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Traumatic luxation of the eyeball
J. Cranio-Max.-Fac. Surg. 19 (1991)
205
J. Cranio-Max.-Fac.Surg. 19 (1991) 205-207 © GeorgThiemeVerlagStuttgart • New York
Summary
Traumatic Luxation of the Eyeball
Traumatic injuries of the orbit may lead to luxation of the eyeball. This complication is of uncommon occurrence. Aetiology, clinical features, prognosis and treatment are discussed on the basis of the occurrence of the luxation of the eyeball in a 30-year-old man.
Karel G. H. van der Wal I, Bert A. E. van der Pol e
Key words
1Dept. of Oral and MaxillofacialSurgery, 2Dept. of Ophthalmology,MedischCentrumLeeuwarden, The Netherlands
Orbit - Fracture - Luxation - Eyeball
Submitted 21.12. 1990, accepted 21.2, 1991
Introduction Trauma to the orbit and surrounding facial structures can lead to numerous complications concerning the eyeball. Luxation of the eyeball is a rare sequel to major trauma to the orbital wall (Brasseur et al. 1987). Luxation of the eyeball means that the eye protrudes between the eyelids with spastic closure of these behind it (McGregor et al., 1969; Duke-Elder and MacFaul, 1972; Chhabra and Kawuma, 1986). Factors which predispose to easy luxation include: 1. shallow orbits which can be seen in infants or in cases of congenital craniofacial anomaly (Cohen, 1986; McGregor et al., 1986; Chhabra and Kawuma, 1986). 2. space-occupying lesions of the orbit (Chhabra and Kawuma 1986, Wood et al. 1988). 3. laxity of fascial ligaments and orbital muscles (Gillespie 1954, Chhabra and Kawuma 1986). Luxation of the eyeball may occur spontaneously, voluntarily and as a result of blunt trauma. Spontaneous luxation was described as a consequence of exophthalmic disorders with protrusion, shallow orbits in craniofacial dysostosis, oxycephaly, brachycephaly, as a rarity with retraction of the eyelids to remove a foreign body, excess orbital fat, and syphilitic gumma (Cohen, 1987; McGregor et al., 1969). Voluntary luxation of the eyeballs is observed mainly in Negroes and has been attributed to a combination of shallow orbits, lax ligaments, and reduplication of the superior oblique muscles (Lyle and McGavic, 1936; Ruedemann et al., 1954). Traumatic luxation of the eyeball is mostly due to a severe accident wherein a violent blow causes an extensive fracture of the orbital rim. Traumatic luxation of the eyeballs may occur due to faulty application of forceps during delivery. The forceps may squeeze the posterior part of the orbit or compress it from the front, acting like the backward thrust of a speculum (Duke-Elder and MacFaul, 1972; Chhabra and Kawuma, 1986; Brasseur et al. 1987). Generally luxation does little harm to the eye itself provided that it can be reduced early. The reduction is achieved by firmly pulling the eyelids forwards and pressing the globe back-
Fig. 1 a
Lateral view showing luxation of the right eyeball.
Fig. 1 b
Cranial view of the luxation of the right eyeball.
Fig.2 a Appearance of the face before the accident.
Fig. 2 b
Post operative results, five months after operation.
wards at the same time. Unless there is associated trauma to the orbit or soft tissue, timely repositioning gives immediate relief and restores visual function (Chhabra and Kawuma, 1986). The condition, though rare and on an average seen once in a lifetime by an ophthalmologist, may perhaps be especially encountered in African patients, on account of the racial differences in normal values for proptosis. Black subjects have a significantly higher values for proptosis than white subjects (Duke-Elder and MacFaul, 1974; DeJuan et al.,
198o).
He had no complaints, no disturbing diplopia and satisfactory (20/20) visual acuity on both eyes. Examination of the ocular motility revealed a minimal limitation of elevation of the right eye, which did not interfere with binocular vision under normal conditions. The position of both eyeballs was symmetrical and there was no en- or exophthalmos of the right eye of any importance in comparison with the left eye. Hertel measurements showed values of 22 and 21 mm, after removal of the fixation materials. Vision was normal in the right eye. The patient appeared to be satisfied with the functional result.
