|Year : 1991 | Volume
| Issue : 4 | Page : 188-189
The missing eyeball-CT evaluation (a case report)
B Raghav, Sushma Vashisht, BR Keshav, Manorama Berry
Department of Radio - Diagnosis, Dr. Rajendra Prasad for Ophthalmic Sciences, New Delhi, India
Department of Radio-Diagnosis, A.I.I.M.S.. New Delhi - 110029
Source of Support: None, Conflict of Interest: None
A case of blow out fracture of the medial wall and floor of the orbit with herniation of the eyeball into the ethmoid sinus diagnosed on CT scan is reported. To the best of our knowledge there is no previous report of prolapse of eyeball into the ethmoid sinus.
|How to cite this article:|
Raghav B, Vashisht S, Keshav B R, Berry M. The missing eyeball-CT evaluation (a case report). Indian J Ophthalmol 1991;39:188-9
| Introduction|| |
A young male victim of blunt trauma to the face was diagnosed clinically to have had a traumatic expulsion of his eye ball. The affected orbit was noted to be anophthalmic. Subsequent computed tomography (CT) showed the globe to be in the ethmoid sinus. To our knowledge there are only three prior reports of prolapse of the globe out of the orbit and they are all into the maxillary sinus ,,
| Case report|| |
Mr. M. a 24 year old male labourer was hit by a brick on the left side of the face and forehead. This resulted in severe pain, local bleeding and disorientation. He was unable to recollect whether his eyeball had been expelled. He was referred to our institute, where he presented a month after the injury. On examination, the right orbit and eye were normal with a vision of 6/6. The left socket was noted to be anophthalmic. The eyelids were congested with echymoses and on attempted separation of the lids remnants of the sclera were seen with purulent discharge. He was treated with gentamycin eye drops and called after one month for trial of an artificial eye. The infection was controlled but the artificial eye could not be retained. Plain X-ray evaluation in the Waters, Caldwells and lateral projections revealed opaque left ethmoid and maxillary sinuses with a raggedness of the left medial orbital margin [Figure - 1].. He was then sent for a computerised tomographic examination (CT) in an effort to locate the globe. Axial and coronal CT demonstrated blowout fractures involving the inferior and medial orbital walls, disorganization of the orbital soft tissues and prolapse of a major portion of the globe into the ethmoid sinus [Figure - 2][Figure - 3]. Unfortunately, the patient did not return to the ophthalmology service after the CT
| Discussion|| |
An orbital wall fracture without involvement of the bony rim is termed a blowout fracture. This occurs when the orbit and eye are struck by a blunt object of size greater than the diameter of the orbital rim .
The effect of compressive forces on the globe, periglobe structures and bony orbital walls is a measure of their intrinsic elasticity and the degree - of movement available to them. The globe is elastic, compressible and has maximum potential mobility. Moderate diffuse forces by blunt objects are transmitted without shattering or tearing of the globe. Considerable preservation of normal intraglobe anatomy occurs by elastic recoil. The periglobe structures namely the muscle cone, vessels and nerves are less elastic than the globe but the presence of considerable fat in the orbit affords mobility to the globe. Deforming forces are therefore, absorbed and transmitted to the bony orbital walls which being rigid and inelastic tend to give way. The thinnest of the bony orbital walls are the orbital floor, medial to the inferior orbital fissure and the medial wall formed by the ethmoidal lamina papyracea. These fractures allow orbital contents to prolapse into the maxillary and ethmoidal sinuses respectively. Depending on the degree and direction of the forces, small or considerable amounts of orbital tissues and rarely even the globe itself may prolapse out of the bony orbit ,,
In our case the victim was initially evaluated at a small primary centre and the unusual nature of the injury (blowout fracture) was not diagnosed. The situation was complicated by attendant orbital sepsis so that the position of the herniated globe into the ethmoid sinus was not initially suspected. Plain X-ray evaluation aroused suspicion of a blowout fracture. Subsequent CT evaluation in axial and coronal planes allowed precise identification of the herniated globe.
Radiological studies are indicated in every patient with midfacial trauma . Plain X-rays in the Caldwell, Waters, and lateral orbital views can demonstrate soft tissue swelling, fractures, sinus opacification and orbital emphysema. When no fracture is seen in the presence of enophthalmos and radiological examination reveals sinus opacification or orbita emphysema a blowout fracture must be suspected .
Accurate delineation of the extent and nature of orbital soft tissue and bony injury requires computed tomography in axial and coronal planes. Coronal CT views best demonstrate inferior wall blowout fractures and routine axial views are most valuable for ethmoidal fractures . The extent and nature of prolapsed tissue which could be orbital fat, trapped muscles or the globe itself as in our case can be demonstrated.
Most blowout fractures involve the inferior orbital wall. Five to ten percent of these have concomitant medial wall fractures . Prolapse of the globe out of the bony orbit is an extreme situation of which there are only three prior reported cases in the literature [l],,.
In all three, the herniated globe had prolapsed into the roomy maxillary sinus after inferior wall fractures. The ethmoid sinus is small and does not allow more than a partial prolapse of the globe.
Two of the three cases reported earlier were in the pre CT era. CT was found valuable in the third case . In the present situation, CT has been instrumental in the diagnosis of this most unusual blowout fracture.
| References|| |
Duke Elder, S., Macfaul, PA. : System. of Ophthalmology. (Henry Kimpton. London) Volume 14, Part I, pp 243-248. 250-251. 1972.
Stasior, O.G. Blow out fractures in modern Ophthalmology.(Butterworth and Co. London) pp 990, 1974.
Berkowitz R. A., Putterman A.M., Patel D.B.: Prolapse of the globe into the maxillary sinus after orbital floor fracture. Am. J. Ophth. 91:253-257.1981.
Nesi.FA.. Spoor TC.. Rarnocki. J.M.: Management of blowout fractures. In management of Ocular. Orbital and Adnexal Trauma ed, by TC. Spoor & FA. Nesi (Raven Press. New York) pp 321-330. 1988.
Koornneff.L. Zonneveld. F.W: Role of direct multiplanar high resolution CT in the assessment and management of orbital trauma. Radiol Clin North Ain 25:753-766, 1987.
Zilkha, A.: Computed tomography of blowout fractures of the medial orbital wall. AJNR 2:427-429. 1981.
[Figure - 1], [Figure - 2], [Figure - 3]
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