Figure 1
Radiograph of facial bones
Right orbital floor fracture with fluid in maxillary antrum.
Ruptured globe following traumatic eye injury
SectionHead & neck imaging
Case TypeClinical Cases
AuthorsDr MAF McNeill, Dr C Nyhsen.
Connected authors
61 years, male
Clinical History
A 61-year-old male patient attended the accident and emergency department following a traumatic injury to the right side of his face. Examination of the eye revealed an irregular pupil, sub-conjuctival haemorrhage and a hyphaema.
Imaging Findings
A 61-year-old male patient attended the accident and emergency department following a traumatic injury to the right side of his face. Although intoxicated and not able to fully recall events at the time, there were suspected punch injuries, where the patient may have sustained a penetrating ring injury to his eye. Clinical examination revealed a large haematoma surrounding the right orbit and zygoma, with lacerations to the upper and lower lid. There was irregularity to the pupil of the right eye, sub-conjunctival haemorrhage and a hyphaema.
CT imaging demonstrated a small and irregular right globe, with irregular low density material in the anterior aspect of the orbit, consistent with a ruptured globe. There was a fracture of the postero-lateral orbit wall and of the anterior wall of the right maxillary antrum. No associated intracranial abnormality was identified.
Surgical exploration revealed a circum-corneal scleral laceration, with a medially dislocated lens, which was excised. The scleral laceration was closed and the lid lacerations repaired. No acute maxillofacial surgery was required. The patient has been left with light perception in the right eye, and may require further surgical intervention to the orbital rim for cosmetic purposes.
CT imaging demonstrated a small and irregular right globe, with irregular low density material in the anterior aspect of the orbit, consistent with a ruptured globe. There was a fracture of the postero-lateral orbit wall and of the anterior wall of the right maxillary antrum. No associated intracranial abnormality was identified.
Surgical exploration revealed a circum-corneal scleral laceration, with a medially dislocated lens, which was excised. The scleral laceration was closed and the lid lacerations repaired. No acute maxillofacial surgery was required. The patient has been left with light perception in the right eye, and may require further surgical intervention to the orbital rim for cosmetic purposes.
Discussion
Orbital injuries pose an important diagnostic challenge for the radiologist. They are commonly associated with multi-organ injuries, and as such, attention must be paid to the orbits in order not to miss potentially sight threatening complications that may be overlooked. Common post traumatic orbital injuries include injuries to the lens, open-globe injuries, ocular detachments, intra-orbital foreign bodies and optic nerve injuries [1].
A ruptured globe is defined by an eye that has sustained a full thickness traumatic disruption to the cornea or sclera. Ruptures associated with hyphaema, vitreous haemorrhage, and disruption of uveal tissue have a poor prognosis despite multiple surgical procedures [2].
In this case, the presence of pupil irregularity and an associated hyphaema led clinicians to suspect a globe rupture. Full examination to the eye was not possible due to peri-orbital soft tissue swelling, and although a rupture was suspected, a confident CT diagnosis was instrumental in guiding management and subsequent surgical exploration.
Whilst clinical examination does still remains a crucial part of assessing the injured eye, it is often difficult to do so with a severely injured patient, and as such imaging the orbits is often essential to direct the management of such patients, as seen in this case.
Plain films are of limited value, demonstrating occult fractures and radio-opaque foreign bodies, but giving little soft tissue information. Ultrasound is contraindicated in globe ruptures, and it is often difficult to perform MRI in the emergency situation.
Therefore CT is the examination of choice. CT findings to suggest a ruptured globe include loss of normal globe contour, dislocation of the lens, volume loss of the globe, scleral discontinuity, intraocular air and intraocular foreign bodies. The goal of optimised CT is to help the radiologist make an accurate diagnosis whilst limiting the amount of radiation to the lens [1].
Sensitivity of CT in detecting open globe injuries seen in a study carried out between 1989 and 1993 was found to be 75% [3]. Another retrospective study in 2004 looking at patients with concurrent head and ocular injury found that the overwhelming majority of patients with decreased visual acuity or reduced extra-ocular muscle motility consequent to trauma had abnormalities demonstrated by orbital CT [4].
It can therefore be concluded CT should play a major role in the assessment of ocular trauma, and every effort should be made to optimise assessment of the orbits in the context of head trauma where appropriate, as this may have significant consequences for patient management and subsequent prognosis.