Case Report
Discussion and Conclusions
A 30-year-old man was involved in a ear accident. He was assessed some three hours after injury, following transfer from an outlying hospital. At this time he presented a luxation of his right eyeball, a blow-in fracture of his right orbit, a fracture of his left hand, an infra-orbital wound and commotio cerebri. Because the patient had aspirated ditch-water he was already intubated at the time of examination. Attempts to replace the eyeball were unsuccessful. Aspiration of the retrobulbar space was negative. The CT scan revealed a blow-in fracture, with considerable displacement of the fracture fragments into the right orbital cavity with a consequent diminution in the intra-orbital volume. Soft tissue contents were displaced in a forward direction and out of the orbital space. Under general anaesthesia, the fractured orbit was reduced by open reduction and by an intra-oral approach. Fixation of the parts using four Champy plates and two transosseous wires. After reconstituting the right orbit, the eyeball could be replaced successfully. On the 11 th postoperative day the ophthalmological condition fairly improved. The patient recovered uneventfully and was dismissed from the hospital on the 14th postoperative day. After 4 months the four Champy plates and the two transosseous wires were removed and the patient was referred to the ophthalmologist for evaluation.
What was the reason for the luxation of the right eyeball in our patient. Obviously we were confronted with a sign rare in maxillofacial traumatology. Before the accident our patient was known by others for having remarkably bulging eyes. He had never had a luxation before, neither traumatically nor voluntary. No other symptoms of hyperthyroid dysfunction were found. The T4 and TSH values were normal and a hormonal origin was excluded. A lateral cephalogram was taken. The tracing showed a normal anterior crossbite and SNA angle of 76 and SNB angle of 78 degrees. The predisposing factor was, in our opinion, the arrested growth of the maxilia, which reduces the length of the orbital floor (Cohen, 1986). The midface hypoplasia contributes to the prominent appearance of the eyeballs. These relatively proptotic eyes are certainly more exposed to the elements and may be more vulnerable to any type of orbital trauma. Repositioning of the bony orbit gives immediate relief and appears to preserve visual function.
Traumatic Luxation of the Eyeball References
Brasseur, G., J. F. Charlin, D. Hubault: Luxation du globe oculaire. Bull. Soc. Opht. France 10 (1987) 1161-1163 Chhabra, H.N., A.M.S. Kawuma: Luxation of the eyeball. Br. J. Ophth. 70 (1986) 150-151 Cohen, M.M.: Craniosynostosis. Raven Press, New York 1986, p.231-233 Duke-Elder, S., P.A. MacFauk System of ophthalmology, Vol. 14. Injuries, Henri Kimpton (1972) 14-15, 294-295 Duke-Eider, S., P.A. MacFauk Systems of ophthalmology, Vol. 13. The ocular adnexa, Henri Kimpton (1974) 1232-1235 Gillespie, ED.: Subluxation of the globes. Southern Med. J. 57 (1964) 216-218 McGregor, M. C., E. Mawas, H. Parizot, J. Reeb: Spontaneous luxation of the eyeballs. Brit. J. Ophth. 53 (1969) 846-853 DeJuan, E., D.P. Hurley, J. D. Sapira: Racial differences in normal values of proptosis. Arch. Intern. Med. 140 (1980) 1230-1231 Lyle, D.J., J. S. McGavic: The cause of voluntary forward luxation of the eyeball. Am. J. Ophth. 19 (1936) 316-320 Ruedemann, A. D., C. Roberts, A. R. Selingson: Voluntary luxation of the globes. Am. J. Ophth. 37 (1954) 351-354 Wood, C. M., A. D. J. Pearson, A. W. Craft, J. W. Howe: Globe luxation in histiocytosis X. Br. J. Ophth. 72 (1988) 631-633
J. Cranio-Max.-Fac. Surg. 19 (1991)
207
Dr. K. G. H. van der Wal, D.D.S., Ph.D. Afd. Mondziekten en Kaakchirurgie Medisch Centrum Leeuwarden Henri Dunantweg 2 8933 AD Leeuwarden The Netherlands
Dear Author! Beginning now, I kindly request that every manuscript, which is submitted to us, be accompanied of two sets of illustrations. This is in contrast to former practice and to the instructions for authors, as published in the Journal. Thank you for your cooperation. H.P.M.F.
