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Orbital Roof Fracture With Ocular Herniation
700
AMERICAN JOURNAL OF OPHTHALMOLOGY
June, 1988
Orbital Roof Fracture With Ocular Herniation Colin Ma, M . D . , and Jeffrey A. Nerad, M . D . Department of Ophthalmology, University of Iowa Hospitals and Clinics.
Fig. 2 (Kersten and Kulwin). Coronal computed tomography demonstrating blowout fracture of the right orbital floor with expansion of the right orbital volume and decompression of soft tissue into the maxillary sinus.
a left lateral tarsorrhaphy, and has not had any further episodes of subluxation. Indications for orbital decompression in pa tients with Graves' ophthalmopathy include compressive optic neuropathy, severe proptosis with lagophthalmos and corneal exposure, and spontaneous luxation of the globes. 1 Because of difficulties in controlled adminis tration, and potential adverse side effects, 23 periocular trauma cannot be considered a satisfactory approach for effecting orbital de compression in patients with Graves' ophthal mopathy and proptosis. However, the thera peutic effect that was achieved in this woman was interesting. The potential hazards of this nonsurgical decompression are exhibited by the outcome of the "procedure" subsequently attempted on the left.
Inquiries to Jeffrey A. Nerad, M.D., Department of Oph thalmology , University of Iowa Hospitals and Clinics, Iowa City, IA 52242. A 61-year-old man suffered a severe crush injury to his face when a tractor rolled over him. Profuse bleeding necessitated packing of the nasal cavity and oropharynx. On initial ocular examination, the patient was comatose, with marked facial swelling. The right eye was proptotic, with extensive subconjunctival hem orrhage and a reactive pupil. The anterior seg ment and fundus were normal. The left eyelids were swollen and the globe could not be found. Computed tomography of the head showed severe fragmentation of facial bones. The right optic canal appeared intact, but the left could not be defined. A round lucency in the left anterior cranial fossa was interpreted as the left eye (Fig. 1). Four days after the injury, the patient was stable medically. Visual acuity was counting fingers in the right eye. A left frontal craniotomy was performed to evacuate a hematoma. The left eye was found, surrounded by orbital fat and brain, above a gaping defect in the orbital roof (Fig. 2). The globe and optic nerve appeared to be intact. The horizontal recti and
References 1. McCord, C. D., Jr.: Current trends in orbital decompression. Ophthalmology 92:21, 1985. 2. Milauskas, A. T., and Fueger, G. F.: Serious ocular complications associated with blowout frac ture of the orbit. Am. J. Ophthalmol. 62:670, 1966. 3. Fradkin, A. H.: Orbital floor fractures and ocu lar complications. Am. J. Ophthalmol. 72:699, 1971.
Fig. 1 (Ma and Nerad). Results of computed tomographic scan with contrast. The left eye is surround ed by an intracerebral hematoma in the left anterior cranial fossa. An air fluid level is present anteriorly. Obliteration of the cerebral sulci and ventricles indi cates the space-occupying effect of the hematoma.
Vol. 105, No. 6
Letters to the Journal
Fig. 2 (Ma and Nerad). Left anterolateral view of the eye in the left anterior cranial fossa during surgical exploration. Arrows indicate the margin of the cranial vault. B, left frontal lobe of the brain; SO and SR, stumps of avulsed superior oblique and superior recti muscles respectively.
