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Prolapse of the Globe Into The Ethmoid Sinus
VOL. 97, NO.5
LETTERS TO THE JOURNAL
659
REFERENCES 1. Hochheimer, B. F., D'Anna, S. A., and Calkins, J. L.: Retinal damage from light. Am. J. Ophthalmo!' 88:1039, 1979. 2. Calkins, J. L., and Hochheimer, B. F.: Retinal light exposure from operation microscopes. Arch. Ophthalmol. 97:2363, 1979. 3. McDonald, H. R, and Irvine, A. R: Lightinduced maculopathy from the operating microscope in extracapsular cataract extraction and intraocular lens implantation. Ophthalmology 90:945, 1983. 4. Fechner, P. U., and Barth, R: Effect on the retina of an air cushion in the anterior chamber and coaxial illumination. Am. J. Ophthalmol. 96:600, 1983.
PROLAPSE OF THE GLOBE INTO THE ETHMOID SINUS JOSE MIGUEL RISCO, M.D., BYRON ARISTOTLE STRATAS, B.A., AND RUFUS H, KNOTT, M. D. Division of Ophthalmology, East Carolina University School of Medicine.
Fig. I (Risco, Stratas, and Knott) Axial cut through the inferior orbits.
orbits showed the left eye to be displaced into the ethmoidal-antral sinus complex (Fig. 2). The next day an initial attempt to replace the eye into the left orbit was unsuccessful because the left glohe could
Inquiries to Jose Miguel Risco, M. D. Di,;ision of Ophthalmology, Department of Surgery, East Carolina School of Medicine, Greenville, Nt: 27834.
A 40-year-old man was struck in the left eye by a 2-inch piece of lumber. The patient was referred here four days later because the eye was completely displaced out of the orbit. The right eye was normal but the left eye had no vision and the globe could not be identified in the left orbit. A computed tomographic scan, including axial and coronal sections, was performed the same day. Computed tomographic sections obtained in an axial plane at a lower level of the orbits disclosed an intact left globe displaced posterornedially and inferiorly, occupying the left ethmoid sinus (Fig. 1). Coronal sections through the posterior
Fig. 2 (Risco, Stratas, and Knott) Coronal cut through the posterior orbits.
660
AMERICAN JOURNAL OF OPHTHALMOLOGY
not be palpated via a Caldwell-Luc maneuver. At that time, the middle and superior nasal turbinates were markedly displaced medially. The eye was replaced into the orbit by pushing it transnasally with a finger. We used a subperiosteal, square silicone implant to secure the eye in the orbit and then packed the nose and antrum. At the end of the procedure, pronounced chemosis limited inspection of the eye. When the patient was reexamined six weeks after surgery, an external examination failed to identify the globe in the orbit. Light perception was noted only when the transillumination was placed into the orbit. A computed tomographic scan showed the globe to be displaced posteriorly in the orbit. The patient decided not to undergo further treatment. Blowout fractures occur almost exclusively at the floor of the orbit which is composed primarily of the orbital plate of the maxilla (0.5 to 1 mm in thicknessl." The relatively large size and surface area of the maxillary sinus and the absence of intrasinusal bony septa make the floor of the orbit especially vulnerable to acute increases in orbital pressure. Interestingly, the orbital plate of the ethmoid sinus (lamina papyracea) is thinner (0.2 to 0.4 mm)! but the presence of intrasinusal bony septa separating the ethmoidal cells seems to reinforce this orbital wall. In our case, complex facial fractures resulted in involvement of the medial wall as well as the floor of the orbit. High-resolution computed tomographic scanning has become the definitive radiologic procedure in the assessment of a complex facial fracture. 3 In our case the integrity and the exact location of the left globe, demonstrated by computed tomography, prompted early surgical intervention. The failure to return the eye to its normal position in the orbit can be attributed to rupture or to severe damage of the suspensary elements."
MAY, 1984
REFERENCES 1. Berkowitz, R. A.• Putterman, A. M., and Patel, D. B.: Prolapse of the globe into the maxillary sinus after orbital floor fracture. Am. J. Ophthalmol. 91:253, 1981. 2. Warwick, R. (ed.): Eugene Wolff's Anatomy of the Eye and Orbit. Philadelphia, W. B. Saunders, 1976, pp. 1-29. 3. Kassel, E. E., Noyek, A. M., and Cooper, P. W.: CT in facial trauma. J. Otolaryngol. 12:2, 1983. 4. Putterman, A. M., Stevens, T., and Urist, M. J.: Nonsurgical management of blow-out fractures of the orbital floor. Am. J. Ophthalmol. 77:232, 1974.
CORRESPONDENCE Correspondence concerning recent articles or other material published in THE JOURNAL should be submitted within six weeks of publication. This correspondence must be typed and prepared in the same way as Letters to THE JOURNAL. Every effort will be made to resolve controversies between the correspondents and the authors of the article before formal publication.