205
J. Cranio-Max.-Fac.Surg. 19 (1991) 205-207 © GeorgThiemeVerlagStuttgart • New York
Summary
Traumatic Luxation of the Eyeball
Traumatic injuries of the orbit may lead to luxation of the eyeball. This complication is of uncommon occurrence. Aetiology, clinical features, prognosis and treatment are discussed on the basis of the occurrence of the luxation of the eyeball in a 30-year-old man.
Karel G. H. van der Wal I, Bert A. E. van der Pol e
Key words
1Dept. of Oral and MaxillofacialSurgery, 2Dept. of Ophthalmology,MedischCentrumLeeuwarden, The Netherlands
Orbit - Fracture - Luxation - Eyeball
Submitted 21.12. 1990, accepted 21.2, 1991
Introduction Trauma to the orbit and surrounding facial structures can lead to numerous complications concerning the eyeball. Luxation of the eyeball is a rare sequel to major trauma to the orbital wall (Brasseur et al. 1987). Luxation of the eyeball means that the eye protrudes between the eyelids with spastic closure of these behind it (McGregor et al., 1969; Duke-Elder and MacFaul, 1972; Chhabra and Kawuma, 1986). Factors which predispose to easy luxation include: 1. shallow orbits which can be seen in infants or in cases of congenital craniofacial anomaly (Cohen, 1986; McGregor et al., 1986; Chhabra and Kawuma, 1986). 2. space-occupying lesions of the orbit (Chhabra and Kawuma 1986, Wood et al. 1988). 3. laxity of fascial ligaments and orbital muscles (Gillespie 1954, Chhabra and Kawuma 1986). Luxation of the eyeball may occur spontaneously, voluntarily and as a result of blunt trauma. Spontaneous luxation was described as a consequence of exophthalmic disorders with protrusion, shallow orbits in craniofacial dysostosis, oxycephaly, brachycephaly, as a rarity with retraction of the eyelids to remove a foreign body, excess orbital fat, and syphilitic gumma (Cohen, 1987; McGregor et al., 1969). Voluntary luxation of the eyeballs is observed mainly in Negroes and has been attributed to a combination of shallow orbits, lax ligaments, and reduplication of the superior oblique muscles (Lyle and McGavic, 1936; Ruedemann et al., 1954). Traumatic luxation of the eyeball is mostly due to a severe accident wherein a violent blow causes an extensive fracture of the orbital rim. Traumatic luxation of the eyeballs may occur due to faulty application of forceps during delivery. The forceps may squeeze the posterior part of the orbit or compress it from the front, acting like the backward thrust of a speculum (Duke-Elder and MacFaul, 1972; Chhabra and Kawuma, 1986; Brasseur et al. 1987). Generally luxation does little harm to the eye itself provided that it can be reduced early. The reduction is achieved by firmly pulling the eyelids forwards and pressing the globe back-
Fig. 1 a
Lateral view showing luxation of the right eyeball.
Fig. 1 b
Cranial view of the luxation of the right eyeball.
Fig.2 a Appearance of the face before the accident.
Fig. 2 b
Post operative results, five months after operation.
wards at the same time. Unless there is associated trauma to the orbit or soft tissue, timely repositioning gives immediate relief and restores visual function (Chhabra and Kawuma, 1986). The condition, though rare and on an average seen once in a lifetime by an ophthalmologist, may perhaps be especially encountered in African patients, on account of the racial differences in normal values for proptosis. Black subjects have a significantly higher values for proptosis than white subjects (Duke-Elder and MacFaul, 1974; DeJuan et al.,
198o).
He had no complaints, no disturbing diplopia and satisfactory (20/20) visual acuity on both eyes. Examination of the ocular motility revealed a minimal limitation of elevation of the right eye, which did not interfere with binocular vision under normal conditions. The position of both eyeballs was symmetrical and there was no en- or exophthalmos of the right eye of any importance in comparison with the left eye. Hertel measurements showed values of 22 and 21 mm, after removal of the fixation materials. Vision was normal in the right eye. The patient appeared to be satisfied with the functional result.