inferior oblique muscles were attached; how ever, avulsed stumps of the vertical recti and superior oblique muscles were found. The pupil was unreactive to light, and there was no right consensual response. The eye was gently repositioned in the orbit and secured by sutur ing the avulsed stumps of the vertical recti muscles in the conjunctival fornices. The bony fragment of the orbital roof was repositioned, and autogenous fascia lata was grafted over the defect in the dura mater. Postoperatively, the left eye occupied a nor mal position within the orbit. The left pupil remained unreactive and visual acuity was no light perception. Two months after the injury, visual acuity improved to 20/30 in the right eye, but remained no light perception in the left. The left eye was moderately enophthalmic. Inferior corneal scarring and a dense cataract that had developed prevented any view of the fundus. A blowout fracture of the orbit occurs when a blow to the eye causes increased intraorbital pressure and herniation of orbital tissue through the relatively thin bone of the orbital floor or medial wall. 1 Complete displacement of the globe into the maxillary sinus has been described, with recovery of excellent vision after repositioning of the eye. 2 In contrast, the thicker orbital roof is usually only breached by large direct forces to the skull, often in the context of multiple craniofacial injuries. 3 Supe rior blowout fractures without fracture of the orbital rim may occur in patients with unusual
701
posterior extensions of the frontal sinuses re sulting in a particularly thin orbital roof. We decided to explore for the left eye because it appeared to be intact and because we wanted to preserve any remaining vision in that eye. The eye was intact macroscopically when exam ined in the cranial cavity, but we could not exclude such causes of blindness as traumatic or ischemic optic neuropathy, or arterial occlu sion. We considered the likelihood of anterior segment ischemia to be small, since Hayreh and Scott4 have demonstrated that the anterior ciliary circulation is adequate if two recti mus cles with their ciliary arteries remain attached to the eye. Although the posterior circulation could not be assessed, the globe was replaced in the orbit with reasonable hope for survival and, possibly, vision. After six months, there is still no vision in the left eye, although it ap pears to be viable. We believe that an attempt should be made to reposition an intact eye that has herniated into the brain, even though our experience with this patient suggests that any trauma which can cause roof fracture and superior herniation is also likely to damage the eye or optic nerve seriously.
References 1. Ratio, G. T.: Blow-in and blow-out fractures of the orbit. Clinical correlations and proposed mecha nisms. Ophthalmic Surg. 15:114, 1984. 2. 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. 3. Flanagan, J. C , McLachlan, D. L., and Shan non, G. M.: Orbital roof fractures. Ophthalmology 87:325, 1980. 4. Hayreh, S. S., and Scott, W. E.: Fluorescein iris angiography II. Arch. Ophthalmol. 96:1390, 1978.
A New Intra-anterior Chamber Iris Suturing Method Yoshihiro Saito, M . D . , and Hirotsugu K i b o s h i , M . D . Department of Ophthalmology, Osaka Kosei-Nenkin Hospital (Y.S.) and Department of Ophthalmology, Yodogawa Christian Hospital (H.K.).
AMERICAN JOURNAL OF OPHTHALMOLOGY
June, 1988
Orbital Roof Fracture With Ocular Herniation Colin Ma, M . D . , and Jeffrey A. Nerad, M . D . Department of Ophthalmology, University of Iowa Hospitals and Clinics.
Fig. 2 (Kersten and Kulwin). Coronal computed tomography demonstrating blowout fracture of the right orbital floor with expansion of the right orbital volume and decompression of soft tissue into the maxillary sinus.
a left lateral tarsorrhaphy, and has not had any further episodes of subluxation. Indications for orbital decompression in pa tients with Graves' ophthalmopathy include compressive optic neuropathy, severe proptosis with lagophthalmos and corneal exposure, and spontaneous luxation of the globes. 1 Because of difficulties in controlled adminis tration, and potential adverse side effects, 23 periocular trauma cannot be considered a satisfactory approach for effecting orbital de compression in patients with Graves' ophthal mopathy and proptosis. However, the thera peutic effect that was achieved in this woman was interesting. The potential hazards of this nonsurgical decompression are exhibited by the outcome of the "procedure" subsequently attempted on the left.
Inquiries to Jeffrey A. Nerad, M.D., Department of Oph thalmology , University of Iowa Hospitals and Clinics, Iowa City, IA 52242. A 61-year-old man suffered a severe crush injury to his face when a tractor rolled over him. Profuse bleeding necessitated packing of the nasal cavity and oropharynx. On initial ocular examination, the patient was comatose, with marked facial swelling. The right eye was proptotic, with extensive subconjunctival hem orrhage and a reactive pupil. The anterior seg ment and fundus were normal. The left eyelids were swollen and the globe could not be found. Computed tomography of the head showed severe fragmentation of facial bones. The right optic canal appeared intact, but the left could not be defined. A round lucency in the left anterior cranial fossa was interpreted as the left eye (Fig. 1). Four days after the injury, the patient was stable medically. Visual acuity was counting fingers in the right eye. A left frontal craniotomy was performed to evacuate a hematoma. The left eye was found, surrounded by orbital fat and brain, above a gaping defect in the orbital roof (Fig. 2). The globe and optic nerve appeared to be intact. The horizontal recti and
References 1. McCord, C. D., Jr.: Current trends in orbital decompression. Ophthalmology 92:21, 1985. 2. Milauskas, A. T., and Fueger, G. F.: Serious ocular complications associated with blowout frac ture of the orbit. Am. J. Ophthalmol. 62:670, 1966. 3. Fradkin, A. H.: Orbital floor fractures and ocu lar complications. Am. J. Ophthalmol. 72:699, 1971.