Comparison of Two Methods of Marking the Visual Axis on the Cornea During Radial Keratotomy EDITOR:
In their article, "Comparison of two methods of marking the visual axis on the cornea during radial keratotomy" (Am. J. Ophthalmol. 96:605, Nov. 1983), E. B. Steinberg, and G. O. Waring seem to be mistaken in their basic premises. They stated that" ... the center of the pupil cannot be used as a reference point." Yet in the Prospective Evaluation of Radial Keratotomy (PERK) study protocol;' " ... no mydri-
LETTERS TO THE JOURNAL
659
REFERENCES 1. Hochheimer, B. F., D'Anna, S. A., and Calkins, J. L.: Retinal damage from light. Am. J. Ophthalmo!' 88:1039, 1979. 2. Calkins, J. L., and Hochheimer, B. F.: Retinal light exposure from operation microscopes. Arch. Ophthalmol. 97:2363, 1979. 3. McDonald, H. R, and Irvine, A. R: Lightinduced maculopathy from the operating microscope in extracapsular cataract extraction and intraocular lens implantation. Ophthalmology 90:945, 1983. 4. Fechner, P. U., and Barth, R: Effect on the retina of an air cushion in the anterior chamber and coaxial illumination. Am. J. Ophthalmol. 96:600, 1983.
PROLAPSE OF THE GLOBE INTO THE ETHMOID SINUS JOSE MIGUEL RISCO, M.D., BYRON ARISTOTLE STRATAS, B.A., AND RUFUS H, KNOTT, M. D. Division of Ophthalmology, East Carolina University School of Medicine.
Fig. I (Risco, Stratas, and Knott) Axial cut through the inferior orbits.
orbits showed the left eye to be displaced into the ethmoidal-antral sinus complex (Fig. 2). The next day an initial attempt to replace the eye into the left orbit was unsuccessful because the left glohe could
Inquiries to Jose Miguel Risco, M. D. Di,;ision of Ophthalmology, Department of Surgery, East Carolina School of Medicine, Greenville, Nt: 27834.
A 40-year-old man was struck in the left eye by a 2-inch piece of lumber. The patient was referred here four days later because the eye was completely displaced out of the orbit. The right eye was normal but the left eye had no vision and the globe could not be identified in the left orbit. A computed tomographic scan, including axial and coronal sections, was performed the same day. Computed tomographic sections obtained in an axial plane at a lower level of the orbits disclosed an intact left globe displaced posterornedially and inferiorly, occupying the left ethmoid sinus (Fig. 1). Coronal sections through the posterior
Fig. 2 (Risco, Stratas, and Knott) Coronal cut through the posterior orbits.
660
AMERICAN JOURNAL OF OPHTHALMOLOGY
not be palpated via a Caldwell-Luc maneuver. At that time, the middle and superior nasal turbinates were markedly displaced medially. The eye was replaced into the orbit by pushing it transnasally with a finger. We used a subperiosteal, square silicone implant to secure the eye in the orbit and then packed the nose and antrum. At the end of the procedure, pronounced chemosis limited inspection of the eye. When the patient was reexamined six weeks after surgery, an external examination failed to identify the globe in the orbit. Light perception was noted only when the transillumination was placed into the orbit. A computed tomographic scan showed the globe to be displaced posteriorly in the orbit. The patient decided not to undergo further treatment. Blowout fractures occur almost exclusively at the floor of the orbit which is composed primarily of the orbital plate of the maxilla (0.5 to 1 mm in thicknessl." The relatively large size and surface area of the maxillary sinus and the absence of intrasinusal bony septa make the floor of the orbit especially vulnerable to acute increases in orbital pressure. Interestingly, the orbital plate of the ethmoid sinus (lamina papyracea) is thinner (0.2 to 0.4 mm)! but the presence of intrasinusal bony septa separating the ethmoidal cells seems to reinforce this orbital wall. In our case, complex facial fractures resulted in involvement of the medial wall as well as the floor of the orbit. High-resolution computed tomographic scanning has become the definitive radiologic procedure in the assessment of a complex facial fracture. 3 In our case the integrity and the exact location of the left globe, demonstrated by computed tomography, prompted early surgical intervention. The failure to return the eye to its normal position in the orbit can be attributed to rupture or to severe damage of the suspensary elements."
MAY, 1984
REFERENCES 1. Berkowitz, R. A.• Putterman, A. M., and Patel, D. B.: Prolapse of the globe into the maxillary sinus after orbital floor fracture. Am. J. Ophthalmol. 91:253, 1981. 2. Warwick, R. (ed.): Eugene Wolff's Anatomy of the Eye and Orbit. Philadelphia, W. B. Saunders, 1976, pp. 1-29. 3. Kassel, E. E., Noyek, A. M., and Cooper, P. W.: CT in facial trauma. J. Otolaryngol. 12:2, 1983. 4. Putterman, A. M., Stevens, T., and Urist, M. J.: Nonsurgical management of blow-out fractures of the orbital floor. Am. J. Ophthalmol. 77:232, 1974.
CORRESPONDENCE Correspondence concerning recent articles or other material published in THE JOURNAL should be submitted within six weeks of publication. This correspondence must be typed and prepared in the same way as Letters to THE JOURNAL. Every effort will be made to resolve controversies between the correspondents and the authors of the article before formal publication.
Comparison of Two Methods of Marking the Visual Axis on the Cornea During Radial Keratotomy EDITOR:
In their article, "Comparison of two methods of marking the visual axis on the cornea during radial keratotomy" (Am. J. Ophthalmol. 96:605, Nov. 1983), E. B. Steinberg, and G. O. Waring seem to be mistaken in their basic premises. They stated that" ... the center of the pupil cannot be used as a reference point." Yet in the Prospective Evaluation of Radial Keratotomy (PERK) study protocol;' " ... no mydri-