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   Table of Contents      
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 34-38

Management of eye trauma by multidisciplinary team in multidisciplinary facilities


1 Ophthalmology Center, Royal Care International Hospital, Khartoum, Sudan
2 Department of Maxillofacial Surgery Ophthalmology, Faculty of Dentistry, Khartoum University, Khartoum, Sudan
3 Department of Ophthalmology, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan
4 Department of Neurosurgery, Royal Care International Hospital, Khartoum, Sudan

Date of Web Publication8-May-2017

Correspondence Address:
Isra Kamal
Ophthalmology Center, Royal Care International Hospital, Khartoum
Sudan
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DOI: 10.4103/1858-6538.205805

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  Abstract 

Eye injuries continue to increase in frequency and are commonly accompanied maxillofacial and head multiple injuries, secondary to road traffic accidents (RTAs). Their management is normally requiring multidisciplinary team management including ophthalmic, maxillofacial, and neurosurgeons, an opportunity which cannot be achieved unless in multidisciplinary facilities. The purpose of this study is to report multidisciplinary management of devastating mid-facial and orbital direct trauma from a shattered car window glass in RTA. A 2-year-old girl was rushed to the Emergency Department of the Royal Care International Hospital in Khartoum, with a mid-facial massive injury involving the orbit, following RTA; her parents were seeking for a second opinion after that the left eye enucleation was planned in another general hospital. The case discussion reviewed the initial examination, resultant management decisions, and final excellent visual outcome.

Keywords: Enucleation, mid-facial, multidisciplinary team management, road traffic accidents, shattered car window glass


How to cite this article:
Kamal I, Elgindi OA, Saleem M, Mirghani N, Osman H, Abdoun O, Barakat S, Ismaiel H. Management of eye trauma by multidisciplinary team in multidisciplinary facilities. Albasar Int J Ophthalmol 2017;4:34-8

How to cite this URL:
Kamal I, Elgindi OA, Saleem M, Mirghani N, Osman H, Abdoun O, Barakat S, Ismaiel H. Management of eye trauma by multidisciplinary team in multidisciplinary facilities. Albasar Int J Ophthalmol [serial online] 2017 [cited 2021 Jul 29];4:34-8. Available from: https://www.bijojournal.org/text.asp?2017/4/1/34/205805


  Introduction Top


The orbit is an anatomical region of clinical and surgical interest to many disciplines. The prominent position of the orbit within the craniofacial skeleton predisposes this region to injury. Orbital injuries are often seen in patients with multiple facial traumatic injuries. Injuries may be limited to the anatomic boundaries of the orbit itself or may be associated with more extensive fractures of the craniofacial skeleton.[1]

In cases of extensive injury to the craniofacial skeleton, the ophthalmologist will likely contribute to the care of the patient as part of a multidisciplinary medical team including specialists in the area of otolaryngology, oral and maxillofacial surgery, plastic surgery, and neurosurgery.

Potential ophthalmic injuries include rupture of the globe (scleral or corneal perforation); iridodialysis; angle recession; hyphema; lens subluxation or dislocation; choroidal, retinal, or vitreous hemorrhage or detachment; and choroidal rupture. Malposition of the globe (e.g., enophthalmos, hypo-ophthalmos), orbital hemorrhage, direct or indirect traumatic optic neuropathy, extraocular muscle injury, eyelid or canthal malposition, and damage to the lacrimal gland or lacrimal drainage apparatus may also be seen.[2],[3],[4]

This is a case report of a 2-year-old patient who had experienced mid-facial laceration associated with orbital roof, zygomatic and temporal bone fractures, following road traffic accident (RTA).


  Case Report Top


A 2-year-old girl was rushed to the emergency room with a mid-facial laceration involving the orbit following RTA; her parents were seeking for a second opinion after that the left eye enucleation was planned in another hospital.

The trauma was direct to the mid-face from a shattered car window glass. The patient arrived 5 h after the trauma. She had a brief loss of consciousness.

