Globe Injury with Orbital Blow Out Fracture

Mugundan¹, Karunakaran Vetri²

¹First-year Emergency Medicine Resident, Kauvery Hospital, Chennai, India

²Consultant, Department of Emergency Medicine, Kauvery Hospital, Chennai, India

Abstract

This case report describes the diagnosis and treatment of a left-sided orbital floor fracture with globe injury, a brief discussion about the indication of surgery, and about recovery from orbital floor fractures. Globe injury with orbital blowout fracture is uncommon. However, the current case illustrates that such an occurrence should be in the differential diagnosis and should be considered when confronted with impact injuries involving a foreign object.

Background

Fractures of the orbit can occur in association with more complex fracture patterns and globe dislocation. Operative intervention of adult orbital floor fractures is generally reserved for fractures producing an alteration in vision. However, less is known about the long-term visual outcomes of orbital floor fracture. Here is a case of an orbital blowout fracture with trauma in a young man.

Case presentation

A 20-years-aged young man presented to the emergency department with an alleged history of road traffic accident 2-wheeler vs 2-wheeler, head-on collision, and sustained injury to left eye, with bleeding from both nostrils. Initially, he was taken to a nearby hospital where first aid was given and shifted here for further management. While being shifted here, the patient had two episodes of hematemesis. He had normal vision in the right eye but no vision in the left.

On Examination

(a). Patient was received in Red Triage zone

Primary Survey:

Airway:

(a). Patent, self-maintaining

(b). C-spine tenderness +

Breathing:

(a). Bilateral chest rises equal,

(b). RR: 20/min, SpO2: 99% RA,

(c). No evidence of respiratory distress,

(d). No accessory muscle uses

Circulation:

(a). HR: 62/min, BP: 100/60 mmHg,

(b). CVS-S1S2+, no murmur,

(c). Capillary Refill time <2 seconds,

(d). Peripheral pulses well felt, Peripheries warm.

(e). PICCLE Negative

Disability and Deformity:

(a). GCS: E4 V5 M6 (15/15)

(b). Moving All 4 limbs,

(c). CBG: 142 mg/dl.

Fig. 1. Orbital Injury.

Fig. 1 shows a deep laceration involving the forehead starting from the medial aspect of the left eyebrow and extending into the left eye with an active bleed. Left eye globe not visualized.

Left eye vision lost.

Right eye: Normal field of vision, Pupils 2 mm RTL.

Nasal bleed involving both nostrils +

Chest: Palpable tenderness, No paradoxical movements

(a). Abdomen: Normal

(b). Both upper and lower limbs: Normal

(c). Peripheral pulses well felt

Exposure and Environment:

(a). Dress soaked with blood and road debris.

Initial Management in ER:

(a). Patient shifted on spine board & cervical collar applied.

(b). Active compression dressing applied over left eye

(c). Inj. TT IM stat was given at nearby hospital

(d). Inj. Tetglobe 500 U IM stat

(e). Inj. Tranexemic acid 1gm IV stat

(f). Inj. Pantoprazole 40mg IV stat

(g). Inj. Emeset 4mg IV stat

(h). Inj. Paracetamol 1gm IV stat

(i). Inj. Magnex forte 1.5gm IV stat

(j). MLC Filed. Local authorities intimated

Shifted to radiology for Trauma series CT:

Fig. 2. CT Facial cut showing Left Ethmoid, maxillary hemosinus.

Fig. 3. 3D Reconstructed image of the bone of the face showing left orbit fracture.

CT Facial Bones showing

(a). Blowout fracture of left orbit extending to left frontal, left ethmoid, left maxillary sinus and left upper alveolus with indistinct globe. No c- spine injury.

(b). Soft tissue swelling and laceration over left orbital, maxillary, frontal and septal region. Left ethmoid and maxillary hemosinus noted.

CT Chest, abdomen, pelvis and whole spine screened: normal

Follow up

(a). Patient was admitted in ICU. GCS and vitals were monitored.

(b). Planned for complete bone and soft tissue closure.

Discussion

(a). Emergency department is the first line of contact for many patients with ocular trauma. Patientâ€™s history helps to differentiate the diagnosis and leads to appropriate treatment. With the help of Seidel test, corneal laceration can be determined

(b). Globe injury must be suspected for all patients presenting with eyelid injuries.

(c). Globe rupture causes pain, decreased vision, hyphaema, loss of anterior chamber depth, or deviation of the pupil toward the laceration.

(d). Ocular ultrasound examination at the bedside can accurately detect a range of pathological disorder and rule out emergent conditions that otherwise require immediate ophthalmologic consultation

(e). Optic nerve sheath diameter has significance in the assessment of papilledema in cases of elevated intracranial pressure in case of penetrating globe injuries.

(f). In patient with ocular injury, if globe rupture is suspected or confirmed, an eye shield be immediately placed over the affected eye and further direct examination should be deferred to avoid putting pressure on the eye. Computed tomography of the head and orbits is recommended to evaluate for open globe injury, intraocular foreign body or orbital wall fractures.

(g). Dislocation of orbital content can also occur in various degrees, these cases need surgical intervention to both explore the extent of the injury and repair the damage. Recovery is variable with the extent and mechanism of injury.

(h). Complete herniation of the Globe through an orbital blow-out fracture is uncommon. These rare cases require surgical intervention. Patient can recover well with good functional results, with the recovery of vision largely determined by the extent of damage to the globe integrity and optic nerve continuity

Conclusion

Traumatic ocular injury is an important, frequent, and preventable emergency that causes visual impairment, lower quality of life, and loss of working capacity. Initiation of appropriate initial management in the emergency department and timely referral of the patient to an ophthalmologist help decrease morbidity.

Acknowledgment

I would like to extend my sincere thanks to Dr. Karunakran Vetri (Consultant, Emergency Department, Kauvery hospital, Chennai) for guiding me to write this article.

References

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3. Ginat DT, Freitag SK. Traumatic globe rupture and herniation into the maxillary sinus. Ophthal Plast Reconstr Surg. 2014;30:168.

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5. M. Güzel, A. Erenler, L. Niyaz, et al. Management of traumatic eye injuries in the emergency department. OA Emerg Med. 2014;2(1):2.

Globe Injury with Orbital Blow Out Fracture