bone graft though re­quires additional surgery in the pa­tient, is readily available and is at­tended with least possible reactions.

An interesting case of comminuted fracture of the orbit due to camel bite, came to us quite sometime after the injury and is being recorded for its unusual cause and response to the conventional surgical approach.


  Case report Top


Ganga Ram, 40 years of age sus­tained face injury due to camel bite on 8-1-67 and was admitted in the surgical ward of this hospital on 9-1-67. He had a lacerated wound about 3 inches' long extending from right lateral canthus to the temporal region. There was marked drooping of the right upper lid. The wound was stitched by the general surgeon in that ward. The case was referred to us for ophthalmic check up on 22-1-67. On examination there was an irregular healed scar, three inches long and a little swelling in the right temporal region and along the lateral orbital wall. On palpation there was a little depression and crepitus, on the lateral wall of right orbit. There was a discharging wound (1/2 inch long) on the left side of the mandible one inch below the lip. The right upper lid was found swollen and drooping and could not be lifted vol­untarily. On attempted closure there was a lagophthalmos of 2 mm. The palpebral fissure was oblique and slanting down towards the lateral canthus. Lateral canthus was dis­placed 12 mm below the medial can­thus [Figure - 1]. Exophthalmometry re­vealed 4 mm anophthalmos of the right eye. The eye ball was displac­ed down by 5 mm [Figure - 2]. Move­ments of the eye ball were markedly restricted laterally and upwards; rest of the movements were normal. The eyeball had escaped injury. The fundus was normal and the vision 6/12. There was diplopia in almost all quadrants except on the inner side. It was more on abduction and ele­vation.

Hess charting showed the restric­tion of the fields belonging to the right inferior oblique and right late­ral rectus.

Skiagram of the orbit and paranasal sinuses [Figure - 3] revealed fracture of the lateral orbital wall and hazyness of the right maxillary antrum with a depressed orbital floor fracture and herniation of soft tissues into the ant­rum.

Laboratory investigations:­

Blood cytology, the E.S.R. and the urine revealed nothing abnormal.

The conjunctival swab culture was sterile though the swab taken from the wound showed Staphylococcus and B. Pyocyaneous which showed sensitivity to chloromycetin.

Management:- (i) Repair of Orbital floor: The case was operated on 13-2-67, under general anaesthesia. The right orbital floor was exposed through lower lid by incising the skin, orbicularis oculi and periosteum to the inferior orbital margin. The or­bital contents with the eye ball were lifted along with the periosteum. The orbital floor was visualised and multi­ple fractures of the floor were found, with herniation of orbital fat and in­ferior oblique muscle into the antrum. These structures were released from the antrum. A 2.5 x 1.5 x 0.5 cm piece of iliac bone was taken from the in­ner side of the right iliac crest by a se­parate incision over this region. The piece was cut to appropriate size and grafted on to the orbital floor with its broader end placed anteriorly. The periosteum was sutured with 5 'O' plain catgut and the wound closed in layers.

(ii) Repair of the lateral canthus: After a skin incision over the lateral canthus ligament the temporalis mus­cle was released at the site of the old scar from the skin and underlying bone. The lateral canthus was ele­vated by defining the lateral palpe­bral ligament and reattaching it a lit­tle above the lateral orbital tubercle. The wound was then closed in layers.

There was very little post operative reaction and at the time of discharge, there was anophthalmos of only 1 mm, depression of the eye ball was found to be fully corrected [Figure - 4] The movements of the eye ball were normal except slight restriction on the lateral side. Diplopia was present only in the right outer quadrant. The lateral canthus was 4 mm below the medial canthus showing a correction of 8 mm .


  Comments Top


'Blow out' fractures are reported due to large blunt objects like human fist, cricket ball, base ball (Smith et al, 1957), the force of which is of such a magnitude which can fracture the firm orbital rim and the floor without damaging the eye ball. .