On examination, she was alert and crying. She had a mid-facial laceration in the forehead starting 2 cm behind the hairline down to the left cheek through the medial aspect of the left eye [Figure 1]. The wound was about 10 cm long. The skin and soft tissue were cut and displaced laterally exposing the underlying bones. There was no massive bleeding. She had telecanthus due to tear in the medial canthal ligament with inferolateral displacement of the left globe [Figure 2] and medial herniation of orbital fat. Left periorbital edema, ecchymosis, and ptosis were obvious [Figure 1]. There was associated tenderness and discontinuity in the upper orbital margin. The left cheek was flat [Figure 1] and tender. The right eye was normal.
Figure 1: The extension of the wound

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Figure 2: Examination of the eye globe with paediatric eye speculum

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The patient was in pain. Visual acuity and detailed ophthalmic examination were difficult to conduct. The wound was cleaned and the patient was kept on intravenous fluids, oral analgesia, and broad spectrum systemic and topical antibiotics. Neurological examination was normal.

After stabilization of the vital signs, examination under sedation with oral chloral hydrate was carried out. A speculum was used to examine the left globe [Figure 2] which found to be intact. The pupil was mid-dilated and reactive. There was no subconjunctival hemorrhage. The sclerocorneal envelope was intact. No hyphema and the lens were clear and in place. Examination with indirect ophthalmoscope revealed positive red reflex and a normal fundus.

Brain computerized tomography (CT) scan and magnetic resonance imaging (MRI) were requested. MRI was normal apart from area of high signal in the left basal ganglia consistent with contusion. CT scan revealed comminuted fracture in the left frontal bone involving the left superior orbital rim [Figure 3] with a small sharp bone fragment dislocated into the left orbit above the globe [Figure 4]. Another comminuted fracture was noted in the left temporal bone extending into the left zygomatic arch [Figure 5] and [Figure 6].
Figure 3: Bone scanning CT scan revealed comminuted fracture in the left frontal bone involving the left superior orbital rim

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Figure 4: CT scan revealed a small sharp bone fragment dislocated into the left orbit above the globe

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Figure 5: CT scan view superior to left globe revealed comminuted fracture in the left temporal bone extending into the left zygomatic arch

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Figure 6: CT scan view at the level of the left globe comminuted fracture in the left temporal bone extending into the left zygomatic arch

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Joint surgical intervention was scheduled the next day under general anesthesia by maxillofacial and oculoplastic surgeons. The frontal, zygomatic, and temporal bone fractures were reduced in place without fixation. The extraocular muscles were traced and were intact. Probing was done to examine the integrity of the lacrimal drainage system of the left eye. The puncta and canaliculi were intact. The lacrimal sac was distorted. The medial canthal ligament was sutured back in the periosteum of the left lacrimal crest. The wound was sutured in layers, and skin was sutured in interrupted fashion [Figure 7] and [Figure 8]. Postoperatively, examination of extraocular muscles function was normal and the patient was following and identifying objects.
Figure 7: Post Skin repair

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Figure 8: Post Skin repair and left medial canthus ligament repair

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She was discharged after 4 days on oral and topical antibiotic and analgesia.

The follow-up in the 1st month was twice a week. Moreover, she was seen by both ophthalmology and maxillofacial specialists. There was good wound healing [Figure 9],[Figure 10],[Figure 11]. The left ptosis was mechanical due to the periorbital edema and was decreasing gradually. There was no epiphora. Visual acuity testing using Preschool Kay pictures was 6118 for both eyes, which is normal for her age.
Figure 9: 2 weeks' post-operative wound healing

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Figure 10: 2 weeks' post-operative wound healing

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Figure 11: 2 months' post-operative wound healing

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  Discussion Top


Orbital trauma may be regarded as crossroads where the signposts, in the more complex injuries, clearly indicate the necessity for additional expertise, which can be provided by other specialties.[5]

In high-energy traumatic forces, patients often have other concomitant injuries. These injuries can be very severe and life-threatening often requiring multidisciplinary management.[6]

The extent of injury created by a sharp object usually causes less serious damage than a blunt penetrating object.[7]

Children are not immune to trauma containing enough energy to fracture the bones of the orbit and damage the adjacent soft tissues.[8] In pediatric populations, differences in the properties and proportions of bone in the craniofacial skeleton and the lack of development of the paranasal sinuses result in orbital fractures that present differently from those in adults.[8]

Whereas the orbital floor and medial wall fractures are the most common locations of fractures in adults, the location in children vary widely in published reports.[9] In young children, any visual compromise risks the development of amblyopia.[7]

In the above-mentioned case, a 2-year-old girl experienced severe trauma with a sharp object directed to the mid-face. The information obtained from the parents about the nature of the trauma was a great guide to a clinical judgment concerning the extent of the damage.

