Traumatic Orbital Roof Fracture With Superior Rectus Entrapment in a Pediatric Patient.

Pediatric patients often present with orbital fractures after facial trauma, most commonly fractures of the orbital floor. Evaluation of orbital fractures for entrapment of the extraocular muscles is crucial, as urgent surgical exploration and possible repair are needed in these cases. We report a 2-year-old male who presented after a fall with multiple left orbital wall fractures, including a roof fracture. On examination, the patient's OS appeared fixed in an upward gaze. Positive forced ductions revealed clinical concern for entrapment of the superior rectus. The patient was taken to the operating room for exploration, and the entrapped superior rectus muscle was freed from the fracture. The patient subsequently recovered fully with complete extraocular movements. This represents the first reported case of superior rectus entrapment in an orbital roof fracture.

Comparación Placas de Titanio vs. Placas Reabsorbibles en Fracturas de Orbita: Revisión de literatura / Comparison of Titanium Plates vs. Resorbable Plates in Orbital Fractures: Literature Review

RESUMEN Introducción: Los tratamientos para fracturas de órbita se basan en la corrección del defecto de las lesiones orbitarias de tipo blow in y blow out (o de estallido), mediante diversas placas y mallas biocompatibles con el organismo, dándose una cicatrización de primera generación evitando un callo óseo y una fijación más rígida. Para el diagnóstico de este tipo de lesiones tenemos inflamación periorbitaria, enoftalmos, diplopía, equimosis, hemorragia subconjuntival. Existen diversos materiales reconstructivos siendo estos compuestos por distintas materias primas, como son los aloplásticos y autógenos; donde encontramos varios tipos como placas de titanio y las placas reabsorbibles siendo estas las más comunes y usadas actualmente, por su bajo estímulo a reabsorciones óseas y evitando efectos secundarios a largo plazo. Estas placas presentan diversos grados de ductilidad y resistencia. Se informó sobre varias complicaciones según el tipo de placas como es la cicatrización, las cirugías postquirúrgicas en caso de placas de titanio, etc. El objetivo de esta revisión es la evaluación de la eficacia las placas reabsorbibles versus placas de titanio en fracturas de órbita. Materiales y métodos: La investigación es de carácter documental, descriptivo y no experimental. En el cual se emplea una metodología de identificación e inclusión de artículos científicos tipo prisma. Resultados y conclusiones: Se verificaron las ventajas y desventajas tanto de las placas reabsorbibles como las de titanio siendo estas similares en la biocompatibilidad con el organismo humano, así como también varias diferencias como el soporte, fuerzas, resistencia de estas, concluyendo que es debatible el material ideal para tratar fracturas de órbita. Se seleccionaron artículos tomando en cuenta el título y objetivos; considerando estudios comparativos, revisiones sistemáticas, revisiones de literatura, los cuales comprendían criterios con respecto a fracturas de órbita y tratamientos quirúrgicos. La búsqueda arrojó 55 artículos en PubMed, 65 en Google, 4 en Scielo y 29 en Science direct, de los cuales se excluyeron libros, monografías, estudios experimentales, dando como resultado 21 artículos para el desarrollo de esta revisión bibliográfica. Y que fueron leídos y analizados en su totalidad, estudiando los objetivos, metodología y conclusión de cada uno de ellos para la posterior comparación.

