Case 27 – A good eye for the ball

Case 27 – A good eye for the ball

A 25 year old softball player presents to your sports clinic with an injury to the left side of his face. Last night, during a softball game, he was hit in the left eye with a softball. Today he presents with blurry vision and swelling around the left eye. He also describes an incident post-injury where he blew his nose and the swelling got much worse.

On examination: Nasal tenderness. Non-tender frontal maxillary orbit. Sensation of cheek and forehead intact. Mild crepitus on palpation of surrounding soft tissue. Normal oculomotor eye movements. Pupil is fixed dilated and vision is intact. Decreased visual acuity of left eye. No Seidel sign.

Imaging:
Figure 1: Coronal CT

Figure 2: Sagittal CT showing subcutaneous emphysema

Figure 3: Sagittal CT

Discussion:

            The orbit is predominantly formed by five bones of the skull: the frontal, ethmoid, sphenoid, zygomatic and maxilla bones. The frontal bone forms the superior orbital rim and roof of the orbit. The lateral wall of the orbit is composed of the sphenoid and zygomatic bones. The infraorbital rim and floor of the orbit is made of the zygomatic and maxillary bones. Finally, the medial wall of the orbit is composed of the maxillary and ethmoid bones (see figure 4). Other structures to be considered in orbital trauma are the extra ocular muscles, the sinuses, medial and lateral canthal ligaments, the lacrimal duct system and infra/supraorbital nerves (see figure 5).

On history, the mechanism of injury should be elicited. Also, information about the following should be obtained: the location of the pain, presence of blurry, double or decreased vision, difficulty with eye movement or double vision in a specific location, numbness of a particular area on the face. Diffuse pain is indicative of orbital hematoma, while pain with eye movement is suggestive of extra ocular muscle involvement. Diplopia, particularly with upward gaze, and infraorbital numbness may suggest orbital floor fracture.

On examination, globe integrity should be determined before proceeding to any ocular function exam. In the presence of globe rupture, immediate ophthalmological consultation should be obtained. Pupillary size, shape and reactivity should be assessed, as well as extra-ocular eye movements and visual acuity. Examination should also include palpation of malar eminences, zygomatic arches and orbital rims. Painful, bony “step-off” should be present if the orbital rim is involved in the fracture. Typically, orbital fractures present with periocular swelling, proptosis early on, enophthalmos later, ecchymosis, chemosis, V2 hypesthesia, and subconjunctival hemorrhage.

Orbital wall fracture is a common cause of periorbital emphysema. Other causes include forceful nose blowing, surgery, and air pressure changes during air travel. Treatment options include observation as it can spontaneously resolve within 2-3 weeks. However, periorbital emphysema can cause ischemic optic neuritis and central retinal artery occlusion. Thus, draining is considered when there is restricted ocular motility, slow pupillary reaction, disc edema or decreased visual acuity.

Possible outcomes from this sort of facial trauma are: orbital zygomatic fracture, nasoethmoid fracture, orbital roof fracture, orbital floor (blowout) fracture, traumatic iritis, corneal abrasion, hyphema, acute glaucoma, lens trauma, vitreous hemorrhage, retinal tears and detachment, and traumatic optic neuropathy.

The decision to observe a fracture versus proceeding to surgery is made based off of clinical exam findings and imaging. An ophthalmologist should be consulted during the initial evaluation if there are any globe injuries such as globe rupture, orbital or optic sheath hematoma, or in the presence of any severe vagal symptoms (nausea, vomiting, bradycardia), which are associated with extra ocular muscle entrapment. Patients with muscle entrapment, enopthalmos, or naso-orbital-ethmoid fractures with injury to canthal ligaments usually require surgery and should have follow-up arranged with a specialist within 24hrs. Initial management for all patients should include follow-up within one week with an ophthalmologist, advise to avoid nose blowing for several weeks to avoid emphysema and possible visual compromise.

Diagnosis: Infraorbital floor fracture, with periorbital subcutaneous emphysema

Management:

The patient was arranged to have follow-up within one week with an ophthalmologist. The patient was advised NOT to blow their nose for 6 weeks and prescribe a decongestant nasal spray.  It was recommended to apply a cold pack over the affected eye for the first 48hrs and elevating the head of the bed.

Figure 4: The bones of the right orbit

Figure 5: Structures associated with the orbit that may be damaged in orbital fractures

Lucas Nguyen (July 12, 2018 – PR ND)

References:

1. Neuman MI, Bachur RG. (Last updated: 2017, Sept.15). Orbital Fractures. Retrieved from https://www-uptodate-com.
2. Joseph, J. M., & Glavas, I. P. (2011). Orbital fractures: a review. Clinical Ophthalmology (Auckland, N.Z.), 5, 95– http://doi.org/10.2147/OPTH.S14972
3. Shah N. (2007). Spontaneous subcutaneous orbital emphysema following forceful nose blowing: Treatment options. Indian J Opthalmol, 55(5): 395.
4. Boyette, J. R., Pemberton, J. D., & Bonilla-Velez, J. (2015). Management of orbital fractures: challenges and solutions. Clinical Ophthalmology (Auckland, N.Z.), 9, 2127– http://doi.org/10.2147/OPTH.S80463