Case Report
Discussion and Conclusions
A 30-year-old man was involved in a ear accident. He was assessed some three hours after injury, following transfer from an outlying hospital. At this time he presented a luxation of his right eyeball, a blow-in fracture of his right orbit, a fracture of his left hand, an infra-orbital wound and commotio cerebri. Because the patient had aspirated ditch-water he was already intubated at the time of examination. Attempts to replace the eyeball were unsuccessful. Aspiration of the retrobulbar space was negative. The CT scan revealed a blow-in fracture, with considerable displacement of the fracture fragments into the right orbital cavity with a consequent diminution in the intra-orbital volume. Soft tissue contents were displaced in a forward direction and out of the orbital space. Under general anaesthesia, the fractured orbit was reduced by open reduction and by an intra-oral approach. Fixation of the parts using four Champy plates and two transosseous wires. After reconstituting the right orbit, the eyeball could be replaced successfully. On the 11 th postoperative day the ophthalmological condition fairly improved. The patient recovered uneventfully and was dismissed from the hospital on the 14th postoperative day. After 4 months the four Champy plates and the two transosseous wires were removed and the patient was referred to the ophthalmologist for evaluation.
What was the reason for the luxation of the right eyeball in our patient. Obviously we were confronted with a sign rare in maxillofacial traumatology. Before the accident our patient was known by others for having remarkably bulging eyes. He had never had a luxation before, neither traumatically nor voluntary. No other symptoms of hyperthyroid dysfunction were found. The T4 and TSH values were normal and a hormonal origin was excluded. A lateral cephalogram was taken. The tracing showed a normal anterior crossbite and SNA angle of 76 and SNB angle of 78 degrees. The predisposing factor was, in our opinion, the arrested growth of the maxilia, which reduces the length of the orbital floor (Cohen, 1986). The midface hypoplasia contributes to the prominent appearance of the eyeballs. These relatively proptotic eyes are certainly more exposed to the elements and may be more vulnerable to any type of orbital trauma. Repositioning of the bony orbit gives immediate relief and appears to preserve visual function.
Traumatic Luxation of the Eyeball References
Brasseur, G., J. F. Charlin, D. Hubault: Luxation du globe oculaire. Bull. Soc. Opht. France 10 (1987) 1161-1163 Chhabra, H.N., A.M.S. Kawuma: Luxation of the eyeball. Br. J. Ophth. 70 (1986) 150-151 Cohen, M.M.: Craniosynostosis. Raven Press, New York 1986, p.231-233 Duke-Elder, S., P.A. MacFauk System of ophthalmology, Vol. 14. Injuries, Henri Kimpton (1972) 14-15, 294-295 Duke-Eider, S., P.A. MacFauk Systems of ophthalmology, Vol. 13. The ocular adnexa, Henri Kimpton (1974) 1232-1235 Gillespie, ED.: Subluxation of the globes. Southern Med. J. 57 (1964) 216-218 McGregor, M. C., E. Mawas, H. Parizot, J. Reeb: Spontaneous luxation of the eyeballs. Brit. J. Ophth. 53 (1969) 846-853 DeJuan, E., D.P. Hurley, J. D. Sapira: Racial differences in normal values of proptosis. Arch. Intern. Med. 140 (1980) 1230-1231 Lyle, D.J., J. S. McGavic: The cause of voluntary forward luxation of the eyeball. Am. J. Ophth. 19 (1936) 316-320 Ruedemann, A. D., C. Roberts, A. R. Selingson: Voluntary luxation of the globes. Am. J. Ophth. 37 (1954) 351-354 Wood, C. M., A. D. J. Pearson, A. W. Craft, J. W. Howe: Globe luxation in histiocytosis X. Br. J. Ophth. 72 (1988) 631-633
J. Cranio-Max.-Fac. Surg. 19 (1991)
207
Dr. K. G. H. van der Wal, D.D.S., Ph.D. Afd. Mondziekten en Kaakchirurgie Medisch Centrum Leeuwarden Henri Dunantweg 2 8933 AD Leeuwarden The Netherlands
Dear Author! Beginning now, I kindly request that every manuscript, which is submitted to us, be accompanied of two sets of illustrations. This is in contrast to former practice and to the instructions for authors, as published in the Journal. Thank you for your cooperation. H.P.M.F.