ABSTRACT Introduction: Treatments for orbit fractures are based on the correction of the defect of blow in and blow out orbital injuries, by means of various plates and meshes biocompatible with the organism, giving a first-generation healing avoiding a bony callus and a more rigid fixation. For the diagnosis of this type of lesions we have periorbital inflammation, enophthalmos, diplopia, ecchymosis, subconjunctival hemorrhage. There are several reconstructive materials being these composed of different raw materials, such as alloplastic and autogenous, where we find several types such as titanium plates and resorbable plates being these the most common and currently used, for its low stimulus to bone resorption and avoiding long-term side effects. These plates have different degrees of ductility and resistance. Several complications have been reported depending on the type of plates, such as scarring, post-surgical surgeries in the case of titanium plates, etc. The objective of this review is to evaluate the efficacy of resorbable versus titanium plates in orbital fractures. Materials and methods: This research are a documentary, descriptive and non-experimental nature. A prism-type methodology of identification and inclusion of scientific articles was used. Results and conclusions: The advantages and disadvantages of both resorbable and titanium plates were verified, being these similar in biocompatibility with the human organism, as well as several differences such as support, forces, resistance of the same, concluding that it is debatable. The ideal material to treat orbital fractures. Articles were selected considering the title and objectives; considering comparative studies, systematic reviews, literature reviews, which included criteria regarding orbital fractures and surgical treatments. The search yielded 55 articles in PubMed, 65 in Google, 4 in Scielo and 29 in Science direct, from which books, monographs, experimental studies were excluded, resulting in 21 articles for the development of this bibliographic review. The 21 articles were read and analyzed in their entirety, studying the objectives, methodology and conclusion of each one of them for subsequent comparison.

Grease-gun injury of the orbit: two cases report and literature review.

BACKGROUND: The grease-guns injury is an uncommon injury to the orbit. We present the twelfth and thirteenth cases of grease-gun injury to the orbit to be reported in the English language literature since 1964. Here we discus and review the presentation, investigation, and treatment of this unusual trauma. CASE PRESENTATION: Case 1 was a 29-year-old man who presented 1 day after a grease-gun injury of the left orbit with severe pain, marked periorbital swelling, and proptosis. Computed tomography (CT) revealed penetration of grease into his left orbit. Following surgical removal, proptosis decreased. The limitation of extraocular movement and loss of visual acuity to finger count was discovered after the initial surgery. Motility gradually returned. Visual acuity recovered after phacoemulsification, capsular tension ring and intraocular lens implantation for traumatic cataract and subluxation. Case 2 was a 6-year-old boy who was referred 2 months after a grease-gun injury for worsening swelling with sinus, necrosis and slight ptosis of the upper left eyelids. This is a case of orbital chronic inflammation from grease-gun injuries masquerading as orbital cellulitis. The imaging findings of CT and magnetic resonance imaging (MRI) are not typical. Surgical exploration and debridement was inevitable and actually relieved the symptoms. CONCLUSIONS: Grease-gun injuries can damage the orbit in different degrees. Careful history inquiry and taking is important to establish the diagnosis. Imaging examinations using CT or MRI are helpful to determine depth of trauma and foreign bodies in the orbit at diagnosis. We suggest that surgical exploration and debridement is a key step in the management.

Success rates of lateral canthotomy and cantholysis for treatment of orbital compartment syndrome.

PURPOSE: Vision loss after facial trauma can occur from orbital compartment syndrome (OCS). Orbital compartment syndrome is commonly treated surgically with a lateral canthotomy and cantholysis (C&C). Our study investigates success rates of lateral C&C for the treatment of OCS amongst emergency medicine (EM) and ophthalmology providers. METHODS: A retrospective cohort study was performed. Cases were identified and the electronic medical record of patients was interrogated for clinical and procedural information. Success of a lateral C&C was defined as a decrease in intraocular pressure (IOP) to <30 mmHg after the first attempt at the procedure. Inclusion criteria included documentation of a procedural attempt, a pre-procedure IOP >30 mmHg and a post-procedure IOP measurement; or alternatively if no pre-procedure IOP was documented but the IOP was >30 on arrival to the level 1 trauma center. Exclusion criteria included periprocedural use of ocular hypotensive medications and comorbid hyphema. RESULTS: The final analysis included 74 eyes from 64 patients. Emergency medicine providers performed the initial lateral C&C in 68% of cases compared to 32% by ophthalmologists, and success rates were comparable - 68% vs 79.2%, respectively (p = 0.413). Poorer visual outcomes were associated with the initial failure of a lateral C&C and head trauma without an orbital fracture. All patients treated with a vertical lid split procedure met the criteria for 'success' as defined by this study. CONCLUSIONS: The success rate of a lateral C&C is comparable amongst EM and ophthalmology providers. Improved training of physicians on the lateral C&C or other simpler procedures, such as the vertical lid split, could improve outcomes in OCS.