Fig. 1 (Ma and Nerad). Results of computed tomographic scan with contrast. The left eye is surround ed by an intracerebral hematoma in the left anterior cranial fossa. An air fluid level is present anteriorly. Obliteration of the cerebral sulci and ventricles indi cates the space-occupying effect of the hematoma.
Vol. 105, No. 6
Letters to the Journal
Fig. 2 (Ma and Nerad). Left anterolateral view of the eye in the left anterior cranial fossa during surgical exploration. Arrows indicate the margin of the cranial vault. B, left frontal lobe of the brain; SO and SR, stumps of avulsed superior oblique and superior recti muscles respectively.
inferior oblique muscles were attached; how ever, avulsed stumps of the vertical recti and superior oblique muscles were found. The pupil was unreactive to light, and there was no right consensual response. The eye was gently repositioned in the orbit and secured by sutur ing the avulsed stumps of the vertical recti muscles in the conjunctival fornices. The bony fragment of the orbital roof was repositioned, and autogenous fascia lata was grafted over the defect in the dura mater. Postoperatively, the left eye occupied a nor mal position within the orbit. The left pupil remained unreactive and visual acuity was no light perception. Two months after the injury, visual acuity improved to 20/30 in the right eye, but remained no light perception in the left. The left eye was moderately enophthalmic. Inferior corneal scarring and a dense cataract that had developed prevented any view of the fundus. A blowout fracture of the orbit occurs when a blow to the eye causes increased intraorbital pressure and herniation of orbital tissue through the relatively thin bone of the orbital floor or medial wall. 1 Complete displacement of the globe into the maxillary sinus has been described, with recovery of excellent vision after repositioning of the eye. 2 In contrast, the thicker orbital roof is usually only breached by large direct forces to the skull, often in the context of multiple craniofacial injuries. 3 Supe rior blowout fractures without fracture of the orbital rim may occur in patients with unusual
701
posterior extensions of the frontal sinuses re sulting in a particularly thin orbital roof. We decided to explore for the left eye because it appeared to be intact and because we wanted to preserve any remaining vision in that eye. The eye was intact macroscopically when exam ined in the cranial cavity, but we could not exclude such causes of blindness as traumatic or ischemic optic neuropathy, or arterial occlu sion. We considered the likelihood of anterior segment ischemia to be small, since Hayreh and Scott4 have demonstrated that the anterior ciliary circulation is adequate if two recti mus cles with their ciliary arteries remain attached to the eye. Although the posterior circulation could not be assessed, the globe was replaced in the orbit with reasonable hope for survival and, possibly, vision. After six months, there is still no vision in the left eye, although it ap pears to be viable. We believe that an attempt should be made to reposition an intact eye that has herniated into the brain, even though our experience with this patient suggests that any trauma which can cause roof fracture and superior herniation is also likely to damage the eye or optic nerve seriously.
References 1. Ratio, G. T.: Blow-in and blow-out fractures of the orbit. Clinical correlations and proposed mecha nisms. Ophthalmic Surg. 15:114, 1984. 2. 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. 3. Flanagan, J. C , McLachlan, D. L., and Shan non, G. M.: Orbital roof fractures. Ophthalmology 87:325, 1980. 4. Hayreh, S. S., and Scott, W. E.: Fluorescein iris angiography II. Arch. Ophthalmol. 96:1390, 1978.
A New Intra-anterior Chamber Iris Suturing Method Yoshihiro Saito, M . D . , and Hirotsugu K i b o s h i , M . D . Department of Ophthalmology, Osaka Kosei-Nenkin Hospital (Y.S.) and Department of Ophthalmology, Yodogawa Christian Hospital (H.K.).