The injured glass was moving diagonally toward the mid-face, the soft tissue was affected first, resulting in medial canthal ligament tear and a complete distortion of the lacrimal sac. It extends further laterally to hit the upper orbital margin and the zygomatic arch. Immediate response and stabilization of the vital signs in a proper emergency department were mandatory.

External examination of lids and adnexa was performed quickly, providing valuable information. Further examination requiring soft-tissue manipulation was performed under sedation with chloral hydrate. Desmarres retractor should be ideally used, but it was not available.

Separation of the eyelids with a speculum and a cotton-tipped applicator revealed herniated orbital fat and displacement of the globe inferomedially. The presence of orbital fat in palpebral fissure should not be confused with globe injury.

Accurate assessment of visual acuity in such child who has been seriously injured was almost impossible. Instead fundal reflex, pupillary response was the best indicators of the visual status. Examination was suggestive of left orbital roof and zygomatic arch fractures. Ocular motility should be assessed to exclude trapdoor fractures, but it was difficult to assess in such child.

The trauma was involving both orbital and cranial bones. It raised the possibility of hidden ocular and neurological insult, apart from the apparent injury.

The radiological assessment with brain and orbit CT scan and MRI provided a solid base for diagnosis and a reference for the consequent follow-up. MRI showed soft tissue in many great details, and ready availability of CT scan has largely replaced plain film X-ray in evaluating orbital trauma, especially when dealing with the pediatric population to avoid the hazardous radiation of X-ray.

Surgery was scheduled on the next day to avoid fibrosis between orbital tissues and bone fragments which make the surgery more difficult. The purpose of the surgery was to restore the orbit to its original status and insure the integrity of the lacrimal drainage system. Reduction without fixation was done to permit growth of bones in such age group, and follow-up with CT scan was advised.[10] The proximal portion of the lacrimal drainage system was intact, but the lacrimal sac was completely distorted. The patient is not complaining of epiphora currently, but she may need dacryocystorhinostomy in the future.


  Conclusion Top


Children eye at RTA multiple injuries can be challenging to assess and difficulty with examination. Good history and minimal examination and prompt referral to multidisciplinary facilities for excellent management of these serious injuries are essential to relive the pose future threat to the child vision.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kuhn F, Morris R, Mester V, Witherspoon CD, Mann L, Maisiak R. Epidemiology and socioeconomics. Ophthalmol Clin North Am 2002;15:145-51.  Back to cited text no. 1
    
2.
Dutton JJ, Manson PN, Iliff N, Putterman AM. Management of blow-out fractures of the orbital floor. Surv Ophthalmol 1990;35:279.  Back to cited text no. 2
    
3.
Rubin PA, Bilyk JR, Shore JW. Management of orbital trauma: Fractures, hemorrhage, and traumatic optic neuropathy. In: Focal Points. Vol. XXI. San Francisco: American Academy of Ophthalmology; 1994.  Back to cited text no. 3
    
4.
Nunery WR. Diagnosis and management of blunt orbital trauma. In: Focal Points. Vol. IV. San Francisco: American Academy of Ophthalmology; 1986.  Back to cited text no. 4
    
5.
Rowe NL, Williams J, editors. Maxillofacial Injuries. 2nd ed. Vol, 1 and 2;(1992); Edinburgh; New York: Churchill Livingstone. [Ll].  Back to cited text no. 5
    
6.
Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope 2003;113:102-6.  Back to cited text no. 6
    
7.
Hollsten DA, Katowitz JA. Pediatric orbital trauma. Pediatric Oculoplastic Surgery. Edinburgh; New York: Churchill Livingstone; 2002. p. 655-67.  Back to cited text no. 7
    
8.
de Haan AB, Willekens B, Klooster J, Los AA, van Zwieten J, Botha CP, et al. The prenatal development of the human orbit. Strabismus 2006;14:51-6.  Back to cited text no. 8
    
9.
Sires BS, Stanley RB Jr., Levine LM. Oculocardiac reflex caused by orbital floor trapdoor fracture: An indication for urgent repair. Arch Ophthalmol 1998;116:955-6.  Back to cited text no. 9
    
10.
Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: Characterization and management. Ophthalmology 2000;107:829-36.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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