Intraorbital Wooden Foreign Body in a Soldier.

The authors report a case of an intraorbital wooden foreign body that was misinterpreted as a radiolucent area of retained air on a computed tomography (CT) scan. A 20-year-old soldier presented to an outpatient clinic following an impingement with a bough while cutting down a tree. He had a 1-cm-deep laceration on the inner canthal area of his right eye. A military surgeon explored the wound and suspected a foreign body, but could not find or extract anything. Thereafter, the wound was sutured and the patient was transferred. An examination revealed an acutely ill-looking man with distressing pain in the medial canthal and supraorbital area associated with ipsilateral ptosis and periorbital edema. A CT scan showed a radiolucent area suspected to be retained air in the medial periorbital area. The wound was explored. Upon removal of the stitch, yellowish pus was drained. An intraorbital piece of wood measuring 1.5 cm×0.7 cm was extracted. The patient's hospital course was uneventful. Pus culture revealed growth of Staphylococcus epidermidis . Wood has a density similar to air and fat and can be difficult to distinguish from soft tissue both on plain x-ray films and CT. In this case, the CT scan showed a radiolucent area resembling retained air. Magnetic resonance imaging is a better method of investigation in cases of a suspected organic intraorbital foreign body. Clinicians should be aware of the possibility of retention of an intraorbital foreign body in patients presenting with periorbital trauma, especially those with even a small open wound.

Closed globe and adnexal eye injuries: Epidemiology, clinical and surgical outcomes, and an economic cost analysis.

BACKGROUND: To examine the epidemiology, visual outcomes, surgical interventions, and socioeconomic costs of closed globe (CGI) and adnexal injuries. METHODS: A retrospective 11-year tertiary-trauma centre study of 529 consecutive CGI was conducted using the Revised Globe and Adnexal Trauma Terminology classification in individuals aged ≥16 years. Outcome measures included best-corrected visual acuity (BCVA), operating theatre visits, and socioeconomic costs. RESULTS: CGI disproportionately impacted young males during work (89.1%) and sports (92.2%), with eye protection only worn in 11.9% and 2.0%, respectively. Home was the most prevalent location (32.5%) due to falls (52.3%) in older females (57.9%). Concomitant adnexal injuries occurred frequently (71.5%), particularly in assaults (88.1%), and included eyelid lacerations (20.8%), orbital injuries (12.5%), and facial fractures (10.2%). Final median BCVA improved to 0.2 logMAR [6/9] (IQR 0-0.2) from 0.5 logMAR [6/18] (IQR 0-0.5) (p < 0.001). Surgery was required in 89 CGI (16.8%) in 123 theatre visits. In multivariable logistical regression modelling, presenting BCVA was predictive of final BCVA (odds ratio [OR] 8.4, 95% confidence interval [95%CI] 2.6-27.8, p < 0.001), while involvement of the lids (OR 2.6, 95%CI 1.3-5.3, p = 0.006), nasolacrimal apparatus (OR 74.9, 95%CI 7.9-707.4, p < 0.001), orbit (OR 5.0, 95%CI 2.2-11.2, p < 0.001), and lens (OR 8.4, 95%CI 2.4-29.7, p < 0.001) predicted for operating theatre visits. Economic costs totalled AUD20.8-32.1 million (USD16.2-25.0 million) and were estimated at AUD44.5-77.0 million (USD34.7-60.1 million) annually for Australia. CONCLUSIONS: CGI is a prevalent and preventable burden on patients and the economy. To mitigate this burden, cost-effective public health strategies should target at-risk populations.

Successful Management of a Spontaneous Retrobulbar Hematoma After Heart Transplantation. A Case Report.