The orbital fracture in the present case is due to camel bite. Here the mechanism of fracture is the compres­sion of the orbital rim between the two jaws of the camel without causing injury to the eye ball and thus result­ing in a combined external and inter­nal comminuted orbital fracture, with the dominant signs of external defor­mity of the orbital rim, depression of the lateral canthus, producing the de­formed inter palpebral fissure, res­tricted movements, enophthalmos, and diplopia. The maxillary antrum was hazy due mostly to the blood and very little due to herniation of the orbital contents. The results are generally best when such cases are operated within 7 to 10 days of injury, but with us there was no other al­ternative except to take a late case and even then the results were fairly satisfactory. The patient was so sa­tisfied with the results that for further improvement in his cosmatic appea­rance he did not like to submit him­self for a second operation.

Orbital exposure may be made ei­ther from lower orbital rim or through Caldwell Luc anterior antrotomy. The best and permanant results are achieved by autogenous cartilaginous graft taken from the iliac crest and placing it over the orbital floor, through the inferior orbital margin.


  Summary Top


A late case of orbital fracture due to camel bite is reported. The sur­gical repair of the orbital floor was done with autogenous bone graft from right iliac crest.[15]

 
  References Top

1.
Anderson, R. A., and Teague, D. A. (1953): Blow out fractures of the or­bital floor. Amer. J. Ophthal., 56, 47­50.  Back to cited text no. 1
    
2.
Anderson, K. J., et al (1965): Processed heterogenous hone. A basic scientific study with preliminary clinical trials in humans. J.A.M.A.; 193: 377-380.  Back to cited text no. 2
    
3.
Anthony, D. 1-1. (1957) Diagnosis and surgical treatment of fractures of the orbit, Trans. Amer. Acad. Ophthal. Otolarvng. 56: 580-587.  Back to cited text no. 3
    
4.
Callahan, A. (195:3) Symposium: Malunited fractures of the zygoma. Bony depressions, particularly depressions of the floor of the orbit. Traps. Amer. Acad. Ophthal. Otolarvng. 57: 875.  Back to cited text no. 4
    
5.
Converse, T. N1. and Smith. B. (1950): Reconstruction of orbital floor by bone grafts. Arch. Ophthal. 44, (Chicago) 1.  Back to cited text no. 5
    
6.
Converse, J. M. and Smith, B. (1.957): Enophthalmos and diplopia in frac­tures of the orbital floor. Brit. J. of plastic surgery, 9, 265-274.  Back to cited text no. 6
    
7.
Lang, W. (1899): Trans. Onhthal. Soc. U.K., 9, 41.  Back to cited text no. 7
    
8.
Lipshutz, H. and Ardizone, R. A, (1963): The use of silicon rubber in the immediate reconstruction of the floor of the orbit. J. Trauma. 3: 563.  Back to cited text no. 8
    
9.
Patterson, R. W., and DePue, R. (1962): Blow out fractures of the orbit. Amer. J. Ophthal: 53, 841-845.  Back to cited text no. 9
    
10.
Patterson, R. W., Mc Coy, W. J. III and Benedict, W. H. (1967): The use of processed bovine bone in orbital floor fractures. Arch. of Ophthal., 78, 360-364.  Back to cited text no. 10
    
11.
Pfeiffer, R. L. (1941): Trans. Amer Ophthal. Soc., 39, 492.  Back to cited text no. 11
    
12.
Quereau, J. V. D., and Sounders, P. F. (1956): Teflon implant to elevate the eye in depressed fracture of the orbit. Arch. Ophthal., (Chicago) 55: 685.  Back to cited text no. 12
    
13.
Smith, B.: Converse, J. M. and Trout­man, R. C. (1962): Plastic and reconstructive surgery of the eye and adnexa. Publisher, Butterworth and Co. Wash­ington, 91, 104.  Back to cited text no. 13
    
14.
Smith, B. and Regan, W. F. (1956): Personal communication to Enopthal­mos and diplopia in fractures of the orbital floor. B. J. of Plastic surgery., Vol. IX, 1957.  Back to cited text no. 14
    
15.
Smith, B. and Re-an, W. F. (1957): Blow out fracture of the orbit. Ameri­can Jr. of Ophthal., 44, 733-739.  Back to cited text no. 15
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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