A ruptured globe is defined by an eye that has sustained a full thickness traumatic disruption to the cornea or sclera. Ruptures associated with hyphaema, vitreous haemorrhage, and disruption of uveal tissue have a poor prognosis despite multiple surgical procedures [2].
In this case, the presence of pupil irregularity and an associated hyphaema led clinicians to suspect a globe rupture. Full examination to the eye was not possible due to peri-orbital soft tissue swelling, and although a rupture was suspected, a confident CT diagnosis was instrumental in guiding management and subsequent surgical exploration.
Whilst clinical examination does still remains a crucial part of assessing the injured eye, it is often difficult to do so with a severely injured patient, and as such imaging the orbits is often essential to direct the management of such patients, as seen in this case.
Plain films are of limited value, demonstrating occult fractures and radio-opaque foreign bodies, but giving little soft tissue information. Ultrasound is contraindicated in globe ruptures, and it is often difficult to perform MRI in the emergency situation.
Therefore CT is the examination of choice. CT findings to suggest a ruptured globe include loss of normal globe contour, dislocation of the lens, volume loss of the globe, scleral discontinuity, intraocular air and intraocular foreign bodies. The goal of optimised CT is to help the radiologist make an accurate diagnosis whilst limiting the amount of radiation to the lens [1].
Sensitivity of CT in detecting open globe injuries seen in a study carried out between 1989 and 1993 was found to be 75% [3]. Another retrospective study in 2004 looking at patients with concurrent head and ocular injury found that the overwhelming majority of patients with decreased visual acuity or reduced extra-ocular muscle motility consequent to trauma had abnormalities demonstrated by orbital CT [4].
It can therefore be concluded CT should play a major role in the assessment of ocular trauma, and every effort should be made to optimise assessment of the orbits in the context of head trauma where appropriate, as this may have significant consequences for patient management and subsequent prognosis.
Differential Diagnosis List
Ruptured right globe.
Final Diagnosis
Ruptured right globe.
References
[1] Wayne S Kubal (2008) Imaging of orbital trauma. Radiographics 28:1729-39 (PMID: 18936032)
[2] Navon SE (1995) Management of the ruptured globe. International Ophthalmology 35:71-91 (PMID: 7751137)
[3] Joseph DP, Pieramici DJ, Beauchamp NJ Jr. (2000) Computed tomography in the diagnosis and prognosis of open globe injuries. Ophthalmology 107:1899-906 (PMID: 11013196)
[4] Lee HJ, Jilani M, Frohman L, Baker S (2004) CT of orbital trauma. Emergency Radiology 10:168-72 (PMID: 15290482)
Case information
| URL: | https://www.eurorad.org/case/8735 |
| DOI: | 10.1594/EURORAD/CASE.8735 |
| ISSN: | 1563-4086 |
Figure 2
CT orbits - axial views
Figure 4
Ct right orbit - saggital reconstruction
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Figure 5
CT orbits - coronal reconstructions
Right-sided ruptured globe with associated anterior antral wall fracture
Right-sided ruptured globe with associated anterior antral wall fracture
Right-sided ruptured globe with orbital floor fracture. Please note that there is neither entrapment of the inferior rectal muscle nor herniation of intra-orbital fat.
Right-sided ruptured globe with orbital floor fracture. Please note that there is neither entrapment of the inferior rectal muscle nor herniation of intra-orbital fat.
Right-sided ruptured globe with associated orbital floor fracture. Please also note the high attenuation fluid which almost completely fills the maxillary sinus. This represents fresh hemorrhage.
Radiograph of facial bones
Right orbital floor fracture with fluid in maxillary antrum.
CT orbits - axial views
Ct right orbit - saggital reconstruction
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
Right sided ruptured globe with associated fractures
CT orbits - coronal reconstructions
Right-sided ruptured globe with associated anterior antral wall fracture
Right-sided ruptured globe with associated anterior antral wall fracture
Right-sided ruptured globe with orbital floor fracture. Please note that there is neither entrapment of the inferior rectal muscle nor herniation of intra-orbital fat.
Right-sided ruptured globe with orbital floor fracture. Please note that there is neither entrapment of the inferior rectal muscle nor herniation of intra-orbital fat.
Right-sided ruptured globe with associated orbital floor fracture. Please also note the high attenuation fluid which almost completely fills the maxillary sinus. This represents fresh hemorrhage.