CASE DESCRIPTION: We present a case of a 65-year-old patient who underwent heart transplantation. After the surgery, left proptosis, conjunctival chemosis, and ipsilateral palpebral ecchymosis were found while he was still intubated. A retrobulbar hematoma was suspected, confirmed by a computed tomography scan. Initially, expectant management was considered, but with the appearance of an afferent pupillary defect, the patient underwent orbital decompression and posterior collection drainage, which prevented visual impairment. CONCLUSION AND IMPORTANCE: Spontaneous retrobulbar hematoma after heart transplantation is a rare condition that risks vision. We intend to discuss the importance of postoperative ophthalmologic examination after heart transplantation in intubated patients for early diagnosis and rapid treatment. Spontaneous retrobulbar hematoma (SRH) after heart transplantation is an exceptional condition that risks vision. Bleeding in the retrobulbar space provokes an anterior ocular displacement, extending the vessels and the optic nerve, which can generate ischemic neuropathy and, finally, a loss of vision [1]. A retrobulbar hematoma is usually associated with trauma or eye surgery. Though, in non-traumatic cases, the underlying cause is not evident. An adequate ophthalmologic examination is usually not performed in complex surgeries like heart transplantation. However, this simple measure can prevent permanent vision loss. Non-traumatic risk factors should also be considered, which include vascular malformations, bleeding disorders, use of anticoagulants, and increased central venous pressure usually triggered by a Valsalva maneuver [2]. The clinical presentation of SRH consists of ocular pain, decreased visual acuity, conjunctival chemosis, proptosis, abnormal extraocular movements, and elevated intraocular pressure (IOP). Its diagnosis is often clinical; however, it can be confirmed with computed tomography or magnetic resonance imaging. Treatment aims to reduce IOP with surgical decompression or pharmacologic measures [2]. In the reviewed literature, less than 5 spontaneous ocular hemorrhages related to cardiac surgery have been reported [3-6], of which only one is related to heart transplantation [3]. A clinical challenge of an SRH after heart transplantation is presented below. Surgical management was performed with a favorable result.

Transorbital penetrating head injury by a wooden chopstick in the cavernous sinus: a case report and literature review.

Penetrating head injury is a relatively rare condition associated with high morbidity and mortality. Although the immediate treatment of penetrating head injury is needed, surgical strategies are varied based on the trajectory of the penetrating objects in the cranium. We present a case of 24-year-old man who sustained a transorbital penetrating injury caused by a wooden chopstick. Neuroimages revealed a linear lesion extending from the left intraorbital segment to the cavernous sinus passing through the superior orbital fissure. The foreign body was successfully removed via the transcranial approach without complications. A careful management based on the perioperative images and correct diagnosis is necessary to avoid unfavorable complications. Four cases of transorbital penetrating injuries have been previously reported, in which the foreign body penetrated through the superior orbital fissure and lodged in the cavernous sinus. The frontotemporal craniotomy with extradural approach can be a useful option to remove foreign bodies around the cavernous sinus regions.

Evidence-Based Medicine for Midface/Orbit/Upper Facial Fracture Repair.

The face is one of the most common areas of traumatic injury, making up approximately 25% of all injuries in 2016. Assault, motor vehicle collision (MVC), fall, sports, occupational, and gunshot wounds (GSW) are all common causes of facial fractures, with MVC and GSW leading to significantly higher severity of injuries. Most facial fractures occur in the upper two-thirds of the face. Most facial fractures require timely assessment, diagnosis, and treatment for optimal restoration of facial structures and functions. Without proper initial management, significant complications including immediate complications such as airway compromise, massive bleeding, infection, intracranial hemorrhages, or even death, and long-term complications such as poor functional outcomes and aesthetic setbacks can occur. The goal of this review is to summarize the management of fractures of the upper face, orbit, and midface and provide an update about complications and their management.

When the Cost of Vaping Is an Eye: A Case of an Open Globe and Superior Orbital Roof Fracture.

The authors report a penetrating orbitocerebral vape pen injury necessitating a primary enucleation and craniotomy to remove the foreign body fragments. A 31-year-old male presented with acute right vision loss after a modifiable vape pen explosion launched multiple projectile fragments into his right eye. CT revealed a deformed globe with multiple radiodense curvilinear fragments in the superior orbital roof and intracranial space. A right frontal craniotomy and orbitotomy with removal of vape pen fragments, reconstruction of the orbital roof, primary enucleation, and eyelid repair were performed in conjunction with neurosurgery. To the best of the authors' knowledge, this is the first reported penetrating globe injury from a vape pen explosion.

An uncommon case of high-pressure paint gun injury to the orbit with multimodality evaluation and literature review.

High-pressure paint injection injury to the orbit is a rare type of orbital trauma. We present an unfortunate case of high-pressure paint injury to the right orbit of a young patient. High-pressure injection injury presents with a unique injury mechanism and resultant deep tissue damage. The superficial appearance of the entry site injury is deceiving; therefore, a thorough evaluation is necessary. Debridement is usually required if foreign body material is present. Antibiotics and steroids are commonly used in such cases.

Removal of iatrogenic orbital foreign bodies with a 3D model.

Facial foreign body (FB) is common after trauma, but iatrogenic orbital FB is a rare and unexpected complication of facial FB removal surgery. We present the case of a 43-year-old man with a glass FB in his nose. During the operation, this FB broke into two pieces, and the larger one pierced into the left orbit, close to the eyeball. A three-dimensional (3D) model was made that accurately recreated the shape and position of the FB in the orbit, according to which the FB was removed. 3D-printing technology is a great tool when dealing with complex facial FB.

Diagnostic uncertainty following orbital injury from a grease gun.

Orbital trauma involving high-pressure grease guns is rare and can cause significant morbidity due to retained intraorbital grease. Grease can appear similar to intraorbital air on cross-sectional imaging, and clinicians should have a high index of suspicion for retained intraorbital grease and know how to recognise this. In this case, we will share the clinical and radiological findings as well as management of retained intraorbital grease.

The Orbital Bones Protect the Globe From Sharp Periorbital Trauma Injuries.

BACKGROUND: The bones of the orbit hold the globe and periocular structures and protect it and other periocular contents. This has been shown in blowout orbital fractures, as well as in high-energy injuries to the periorbital region. However, there is little information regarding how the orbital bones protect the globe after periorbital trauma from sharp objects. OBJECTIVES: This study reports 4 cases of traumatic injury from sharp objects to the periorbital area and eyelids to demonstrate the protective features of the orbital bones. RESULTS: The anatomy of the periorbital bones clearly protected the globe from direct trauma in all the 4 cases. CONCLUSIONS: There was no harm to the orbit or visual impairment after the successful treatment with definitive surgery.

Long-Term Burden of Pain and Reduced Visual Acuity after Gunshot Wounds to the Orbit.

PURPOSE: To characterize the clinical presentation, surgical management, long-term complications and outcomes of Gunshot Wounds(GSW) to the orbit. METHODS: An extended case series with retrospective chart-review was conducted on all cases (1985-2020) of traumatic ocular injuries secondary to GSWs at an academic institution with a level 1 trauma center. Predictors included demographic information, clinical and radiologic examination findings, and surgical intervention at time of presentation. Outcomes included long-term lid malposition, visual acuity, pain, and secondary surgery. Descriptive statistics and tests of association were performed, including Fishers exact tests for categorical data, Kruskal-Wallis rank sum tests, analysis of variance, and, in the case of repeated measures, generalized estimating equations. RESULTS: 88 patients with GSW involving the orbit were included with average age of 32.6 years (sd = 15.7). Patients were 85.2% male, 75% African-American, 25.0% Caucasian, and 5.7% Hispanic. Median follow up was 43.3 months (4.6, 136.4). The injuries at presentation were 53.4% intracranial, 21.6% open globe, 80.7% orbital fracture, 89.8% lid laceration. Visual acuity did not significantly improve over time. Long-term complications included abnormal lid or globe position in 26.1% of patients, reduced visual acuity in 55.2%, and persistent pain in 50.6%. CONCLUSION: To our knowledge, this represents the first and largest clinical epidemiologic study with insight into the clinical presentation, surgical intervention, and long-term outcomes of GSW to the orbit. The results demonstrate a long-term burden of persistent pain and reduced visual acuity in patients who suffer from GSW to the globe and orbit. This study may guide patient management and communications.

A Rare Case of Orbitocranial Penetrating Injury with Intracranial Wooden Foreign Body Residue.

Orbitocranial penetrating injuries (OPIs) caused by wooden foreign bodies (WFBs) are very rare and life threatening. Their diagnosis and treatment could be challenging for an ophthalmologist, requiring us to remain alert for possible intracranial extension. We present a case of a 52-year-old man with a residual wooden foreign body in the left frontal lobe. He had a notable history of trauma from a fall on a tree stump and surgical removal of a wooden foreign body from his left orbit 6 years ago. He was referred to us due to recurrent discharge from the eyelid wound. Wooden foreign body residue was successfully removed with a carefully planned craniotomy without complications. This case describes the clinical manifestation, radiographic features, and treatment of this rare trauma, with an emphasis on imaging diagnosis and multi-disciplinary management.

Lesión penetrante intracraneana transorbitaria, con compromiso de seno cavernoso en paciente pediátrico / Transorbital penetrating intracranial injury, with cavernous sinus involvement

Las lesiones traumáticas penetrantes transorbitarias-intracraneanas son infrecuentes en población pediátrica, pudiendo ocurrir en el contexto de accidentes domésticos, deportivos o escolares. Pueden extenderse a la base del cráneo y comprometer estructuras vasculares como el seno cavernoso y carótida interna. Se presenta el caso de una niña de 6 años de edad, que sufre lesión penetrante transorbitaria intracraneal con un lápiz de madera, con trayecto cruzado desde borde medial de órbita izquierda, transetmoidal y transesfenoidal, ingresando a región selar derecha e improntando a arteria carótida derecha (porción cavernosa). Luego de los estudios prequirúrgicos, se realizó extirpación de cuerpo extraño con cirugía endoscópica+control endovascular en caso de lesión carotidea. Posterior a resecar cuerpo extraño, se reparó fístula de LCR evidenciada intraoperatoriamente. La paciente se recuperó adecuadamente, sin déficit neurológico, sin fístula postoperatoria de LCR, sin infección del SNC ni alteración oculomotora (AU)

Transorbitary intracranial penetrating traumatic injuries are uncommon in the pediatric population, and may occur in the context of domestic, sporting or school accidents. They can extend to skull base and compromise vascular structures such as cavernous sinus and internal carotid. We present a case of 6 years-old girl that suffered an intracranial transorbital penetrating injury with a wooden pencil that crossed from the medial edge of left orbit, transetmoidal and trans-sphenoidal, entering the right sellar region and leaving its end in contact with carotid artery (cavernous segment). After pre-surgical studies, foreign body removal was performed with endoscopic surgery+endovascular control in case of carotid injury. After removing the foreign body, a CSF fistula occurred and was repaired. Patient recovered adequately, without neurological deficit, without postoperative CSF fistula, without CNS infection or oculomotor alteration (AU)

Misdiagnosis of Orbital Foreign Body as Glaucoma Drainage Device.

BACKGROUND: Sight-threatening complications from retained orbital and intraocular foreign bodies are frequently reported in literature. Delays in diagnosis can result in severe complications, including choroidal neovascularization, infection, and irreversible vision loss. Therefore, it is imperative that emergency physicians consider the possibility of orbital and intraocular foreign bodies when evaluating patients with acute facial trauma. CASE REPORT: A 91-year-old woman with a history of laser-treated glaucoma and cataracts presented to an outside emergency department after a ground-level fall. A maxillofacial noncontrast computed tomography scan showed no facial fractures or hemorrhage, but a 41 mm × 4 mm foreign body within the intraconal compartment of the right orbit was identified. The object was presumed to be an implanted glaucoma drainage device, and the patient was discharged without antibiotics. One day after discharge, the patient developed right periorbital swelling and erythema with increasing purulent discharge and skin thickening, ultimately requiring transfer to our facility for management of complex right orbital cellulitis, orbital compartment syndrome, and surgical foreign body removal. Despite globe exploration and surgical intervention, the patient developed a frozen globe with no light perception in the right eye. Why Should an Emergency Physician Be Aware of This? Subtle ophthalmologic emergencies such as sight-threatening foreign bodies can be challenging to diagnose on imaging, particularly with the advent of implantable ocular technology. When an orbital foreign body is discovered in the context of facial trauma, early ophthalmology consultation should be considered.